FOREIGN NURSING THEORISTS

Carative NursingJean Watson

BIOGRAPHY

Theorist was born in West Virginia, US Educated: BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD, University of Colorado, 1973 Distinguished Professor of Nursing and endowed Chair in Caring Science at the University of Colorado Health Sciences Center. Fellow of the American Academy of Nursing. Previously, Dean of Nursing at the University Health Sciences Center and President of the National League for Nursing Undergraduate and graduate degrees in nursing and psychiatric-mental health nursing and PhD in educational psychology and counseling. She has six (6) Honorary Doctoral Degrees. Her research has been in the area of human caring and loss. In 1988, her theory was published in nursing: human science and human care.

The seven assumptions Caring can be effectively demonstrated and practiced only interpersonally. Caring consists of carative factors that result in the satisfaction of certain human needs. Effective caring promotes health and individual or family growth. Caring responses accept person not only as he or she is now but as what he or she may become. A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. Caring is more healthogenic than is curing. A science of caring is complementary to the science of curing. The practice of caring is central to nursing.

The ten primary carative factors1. The formation of a humanistic- altruistic system of values. 2. The installation of faith-hope. 3. The cultivation of sensitivity to ones self and to others. 4. The development of a helping-trust relationship 5. The promotion and acceptance of the expression of positive and negative feelings.

6. The systematic use of the scientific problem-solving method for decision making 7. The promotion of interpersonal teaching-learning. 8. The provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment. 9. Assistance with the gratification of human needs. 10. The allowance for existential-phenomenological forces. The first three carative factors form the philosophical foundation for the science of caring. The remaining seven carative factors spring from the foundation laid by these first three.

1.The formation of a humanistic- altruistic system of values Begins developmentally at an early age with values shared with the parents. Mediated through ones own life experiences, the learning one gains and exposure to the humanities. Is perceived as necessary to the nurses own maturation which then promotes altruistic behavior towards others. 2.Faith-hope Is essential to both the carative and the curative processes. When modern science has nothing further to offer the person, the nurse can continue to use faith-hope to provide a sense of well-being through beliefs which are meaningful to the individual. 3.Cultivation of sensitivity to ones self and to others Explores the need of the nurse to begin to feel an emotion as it presents itself. Development of ones own feeling is needed to interact genuinely and sensitively with others. Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in both the nurse and those with whom the nurse interacts. The nurses promote health and higher level functioning only when they form person to person relationship. 4.Establishing a helping-trust relationship Strongest tool is the mode of communication, which establishes rapport and caring. Characteristics needed to in the helping-trust relationship are: Congruence Empathy Warmth Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding. 5.The expression of feelings, both positive and negative Feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship. Awareness of the feelings helps to understand the behavior it engenders.6.The systematic use of the scientific problem-solving method for decision making The scientific problem- solving method is the only method that allows for control and prediction, and that permits self-correction. The science of caring should not be always neutral and objective.7. Promotion of interpersonal teaching-learning The caring nurse must focus on the learning process as much as the teaching process.

Understanding the persons perception of the situation assist the nurse to prepare a cognitive plan. 8. Provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment Watson divides these into eternal and internal variables, which the nurse manipulates in order to provide support and protection for the persons mental and physical well-being. The external and internal environments are interdependent. Nurse must provide comfort, privacy and safety as a part of this carative factor. 9. Assistance with the gratification of human needs It is based on a hierarchy of need similar to that of the Maslows. Each need is equally important for quality nursing care and the promotion of optimal health. All the needs deserve to be attended to and valued. Watsons ordering of needs Lower order needs (biophysical needs) The need for food and fluid The need for elimination The need for ventilation Lower order needs (psychophysical needs) The need for activity-inactivity The need for sexuality Higher order needs (psychosocial needs) The need for achievement The need for affiliation Higher order need (intrapersonal-interpersonal need) The need for self-actualization 10. Allowance for existential-phenomenological forces Phenomenology is a way of understanding people from the way things appear to them, from their frame of reference. Existential psychology is the study of human existence using phenomenological analysis. This factor helps the nurse to reconcile and mediate the incongruity of viewing the person holistically while at the same time attending to the hierarchical ordering of needs. Thus the nurse assists the person to find the strength or courage to confront life or death.Watsons theory and the four major concepts1. Human being Human being refers to .. a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. He, human is viewed as greater than and different from, the sum of his or her parts.2. Health Watson adds the following three elements to WHO definition of health: A high level of overall physical, mental and social functioning A general adaptive-maintenance level of daily functioning The absence of illness (or the presence of efforts that leads its absence)

3. Environment/society According to Watson, caring (and nursing) has existed in every society. A caring attitude is not transmitted from generation to generation. It is transmitted by the culture of the profession as a unique way of coping with its environment.4. Nursing Nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health. It focuses on health promotion and treatment of disease. She believes that holistic health care is central to the practice of caring in nursing. She defines nursing as..a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions.

Self-Care TheoryDorothea Orem (1914-2007)

BIOGRAPHY

One of foremost nursing theorists. Born 1914 in Baltimore. Earned her diploma at Providence Hospital Washington, DC 1939 BSN Ed., Catholic University of America 1945 MSN Ed., Catholic University of America Involved in nursing practice, nursing service, and nursing education During her professional career, she worked as a staff nurse, private duty nurse, nurse educator and administrator and nurse consultant Received honorary Doctor of Science degree in 1976 Published first formal articulation of her ideas in Nursing: Concepts of Practice in 197, second in 1980, and in 1995.

Development of Theory 1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice. 1959 Orem subsequently served as acting dean of the school of Nursing and as an assistant professor of nursing education at CUA. She continued to develop her concept of nursing and self-care during this time. Orems Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001.Major Assumptions People should be self-reliant and responsible for their own care and others in their family needing care People are distinct individuals

Nursing is a form of action interaction between two or more persons Successfully meeting universal and development self-care requisites is an important component of primary care prevention and ill health A persons knowledge of potential health problems is necessary for promoting self-care behaviors Self-care and dependent care are behaviors learned within a socio-cultural context

Definition of Domain Concept1. Nursing is art, a helping service, and a technology Actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments Encompasses the patients perspective of health condition ,the physicians perspective , and the nursing perspective Goal of nursing to render the patient or members of his family capable of meeting the patients self-care needs To maintain a state of health To regain normal or near normal state of health in the event of disease or injury To stabilize ,control ,or minimize the effects of chronic poor health or disability2. Health health and healthy are terms used to describe living things It is when they are structurally and functionally whole or sound, wholeness or integrity. .includes that which makes a person human, operating in conjunction with physiological and psychophysiological mechanisms and a material structure and in relation to and interacting with other human beings.3. Environment environment components are enthronement factors, enthronement elements, conditions, and developed environment 4. Nursing client - A human being who has "health related /health derived limitations that render him incapable of continuous self-care or dependent care or limitations that result in ineffective / incomplete care. A human being is the focus of nursing only when a self care requisites exceeds self-care capabilities

OREMS GENERAL THEORY OF NURSINGOrems general theory of nursing in three related parts: Theory of self-care Theory of self-care deficit Theory of nursing system

A. Theory of Self CareThis theory Includes: Self-care practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being Self care agency is a human ability which is "the ability for engaging in self-care" -conditioned by age developmental state, life experience sociocultural orientation health and available resources.

Therapeutic self-care demand "totality of self-care actions to be performed for some duration in order to meet self-care requisites by using valid methods and related sets of operations and actions" Self-care requisites-action directed towards provision of self-care. 3 categories of self-care requisites are:1. Universal Developmental Health deviation2. Universal self-care requisites Associated with life processes and the maintenance of the integrity of human structure and functioning Common to all , ADL Identifies these requisites as: Maintenance of sufficient intake of air ,water, food Provision of care associated with elimination process Balance between activity and rest, between solitude and social interaction Prevention of hazards to human life well-being and Promotion of human functioning3. Developmental self-care requisites Associated with developmental processes/ derived from a condition or associated with an event E.g. adjusting to a new job adjusting to body changes Health deviation self-care Required in conditions of illness, injury, or disease .these include:-- Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of pathologic conditions Effectively carrying out medically prescribed measures Modifying self-concepts in accepting oneself as being in a particular state of health and in specific forms of health care Learning to live with effects of pathologic conditionsB. Theory of self-care deficit Specifies when nursing is needed Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited in the provision of continuous effective self-care. Orem identifies 5 methods of helping: Acting for and doing for others Guiding others Supporting another Providing an environment promoting personal development in relation to meet future demands Teaching anotherC. Theory of Nursing Systems Describes how the patients self-care needs will be met by the nurse , the patient, or both Identifies 3 classifications of nursing system to meet the self-care requisites of the patient:- Wholly compensatory system

Partly compensatory system Supportive educative system Design and elements of nursing system define Scope of nursing responsibility in health care situations General and specific roles of nurses and patients Reasons for nurses relationship with patients and The kinds of actions to be performed and the performance patterns and nurses and patients actions in regulating patients self-care agency and in meeting their self-care demand Orem recognized that specialized technologies are usually developed by members of the health profession A technology is systematized information about a process or a method for affecting some desired result through deliberate practical endeavor ,with or without use of materials or instruments

DiagramSelf care deficitNursing system

Self care

Four Conservation PrinciplesMyra Estrine Levine

BIOGRAPHY Born in Chicago Very fond of her father who was often ill and frequently hospitalized with GI problem. This was the reason of choosing nursing as a career Also called as renaissance women-highly principled, remarkable and committed to patients quality of care Died in 1996 Educational Achievement Diploma in nursing:-Cook county SON, Chicago, 1944 BSN:-University of Chicago,1949 MSN:-Wayne state University, Detroit, 1962 Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989 Received honorary doctorate from Loyola University in 1992 Achievements Clinical experience in OT technique and oncology nursing Civilian nurse at the Gardiner general hospital

Director of nursing at Drexel home in Chicago Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska Administrative supervisor at university of Chicago Chairperson of clinical nursing at cook country SON Visiting professor at Tel Aviv university in Israel Conservational model Goal: To promote adaptation and maintain wholeness using the principles of conservation Model guides the nurse to focus on the influences and responses at the organismic level Nurse accomplishes the goal of model through the conservation of energy, structure and personal and social integrity Adaptation Every individual has a unique range of adaptive responses The responses will vary by heredity, age, gender or challenges of illness experiences Example: The response to weakness of cardiac muscle is an increased heart rate, dilation of ventricle and thickening of myocardial muscle While the responses are same, the timing and manifestation of organismic responses will be unique for each individual pulse rate) An ongoing process of change in which patient maintains his integrity within the realities of environment Achieved through the "frugal, economic, contained and controlled use of environmental resources by individual in his or her best interest" Wholeness Exist when the interaction or constant adaptations to the environment permits the assurance of integrity Promoted by use of conservation principle Conservation The product of adaptation "Keeping together "of the life systems or the wholeness of the individual Achieving a balance of energy supply and demand that is with in the unique biological realities of the individual

Nursings paradigm 1. Person A holistic being who constantly strives to preserve wholeness and integrity A unique individual in unity and integrity, feeling, believing, thinking and whole system of system 2. Environment Competes the wholeness of person Internal Homeostasis Homeorrhesis External Preconceptual Operational Conceptual

Internal Environment Homeostasis: A state of energy sparing that also provide the necessary baselines for a multitude of synchronized physiological and psychological factors A state of conservation Homeorrhesis: A stabilized flow rather than a static state Emphasis the fluidity of change within a space-time continuum Describe the pattern of adaptation, which permit the individuals body to sustain its well-being with the vast changes which encroach upon it from the environment External Environment Preconceptual: Aspect of the world that individual are able to intercept Operational: Elements that may physically affects individuals but not perceived by hem: radiation, micro-organism and pollution Conceptual: Part of person's environment including cultural patterns characterized by spiritual existence, ideas, values, beliefs and tradition Person and environment Adaptation Organismic response Conservation Adaptation Characteristics Historicity: Adaptations are grounded in history and await the challenges to which they respond Specificity: Individual responses and their adaptive pattern varies on the base of specific genetic structure Redundancy: Safe and fail options available to the individual to ensure continued adaptation Organismic response A change in behavior of an individual during an attempt to adapt to the environment Help individual to protect and maintain their integrity They co-exist They are four types: 1. Flight or fight: An instantaneous response to real or imagined threat, most primitive response 2. Inflammatory: response intended to provide for structural integrity and the promotion of healing 3. Stress: Response developed over time and influenced by each stressful experience encountered by person 4. Perceptual: Involves gathering information from the environment and converting it in to a meaning experience Nine models of guided assessment Vital signs Body movement and positioning Ministration of personal hygiene needs Pressure gradient system in nursing interventions Nursing determination in provision of nutritional needs Pressure gradient system in nursing Local application of heat and cold Administration of medicine

Establishing an aseptic environmentAssumption The nurse creates an environment in which healing could occur A human being is more than the sum of the part Human being respond in a predictable way Human being are unique in their responses Human being know and appraise objects ,condition and situation Human being sense ,reflects, reason and understand human being action are self-determined even when emotional Human being are capable of prolonging reflection through such strategists raising questions Levines work & Characteristics of theory Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon The concept of illness adaptation, using interventions, and the evaluation of nursing interventions are interrelated .they are combined to look at nursing care in a different way (more comprehensive view incorporating total patient care) form previous time. Theories must be logical in nature. Levines ideas about nursing care are organized in such a way as to b sequential and logical. they can be used to explain the consequences of nursing action Theories should be relatively simple yet generalizable. Levines theory is easy to use. Its major elements are easily comprehensible and the relationship have the potential for being complex but are easily manageable Certain isolated aspect of the theory are the generalizable i.e. those related to the conservational principles Theories can be the bases for hypotheses that can be tested. Levines idea can be tested Hypothesis can be derived from them. The principle of conservation are specific enough to be testable Levines work & Characteristics of theory Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them. Since Levines idea have not yet been widely researched ,it is hard to determine the contribution to the general body of knowledge with in the discipline Theories can be utilized by the practitioner to guide and improve their practice. Paula E.Crawford-gamble-successfully applied Levines theory to the female patient undergoing surgery for the traumatic amputation of the fingers These ideas lend themselves to use in practice particularly in acute care setting Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated. Levines ideas seem to be consistent with other theories, laws and principles particularly those from the humanities and sciencesConservational Principle Conservation of energy Conservation of structural integrity Conservation of personal integrity Conservation of social integrity

1. Conservation of energy Refers to balancing energy input and output to avoid excessive fatigue includes adequate rest, nutrition and exercise Example: Availability of adequate rest Maintenance of adequate nutrition

2. Conservation of structural integrity Refers to maintaining or restoring the structure of body preventing physical breakdown And promoting healingExample: Assist patient in ROM exercise Maintenance of patients personal hygiene 3. Conservation of personal integrity Recognizes the individual as one who strives for recognition, respect, self-awareness, selfhood and self determination Example: Recognize and protect patients space needs

4. Conservation of social integrity An individual is recognized as someone who resides with in a family, a community ,a religious group, an ethnic group, a political system and a nation Example: Position patient in bed to foster social interaction with other patients Avoid sensory deprivation Promote patients use of newspaper, magazines, radio. TV Provide support and assistance to family

3. Health Health is a wholeness and successful adaptation It is not merely healing of an afflicted part ,it is return to daily activities, selfhood and the ability of the individual to pursue once more his or her own interest without constraints Disease: It is unregulated and undisciplined change and must be stopped or death will ensue

4. Nursing "Nursing is a profession as well as an academic discipline, always practiced and studied in concert with all of the disciplines that together from the health sciences" The human interaction relying on communication ,rooted in the organic dependency of the individual human being in his relationships with other human beings Nursing involves engaging in "human interactions"

Diagram

Science of Unitary Human BeingsMartha Roger

BIOGRAPHY Born :May 12, 1914, Dallas, Texas Diploma : Knoxville General Hospital School of Nursing(1936) Graduation in Public Health Nursing : George Peabody College, TN, 1937 MA :Teachers college, Columbia university, New York, 1945 MPH :Johns Hopkins University, Baltimore, MD, 1952 Doctorate in nursing :Johns Hopkins University, Baltimore, 1954 Fellowship: American academy of nursing Position: Professor Emerita, Division of Nursing, New York University, Consultant, Speaker Died : March 13 , 1994Publications of Martha Rogers Theoretical basis of nursing (Rogers 1970) Nursing science and art :a prospective (Rogers 1988) Nursing :science of unitary, irreducible, human beings update (Rogers 1990) Vision of space based nursing (Rogers 1990)Rogers nursing theory Nursing is both a science and art. the uniqueness of nursing, like that of any other science, lies in the phenomenon central to its focus. Nurses long established concern with the people and the world they live is in a natural forerunner of an organized abstract system encompassing people and the environments.

The irreducible nature of individuals is different from the sum of the parts. The integral ness of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm the identity of nursing as a science. The purpose of nurses is to promote health and well-being for all persons wherever they are. Evolution of abstract system The development of the abstract system was strongly influenced by an early grounding in arts and background of science and her keen interest in space The science of unitary human beings originated as a synthesis of facts and ideas from multiple sources of knowledge The uniqueness is in the central phenomena : people and environment The Rogerian view of causality emerges from an infinite universe of open system.Overview of Rogerian model Rogers model provides the way of viewing the unitary human being Humans are viewed as integral with the universe The unitary human being and the environment are one ,not dichotomous Nursing focus on people and the manifestations that emerge from the mutual human /environmental field process Change of pattern and organization of the human field and the environmental field is propagated by waves The manifestations of the field patterning that emerge are observable events The identification of the pattern provide knowledge and understanding of human experience Basic characteristics which describes the life process of human: energy field, openness, pattern, and pan dimensionality Basic concepts include unitary human being, environment, and homeodynamic principles Concepts of Rogers model Energy field The energy field is the fundamental unit of both the living and nonliving This energy field "provide a way to perceive people and environment as irreducible wholes" The energy fields continuously varies in intensity, density, and extent Openness The human field and the environmental field are constantly exchanging their energy There are no boundaries or barrier that inhibit energy flow between fields Pattern Pattern is defined as the distinguishing characteristic of an energy field perceived as a single waves "pattern is an abstraction and it gives identity to the field" Pan dimensionality Pan dimensionality is defined as "nonlinear domain without spatial or temporal attributes" The parameters that human uses in language to describe events are arbitrary. The present is relative; there is no temporal ordering of lives. Homeodynamic principles The principles of homeodynamic postulates the way of perceiving unitary human beings

The fundamental unit of the living system is an energy field Three principle of homeodynamics Resonancy Helicy integralityResonance Resonance is an ordered arrangement of rhythm characterizing both human field and environmental field that undergoes continuous dynamic metamorphosis in the human environmental process

Helicy Helicy describes the unpredictable, but continuous, nonlinear evolution of energy fields as evidenced by non-repeating rhythmic ties The principle of Helicy postulates an ordering of the humans evolutionary emergence Integrality Integrality covers the mutual, continuous relationship of the human energy field and the environmental field. Changes occur by the continuous patterning of the human and environmental fields by resonance waves The fields are one and integrated but unique to each otherNursing Paradigms 1. Unitary Human Being (person) A unitary human being is an "irreducible, indivisible, pan dimensional (four-dimensional) energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from knowledge of the parts" and "a unified whole having its own distinctive characteristics which cannot be perceived by looking at, describing, or summarizing the parts" The people has the capacity to participate knowingly and probabilistically in the process of change 2. Environment The environment is an "irreducible ,pan dimensional energy field identified by pattern and integral with the human field" The fields coexist and are integral. Manifestations emerge from this field and are perceived. 3. Health Rogers defined health as an expression of the life process; they are the "characteristics and behavior emerging out of the mutual, simultaneous interaction of the human and environmental fields" Health and illness are the part of the sane continuum. The multiple events taking place along life's axis denote the extent to which man is achieving his maximum health potential and very in their expressions from greatest health to those conditions which are incompatible with the maintaining life process4. Nursing The concept Nursing encompasses two dimensions Independent science of nursing An organized body of knowledge which is specific to nursing is arrived at by scientific research and logical analysis Art of nursing practice: The creative use of science for the betterment of the human

The creative use of its knowledge is the art of its practice Nursing exists to serve people. it is the direct and overriding responsibility to the society The safe practice of nursing depends on the nature and amount of scientific nursing knowledge the individual brings to practice. the imaginative, intellectual judgment with which such knowledge is made in service to the man kind People need knowledgeable nursing.

Behaviour System ModelDorothy E. Johnson

BIOGRAPHY Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia. B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her M.P.H. from Harvard University in Boston in 1948. From 1949 till retirement in 1978 she was an assistant professor of pediatric nursing, an associate professor of nursing, and a professor of nursing at the University of California in Los Angeles. Johnson stressed the importance of research-based knowledge about the effect of nursing care on clients.

Behavior system model Dorothy first proposed her model of nursing care in 1968 as fostering ofthe efficient and effective behavioral functioning in the patient to prevent illness". She also stated that nursing was concerned with man as an integrated whole and this is the specific knowledge of order we require. In 1980 Johnson published her conceptualization of behavioral system of model for nursingwhere she explains her definitions of the behavioral system model.

Definition of nursing She defined nursing as an external regulatory force which acts to preserve the organization and integration of the patients behaviors at an optimum level under those conditions in which the behaviors constitutes a threat to the physical or social health, or in which illness is found

Four goals of nursing are to assist the patient:1. Whose behavior commensurate with social demands.2. Who is able to modify his behavior in ways that it supports biological imperatives3. Who is able to benefit to the fullest extent during illness from the physicians knowledge and skill.4. Whose behaviordoes not give evidence of unnecessary trauma as a consequence of illnessAssumptionsThere are several layers of assumptions that Johnson makes in the development of conceptualization of the behavioral system model viz. Assumptions about system

Assumptions about structure Assumptions about functions

Assumptions about systemThere are4 assumptions of system:1. First, there is organization, interaction, interdependency and integration of the parts and elements ofbehaviors that go to make up thesystem 2. A system tends to achieve a balance among the various forces operating within and upon it', and that man strive continually to maintain a behavioral system balance and steady state by more or less automatic adjustments and adaptations to the natural forces impinging upon him. 3. A behavioral system, which both requires and results in some degree of regularity and constancy in behavior, is essential to man that is to say, it is functionally significant in that it serves a useful purpose, both in social life and for the individual. 4. Last, system balance reflects adjustments and adaptations that are successful in some way and to some degree.

Assumptions about structure and function of each subsystem from the form the behavior takes and the consequences it achieves can be inferred what drive has been stimulated or what goal is being sought Each individual has a predisposition to act with reference to the goal, in certain ways rather than the other ways. This predisposition is called as set. Each subsystem has a repertoire of choices or scope of action The fourth assumption is that it produce observable outcome that is the individuals behavior.Each subsystem has three functional requirements 1. System must be protected" from noxious influences with which system cannot cope.2. Each subsystem must be nurtured through the input of appropriate supplies from the environment.3. Each subsystem must be stimulated for use to enhance growth and prevent stagnation. These behaviors are orderly, purposeful and predictable and sufficiently stable and recurrent to be amenable to description and explanationJohnsons Behavioral Subsystem Attachment or affiliative subsystem: social inclusion intimacy and the formation and attachment of a strong social bond. Dependency subsystem: approval, attention or recognition and physical assistance Ingestive subsystem: the emphasis is on the meaning and structures of the social eventssurrounding the occasion when the food is eaten Eliminative subsystem: human cultures have defined different socially acceptable behaviors for excretion of waste, but the existence of such a pattern remains different from culture to Culture. Sexual subsystem:" both biological and social factoraffect the behavior in the sexual subsystem Aggressive subsystem: " it relates to the behaviors concerned with protectionand self-preservation Johnson views aggressive subsystem as one that generates defensive response from the individual when life or territory is being threatened

Achievement subsystem: provokes behavior that attempt to control the environment intellectual, physical, creative, mechanical and social skills achievement are some of the areas that Johnson recognizes".

Representation of Johnson's Model

Goal-----Set---Choice of Behavior ---Behavior

Affiliation Dependency Sexuality Aggression Elimination Ingestion Achievement

Adaptation ModelSister Callista Roy

BIOGRAPHY

Sr.Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and teacher Professor and Nurse Theorist at the Boston College of Nursing in Chestnut Hill Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs. Fabien Roy she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in 1963. a master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966. She also earned a masters and PhD in Sociology in 1973 and 1977, respectively. Sr. Callista had the significant opportunity of working with Dorothy E. Johnson Johnson's work with focusing knowledge for the discipline of nursing convinced Sr. Callista of the importance of describing the nature of nursing as a service to society and prompted her to begin developing her model with the goal of nursing being to promote adaptation. She joined the faculty of Mount St. Mary's College in 1966, teaching both pediatric and maternity nursing. She organized course content according to a view of person and family as adaptive systems. She introduced her ideas about Adaptation Nursing as the basis for an integrated nursing curriculum. Goal of nursing to direct nursing education, practice and research Model as a basis of curriculum impetus for growth--Mount St. Marys College 1970-The model was implemented in Mount St. Marys school

1971- She was made chair of the nursing department at the college.

Influencing Factors Family Education Religious Background Mentors Clinical Experience THEORY DESCRIPTION The central questions of Roys theory are: Who is the focus of nursing care? What is the target of nursing care? When is nursing care indicated? Roys first ideas appeared in a graduate paper written at UCLA in 1964. Published these ideas in "Nursing outlook" in 1970 Subsequently different components of her framework crystallized during 1970s, 80s, and 90s Over the years she identified assumptions on which her theory is based. Explicit assumptions (Roy 1989; Roy and Andrews 1991) The person is a bio-psycho-social being. The person is in constant interaction with a changing environment. To cope with a changing world, person uses both innate and acquired mechanisms which are biological, psychological and social in origin. Health and illness are inevitable dimensions of the persons life. To respond positively to environmental changes, the person must adapt. The persons adaptation is a function of the stimulus he is exposed to and his adaptation level The persons adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response. The person has 4 modes of adaptation: physiologic needs, self- concept, role function and inter-dependence. "Nursing accepts the humanistic approach of valuing other persons opinions, and viewpoints" Interpersonal relations are an integral part of nursing There is a dynamic objective for existence with ultimate goal of achieving dignity and integrity. Implicit assumptions A person can be reduced to parts for study and care. Nursing is based on causality. Patients values and opinions are to be considered and respected. A state of adaptation frees an individuals energy to respond to other stimuli. ROY ADAPTATION MODEL CONCEPTS: EARLY AND REVISED Adaptation -- goal of nursing Person -- adaptive system Environment -- stimuli Health -- outcome of adaptation Nursing -- promoting adaptation and health Concepts-Adaptation Responding positively to environmental changes.

The process and outcome of individuals and groups who use conscious awareness, self-reflection and choice to create human and environmental integration

Concepts-Person Bio-psycho-social being in constant interaction with a changing environment Uses innate and acquired mechanisms to adapt An adaptive system described as a whole comprised of parts Functions as a unity for some purpose Includes people as individuals or in groups-families, organizations, communities, and society as a whole.

Concepts-Environment Focal - internal or external and immediately confronting the person Contextual- all stimuli present in the situation that contribute to effect of focal stimulus Residual-a factor whose effects in the current situation are unclear All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources, including focal, contextual and residual stimuli Concepts-Health Inevitable dimension of person's life Represented by a health-illness continuum A state and a process of being and becoming integrated and whole Concepts-Nursing To promote adaptation in the four adaptive modes To promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity by assessing behaviors and factors that influence adaptive abilities and by intervening to enhance environmental interactions Concepts-Subsystems Cognator subsystem A major coping process involving 4 cognitive-emotive channels: perceptual and information processing, learning, judgment and emotion. Regulator subsystem a basic type of adaptive process that responds automatically through neural, chemical, and endocrine coping channels Relationships Derived Four Adaptive Modes 500 Samples of Patient Behavior What was the patient doing? What did the patient look like when needing nursing care? Four Adaptive Modes Physiologic Needs Self-Concept Role Function Interdependence

Diagram

Betty Neuman's System Model

BIOGRAPHY

Betty Neumans system model provides a comprehensive flexible holistic and system based perspective for nursing. It focuses on the response of the client system to actual or potential environmental stressors and the use of primary, secondary and tertiary nursing prevention intervention for retention, attainment, and maintenance of optimal client system wellness.

HISTORY AND BACKGROUND OF THE THEORIST Betty Neuman was born in 1924, in Lowel, Ohio. BS in nursing in 1957 MS in Mental Health Public health consultation, from UCLA in 1966. Ph.D. in clinical psychology A pioneer in the community mental health movement in the late 1960s. Developed the model while working as a lecturer in community health nursing at University of California, Los Angeles. The model was published in 1972 as A Model for Teaching Total Person Approach to Patient Problems in Nursing Research. It was refined and subsequently published in the first edition of Conceptual Models for Nursing Practice, 1974, and in the second edition in 1980.

DEVELOPMENT OF THE MODEL Neumans model was influenced by a variety of sources: The philosophy writers deChardin and Cornu (on wholeness in system).

Von Bertalanfy, and Lazlo on general system theory. Selye on stress theory. Lararus on stress and coping.

BASIC ASSUMPTIONS Each client system is unique, a composite of factors and characteristics within a given range of responses contained within a basic structure. Many known, unknown, and universal stressors exist. Each differ in its potential for disturbing a clients usual stability level or normal LOD (Line of Defence). The particular inter-relationships of client variables at any point in time can affect the degree to which a client is protected by the flexible LOD against possible reaction to stressors. Each client/ client system has evolved a normal range of responses to the environment that is referred to as a normal LOD. The normal LOD can be used as a standard from which to measure health deviation. When the flexible LOD is no longer capable of protecting the client/ client system against an environmental stressor, the stressor breaks through the normal LOD The client whether in a state of wellness or illness, is a dynamic composite of the inter-relationships of the variables. Wellness is on a continuum of available energy to support the system in an optimal state of system stability. Implicit within each client system are internal resistance factors known as LOR, which function to stabilize and realign the client to the usual wellness state. Primary prevention relates to G.K. that is applied in client assessment and intervention, in identification and reduction of possible or actual risk factors. Secondary prevention relates to symptomatology following a reaction to stressor, appropriate ranking of intervention priorities and treatment to reduce their noxious effects. Tertiary prevention relates to adjustive processes taking place as reconstitution begins and maintenance factors move the back in circular manner toward primary prevention. The client as a system is in dynamic, constant energy exchange with the environment.

MAJOR CONCEPTSContent the variables of the person in interaction with the internal and external environment comprise the whole client system Basic structure/Central core The common client survival factors in unique individual characteristics representing basic system energy resources. The basic structure, or central core, is made up of the basic survival factors that are common to the species (Neuman,2002). These factors include:- - Normal temp. range, Genetic structure.- Response pattern. Organ strength or weakness, Ego structure Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being used by the system. A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance. Degree to reaction The amount of system instability resulting from stressor invasion of the normal LOD.

Entropy A process of energy depletion and disorganization moving the system toward illness or possible death. Flexible LOD It is a protective, accordion like mechanism that surrounds and protects the normal LOD from invasion by stressors. Normal LOD It represents what the client has become over time, or the usual state of wellness. It is considered dynamic because it can expand or contract over time. Line of Resistance-LOR The series of concentric circles that surrounds the basic structure. Protection factors activated when stressors have penetrated the normal LOD, causing a reaction symptomatology. E.g. mobilization of WBC and activation of immune system mechanism Input- output The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time. Negentropy A process of energy conservation that increase organization and complexity, moving the system toward stability or a higher degree of wellness. Open system A system in which there is continuous flow of input and process, output and feedback. It is a system of organized complexity where all elements are in interaction. Prevention as intervention Interventions modes for nursing action and determinants for entry of both client and nurse in to health care system. Reconstitution The return and maintenance of system stability, following treatment for stressor reaction, which may result in a higher or lower level of wellness. Stability A state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity. Stressors Environmental factors, intra (emotion, feeling), inter (role expectation), and extra personal (job or finance pressure) in nature, that have potential for disrupting system stability. A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a positive or negative outcome. Wellness/Illness Wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client. Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002). Illness is an excessive expenditure of energy when more energy is used by the system in its state of disorganization than is built and stored; the outcome may be death (Neuman, 2002).

PREVENTION The primary nursing intervention. Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body.Primary Prevention Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primary the flexible LOD) to enable him to better deal with stressors Primary prevention includes health promotion and maintenance of wellness. Secondary Prevention Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing system. Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor. Tertiary Prevention Tertiary prevention occurs after the system has been treated through secondary prevention strategies. Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution. FOUR NURSING PARADIGMS 1. PERSON Human being is a total person as a client system and the person is a layered multidimensional being. Each layer consists of five person variable or subsystems: Physiological - Refers of the physicochemical structure and function of the body. Psychological - Refers to mental processes and emotions. Socio-cultural - Refers to relationships; and social/cultural expectations and activities. Spiritual - Refers to the influence of spiritual beliefs. Developmental - Refers to those processes related to development over the lifespan. 2. ENVIRONMENT The environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time. These forces include the intrapersonal, interpersonal and extra-personal stressors which can affect the persons normal line of defense and so can affect the stability of the system. The internal environment exists within the client system. The external environment exists outside the client system. The created environment is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness. 3. HEALTH Health as being equated with wellness. Health/wellness is defined as the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995). The client system moves toward illness and death when more energy is needed than is available. The client system moved toward wellness when more energy is available than is needed.

4. NURSING Neuman sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor. The person is seen as a whole, and it is the task of nursing to address the whole person. Neuman defines nursing as action which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors. Neuman states that, because the nurses perception will influence the care given, then not only must the patient/clients perception be assessed, but so must those of the caregiver (nurse). The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions

Diagram Person / physiologic needs

Primary CORE

Tertiary Secondary

Betty Neuman's System Model

LOCAL NURSING THEORISTS

Retirement and Role Discontinuities Sister Letty Kuan

BIOGRAPHY Born on November 19, 1936 in Katipunan-Dipolog, Zamboanga del Norte Sister Letty G. Kuan is a nurse with two (2) Masters Degrees, MA in Nursing and MS in Education major in Guidance Counselling. Holds a Doctoral Degree in Education major in Guidance Counselling. All these postgraduatestudies were obtained from the University of the Philippines - Diliman, Quezon City For her vast contributions to the University of the Philippines - College of Nursing faculty and academic achievements, she was awarded the distinctive post of Professor Emeritus, a title awarded only to a few who met the strict criteria set by the University of the Philippines in September 2004. She has clinical fellowship and specialization in Neuropsychology obtained from University of Paris, France in (Salpetriere Hospital). Neurogerontology in Watertown, New York (Good Samaritan Hospital) and Syracuse University, New YorkBasic Assumptions and Concepts: Physiological Age-> is the endurance of cells and tissues to withstand the wear-and-tear phenomenon of the human body. Some individuals are gifted with strong genetic affinity to stay young for a long time. Role-> refers to the set of shared expectations focused upon a particular position. These may include beliefs about what goals or values the position incumbent is to pursue and the norms that will govern his behavior. It is also the set of shared expectations from the retirees socialization experiences and the values internalized while preparing for the position as well as the adaptations to the expectations socially defined for the position itself. For every social role, there is complementary set of roles in the social structure among which interaction constantly occurs. Change of Life-> is the period between near retirement and post retirement years. In medico-physiologic terms, this equates with the climacteric period of adjustment and readjustment to another tempo of life. Retiree-> is an individual who has left the position occupied for the past years of productive life because he/she has reached the prescribed retirement age of has completed the required years of service. Role Discontinuity ->is the interruption in the line of status enjoyed or role performed. The interruption may be brought about by an accident, emergency, and change of position or retirement. Coping Approaches ->refer to the interventions or measures applied to solve a problematic situation or state in order to restore or maintain equilibrium and normal functioning.Determinants of positive perceptions in retirement and positive reactions toward role discontinuities:1. Health Status refer to physiological and mental state of the respondents, classified as either sickly or healthy.2. Income (economic level) refers to the financial affluence of the respondent which can be classified as poor, moderate or rich.3. Work Status4. Family Constellation means the type of family composition described either close knit or extended family where three more generations of family members live under one roof; or distanced family, whose member live in separate dwelling units; or nuclear type of family where only husband, wife and children live together.5. Self-Preparation

CONCEPTUAL MODEL

Strengths The theory can be applied not only for the population undergoing retirement process, but also for the population that is undergoing life transitions. The theory is easy to understand, wherein most people can relate to the effects of role change.Weakness/ Limitations The theory focuses too much on the positive determinants. Retirement adjustment is clearly a multidimensional process but the theory only used a single indicator which is the positive determinants to retirement. Usefulness The theory is useful in geriatric nursing where nurses can derive a plan of care to help the patient to have ease of movement through a transitional process If individuals have a better understanding of the retirement process and their new role, they will prepare and adjust better. (Kelly & Swisher, 1998)

PREPARE ME Interventions & the Quality of Life of Advance Progressive Cancer Patients Carmencita Abaquin

BIOGRAPHY Obtained her Masters Degree in Nursing from the University of the Philippines College of Nursing. An expert in Medical Surgical Nursing with subspecialty in Oncologic Nursing, which made her known both here and abroad She had served the University of the Philippines College of Nursing, as faculty and held the position as Secretary of the College of Nursing. Being appointed as Chairman of the Board of Nursing speaks of her competence and integrity in the field she has chosenBASIC ASSUMPTIONS AND CONCEPTSPREPARE ME (Holistic Nursing Interventions) are the nursing interventions provided to address the multi-dimensional problems of cancer patients that can be given in any setting where patients choose to be confined. This program emphasizes a holistic approach to nursing care. PREPARE ME has the following components:1. Presence being with another person during the times of need. This includes therapeutic communication, active listening, and touch.2. Reminisce Therapy recall of past experiences, feelings and thoughts to facilitate adaptation to present circumstances.3. Prayer4. Relaxation- Breathing techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, and anxiety.5. Meditation encourages an elicit form of relaxation for the purpose of altering patients level of awareness by focusing on an image or thought to facilitate inner sight which helps establish connection and relationship with God. It may be done through the use of music and other relaxation techniques.

6. Values Clarification assisting another individual to clarify his own values about health and illness in order to facilitate effective decision making skills. Through this, the patient develops an open mind that will facilitate acceptance of disease state or may help deepen or enhance values. The process of values clarification helps one become internally consistent by achieving closer between what we do and what we feel.

Origins of the theory the incidence of cancer has significantly increased not only in the Philippines but also worldwide

Meaning of theory1. Terminally-ill patients especially cancer patients require holistic approach of nursing in different aspects of man namely the emotional, psychological, social and spiritual. In this premise, patients with incurable disease require multidimensional nursing care to improve quality of life. 2. PREPARE ME nursing interventions are effective in improving quality of life in terminally-ill patients.3. Utilization of intervention as a basic part of care given to cancer patients, likewise, incorporation in the basic nursing curriculum in the care of these patients. PREPARE ME must be introduced and focus during training of nurse both in academe and practice.4. Development of training programs for care provider as well as health care profession where intervention is a part of treatment modalities.5. The nurse must be honest about the feedback on his/her condition. Nurses must do this so that they would know what the expectations of the patient and the family so that they may render a holistic caring style for the patient together with his family in his dying days. This would help the patient and family address the needs of the patient in any manner possible. (Physical, emotional and spiritual) 6. The nurse must help make a supportive environment for the patient and his family in his dying days. An environment like this would promote dignity in his days left thus helping the patient accept his fate and help him/her be ready for the afterlife. The family is also guided in this rough time addressing their grieving process by instilling in them that death is part of life.

CONCEPTUAL MODELHolistic Nursing InterventionsPrepare MePresenceReminisce TherapyPrayerRelaxation-BreathingMeditationSYMPTOM RELIEFQUALITYOFLIFE

Terminally ill Patients (Cancer)PhysicalPsychologicalSocialReligiousLevel of Independence

Strengths: It provides us standardized and holistic approach in addressing the needs of terminally ill cancer patients. It can also be used for other terminal cases.Weakness/ Limitations: More time is needed to make the patient interested in PREPARE ME interventions because they are already experiencing loss of interest in things "Understaffing in Philippine hospitals is prevalent. (Inamarga, 2009) In the Philippine setting, due to understaffing and financial constrain, time for bed side care is limitedUsefulness 1. This theory is useful in addressing the needs of terminally-ill cancer patients. This encompassed different aspects including family relationship and self-actualization. 2. Appreciating the impact of a relative's cancer and offering guidance and support via patient-centered counseling can enhance quality of care