Annotations on Nursing Theories

1. Florence Nightingale’s Environmental Theory She stated in her nursing notes that nursing “is an act of utilizing the environment of the patient to assist him in his recovery” (Nightingale 1860/1969), that it involves the nurse’s initiative to configure environmental settings appropriate for the gradual restoration of the patient’s health, and that external factors associated with the patient’s surroundings affect life or biologic and physiologic processes, and his development. She defined in her environmental theory are the following factors present in the patient’s environment: pure or fresh air, pure water, sufficient food supplies, sufficient drainage, cleanliness, light (especially direct sunlight).

Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. The factors posed great significance during Nightingale’s time, when health institutions had poor sanitation, and health workers had little education and training and were frequently incompetent and unreliable in attending to the needs of the patients. Also emphasized in her environmental theory is the provision of a quiet or noise-free and warm environment, attending to patient’s dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient.

Nightingale’s theory was shown to be applicable during the Crimean War when she, along with other nurses she had trained, took care of injured soldiers by attending to their immediate needs, when communicable diseases and rapid spread of infections were rampant in this early period in the development of disease-capable medicines. The practice of environment configuration according to patient’s health or disease condition is still applied today, in such cases as patients infected with Clostridium tetani (suffering from tetanus), who need minimal noise to calm them and a quiet environment to prevent seizure-causing stimulus.

2. Dorothy Johnson Behavioral System Model

Johnson was an early proponent of nursing as a science as well as an art. She also believed nursing had a body of knowledge reflecting both the science and the art. From the beginning, Johnson (1959) proposed that the knowledge of the science of nursing necessary for effective nursing care included a synthesis of key concepts drawn from basic and applied sciences. In 1961, Johnson proposed that nursing care facilitated the client’s maintenance of a state of equilibrium. Johnson proposed that clients were “stressed” by a stimulus of either an internal or external nature. These stressful stimuli created such disturbances, or “tensions,” in the patient that a state of disequilibrium occurred.

Johnson identified two areas that nursing care should be based in order to return the client to a state of equilibrium. First, by reducing stressful stimuli, and second, by supporting natural and adaptive processes. Johnson’s behavioral system theory springs from Nightingales belief that nursing’s goal is to help individuals prevent or recover from disease or injury. The “science and art” of nursing should focus on the patient as an individual and not on the specific disease entity. Johnson used the work of behavioral scientists in psychology, sociology, and ethnology to develop her theory.

The model is patterned after a systems model; a system is defined as consisting of interrelated parts functioning together to form a whole. Johnson states that a nurses should use the behavioral system as their knowledge base; comparable to the biological system that physicians use as their base of knowledge (Lobo, 1995). The reason Johnson chose the behavioral system model is the idea that “all the patterned, repetitive, purposeful ways of behaving that characterize each person’s life make up an organized and integrated whole, or a system” (other). Johnson states that by categorizing behaviors, they can be predicted and ordered. Johnson categorized all human behavior into seven subsystems (SSs): Attachment, Achievement, Aggressive, Dependence, Sexual, Ingestive, and Eliminative.

Each subsystem is composed of a set of behavioral responses or tendencies that share a common goal. These responses are developed through experience and learning and are determined by numerous physical, biological, psychological, and social factors. Four assumptions are made about the structure and function of each SS. These four assumptions are the “structural elements” common to each of the seven SSs. The first assumption is “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”. The ultimate goal for each subsystem is expected to be the same for all individuals.

The second assumption is that each individual has a “predisposition to act, with reference to the goal, in certain ways rather than in other ways” (Johnson, 1980). This predisposition to act is labeled “set” by Johnson. The third assumption is that each subsystem has available a repertoire of choices or “scope of action” alternatives from which choices can be made. As life experiences occur, individuals add to the number of alternative actions available to them. At some point, however, the acquisition of new alternatives of behavior decreases as the individual becomes comfortable with the available repertoire.

The fourth assumption about the behavioral subsystem is that they produce observable outcomes-that is, the individual’s behavior. The observable behaviors allow an outsider to note the actions the individual is taking to reach a goal related to a specified SS. In addition, each of the SSs has three functional requirements. First, each subsystem must be “protected from noxious influences with which the system cannot cope”. Second, each subsystem must be “nurtured through the input of appropriate supplies from the environment.” Finally each subsystem must be “stimulated for use to enhance growth and prevent stagnation.”

As long as the SSs are meeting these functional requirements, the system and the SSs are viewed as self-maintaining and self- perpetuating. The internal and external environments of the system need to remain orderly and predictable for the system to maintain homeostasis. The interrelationships of the structural elements of the subsystem to maintain a balance that is adaptive to that individual’s needs. Johnson’s Behavioral Subsystems The Attachment subsystem is probably the most critical, because it forms the basis for all social organization. It provides survival and security. Its consequences are social inclusion, intimacy, and formation and maintenance of a strong social bond. The Achievement subsystem attempts to manipulate the environment.

Its function is control or mastery of an aspect of self or environment to some standard of excellence. Areas of achievement behavior include intellectual, physical, creative, mechanical, and social skills. The Aggressive subsystem function is protection and preservation. It holds that aggressive behavior is not only learned, but has a primary intent to harm others. However, society has placed limits when dealing with self-protection and that people and their property be respected and protected. The Dependency subsystem promotes helping behavior that calls for a nurturing response. Its consequences are approval, attention or recognition, and physical assistance.

Ultimately, dependency behavior develops from the complete reliance on others for certain resources essential for survival. An imbalance in a behavioral subsystem produces tension, which results in disequilibrium. The Ingestive and Eliminative SSs “have to do with when, how, what, how much and under what conditions we eat, and when, how, and under what conditions we eliminate”. The Sexual subsystem has the dual functions of procreation and gratification. It begins with the development of gender role identity and includes the broad range of sex role behaviors. When there is an alteration in the “equilibrium” that exists, Johnson’s Model tends to diagnose to a subsystem rather than a specific problem.

Johnson’s Model states that it is at this point when the nurse is needed in order to return the client to homeostasis. The application of any nursing model to practice requires three conditions: the model’s congruence with practice requirements, its comprehensive development in relation to practice requirements, and its specificity in relation to practice requirements. These conditions governing a nursing model’s applicability should be understood to enable practitioners to appropriately and effectively use models in practice. What is nursing practice and what are requirements of the practice? Nursing practice derives its definition from that of professional practice, the action or process of performing something, the habitual or customary performance of something. Professional practice has three main requirements: perspective, structure and scientific substance.

The first requirement is the perspective, or a mental view, of facts or ideas and their interrelationships pertinent of the professions’ practice. In nursing, the perspective of the practice refers to nursing’s view of the patient and its role in relation to the patient. More specifically, the profession’s perspective clarifies the nature, goal, focus, and scope of its realm of its science and practice. By so doing, the profession’s perspective distinguishes nursing’s realm of science and practice from those of related fields. At the same time, the perspective identifies appropriate alignments between nursing’s research and practice and those of other professions. In other words, the professional perspective provides the professional with a knowledge base and a mind-set about the patient, about her/his role in relation to the patient, and her/his actions necessary to fulfill that role.

The second requirement of professional practice is a structure for practice to organize and standardize practice and, thus, render practice habitual and customary. Professional practice is structured to evaluate a client’s well-being, identify problems, and provide solutions. The latter require organized and scientifically rational processes of assessment, diagnosis, intervention, and evaluation of outcomes. In nursing, this structure pertains to the Nursing Process. Finally, the third requirement of professional practice is the coherent scientific body of knowledge that underlies it or the profession’s actions and processes.

The scientific body of knowledge includes facts, theories, hypotheses, and precepts, and assumptions underlying both the perspective and structure of practice. In nursing, this body of knowledge includes the facts, theories, hypotheses, and precepts about nursing, nursing practice actions, and nursing practice methods. Stated more specifically, nursing practice requires a body of scientific knowledge that rationalizes its view of the client, its role, nature, goal focus, and scope. Furthermore, nursing practice requires a body of scientific knowledge that rationalizes the nursing methods of assessment, diagnosis, intervention, and evaluation of outcomes. The JBS model meets the professional perspective requirements because of its interaction between the SSs. The SSs are interactive and interdependent, restoration in one subsystem could effect restoration of behavior in another or others.

Thus requiring diagnostic and interventive action directed at all the SSs. The model as it stood before did not meet the practice structure requirements well, but interaction and studies into the model prompted Johnson to add five types of interventions-nurturance, stimulation, protection, regulation, and control. It still leaves a gap in where to actually look for the problems that exist. The JBS model does not meet the scientific substance for practice well because it needs to be tested on its concepts, propositions, and assumptions. Despite the obvious overall failure of the JBS model to pass the professional requirements, the model is always being tested by someone, and someday maybe conclude its worth and add to its value.

3. Madeleine Leininger’s Transcultural Nursing Theory Care is the essence of nursing and a distinct, dominant, and unifying focus. Care (caring) is essential for well being, health, healing, growth survival, and to face handicaps or death. Culture care is the broadest holistic means to know, explain, interpret, and predict nursing care phenomena to guide nursing care practices. Nursing is a transcultural, humanistic and scientific care discipline and profession with the central purpose to serve human beings worldwide.

Care (caring) is essential to curing and healing, for there can be no curing without caring. Culture care concepts, meanings, expressions, patterns, processes, and structural forms of care are different (diversity) and similar (towards commonalities or universalities) among all cultures of the world. Every human culture has lay (generic, folk, or indigenous) care knowledge and practices and usually some professional care knowledge and practices which vary transculturally. Cultural care values, beliefs, and practices are influenced by and tend to be embedded in worldview, language, religious (or spiritual), kinship (social), political (or legal), educational, economic, technological, ethnohistorical, and environmental context of a particular culture. Beneficial, healthy, and satisfying culturally based nursing care contributes to the well being of individuals, families, groups, and communities within their environmental context.

Culturally congruent or beneficial nursing care can only occur when the individual, group, community, or culture care values, expressions, or patterns are known and used appropriately and in meaningful ways by the nurse with the people. Culture care differences and similarities between professional caregiver(s) and client (generic) care-receiver(s) exist in any human culture worldwide. Clients who experience nursing care that fails to be reasonably congruent with their beliefs, values, and caring lifeways will show signs of cultural conflicts, noncompliance, stresses and ethical or moral concerns.

The qualitative paradigm provides new ways of knowing and different ways to discover the epistemic and ontological dimensions of human care transculturally. The theory of culture care diversity and universality. “Leininger defined nursing as a learned scientific and humanistic profession and discipline focused on human care phenomena and caring activities in order to assist, support, facilitate or enable individuals or groups to maintain or regain their health or well-being in culturally meaningful and beneficial ways, or to help individuals face handicaps or death.” Transcultural nursing: Concepts, theories, research & practice.

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