Components of a theory

Theories provide a foundation of knowledge for the direction and delivery of nursing care. For example, in Betty Neuman’s systems model (Neuman and Young, 1972), the goal of nursing is to assist individuals, families and groups to attain and maintain maximum levels of total wellness by purposeful interventions. The Neuman systems model focuses on nursing care for the client as a whole, encompassing all aspects of the client’s life.

Types of theories

The general purpose of a theory is important because it specifies the context and situation in which the theory applies (Chinn and Kramer, 1995). Theories have different purposes and may be classified by levels of abstraction (grand theories versus mid-range theories) or the goals of the theory (descriptive or prescriptive). Theories may describe, predict or prescribe activities for the phenomena of interest.

In Australia and the United Kingdom it is now well accepted that theories are developed at various levels of formality. Pearson and others (2005a) describe personal, local, grand and epistemological theories and meta-theory. Personal theory is unique to the individual and is shaped by the experiences, assumptions and explanations of that individual. Local theory applies to a particular setting or group, such as a hospital ward, primary school or community health centre. Grand theories, which are discussed in more depth in the next section, are concerned with explaining particular phenomena within an activity or field of study. Epistemological theory is concerned with how we know or perceive and investigate the world and what we believe to be legitimate sources of knowledge. Finally, meta-theory defines and classifies theory. Thus, theory surrounds human activity and guides us in our decision making and judgment.

Components of nursing models

Within any scientific discipline there are specific components of the domain. A domain is the perspective and territory of the discipline and contains the subject, central concepts, values and beliefs, phenomena of interest and the central problems of the discipline. Components of a discipline’s domain are described in a paradigm. A paradigm is a term used to denote the links to science, philosophy and theory accepted by a discipline (Pearson and others, 2005a).

Nursing’s paradigm directs the activity of the nursing profession, including knowledge, philosophy, theory, educational experience, practice orientation, research methodology and literature identified with the profession (Marriner-Tomey and Alligood, 1998; Meleis, 2007). Nursing identified its domain in a paradigm that includes four links of interest: the person, health, environment/situation and nursing.

Person refers to the recipient of care, including individual clients, families and the community. The person is central to the care being provided. Because the person’s needs are multidimensional, it is important that nursing provides care individualised to the client’s needs.

Health is defined in different ways by the client, the clinical setting and the healthcare profession, and is the goal of nursing care. The World Health Organization (1987) in the Ottawa Charter defines health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. This definition has been questioned and modified by different organisations and groups, as it is felt to be too idealistic and its breadth may suggest that few people are seen as healthy. Most national nursing organisations see health as a dynamic and continuously changing state that relates to feelings of wellbeing within a given setting. The nurse is challenged to provide care based on the client’s individualised level of health and healthcare needs at the time of care delivery.

Environment/situation includes all possible conditions affecting the client and the setting in which healthcare needs occur. For example, a client’s level of health and healthcare needs can be influenced by factors in the home, school, workplace or community settings. An adolescent girl with type 1 diabetes mellitus may need to adapt her care regimen to physical activities of school, to the demands of a part-time job and to the timing of social events. There is continuous interaction between the client and the environment. This interaction can have positive and negative effects on the person’s level of health and healthcare needs.

Nursing is the diagnoses and treatment of human responses to actual or potential health problems (Gordon, 2007). For example, a nurse does not diagnose the client’s heart condition, but instead develops nursing diagnoses of fatigue, change in body image and altered coping. From these nursing diagnoses, the nurse creates an individualised plan of care. Nurses use critical thinking skills and integrate knowledge, experience, attitudes and standards into the individualised plan of care for each client.

Systems theory

A system is made up of separate components. The parts rely on one another, are interrelated, share a common purpose and together form a whole. The system has a specific purpose or goal and uses a process to achieve that goal. The content is the product and information obtained from the system.

Input is the information that enters the system. Output is the end-product of a system. Feedback is the process through which the output is returned to the system. Systems can be either open or closed. An open system interacts with its environment. There is an exchange of information between the system and the environment. Factors that change the environment can also have an impact on the system. A closed system is one that does not interact with the environment. An example of a closed system is a chemical reaction occurring in an isolated apparatus.

One example of a system is the nursing process (Figure 3-1). The purpose of the nursing process is to provide systematic and individualised client care. The nursing process is an open system because it interacts with its environment, continually changing as the client’s nursing needs change. Input to the system comes from the client’s assessment data (e.g. how the client interacts with the environment, thus creating healthcare needs) and from the nurse. The output, i.e. the client’s response to nursing interventions (e.g. client’s status for returning to the environment), is returned as feedback to the nursing process system and the client successfully or unsuccessfully functions in the environment.

FIGURE 3-1 The nursing process as a system.

Nursing theories may have a systems model as the theoretical base; for example, Betty Neuman (1972, 1995) defines a total-person model of holism and an open-system approach. As an open system the person interacts with the environment. The environment is both external and internal and the person interacts with stressors from the environment, which affect the system.

Basic human needs

Maslow’s (1970) hierarchy of needs is an interdisciplinary theory useful for designating priorities of care. The hierarchy of human needs arranges the basic needs in five levels of priority (Figure 3-2). The most basic, or first, level includes physiological needs such as air, water and food. The second level includes safety and security needs, which involve physical and psychological security. The third level contains love and belonging needs, including friendship, social relationships and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement and self-worth. The final level is the need for self-actualisation, the state of fully achieving potential and having the ability to solve problems and cope realistically with life’s situations. Basic physiological and safety needs are usually first priority; however, the nurse may encounter situations in which there are no emergent physical or safety needs but in which high priority must be given to the psychological, sociocultural, developmental or spiritual needs of the client.

FIGURE 3-2 Maslow’s hierarchy of needs.

Redrawn from Maslow AH 1970 Motivation and personality, ed 2. New York, Harper & Row. Reproduced with permission of John Wiley & Sons.

Clients entering the healthcare system generally have unmet needs. For example, a person brought to an emergency room experiencing acute pneumonia has an unmet need for oxygen, the most basic physiological need. An older woman in a high-crime area may be concerned about physical safety and, while hospitalised, may have a need for psychological security because of fear that her home will be burgled. A widowed homemaker whose children have moved away may feel that she does not belong or is not loved. Nurses in all practice settings strive to help clients and their families meet these needs.

The hierarchy of needs is a useful way for nurses to plan individualised care for a client. One need may take priority over another (such as restoration of an adequate airway before the nurse educates the client in adjusting to an emotional conflict). The nurse uses priorities to determine nursing diagnoses, develop goals and expected outcomes and select nursing interventions.

Health and wellness models

Health and wellness models are designed to help healthcare professionals understand the relationships between these two concepts and the client’s attitudes towards health and health practices. Knowledge of these models assists nurses in understanding and predicting the client’s health behaviours, including use of healthcare services and adherence to recommended therapies.

Stress and adaptation

Stress and adaptation are universal and dynamic. Everyone experiences stress and attempts to adapt to the stressors. Stressors and stress responses are physiological and behavioural. As a result, the models that explain the stress response are usually bio-behavioural and provide the framework for care of clients experiencing stress. Chapter 42 explains the more prominent theories and demonstrates how these models are used in nursing practice.

Developmental theories

Human growth and development is an orderly predictive process that begins with conception and continues until death. There are a variety of well-tested theoretical models that describe and predict behaviour and development at various phases of the life continuum. Chapter 19 details these theories and Chapters 20–22 Chapter 21 Chapter 22 demonstrate changes in growth and development in various age groups.

Psychosocial theories

Nursing is an eclectic discipline that strives to meet the holistic needs of clients in their physiological, psychological, sociocultural, developmental and spiritual domains. There are theoretical models that explain and/or predict client responses in each of these domains. For example, Chapter 17 discusses models for understanding diversity and implementing care to meet the diverse needs of clients. Chapter 18 describes family theory and how to meet the needs of the family when the family is the client or when the family is the caregiver. Chapter 25 discusses several models of grieving and demonstrates how to help clients through loss, death and grief.

Nightingale

Contemporary authors are returning to the work of Florence Nightingale as a potential theoretical and conceptual model for nursing (Marriner-Tomey and Alligood, 1998; Meleis, 2007). Meleis (2007) suggests that Nightingale’s concept of the environment as the focus of nursing care and her warning that nurses need not know all about the disease process are early attempts to differentiate between nursing and medicine.

Nightingale did not view nursing as limited merely to the administration of medications and treatments, but rather as oriented towards providing fresh air, light, warmth, cleanliness, quiet and adequate nutrition (Nightingale, 1860; Torres, 1986). Through observation and data collection, she linked the client’s health status with environmental factors and initiated improved hygiene and sanitary conditions during the Crimean War.

Torres (1986) notes that Nightingale provided basic concepts and propositions that could be supported and used for practice in nursing. Nightingale’s descriptive theory provides nurses with a way to think about nursing with a frame of reference that focuses on clients and the environment (Torres, 1986). Nightingale’s letters and writings direct the nurse to act on behalf of the client. Her principles were visionary and encompass the areas of practice, research and education. Most importantly, her concepts and principles shaped and delineated nursing practice (Marriner-Tomey and Alligood, 1998). Nightingale taught and used the nursing process, noting that ‘vital observation [assessment] … is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort’.

Peplau’s theory

Hildegard Peplau’s theory (1952) focuses on the individual, nurse and interactive process; the result is the nurse–client relationship (Torres, 1986; Yamashita, 1997). According to this theory, the client is an individual with a felt need, and nursing is an interpersonal and therapeutic process. Nursing’s goal is to educate the client and family and to help the client reach mature personality development (Chinn and Kramer, 1995). The nurse strives to develop a nurse–client relationship in which the nurse serves as a resource person, counsellor and surrogate.

For example, when the client seeks help, the nurse and client first discuss the nature of the problem and the nurse explains the services available. As the nurse–client relationship develops, the nurse and client mutually define the problem and find potential solutions. The client gains from this relationship by using available services to meet needs, and the nurse assists the client in reducing anxiety related to the healthcare problem. Peplau’s theory is unique in that the collaborative nurse–client relationship creates a ‘maturing force’ through which interpersonal effectiveness assists in meeting the client’s needs (Beeber and others, 1990). When the original needs have been resolved, new needs may emerge. The nurse–client interpersonal relationship is characterised by the following overlapping phases: orientation, identification, explanation, and resolution (Chinn and Kramer, 1995).

Peplau’s theory and ideas were developed to provide a design for the practice of psychiatric nursing. Nursing research on anxiety, empathy, behavioural tools and tools to evaluate verbal responses resulted from Peplau’s conceptual model (Marriner-Tomey and Alligood, 1998).

Henderson’s theory

Henderson (1966) defines nursing as assisting the individual, sick or well, in the performance of those activities that contribute to health recovery or peaceful death that the individual would perform unaided if he or she had the necessary strength, will or knowledge. The process of nursing strives to do this as rapidly as possible, and the goal is independence.

Henderson organised the theory into 14 basic needs of the whole person and included phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual and developmental. Together the nurse and client work in unison to meet these needs and attain client-centred goals.

Abdellah’s theory

The nursing theory developed by Faye Abdellah and others (1960) emphasises delivering nursing care for the whole person to meet the physical, emotional, intellectual, social and spiritual needs of the client and family. When using this approach, the nurse needs knowledge and skills in interpersonal relations, psychology, growth and development, communication and sociology, as well as knowledge of the basic sciences and specific nursing skills. The nurse is a problem solver and decision maker. The nurse formulates an individualised view of the client’s needs that may arise in the following four areas:

From these four areas, Abdellah and others (1960) identified 21 specific client needs, which are often referred to as Abdellah’s 21 nursing problems.

Levine’s theory

Myra Levine’s (1973) nursing theory views the client as an integrated being who interacts with and adapts to the environment. Levine believes that nursing intervention is a conservation activity, with conservation of energy as a primary concern (Fawcett, 1992). Health is viewed in terms of the conservation of energy. Levine refers to four conservation principles of nursing as:

With this approach, nursing care involves conservation activities aimed at the best use of the client’s resources.

Johnson’s theory

Dorothy Johnson’s (1968, 1980) theory of nursing focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing is to reduce stress so that the client can move more easily through recovery. Johnson describes basic needs in terms of the following categories of behaviour:

According to Johnson, the nurse assesses the client’s needs in these categories of behaviour, called behavioural subsystems. Under normal conditions the client functions effectively in the environment. When stress disrupts normal adaptation, however, behaviour becomes erratic and less purposeful. The nurse identifies this inability to adapt and provides nursing care to resolve problems in meeting the client’s needs.

Rogers’ theory

In her theory, Martha Rogers (1970) considers the individual (unitary human being) as an energy field co-existing within the universe. The individual is in continuous interaction with the environment and is a unified whole, possessing personal integrity and manifesting characteristics that are more than the sum of the parts (Lutjens, 1995; Rogers, 1970). A unitary human being is a ‘four-dimensional energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from the knowledge of parts’ (Marriner-Tomey and Alligood, 1998). The four dimensions used in Rogers’ theory—energy fields, openness, pattern and organisation, and dimensionality—are used to derive principles related to human development.

Rogers views nursing primarily as a science and is committed to nursing research and theory development. Nursing therefore incorporates knowledge of the basic sciences and physiology, as well as nursing knowledge.

Orem’s theory

Dorothea Orem (1971) developed a definition of nursing that emphasises the client’s self-care needs. Orem defines self-care as a learned goal-oriented activity directed towards the self in the interest of maintaining life, health, development and wellbeing (Orem, 1991). Orem describes her philosophy of nursing in this way:

Thus the goal of Orem’s theory is helping the client perform self-care. According to Orem, nursing care is necessary when the client is unable to fulfil biological, psychological, developmental or social needs. The nurse determines why a client is unable to meet these needs, what must be done to enable the client to meet them and how much self-care the client is able to perform. The goal of nursing is to increase the client’s ability to independently meet these needs (Hartweg and Orem, 1995).

King’s theory

Imogene King’s goal attainment theory (1971, 1981, 1987) focuses on three dynamic interacting systems: personal, interpersonal and social (King, 1997). A personal relationship forms between client and nurse. The nurse–client relationship is the vehicle for the delivery of nursing care, which is a dynamic interpersonal process in which the nurse and client are affected by each other’s behaviour as well as by the healthcare system (King, 1971, 1981). The nurse’s goal is to use communication to assist the client in re-establishing or maintaining a positive adaptation to the environment.

Neuman’s theory

Betty Neuman’s theory (Neuman, 1995) defines a total-person model for nursing incorporating a holistic concept and an open-systems approach (Marriner-Tomey and Alligood, 1998). To Neuman, the person is a dynamic composite of physiological, sociocultural, developmental, psychological and spiritual components that function as an open system. As an open system, the person interacts with, adjusts to and is adjusted by the environment, which is viewed as a stressor (Chinn and Kramer, 1995). The internal environment consists of influences within the client (intrapersonal). The external environment is influences outside the client (interpersonal). The created environment is the client’s attempt to create a safe setting, which may be made up of conscious or unconscious mechanisms (Reed, 1995). Each environment provides potential threats from stressors, which disrupt the system. Neuman’s model includes intrapersonal, interpersonal and extrapersonal stressors (Marriner-Tomey and Alligood, 1998; Neuman, 1995).

Neuman believes that nursing is concerned with the whole person. The goal of nursing is to assist individuals, families and groups in attaining and maintaining a maximum level of total wellness (Neuman and Young, 1972). The nurse assesses, manages and evaluates client systems. Nursing focuses on the variables affecting the client’s response to the stressor (Chinn and Kramer, 1995). Nursing actions are in the primary, secondary and tertiary levels of prevention. Primary prevention focuses on strengthening a line of defence by identifying actual or potential risk factors associated with stressors. Secondary prevention strengthens internal defences and resources by establishing priorities and treatment plans for identified symptoms, and tertiary prevention focuses on readaptation. The main goals in tertiary prevention are to strengthen resistance to stressors through client education and help prevent a recurrence of the stress response (Marriner-Tomey and Alligood, 1998).

Roy’s theory

Sister Callista Roy’s adaptation theory (Roy, 1980, 1984, 1989; Roy and Obloy, 1979) views the client as an adaptive system. According to Roy’s model, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness (Marriner-Tomey and Alligood, 1998). The need for nursing care arises when the client cannot adapt to internal and external environmental demands. All individuals must adapt to the following demands:

The nurse determines which demands are causing problems for a client and assesses how well the client is adapting to them. Nursing care is then directed at helping the client adapt. For example, a client who has a significant postoperative blood loss and now has a low haemoglobin count needs nursing interventions designed to help the client adapt to the associated fatigue. The nurse may design interventions to allow sufficient rest.

Watson’s theory

Watson’s philosophy of transpersonal caring (1979, 1985, 1988) defines the outcome of nursing activity regarding the humanistic aspects of life (Marriner-Tomey and Alligood, 1998; Watson, 1979). The action of nursing is directed at understanding the interrelationship of health, illness and human behaviour. Nursing is concerned with promoting and restoring health and preventing illness.

Watson’s model is designed around the caring process, assisting clients to attain or maintain health or to die peacefully. This caring process requires the nurse to be knowledgeable about human behaviour and human responses to actual or potential health problems, individual needs, how to respond to others and strengths and limitations of the client and family, as well as those of the nurse. In addition, the nurse comforts and offers compassion and empathy to clients and their families. Caring represents all of the factors the nurse uses to deliver healthcare to the client (Watson, 1987) (see Research highlight).

Benner and Wrubel’s theory

The primacy of caring is a model proposed by Benner and Wrubel (1989). In this model, caring is central. Caring creates the possibilities for coping, enables possibilities for connecting with and concern for others and allows for the giving and receiving of help (Chinn and Kramer, 1995).

As defined in this theory, caring means that persons, events, projects and things matter to people. Caring itself presents a connection. Caring represents a wide range of involvement, e.g. caring about one’s family, caring about one’s friendships and caring about one’s clients. Benner sees the personal concern as an inherent feature of nursing practice. In caring for one’s clients, nurses help clients recover, noticing those interventions that are successful and can therefore guide future caregiving.

Parse’s theory

The theory of human becoming (Parse, 1987, 1989, 1995) states that clients are open, mutual and in constant interaction with the environment. Health is a process of the individual relating to the environment. Health is a lived experience, which is continually changing. The client redefines health as the interaction evolves with the environment.