Nursing Philosophies

Nursing Conceptual Models

Theories and Grand Theories

Middle Range Theories
The Future of Nursing Theory
Nursing Philosophies

▪ Nursing philosophy set forth the meaning of nursing phenomena through

analysis and logical argument.
▪ Philosophies contribute to nursing knowledge with direction for the
discipline, forming a basis for professional scholarship leading to new
theoretical understanding.
▪ Philosophies are works that provide broad understandings that advance the
discipline of nursing and its professional application.
Nursing Philosophies
•Florence Nightingale
•Jean Watson
•Marilyn Anne Ray
•Patricia Benner
•Karl Martinsen
•Katie Eriksson
Florence Nightingale
“Recognition of nursing as a professional endeavor distinct from medicine began with Nightingale.”
Chin and Kramer, 2018

Florence Nightingale (1820-1910), known

as “The Lady With the Lamp,” was a
British nurse, social reformer and
statistician best known as the founder of
modern nursing. Her experiences as a
nurse during the Crimean War were
foundational in her views about sanitation.

She established St. Thomas’s Hospital and

the Nightingale Training School for Nurses
in 1860. Her efforts to reform healthcare
greatly influenced the quality of care in
the 19 and 20 centuries.
• Nightingale is best known for her pioneering work in the field of nursing. She tended to wounded soldiers during
the Crimean War. She became known as the “Lady with the Lamp” because of her night rounds. While nursing
soldiers during the war, Nightingale worked to improve nutrition and conditions in the wards. Many injured
soldiers were dying from illnesses separate from their injuries, such as typhoid, cholera, and dysentery.

• Nightingale made changes on the wards or started the process by calling the Sanitary Commission. Her work led
to a reduction in the death rates of injured soldiers from 42% to 2%. Nightingale believed the deaths were the
result of poor nutrition, inadequate supplies, and the soldiers being dramatically overworked. After collecting
evidence that pointed to unsanitary conditions as a major cause of death, Nightingale worked to improve
sanitation in army and civilian hospitals during peacetime.

• After the Crimean War, she established a nursing school at St. Thomas’ Hospital in London in 1860. The first
nurses trained at this school began working in 1865 at the Liverpool Workhouse Infirmary. It was the first
secular nursing school in the world, and is now part of King’s College London. Her work laid the foundation for
modern nursing, and the pledge all new nurses take was named after her.
Florence Nightingale is attributed with establishing the modern practice of nursing.
One of her nursing theories is the Environmental Theory, which incorporates the patients’ surrounding
environment in his or her nursing care plan.

• In this theory, the role of the nurse is to use the patient’s environment to help him or her recover
and get back to the usual environment.
• The reason the patient’s environment is important is because it can affect his or her health in a
positive or negative way.
• Some environmental factors affecting health according to Nightingale’s theory are fresh air, pure
water, sufficient food and appropriate nutrition, efficient drainage, cleanliness, and
light or direct sunlight.
• If any of these factors is lacking, it can delay the patient’s recovery. Nightingale also emphasized
providing a quiet, warm environment for patients to recover in.
• The theory also calls for nurses to assess a patient’s dietary needs, document food intake times,
and evaluate how the patient’s diet affects his or her health and recovery.
The ten major concepts of the Environment Theory, also identified as Nightingale’s Canons,
are:

1.Ventilation and warming

2.Light and noise
3.Cleanliness of the area
4.Health of houses
5.Bed and bedding
6.Personal cleanliness
7.Variety
8.Offering hope and advice
9.Food
10.Observation
There are seven assumptions made in the Environment Theory, which focuses on taking
care of the patient’s environment in order to reach health goals and cure illness. These
assumptions are:

1.Natural laws
2.Mankind can achieve perfection
3.Nursing is a calling
4.Nursing is an art and a science
5.Nursing is achieved through environmental alteration
6.Nursing requires a specific educational base
7.Nursing is distinct and separate from medicine
According to Nightingale, nursing is separate from medicine. The goal of nursing is to put the patient
in the best possible condition in order for nature to act. Nursing is “the activities that promote health
which occur in any caregiving situation.” Health is “not only to be well, but to be able to use well
every power we have.” Nightingale’s theory addresses disease on a literal level, explaining it as the
absence of comfort.

The environment paradigm in Nightingale’s model is understandably the most important aspect. Her
observations taught her that unsanitary environments contribute greatly to ill health, and that the
environment can be altered in order to improve conditions for a patient and allow healing to occur.
Nightingale’s Modern Nursing Theory also impacted nursing education. She was the first to suggest
that nurses be specifically educated and trained for their positions in healthcare. This allowed there
to be standards of care in the field of nursing, which helped improve overall care of patients.
Jean Watson
“We are the light in institutional darkness, and in this model we get to return to the light of our humanity.”

Jean Watson is an American nursing professor and

Philosophy and Theory
nurse theorist. of Transpersonal Caring
She is known for her philosophy, Jean Watson's
Philosophy of Science and Caring.

This philosophy focuses on how nurses care for their

patients and how this care can help patients get better.
She believed that nurses should focus on how to make
patients more healthy in a caring manner that extends
beyond declaring a medical cure.
• Jean Watson's Nursing Theory focuses on how nurses express care to their patients. While she
recognizes that medicine and a medical diagnoses is crucial for care, she also believes that patients are
best cared for when they are met in a caring way. She says that this care will help patients develop a
healthier wellness plan and live better. Watson was inspired by philosophers, such as Pierre Teilhard de
Chardin, Carl Rogers, and Abraham Maslow.

• She expanded on their concept of the transpersonal relationship.

• Transpersonal relationships are said to be those relationships that involve a caring and spiritual union.
Watson added her own interpretation and explained that a transpersonal nurse focused his or her care on
healing, caring, and wholeness instead of pathology, disease, and illness.
10 Caritas Processes
1. Sustaining Humanistic-Altruistic Values by Practicing Loving-
Kindness, Compassion, and Equanimity With Self/Other
(Embrace)
2. Being Authentically Present; Enabling Faith, Hope, and Belief
System; Honoring Subjective Inner, Life-World of Self/Others
(Inspire)
3. Being Sensitive to Self and Others by Cultivating Own Spiritual
Practices, Beyond Ego-Self to Transpersonal Presence (Trust)
4. Development and Sustaining Loving, Trusting-Caring
Relationships (Nurture)
5. Allowing for Expression of Positive and Negative Feelings –
Listening Authentically to Another Person’s Story (Forgive)
10 Caritas Processes

• Creative Problem Solving – “Solution Seeking” through Caring

Process, Full Use of Self and Artistry of Caring and Healing Practices
via Use of All Ways of Knowing /Being/Doing/Becoming (Deepen)
• Engage in Transpersonal Teaching and Learning Within Context of
Caring Relationship , Staying Within Other’s Frame of Reference
(Balance)
• Creating a Healing Environment at All Levels, a Subtle Environment
for Energetic, Authentic Caring Practice (Co-Create)
• Reverentially Assisting with Basic Needs as Sacred Acts, Sustaining
Human Dignity (Minister)
• 10. Opening and Attending to the Spiritual, Mystery, Unknowns-
Allowing to Miracles (Open)
 Nowadays, a lot of people choose nursing as a profession. There are many reasons
to consider becoming a professional nurse, but compassion is often a trait required of
nurses. This is for the reason that taking care of the patients’ needs is its primary purpose.
Jean Watson’s “Philosophy and Theory of Transpersonal Caring” mainly concerns how
nurses care for their patients and how that caring progresses into better plans to promote
health and wellness, prevent illness and restore health.

In today’s world, nursing seems to be responding to the various demands of the machinery with
less consideration of the needs of the person attached to the machine. In Watson’s view, the disease
might be cured, but illness would remain because, without caring, health is not attained. Caring is the
essence of nursing and connotes responsiveness between the nurse and the person; the nurse co-
participates with the person. Watson contends that caring can help the person gain control, become
knowledgeable, and promote healthy changes.
What is Watson’s Theory of Transpersonal Caring?

• According to Watson’s theory, “Nursing is concerned with

promoting health, preventing illness, caring for the sick, and
restoring health.”
• It focuses on health promotion, as well as the treatment of
diseases. According to Watson, caring is central to nursing
practice and promotes health better than a simple medical cure.
• The nursing model also states that caring can be demonstrated
and practiced by nurses. Caring for patients promotes growth; a
caring environment accepts a person as they are and looks to
what they may become.
The Philosophy and Science of Caring have four major concepts:
human being, health, environment or society, and nursing.

• Society
• The society provides the values that determine how one should behave
and what goals one should strive toward. Watson states:
• “Caring (and nursing) has existed in every society. Every society has had
some people who have cared for others. A caring attitude is not
transmitted from generation to generation by genes. The culture of the
profession transmits it as a unique way of coping with its environment.”
• Human being
• Human being is a valued person to be cared for, respected, nurtured,
understood, and assisted; in general, a philosophical view of a person as a
fully functional integrated self. A human is viewed as greater than and
different from the sum of his or her parts.
• Health
• Health is the unity and harmony within the mind, body, and soul; health is
associated with the degree of congruence between the self and the self as
experienced. It is defined as a high level of overall physical, mental, and
social functioning; a general adaptive-maintenance level of daily
functioning; and the absence of illness, or the presence of efforts leading
to the absence of illness.
• Nursing
• Nursing is a human science of persons and human health-illness
experiences mediated by professional, personal, scientific, esthetic, and
ethical human care transactions.
Patricia Benner
“The nurse patient relationship is not a uniform, professionalized blueprint but rather a
kaleidoscope of intimacy and distance in some of the most dramatic, poignant, and mundane
moments of life.”

Dr. Benner is the author of books including:

1. From Novice to Expert

2. The Primacy of Caring
3. Interpretive Phenomenology: Embodiment, Caring and
Ethics in Health and Illness
4. The Crisis of Care
5. Expertise in Nursing Practice: Caring, Clinical
Judgment, and Ethics
6. Caregiving
7. Clinical Wisdom and Interventions in Critical Care: A
Thinking-In-Action Approach
Philosophical Sources
• Benner studies clinical nursing practice in an attempt to discover and describe the knowledge embedded
in nursing practice. She maintains that knowledge accrues over time in a practice discipline and is
developed through dialogue in relationship and situational contexts.
• She refers to this work as articulation research, as was noted earlier. One of the first philosophical
distinctions that Benner made was to differentiate between practical and theoretical knowledge.
• Benner stated that knowledge development in a practice discipline “consists of extending practical
knowledge (know-how) through theory-based scientific investigations and through the charting of the
existent ‘know-how’ developed through clinical experience in the practice of that discipline” (1984a, p. 3).
• She believes that nurses have been delinquent in documenting their clinical learning, and “this lack of
charting of our practices and clinical observations deprives nursing theory of the uniqueness and richness
of the knowledge embedded in expert clinical practice” (Benner, 1983, p. 36). Benner has contributed
extensively to the description of the know-how of nursing practice.
• Benner (1984a) adapted the Dreyfus model to clinical nursing practice. The Dreyfus brothers developed the skill

acquisition model by studying the performance of chess masters and pilots in emergency situations (Dreyfus &

Dreyfus, 1980; Dreyfus & Dreyfus, 1986).

• This model is situational and describes five levels of skill acquisition and development: (1) novice, (2)

advanced beginner, (3) competent, (4) proficient, and (5) expert.

• The model posits that changes in four aspects of performance occur in movement through the levels of skill

acquisition as follows: (1) movement from a reliance on abstract principles and rules to the use of past, concrete

experience, (2) shift from reliance on analytical, rule-based thinking to intuition, (3) change in the learner’s

perception of the situation from viewing it as a compilation of equally relevant bits to viewing it as an

increasingly complex whole, in which certain parts stand out as more or less relevant, and (4) passage from a

detached observer, standing outside the situation, to one of a position of involvement, fully engaged in the

situation (Benner, Tanner, & Chesla, 1992).

MAJOR CONCEPTS & DEFINITIONS

NOVICE
• In the novice stage of skill acquisition in the Dreyfus model, the
person has no background experience of the situation in which he or
she is involved.
• Context-free rules and objective attributes must be given to guide
performance. There is difficulty discerning between relevant and
irrelevant aspects of a situation.
• Generally, this level applies to students of nursing, but Benner has
suggested that nurses at higher levels of skill in one area of practice
could be classified at the novice level if placed in an area or situation
unfamiliar to them (Benner, 1984a).
ADVANCED BEGINNER

• The advanced beginner stage in the Dreyfus model develops when the person can demonstrate marginally
acceptable performance, having coped with enough real situations to note, or to have pointed out by a mentor,
the recurring meaningful components of the situation. The advanced beginner has enough experience to grasp
aspects of the situation (Benner, 1984a). Unlike attributes and features, aspects cannot be objectified
completely because they require experience based on recognition in the context of the situation.

• Nurses functioning at this level are guided by rules and are oriented by task completion. They have difficulty
grasping the current patient situation in terms of the larger perspective. However, Dreyfus and Dreyfus (1996)
state the following:

Through practical experience in concrete situations with meaningful elements which neither the
instructor nor student can define in terms of objective features, the advanced beginner starts intuitively
to recognize these elements when they are present. We call these newly recognized elements
“situational” to distinguish them from the objective elements of the skill domain that the beginner can
recognize prior to seeing concrete examples (p. 38).

• Clinical situations are viewed by nurses who are in the advanced beginner stage as a test of their abilities and
the demands of the situation placed on them rather than in terms of patient needs and responses (Benner et al.,
1992). Advanced beginners feel highly responsible for managing patient care, yet they still rely on the help of
those who are more experienced (Benner et al., 1992). Benner places most newly graduated nurses at this level.
COMPETENT

• Through learning from actual practice situations and by following the actions of others, the advanced beginner moves to the
competent level (Benner et al., 1992). The competent stage of the Dreyfus model is typified by considerable conscious and
deliberate planning that determines which aspects of current and future situations are important and which can be ignored
(Benner, 1984a).

• Consistency, predictability, and time management are important in competent performance. A sense of mastery is acquired
through planning and predictability (Benner et al., 1992). The level of efficiency is increased, but “the focus is on time
management and the nurse’s organization of the task world rather than on timing in relation to the patient’s needs” (Benner et
al., 1992, p. 20). The competent nurse may display hyper-responsibility for the patient, often more than is realistic, and may
exhibit an ever-present and critical view of the self (Benner et al., 1992).

• The competent stage is most pivotal in clinical learning, because the learner must begin to recognize patterns and determine
which elements of the situation warrant attention and which can be ignored. The competent nurse devises new rules and
reasoning procedures for a plan while applying learned rules for action on the basis of relevant facts of that situation. To
become proficient, the competent performer must allow the situation to guide responses (Dreyfus & Dreyfus, 1996). Studies
point to the importance of active teaching and learning in the competent stage to coach nurses who are making the transition
from competency to proficiency (Benner et al., 1996; Benner et al., 1999).
PROFICIENT

• At the proficient stage of the Dreyfus model, the performer perceives the situation as a whole (the total picture)

rather than in terms of aspects, and the performance is guided by maxims. The proficient level is a qualitative

leap beyond the competent. Now the performer recognizes the most salient aspects and has an intuitive grasp

of the situation based on background understanding (Benner, 1984a).

• Nurses at this level demonstrate a new ability to see changing relevance in a situation, including recognition and

implementation of skilled responses to the situation as it evolves. They no longer rely on preset goals for

organization, and they demonstrate increased confidence in their knowledge and abilities (Benner et al., 1992).

At the proficient stage, there is much more involvement with the patient and family (see the Case Study). The

proficient stage is a transition into expertise (Benner et al., 1996).

EXPERT
• The fifth stage of the Dreyfus model is achieved when “the expert performer no longer relies on
analytical principle (rule, guideline, maxim) to connect her or his understanding of the situation to
an appropriate action” (Benner, 1984a, p. 31). Benner described the expert nurse as having an
intuitive grasp of the situation and as being able to identify the region of the problem without losing
time considering a range of alternative diagnoses and solutions. There is a qualitative change as
the expert performer “knows the patient,” meaning knowing typical patterns of responses and
knowing the patient as a person. Key aspects of the expert nurse’s practice are as follows (Benner
et al., 1996):

• image Demonstrating a clinical grasp and resource based practice

• image Possessing embodied know-how
• image Seeing the big picture
• image Seeing the unexpected

• The expert nurse has this ability to recognize patterns on the basis of deep experiential
background. For the expert nurse, meeting the patient’s actual concerns and needs is of utmost
importance, even if it means planning and negotiating for a change in the plan of care. There is
almost a transparent view of the self (Benner et al., 1992).
•Marilyn Anne Ray
Theory of Bureaucratic Caring
•Kari Martinsen
Philosophy of Caring
•Katie Eriksson
Theory of Caritative Caring
Nursing Conceptual Models
•Myra Estrin Levin
•Martha E. Rogers
•Dorothea E. Orem
•Imogene M. King
•Betty Neuman
•Sister Callista Roy
•Dorothy Johnson
Nursing Conceptual Models
• Nursing conceptual models are concepts and their relationships that specify a
perspective and produce evidence among phenomena specific to the discipline.
• Conceptual models address broad metaparadigm concepts (human beings,
health, nursing and environment) that are central to their meaning in the context
of a particular framework and the discipline of nursing.
• Nursing conceptual models provide perspectives with different foci for critical
thinking about persons, families, and communities and for making knowledgeable
nursing decisions.
• Nursing conceptual models provide a nursing perspective for theory development
at various levels of abstractions.
Myra Estrin Levin (1921–1996) is a nursing theorist known for her esoteric
nursing model—the Conservation Model. In this model, nursing aims to
promote adaptation and maintain wholeness using the four principles of
conservation.
Nursing Theory: The Conservation Model
• Levine’s conservation model believes nursing intervention is a conservation
activity, with energy conservation as a fundamental concern, four
conservation principles of nursing.
• It guides nurses to concentrate on the importance and responses at the level
of the person.
• Nurses fulfill the theory’s purpose by conserving energy, structure, and
personal and social integrity.
• Every patient has a different array of adaptive responses, which vary based on
personal factors, including age, gender, and illness. The fundamental concept of
Myra Estrin Levine’s theory is conservation. When an individual is in a phase of
conservation, it means that the person can adapt to the health challenges with the
slightest amount of effort. The core of Levine’s Conservation Model is to improve a
person’s physical and emotional well-being by considering the four domains of
conservation she set out.
• The core of the conservation model is to improve a person’s physical and emotional
well-being by considering the four domains of conservation she set out. Nursing’s
role in conservation is to help the person with the process of “keeping together” the
total person through the least amount of effort.
Levine (1989) proposed the following four principles of
conservation:
1.The conservation of energy of the individual.
2.The conservation of the structural integrity of the individual.
3.The conservation of the personal integrity of the individual.
4.The conservation of the social integrity of the individual.
Major Concepts of Levine’s Conservation Model
• The environment
• Person
• Health
• Nursing
• Adaptation
• Conservation
• Personal integrity
• Social integrity
• Structural integrity
Martha E. Rogers
Science of Unitary Human Beings
• Martha Rogers’ theory is known as the Science of Unitary Human Beings (SUHB). The
theory views nursing as both a science and an art as it provides a way to view the
unitary human being, who is integral with the universe. The unitary human being and
his or her environment are one. Nursing focuses on people and the manifestations that
emerge from the mutual human-environmental field process.
• SUHB contains two dimensions: the science of nursing, which is the knowledge specific
to the field of nursing that comes from scientific research; and the art of nursing, which
involves using the science of nursing creatively to help better the lives of the patient.
There are eight concepts in Rogers’ nursing theory:
• energy field,
• openness,
• pattern,
• pan-dimensionality,
• hemodynamic principles, r
• esonance,
• helicy, and
• integrality.
• Rogers’ theory defined Nursing as “an art and
science that is humanistic and humanitarian. It is
directed toward the unitary human and is
concerned with the nature and direction of human
development. The goal of nurses is to participate in
the process of change.”
• According to Rogers, the Science of Unitary
Human Beings contains two dimensions: the
science of nursing, which is the knowledge specific
to the field of nursing that comes from scientific
research; and the art of nursing, which involves
using the science of nursing creatively to help
better the lives of the patient.
Dorothea E. Orem: Self-Care Deficit Theory

• Dorothea Orem’s Self-Care Deficit Theory focuses on each “individual’s

ability to perform self-care, defined as ‘the practice of activities that
individuals initiate and perform on their own behalf in maintaining life,
health, and well-being.'” The Self-Care or Self-Care Deficit Theory of Nursing
is composed of three interrelated theories: (1) the theory of self-care, (2) the
self-care deficit theory, and (3) the theory of nursing systems, which is further
classified into wholly compensatory, partially compensatory and supportive-
educative.
Major Concepts of the Self-Care Deficit Theory
• Nursing
Nursing is an art through which the practitioner of nursing gives specialized assistance to persons with disabilities, making more than ordinary
assistance necessary to meet self-care needs. The nurse also intelligently participates in the medical care the individual receives from the physician.
• Humans
Humans are defined as “men, women, and children cared for either singly or as social units” and are the “material object” of nurses and others who
provide direct care.
• Environment
The environment has physical, chemical, and biological features. It includes the family, culture, and community.
• Health
Health is “being structurally and functionally whole or sound.” Also, health is a state that encompasses both the health of individuals and groups, and
human health is the ability to reflect on oneself, symbolize experience, and communicate with others.
• Self-Care
Self-care is the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health, and well-being.
Imogene M. King: Theory of Goal Attainment
• The Theory of Goal Attainment states that “Nursing is a process of action, reaction,
and interaction whereby nurse and client share information about their perception in
the nursing situation.”
• Imogene King’s Theory of Goal Attainment was first introduced in the 1960s. From the
title itself, the model focuses on the attainment of certain life goals. It explains that the
nurse and patient go hand-in-hand in communicating information, set goals together,
and then take actions to achieve those goals. The factors that affect the attainment of
goals are roles, stress, space, and time. On the other hand, the nurse’s goal is to help
patients maintain health so they can function in their individual roles. The nurse’s
function is to interpret information in the nursing process, plan, implement, and
evaluate nursing care.
• There are three interacting systems in the Theory of Goal Attainment, according to King. These are
the personal system, the interpersonal system, and the social system. Each system is given different
concepts. The personal system concepts are perception, self, growth and development, body image,
space, and time. The concepts for the interpersonal system are interaction, communication,
transaction, role, and stress. The social system concepts are organization, authority, power, status,
and decision-making.

• Imogene M. King’s Theory of Goal Attainment focuses on this process to guide and direct nurses in
the nurse-patient relationship, going hand-in-hand with their patients to meet good health goals.

• King’s Theory of Goal Attainment was first introduced in the 1960s. From the title itself, the model
focuses on the attainment of certain life goals. It explains that the nurse and patient go hand-in-
hand in communicating information, set goals together, and then take actions to achieve those
goals.
• King has interrelated the concepts of interaction, perception, communication, transaction, self, role,
stress, growth and development, time, and space into a goal attainment theory. Her theory deals
with a nurse-client dyad, a relationship to which each person brings personal perceptions of self,
role, and personal growth and development levels. The nurse and client communicate, first in
interaction and then in the transaction, to attain mutually set goals. The relationship takes place in
space identified by their behaviors and occurs in forward-moving time.
Major Concepts and Subconcepts
• Nursing
Nursing is a process of action, reaction, and interaction whereby nurse and client share information about their perceptions in the nursing
situation. The nurse and client share specific goals, problems, and concerns and explore how to achieve a goal.
• Health
Health is a dynamic life experience of a human being, which implies continuous adjustment to stressors in the internal and external
environment through optimum use of one’s resources to achieve maximum daily living potential.
• Individual
Individuals are social beings who are rational and sentient. Humans communicate their thoughts, actions, customs, and beliefs through
language. Persons exhibit common characteristics such as the ability to perceive, think, feel, choose between alternative courses of action, set
goals, select the means to achieve goals, and make decisions.
• Environment
The environment is the background for human interactions. It is both external to, and internal to, the individual.
• Action
Action is defined as a sequence of behaviors involving mental and physical activity. The sequence is first mental action to recognize the
presenting conditions; then physical action to begin activities related to those conditions; and finally, mental action to exert control over the
situation, combined with physical action seeking to achieve goals.
• Reaction
The reaction is not specifically defined but might be considered in the sequence of behaviors described in action.
Betty Neuman: Neuman Systems Model
• Betty Neuman (1924 – present) is a nursing theorist who developed the Neuman Systems
Model. She gave many years perfecting a systems model that views patients holistically. She
inquired about theories from several theorists and philosophers and applied her knowledge in
clinical and teaching expertise to develop the Neuman Systems Model that has been accepted,
adopted, and applied as a core for nursing curriculum in many areas worldwide.
• Betty Neuman describes the Neuman Systems Model as “a unique, open-system-based
perspective that provides a unifying focus for approaching a wide range of concerns. A system
acts as a boundary for a single client, a group, or even several groups; it can also be defined
as a social issue. A client system in interaction with the environment delineates the domain of
nursing concerns.”
• The Neuman Systems Model views the client as an open system that responds to stressors in the
environment. The client variables are physiological, psychological, sociocultural, developmental, and
spiritual. The client system consists of a basic or core structure that is protected by lines of
resistance. The usual health level is identified as the normal defense line protected by a flexible line
of defense. Stressors are intra-, inter-, and extra personal in nature and arise from the internal,
external, and created environments. When stressors break through the flexible line of defense, the
system is invaded, and the lines of resistance are activated. The system is described as moving into
illness on a wellness-illness continuum. If adequate energy is available, the system will be
reconstituted with the normal defense line restored at, below, or above its previous level.
• Nursing interventions occur through three prevention modalities. Primary prevention occurs before
the stressor invades the system; secondary prevention occurs after the system has reacted to an
invading stressor; tertiary prevention occurs after secondary prevention as reconstitution is being
established.
Major Concepts of Neuman Systems Model
• Human being
The human being is an open system that interacts with internal and external environment forces or stressors. The human is constantly changing, moving toward a dynamic state of system stability or
illness of varying degrees.
• Environment
The environment is a vital arena that is germane to the system and its function. The environment may be viewed as all factors that affect and are affected by the system. In Neuman Systems Model
identifies three relevant environments: (1) internal, (2) external, and (3) created.
• The internal environment exists within the client system. All forces and interactive influences that are solely within the client system’s boundaries make up this environment.
• The external environment exists outside the client system.
• The created environment is unconsciously developed and is used by the client to support protective coping.
• Health
In Neuman’s nursing theory, Health is defined as the condition or degree of system stability and is viewed as a continuum from wellness to illness. When system needs are met, optimal wellness exists.
When needs are not satisfied, illness exists. When the energy needed to support life is not available, death occurs.
• Nursing
Nursing’s primary concern is to define the appropriate action in situations that are stress-related or concerning possible reactions of the client or client system to stressors. Nursing interventions aim to
help the system adapt or adjust and retain, restore, or maintain some degree of stability between the client system variables and environmental stressors, focusing on conserving energy.
• Open System
A system in which there is a continuous flow of input and process, output and feedback. It is a system of organized complexity, where all elements are in interaction.
• Basic Stricture and Energy Resources
• The basic structure, or central core, comprises those basic survival factors common to the species. These factors include the system variables, genetic features, and
strengths and weaknesses of the system parts.
• Client Variables
Neuman views the individual client holistically and considers the variables simultaneously and comprehensively.
• The physiological variable refers to the structure and functions of the body.
• The psychological variable refers to mental processes and relationships.
• The sociocultural variable refers to system functions that relate to social and cultural expectations and activities.
• The developmental variable refers to those processes related to development over the lifespan.
• The spiritual variable refers to the influence of spiritual beliefs.

• Flexible line of defense

A protective accordion-like mechanism that surrounds and protects the normal line of defense from invasion by stressors.
• Normal line of defense
An adaptational level of health developed over time and is considered normal for a particular individual client or system; it becomes a standard for wellness-deviance
determination.
• Lines of resistance
Protection factors are activated when stressors have penetrated the normal line of defense, causing reaction symptomatology.
Sister Callista Roy: Adaptation Model of Nursing
• The Adaptation Model of Nursing is a prominent nursing theory aiming to explain or define the provision
of nursing science. In her theory, Sister Callista Roy’s model sees the individual as a set of interrelated
systems that maintain a balance between various stimuli.

• The Roy Adaptation Model was first presented in the literature in an article published in Nursing Outlook
in 1970 entitled “Adaptation: A Conceptual Framework for Nursing.” In the same year, Roy’s Adaptation
Model of Nursing was adapted in Mount St. Mary’s School in Los Angeles, California.

• Roy’s model was conceived when nursing theorist Dorothy Johnson challenged her students to develop
conceptual models of nursing during a seminar. Johnson’s nursing model was the impetus for the
development of Roy’s Adaptation Model.
• Roy’s model incorporated concepts from Adaptation-level Theory of Perception from
renowned American physiological psychologist Harry Helson, Ludwig von Bertalanffy’s
System Model, and Anatol Rapoport’s system definition.

• First, consider the concept of a system as applied to an individual. Roy conceptualizes

the person in a holistic perspective. Individual aspects of parts act together to form a
unified being. Additionally, as living systems, persons are in constant interaction with
their environments. Between the system and the environment occurs an exchange of
information, matter, and energy. Characteristics of a system include inputs, outputs,
controls, and feedback.
• Person
“Human systems have thinking and feeling capacities, rooted in consciousness and meaning, by which they adjust
effectively to changes in the environment and, in turn, affect the environment.”
Based on Roy, humans are holistic beings that are in constant interaction with their environment. Humans
use a system of adaptation, both innate and acquired, to respond to the environmental stimuli they experience. Human
systems can be individuals or groups, such as families, organizations, and the whole global community.
• Environment
“The conditions, circumstances and influences surrounding and affecting the development and behavior of persons or
groups, with particular consideration of the mutuality of person and health resources that includes focal, contextual
and residual stimuli.”
The environment is defined as conditions, circumstances, and influences that affect humans’ development
and behavior as an adaptive system. The environment is a stimulus or input that requires a person to adapt. These
stimuli can be positive or negative.
Roy categorized these stimuli as focal, contextual, and residual. Focal stimuli are that confront the human
system and require the most attention. Contextual stimuli are characterized as the rest of the stimuli present with the
focal stimuli and contribute to its effect. Residual stimuli are the additional environmental factors present within the
situation but whose effect is unclear. This can include previous experience with certain stimuli.
• Health
“Health is not freedom from the inevitability of death, disease, unhappiness, and stress, but the ability to cope with them in a competent way.”
• Health is defined as the state where humans can continually adapt to stimuli. Because illness is a part of life, health results from a process
where health and illness can coexist. If a human can continue to adapt holistically, they will maintain health to reach completeness and
unity within themselves. If they cannot adapt accordingly, the integrity of the person can be affected negatively.
• Nursing
“[The goal of nursing is] the promotion of adaptation for individuals and groups in each of the four adaptive modes, thus contributing to
health, quality of life, and dying with dignity.”
In Adaptation Model, nurses are facilitators of adaptation. They assess the patient’s behaviors for adaptation, promote positive adaptation by
enhancing environment interactions and helping patients react positively to stimuli. Nurses eliminate ineffective coping mechanisms and
eventually lead to better outcomes.
• Adaptation
Adaptation is the “process and outcome whereby thinking and feeling persons as individuals or in groups use conscious awareness
and choice to create human and environmental integration.”
Dorothy Johnson: Behavioral System Model
• Dorothy E. Johnson is well-known for her “Behavioral System Model,” which was first proposed in
1968. Her model was greatly influenced by Florence Nightingale’s book, Notes on Nursing. It
advocates fostering efficient and effective behavioral functioning in the patient to prevent illness and
stresses the importance of research-based knowledge about the effect of nursing care on patients.
• Johnson’s Behavioral System Model is a nursing care model that advocates the fostering of efficient
and effective behavioral functioning in the patient to prevent illness. The patient is identified as a
behavioral system composed of seven behavioral subsystems: affiliative, dependency, ingestive,
eliminative, sexual, aggressive, and achievement. Each subsystem’s three functional requirements
include protection from noxious influences, provision for a nurturing environment, and stimulation
for growth. An imbalance in any of the behavioral subsystems results in disequilibrium. It is
nursing’s role to assist the client in returning to a state of equilibrium.
• Dorothy Johnson’s theory defined Nursing as “an external regulatory force which acts to preserve
the organization and integration of the patient’s behaviors at an optimum level under those
conditions in which the behavior constitutes a threat to the physical or social health, or in which
illness is found.”
• It also states that “each individual has patterned, purposeful, repetitive ways of acting that comprises
a behavioral system specific to that individual.”
• Human Beings
Johnson views human beings as having two major systems: the biological system and the behavioral system. It is the role of medicine to focus on the biological system, whereas
nursing focuses on the behavioral system.
The concept of a human being was defined as a behavioral system that strives to make continual adjustments to achieve, maintain, or regain balance to the steady-state adaptation.
• Environment
The environment is not directly defined, but it is implied to include all elements of the human system’s surroundings and includes interior stressors.
• Health
Health is seen as the opposite of illness, and Johnson defines it as “some degree of regularity and constancy in behavior. The behavioral system reflects adjustments and
adaptations that are successful somehow, and to some degree… adaptation is functionally efficient and effective.”
• Nursing
• Nursing is seen as “an external regulatory force that acts to preserve the organization and integrate the patient’s behavior at an optimal level under those conditions in which
the behavior constitutes a threat to physical or social health or in which illness is found.”
• Behavioral system
• Man is a system that indicates the state of the system through behaviors.
• System
• That which functions as a whole under organized independent interaction of its parts.
• Subsystem
• A mini system is maintained concerning the entire system when it or the environment is not disturbed.
Theories and Grand Theories
• Anne Boykin and Savina Schoenhofer
• Afaf Ibrahim Meleis
• Nola J. Pender
• Madeleine M. Leininger
• Margaret A. Newman
• Rosemarie Rizzo Parse
• Helen C. Erickson, Evelyn M. Tomlin, Mary Ann P. Swain
• Gladys L. Husted and James H. Husted
Middle Range Theories
• Ramona T. Mercer
• Merle Mishel
• Pamela G. Reed
• Carolyn L. Wiener and Marylin J. Dodd
• Georgene Gaskill Eakes, Mary Lermann Burke, and Margaret A. Hainsworth
• Phil Barker
• Katherine Kolcaba
• Cheryl Tatano Beck
• Kristen M. Swanson
• Cornelia M. Ruland and Shirley M. Moore
The Future of Nursing Theory