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Nursing Theories

Grand Nursing Theories -

Most complex and widest in scope of the levels of theory Attempt to explain broad areas within the discipline Composed of relatively abstract concepts Developed through thoughtful appraisal of existing ideas Provide a background of philosophical reasoning Two paradigms: totality and simultaneity

A. Human Needs Theories (particulate–deterministic): - Humans are viewed a reducible (sum of parts), biopsychosocial-spiritual being that react to their environment in a causal way. - Change is linear, causal and predictable. - Earliest theorists drew from the empirical (positivist) worldview focusing on meeting needs and were developed to distinguish nursing from medicine. 1) Florence Nightingale - Environmental Theory: focus on improved cleanliness, ventilation, warming, light, noise, bedding (environment was the central concept) - Nursing is based on compassion, observation, experience, statistical data, sanitation, nutrition, and administrative skills. - Nursing— an art that serves to “put the constitution in such a state that it will have no disease, or that it can recover from disease.” - Health—“to be well and to be able to use well every power we have” - A nurse may be anyone who had “charge of the personal health of somebody.”

2) Virginia Henderson - Nursing is “patient centered and organized around nursing problems.” - The nurse was the focus and the theory related to the nursing metaparadigm. - Nursing—“to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery . . . that he would perform unaided if he had the necessary strength, will or knowledge . . .” - Health—inferred to be a balance in all realms of human life - Person—“patient” as someone who needs nursing care - Environment—maintaining a supportive environment (14 activities) 3) Dorothea Orem - Self-Care Deficit Theory (three nested theories: Theory of self-care, Theory of self-care deficit and Theory of nursing system) - When therapeutic self-care demand exceeds self-care agency, a self-care deficit exists and nursing is needed. - Nursing—”an art through which the practitioner gives specialized assistance to persons with disabilities to meet needs for self-care” - Health—“being structurally and functionally whole or sound”; also a state that encompasses both the health of individuals and groups - Person—“men, women, and children cared for”; objects of nursing care - Environment—has physical, chemical, and biological features (includes the family, culture, and community) 4) Betty Neuman - The Neuman Systems Model (stress and reaction to stress) - Client is an open system and exchanges between the client/system and environment are reciprocal. - Stressors are stimuli that produce tensions and might cause system instability. - Nursing is provided to achieve optimal stability. - Concept of “prevention as intervention” with multiple lines of resistance - Client variables (physiological, psychological, sociocultural, developmental, and spiritual) are considered in care. - Nursing—Major concern is to maintain client system stability through assessing environmental and other stressors to assist the client in maintaining wellness. - Health—“a continuum; wellness and illness are at opposite ends” - Person—“human beings” as a composite of variables (physiological, psychological, sociocultural, developmental and spiritual) - Environment—“both internal and external forces surrounding the client, influencing and being influenced by the client at any point in time”

B. Interactive Process Theories (integrative, reciprocal): - Interactive theories came after the needs-based theories. - Recognize that reality is multidimensional and contextual - Objectivity and subjectivity are desirable. - Humans are holistic beings that interact reciprocally with their environment. - Theorists frequently stress that humans should be considered in the context of their environment and the theories use a systems approach. 1) Myra Levine - The Conservation Model was developed from Nightingale’s idea of creating an environment to assist healing. - The nurses are seen as part of the environment and uses skill, knowledge, and compassion to assist each client to confront environmental challenges in resolving problems. - Effectiveness of interventions is determined by maintenance of client integrity. o Wholeness (holism)—“wholeness emphasizes a sound, organic, progressive, mutuality between diversified functions and parts within an entirety”; wholeness is integrity o Adaptation—“process of change whereby the individual retains his

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integrity within the realities of his internal and external environment”; conservation is the outcome o Conservation—“the way complex systems are able to continue to function even when severely challenged” Conversation of energy and structural, personal and social integrity for health.

2) Sister Callista Roy - The Roy Adaptation Model - Four adaptive modes: Physiologic–physical mode, Self-concept–group identity mode, Role function mode and Interdependence mode - Goal of nursing is promotion of adaptation in each of the four adaptive modes; this contributes to health, quality of life, and dying with dignity. - The person is an open system that receives input or stimuli from both the environment and the self; Adaptation occurs when the person responds positively to environmental change; this promotes integrity leading to health.

3) Erickson, Tomlin, and Swain - Modeling and Role-Modeling Theory: ability of the individual to mobilize resources when confronted with stressors. - Nursing requires an interpersonal and interactive nurse–client relationship. - Nurses assess (model), plan (role-model), and intervene (five aims of intervention) based on the client’s perspective of the world. - Nursing is the holistic helping of persons with their self-care activities in relation to health; it is an interactive, interpersonal processes to achieve perceived holistic health. 4) Jean Watson - Human Science and Human Caring Theory: describes caring as the essence of nursing and the moral ideal rather than a task-oriented behavior. - Carative factors became clinical caritas processes (meaning to cherish, appreciate, and to give special attention to) - Nursing involves transpersonal human-to-human attempts to protect, enhance, and preserve humanity by helping a person find meaning in illness, suffering, pain, and existence; it involves helping others gain self-knowledge, control, and self-healing wherein a sense of inner harmony is restored. - Goals of nursing: Enhance mental–spiritual growth for self and others, find meaning in one’s own existence and experiences, discover inner power and control and encourage transcendence and self-healing.

C. Unitary Process Theories (unitary, simultaneity): - Views humans as unitary beings that are self-evolving and self-regulating and are in constant and simultaneous interaction w/ a universal energy system. - Humans are known by patterns of energy and distinctions from others. - Change is unidirectional and unpredictable. 1) Martha Rogers - Science of Unitary Humans - The universe is a collection of open systems interacting constantly w/o causality. - Humans are unitary, dynamic energy fields, integral w/ environmental fields. - Human field—irreducible, indivisible energy field identified by pattern and manifesting characteristics that are specific to the whole - Patterns are unique and include behaviors, qualities, and characteristics - Pandimensionality—nonlinear domain without spatial or temporal attributes; infinite domain without limit - Homeodynamics—Changes in the life process in man are inseparable from environmental changes and reflect mutual interaction between the two - Helicy—continuous innovative, unpredictable, increasing diversity of human and environmental patterns (spiral, nonrepetitive) movement - Resonancy—continuous change from lower to higher frequency wave patterns in human and environmental fields - Integrality—continuous mutual human and environmental field interaction process - Nursing is concerned with maintaining and promoting health, preventing illness, and caring for the sick and disabled by helping humans achieve well-being. - Nursing goals: promote symphonic interaction between man and environment, strengthen the coherence and integrity of the human field and direct patterning of the human/environmental fields for realization of maximum health potential

2) Margaret Newman - Health as Expanding Consciousness: those “for whom health as the absence of disease or disability is not possible.” - Asserts that everyone is part of the universal process of expanding consciousness, which includes: o Becoming more of oneself o Finding greater meaning in life o Reaching new dimensions of connectedness with other people/the world -

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Changes occur simultaneously—not in linear fashion. Health is a process of developing awareness of self and the environment. Health includes the ability to perceive alternatives and respond accordingly and can be viewed as manifestations of the pattern(s) of the individual. Fluctuations in patterns that result in sickness can reorganize the relationship of pattern more harmoniously. Illness may provide the disequilibrium needed to maintain vital active exchange with the environment—The result is growth or evolution to create a new sense of balance. Focus of nursing is not on identifying what is wrong and planning to correct the problems; the nurse should partner with the client in pattern identification and coming together in a time of chaos and change.

3) Rosemarie Parse - The Theory of Humanbecoming: sets quality of life from the person’s own perspective as the goal of nursing practice - Theory focuses on freely choosing personal meaning, cocreating rhythmical patterns of relating, and cotranscending multidimensionally - Humans coexist in rhythmical patterns with the environment and are unitary, continuously co-constituting patterns of relating. - Humanbecoming is freely choosing personal meaning in situations in the intersubjective process of living values priorities and cocreating rhythmical patterns of relating in mutual process with the universe. - Nurses guide individuals and families in choosing possibilities in changing the health process (“dwells with the rhythms of the person and family” as they move through the experience). - Nurses illuminate meaning, synchronize rhythms, and mobilize transcendence.

Middle Range Nursing Theories - Between grand and practice theories (fewer concepts/more limited aspect of reality) - Middle range theories are easy to apply in practice and can readily be used for research. -

Ideas are relatively simple, consider a limited number of concepts (health promotion, comfort, etc.), can be tested empirically and focus on client problems and outcomes.

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May be categorized as “high,” “middle,” and “low” middle range theories o High middle range theories include broad, fairly abstract concepts (caring, transcendence, adaptation, culture) o Middle range theories generally consist of theoretically defined, fairly specific constructs (uncertainty in illness, unpleasant symptoms, chronic sorrow) o Low middle range theories are more defined and specific (women’s anger, acute pain management, intervention for postsurgical pain)

A. High Middle Range Theories 1) Pender's Health Promotion Model (Nola Pender) - Explores biopsychosocial processes that motivate individuals to engage in behaviors that promote health - Focus on individual characteristics and experiences, behavior-specific cognitions and affect, and behavior outcomes -

Used by nurses to develop and execute health-promoting interventions

2) Leininger’s Culture Care Theory (Madeleine Leininger) - Purpose of the theory is to generate knowledge related to caring for persons considering their cultural heritage and values and to provide “culturally congruent” nursing care to persons of diverse cultures. - Major concepts of the model are culture, culture care, cultural differences (diversities), and cultural similarities (universals). -

Central tenet of the theory is that it is important for the nurse to understand the individual’s view of illness.

3) Transitions Theory (Afaf Meleis) - Began with observations of experiences faced as people deal with changes related to health, well-being, and ability to care for themselves - Categories of transitions: developmental, situational, health–illness and organizational

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Goal of nursing therapeutics is to recognize and address potential problems encountered during transitional experiences and to develop preventive and therapeutic interventions to support patients during these occasions

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Nurses should consider “facilitators” and “inhibitors” of transitions.

4) Synergy Model - Purpose is to describe nurses’ contributions, activities, and outcomes related to caring for critically ill patients. - Three levels of outcomes: Those derived from the patient, those derived from the nurse, and those derived from the health care system. - Patient outcomes include functional and behavioral change, trust, satisfaction, comfort, and quality of life. -

Nurse outcomes include physiological changes, complications, and attainment of objectives.

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System outcomes include recidivism, costs, and resource utilization.

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When patient characteristics and nurse competencies match and “synergize,” outcomes for the patient are optimal

B. Middle Range Theories 1) Uncertainty in Illness Theory (Merle Mishel) - Intent to explain stress resulting from hospitalization - Theory explains how clients cognitively process illness-related stimuli and construct meaning in these events. -

Uncertainty is the inability to structure meaning and develops if the person does not form a “cognitive schema” for the illness.

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Adaptation is the desirable end state, achieved after coping with the uncertainty

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Nursing should develop interventions to influence the person’s cognitive process to address the uncertainty, thus producing positive coping and adaptation.

2) Comfort Theory (Katherine Kolcaba) - Observes that patients experience need for comfort in stressful health care situations. - Comfort is the “satisfaction of the basic human needs for relief, ease, or transcendence arising from health care situations that are stressful.” -

Increasing comfort can result in having negative tensions reduced and positive tensions engaged.

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Needs of the patient are identified by the nurse, who then implements interventions to meet them.

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Outcomes of comfort can be measurable, holistic, positive, and nurse sensitive.

3) Theory of Unpleasant Symptoms - Based on the premise that there are commonalities in experiencing different symptoms in and among different groups and in different situations. - Developed to integrate existing knowledge about a variety of symptoms to improve symptom management -

Helps nurses recognize the need to assess multiple aspects of symptoms including characteristics of the symptom(s), the disease, or other cause.

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Major components: symptoms that the individual is experiencing, influencing factors that affect the symptom experience and consequence of the symptom

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Symptoms are described in terms of duration, intensity, distress, and quality

C. Low Middle Range Theories 1) Theory of Chronic Sorrow - First coined to describe the grief of parents of children with mental deficiencies. - Chronic sorrow is the “periodic recurrence of permanent, pervasive sadness or other grief related feelings associated with a significant loss.” -

The theory was developed to help analyze individual responses of people experiencing ongoing disparity due to chronic illness, caregiving responsibilities, loss of the “perfect” child, or bereavement.

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The loss is ongoing with no predictable end and disparity is created when the reality is different from the idealized.

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Trigger events (e.g., milestones, situations, and conditions that create negative disparity) exacerbate the experience of disparity.

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Interventions include listening, offering support and reassurance, providing information, and appreciating the uniqueness of each individual.

2) Beck’s Theory of Postpartum Depression (Cheryl Beck)

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Concepts or stages Encountering terror (anxiety attacks, obsessive thinking)

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Dying of self (“unrealness,” isolation, contemplating self-destruction)

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Struggling to survive (prying for relief, seeking solace)

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Regaining control (making transitions, attaining recovery)

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Stages: o Encountering terror (anxiety attacks, obsessive thinking) o Dying of self (“unrealness,” isolation, contemplating self-destruction) o Struggling to survive (prying for relief, seeking solace) o Regaining control (making transitions, attaining recovery)

Borrowed Theories A. Sociological Theories 1) General Systems Theory - Considered to be a “grand” theory because of its universal relevancy - Presumes that there are universal principles of organization which hold for all systems, whether they are physical, chemical, biological, mental, social, etc. - Systems are composed of structural and functional components. -

Living systems are open, and there is an ongoing exchange of matter, energy, and information (input, throughput, output and feedback)

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A system must achieve a balance internally and externally (equilibrium)

2) Feminist Theory - An analysis of women’s subordination (within families and all other institutions) for the purpose of determining how to change it. - Gender differences and subordination have been viewed as natural and inevitable. - A core assumption in feminist theories is that women are oppressed. -

Gender differences are used to legitimize and perpetuate power relationships between men and women.

3) Critical Social Theory (Jürgen Habermas)

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Began in Marx’s argument that oppression requires revolutionary action. Describes “distortions and constraints that impede free, equal, and uncoerced participation in society.” Critical social theory uses societal awareness to expose social inequalities that keep people from reaching their full potential.

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The purpose of critical social theory is to uncover an oppressive situation and motivate victims to free themselves from oppression.

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The dominate group has the power to enforce norms/values on other groups.

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Critical social theory aims to provide an environment in which individuals can become empowered, enlightened, and emancipated.

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Concepts from critical social theory have been used to describe rationale for enhancing care and eliminating disparities

4) Chaos Theory - Unstable, aperiodic behavior in nonrandom, nonlinear, dynamical systems - Focuses on the underlying order in the disorder of natural and social systems and to understand how change occurs in nonlinear, dynamical systems over time. -

Natural and social systems survive because of their nonlinear behavior.

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A strange attractor exerts pull on objects to return them to their starting point.

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Bifurcation—transition from a steady state to a state characterized by an abrupt, significant change in behavior

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Dissipative structures—the capacity of systems in non-equilibrium conditions to change to ...