MIDDLE RANGE

NURSING THEORY
MARY JANELLE MANDAL
MIDDLE RANGE NURSING
THEORY
● More limited in scope (compared to grand theories) and present
concepts and propositions at a lower level of abstraction. They
address a specific phenomenon in nursing.
● Due to the difficulty of testing grand theories, nursing scholars
proposed using this level of theory.
● Most middle-range theories are based on a grand theorist’s works,
but they can be conceived from research, nursing practice, or the
theories of other disciplines.
● Nursing middle range theories serve as valuable frameworks for
addressing specific aspects of nursing practice, education, and
research.
● These theories bridge the gap between broad nursing
philosophies and specific clinical applications, offering
practical guidance for nurses in various settings.
 MIDDLE RANGE NURSING
THEORY
● Middle range theories are designed to be more focused and
applicable, allowing nurses to address specific patient needs
and challenges effectively.
● They provide a structured approach to understanding and
addressing complex nursing phenomena, making them
essential tools for evidence-based practice.
● Middle range theories help nurses make informed decisions,
develop interventions, and contribute to the advancement of
nursing knowledge in a systematic and practical manner.
● These theories are developed through research and are
continually refined and tested to ensure their relevance and
effectiveness in contemporary healthcare settings.
● Nursing middle range theories play a crucial role in
enhancing the quality of patient care, improving nursing
practice, and shaping the future of the nursing profession.
 10 MIDDLE RANGE THEORIST

1.Hildegard E Peplau - Interpersonal Relations Theory

2. Ida Jean Orlando - Deliberative Nursing Process Theory
3. Joyce Travelbee - Human-to-Human Relationship Model
4. Madeleine Leininger - Transcultural Nursing Theory
5. Rosemarie Rizzo Parse -Human Becoming Theory
6.Margaret A. Newman - Health as Expanding Consciousness
7. Nola J. Pender - Health Promotion Model
8. Katherine Kolcoba - Theory of Comfort
9. Ramona T Mercer - theory of maternal role attainment
10. Helen C. Erickson; Evelyn M. Tomlin; Mary Ann P Swain - Modeling and Role-Modeling
 Hildegard E Peplau
● Pioneered the Theory of Interpersonal Relations
● Peplau’s theory defined Nursing as “An
interpersonal process of therapeutic interactions
between an individual who is sick or in need of
health services and a nurse specially educated to
recognize, respond to the need for help.”
● Her work is influenced by Henry Stack Sullivan,
Percival Symonds, Abraham Maslow, and Neal
Elgar Miller.
● It helps nurses and healthcare providers develop
more therapeutic interventions in the clinical setting.
History Of Theory

● Hildegard E. Peplau was born in Reading, Pennsylvania, in 1909.

● She pursued a nursing career and obtained her nursing diploma from
Pottstown Hospital School of Nursing in 1931.
● In the 1940s, Peplau served as a nurse in the U.S. Army Nurse Corps
during World War II, which provided her with valuable experience in
psychiatric nursing.
● Peplau's groundbreaking work in psychiatric nursing laid the foundation
for her influential nursing theory, known as the "Interpersonal Relations in
Nursing" theory.
● Her theory was first published in 1952 in her book "Interpersonal
Relations in Nursing: A Conceptual Framework for Psychodynamic
Nursing."
● The theory emphasized the importance of the nurse-patient relationship as
a therapeutic tool in the healing process, recognizing the emotional and
psychological aspects of nursing care.
 History Of Theory
● Peplau's theory introduced the idea of the nurse as a
facilitator of interpersonal relationships and
highlighted the roles of teacher, counselor, and
resource person in the nurse-patient dynamic.
● Her work greatly contributed to the
professionalization of nursing and the shift from a
task-oriented approach to a more patient-centered and
holistic model of care.
● Over the years, Peplau continued to refine her theory
and published subsequent editions of her book,
incorporating new ideas and insights into the evolving
field of nursing.
● Hildegard E. Peplau's theory remains a significant and
enduring framework in psychiatric and mental
health nursing, emphasizing the importance of the
therapeutic nurse-patient relationship in promoting
health and well-being.
What Is The Theory All About
● Foundation: Peplau's Theory of Interpersonal Relations is a nursing theory that emphasizes the
significance of the nurse-patient relationship as a central component of nursing practice.
● Interpersonal Process: The theory focuses on the interpersonal process that occurs between the nurse and
the patient during their interactions.
● Phases of Nursing: Peplau identified four phases of the nurse-patient relationship: orientation,
identification, exploitation, and resolution. These phases represent the stages of development in the
therapeutic relationship.
● Goal of the Theory: The primary goal of Peplau's theory is to promote the patient's health and well-being
by facilitating their understanding of their health conditions, empowering them to make informed
decisions, and providing emotional support.
 Assumptions

Hildegard Peplau’s Interpersonal Relations Theory’s

assumptions are:
(1) Nurse and the patient can interact.
(2) Peplau emphasized that both the patient and nurse
mature as the result of the therapeutic interaction.
(3) Communication and interviewing skills remain
fundamental nursing tools. And lastly,
(4) Peplau believed that nurses must clearly understand
themselves to promote their client’s growth and avoid
limiting their choices to those that nurses value.
 Concepts Being Utilized

PERSON ENVIRONMENT

01 organism (“strives in its own

way to reduce tension
generated by needs.”)that tries
03 consists of existing forces
outside of the person and put
in the context of culture
to reduce anxiety caused by
needs
NURSING HEALTH
significant therapeutic “a word symbol that implies

02
interpersonal process that
functions cooperatively with
04 forward movement of
personality and other ongoing
another human process that makes human processes in the
health possible for individuals in direction of creative,
communities. constructive, productive,
personal, and community
living”
 Subconcepts of the Interpersonal Relations Theory

Peplau’s model has proved greatly used by later nurse theorists and clinicians in developing more sophisticated and
therapeutic nursing interventions. The following are the roles of the Nurse in the Therapeutic relationship identified
by Peplau:

Stranger: offering the client the same acceptance and courtesy that the nurse would respond to any stranger
Resource person: providing specific answers to questions within a larger context
Teacher: helping the client to learn formally or informally
Leader: offering direction to the client or group
Surrogate: serving as a substitute for another such as a parent or a sibling
Counselor: promoting experiences leading to health for the client such as expression of feelings
Technical Expert: providing physical care for the patient and operates equipment

Peplau also believed that the nurse could take on many other roles, but these were not defined in detail. However, they
were “left to the intelligence and imagination of the readers.” (Peplau, 1952)
 Theoretical Framework

● Orientation Phase: In this initial phase, the nurse and patient establish trust, gather information, and set the goals and
expectations for the therapeutic relationship.
● Identification Phase: During this phase, the patient begins to identify with the nurse as a caregiver and may develop
feelings of attachment and dependence.
● Exploitation Phase: In the exploitation phase, the patient derives the full benefits of the therapeutic relationship,
utilizing the nurse's support, guidance, and education to address their health needs.
● Resolution Phase: The final phase involves the termination of the nurse-patient relationship. It allows for reflection on
the progress made, evaluation of the goals achieved, and emotional closure.
 Four Phases of the therapeutic nurse-patient relationship:

1. Orientation Phase
The nurse’s orientation phase involves engaging the client in treatment, providing explanations and
information, and answering questions.
● Problem defining phase
● It starts when the client meets the nurse as a stranger.
● Defining the problem and deciding the type of service needed
● Client seeks assistance, conveys needs, asks questions, shares preconceptions and expectations of past
experiences.
● Nurse responds, explains roles to the client, identifies problems, and uses available resources and
services.
 Four Phases of the therapeutic nurse-patient relationship:

2. Identification Phase
The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger.
● Selection of appropriate professional assistance
● Patient begins to have a feeling of belonging and a capability of dealing with the problem, which decreases the feeling of
helplessness and hopelessness.

3. Exploitation Phase
In the exploitation phase, the client makes full use of the services offered.
● In the exploitation phase, the client makes full use of the services offered.
● Use of professional assistance for problem-solving alternatives
● Advantages of services are used based on the needs and interests of the patients.
● The individual feels like an integral part of the helping environment.
● They may make minor requests or attention-getting techniques.
● The principles of interview techniques must be used to explore, understand and adequately deal with the underlying problem.
● Patient may fluctuate on independence.
● Nurse must be aware of the various phases of communication.
● Nurse aids the patient in exploiting all avenues of help, and progress is made towards the final step.
 Four Phases of the therapeutic nurse-patient relationship:
4. Resolution Phase
In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The relationship
ends.

● In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The
relationship ends.
● Termination of professional relationship
● The patient’s needs have already been met by the collaborative effect of patient and nurse.
● Now they need to terminate their therapeutic relationship and dissolve the links between them.
● Sometimes may be difficult for both as psychological dependence persists.
● The patient drifts away and breaks the nurse’s bond, and a healthier emotional balance is demonstrated, and both
become mature individuals.
 Analysis
Peplau conceptualized clear sets of nurse’s roles that every nurse can use with their practice. It implies
that a nurse’s duty is not just to care, but the profession encompasses every activity that may affect the
patient’s care.

The idea of a nurse-client interaction is limited to those individuals incapable of conversing, specifically
those who are unconscious.

The concepts are highly applicable to the care of psychiatric patients considering Peplau’s background.
But it is not limited to those sets of individuals. It can be applied to any person capable and has the will
to communicate.

The phases of the therapeutic nurse-client are highly comparable to the nursing process, making it vastly
applicable. Assessment coincides with the orientation phase; nursing diagnosis and planning with the
identification phase, implementation as to the exploitation phase, and evaluation with the resolution
phase.
 STRENGTH AND WEAKNESSES

Strengths Weaknesses
● Peplau’s theory helped later nursing ● Though Peplau stressed the nurse-client
theorists and clinicians develop more relationship as the foundation of nursing
therapeutic interventions regarding the roles practice, health promotion and maintenance
that show the dynamic character typical in were less emphasized.
clinical nursing. ● Also, the theory cannot be used in a patient
● Its phases provide simplicity regarding the who doesn’t have a felt need, such as with
nurse-patient relationship’s natural withdrawn patients.
progression, which leads to adaptability in
any nurse-patient interaction, thus providing
generalizability.
 Significance Of The Theory

● Humanizing Healthcare: Peplau's Theory of Interpersonal Relations humanizes healthcare by

emphasizing the importance of genuine human connections between nurses and patients, promoting a
more compassionate and patient-centered approach to care.
● Improved Patient Outcomes: The theory contributes to improved patient outcomes by fostering trust,
communication, and collaboration, which can enhance adherence to treatment plans and promote
healing.
● Evidence-Based Practice: The theory supports evidence-based practice by highlighting the
therapeutic value of the nurse-patient relationship and encouraging nurses to base their interventions
on patient needs and preferences.
● Holistic Care Approach: It promotes a holistic care approach, addressing not only the physical
aspects of health but also the emotional, psychological, and social well-being of patients.
● Patient Empowerment: Peplau's theory empowers patients to take an active role in their healthcare
decisions, promoting autonomy and self-efficacy.
 Examples Of The Theory In Practice Or Case
Studies

EXAMPLE 1: Home Healthcare: A home healthcare nurse uses Peplau's theory to care for an elderly
patient with a chronic illness who is experiencing isolation and depression. Through regular visits and a
friendly, empathetic approach, the nurse becomes a valuable resource person and counselor, helping the
patient manage their condition, combat loneliness, and improve their overall quality of life.

EXAMPLE 2: Mental Health Crisis Intervention: In an emergency room, a nurse utilizes Peplau's theory
when caring for a patient experiencing a mental health crisis. By assuming the role of a counselor and
providing active listening, the nurse helps the patient express their feelings and thoughts, reducing their
anxiety and facilitating communication with the mental health team. The patient's immediate needs are
addressed more effectively, and a therapeutic relationship is established to guide ongoing care.
 Ida Jean Orlando
● She developed the Nursing Process Theory.
● “Patients have their own meanings and interpretations of
situations, and therefore nurses must validate their
inferences and analyses with patients before drawing
conclusions.”
● Allows nurses to formulate an effective nursing care plan
that can also be easily adapted when and if any
complexity comes up with the patient.
● According to her, persons become patients requiring
nursing care when they have needs for help that cannot
be met independently because of their physical
limitations, negative reactions to an environment, or
experience that prevents them from communicating their
needs.
● The role of the nurse is to find out and meet the patient’s
immediate needs for help.
 History Of Theory

● Early Life and Education: Ida Jean Orlando was born in 1926 in New York City and pursued her nursing
education at the New York Medical College and Bellevue School of Nursing.
● Clinical Nursing Experience: Orlando gained valuable clinical experience as a staff nurse and later as a
supervisor at various healthcare institutions, including Boston Children's Hospital and the Boston
Psychopathic Hospital.
● Educational Achievements: She earned a Bachelor of Science in Public Health Nursing from St. John's
University in 1951 and a Master's degree in Mental Health Nursing from Columbia University in 1954.
● Theory Development: Orlando developed her Nursing Process Theory in the 1950s in response to the
need for a clearer understanding of the nurse-patient relationship and effective patient care.
● Publication of Theory: Her theory was first published in her book "The Dynamic Nurse-Patient
Relationship" in 1961, introducing the nursing community to her ideas on effective nursing practice.
● Focus on Nurse-Patient Interaction: Orlando's theory emphasized the significance of the nurse-patient
interaction and the importance of communication in the nursing process.
● Immediate Reaction Concept: Central to her theory was the concept of the nurse's "immediate reaction"
to patient behavior, which served as a vital cue for identifying unmet patient needs.
 History Of Theory
● Dynamic and Iterative Process: Orlando's theory described
the nurse-patient relationship as a dynamic and iterative
process, with ongoing assessment, validation, and response to
patient needs.
● Application in Nursing Practice: Her theory provided a
structured framework for nurses to better understand, assess,
and meet patients' immediate needs, ultimately improving the
quality of care.
● Teaching and Research: Orlando's contributions extended
beyond theory development to teaching positions at
universities and ongoing research, particularly in the field of
psychiatric nursing.
● Enduring Influence: Ida Jean Orlando's Nursing Process
Theory remains relevant in contemporary nursing practice,
guiding nurses in building therapeutic relationships and
delivering patient-centered care. Her work has left a lasting
impact on the field of nursing.
 What Is The Theory All About
● Focuses on the nurse-patient interaction.
● Emphasis on the importance of effective communication
● Nursing is seen as a dynamic process
● Goal is to meet the patient’s immediate needs
● Nursing action are based on the nurse’s perception of the patient’s needs
● Validation of the nursing actions through patient feedback.
● It is also constantly evolving and adapting to the patient’s changing needs
● Aims to help patients overcome their distress.
 Assumptions

1. When patients cannot cope with their needs on their own, they become distressed by feelings of
helplessness.
2. In its professional character, nursing adds to the distress of the patient.
3. Patients are unique and individual in how they respond.
4. Nursing offers mothering and nursing analogous to an adult who mothers and nurtures a child.
5. The practice of nursing deals with people, the environment, and health.
6. Patients need help communicating their needs; they are uncomfortable and ambivalent about their
dependency needs.
7. People can be secretive or explicit about their needs, perceptions, thoughts, and feelings.
 Assumptions

8. The nurse-patient situation is dynamic; actions and reactions are influenced by both the nurse and the patient.
9. People attach meanings to situations and actions that aren’t apparent to others.
10. Patients enter into nursing care through medicine.
11. The patient cannot state the nature and meaning of his or her distress without the nurse’s help or him or her
first having established a helpful relationship with the patient.
12. Any observation shared and observed with the patient is immediately helpful in ascertaining and meeting his or
her need or finding out that he or she is not in need at that time.
13. Nurses are concerned with the needs the patient is unable to meet on his or her own.
 Concepts Being Utilized
PERSON ENVIRONMENT
individuality and the dynamic
01 nature of the nurse-patient
relationship. For her, humans in 03
disregarded the environment in her
theory, only focusing on the patient’s
immediate need, chiefly the
need are the focus of nursing relationship and actions between the
practice. nurse and the patient

NURSING
unique and independent in its HEALTH

02
concerns for an individual’s need
for help in an immediate situation. health is replaced by a sense of
The efforts to meet the
individual’s need for help are
04 helplessness as the initiator of
a necessity for nursing. She
carried out in an interactive stated that nursing deals with
situation and in a disciplined individuals who require help.
manner that requires proper
training.
Theoretical Framework
 Theoretical Framework
1. Patient-Centered Focus: Orlando's theory places the patient at the center of nursing care. It emphasizes
that nursing care should be tailored to meet each patient's unique needs and concerns.
2. Perception and Observation: A crucial element of this theory is the nurse's ability to perceive and
observe the patient's behavior and verbal expressions. These cues serve as the foundation for
understanding the patient's needs.
3. Immediate Reaction: Orlando introduced the concept of the "immediate reaction," where the nurse's
intuitive response to the patient's behavior and cues helps identify the patient's distress or need for help. It's
like a nurse's instinctual response to what the patient is going through.
4. Validation: After perceiving and reacting to patient cues, the nurse seeks validation from the patient. This
means the nurse asks the patient to confirm whether their understanding of the patient's needs is correct.
This step ensures that the nurse's assessment is accurate and aligns with the patient's experience.
 Theoretical Framework
5. Deliberative Nursing Process: The theory revolves around the Deliberative Nursing Process, a systematic
approach that involves several steps:
a. Assessment: The nurse observes, perceives, and validates patient needs.
b. Diagnosis: Based on the assessment, the nurse identifies the patient's problem or need.
c. Planning: The nurse develops a plan of action to address the identified needs.
d. Intervention: The nurse carries out the planned interventions to meet the patient's needs.
e. Evaluation: After the interventions, the nurse assesses whether they were effective in addressing the
patient's needs and whether the patient's condition has improved.
6. Dynamic Nurse-Patient Relationship: Orlando's theory views the nurse-patient relationship as dynamic and
ever-changing. It emphasizes that the relationship is not a one-time event but a continual process of
assessment, interaction, and care.
7. Effective Communication: Effective communication between the nurse and the patient is vital. Nurses need
to be skilled at listening, clarifying, and understanding the patient's needs and concerns. This communication
is what allows the nurse to validate their perceptions.
8. Problem-Solving: Nurses engage in problem-solving to develop appropriate nursing interventions that
address the patient's identified needs. This step requires critical thinking and creativity to provide the best
care.
 Analysis

Compared to other nursing theories, which are task-oriented, Orlando gave a clear-cut approach to patient-
oriented nursing theory. It uplifts the integrity of individualized nursing care. This strengthens the role of the
nurse as an independent nurse advocate for the patient. The nurse-patient interaction dynamic concept was
justified since the patient’s participation in the relationship was sought. The whole process is in constant
revision through continuous validation of the nurse’s findings with that of the patient. Because the nurse has
to explore her reactions with the patient constantly, it prevents inaccurate diagnosis or ineffective plans.

Since the model is applied to an immediate situation, its applicability to a long-term care plan is not feasible.

The concept of interaction also limits it to individuals capable of conversing, a shared limitation with other
nurse-client dynamic theories – this theory does not cover unconscious patients.
 STRENGTH AND WEAKNESSES
Weaknesses
Strengths ● The lack of operational definitions of
● The guarantee that patients will be treated as
society or environment was evident, limiting
individuals is very much applied in
the development of the research hypothesis.
Orlando’s theory of the Deliberative
Nursing Process. Each patient will have an ● Orlando’s work focuses on short-term care,
active and constant input into their own
particularly aware and conscious
care.
individuals, and the virtual absence of
● The assertion of nursing’s independence as a
reference groups or family members.
profession and her belief that this
independence must be based on a sound
theoretical framework.
● The model also guides the nurse to evaluate
her care in terms of objectively observable
patient outcomes.
 Significance Of The Theory

● Patient-Centered Care: Orlando's theory underscores the importance of tailoring nursing care to meet
each patient's unique needs, promoting individualized and patient-centered care.
● Effective Communication: The theory places a strong emphasis on effective communication between
nurses and patients, improving the understanding of patient needs and concerns.
● Problem-Solving: Orlando's framework encourages nurses to engage in problem-solving, enabling
them to develop appropriate interventions that address the patient's identified needs.
● Empowerment: The theory empowers nurses to actively engage with patients, involving them in care
decisions and promoting a sense of partnership in the care process.
● Holistic Care: Orlando's theory recognizes the holistic nature of patient needs, encompassing physical,
emotional, and psychological aspects of care.
● Quality Nursing Practice: It guides nurses in delivering high-quality care that not only addresses
immediate needs but also promotes overall patient well-being.
 Significance Of The Theory

● Improving Patient Outcomes: By focusing on individualized care and effective nurse-patient

interactions, Orlando's theory contributes to improved patient outcomes and satisfaction.
● Enhancing Nursing Practice: The theory enhances nursing practice by providing a structured
framework for assessment, problem-solving, and communication, ultimately improving the quality of
care.
● Professional Development: Orlando's theory has contributed to the professional development of
nurses, emphasizing the importance of the nurse's role in assessing and meeting patient needs.
● Impact on Education: It has had a significant impact on nursing education, guiding students in
understanding the nurse-patient relationship and effective care delivery.
● Patient Care Advancements: Orlando's theory has led to advancements in patient care approaches,
particularly in the context of nurse-patient interactions and problem-solving skills.
● Continued Relevance: The theory remains relevant in contemporary nursing practice, providing a
timeless framework for enhancing patient care and nurse-patient relationships.
 Examples Of The Theory In Practice Or Case
Studies
EXAMPLE 1: Medical-Surgical Nursing
A medical-surgical nurse observes a postoperative patient grimacing in pain and fidgeting in bed. The nurse's
immediate reaction prompts them to approach the patient and ask about their pain level. After validating the patient's
discomfort, the nurse collaborates with the healthcare team to adjust pain management strategies, ensuring the
patient's pain is effectively controlled.

EXAMPLE 2: Home Healthcare

A home healthcare nurse caring for an elderly patient with multiple chronic conditions notes the patient's weight loss
and increasing frailty. The nurse's immediate reaction is to ask the patient about their eating habits and any difficulties
they may be experiencing. After validation, the nurse collaborates with a dietitian to develop a personalized nutrition
plan and coordinates with physical therapists to improve the patient's mobility and overall well-being.
THANK YOU FOR
LISTENING!
REFERENCES
Wayne, G. (2023). Nursing Theories and Theorists: The Definitive guide for nurses. Nurseslabs.
https://nurseslabs.com/nursing-theories/#h-margaret-a-newman

Gonzalo, A. (2023a). Hildegard Peplau: Interpersonal Relations Theory. Nurseslabs.

https://nurseslabs.com/hildegard-peplaus-interpersonal-relations-theory/

Gonzalo, A. (2023b). Ida Jean Orlando: Deliberative Nursing Process Theory. Nurseslabs.
https://nurseslabs.com/ida-jean-orlandos-deliberative-nursing-process-theory/
Madeleine Leininger

(The Transcultural Nursing Theory)

Biography
● Madeleine Leininger was born on July 13, 1925, in Sutton, Nebraska. She lived on a farm with her four brothers and
sisters and graduated from Sutton High School.
● After graduation from Sutton High, she was in the U.S. Army Nursing Corps while pursuing a basic nursing program.
Her aunt, who had congenital heart disease, led her to pursue a career in nursing.
● In 1945, Madeleine Leininger, together with her sister, entered the Cadet Nurse Corps, a federally-funded program to
increase the number of nurses trained to meet anticipated needs during World War II.
● She earned a nursing diploma from St. Anthony’s Hospital School of Nursing, followed by undergraduate degrees at
Mount St. Scholastica College and Creighton University.
● Leininger opened a psychiatric nursing service and educational program at Creighton University in Omaha, Nebraska.
She earned the equivalent of a BSN through her studies in biological sciences, nursing administration, teaching, and
curriculum during 1951-1954.
● She received a Master of Science in Nursing from the Catholic University of America in 1954.
● And in 1965, Leininger embarked upon a doctoral program in Cultural and Social Anthropology at the University of
Washington in Seattle and became the first professional nurse to earn a Ph.D. in anthropology.
● In the early 1950s, Madeleine Leininger worked as a clinical mental health specialist in a child guidance
center with mildly disturbed children of diverse cultural backgrounds.
● It was during this time she saw challenges and uncaring actions in the care of children and realized that
only limited research had been conducted in relation to care within specific cultures and in health
institutions.
● It was evident to her that nurses and other health professionals had failed to recognize and appreciate
the important role of culture in healing, in caring processes, and in healthcare treatment practices.
● Culture and care were identified by Leininger as major dimensions missing in nursing healthcare
services (Leininger,1978, 1995).
● The theorist tried to use psychoanalytic and other mental health ideas popular after World War II to help
patients, but these practices were woefully inadequate to explain or help children and adults of diverse
cultural backgrounds.
● The theorist’s interest continued to grow along with her many questions about the interface of culture
and care. Leininger decided that understanding and responding appropriately and therapeutically to
clients from different cultures was a critical need that merited theoretical explanations and research
investigations to discover beneficial outcomes.
The Transcultural Nursing Theory
● Through her observations, while working as a nurse, Madeleine Leininger identified a lack of
cultural and care knowledge as the missing component to a nurse’s understanding of the
many variations required inpatient care to support compliance, healing, and wellness, which
led her to develop the theory of Transcultural Nursing also known as Culture Care Theory.
● This theory attempts to provide culturally congruent nursing care through “cognitively based
assistive, supportive, facilitative, or enabling acts or decisions that are mostly tailor-made to
fit with the individual, group’s, or institution’s cultural values, beliefs, and lifeways.”
● Leininger’s theory’s main focus is for nursing care to fit with or have beneficial meaning and
health outcomes for people of different or similar cultural backgrounds. With these, she has
developed the Sunrise Model in a logical order to demonstrate the interrelationships of the
concepts in her theory of Culture Care Diversity and Universality.
● The Transcultural Nursing Theory or Culture Care Theory by Madeleine Leininger
involves knowing and understanding different cultures concerning nursing and health-illness caring
practices, beliefs, and values to provide meaningful and efficacious nursing care services to people’s
cultural values health-illness context.
● It focuses on the fact that different cultures have different caring behaviors and different health and
illness values, beliefs, and patterns of behaviors.
● The cultural care worldview flows into knowledge about individuals, families, groups, communities, and
institutions in diverse health care systems. This knowledge provides culturally specific meanings and
expressions about care and health. The next focus is on the generic or folk system, professional care
system(s), and nursing care. Information about these systems includes the characteristics and the
specific care features of each. This information allows for the identification of similarities and
differences or cultural care universality and cultural care diversity.
● Next are nursing care decisions and actions which involve cultural care preservation/maintenance,
cultural care accommodation/negotiation, and cultural care re-patterning or restructuring. It is here
that nursing care is delivered.
● In 1995, Madeleine Leininger defined transcultural nursing as “a substantive area
of study and practiced focused on comparative cultural care (caring) values, beliefs,
and practices of individuals or groups of similar or different cultures to provide
culture-specific and universal nursing care practices in promoting health or well-
being or to help people to face unfavorable human conditions, illness, or death in
culturally meaningful ways.”
● The Transcultural Nursing Theory first appeared in Leininger’s Culture Care
Diversity and Universality, published in 1991, but it was developed in the 1950s.
The theory was further developed in her book Transcultural Nursing, which was
published in 1995. In the third edition of Transcultural Nursing, published in 2002,
the theory-based research and the Transcultural theory application are explained.
Major Concepts of the Transcultural Nursing
Theory
1. Transcultural Nursing

Transcultural nursing is defined as a learned subfield or branch of nursing that focuses upon the
comparative study and analysis of cultures concerning nursing and health-illness caring practices, beliefs,
and values to provide meaningful and efficacious nursing care services to their cultural values and health-
illness context.

2. Ethnonursing

Nursing is defined as a learned humanistic and scientific profession and discipline which is focused on
human care phenomena and activities to assist, support, facilitate, or enable individuals or groups to
maintain or regain their well-being (or health) in culturally meaningful and beneficial ways, or to help
people face handicaps or death.
Major Concepts of the Transcultural Nursing Theory
cont’d.
3. Professional Nursing Care (Caring)

Professional nursing care (caring) is defined as formal and cognitively learned professional care knowledge and
practice skills obtained through educational institutions that are used to provide assistive, supportive, enabling, or
facilitative acts to or for another individual or group to improve a human health condition (or well-being),
disability, lifeway, or to work with dying clients.

4. Cultural Congruent (Nursing) Care

Cultural congruent (nursing) care is defined as those cognitively based assistive, supportive, facilitative, or
enabling acts or decisions that are tailor-made to fit with the individual, group, or institutional, cultural values,
beliefs, and lifeways to provide or support meaningful, beneficial, and satisfying health care, or well-being
services.
Major Concepts of the Transcultural Nursing
Theory (cont’d.)
5. Health

It is a state of well-being that is culturally defined, valued, and practiced. It reflects individuals’ (or groups) ‘ ability
to perform their daily role activities in culturally expressed, beneficial, and patterned lifeways.

6. Human Beings

Such are believed to be caring and capable of being concerned about others’ needs, well-being, and survival.
Leininger also indicates that nursing as a caring science should focus beyond traditional nurse-patient interactions
and dyads to include families, groups, communities, total cultures, and institutions.

7. Society and Environment

Leininger did not define these terms; she speaks instead of worldview, social structure, and environmental
context.
Major Concepts of the Transcultural Nursing
Theory (cont’d.)
7. Worldview

Worldview is how people look at the world, or the universe, and form a “picture or value stance” about the world
and their lives.

8. Cultural and Social Structure Dimensions

Cultural and social structure dimensions are defined as involving the dynamic patterns and features of interrelated
structural and organizational factors of a particular culture (subculture or society) which includes religious, kinship
(social), political (and legal), economic, educational, technological, and cultural values, ethnohistorical factors, and
how these factors may be interrelated and function to influence human behavior in different environmental
contexts.
Major Concepts of the Transcultural Nursing Theory
(cont’d.)
9. Environmental Context

Environmental context is the totality of an event, situation, or particular experience that gives meaning to human
expressions, interpretations, and social interactions in particular physical, ecological, sociopolitical, and/or cultural settings.

10. Culture

Culture is learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guides their
thinking, decisions, and actions in patterned ways.

11. Culture Care

Culture care is defined as the subjectively and objectively learned and transmitted values, beliefs, and patterned lifeways
that assist, support, facilitate, or enable another individual or group to maintain their well-being, health, improve their
human condition lifeway, or deal with illness, handicaps or death.
Major Concepts of the Transcultural Nursing Theory
(cont’d.)
12. Culture Care Diversity

Culture care diversity indicates the variabilities and/or differences in meanings, patterns, values, lifeways, or
symbols of care within or between collectives related to assistive, supportive, or enabling human care expressions.

13. Culture Care Universality

Culture care universality indicates the common, similar, or dominant uniform care meanings, patterns, values,
lifeways, or symbols manifest among many cultures and reflect assistive, supportive, facilitative, or enabling ways
to help people. (Leininger, 1991)
Subconcepts of the Transcultural Nursing Theory
1. Generic (Folk or Lay) Care Systems

Generic (folk or lay) care systems are culturally learned and transmitted, indigenous (or traditional), folk (home-
based) knowledge and skills used to provide assistive, supportive, enabling, or facilitative acts toward or for another
individual, group, or institution with evident or anticipated needs to ameliorate or improve a human life way, health
condition (or well-being), or to deal with handicaps and death situations.

2. Emic

Knowledge gained from direct experience or directly from those who have experienced it. It is generic or folk
knowledge.

3. Professional Care Systems

Professional care systems are defined as formally taught, learned, and transmitted professional care, health, illness,
wellness, and related knowledge and practice skills that prevail in professional institutions, usually with
multidisciplinary personnel to serve consumers.
Subconcepts of the Transcultural Nursing Theory (cont’d)
4. Etic

The knowledge that describes the professional perspective. It is professional care knowledge.

5. Ethnohistory

Ethnohistory includes those past facts, events, instances, experiences of individuals, groups, cultures, and
instructions that are primarily people-centered (ethno) and describe, explain, and interpret human lifeways within
particular cultural contexts over short or long periods of time.

6. Care as a noun is defined as those abstract and concrete phenomena related to assisting, supporting, or enabling
experiences or behaviors toward or for others with evident or anticipated needs to ameliorate or improve a human
condition or lifeway.

7. Care as a verb is defined as actions and activities directed toward assisting, supporting, or enabling another
individual or group with evident or anticipated needs to ameliorate or improve a human condition or lifeway or face
death.
Subconcepts of the Transcultural Nursing Theory (cont’d)

8. Culture Shock

Culture shock may result when an outsider attempts to comprehend or adapt effectively to a different
cultural group. The outsider is likely to experience feelings of discomfort and helplessness and some
degree of disorientation because of the differences in cultural values, beliefs, and practices. Culture shock
may lead to anger and can be reduced by seeking knowledge of the culture before encountering that
culture.

9. Cultural Imposition

Cultural imposition refers to the outsider’s efforts, both subtle and not so subtle, to impose their own
cultural values, beliefs, behaviors upon an individual, family, or group from another culture. (Leininger,
1978)
Sunrise Model of Madeleine Leininger’s Theory

● The Sunrise Model is relevant because it enables nurses to develop critical and complex
thoughts about nursing practice. These thoughts should consider and integrate cultural and
social structure dimensions in each specific context, besides nursing care’s biological and
psychological aspects.
● The cultural care worldview flows into knowledge
about individuals, families, groups, communities,
and institutions in diverse health care systems. This
knowledge provides culturally specific meanings
and expressions concerning care and health. The
next focus is on the generic or folk system,
professional care systems, and nursing care.
Information about these systems includes the
characteristics and the specific care features of
each. This information allows for the identification
of similarities and differences or cultural care
universality and cultural care diversity.

● Next are nursing care decisions and actions which

involve cultural care preservation or maintenance,
cultural care accommodation or negotiation, and
cultural care repatterning or restructuring. It is
here that nursing care is delivered.
Three Culture Care Decision and Action Modes

In the culture care theory, Leininger predicted three culture care decision and action modes for
providing culturally congruent nursing care. The three modes were highly innovative and
unique in nursing and health care. Leininger (1994) held that nurses needed creative and
different approaches to make care and culture needs meaningful and helpful to clients. These
three theoretically predicted decision and action modes of the culture care theory were
defined as:

1. Culture care preservation and-or maintenance referred to those assistive, supporting,

facilitative, or enabling professional acts or decisions that help cultures to retain,
preserve or maintain beneficial care beliefs and values or to face handicaps and death.
Three Culture Care Decision and Action Modes (cont’d)

2. Culture care accommodation and-or negotiation referred to those assistive,

accommodating, facilitative, or enabling creative provider care actions or decisions
that help cultures adapt to or negotiate with others for culturally congruent, safe
and effective care for their health, wellbeing, or to deal with illness or dying.

3. Culture care repatterning and-or restructuring referred to those assistive,

supportive, facilitative, or enabling professional actions and mutual decisions that
would help people to reorder, change, modify or restructure their lifeways and
institutions for better (or beneficial) health care patterns, practices or outcomes.
(Leininger, 1991a/b, 1995; Leininger & McFarland 2002).
Assumptions

● Different cultures perceive, know, and practice care differently, yet there are some
commonalities about care among all world cultures.
● Values, beliefs, and practices for culturally related care are shaped by, and often embedded in,
“the worldview, language, religious (or spiritual), kinship (social), political (or legal),
educational, economic, technological, ethnohistorical, and environmental context of the
culture.
● While human care is universal across cultures, caring may be demonstrated through diverse
expressions, actions, patterns, lifestyles, and meanings.
● Cultural care is the broadest holistic means to know, explain, interpret, and predict nursing
care phenomena to guide nursing care practices.
● All cultures have generic or folk health care practices, that professional practices vary across
cultures, and that there will be cultural similarities and differences between the care-receivers
(generic) and the professional caregivers in any culture.
Assumptions (cont’d.)

● Care is the distinct, dominant, unifying, and central focus of nursing, and while curing and healing
cannot occur effectively without care, care may occur without a cure.
● Care and caring are essential for humans’ survival and their growth, health, well-being, healing, and
ability to deal with handicaps and death.
● Nursing, as a transcultural care discipline and profession, has a central purpose of serving human
beings in all areas of the world; that when culturally based nursing care is beneficial and healthy, it
contributes to the well-being of the client(s) – whether individuals, groups, families, communities, or
institutions – as they function within the context of their environments.
● Nursing care will be culturally congruent or beneficial only when the nurse knows the clients. The
clients’ patterns, expressions, and cultural values are used in appropriate and meaningful ways by the
nurse with the clients.
● If clients receive nursing care that is not at least reasonably culturally congruent (that is, compatible
with and respectful of the clients’ lifeways, beliefs, and values), the client will demonstrate signs of
stress, noncompliance, cultural conflicts, and/or ethical or moral concerns.
Conclusions

Madeline Leininger’s Theory of Transcultural Nursing, one that depends on the

communication and care exhibited by the nurse, actively incorporates the patient’s values,
beliefs, and background into every step of the nursing process. In instances where the nurse
has the chance to make a patient more comfortable according to his or her perceived style of
care, the nurse must professionally and effectively pursue this environment on behalf of the
patient and make every attempt to understand the motives behind the his or her wishes, free
from judgement.
Significance of the Theory

In the past one hundred years, innovations in travel and healthcare have resulted in new ways to
approach patient well-being with respect to culture. At the center of major healthcare advancement
and a worldwide destination for world class care, the United States is at the forefront of globalized
healthcare. Nurses in particular have the opportunity to meet immigrants, refugees, and a plethora
of other patients of different cultural backgrounds, a concept not necessarily regarded very
frequently among caregivers (Leininger & McFarland, 2002, p. 3). Madeleine Leininger’s (1978)
theory of transcultural nursing embodies the basis of this work: If human beings are to survive and
live in a healthy, peaceful and meaningful world, then nurses and other health care providers need to
understand the cultural care beliefs, values and lifeways of people in order to provide culturally
congruent and beneficial health care. (p. 3)
Examples of the Theory in Practice
Due to varying education, environments, and experiences, some healthcare professionals are not as readily
prepared to handle differences in patient backgrounds. Examples of such discrepancies have been illustrated
by Leininger, where providers lack full understanding of patient needs and find the experiences peculiar when
in fact a transcultural provider would both comprehend and accommodate such variances in care requested.
A familiar example of the lack of transcultural understanding in a healthcare setting is seen of a Mexican-
American woman late to her appointment. The patient explained her situation: lack of transportation, child
care, and directions. However, the hospital staff did not understand the woman’s hardship and did not
accommodate the patient. Consequently, the highly upset patient sought a local healer instead of pursuing
mainstream healthcare (Leininger, 2001, p. 64).

In another scenario incorporating non-Western thinking is of a deceased Vietnamese child, whose entire
extended family accompanied him at the emergency department and covered his head with a white sheet.
The family’s actions confused nurses and doctors, especially with the number of mourning family members
present, making providers feel uncomfortable. The transcultural nurse would have realized that the scenario
was a spiritual tradition performed by the Vietnamese in times of family misfortune (Leininger, 2001, p. 63).
Examples of the Theory in Practice

Finally, in another non-Western scenario, a Chinese man was told to drink cold water without alternative
beverages being offered. He refused it and was then told if he did not drink the water that he would
require intravenous fluids. The patient’s daughter subsequently needed to explain to the staff that her
father preferred hot tea as an alternative (Leininger, 2001, p. 63). A transcultural provider would have
attempted to communicate with the patient, accommodating his preferences instead of threatening him or
becoming frustrated with the situation.
References
Transcultural Nursing Society. (n.d.). Transcultural Nursing Society. Retrieved August 1, 2014, from https://www.tcns.org/

Tributes to Dr. Madeleine Leininger. (n.d.). Tributes to Dr. Madeleine Leininger. Retrieved August 1, 2014, from
https://www.madeleine-leininger.com/

Leininger, M. (1978). Transcultural nursing: Concepts, theories, and practices. In George, J. (Ed.). Nursing theories: the base for
professional nursing practice. Norwalk, Connecticut: Appleton & Lange.

Leininger, M. (1979). Transcultural nursing. In George, J. (Ed.). Nursing theories: the base for professional nursing practice. Norwalk,
Connecticut: Appleton & Lange.

Leininger, M. M. (1991). Culture care diversity and universality: A theory of nursing. In George, J. (Ed.). Nursing theories: the base for
professional nursing practice. Norwalk, Connecticut: Appleton & Lange.

The Theory of Culture Care and Universality; Marilyn McFarland, Hiba Webbe-Alamah

Madeleine Leininger and the Transcultural Theory of Nursing Daniel A. Busher Betancourt Cleveland State University; Volume 2,
Issue 1, October 2015
 Joyce Travelbee
(Human-to-Human Relationship Model)
Introduction
● Joyce travelbee (1926-1973) was a theoretical nurse who developed the interpersonal
aspects of nursing with a particular focus on psychiatric nursing.

● Her studies made great contributions to the field of nursing, promoting improvements
between the interpersonal relationships of the nurse and the patient.

● She believed that patients were seen as objects of care and not as humans, and that
this was a main point that should be changed to offer timely help.
Life story, Educational Background & Career

● Joyce Travelbee (1926-1973), was a psychiatric nurse, educator and a writer. In 1956, she graduated
from Louisiana State University with her BSN degree.
● In 1959, she earned her Master's of Science Degree from Yale University. In 1963 she started to issue
articles and journals in nursing. In 1966 she issued her 1st book titled Interpersonal Aspects of Nursing
followed by a continuation of that book published in 1971.
● Her next book Intervention in Psychiatric Nursing: Process in the One-to-One Relationship, was
published in 1969. In the year 1973 she began her Doctoral program in Florida, which she would not
live to finish.
● In the summer of 1973, at the age of 47 Joyce Travelbee died after a brief sickness. She was continually
developing new methods and was far ahead of her time in the development of these concepts.
● Joyce Travelbee believes that nursing requires a holistic approach that considers all factors affecting a
client's health—physical, physiological, psychological, mental, social, cultural, developmental and
spiritual well-being.
Theoretical Sources
● Catholic charity institutions
● Ida Jean Orlando, her instructor—“The nurse is responsible for helping the patient
avoid and alleviate the distress of unmet needs.” The nurse and patient interrelate
with each other.
● Viktor Frankl, a survivor of Auschwitz and other Nazi concentration camps—
proposed the theory of logotherapy in which a patient is actually confronted with
and reoriented toward the meaning of his life.
Major Concepts
SUFFERING, which is “an experience that varies in intensity, duration and
depth…a feeling of unease, ranging from mild, transient mental, physical or
mental discomfort to extreme pain….”

MEANING, which is the reason attributed to a person

NURSING, which helps a person find meaning in the experience of illness and
suffering; has a responsibility to help people and their families find meaning;
and the nurse’s spiritual and ethical choices, and perceptions of illness and
suffering, which are crucial to help patients find meaning.
Major Concepts (cont’d)
HOPE which is a faith that can and will be a change that would bring something better with it. Six
important characteristics of hope are: dependence on other people, future orientation, escape
routes, the desire to complete a task or have an experience, confidence that others will be there
when needed, and the acknowledgment of fears and moving forward towards its goal.

COMMUNICATION which is “a strict necessity for good nursing care.”

SELF-THERAPY which is the ability to use one’s own personality consciously and in full
awareness in an attempt to establish relatedness and to structure nursing interventions. This refers
to the nurse’s presence physically and psychologically.

TARGETED INTELLECTUAL APPROACH by the nurse toward the patient’s situation.

Theory’s Background
● Travelbee based the assumptions of her theory on the concepts of existentialism by Soren
Kierkegaard and logotherapy by Viktor Frankl. Existential theory believes that humans are constantly
faced with choices and conflicts and is accountable to the choices we make in life. (Viktor Frankl who
states that feeling full is the best protection and cure for emotional instability.)

Travelbee believed nursing is accomplished through human-to-human relationships that begin with
the original encounter and then progress through stages of emerging identities, developing feelings
of empathy, and later feelings of sympathy.The nurse and patient attain a rapport in the final stage.
For meeting the goals of nursing it is a prerequisite to achieving a genuine human-to-human
relationships.
Human-to-Human Relationship Model
This relationship can only be established by an interaction process.

It has five phases.

1. Original encounter
2. Emerging identities
3. Empathy
4. Sympathy
5. Rapport
Phases of Interaction

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Human -to Human
Relationship Model
Nursing Paradigm
Person

- Person is defined as a human being.

- Both the nurse and the patient are human beings.

- A human being is a unique, irreplaceable individual who is in continuous process of becoming, evolving and changing

Health

- Health is subjective and objective.

- Subjective health—is an individually defined state of well being in accord with self-appraisal of physical-emotional-
spiritual status.

- Objective health—is an absence of discernible disease, disability of defect as measured by physical examination,
laboratory tests and assessment by spiritual director or psychological counselor.
Nursing Paradigm (cont’d)
Environment
- Environment is not clearly defined.
- She defined human conditions and life experiences encountered by all men as sufferings, hope,
pain and illness.

Nursing
- Nursing is an interpersonal process whereby the professional nurse practitioner assists an
individual, family or community to prevent or cope with experience or illness and suffering, and if
necessary to find meaning in these experiences.”
Significance of the Theory

Travelbee provides nursing with the criteria for connecting to ill persons. She has created
a conceptual framework upon which to base therapeutic relationships with patients,
families, and communities in distress or having the potential for suffering. Her
definitions of the components of the metaparadigm of nursing’s phenomena of interest
add to the social significance and social utility of her theory (Roy, 1988). Travelbee’s
model teaches nurses to understand—or at least explore—the meaning of illness and
suffering in themselves. It is through this existential identification that one human being
can relate to another human being.
Examples of the Theory in Practice

1. Nursing Practice:
Travelbee’s use of the interpersonal process in nursing intervention and
her focus on suffering and illness helped to define areas of concern for psychiatric mental
health nurses as well as all nursing fields. She is also credited with greatly influencing the
hospice movement. Travelbee believed that understanding illness and suffering enables the
patient to accept the illness and use it as self-actualizing life experience. As a hospice nurse,
the dying patient must find meaning in his or her death before he or she can ever begin to
accept the actuality of death.
Examples of the Theory in Practice (cont’d)
2. Nursing Education
Travelbee created a conceptual framework upon which to base
therapeutic relationships with patients, families, and communities in distress or having the
potential for suffering. Her model teaches nurses to understand the meaning of illness and
suffering in themselves. (Shelton, 2016) Furthermore, it assists nurses in building empathy
and sympathy.

3. Nursing Research
Travelbee’s theory that “patients are seen as unique individuals and as human beings is in
keeping with the current guidelines and expectations set forth by agencies such as the Institute
of Medicine, the American Nurses Association, and the Joint Commission for Hospital
Accreditation. Care should be patient-centered” (Shelton, 2016). Travelbee’s theory has been
applied in the research for caring for cancer patients and of newly diagnosed patients.
 Rosemarie Rizzo
Parse
(Human Becoming Theory)
Introduction
The Parse theory of human becoming guides nurses in their practice to focus on
quality of life as it is described and lived (Karen &Melnechenko, 1995).

The human becoming theory of nursing presents an alternative to both the

conventional biomedical approach and the bio-psycho-social-spiritual (but still
normative) approach of most other theories of nursing.(ICPS)

The human becoming theory posits quality of life from each person's own
perspective as the goal of nursing practice.(ICPS)

Rosemarie Rizzo Parse first published the theory in 1981 as the "Man-living-health"
theory (ICPS)
About the theorist
● Educated at Duquesne University, Pittsburgh
● MSN and Ph.D. from University of Pittsburgh
● Published her theory of nursing, Man-Living-Health in 1981
● Name changed to Theory of Human Becoming in 1992
● Editor and Founder, Nursing Science Quarterly
● Has published eight books and hundreds of articles about Human
Becoming Theory
● Professor and Niehoff Chair at Loyola University, Chicago
What is the Theory all about
According to Parse, in her theory that was first published in 1981 as the “Man-Living-
Health” theory that was changed to the “Human Becoming Theory” in 1992, “nursing is a
science and the performing art of nursing is practiced in relationships with persons
(individuals, groups, and communities) in their processes of becoming.” This explains
that a person is more than the sum of the parts, the environment and the person are
inseparable, and that nursing is a human science and art that uses an abstract body of
knowledge to help people.

Her theory guides the practice of nurses to focus on quality of life as it is described and
lived as it presents an alternative to both the conventional biomedical approach as well
as the bio-psycho-social-spiritual approach of most other theories and models of
nursing. Simply put, Parse’smodel rates quality of life from each person’s own
perspective as the goal of practice of nursing.
Theory Development and Its Model

● The Human Becoming Theory was developed as a human

science nursing theory in the tradition of Dilthey, Heidegger,
Sartre, Merleau-Ponty, and Gadamer and Science of
Unitary Human Beings by Martha Rogers.
● Thus, the assumptions underpinning the theory were
synthesized from works by their works - European
philosophers, Heidegger, Sartre, and Merleau- Ponty, along
with works by the pioneer American nurse theorist, Martha
Rogers
● The model makes assumptions about man and becoming, as
well as three major assumptions about human becoming
which are, meaning, rhythmicity, and transcendence, where
the theory is structured or centered around.
The theory’s assumptions are listed as follows:

About Man
• The human is coexistent while co-constituting rhythmical patterns with the universe.
• The human is open, freely choosing meaning in a situation, as well as bearing responsibility
for decisions made.
• The human is unitary, continuously co-constituting patterns of relating.
• The human is transcending multidimensionally with the possibles.

About Becoming
• Becoming is unitary with human-living-health.
• Becoming is a rhythmically co-constituting the human-universe process.
• Becoming is the human’s pattern of relating value priorities.
• Becoming is an intersubjective process of transcending with the possibles.
• Becoming is the unitary human’s emerging.
Three Major Assumptions About Human Becoming
Meaning
• Human becoming is freely choosing personal meaning in situations in the intersubjective
process of living value priorities.
• Man’s reality is given meaning through lived experiences.
• Man, and environment co-create.

Rhythmicity
• Human becoming is co-creating rhythmic patterns of relating in mutual process with the
universe.
Man, and environment co-create (imaging, valuing, language) in rhythmical patterns.

Transcendence
• Human becoming is co-transcending multidimensionally with emerging possibilities.
• Refers to reaching out and beyond the limits a person set.
• One constantly transforms.
Nursing Paradigm
Person Health
Open being who is more than and Open process of being and becoming.
different from the sum of the parts Involves synthesis of values

Environment Nursing
Everything in the person and his A human science and art that uses an
experiences abstract body of knowledge to serve
Inseparable, complimentary to and people
evolving with
Symbol of Human Becoming Theory
Rosemarie Rizzo Parse’s Human Becoming Theory includes the Totality
Paradigm, which states that man is a combination of biological,
psychological, sociological, and spiritual factors. It also includes the
simultaneity paradigm, which states that man is a unitary being in
continuous, mutual interaction with the environment.

Parse’s theory includes a symbol with three elements:

● The black and white colors represent the opposite

paradox significant to ontology of human becoming,
while green represents hope.
● The joining in the center of the symbol represents the
co-created mutual human universe process at the
ontological level, and the nurse-patient process.
● The green and black swirls intertwining represent the
human universe co-creation as an ongoing process of
becoming.
STRENGTHS WEAKNESSES
Research considered to be in a “closed circle”
Differentiates nursing from other
disciplines
Rarely quantifiable results - Difficult to compare to
Practice - Provides guidelines of care and other research studies, no control group,
standardized questions, etc.
useful administration
Does not utilize the nursing process/diagnoses
Useful in Education
Negates the idea that each person engages in a
Provides research methodologies unique lived experience

Provides framework to guide inquiry of Not accessible to the novice nurse

other theories (grief, hope, laughter, etc.)
Not applicable to acute, emergent care
Examples of the Theory in Practice or Case Study

Nursing Practice
A transformative approach to all levels of nursing
Differs from the traditional nursing process, particularly in that it does not seek to “fix” problems
Ability to see patient’s perspective allows nurse to “be with” patient and guide them toward
desired health outcomes
Nurse-person relationship co-creates changing health patterns

Research
Enhances understanding of human lived experience, health, quality of life and quality of
nursing practice
Expands the theory of human becoming
Builds new nursing knowledge about universal lived experiences which may ultimately
contribute to health and quality of lide
Thank You!
 NEWMAN’S THEORY:
HEALTH AN EXPANDING
CONSCIOUSNESS
Middle - Range Theories

JOSUE LUCKSLEY EFRAIM P. MARAVILLA, RN

MARGARET NEWMAN’S BIOGRAPHY

Born on Oct. 10, 1933

Bachelor’s Degree – University of
Tennessee in 1962
Master’s Degree – University of California in
1964
Doctorate – New York University in 1971
She has worked in – University of
Tennessee, New York University,
Pennsylvania State University, University of
Minnesota
“ Health is the expansion of
consciousness”
-Newman, 1983
 INTRODUCTION

 The theory of health as expanding consciousness stimulated by concern for

those for whom health as the absence of disease or disability is not possible,
(Newman, 2010).

 The theory has progressed to include the health of all persons regardless of the
presence or absence of disease, (Newman, 2010).

 The theory asserts that every person in every situation, no matter how
disordered and hopeless it may seem, is part of the universal process of
expanding consciousness, (Newman, 2010).
The theory emanated from Newman’s early personal
family experiences. Her mother’s struggle with a chronic
illness and her dependency on Newman sparked an
interest in nursing. From that experience evolved the idea
that “illness reflected the life patterns of the person and
that what was needed was the recognition of that pattern
and acceptance of it for what it meant to that person”.
 THEORETICAL SOURCES

• “Theory of Unitary Human Beings”

1 Martha Rogers • The main basis of the development of Newman’s Theory.

• The health of a human being is a unitary phenomenon, an evolving pattern of

human-environment (Rogers, 1970).

2 Itzhak Bentov • “The Concept of Evolution of Consciousness”

• “Life is a process of expanding consciousness. Consciousness is the informational capacity of
the system and can be seen in the quality of interaction of the systems with the
environment” (Bentov, 1978).

3 Arthur Young • “The Theory of Process”

• A person moves through stages of consciousness involving the loss of freedom in the
development of self-identity until a turning point is reached when the ‘old rules’ don’t work
anymore. The life task is to discover the ‘new rules’ and move toward increasing freedom
and higher consciousness (Young, 1976).
 THEORETICAL SOURCES

4 David Bohm • “The Theory of Implicate”

• The explicate order is a manifestation of the implicate

order. (Bohm, 1980).

5 Prigogine • “Theory of Dissipative Structure”

• A system fluctuates in an orderly manner until the
occurrence of a disruptive event, at which time the
system moves in seemingly random, disorderly ways until
it chooses a new direction at a higher level of organization
(Prigogine, 1976).
 ARTHUR YOUNG’S
THE THEORY OF PROCESS
MAJOR CONCEPTS AND DEFINITION
 HEALTH

 Roger’s insistence that health and illness are simply manifestations of the
rhythmic fluctuations of the life process is the foundation for viewing health and
illness as a unitary process moving through variations in order-disorder. From this
standpoint, one can no longer think of health and illness in the dichotomous way
characterized by medical science; that is, health as absence of disease or health
as a continuum from wellness to illness. Health and the evolving pattern of
consciousness are the same.
 In Newman’s theory, health is an expansion of consciousness defined as the
informational capacity of the system and seen as the ability of the person to
interact with the environment (Newman, 1994). According to Newman (1999),
“Health is the pattern of the whole, and wholeness is one cannot lose it or gain
it”.
 PATTERN
A person is identified by her or his pattern, which reflects the pattern
of the person within the larger pattern of the environment. The
pattern is evolving through various permutations of order and
disorder, including what in everyday language is called health and
disease. Pattern recognition emerges from a process of uncovering
meaning in a person’s life. Meaning is inherent in pattern, and vice
versa.
Pattern is characterized by “movement, diversity, and rhythm” and is
described as a “design, or framework as is seen in person-environment
interactions”.
Pattern Recognition is the “insight or recognition of a principle,
realization of a truth, or reconciliation of a duality” and is “key to the
 CONSCIOUSNESS

Defined as the informational capacity of the system (in this

case, the human being); that is, the ability of the system to
interact with the environment (Bentov, 1978).
Consciousness includes not only the cognitive and affective
awareness normally associated with consciousness, but also the
interconnectedness of the entire living system, which includes
physiochemical maintenance and growth processes as well as
the immune system. This pattern of information, which is the
consciousness of the system, is part of a larger, undivided
pattern of an expanding universe.
THREE CORRELATES OF CONSCIOUSNESS:

MOVEMENT
TIME
SPACE
Parallel between Newman’s theory of Expanding consciousness and Young’s Stages of Human Evolution.
To see health as the pattern of the whole, one needs to see
disease not as a separate entity but as a manifestation of the
evolving pattern of person-environment interaction. The
paradigm shift is:

From treatment of symptoms to a search of pattern.

From viewing disease and disruption as negative to viewing
them as part of the self-organizing process of expanding
consciousness.
From viewing the nursing role as addressing the problems of
disease to assisting people to get in touch with their own
pattern of expanding consciousness.
 MAJOR ASSUMPTIONS

1. Health encompasses conditions heretofore described as illness,

or, in medical terms, pathology.
2.These pathological conditions can be considered a manifestation
of the total pattern of individual.
3. The pattern of the individual that eventually manifests itself as
pathology is primary and exists prior to structural and functional
changes.
4.Removal of the pathology in itself will not change the pattern of
the individual.
5.Health is an expansion of consciousness.
 NURSING
PARADIGMS
 NURSING
Nursing is “caring in the human
health experience”.
Nursing is seen as a partnership
between the nurse and client, with
both growth in the “sense of
higher levels of consciousness”.
 HEALTH

“Health and illness are

synthesized as health – the
fusion on one state of being
(disease) with its opposite
(non-disease) results in
what can be regarded as
health”
 PERSON/HUMAN
“The human is unitary, that is cannot be divided
into parts, and is inseperable from the larger
unitary field”.
“Persons as individuals, and human beings as a
species are identified by their patterns
consciousness”.
“The person does not possess consciousness – the
person is consciousness”
Persons are “centers of consciousness” within an
overall pattern of expanding consciousness.
 ENVIRONMENT
 Environment is described as
a “universe of open system”.
Nurse and patient coming together and moving apart in process recognition,
insight, and transformation.
 SIGNIFICANCE OF THE THEORY
“The theory has progressed to include the health of all
persons regardless of the presence or absence of disease.
The theory asserts that every person in every situation no
matter how disordered and hopeless it may seem, is part of
the universal process of expanding consciousness – a
process of becoming more of oneself, of finding greater
meaning in life, and of reaching new dimensions of
consciousness with other people and the world”
(Newman, 2010)
STRENGTHS
AND
WEAKNESSES
 STRENGTHS

oCan be applied in any setting

oGenerates caring interventions
 WEAKNESSES

oAbstract
oMulti-dimensional
oQualitative
oLittle discussion on environment
ACCEPTANCE OF THE
THEORY IN NURSING
COMMUNITY
 PRACTICE
Newman’s model of Health is useful in the practice of
nursing because it contained concepts used by the
nursing profession. Movement and time are an
intrinsic part of nursing intervention, that is, range-of-
motion, ambulation, turning side to side, coughing,
and deep breathing exercise. These parameters are
used each day by the nursing practice.
 RESEARCH
Some researchers have attempted to test Newman’s propositions
of time, space, and movement.

A negative correlation was found between depression and subjective

time – findings do not support an increasing level of consciousness
with age.

Cooperative inquiry or interactive, integrative participation

- Newman stated that research should center around “participatory
investigations in which subjects (clients) are our partners, our core-
researchers, in our search for health patterns”.
CASE STUDY
 REFERENCES
• Martha, R. Alligood, (2014). Nursing Theorists and Their Work. 8th
ed. Missouri: Elsevier.
• Marilyn E. Parker, (2005). Nursing theories an nursing practice. 2nd
ed. Philadelphia: Davis company.
• Tomey, A.M., (1994). Nursing Theorists and Their Work. 3rd ed.
Missouri: Mosby
• http://currentnursing.com/
• http://healthasexpandingconsciousness.org/
 NOLA PENDER:
“HEALTH
PROMOTION MODEL”
BY: JOSUE LUCKSLEY EFRAIM P. MARAVILLA, RN
 INTRODUCTION
• Improving and protecting the health of the people have always been a priority
for healthcare workers and policy makers.
• Initially, healthcare focused mainly on recovering health and later stages, more
attention paid towards prevention of illness and health promotion.
• WHO states that health promotion is the fundamental strategy in healthcare
that implies changes in behavior and adoption of patterns that promote good
health.
• Among the many models of health related quality of life, Pender’s Health
Promotion behavior model helps to identify factors influenced the decisions
and actions of individuals that were made to prevent disease and promote a
healthy lifestyle.
 BIOGRAPHY

• Nola Pender was born on August 16, 1941, in Lansing,

Michigan.
• Her first encounter with the nursing profession was when
she was 7 years old and witnessed the care given to her
hospitalized aunt by nurse.
• This situation led her to the desire to care for other
people and her goal was to help people care for
themselves.
 EDUCATION
• Nola Pender entered the School of Nursing at West Suburban Hospital in Oak
Park, Illinois, and received her nursing diploma in 1962.
• In 1965, she received her Master’s Degree in Human Growth and
Development from the same university.
• She obtain her Ph.D. in psychology and education in 1969 at Northwestern
University in Evanston, Illinois.
• Pender’s dissertation research investigated developmental changes in the
encoding process of short-term memory in children.
• Years later, she finished masters-level work in community health nursing at
Rush University.
 CAREER AND ACHIEVEMENTS

• American community health nursing educator.

• Fellow American Academy Nursing; member American Nurses
Association (Chairman Research Cabinet 1982-1984).
• Midwest Nursing Research Society ( President 1985-1987).
• American Academy Nursing ( President 1991-1993).
• National Institutes of Health ( National Advisory Council Nursing
Research National Center for Nursing Research 1987-1990, research
program grantee 1985-1991).
• Nola J. Pender has been listed as a noteworthy community
health nursing educator.
• Designated as a living legend of the American Academy of
Nursing in 2012.
• Professor Emerita – Division of Health Promotion & Risk
Reduction, Michigan State University School of Nursing.
• Distinguished Professor – Loyola University Chicago,
School of Nursing.
 WHAT IS THE THEORY ALL ABOUT?

• Have you ever noticed advertisements

in malls, grocery stores, or schools that
advocate healthy eating or regular
exercise?
• Have you gone to local centers or
hospitals promoting physical activities
and smoking cessation programs?
 THEORETICAL SOURCE

Feather’s Expectancy Value Theory

• Patients will work towards goal they see as beneficial and achievable.

Bandura’s Social Cognitive Theory

• Self efficacy – confidence of the patient to carry out an action.
NOLA PENDER’S HEALTH PROMOTION MODEL
• Nola Pender’s Health Promotion Model theory was originally
published in 1982 and later improved in 1996 and 2002.
• The Health Promotion Model notes that each person has
unique personal characteristics and experiences that affect
subsequent actions.
• Health promoting behavior is the desired behavioral outcome
and is the endpoint in the Health Promotion Model.
 HEALTH PROMOTION MODEL (HPM)

• The Health Promotion Models (HPM) proposed by Nola J. Pender (1982;

revised, 1996) was designed to be a “complimentary counterpart to
models of health promotion”.
• It defines health as “a positive dynamic state not merely the absence of
disease”.
• Health Promotion is directed at increasing a client’s level of well being.
• The model describes the Multi-Dimensional nature of persons as they
interact within their environment to pursue health.
 THE MODEL FOCUSES ON THE FOLLOWING
THREE AREAS:

1. Individual Characteristics and Experiences

2. Behavioral – specific cognitions and affect
3. Behavioral outcomes
 ASSUMPTIONS OF THE MODEL

1. Individuals seek to actively regulate their own behavior.

2. Individuals in all their biopsychosocial complexity interact with the
environment, progressively transforming the environment and being
transformed over time.
3. Health professionals constitute a part of the interpersonal
environment, which exerts influence on persons throughout their life
span.
4. Self-initiated reconfiguration of person-environment interactive
patterns is essential to behavioral change.
MAJOR CONCEPT OF THE HEALTH PROMOTION
MODEL

• Health Promotion is defined as behavior motivated by the

desire to increase well-being and actualize human health
potential. It is an approach to wellness.
• Health Protection or illness prevention is described as
behavior motivated desire to actively avoid illness, detect it
early, or maintain functioning within the constraints of illness.
 INDIVIDUAL FACTORS AND EXPERIENCES

 Prior Related Behavior – frequency of the same or similar health behavior in the past.
 Personal Factors:

a. Biological – age, gender, body mass index, pubertal status, aerobic capacity,
strength, agility, or balance.
b. Sociocultural – race, ethnicity, acculturation, education, socioeconomic status
c. Psychological – self-esteem, self – motivation, perceived health status, and
definition of health
 BEHAVIOR – SPECIFIC COGNITIONS AND
AFFECT
Perceived benefits of action – anticipated positive outcomes that will occur from health
behavior.
Perceived barriers to action – perceptions of the blocks, hurdles, and personal costs of
understanding a health behavior.
Perceived self – efficacy – judgement of personal capability to organize and execute a particular
health behavior; self – confidence in performing the health behavior successfully.
Activity – related affect – subjective feeling states or emotions occurring prior to, during and
following a specific health behavior.
Interpersonal influences ( Family, Peers, Providers): norms, social support, role
models, perceptions concerning the behaviors, beliefs, or attitudes of relevant others.
Situational influences ( Options, demand characteristics, aesthetics) – perceptions of
the compatibility of life context or the environment with engaging in a specific health
behavior.
Commitment to plan of action – intention to carry out a particular health behavior
including the identification of specific strategies to do so successfully.
Immediate competing demands and preferences – alternative behaviors that intrude
into consciousness as possible courses of action just prior to the intended occurrence
of a planned health behavior.
 BEHAVIORAL OUTCOME – HEALTH
PROMOTING BEHAVIOR
Health Promoting Behavior – the desired behavioral end point or
outcome of health decision-making and preparation for action.
 PENDER’S
HEALTH
PROMOTION
MODEL
 NURSING
METAPARADIGM
PERSON:

 Refers to the individual who is the primary focus of the model.

 Each person has a unique personal characteristics and experiences that
affect subsequent actions.
 It is recognized that individuals learn health behaviors within the context
of the family and the community.
ENVIRONMENT:

 Refers to physical, interpersonal and economic

circumstances in which persons live the quality of
the environment depends on the absence of toxic
substances, availability of restorative experiences
and accessibility.
HEALTH:
 Health is viewed as Positive high level
state.
 According to Pender, the person’s
definition of health for himself or herself
is more important than any general
definition of health.
NURSING:
 Does not specifically define nursing
 The role of nurse includes raising
consciousness related to health promoting
behavior, promoting self efficacy, enhancing
the benefits of change, controlling the
environment to support.
 SIGNIFICANCE OF THEORY
• The HPM provides a counterpart to model based on illness-prevention.
• Enhances individual’s functional ability and improves their quality of
life.
• Benefits society as a whole which include economic prosperity,
interpersonal harmony, decreased social violence, suicide, sexually
transmitted disease, and reduced health care costs.
• Useful in many different settings such as workplaces, homes and health
centers.
• Research using the HPM: smoking cessation, weight management,
exercise and stress management.
• The HPM allows for personalized nursing interventions with care plans
designed with patient-specific goals.
• Can be used for conducting studies that predict effective
factors/barriers in health-promotion behaviors, detect impacts of
intervention program for improving health promotion behaviors, test
this model, and identify quality of life.
 STRENGTHS
• The health promotion model is simple to understand yet it is complex
in structure.
• Nola Pender’s nursing theory gave much focus on health promotion and
disease prevention making it stand out from other nursing theories.
• It is highly applicable in the community health setting.
• It promotes the independent practice of the nursing profession being the
primary source of health promoting interventions and education.
 WEAKNESSES

• The Health Promotion Model of Pender was not able to define the
nursing metaparadigms or the concepts that a nursing theory should
have, man, nursing, environment, and health.
• The conceptual framework contains multiple concepts which may
invite confusion to the reader.
• Its applicability to an individual currently experiencing a disease state
was not given emphasis.
 CASE STUDY
• Sally, a 25 year old, Caucasian student wants to lose weight. She would like to have more energy during
the day. She is tired of seeing the scale in the 180s. High blood pressure runs in her family. Her father has
had three stents put into his heart by the age of 50 and had a mild heart attack. Upon assessment her blood
pressure is 118/44mmHg, height is 5’3”, weight 182lbs. Sally states that her stress level is high. She is
unable to get a job, and has two children to take care of. Her husband works full-time making minimum
wage. She is a non smoker. She levels the office to have more blood work completed.
• Questions:
1. What evidence would show Sally is ready for weight loss management?
2. What are some perceived barriers and perceived benefits of action?
3. What are some personal factors that affect her weight loss and health?
4. What are some behavior options to over with Sally?
 ANSWERS
1. What evidence would show Sally is ready for weight loss management?
- She came to the office on her own
- She is tired of the scale being in the 180’s
- Family History

2. What are some perceived barriers and perceived benefits of action?

- Perceived Barriers
a. Not having enough time or energy to exercise
b. Not having money to buy healthy foods
c. High stress level
- Perceived Benefits of Action
d. More energy to play with children
e. Healthier
f. Decreased chances of heart disease
3. What are some personal factors that affect her weight loss and health?
a. Young Adult
b. BMI is obese
c. Sees self as overweight
d. Lower socio-economic status
e. Caucasian
f. College Education

4. What are some behavior options to go over with Sally?

a. Help establish an exercise routine that fits into her schedule
b. Set short and long term goals
c. Schedule weekly weight checks
d. Go over a healthy diet
e. Talk about stress management
f. Address any dietary concerns
 REFERENCES
• Byam-Williams, J.B. (2010), Salyer, J. Factors influencing the health-related lifestyle
of community- dwelling older adults. Home Healthcare Nurse, 28 (2), p 115-121.
• Current Nursing. (2010). Health Promotion Model. Retrieved from
http://currentnursing.com/nursing_theory/health_promotion_model.html
• Nursing Theory. (2010). Health Promotion Model. Retrieved from
http://www.nursingtheory.net /mr_healthpromotion.html
• Pender, N. J., Murdaugh, C. L., & Parsons, M. (2006). Health Promotion in Nursing
Practice.
Upper Saddle River, New Jersey: Pearson Prentice Hall.
 Katharine
Kolcaba
“Comfort Theory”
Middle Range Theory
By: Josue Lucksley Efraim P. Maravilla, RN
 Theorist Background
• Founder of Comfort Theory in Nursing
• Born on Dec. 28th , 1944 in Cleveland, Ohio
• Diploma in Nursing – St. Luke’s Hospital 1965
• BSN – Frances Payne Bolton School of Nursing – 1987
• PhD and Clinical Nursing Specialist – 1997
• Associate Professor of Nursing Emeritus at the University
of Akron College of Nursing.
 What is Comfort?
• According the Kolcaba, K. it is the state of having addressed basic needs for ease, relief, and
transcendence met in 4 contexts of experience (physical, psychospiritual, sociocultural, and
environmental)
• Comfort involves identifying the comprehensive needs of patients, families, and nurses and
addressing those needs.
• Comfort Theory originated from a Masters Program Assignment – to diagram her nursing practice.
• Comfort was the state she wanted her Alzheimer patient’s to be in when not participating in
activities or tasks. Comfort became her focus in nursing practice and research.
• On later part, comfort theory was applied to other fields of nursing, such as perioperative care and
pediatrics.
Conceptual Framework for Kolcaba’s
Comfort Theory
 Types of Comfort
• Relief – when a particular needs of a patient is satisfied. Has the same
principles as Orlando’s (1961/1990) need-based philosophy of nursing.
• Ease - a state whereby a person is calm and content. Consistent wit the
13 fundamental human requirements by Henderson (1978).
• Transcendence – a state in which one outgrows difficult situations or
pain. It Originates from the principles used by Paterson & Zderad,
(1976/1988) to denote more being.
 Four Context of Comfort
1. Physical – pertaining to sensations (pain, cold, heat, tingling), homeostatic mechanisms
(temperature control, bleeding, vomiting) or function of the immune system.
2. Psychospiritual – pertaining to internal awareness of self, including esteem, identity,
sexuality, meaning in ones life, and one’s feelings or beliefs in a higher power or superior
being.
3. Environmental – pertaining to the external background of human experience
(temperature, light, sound, odor, color, furniture, landscape).
4. Social – pertaining to interpersonal, family and societal relationship; also includes family
traditions, rituals, and religious practices.
 TAXONOMIC STRUCTURE
• It is the combined three types of comfort and four contexts to create a 12
cell grid. This structure was created by Kolcaba in 1991.
• This can be used as a guide when assessing a patient’s level of comfort.
• These aspects of comfort are interrelated with one another. Kolcaba did
not mean for them to be measured exactly because she felt the process
would be time – consuming and inaccurate (Kolcaba, 2003). However, a
pattern of care can be established whereby patients comfort needs are
intuitively assessed in the four contexts.
TAXONOMIC STRUCTURE
 NURSING METAPARADIGMS

• Human beings
 Includes all in need of healthcare individuals, families and entire communities or
institutions.
 The aspect of comfort is an important and innate need to be attained. All humans
deserves to be as comfortable as possible.
 Patient – focused care is integral to attaining comfort.
 When patients are more comfortable, they are more likely to engage in health seeking
behaviors including internal or external behaviors or even a peaceful death.
 NURSING METAPARADIGMS

• Environment
 Manipulation of the external surroundings of the patient to facilitate comfort by means
of touch, sights, sounds, lighting or odors to promote a calming and comforting
atmosphere.
 When the words and actions of the nurse are comforting in addition to the intent of
providing comfort then the interventions are often perceived more as a comfort measure
by the patients (Kolcaba, 2003).
 Eliminate negativity in the environment if possible to promote a positive thinking and
attitudes.
 NURSING METAPARADIGMS

• Health
 According to Katherine Kolcaba (2003), “Health is comfort”.
 To be in good health a patient must attain what they consider their highest degree of comfort.
 Comfort is a positive dynamic state and the health care team can do more to enhance comfort if
they go beyond the treatment of discomforts and physical health (Kolcaba, 2003)
 When one of the four contexts or three types of comfort is not balanced or being met then the
patient may not be at their highest level of wellness or health along the health continuum.
 NURSING METAPARADIGMS

• Nursing
 Continual active use of the nursing process to assess the comfort of the patient and address
their needs to attain comfort.
 Assessing and Reassessing whether the interventions implemented were successful in
improving the comfort of the patient.
 Providing competent empathetic, compassionate, skilled and holistic nursing care to each
patient, without inflicting judgement.
 Maintaining a strong, trusting nurse-patient relationship and involving the patient in
meeting their comfort needs and goals will make the process more successful.
 ASSUMPTIONS
• Nursing care is more efficient when theory is use because care can be
delivered in an organized manner.
• Science of Nursing is about the comfort of patients, families, and nurses.
• When nurses provide comfort measures, such as turning a patient every 2
hours, the patient is expected to have a positive outcome.
• Care is delivered and based on a humanistic and holistic approach and
patient’s needs (Kolcaba, 1991).
 Significance of the Theory
• The use Kolcaba’s Theory of Comfort in other healthcare practices has
been formulated to change “nursing interventions” and redefine as
“comfort interventions”. (March & McCormick, 2009).
 Case Study
• MN a male client is operated for gallstones. On a postoperative night, the
nurse finds that the client is not sleeping and is tossing and turning. He
had colonoscopy two days ago, and is suspicious of colon cancer because
his sister passed away two months ago with colon cancer. No family
member has visited him yet since his admission. Patient yells at the nurse
as she responds to his call light, “you guys will not shut up for me to
sleep and I have been in pain all night”. Which nursing action is most
appropriate? Using taxonomic structure, formulate a plan of care for MN.
 References:
• Apostolo, J.L.A., & Kolcaba, K., (2009). The effects of guided imagery on comfort, depression, anxiety, and stress
of psychiatric inpatients with depressive disorders. Archives of Psychiatric Nursing, 23(6), 403-411
• Kolcaba, (1991). A Taxonomic Structure for the. Journal of Nursing Scholarship , 23 (4), pp. 237-240.
• Kolcaba, K. (1995). Comfort as process and product, merged in holistic nursing art. Journal of Holistic Nursing,
128-129. Retrieved from http://jhn.sagepub.com/content/13/2/117
• Kolcaba, K. (2003). Comfort theory and practice: A vision for holistic health care and research. P. 9-17, 34-35, 59-
68. Springer Publishing Company: New York.
• Kolcaba, K., & DiMarco, M. A. (2005). Comfort theory and its application to pediatric nursing, Pediatric
Nursing, 31 (3), p. 187-194. Retrieved from PubMed
• Kolcaba, K., Tilton, C., & Drouin. (2006). Comfort theory: a unifying framework to enhance the practice
environment. The Journal of Nursing Administration, 36(11), p538-544. Retrieved from:
http://journals.lww.com/jonajournal/pages/issuelist.aspx
RAMONA T.MERCER
Biography and
Theory
Ramona T. Mercer
boigraphy
 Ramona Thieme Mercer (born October 4,
1929) is the author of a mid-range nursing
theory known as maternal role attainment.
Mercer has contributed many works to the
refinement of this theory and is credited as a
nurse-theorist. She was the Nahm Lecturer
1984 at the University of California
 Career
 Mercer earned a diploma from St. Margaret’s School of Nursing
in Montgomery, Alabama. She earned an undergraduate degree
in nursing with distinction from the University of New Mexico in
1962, followed by a master's degree in maternal child nursing
from Emory University

 in 1964. For ten years, she worked as a staff nurse, head nurse
and instructor. She was a faculty member at Emory University for
five years until she left to pursue doctoral studies in maternity
nursing at the University of Pittsburgh. Mercer earned a diploma
from St. Margaret’s School of Nursing in Montgomery, Alabama.
She earned an undergraduate degree in nursing with distinction
in 1964. For ten years, she worked as a staff nurse, head nurse
and instructor.
HONORS AN AWARD

• 1988: Distinguished Research Lectureship Award,

Western Society for Research in Nursing
(inaugural award)
2003: Living Legend, American Academy of
Nursing
2004: Distinguished Alumni Award, University of
New Mexico College of Nursing
 WORKS
• (1980). "Teenage motherhood: The first year". Journal of Obstetric,
Gynecologic, and Neonatal Nursing
• IN (1981) "A theoretical framework for studying factors that impact on
the maternal role".
• .IN (1985). "The process of maternal role attainment over the first
year". Nursing Research..
• IN (1986). First-time motherhood: Experiences from teens to forties.
New York: Springer.
• Mercer, Ramona; May, KA; Ferketich, S; Dejoseph, J (1986).
"Theoretical models for studying the effect of antepartum stress on the
family".
• IN (1995). Becoming a mother: Research on maternal identity from
Rubin to the present. New York: Springer.
• Mercer,and Ferketich, S. (1990). "Predictors of parental attachment
during early parenthood". Journal of Advanced Nursing. Mercer and
Ferketich, S.
• (1994). "Predictors of maternal role competence by risk
status". Nursing Research
Ramona T. Mercer is a well-known
nursing theorist who has made
significant contributions to the field of
nursing. Her work primarily focuses on
maternal role attainment and the
Maternal Role Attainment Theory.
 History of the Theory

Ramona T. Mercer developed the Maternal

Role Attainment Theory in the 1980s. This
theory was formulated as a response to the
need for a comprehensive framework to
understand how women develop as
mothers during pregnancy and the
postpartum period.
 What is the Theory All About

The Maternal Role Attainment Theory is

all about understanding the process
through which women develop and
internalize the role of motherhood. It
explores the various stages and factors that
influence how women perceive and fulfill
their roles as mothers.
 4 Concepts Being Utilized
 Key concepts in Mercer's theory include:
1.Maternal Role Attainment: The process through
which a woman develops and learns the role of a mother.
2.Maternal Role Development: The progression of a
woman from being pregnant to becoming an experienced
mother.
3.Maternal Role Competence: The ability to perform
the maternal role effectively.
4. Maternal Role Satisfaction: The degree to which a
woman is satisfied with her role as a mother.
 Theoretical Framework

The theoretical framework of Mercer's

theory is based on a developmental
perspective. It suggests that maternal role
attainment is a process that evolves over
time and is influenced by a variety of
biological, psychological, and social
factors.
 Significance of the Theory

 Mercer's Maternal Role Attainment Theory has been

highly significant in the field of nursing, particularly in
maternal and child health. It has provided a structured
framework for nurses and healthcare professionals to
understand, assess, and support women as they
transition into motherhood. This theory has also
influenced nursing practice, research, and education in
the context of maternal and child health.
Examples of the Theory in Practice or
Case Studies
• Prenatal Education Programs: Nurses and healthcare providers
often use Mercer's theory to design prenatal education programs that
help expectant mothers prepare for their maternal roles.
• Postpartum Support: Nurses use the theory to assess and provide
support to new mothers in the postpartum period, helping them adapt
to their new roles and build confidence in caring for their infants.
• Research Studies: Researchers have used Mercer's theory to explore
various aspects of maternal role attainment, such as the experiences
of adolescent mothers, the impact of cultural factors, and the role of
social support.
 Helen Erickson
Boigraphy and Theory
• Helen Lorraine (Cook) Erickson (born 1936) is the
primary author of the modeling and role-modeling theory of
nursing. Her work, co-authored with Evelyn Tomlin and Mary
Ann Swain, was published in the 1980s and derived from her
experience in clinical practice. In 2006 she edited a book that
provides additional information describing the relationships
among soul, spirit, and human form.
 Career
• Erickson was the first president of the Society for the Advancement of
Modeling and Role-Modeling (SAMRM). The organization was
established in 1986 at The University of Michigan She holds the title of
Professor Emeritus at The University of Texas at Austin. She has
served on the Board of Directors for the American Holistic Nurses
Certification Corporation.
 Personal
•Erickson was married to Lance
Erickson in 1957 in Clare, Michigan.
Together they live in Cedar Park,
Texas.
•
Works
Erickson, H. Ed. (2010) Exploring the Interface Between the Philosophy and Discipline of
Holistic Nursing : Modeling and Role-Modeling at Work. Cedar Park, TX:Unicorns
Unlimited.
• Erickson, H. (2010). Erickson, Tomlin, & Swain theory of Modeling and role-modeling. In M.
Parker (Ed). Nursing theories and Nursing Practices. Philadelphia, PA: F A Davis
Company.
• Erickson, H. (2009) Holistic Nurses’ Examinations: Past, Present, Future Journal of Holistic
Nursing, Sept 2009; vol. 27: pp. 186 – 202.
• Erickson, H. (2008) What is holistic nursing and why is it important? Advances for Nurses.
Vol 6, Issue 20, September 29, pp. 31
• Erickson, H. (2007) Philosophy and theory of holism, Nursing clinics of North America, Vol.
42 (2), pp. 139–163.
• Erickson, H. (Ed) (2006). Modeling and Role-Modeling: A View From the Client’s World.
TX: Unicorns Unlimited.
• Erickson, H. (2006). Searching for Life Purpose: Discovering Meaning. In H. Erickson (Ed).
Modeling and Role-Modeling: A View From the Client’s World. Tx: Unicorns Unlimited,
pp. 5–32.
• Walker, M. & Erickson, H. (2006). Mind-body-spirit relations. In H. Erickson (Ed). Modeling
• Helen Erickson is a nursing theorist who, along with
her colleagues Evelyn M. Tomlin and Mary Ann P.
Swain, developed the Theory of Modeling and Role
Modeling (TMRM). Here's an overview of the
elements you requested regarding the Theory of
Modeling and Role Modeling.
 History of the Theory
• The Theory of Modeling and Role Modeling (TMRM)
was developed in the late 1970s and early 1980s by Helen
Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain. It
was created as a response to the need for a comprehensive
nursing theory that focused on individualized care, human
development, and the nurse-client relationship.
 What is the Theory All About
• TMRM is a nursing theory that emphasizes the importance of
understanding the unique experiences and perspectives of each
patient or client. It posits that nurses should strive to model and
role model, meaning they should demonstrate empathy, respect,
and a willingness to understand the patient's world from their
perspective. It's about forming a therapeutic relationship that
facilitates the client's growth and healing.
 Concepts Being Utilized
• Key concepts in the Theory of Modeling and Role Modeling include:
• 1.Client: The individual receiving care, with unique needs, experiences, and
perspectives.
• 2 Modeling: The nurse's ability to demonstrate empathy, understanding, and
respect.
• 3.Role Modeling: The nurse's ability to serve as a positive role model, providing a
supportive and nurturing environment for the client's growth.
• 4 Health: Defined as the client's perception of their own well-being and ability to
reach their full potential.
• 5 Environment: The physical, social, and emotional context in which the nurse-
client interaction occurs.
 Theoretical Framework
• The theoretical framework of TMRM is rooted in
humanistic and developmental psychology, as well as
nursing science. It acknowledges the importance of the
nurse-client relationship and the role of the nurse in
facilitating the client's self-actualization and well-
being.
 Significance of the Theory
• The Theory of Modeling and Role Modeling is significant in
nursing because it provides a framework for delivering holistic
and individualized care. It emphasizes the nurse's role in
creating a therapeutic environment that supports the client's
growth and healing. This theory has been used to guide nursing
practice, education, and research, particularly in areas where
personalized care is essential.
 Examples of the Theory in Practice or Case Studies
• Pediatric Nursing: In pediatric nursing, TMRM can be applied by nurses
to understand the unique needs and experiences of children and their
families. Nurses can model empathy and provide emotional support to
both the child and their parents.
• Palliative Care: In end-of-life care, nurses can use TMRM to provide
compassionate care that addresses the physical, emotional, and spiritual
needs of patients and their families.
• Psychiatric Nursing: In psychiatric nursing, TMRM can be employed to
build trust and rapport with clients, helping them feel understood and
valued.