Theories applied to Community Health Nursing.
Although there are many nursing theories, frameworks, and models iursing, this chapter addresses only selected ones. The theories discussed have been selected
because they represent the development of nursing’s scientific thought.
Nursing is a profession focused on assisting individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. Modern definitions of nursing define it as a science and an art that focuses on promoting quality of life as defined by persons and families, throughout their life experiences from birth to care at the end of life.
Florence Nightingale is often regarded as the founder of moderursing, which flourished in response to the Crimean War. Other important nurses include Agnes Elizabeth Jones and Linda Richards who established quality nursing schools in the
Florence Nightingale, OM, RRC (12 May 1820 – 13 August 1910), who came to be known as The Lady of the Lamp, was a pioneer of modern nursing, a noted statistician and an inspiration to all.
Her parents were William Edward Nightingale (1794–1875) and Frances Fanny Nightingale née Smith (1789–1880). William Nightingale was born
Inspired by what she took as rebellion against the expected role for a Christian divine calling, experienced first in 1837 at
She cared for poor and indigent people. In December
In 1846 she visited
Nightingale was courted by politician and poet Richard Monckton Milnes, 1st Baron Houghton, but she rejected him, convinced that marriage would interfere with her ability to follow her calling to nursing. When in Rome in 1847, recovering from a mental breakdown precipitated by a continuing crisis of her relationship with Milnes, she met Sidney Herbert, a brilliant politician who had been Secretary at War (1845–1846), a position he would hold again during the Crimean War. Herbert was already married, but he and Nightingale were immediately attracted to each other and they became lifelong close friends. Herbert was instrumental in facilitating her pioneering work in
Nightingale also had strong and intimate relations with Benjamin Jowett, particularly about the time that she was considering leaving money in her will to establish a Chair in Applied Statistics at the
Nightingale’s career in nursing began in 1851, when she received four months training in
On August 22, 1853, Nightingale took a post of superintendent at the Institute for the Care of Sick Gentlewomen in
, a position she held until October 1854. Her father had given her an annual income of £500 (roughly US$50,000/£25,000 in present terms), which allowed her to live comfortably and to pursue her career. James Joseph Sylvester was her mentor.
Crimean War
Florence Nightingale’s most famous contribution came during the Crimean War, which became her central focus when reports began to filter back to
Nightingale arrived early in November 1854 at Selimiye Barracks in Scutari (modern-day Üsküdar in
Nightingale continued believing the death rates were due to poor nutrition and supplies and overworking of the soldiers. It was not until after she returned to
Return home
Florence Nightingale returned to
In response to an invitation from Queen
A young Florence Nightingale
Later career
While she was still in
By 1859 Nightingale had £45,000 at her disposal from the Nightingale Fund to set up the
Nightingale wrote Notes on Nursing, which was published in
Nightingale’s work served as an inspiration for nurses in the American Civil War. The Union government approached her for advice in organizing field medicine. Although her ideas met official resistance, they inspired the volunteer body of United States Sanitary Commission.
In 1869 Nightingale and Elizabeth Blackwell opened the Women’s
In the 1870s, Nightingale mentored Linda Richards, “
By 1882 Nightingale nurses had a growing and influential presence in the embryonic nursing profession. Some had become matrons at several leading hospitals, including, in London, St Mary’s Hospital, Westminster Hospital, St Marylebone Workhouse Infirmary and the Hospital for Incurables at Putney; and throughout Britain, e.g. Royal Victoria Hospital, Netley; Edinburgh Royal Infirmary; Cumberland Infirmary; Liverpool Royal Infirmary as well as at Sydney Hospital, in New South Wales, Australia.
In 1883 Nightingale was awarded the Royal Red Cross by Queen
By 1896, Florence Nightingale was bedridden. She may have had what is now known as chronic fatigue syndrome and her birthday is now celebrated as the International CFS Awareness Day. During her bedridden years, she also made pioneering work in the field of hospital planning, and her work propagated quickly across
She died on August 13, 1910. The offer of burial in Westminster Abbey was declined by her relatives, and she is buried in the graveyard at St. Margaret Church in
Nightengale was a Christian universalist.
Contributions to statistics
Florence Nightingale had exhibited a gift for mathematics from an early age and excelled in the subject under the tutorship of her father. She had a special interest in statistics, a field in which her father, a pioneer in the nascent field of epidemiology, was an expert. She made extensive use of statistical analysis in the compilation, analysis and presentation of statistics on medical care and public health.
Nightingale was a pioneer in the visual presentation of information. Among other things she used the pie chart, which had first been developed by William Playfair in 1801. After the Crimean War, Nightingale used the polar area chart, equivalent to a modern circular histogram or rose diagram, to illustrate seasonal sources of patient mortality in the military field hospital she managed. Nightingale called a compilation of such diagrams a “coxcomb”, but later that term has frequently been used for the individual diagrams. She made extensive use of coxcombs to present reports on the nature and magnitude of the conditions of medical care in the Crimean War to Members of Parliament and civil servants who would have been unlikely to read or understand traditional statistical reports.
In her later life Nightingale made a comprehensive statistical study of sanitation in Indian rural life and was the leading figure in the introduction of improved medical care and public health service in
In 1858 Nightingale was elected the first female member of the Royal Statistical Society and she later became an honorary member of the American Statistical Associating.
Nightingale did not develop a theory of nursing as theory is defined today, but rather she provided the nursing profession with the philosophical basis from which other theories have emerged and developed. Nightingale’s ideas about nursing have guided both theoretical thought and actual nursing practice throughout the history of moderursing. Nightingale considered nursing similar to a religious calling to be answered only by women with an all-consuming and passionate response. She considered nursing to be both an art and a science and believed that nurses should be formally educated.
Her writings did not focus on the nature of the person but did stress the importance of caring for the ill person rather than caring for the illness. In Nightingale’s view, the person was a passive recipient of care, and nursing’s primary focus was on the manipulation of the person’s environment to maintain or achieve a state of health. Despite the fact that she did not believe in the germ theory, her experiences in the Crimean War magnified her interest in the principles of sanitation and the relationship between environment and health. A person’s health was the direct result of environmental influences, specifically cleanliness, light, pure air, pure water, and efficient drainage. Through manipulating the environment, nursing “aims to discover the laws of nature that would assist in putting the patient in the best possible condition so that nature can effect a cure” (Nightingale, 1859, p. 6). Nursing’s main focus was health, and health was closely related to nursing. Nursing was concerned with the healthy, as well as the sick (Nightingale, 1859). Nightingale’s principles regarding environmenthealth-nursing were implemented in
Early Nursing Theories
By its very nature, the development of nursing’s theoretical base has progressed in a methodical and systematic, albeit slow, fashion. Knowledge development is an
ongoing process that is often influenced by driving forces outside the discipline of nursing. The early nurse theorists were not attempting to address the etaparadigm
concepts because initial consensus on these had not yet been achieved. Rather, these theories were attempting to answer the question, “What is nursing?”
Hildegard Peplau
Hildegard Peplau, a psychiatric nurse, combined her research and experience in the development of a theory of psychodynamic nursing, published in Interpersonal Relations in Nursing (1952).
Hildegard Peplau was born in
During World War II, Hildegard Peplau was a member of the Army Nurse Corps and worked in a neuropsychiatric hospital in
Drawing from her own knowledge and that from other disciplines, Peplau defined the concepts and stages involved in the development of the nurse-client relationship. From that relationship, she identified the roles of the nurse as stranger, resource person, teacher, leader, surrogate, and counselor. Peplau developed a middle-range theory with a focus on both nursing and the person and did not incorporate all aspects of the metaparadigm into her theory. Although other theories may view the nurseclient relationship differently, the primacy of this relationship iursing has remained.
Virginia Henderson
Virginia Henderson’s definition of nursing, considered to be a classic, first appeared in 1955. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he has the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15) Together with Bertha Harmer,
Faye Abdellah
Faye Abdellah, acknowledging the influence of
research that was done regarding these commoeeds/problems has served as a foundation for the development of what we now know as nursing diagnoses.
Joyce Travelbee
Joyce Travelbee, an educator and psychiatric nurse, was influenced by the philosophy of existentialism, a movement that is centered on individual existence in an
incomprehensible world and the role that free will plays in it, and searched to find meaning in life’s experiences. She extensively developed the ideas of sympathy,
empathy, and rapport in which the nurse could begin to comprehend and relate to the uniqueness of others. Her work focused on the human-to-human relationship
and on finding meaning in experiences such as pain, illness, and distress. Travelbee based most of her theory on her own experiences and readings and
first published her work in Interpersonal Aspects of Nursing in 1966.
Josephine Paterson and Loretta Zderad
The work of Josephine Paterson and Loretta Zderad was similar to that of Travelbee in that it emphasized the humanistic and existential basis of nursing practice.
According to Paterson and Zderad, theory developed from the practice of nursing. Although the models proposed by Travelbee and Paterson and Zderad had some impact at the time of their initial introduction, they did not gain wide popularity and application in nursing. The work of Travelbee and Paterson and Zderad most appropriately fit the Simultaneity Paradigm. Current theorists—such as Watson,
Contemporary Nursing Theories
Although early nursing theorists attempted to answer the question “What is nursing?,” contemporary theorists addressed the metaparadigm concepts in more depth,
focused more specifically oursing actions, and tried to answer the question “When is nursing needed?” The work of contemporary theorists such as Levine,
and
Myra Levine’s Conservation Theory is directly grounded iursing practice. In her attempt to describe, explain, and predict the phenomena of concern to nursing,
Levine published the four conservation principles in
1. Conservation of Energy: “The individual requires a balance of energy and a constant renewal of energy to maintain life activities” (Levine, 1990, p. 197).
2. Conservation of Structural Integrity: “Structural integrity is concerned with the processes of healing . . . to restore wholeness and continuity after injury or illness” (Levine, 1989, p. 333).
3. Conservation of Personal Integrity: “Everyone seeks to defend his or her identity as a self, in both that hidden, intensely private person that dwells within and in the public faces assumed as individuals move through their relationships with others” (Levine, 1989, p. 334).
4. Conservation of Social Integrity: “No diagnosis should be made that does not include the other persons whose lives are entwined with that of the individual” (Levine, 1989, p. 336).
Conservation: Symbolized by a light bulb in the center. Light bulbs give light and are productive. Light bulbs also symbolize ideas… theories are ideas.
Historicity: genetics. The hearts show dominant (dark pink) and recessive (light pink) traits.
Specificity: Different pathways are coming from the center of the light bulb representing the multiple stimulus response pathways.
Redundancy: If one pathway can’t get the job done, another pathway will compensate. (ADWSUF04)
According to Levine, the person is who the person knows himself or herself to be and the environment is the context in which the person lives his or her life. In Levine’s view, health is socially defined and the goal of nursing is based on the four conservation principles. Levine did not operationally define and relate the metaparadigm concepts in her theory because her original work was initially intended to be a medical-surgical nursing textbook and not a developed nursing theory. In
reevaluating her theory 20 years later, Levine stated that she has “grown in [her] conviction that they [the conservation principles] continue to offer an approach
to nursing that is scientific, research oriented, and above all suitable in daily practice in many environments” (Levine, 1989, p. 331).
A nurse who is involved in acute care situations such as an emergency room or intensive care unit often deals with clients who are exposed to severe threats to physiological integrity. The conservation of structural integrity is often the immediate priority in these acute care situations. For example, when a nurse in an emergency room is dealing with a client who has been in a severe motor vehicle accident, the client’s structural integrity is at risk. When the client’s structural integrity has been damaged, the client must put all available energy into healing the self. The nurse tries to provide care for that client so that energy can be conserved for the processes of healing. In addition to experiencing a threat to structural integrity, this client has other needs as well. The client has social relationships and these relationships are also disrupted by the accident. The nurse is concerned with the client’s spouse and family who are part of the social unit. Even in this time of crisis in the emergency room, the client’s social integrity is of concern. Finally, the nurse is also concerned about the client’s personal integrity because the traumatic experience and necessary treatment can be frightening and dehumanizing. As the nurse strives to maintain the client’s structural, social, and personal integrity, the nurse recognizes that the client is a person who is a unique individual. Levine’s four conservation principles can also be useful in a home setting in which the family rather than a single individual is the client. The nurse recognizes that energy within the family needs to be maintained to keep the family whole. In caring for the family, the nurse needs to maintain the structural, social, and personal integrity of the family and of each individual while dealing with the illness of a specific family member. Consider, for example, the nurse who makes a home health visit to see a child with cystic fibrosis. In this situation, the nurse’s attentioeeds to be directed toward conservation of energy for the child. To help conserve the child’s energy for breathing, exercises must be taught to and done by others. The nurse directs strategies toward conserving the child’s structural integrity while recognizing that the child is a unique individual and is a member of a social group, the family. Conservation of social integrity would be accomplished through maintaining interest in and monitoring the family dynamics.
Levine is pragmatic, and the conservation principles can be applied to most nursing situations. Her theory is appropriate for use in situations in which the nurse has had a long-term relationship with the client, yet is also useful for short-term relationships. Levine’s theory is congruent with the characteristics of the Totality Paradigm.
Dorothea Orem
In attempting to plan a nursing curriculum for licensed practical nurses, Dorothea Orem was searching for a pragmatic framework to organize nursing knowledge.
She focused on the questions “What is nursing?” and “When do people need nursing care?” and from this she derived that people need nursing when they are unable
to care for themselves. In 1971, she presented the Self- Care Deficit Theory of Nursing (S-CDTN) in the book Nursing Concepts of Practice and has continually revised
and updated her theory.
theories in practice.” As a grand theory, the S-CDTN has three interconnecting theories: Theory of Self- Care, Theory of Self-Care Deficit, and Theory of Nursing Systems. Each one is discussed below.
Theory of Self-Care
According to this theory, self-care is a learned behavior and a deliberate action in response to a need.
self-care requisites, developmental self-care requisites, and health-deviation self-care requisites. Universal self-care requisites are common to all human beings and include both physiological and social interactioeeds. Developmental self-care requisites are the needs that arise as the individual grows and develops. Health-deviation self-care requisites result from the needs produced by disease or illness states. Self-care is performed by mature and maturing individuals. When
someone else must perform a self-care need, it is termed dependent care.
Interpretation of
Self care: The flag design represents independence. People are independent when they do what they can to maintain life, health, and well-being.
Self-care deficit: The handicap symbol, made into a compass, symbolizes dependency of the patient coupled with the guidance, direction, and support of the nurse.
Nursing systems: Represented by the fish and hook because it reminds me of the saying: “Give a man a fish, feed him for a day. Teach a man to fish, feed him for a lifetime.” The nurse compensates for what the patient cannot do for himself while teaching how to care for himself.
Nursing Process: All the symbols are encompassed in a larger symbol- an apothecary symbol. This symbol represents diagnosis and prescription, determining why nursing care is needed. (ADWSUF04)
Theory of Self-Care Deficit
This theory purports that nursing care is needed when people are affected by limitations that do not allow them to meet their self-care needs. The relationship
between the nurse and the client is established when a self-care deficit is present. Self-care deficits, not medical diagnosis, determine the need for nursing care.
According to
Theory of Nursing Systems
This is the unifying theory that “subsumes the theory of self-care deficit which subsumes the theory of self-care” (Orem, 1991, p. 66). The Theory of Nursing Systems attempts to answer the question “What do nurses do?” This was the original question that prompted the development of
the nurse can assist the postoperative client to ambulate. The nurse may bring in a meal tray for the client who is able to feed self. The nurse compensates for what the client cannot do. The client is able to perform selected self-care activities but also accepts care performed by the nurse for needs the client is unable to meet independently. In the supportive-educative nursing system, the nurse’s actions are to help clients develop their own self-care abilities through knowledge, support, and encouragement. Clients must learn and perform their own self-care activities. The supportive-educative nursing system is being used when a nurse guides a new mother to breastfeed her baby.
Types of Nursing Systems
When caring for clients who require the wholly compensatory nursing system, how would you feel about giving complete personal care to a client who has experienced a stroke and is unable to bathe or toilet himself or herself? How would you approach such a situation?
Neuman Systems Model
Born 1924 near
In 1947 she received RN Diploma from Peoples Hospital School of Nursing,
Dr. Neuman is recognized as pioneer in the field of nursing involvement in community mental health. She began developing her model while lecturing in community mental health at UCLA. In 1972 her model was first published as a ‘Model for teaching total person approach to patient problems’ in Nursing Research. In 1985 she received her doctorate in Clinical Psychology from
The Neuman Systems Model was originally developed in 1970 at the
The Neuman Systems Model is a unique, systems-based perspective that provides a unifying focus for approaching a wide range of nursing concerns. The Neuman Systems Model is a comprehensive guide for nursing practice, research, education, and administration that is open to creative implementation…(and) has the potential for unifying various health-related theories, clarifying the relationships of variables iursing care and role definitions at various levels of nursing practice. The multidimensionality and wholistic systemic perspective of the Neuman Systems Model is increasingly demonstrating its relevance and reliability in a wide variety of clinical and educational settings throughout the world. (Betty Neuman, 2002)
The Omaha System is a comprehensive, research-based classification system designed for use in diverse community, case management, long-term care, and educational settings to enhance health care practice, documentation, and information management. Consisting of three interrelated components –
· the Problem Classification Scheme,
· the Intervention Scheme, and the Problem Rating Scale for Outcomes – it provides a structure to document client needs and strengths, describe practitioner interventions, and measure client outcomes.
Work on the Omaha System began in the 1970s when Visiting Nurse Association (VNA) of Omaha (Nebraska) staff began revising their home health and public health client records and adopting a problem-oriented approach. The goal was to provide a useful guide for practice, a method for documentation, and a framework for information management. From the beginning, DeLanne Simmons, VNA of Omaha Chief Executive Officer, envisioned a computerized management information system that incorporated an integrated, valid and reliable clinical information system organized around clients who received services, not the multidisciplinary practitioners who provided services.
Between 1975 and 1986, three research projects were funded by the Division of Nursing, US DHHS to develop and refine the Omaha System. Further research designed to establish reliability, validity, and usability was conducted between 1989 and 1993, and funded by a National Institute of Nursing Research, NIH RO-1 grant. Practitioners employed at the VNA of Omaha and 7 diverse test sites located throughout the
During the early years, information was disseminated through workshops and speeches. The first Omaha System article was published in 1981, the first books in 1992, and the current book in 2005.
