Nursing Theories

Faye Glenn Abdellah's Contribution to Nursing Theory: Twenty-One Nursing Problems

According to Abdellah's Twenty-One Nursing Problems theory of nursing, "Nursing isbased on an art and science that moulds the attitudes, intellectual competencies, andtechnical skills of the individual nurse into the desire and ability to help people, sick orwell, cope with their health needs." The patient-centered approach to nursing wasdeveloped from Abdellah's practice, and the theory is considered a human needs theory.It was created to help with nursing education, so it most applicable in that area. Thenursing model is intended to guide care in hospitals, but can be applied to communitynursing, as well. The model has interrelated concepts of health and nursing problems, aswell as problem-solving, which is an activity inherently logical in nature. Abdellah'stheory identifies ten steps to identify the patient's problem and 11 nursing skills used todevelop a treatment typology. The ten steps are:

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 patient's 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 his or her behavior.8. Explore the patient and his or her family's reactions to the therapeutic plan and

involve them in the plan.9. Identify how the nurses feel about the patient's nursing problems.10. Discuss and develop a comprehensive nursing care plan.

The 11 nursing skills are:

1. observation of health status2. skills of communication3. application of knowledge4. teaching of patients and families5. planning and organization of work6. use of resource materials7. use of personnel resources8. problem-solving9. direction of work of others10. therapeutic uses of the self11. nursing procedure

The model identifies nursing as a helping profession. Nursing care is doing something toor for a patient, or providing information to the patient with the intention of meetingneeds, increasing self-ability, or alleviating impairment. In other words, helping patientsbecome more healthy.

Abdellah describes health as a state mutually exclusive of illness. There is no definition ofhealth given by her in the theory, but she speaks to "total health needs" and "a healthystate of mind and body" in her description of nursing as a comprehensive service.

The nursing process in Abdellah's Twenty-One Nursing Problems theory is: assessment,nursing diagnosis, planning, implementation, and evaluation.

In the assessment phase, nursing problems provide guidelines for the collection of data.A principle underlying the problem-solving approach is that for each identified problem,pertinent data is collected. The overt or covert nature of problems necessitates a director indirect approach, respectively.

The results of the collection of data in the assessment phase determine the patient'sspecific problems, which can be grouped under one or more of the broader nursingproblems. This creates the nursing diagnosis.

The statement of nursing problems most closely resembles goal statements. Using thegoals in the framework, a nursing care plan is developed and appropriate nursinginterventions are determined. Putting those interventions in action is the implementationphase of the nursing process.

After the interventions have been carried out, the evaluation takes place. The mostappropriate evaluation would be the nurses progress or lack of progress toward theachievement of the goals established in the planning phase.

Phil Barker's Contribution to Nursing Theory: Tidal Model

The Tidal Model of nursing, created by Phil Barker, Poppy Buchanan-Barker and theircolleagues, is widely used in mental health nursing. It views health and illness as fluid,and life as a journey undertaken on an ocean of experience. However, it states thatpatients can become physically, emotionally, or spiritually shipwrecked. This metaphor ofwater throughout the theory should be appreciated by nurses to help them gain a betterunderstanding of the patient's current situation, as well as the inevitability of change.

Barker's model includes six philosophical assumptions: a belief in the virtue of curiosity;recognition of the power of resourcefulness; respect for the patient's wishes; acceptanceof the paradox of crisis as opportunity; acknowledging that all goals must belong to thepatient; and the virtue of pursuing elegance, which means the simplest possible meansshould be sought.

In order for the nurse to start the engagement process with the patient, six things mustbe accepted: recovery is possible; change is inevitable; ultimately, people know what'sbest for them; the patient has all the resources he or she needs to start the recoveryjourney; the patient is the teacher and the helpers are the students; and the helperneeds to be creatively curious, to learn what needs to be done to help the patientrecover.

The engagement process takes place in three domains: self, world, and others. The selfdomain is where people feel their experiences, and it includes an emphasis on makingpatients more secure through the development of a Security Plan to reduce threats to thepatient and others around him or her. The world domain is where people hold theirstories. The Tidal Model nurse uses a specific way of questioning to explore the patient'sstory, reveal its hidden meanings, the patient's resources, and find out what needs to bedone to help with his or her recovery. The others domain represents the relationships ofthe patient, past, present, and future. This includes the patient's care team.

The values of the Tidal Model are revealed in the Ten Commitments:

1. Value the voice. That is, the patient's story is paramount.2. Respect the language, which means to let the patient use his or her own

language.3. Develop genuine curiosity, or show interest in the patient's story.4. Become the apprentice to learn from the person being helped.5. Reveal personal wisdom. Patients are experts in their own stories.6. Be transparent. Nurses should model confidence by being transparent and helping

make sure the patient always knows exactly what's being done.7. Use the available toolkit; the patient's story contains valuable information as to

what works and what doesn't.8. Craft the step beyond. That is, the patient and nurse work together to construct

an appreciation of what needs to be done in that moment.9. Give the gift of time to foster change.10. Know that change is constant.

Each of the Ten Commitments has two Competencies associated with it. These wereintroduced to help with generating practice-based evidence for the Tidal Model.

Patricia Benner's Contribution to Nursing Theory: From Novice to ExpertConcept

Patricia Benner developed a concept known as "From Novice to Expert." This conceptexplains that nurses develop skills and an understanding of patient care over time from acombination of a strong educational foundation and personal experiences.

Benner proposed that a nurse could gain knowledge and skills without actually learning atheory. She describes this as a nurse "knowing how" without "knowing that." She furtherexplains that the development of knowledge in fields such as nursing is made up of theextension of knowledge through research and understanding through clinical experience.

The theory identifies five levels of nursing experience: novice, advanced beginner,competent, proficient, and expert.

A novice is a beginner with no experience. They are taught general rules to help performtasks, and their rule-governed behavior is limited and inflexible. In other words, they aretold what to do and simply follow instruction.

The advanced beginner shows acceptable performance, and has gained prior experiencein actual nursing situations. This helps the nurse recognize recurring meaningfulcomponents so that principles, based on those experiences, begin to formulate in orderto guide actions.

A competent nurse generally has two or three years' experience on the job in the samefield. For example, two or three years in intensive care. The experience may also besimilar day-to-day situations. These nurses are more aware of long-term goals, and theygain perspective from planning their own actions, which helps them achieve greaterefficiency and organization.

A proficient nurse perceives and understands situations as whole parts. He or she has amore holistic understanding of nursing, which improves decision-making. These nurseslearn from experiences what to expect in certain situations, as well as how to modifyplans as needed.

Expert nurses no longer rely on principles, rules, or guidelines to connect situations anddetermine actions. They have a deeper background of experience and an intuitive graspof clinical situations. Their performances are fluid, flexible, and highly-proficient. Benner'swritings explain that nursing skills through experience are a prerequisite for becoming anexpert nurse.

These different levels of skills show changes in the three aspects of skilled performance:movement from relying on abstract principles to using past experiences to guide actions;change in the learner's perception of situations as whole parts rather than separatepieces; and passage from a detached observer to an involved performer, engaged in thesituation rather than simply outside of it.

The levels reflect movement from reliance on past principles to the use of pastexperience and change in the perception of the situation as a complete whole withcertain relevant parts. Each step builds on the previous step as principles are refined andexpanded by experience and clinical expertise.

Benner's theory of From Novice to Expert changed the understanding of what it means tobe an expert in the nursing field. This moves the label from a nurse with the highest payor the most prestigious title to the nurse who provided the best care to his or herpatients.

Helen C. Erickson's Contribution to Nursing Theory: Modeling and RoleModeling Theory

The Modeling and Role Modeling Theory of nursing was created by Helen C. Erickson,along with Evelyn M. Tomlin and Mary Ann P. Swain. It was first published in their book,Modeling and Role Modeling: A Theory and Paradigm for Nursing, which was published in1983.

The Modeling and Role Modeling Theory draws on concepts from Piaget's Theory ofCognitive Development, Maslow's Theory of Hierarchy of Needs, Erikson's Theory ofPsychosocial Stages, and Selye and Lazarus's General Adaptation Syndrome. Erickson'stheory helps nurses care for their patients by recognizing each individuals uniqueness,and focusing on the individual patient's needs. It is also a self-care method of nursing,which means it is based on the patient's perceptions of the environment, and adaptsbased on individual stressors for that patient.

According to the theory, modeling recognizes that each patient has a unique perspectiveof his or her world. Modeling is a process that enables a nurse to understand that uniqueperspective and learn to appreciate its importance to the patient. The nurse uses theprocess of modeling to understand the world from the patient's perspective. TheModeling and Role Modeling Theory of nursing helps the nurse to do this by explainingsome of the similarities and differences among patients.

Role modeling accepts each patient regardless of his or her perspective on the world, andcares for the patient in order to work toward health. According to the nursing theory, thepatient is the expert in his or her own care, and knows best in how he or she should becared for to get back to health.

In the Modeling and Role Modeling Theory, the roles of nursing are facilitation,nurturance, and unconditional acceptance. In addition, Erickson's model says that thefive goals of nursing intervention are: to build trust, to promote the patient's positiveorientation, to promote the patient's control, to affirm and promote the patient'sstrengths, and to set mutual, health-directed goals.

Katie Eriksson's Contribution to Nursing Theory: Theory of Caritative Caring

The Theory of Caritative Caring was developed by Katie Eriksson. This model of nursingdistinguishes between caring ethics, the practical relationship between the patient andthe nurse, and nursing ethics. Nursing ethics are the ethical principles that guide anurse's decision-making abilities. Caritative caring consists of love and charity, which isalso known as caritas, and respect and reverence for human holiness and dignity.According to the theory, suffering that occurs as a result of a lack of caritative care is aviolation of human dignity.

Lydia E. Hall's Contribution to Nursing Theory: Care, Cure, Core Theory ofNursing

Lydia E. Hall developed the Care, Cure, Core Theory of Nursing in the late 1960s as aresult of her work in psychiatry, as well as her experiences at the Loeb Center. In hercareer, she promoted involvement of community members in health-care issues, as well.

Also known as "the Three Cs of Lydia Hall," Hall's theory contains three independent butinterconnected circles. The three circles are: the core, the care, and the cure.

The core is the patient to whom nursing care is directed. The core has set goals by him orherself rather than by a healthcare provider or family and friends. The core makesdecisions and behaves according to his or her feelings and values.

The cure is the attention given to the patient by the nurse and other medicalprofessionals. In this model, the focus of care is not only on the nurse, but on allhealthcare professionals involved in the care of the patient. The cure includesinterventions or actions geared toward treating the patient of whatever illness, disease,or disability he or she may be suffering from.

The care circle is Hall's explanation of the role of nurses in her model. According to thetheory, nurses are focused on performing the noble task of nurturing patients. Thisspecifically speaks to the "motherly" nature of nursing, which may include a nurse

addressing a patient's comfort issues. The role of nursing also includes educatingpatients, and helping a patient meet any needs he or she is unable to meet alone.

The theory puts emphasis on the importance of the total patient rather than looking atone part or aspect. There is also emphasis put on all three aspects of the theory (care,cure, and core circles) functioning together.

Virginia Henderson's Contribution to Nursing Theory: Nursing Need Theory

Henderson's Need Theory emphasizes the importance of patient independence so thatthe patient will continue to progress after being released from the hospital. Hendersondescribed the role of the nurse as one of the following: substitutive, which is doingsomething for the patient; supplementary, which is helping the patient do something; orcomplementary, which is working with the patient to do something. All of these roles areto help the patient become as independent as possible.

She categorized nursing activities into fourteen components based on human needs. Thefourteen components of Henderson's concept are as follows:

1. Breathe normally. Eat and drink adequately.2. Eliminate body wastes.3. Move and maintain desirable postures.4. Sleep and rest.5. Select suitable clothes-dress and undress.6. Maintain body temperature within normal range by adjusting clothing and

modifying environment.7. Keep the body clean and well groomed and protect the integument.8. Avoid dangers in the environment and avoid injuring others.9. Communicate with others in expressing emotions, needs, fears, or opinions.10. Worship according to one's faith.11. Work in such a way that there is a sense of accomplishment.12. Play or participate in various forms of recreation.13. Learn, discover, or satisfy the curiosity that leads to normal development and

health and use the available health facilities.

While a nurse's job is to care for patients, it is also to help patients be able to care forthemselves when they leave the healthcare facility. This will help ensure that the patienthas fewer setbacks during recovery from the illness or injury, and will help the transitioninto self-care be smoother since a nurse will be helping and supervising along the wayuntil the patient goes home. For those nurses who work in rehabilitation, Henderson'stheory is one that can be easily used every day, and it will be the patients who benefitfrom it

Dorothy Johnson's Contribution to Nursing: Behavior System Model

Johnson is known for her Behavior System Model of Nursing, which was first proposed in1968. The model advocates the fostering of efficient and effective behavioral functioningin the patient to prevent illness. The patient is defined as a behavioral system composed

of seven behavioral subsystems. Each subsystem is comprised of four structuralcharacteristics. An imbalance in each system results in disequilibrium. The nurse's role isto help the patient maintain his or her equilibrium.

Johnson's theory of nursing defines nursing as "an external regulatory force which acts topreserve the organization and integration of the patients behaviors at an optimum levelunder those conditions in which the behavior constitutes a threat to the physical or socialhealth, or in which illness is found."

The goals of nursing are fourfold, according to the Behavior System Model:

1. To assist the patient whose behavior is proportional to social demands.2. To assist the patient who is able to modify his behavior in ways that it supports

biological imperatives.3. To assist the patient who is able to benefit to the fullest extent during illness from

the physician's knowledge and skill.4. To assist the patient whose behavior does not give evidence of unnecessary

trauma as a consequence of illness.

The assumptions made by Johnson's theory are in three categories: assumptions aboutsystem, assumptions about structure, and assumptions about functions.

There are four assumptions about system in the model:

1. There is "organization, interaction, interdependency and integration of the partsand elements of behaviors that go to make up the system."

2. A system "tends to achieve a balance among the various forces operating withinand upon it, and that man strive continually to maintain a behavioral systembalance and steady state by more or less automatic adjustments and adaptationsto the natural forces occurring on him."

3. A behavioral system, which requires and results in some degree of regularity andconstancy in behavior, is essential to man. It is functionally significant because itserves a useful purpose in social life as well as for the individual.

4. "System balance reflects adjustments and adaptations that are successful in someway and to some degree."

The four assumptions about structure and function are that:

1. "from the form the behavior takes and the consequences it achieves can beinferred what 'drive' has been stimulated or what 'goal' is being sought."

2. Each individual person has a "predisposition to act with reference to the goal, incertain ways rather than the other ways." This predisposition is called a "set."

3. Each subsystem has a repertoire of choices called a "scope of action."4. The individual patient's behavior produces an outcome that can be observed.

There are three functional requirements for the subsystems.

The system must be protected from toxic influences with which the system cannot cope.

Each system has to be nurtured through the input of appropriate supplies from theenvironment.

The system must be stimulated for use to enhance growth and prevent stagnation.

These behaviors are "orderly, purposeful and predictable and sufficiently stable andrecurrent to be amenable to description and explanation."

Johnson's theory defines health as a purposeful adaptive response to internal andexternal stimuli in order to maintain stability and comfort. The main goal of nursing is tofoster equilibrium within the individual patient. The practice of nursing is concerned withthe organized and integrated whole, but maintaining a balance in the behavior systemwhen illness occurs is the major focus of the career.

The nursing process of the Behavior System Model of Nursing begins with an assessmentand diagnosis of the patient. Once a diagnosis is made, the nurse and other healthcareprofessionals develop a nursing care plan of interventions and setting them in motion.The process ends with an evaluation, which is based on the balance of the subsystems.

Imogene King's Contribution to Nursing Theory: Theory of Goal Attainment

Imogene King's Theory of Goal Attainment was first introduced in the 1960s. The basicconcept of the theory is that the nurse and patient communicate information, set goalstogether, and then take actions to achieve those goals. It describes an interpersonalrelationship that allows a person to grow and develop in order to attain certain life goals.The factors that affect the attainment of goals are roles, stress, space, and time.

According to King, the patient is a social being who has three fundamental needs: theneed for health information, the need for care that seeks to prevent illness, and the needfor care when the patient is unable to help him or herself. She explains health asinvolving life experiences of the patient, which includes adjusting to stressors in theinternal and external environment by using resources available. The environment is thebackground for human interaction. It involves the internal environment, which transformsenergy to enable people to adjust to external environmental changes, and it involves theexternal environment, which is formal and informal organizations. A nurse is consideredpart of the patient's environment.

The three interacting systems in her Theory of Goal Attainment are the personal system,the interpersonal system, and the social system. Each system is given different concepts.The concepts for the personal system are: perception, self, growth and development,body image, space, and time. The concepts for the interpersonal system are: interaction,communication, transaction, role, and stress. The concepts for the social system are:organization, authority, power, status, and decision making.

King's Theory of Goal Attainment defines nursing as "process of action, reaction andinteraction by which nurse and patient share information about their perception innursing situation." According to King, nursing's focus is on the care of the patient, and itsgoal is the health care of patients and groups of patients.

According to King, the goal of the nurse is to help patients maintain health so they canfunction in their individual roles. The nurse's function is to interpret information in thenursing process, to plan, implement, and evaluate nursing care.

In the nurse-patient relationship, the nurse first uses his or her knowledge base to assessthe patient and make a diagnosis. After the diagnosis, the nurse creates a plan forinterventions to solve problems that were identified in the assessment and diagnosis.

Once a care plan is created, actions are implemented to achieve the patient's healthgoals. Finally, the nurse evaluates the patient to determine whether or not the goals wereachieved.

In the healthcare field, the ultimate goal in the nurse-patient relationship is to help thepatient achieve his or her goals for getting healthy. By using the nursing processdescribed in Imogene King's Theory of Goal Attainment, a nurse can be more effective inworking with a patient to achieve those goals, and can truly help patients.

Katharine Kolcaba's Contribution to Nursing Theory: Comfort Theory

Kolcaba developed her nursing theory in the 1990s. It is a middle range nursing theorydesigned for nursing practice, research, and education. According to her theory, patientcomfort exists in three forms: relief, ease, and transcendence. These comforts can occurin four contexts: physical, psychospiritual, environmental, and sociocultural.

Relief comfort usually comes in the form of pain management through medications.When medications are administered, the patient has a sense of relief from the pain. Easecomfort is focused more on the environment and psychological state of the patient. Forexample, after issues of anxiety are addressed and dealt with, a patient feels at ease.Finally, transcendence comfort comes when a patient is able to rise above challengesthat occur in care and recovery.

In this theory, the role of a nurse is to assess a patient's comfort needs and create anursing care plan to meet those needs. As a patient's comfort needs change, the nurse'sinterventions change, as well. Through this method, nurses are able to ensure theirpatients are properly cared for, and that they are comfortable. If a patient is comfortable,he or she will feel emotionally and mentally better, which will aid in recovery.

Madeleine Leininger's Contribution to Nursing Theory: Transcultural Nursing

Madeleine Leininger's theory of Transcultural Nursing, also known as Culture Care Theory,falls under both the category of a specialty, as well as a general practice area. The theoryhas now developed into a discipline in nursing.

The Transcultural Nursing theory first appeared in Leininger's Culture Care Diversity andUniversality, published in 1991, but it was developed in the 1950s. The theory wasfurther developed in her book Transcultural Nursing, which was published in 1995. In thethird edition of Transcultural Nursing, published in 2002, the theory-based research andthe application of the Transcultural theory are explained.

Transcultural nursing is a study of cultures to understand both similarities and differencesin patient groups. Culture is a set of beliefs held by a certain group of people, handeddown from generation to generation.

In transcultural nursing, nurses practice according to the patient's culturalconsiderations. It begins with a culturalogical assessment, which takes the patient's

cultural background into consideration in assessing the patient and his or her health.Once the assessment is complete, the nurse should use the culturalogical assessment tocreate a nursing care plan that also takes the patient's cultural background intoconsideration.

There are many reasons it's beneficial for nurses to use cultural knowledge of patients totreat them. First of all, it helps nurses to be aware of ways in which the patient's cultureand faith system provide resources for their experiences with illness, suffering, and evendeath. It helps nurses to be understanding and respectful of the diversity that is oftenvery present in a nurse's patient load. It also helps strengthen a nurse's commitment tonursing based on nurse-patient relationships and emphasizing the whole person ratherthan viewing the patient as simply a set of symptoms or an illness. Finally, using culturalknowledge to treat a patient also helps a nurse to be open minded to treatments that canbe considered non-traditional, such as spiritually based therapies like meditation andanointing.

In the Transcultural Nursing theory, nurses have a responsibility to understand the role ofculture in the health of the patient. Not only can a cultural background influence apatient's health, but the patient may be taking home remedies that can affect his or herhealth, as well.

Leininger identified three nursing decisions and actions that achieve culturally friendlycare for the patient. They are: cultural preservation or maintenance, cultural careaccomodation or negotiation, and cultural care repatterning or restructuring.

The nurse's assessment of the patient should include a self-assessment that addresseshow the nurse is affected by his or her own cultural background, especially in regards toworking with patients from culturally diverse backgrounds. The nurse's diagnosis of thepatient should include any problems that may come up that involve the healthcareenvironment and the patient's cultural background. In addition, the nurse's care planshould involve aspects of the patient's cultural background when needed. Finally, thenurse's evaluation should include a self-evaluation of attitudes toward caring for patientsfrom differing cultural backgrounds.

In today's healthcare field, it is required for nurses to be sensitive to their patients'cultural backgrounds when creating a nursing plan. This is especially important since somany people's culture is so integral in who they are as individuals, and it is that culturethat can greatly affect their health, as well as their reactions to treatments and care.Thanks to Madeleine Leininger's Transcultural Nursing theory, nurses can look at how apatient's cultural background is involved in his or her health, and use that knowledge tocreate a nursing plan that will help the patient get healthy quickly while still beingsensitive to his or her cultural background.

Myra Estrine Levine's Contribution to Nursing Theory: Four ConservationPrinciples

Levine developed the Four Conservation Principles. In this model, the goal of nursing is topromote adaptation and maintain wholeness using the principles of conservation. Themodel guides nurses to focus on the influences and responses at the level of the

organism. Nurses accomplish the theory's goal through the conservation of energy,structure, and personal and social integrity.

According to Levine, every individual has a unique range of adaptive responses. Theyvary by heredity, age, gender or the challenges that come with experiencing an illness.The responses are the same, but the timing and manifestation of the responses areunique to each individual pulse rate. Adaptation is an ongoing process of change in whichthe patient is able to maintain his or her integrity while staying within the realities of theenvironment. This is achieved through the "frugal, economic, contained and controlleduse of environmental resources by the individual in his or her best interest."

Wholeness exists when the patient's interaction with the environment allows integrity tobe assured. Wholeness is promoted by the use of the conservation principle.

Conservation is the product of adaptation. It is the achievement of a balance of energysupply and demand that is within the unique biological realities of the individual patient.The conservation principle has four aspects: conservation of energy, conservation ofstructural integrity, conservation of personal integrity, and conservation of socialintegrity.

Conservation of energy refers to balancing how energy goes in and out of the body toavoid fatigue. It includes adequate rest, nutrition, and exercise. Conservation ofstructural integrity refers to maintaining or restoring the physical body and promotingphysical healing. The conservation of personal integrity recognizes the patient's need forrecognition, respect, self-awareness, and self-determination. In this area, for example, anurse will honor a patient's need for personal space. The conservation of social integrityaddresses the patient's interactions and relationships with other people, such as in afamily, community, or religious group.

In this theory, nursing is a profession and an academic discipline, and should be studiedand practiced in harmony with all disciplines that make up the health sciences. Nursinginvolves engaging in human interactions. Levine states that the goal of nursing is topromote wholeness, while realizing that every individual requires a unique cluster ofactivities to achieve wholeness. The patient's individual integrity is his or her concern,and it is the nurse's responsibility to assist him or her to defend and seek the realizationof that individual integrity.

Levine offers nine models of guided assessment in the Four Conservation Principlestheory of nursing. They are:

1. vital signs2. body movement and positioning3. meeting personal hygiene needs4. pressure gradient system in nursing interventions5. nursing determination in provision of nutritional needs6. pressure gradient system in nursing7. local application of hot and cold8. administration of medicine9. establishing an aseptic environment

The nursing process used in this model is:

1. Assessment2. Trophicognosis

3. Hypothesis4. Interventions5. Evaluation

Kurt Lewin's Contribution to Nursing Theory: Change Theory

Considered the father of social psychology, Kurt Lewin developed the nursing modelknown as Change Theory. He theorized a three-stage model of change that is known asthe "unfreezing-change-refreeze model" that requires prior learning to be rejected andreplaced. It states behavior as "a dynamic balance of forces working in opposingdirections."

The three concepts identified in Lewin's Change Theory are driving forces, restrainingforces, and equilibrium.

Driving forces are forces that push in a direction that causes change to occur. Theyfacilitate change because they push the person in the desired direction. They cause ashift in the equilibrium towards change. Restraining forces are those forces that counterdriving forces. They hinder change because they push the person in the oppositedirection. They cause a shift in the equilibrium which opposes change. Equilibrium is astate of being where driving forces equal restraining forces and no change occurs.Equilibrium can be raised or lowered by changes that occur between the driving andrestraining forces.

This model of nursing consists of three distinct stages which are vital to the theory. Theyare unfreezing, moving to a new level or changing (or movement), and refreezing.

Unfreezing is the process which involves finding a method of making it possible forpeople to let go of an old pattern that was, in some way, counterproductive. It isnecessary to overcome the strains of individual resistance and group conformity. It canbe achieved by the use of three methods. First, increase the driving forces that directbehavior away from the existing situation or status quo. Second, decrease the restrainingforces that affect movement negatively. Third, find some combination of the first twomethods.

The second stage involves a process of change in feeling, behavior, thought, or all three,that is more productive in some way. The refreezing stage involves establishing thechange as a habit so it becomes the standard. Without the refreezing stage, the old wayscan easily return.

Ramona Mercer's Contribution to Nursing Theory: Maternal Role AttainmentTheory

The Maternal Role Attainment Theory, a mid-range theory, was developed to serve as aframework for nurses to provide appropriate health care interventions for nontraditionalmothers in order for them to successfully adopt a strong maternal identity. Though thistheory can be used throughout pregnancy and after childbirth to help mothers connectwith their babies, it can also be beneficial for adoptive mothers, foster mothers, or otherswho have had nontraditional motherhood unexpectedly, such as taking care of a relativeor friend's child as the result of a death. The process helps the mother form anattachment to the infant, which in turn helps the infant form an attachment with themother. This helps in the building of the mother-child relationship as the infant grows.

The primary concept of this theory is the developmental and interactional process, whichoccurs over a period of time. In the process, the mother bonds with the infant, acquirescompetence in general caretaking tasks, and comes to express joy and pleasure in thematernal role.

The nursing process follows four stages of acquisition in the Maternal Role AttainmentTheory. First is the anticipatory stage, which addresses the social and psychologicaladaptation to the maternal role, and learning expectations. Second is the formal stage,which is the assumption of the role at birth, and addresses behaviors guided by others inthe mother's social system and network. For example, "My mother always said..." Third isthe informal stage, in which the mother develops her own ways of mothering notconveyed by her social system. Finally, the fourth stage is the personal stage, in whichthe mother experiences harmony, confidence, and competence in her maternal role.

Betty Neuman's Contribution to Nursing Theory: Neuman Systems Model

In 1970 she began developing her Systems Model as a way to teach introductory nursingto students by giving them a holistic view of patients that included the physiological,psychological, sociological, and developmental aspects. It was first developed as agraduate course guide, and in 1972, the May/June edition of Nursing Research published"A model for teaching total person approach to patient problems." In 1974, Neuman'smodel was refined and published in Conceptual Models for Nursing Practice. It wasclassified as a systems model, and was titled "The Betty Neuman Health-Care SystemsModel: A Total Person Approach to Patient Problems." In this publication, the term"patient" was replaced with the term "client."

The Neuman Systems Model is based on the patient's relationship to stress, reaction to it,and reconstitution factors that are dynamic. The Neuman Systems Model is universal innature, which allows it to be adapted to a variety of situations, and to be interpreted inmany different ways.

The central philosophy of Neuman's nursing theory consists of energy resources that aresurrounded by three things: several lines of resistence, which represent the internalfactors helping the patient fight against a stressor; the normal line of defense, whichrepresents the patient's equilibrium; and the flexible line of defense, which representsthe dynamic nature that can rapidly change over a short time.

In the Neuman Systems Model, the nurse's role is to keep the system's stability by usingthree levels of prevention. The first is primary prevention, which protects the normal lineand strengthens the flexible line of defense. The secondary prevention is used to

strengthen the internal lines of resistence, which reduces the reaction and increasesresistence factors. Finally, tertiary prevention readapts, stabilizes, and protects thepatient's return to wellness after treatment.

Margaret A. Newman's Contribution to Nursing Theory: Health as ExpandingConsciousness

The initial idea for Newman's Health as Expanding Consciousness Theory came togetheras a result of an invitation to speak at a conference on nursing in 1978. It stems fromRogers' Theory of Unitary Human Beings. It was stimulated by concern for those forwhom the absence of disease or disability is not possible. Newman was also influencedby Bentov's concept of the evolution of consciousness, Young's Theory of Process, andBohm's Theory of Implicate.

This grand theory of nursing claims that every person in every situation, regardless ofhow disordered and hopeless it may seem, is part of the universal process of expandingconsciousness, which is a process of becoming more of oneself, finding greater meaningin life, and of reaching new dimensions of connectedness with other people and theworld.

Newman's theory makes six assumptions. They are:

1. Health encompasses conditions heretofore described as illness, or, in medicalterms, pathology.

2. These pathological conditions can be considered a manifestation of the totalpattern of the individual patient.

3. The pattern of the individual patient that eventually manifests itself as pathologyis primary, and exists prior to structural or functional changes.

4. Removal of the pathology in itself will not change the pattern of the individualpatient.

5. If becoming ill is the only way an individual patient's pattern can manifest itself,then that is health for that individual patient.

6. Health is an expansion of the consciousness.

According to Newman, "The theory of health as expanding consciousness (HEC) wasstimulated by concern for those for whom health as the absence of disease or disability isnot possible. Nurses often relate to such people: people facing the uncertainty,debilitation, loss and eventual death associated with chronic illness. The theory hasprogressed to include the health of all persons regardless of the presence or absence ofdisease. The theory asserts that every person in every situation, no matter howdisordered and hopeless it may seem, is part of the universal process of expandingconsciousness - a process of becoming more of oneself, of finding greater meaning in life,and of reaching new dimensions of connectedness with other people and the world."

Humans are open to the whole energy system of the universe and constantly interactingwith the energy. With the process of interaction, humans are evolving their individualpatterns of whole. According to Newman, the pattern of the individual patient isessential. The expanding consciousness is pattern recognition.

How a disease manifests in an individual patient depends on the pattern of that patient,so the pathology of the disease exists before the symptoms appear. By this logic, theremoval of the symptoms of the disease will not change the patient's individual structureor pattern.

The model also addresses the interrelatedness of time, space, and movement. Time andspace are the temporal pattern of the patient, and have a complementary relationship.People are constantly changing through time and space, which is movement, whichshows a unique pattern of reality.

According to Newman, nursing is the process of recognizing the patient in relation to theenvironment, and it is the process of the understanding of consciousness. The nursehelps patients understand how to use the power they have within in order to develop ahigher level of consciousness. Therefore, it helps to realize the process of disease, itsrecovery, and its prevention. Nursing is seen as a partnership between the nurse andpatient, and both grow in the sense of higher levels of consciousness.

Florence Nightingale's Contribution to Nursing Theory: Environmental Theory

Florence Nightingale is attributed with establishing the modern practice of nursing. Shealso contributed to the field with nursing theories still used today. One of her nursingtheories is the Environmental Theory, which incorporates the patients' surroundingenvironment in his or her nursing care plan.

In this theory, the role of the nurse is to use the patient's environment to help him or herrecover and get back to the usual environment. The reason the patient's environment isimportant is because it can affect his or her health in a positive or negative way. Someenvironmental factors affecting health according to Nightingale's theory are fresh air,pure water, sufficient food and appropriate nutrition, efficient drainage, cleanliness, andlight or direct sunlight. If any of these factors is lacking, it can delay the patient'srecovery. Nightingale also emphasized providing a quiet, warm environment for patientsto recover in. The theory also calls for nurses to assess a patient's dietary needs,document food intake times, and evaluate how the patient's diet affects his or her healthand recovery.

Determining a patient's environment for recovery based on his or her condition ordisease is still practiced today, such as in patients suffering from tetanus, who needminimal noise to keep them calm and prevent seizures.

Ida Jean Orlando's Contribution to Nursing Theory: Deliberative NursingProcess

Ida Jean Orlando's Deliberative Nursing Process is set in motion by the behavior of thepatient. According to the theory, all patient behavior can be a cry for help, both verbaland non-verbal, and it is up to the nurse to interpret the behavior and determine theneeds of the patient. The Deliberative Nursing Process has five stages: assessment,diagnosis, planning, implementation, and evaluation.

In the assessment stage, the nurse completes a holistic assessment of the patient'sneeds. This is done without taking the reason for the encounter into consideration. Thenurse uses a nursing framework to collect both subjective and objective data about thepatient.

The diagnosis stage uses the nurse's clinical judgment about health problems. Thediagnosis can then be confirmed using links to defining characteristics, related factors,and risk factors found in the patient's assessment. The planning stage addresses each ofthe problems identified in the diagnosis. Each problem is given a specific goal oroutcome, and each goal or outcome is given nursing interventions to help achieve thegoal. By the end of this stage, the nurse will have a nursing care plan.

In the implementation stage, the nurse begins using the nursing care plan. Finally, in theevaluation stage, the nurse looks at the progress of the patient toward the goals set inthe nursing care plan. Changes can be made to the nursing care plan based on how well(or poorly) the patient is progressing toward the goals. If any new problems are identifiedin the evaluation stage, they can be addressed, and the process starts over again forthose specific problems.

The goal of this model is for a nurse to act deliberately rather than automatically. Thisway, a nurse will have a meaning behind the action which means the patient gets caregeared specifically toward his or her needs at that time. This nursing process is also onethat can easily be adapted to different patients with different problems, and can bestopped at anytime, depending on the patient's progress or health. This makes Orlando'stheory universal for the nursing field.

Nursing care has to be flexible. Not only does a nursing care plan depend on the needs ofthe patient at the time of admittance, but it also needs to be able to change when and ifany complications come up during the treatment and recovery process. Ida JeanOrlando's Deliberative Nursing Process directly addresses this need for flexibility, andhelps nurses focus on the patient rather than simply sticking to a nursing care plan nomatter what.

Dorothea E. Orem's Contribution to Nursing Theory: Self-Care Deficit NursingTheory (SCDNT)

The Self-Care Deficit Nursing Theory, also known as the Orem Model of Nursing, wasdeveloped by Dorothea Orem between 1959 and 2001. It is considered a grand nursingtheory, which means the theory covers a broad scope with general concepts that can beapplied to all instances of nursing.

The central philosophy of the Self-Care Deficit Nursing Theory is that all patients want tocare for themselves, and they are able to recover more quickly and holistically byperforming their own self-care as much as they're able. This theory is particularly used inrehabilitation and primary care or other settings in which patients are encouraged to beindependent.

The self-care requisites identified by Dorothea Orem fall into one of three categories. Thefirst is universal self-care requisites, which are needs that all people have. These includethings like air, water, food, activity and rest, and hazard prevention. The second is

developmental self-care requisites, which has two sub-categories: maturational, whichprogress the patient to a higher level of maturation, or situational, which prevent againstharmful effects in development. The third category is health deviation requisites, whichare needs that come up based on the patient's condition. If a patient is unable to meettheir self-care requisites, a "self-care deficit" occurs. In this case, the patient's nursesteps in with a support modality which can be total compensation, partial compensation,or education and support.

One of the benefits of Dorothea Orem's Self-Care Deficit Nursing Theory is that it caneasily be applied to a variety of nursing situations and patients. The generality of itsprinciples and concepts make it easily adaptable to different settings, and nurses andpatients can work together to ensure that the patients receive the best care possible, butare also able to care for themselves. Thanks to Dorothea Orem's dedication to nursing, aswell as her hard work in the field, nurses can use her theory today to care for patientsand make their transition from the hospital or full-time care facility to their own homemuch smoother.

Rosemarie Rizzo Parse's Contribution to Nursing Theory: Human BecomingTheory

Rosemarie Rizzo Parse created the Human Becoming Theory of Nursing, which guidesnurses to focus on quality of life from each person's own perspective as the goal ofnursing. It presents an alternative to most of the other theories of nursing, which take abio-medical or bio-psycho-social-spiritual approach.

It was first published in 1981 as the "Man-living-health" theory, and in 1992 the namewas changed to "the Human Becoming Theory." It was developed as a human sciencenursing theory, and the assumptions underpinning the theory come from the works ofHeidegger, Sartre, and Merleau-Ponty, as well as Martha Rogers, who was a pioneerAmerican nursing theorist.

The Human Becoming Theory is a combination of biological, psychological, sociological,and spiritual factors, and states that a person is a unitary being in continuous interactionwith his or her environment. It is centered around three themes: meaning, rhythmicity,and transcendence.

The theme of meaning says that Human Becoming is choosing personal meaning insituations, and that a person's reality is given meaning through experiences he or shelives in the environment. Rhythmicity explains that Human Becoming is cocreatingrhythmical patterns of relating with the universe, and that a person and the environmentcocreate in rhythmical patterns. Transcendence says that Human Becoming refers toreaching beyond the limits a person sets, and that a person is constantly transforminghim or herself.

In terms of nursing, the Human Becoming Theory explains that a person is more than thesum of the parts, the environment and the person are inseparable, and that nursing is ahuman science and art that uses an abstract body of knowledge to help people. Thetheory allows nurses to create a stronger nurse-patient relationship because the nurse isnot focused on "fixing" problems, but is viewing the patient as a whole person livingexperiences through his or her environment.

The Human Becoming Theory of Nursing is a model that focuses on the quality of life ofthe patient and sees the patient not as different aspects of a whole, but as a person. Thisis different than many other nursing theories, and allows nurses to do what so many ofthem go into the nursing field to help people.

Nola Pender's Contribution to Nursing Theory: Health Promotion Model

Nola Pender developed her Health Promotion model, often abbreviated HPM, after seeingprofessionals intervening only after patients developed acute or chronic health problems.She became convinced that patients' quality of life could be improved by the preventionof problems before this occurred, and health care dollars could be saved by thepromotion of healthy lifestyles. After researching current models and discovering thatmost focused on negative motivation, she developed a model that focused on positivemotivation. The first version of the model appeared in literature in 1982. It was revised in1996 based on changing theoretical perspectives and empirical findings.

The purpose of the model is to assist nurses in understanding the major determinants ofhealth behaviors as a basis for behavioral counseling to promote healthy lifestyles.Pender's theory encourages scholars to look at variables that have been shown to impacthealth behavior. It uses research findings from nursing, psychology, and public healthinto a model of health behavior. The model can be used as a foundation to structurenursing protocols and interventions. In practices, nurses should focus on understandingand addressing the variables most predictive of given health behaviors.

There are five key concepts in the Health Promotion Model: person, environment,nursing, health, and illness.

The person is a biophysical organism shaped by the environment, but also seeks tocreate an environment in which human potential can be fully expressed. Because of this,the relationship between person and environment is reciprocal. Individual characteristicsand life experiences shape behaviors. The environment is described as the social,cultural, and physical context in which life unfolds. It can be manipulated by theindividual to create a positive context of cues and facilitators for health-enhancingbehaviors. The role of nursing is a collaboration among patients, families, andcommunities to create the best conditions for the expression of optimal health and high-level well-being. Health is defined as the actualization of human potential through goal-directed behavior, self-care, and relationships with others with necessary adjustmentsmade to maintain relevant environments. Illnesses are discrete events in the life that canhinder or facilitate the patient's continuing quest for health.

The model is based on the following assumptions:

1. People try to create conditions of living through which they can express theirunique human potential.

2. People have the capacity for reflective self-awareness, including assessment oftheir own competencies.

3. People value positive growth, and strive to find a balance between stability andchange.

4. People seek to actively regulate their own behavior.5. People interact with their environment, transforming it and themselves over time.6. Nurses and other health professionals make up a part of the interpersonal

environment, which exerts influence on people throughout their lifespan.7. Self-initiated reconfiguration of the interactive patterns between people and their

environments is necessary for a change in behavior.8. The model is based on the following theoretical propositions:9. Behavior and characteristics influence beliefs, affect, and enactment of health-

promoting behavior.10. People commit to engaging in behaviors from which they anticipate deriving

personally valued benefits.11. Barriers can constrain commitment to action.12. Competence to execute a given behavior increases the likelihood of commitment

to action and actual performance of the behavior.13. Greater perceived self-efficacy results in fewer barriers to a specific health

behavior.14. Positive affect toward a behavior results in greater perceived self-efficacy.15. When positive emotions are associated with a behavior, the probability of

commitment and action is increased.16. People are more likely to commit to health-promoting behaviors when others

model the behavior, expect it to occur, and provide support to enable it.17. Families, peers, and health care providers are important sources of interpersonal

influence that can increase or decrease commitment to health-promotingbehavior.

18. Situational influences in the external environment can increase or decreasecommitment to or participation in health-promoting behavior.

19. The greater the commitment to a specific plan of action, the more likely health-promoting behaviors are to be maintained over time.

20. Commitment to a plan of action is less likely to result in the desired behaviorwhen competing demands over which persons have little control requireimmediate attention.

21. Commitment to a plan of action is less likely to result in the desired behaviorwhen other actions are more attractive and thus preferred over the targetbehavior.

22. People can modify cognitions, affect, interpersonal influences, and situationalinfluences to create incentives for health-promoting behavior.

Hildegard Peplau's Contribution to Nursing Theory: The Theory of InterpersonalRelations

Peplau's model for nursing, which helped later nursing theorists and clinicians developmore therapeutic interventions, includes seven nursing roles, which show the dynamiccharacter roles typical in clinical nursing.

The Seven Nursing Roles are: the stranger role, in which the nurse receives the patientthe way a stranger is met in other situations, and provides an atmosphere to build trust;

the resource role, in which the nurse answers questions, interprets data, and givesinformation; the teaching role, in which the nurse gives instructions and providestraining; the counseling role, in which the nurse helps the patient understand themeaning of current circumstances, as well as provides guidance and encouragement inorder for change to occur; the surrogate role, in which the nurse acts as an advocate onbehalf of the patient; the active leadership role, in which the nurse helps the patient takeresponsibility for meeting treatment goals; and the technical expert role, in which thenurse provides physical care for the patient and operates equipment.

For those who become nurses to work with people, studying Hildegard Peplau's model ofnursing can be very useful. By better understanding the seven roles of nursing, they canapply different roles in different situations, which will ensure that their patients receivethe best care possible, and will ultimately speed along treatment and recovery.

Isabel Hampton Robb's Contribution to Nursing Theory: Nursing Education

Robb's most notable contribution to nursing was in the field of education. The reformsshe put into place set standards for nursing education, and most of them are stillfollowed today. Specifically, she developed and implemented a grading policy for nursingstudents that required nurses to prove their abilities in order to be awardedqualifications. She was an advocate for reducing the long hours involved in trainingnurses, as well as improving education in nursing schools.

It is thanks to Isabel Hampton Robb that nursing education is what it is today. Because ofthe work Robb did in improving nursing education, patients are able to get better care,and nurses are more prepared to enter their careers after earning their degrees. Herpassion for nursing education changed standards, and her ideas and contributions havewithstood the test of time, despite the rapid advancements that occur in the healthcarefield.

Martha E. Rogers' Contribution to Nursing Theory: Science of Unitary HumanBeings

Patients are considered "unitary human beings," who cannot be divided into parts, buthave to be looked at as a whole. According to Rogers's model, patients have the capacityto participate knowingly in the process of change. The environment is also irreducible,and coexists with unitary human beings. In this model, humans are viewed as integralwith the universe. That is, the patient and his or her environment are one.

Rogers defined health as an expression of the life process. To that end, illness and healthare part of the same continuum, and the events occurring throughout the patient's lifeshow how the patient is achieving his or her health potential.

The basic characteristics that describe the life process of the patient are: energy field,openness, pattern, and pan dimensionality. The energy field is the fundamental unit ofall, both the living and unliving. It provides a way to view the patient and his or herenvironment as wholes, and it continuously changes in intensity, density, and extent.Openness refers to the fact that the human and environmental fields are constantlyexchanging their energies. That is, there are no boundaries that block the flow of energybetween fields. Pattern is the distinguishing characteristic of an energy field that is seenas a single wave. It's an abstraction, and simply serves to give identiy to the field. Pandimensionality is a domain that has no spatial or temporal attributes.

Nursing in the Science of Unitary Human Beings contains two dimensions: the science ofnursing, which is the knowledge specific to the field of nursing that comes from scientificresearch; and the art of nursing, which involves using the science of nursing creatively tohelp better the life of the patient.

In this model, the role of the nurse is to serve people. Rogers also proposes noninvasivemodalities for nursing, such as therapeutic touch, humor, music, meditation and guidedimagery, and even the use of color. The interventions of nurses are meant to coordinatethe rhythm between the human and environmental fields, help the patient in the processof change, and to help patients move toward better health. The practice of nursing,according to Rogers, should be focused on pain management, and supportivepsychotherapy for rehabilitation.

It is often important to look at both the patient as a whole person, and the patient'senvironment when treating the patient for an injury or illness. Martha E. Rogers's Scienceof Unitary Human Beings addresses the importance of the environment as an integralpart of the patient, and uses that knowledge to help nurses blend the science and art ofnursing to ensure patients have a smooth recovery and can get back to the best healthpossible.

Sister Callista Roy's Contribution to Nursing Theory: Adaptation Model ofNursing

Developed by Roy in 1976, the Adaptation Model of Nursing asks three central questions:Who is the focus of nursing care? What is the target of nursing care? and When is nursingcare indicated? This model looks at the patient from a holistic perspective.

The three concepts of her model are the human being, adaptation, and nursing. Underthe concept of adaptation are four modes: physiological, self concept, role function, andinterdependence.

The physiological mode deals with the maintenance of the physical body. This includesbasic human needs such as air, water, food, and temperature regulation. The function ofthe mode of self-concept is the need for the maintenance of the mind. The person'sperceptions of his or her physical and personal self are included in this mode. Socialintegrity is emphasized in the role function mode. This addresses people's adaptations to

different role changes that occur throughout a lifetime. The interdependence mode alsoaddresses social integrity. This mode deals with the balance between independence andinterdependence in a person's relationships with other people.

According to Roy's model, the goal of nursing is to promote adaptation of the patientduring illness and health in all four of the modes. The nurse's actions begin withassessment on two levels. First, the nurse makes a judgment as to the presence orabsence of maladaptation. Second, the nurse focuses on the stimuli influencing thepatient's maladaptive behavior. The nurse then takes actions to promote adaptation bymanipulating the environment, elements of the patient system, or both as part of theirnursing care plan.

Nursing is not rigid. And by applying Roy's Adaptive Model of Nursing to your nursingpractice, you can be sure that the care you give your patients will be the highest qualityyou can provide for that individual patient in his or her individual situation.