1. Chapter 3 Theories and Models of Nursing
Joseph T. Catalano

2. Theory Versus Model Theory A mental viewing A proposed idea or plan
A formulation (statement) of a relationship that helps explain some observable phenomenon

3. Theory Versus Model (cont’d)
A small copy or imitation of a design
A generalized hypothetical description often based on an analogy used to explain something
A representation that helps explain the concept or object it represents
A way of seeing all the parts in relationship to the whole

4. Nursing Models and Theories Answer the Questions
What is nursing?
What do nurses do?
What are nurses?
What is health?
Who is the client?

5. Systems Theory Ludwig Von Bertanlanfty (1968)
Definition
Systems theory is a way of studying human behavior (physical, psychological, social) scientifically through “wholes” that function “holistically” because of the interdependence of their parts.

6. System
Definition
A system is a whole that functions as a whole due to the interdependence of its parts.
A set of parts connected to function as a whole for some purpose; it functions due to the interdependence of its parts.

7. Levels of Systems Physical or mechanical systems
Basically structural in nature
Tend to be static
Source of knowledge is from physics, astronomy, geology

8. Levels of Systems (cont’d)
Biological systems
Oriented to process (change)
Tend to be dynamic
Found in living organisms
Source of knowledge is from biology, zoology, botany, and other natural sciences

9. Levels of Systems (cont’d)
Human and social systems
Combine both physical and biological
Add abstract concepts and ideas
Concerned with relationship patterns
Source of knowledge is from sociology, arts, humanities, religion, and similar behavioral sciences

10. Key Terms Used in Systems Theory
Equifinality: the progressive complexity of interaction patterns found in systems; that is, the tendency that systems have to go from simple to complex
Energy pool: the source of power that is needed by all systems to function

11. Key Concepts
Nonsummativity: the degree of inter-relatedness among the systems parts
The higher the degree of nonsummativity, the greater the interdependence of components.
A high degree of nonsummativity is shown when a change in one part affects all the other parts and the total system.
All systems need some degree of nonsummativity to function.

12. Study of Systems
Focal unit: the particular part of the system you are interested in studying (e.g., cell, molecule, two people interacting)
Microsystem: looks at one small focal unit
Mezzosystem: looks at several microsystems

13. Study of Systems (cont’d)
Macrosystem: looks at large or complex interrelationships; examples include
How the nervous system and endocrine system interact
How the attitudes of Native Americans affects their health care

14. Key Concepts (cont’d)
Subsystem: one of the lesser systems that make up the total system
Suprasystem: any subsystem that is outside the system under study
Open system: one that has an ongoing dynamic exchange of data with the environment and other systems

15. Key Concepts (cont’d)
Closed system: one that does not exchange data with the environment
Self-contained
Slow to change
Examples include chemical reactions; rocks; social systems that do not accept change, such as government entities that exist only to survive

16. Key Concepts (cont’d)
Interface: the space that exists outside the system that acts as a medium to transfer information, energy, and so on (environment)
Entropy: the tendency of the system to become disorganized and nonfunctional
Negentropy: the mechanism by which a system maintains itself in homeostasis–a dynamic process

17. Key Concepts (cont’d)
Input/output channels: ways that the system exchanges data with the environment
Throughput: mechanism that allows input to enter and output to leave through a semipermeable membrane–the outer edge of the system

18. Key Concepts (cont’d)
Feedback loop: channel through which both positive and negative feedback enter and leave the system
Positive feedback: data that lead to change
Negative feedback: data that maintain stability or produce no change

19. Four Essential Parts to All Systems
Input Output
Feedback Loop

20. Roy Adaptation Model
All nursing models should address or define four concepts.
Person
Environment
Health (illness)
Nursing

21. Systems Theory and Roy Model
Stimuli System (Man) Behavioral
Second level First level
Input Output
Responses
Feedback Loop (Evaluation)

22. Key Concepts Behavioral responses (output) can be either
Adaptive: a coping process that allows the person to adjust to stimuli (input) and maintain a state of health, or
Nonadaptive (noneffective): the person is unable to cope with the stimuli and is in a state of illness.

23. Key Concepts (cont’d)
Stimuli (input): those factors that affect the person in some way; three categories
Focal stimuli: obvious stimuli that produce a direct response; the direct cause
Contextual stimuli: environmental factors that may affect the focal stimuli at the same time
Residual stimuli: factors that are not obvious or may be subconscious, such as values and upbringing; cannot validate—just assume they are there

24. Key Concepts (cont’d) Stimuli are considered second-level assessments.
Assessed after the first-level assessments
May or may not be able to change the stimuli

25. Modes of Assessment
Four modes of assessment: tries to determine how the person adapts to stimuli
Physiological mode: the person’s physical response to the stimuli
Self-concept mode: the person’s thoughts and feelings about himself or herself
Role-function mode: how the person’s role or roles change as a result of the stimuli

26. Modes of Assessment (cont’d)
Interdependence mode looks at
Support systems
Religious beliefs
Interactions with significant others
Degree of dependency on others

27. Man (Person)
Man (person, patient, client) is the center of the Roy model.
The term is defined as a bio, psycho, social, spiritual being who is in a constant state of adaptation to the environment.
It is not just an individual, but can be a family, community, or society as a whole.

28. Man (Person) (cont’d) Two parts to man
Regulator: those autonomic biological responses to stimuli.
Neuroendocrine response to stress
Not under conscious control of person

29. Man (Person) (cont’d) Cognator: mind and will
Person is able to think and consciously manipulate the stimuli
Assigns values to events in life

30. Evaluation (Feedback Loop)
Answers the question: Did the adaptation response work?
Can be either positive or negative
Positive feedback leads to change and increased adaptation.
Negative feedback can lead to either maintenance or nonadaptation.

31. Key Concepts Person (man)
A holistic being who reacts to everything around him or her (open system with subsystems)
Has four capacities
Thinking or intellectual skill (cognator)
Feelings and emotions (regulator)
Reflection and memory (cognator)
Make choices; free will (cognator)

32. Key Concepts (cont’d) Environment
Everything that affects the person both inside and outside
Examples
Room temperature
Emotional state
Pain
Income
Family relationships

33. Key Concepts (cont’d) Health The person’s ability to adapt to stimuli
The way the person and the environment interact to allow the person to live life to its fullest potential
Health frees energy to be used in other areas of life and maintain adaptation.
A continuum, not an absolute state
The person can be at a different point along the continuum any given time in his or her life.

34. The Health Continuum
The health continuum is relative to adaptation ability and perception.
Illness Health

35. Key Concepts (cont’d) Nursing
The art and science of caregiving that focuses on the promotion of the person’s positive adaptation to the environment (health)
Helps the person grow and have a meaningful life in the environment
Promotes integrity of the person
Contributes to the overall goal of a healthy society

36. Nursing How do nurses achieve their goal of promoting adaptation?
By manipulating the stimuli through
Education
Changing the environment
Altering the physiological condition of the person

37. Nursing (cont’d)
Where do nurses give nursing care? Wherever there is a person (patient)
Who is the object of nursing care?
Individuals
Families
Communities
Society

38. The Roy Model and the Nursing Process
The Roy model fits well with the five steps of the nursing process.
Assessment
Analysis
Planning
Implementation
Evaluation

39. The Orem Self-Care Model
Dorothea E. Orem’s model of nursing is based on the belief that health care is each individual’s own responsibility.
The model is aimed at helping clients direct and carry out activities that either help maintain or improve their health.

40. Key Concepts Client Health
A biological, psychological, and social being with the capacity for self-care
Health
The person’s ability to live fully within a particular physical, biological, and social environment, achieving a higher level of functioning that distinguishes the person from lower life forms.
Quality of life is an extremely important element.

41. Key Concepts (cont’d) Self-Care A two-part concept
The first type is universal self-care.
Includes those elements commonly found in everyday life that support and encourage normal human growth, development, and functioning.

42. Key Concepts (cont’d) Self-Care (cont’d)
Persons who are healthy carry out the six activities to maintain a state of health
Air, water, and food
Excretion of waste
Activity and rest
Solitude and social interactions
Avoiding hazards to life and well-being
Being normal mentally under universal self-care

43. Key Concepts (cont’d) Self-Care (cont’d)
The second type of self-care comes into play when the individual is unable to conduct one or more of the six self-care activities.
It is called health deviation self-care.
It includes those activities carried out by individuals who have diseases, injuries, physiological or psychological stress, or other health-care concerns.

44. Key Concepts (cont’d) Environment
Environment is the medium through which clients move as they conduct their daily activities.
The environment is generally viewed as a negative factor in a person’s health status because many environmental factors detract from the ability to provide self-care.

45. Key Concepts (cont’d) Nursing
The primary goal of nursing is to help the client conduct self-care activities to reach the highest level of human functioning.
There is a range of levels of self-care ability.
Three distinct levels, or systems, of nursing care are possible.
As clients become less able to care for themselves, their nursing care needs increase.

46. Key Concepts (cont’d) Three levels of nursing care
Wholly compensated care
Partially compensated care
Supportive developmental care

47. The King Model of Goal Attainment
Believes that nursing must function in all three system levels found in the environment.
Personal
Interactional
Social
The primary function of nursing is at the personal systems level, where care of the individual is the main focus.

48. Key Concepts Client The focal point of care is the person or client.
The client is viewed as an open system that exchanges energy and information with the environment—a personal system with physical, emotional, and intellectual needs that change and grow during the course of life.
These needs cannot be met completely by the client alone.

49. Key Concepts (cont’d) Environment Important concept
Encompasses interrelated elements
Personal and interpersonal systems or groups are central to the concept of environment.
They are formed at various levels according to internal goals established by the client.

50. Key Concepts (cont’d) Environment includes Health Personal systems
Interpersonal systems
Social systems
Health
A dynamic process that involves a range of human life experiences
Health exists in people when they can achieve their highest level of functioning.

51. Key Concepts (cont’d) Health (cont’d)
Health is the primary goal of the client in the King model.
It is achieved by
Continually adjusting to environmental stressors
Maximizing the use of available resources
Setting and achieving goals for one’s role in life

52. Key Concepts (cont’d) Nursing
A dynamic process and a type of personal system based on interactions between the nurse and the client.
During these interactions, the nurse and the client jointly evaluate and identify the health-care needs, set goals for fulfillment of the needs, and consider actions to take in achieving those goals.

53. Key Concepts (cont’d) Nursing (cont’d)
Nursing is a multifaceted process that includes a range of activities.
Promotion and maintenance of health through education
Restoration of health through care of the sick and injured
Preparation for death through care of the dying

54. The Watson Model of Human Caring
This model uses a philosophical approach rather than the systems theory approach.
Its main concern is the balance between
The impersonal aspects of nursing care that are found in the technological and scientific aspects of practice, and
The personal and interpersonal elements of care that grow from a humanistic belief in life.

55. Key Concepts Client The Watson model views the client as someone who
Has needs
Grows and develops throughout life
Eventually reaches a state of internal harmony

56. Key Concepts (cont’d) Client (cont’d)
Is viewed as a gestalt, or whole entity
Has value because of inherent goodness and capacity to develop
This gestalt, or holistic view of the human being is a recurring theme in the Watson model.
Emphasizes that the total person is more important to nursing care than the individual injury or disease process that produced the need for care.

57. Key Concepts (cont’d) Environment
Closely intertwined with the concept of nursing
Viewed primarily as a negative element in the health-care process
Consists of those factors that the client must overcome to achieve a state of health
Can be both external (physical and social elements) and internal (psychological reactions that affect health)

58. Key Concepts (cont’d) Health
A dynamic state of growth and development that leads to reaching full potential as a human.
Viewed as a continuum along which a person at any point may tend more toward health or more toward illness.
Illness = the client’s inability to integrate life experiences and the failure to achieve full potential or inner harmony.
Illness is not necessarily synonymous with disease processes.

59. Key Concepts (cont’d) Nursing
There is a clear distinction between the science of nursing and the practice of curing (medicine).
Nursing is the science of caring in which the primary goal is to assist the client to reach the greatest level of personal potential.
Curing involves the conduct of activities that have the goal of treatment and elimination of disease.

60. Key Concepts (cont’d) Values Basic to nursing
Based on the belief that all people are inherently valuable because they are human.
Nurses should have a strong sense of faith and hope in people because of the human potential for development.

61. Key Concepts (cont’d) Caring
Activities important in the practice of nursing in a caring way
Establishing a relationship of help and trust between the nurse and the client.
Encouraging the client to express both positive and negative feelings with acceptance.
Manipulating the environment to make it more supportive, protective, or corrective for the client with any type of disease process.
Assisting in whatever way is deemed appropriate to meet the basic human needs of the client.

62. The Johnson Behavioral System Model
This model integrates systems theory with behavioral theory.
It considers client behavior to be the key to preventing illness and to restoring health when illness occurs.
Human behavior is really a type of system in itself.
Human behavior is influenced by input factors from the environment and has output that in its turn affects the environment.

63. Key Concepts
Client
The person, or client, is viewed as a behavioral system that is an organized and integrated whole.
The whole is greater than the sum of its parts because of the integration and functioning of its subsystems.
The client as a behavioral system is composed of seven distinct behavioral subsystems.

64. Key Concepts (cont’d) Behavioral subsystems Security Dependency
Taking in
Elimination behavior
Sexual behavior
Self-protection
Achievement

65. Key Concepts (cont’d) Health
A state of health exists when balance and steady state exist within the behavioral systems of the client.
Under normal circumstances, the human system can maintain balance without external intervention.
Balance may be disturbed by physical disease, injury, or emotional crisis as to require external assistance.
Out-of-balance state = the state of illness.

66. Key Concepts (cont’d) Environment
It is all those internal and external elements that have an effect on the behavioral system.
External factors include air temperature and relative humidity.
Sociological factors include family, neighborhood, and society in general.
The internal environment includes bodily processes, psychological states, religious beliefs, and political orientation.

67. Key Concepts (cont’d) Environment (cont’d) Nursing
All seven behavioral subsystems are involved with the client’s relationship to the environment through the regulation of input and output.
Nursing
An activity that helps the individual achieve and maintain an optimal level of behavior (state of health) through the manipulation and regulation of the environment.  

68. Key Concepts (cont’d) Nursing (cont’d)
Functions in both health and illness
Nursing interventions either maintain or restore health.
Four activities involved in the regulation of the environment
Restricting harmful environmental factors
Defending the client from negative environmental influences
Inhibiting adverse elements from occurring
Facilitating positive internal environmental factors in the recovery process

69. Key Concepts (cont’d) Nursing (cont’d)
The nurse provides direct services to the client.
The nurse interacts with, and sometimes intervenes in, the multiple subsystems that are in the client’s environment.

70. The Neuman Health-Care Systems Model
This model focuses on the individual and his or her environment.
It is applicable to a variety of health-care disciplines apart from nursing.
This model draws from systems theory and stress theory.
It has an overall holistic view of humanity and health care.

71. Key Concepts
Client
The client is viewed as an open system that interacts constantly with internal and external environments through the system’s boundaries.
The client-system’s boundaries are called lines of defense and resistance.
Represented graphically as a series of concentric circles that surround the basic core of the individual.
The goal of these boundaries is to keep the basic core system stable by controlling system input and output.

72. Key Concepts (cont’d) Health
Health is the relatively stable internal functioning of the client.
Optimal health exists when the client is maintained in a high state of wellness or stability.
Health is a continuum that reflects the client’s internal stability while moving from wellness to illness and back.

73. Key Concepts (cont’d) Illness
Illness exists when the client’s core structure becomes unstable through the effects of environmental factors that overwhelm and defeat the lines of defense and resistance.
These environmental factors, whether internal or external, are called stressors.

74. Key Concepts (cont’d) Environment
The environment is composed of internal and external forces, or stressors, that produce change or response in the client.
Stressors may be helpful or harmful, strong or weak.
Stressors are classified according to their relationship to the basic core of the client-system.

75. Key Concepts (cont’d) Environment (cont’d)
Stressors completely outside the basic core = extrapersonal stressors.
Either physical, such as atmospheric temperature, or
Sociological, such as living in either a rural or an urban setting.

76. Key Concepts (cont’d) Environment (cont’d)
Interpersonal stressors arise from interactions with other human beings.
Marital relationships
Career expectations
Friendships
Intrapersonal stressors occur within the client.
Involuntary physiological responses
Psychological reactions
Internal thought

77. Key Concepts (cont’d) Nursing
The nurse’s role is to identify at what level or in which boundary a disruption in the client’s internal stability has taken place and then to aid the client in activities that strengthen or restore the integrity of that particular boundary.

78. Key Concepts (cont’d) Nursing (cont’d)
The main concern is to identify stressors that will disrupt a defensive boundary in the future (prevention).
Or, identify a stressor that has already disrupted a defensive boundary, thereby producing instability (illness).

79. Key Concepts (cont’d) Nursing (cont’d) Based on the nursing process
Identifies three levels of intervention
Primary
Secondary
Tertiary

80. Middle Range Theories and Models
A set of relatively concrete concepts or propositions that lie between a minor working hypothesis found in everyday nursing research and a well-developed major nursing theory.

81. Middle Range Theories and Models (cont’d)
These theories and models are less comprehensive and more focused than the major nursing theories; they do not have all four elements.
They are not as specific or concrete as situation-specific practice theories.
Middle Range
theories
Major
theories
Practice
theories
concrete
abstract

82. Middle Range Theories and Models (cont’d)
Middle range theories contain only a few basic ideas or concepts that the researcher is attempting to prove or illustrate.
They do not have a large number of variables.
These theories tend to focus on one or two problems that are linked either to human beings, environment, health care, or nursing.
They are less abstract than the major theories.
They are more easily applied to practice hypotheses.

83. Middle Range Theories and Models (cont’d)
Middle range theories should have socially significant meaning.
They deal with people or populations with health-care conditions.
They should also have theoretical significance, meaning that they develop a new set of facts or data that adds to the theoretical knowledge base of nursing (evidence-based practice [EBP]).