Тема 18

NURSING THEORIES. ROLES AND FUNCTIONS OF THE NURSE

The following sections describe, in chronological order, the general focus of several im­portant theories of the philosophy of nursing. A nursing curriculum will often include one or more of these nurs­ing theories as a part of its conceptual framework (see Table SUMMARY OF NURSING THEORIES).

Peplau's Theory

Hildegard Peplau's theory (1952) focuses on interper­sonal relationships people form as they pass through de­velopmental stages. Nursing's purpose is to educate the client and family and help the client to reach mature per­sonality development (Chinn, Jacobs, 1991). Therefore the nurse develops a nurse-client relationship in which the nurse is a resource person, counsellor, and surro­gate. When the client seeks help, the nurse discusses the nature of the problem and explains the services available. As the nurse-client relationship develops, the nurse helps the client to identify the problem and po­tential solutions. The client gains from this relationship by using available services to meet needs. When the original needs have been resolved, new needs may appear.

Abdellah's Theory

The nursing theory developed by Faye Abdellah et al. (1960) emphasises delivering nursing care for the whole person to meet physical, emotional, intellectual, social and spiritual needs. The nurse needs knowledge and skills in interpersonal relations, psychology, growth and development, communication, sociology, and the basic sciences, as well as specific nursing skills. The nurse, a problem solver and decision maker, forms an individualised view of the client's needs, which may occur in the following areas:

1. Comfort, hygiene, and safety

2. Physiological balance

3. Psychological and social factors

4. Sociological and community factors

In these areas, Abdellah et al. (1960) identify 21 spe­cific client problems (often referred to as "Abdellah's 21 nursing problems"), which emphasise the physical (e.g., maintenance of elimination or sensory function) and psychological needs (e.g., maintenance of effective ver­bal and non-verbal communication) of each client. The nurse helps the client meet these needs by facilitating and maintaining a healthy physical condition in the best therapeutic environment possible. The nurse uses inter­personal skills, sound medical knowledge, and commu­nity resources to provide individualised holistic care.

Henderson's Theory

Virginia Henderson's nursing theory involves basic needs of the whole person. Henderson (1964a) defines nursing as:

assisting the individual sick or well in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

Henderson (1964) identifies specific needs, often called "Henderson's 14 basic needs," such as breathe normally, sleep, and rest. These emphasise maintaining a safe, healthy way of living, associated with good hy­giene, an active social life, and personal development.

Orlando's Theory

To Ida Orlando (1961), the client is an individual with a need that, when met, diminishes distress, increases ad­equacy, or enhances well-being (Chinn, Jacobs, 1991). Her theory focuses on nurses' reactions to client behaviour in terms of the client's immediate need (Torres, 1986). Orlando's theory describes three elements— client behaviour, nurse reaction, and nurse actions—that compose the nursing situation (Marriner-Tomey, 1994). After nurses assess the client's needs, they recognise the impact of that need on the client's level of health and then act automatically or deliberately to meet the need. Nursing acts to reduce the client's distress.

Johnson's Theory

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

1. Security-seeking behaviour

2. Nurturance-seeking behaviour

3. Mastery of oneself and one's environment accord­ing to internalised standards of excellence

4. Taking nourishment in socially and culturally acceptable ways

5. Ridding the body of waste in socially and culturally acceptable ways

6. Sexual and role identity behaviour

7. Self-protective behaviour

The nurse assesses the client's needs in these cate­gories. The client is able to function fairly effectively in the environment under normal conditions. When stress disrupts normal adaptation, however, behaviour becomes erratic and less purposeful. The nurse identifies the in­ability to adapt and provides nursing care to resolve problems in meeting the client's needs.

King's Theory

Imogene King's theory (1971,1981) also focuses on the interpersonal relationship between the client and nurse. The nurse-client relationship is the vehicle for the nurs­ing process, a dynamic interpersonal process in which the nurse and the client are affected by each other's behaviour and the health care system. The nurse communi­cates to assist the client in re-establishing or maintaining a positive adaptation to the environment.

Orem's Theory

Dorothea Orem's (1971) definition of nursing emphasises the self-care needs of the client. Orem describes her philosophy of nursing as follows:

Nursing has as a special concern man's needs for self-care ac­tion and the provision and management of it on a continuous basis in order to sustain life and health, recover from disease or injury, and cope with their effects. Self-care is a require­ment of every person—man, woman, and child. When self-care is not maintained, illness, disease, or death will occur. Nurses sometimes manage and maintain required self-care continually for persons who are totally incapacitated. In other instances, nurses help persons to maintain required self-care by performing some but not all care measures, by supervising others who assist patients, and by instructing and guiding in­dividuals as they gradually move toward self-care.

The goal of Orem's self-care deficit theory is helping the client achieve self-care. Nursing care is necessary when the client is unable to fulfil biological, psychological, de­velopmental, or social needs. The nurse determines reasons a client is unable to meet self-care needs, ac­tions that will enable the client to meet these needs, and client self-care abilities.

Neuman's Theory

Betty Neuman forms a total-person model by incorpo­rating the holistic concept and the open-system ap­proach (Marriner-Tomey, 1994). Neuman views the per­son as a dynamic composite of physiological, sociocultural, and developmental variables functioning as an open system (Neuman and Young, 1972). Her goal of nursing is to assist individuals, families, and groups to attain and maintain a maximal level of total wellness.

The nurse assesses, manages, and evaluates client systems and focuses on factors affecting the client's re­sponse to stressors. Nursing actions are in one of the following levels of prevention: primary, secondary, and tertiary. Primary prevention strengthens a line of defence through identification of actual or potential risk factors associated with stressors. Secondary prevention strengthens internal defences and resources by estab­lishing priorities and treatment plans for identified needs. Tertiary prevention focuses on readaptation (Neuman, 1982).

Levine's Theory

Myra Levine's nursing theory (1973) views the client as an integrated being who interacts with and adapts to the environment. Conservation of energy is a primary con­cern. In this theory, health is viewed in terms of con­servation of energy in the following areas, which Levine calls the "four conservation principles of nursing":

1. Conservation of client energy

2. Conservation of structural integrity

3. Conservation of personal integrity

4. Conservation of social integrity With this approach, nursing care involves conservation

With this approach, nursing care involves conservation activities aimed at optimal use of client's resources.

SUMMARY OF NURSING THEORIES

Theorist	Goal of nursing	Framework for practice
Hildegard Peplau (1952)	To develop interpersonal interaction between client and nurse	Interpersonal theoretical model emphasizing relationship between client and nurse
Faye Abdellah (1960)	To deliver nursing care for whole individual	Problem solving based on 21 nursing problems
Ida Orlando (1961)	To respond to client’s behavior in terms of immediate needs	Three elements, including client behavior, nurse reaction, and nurse action, composing a nursing situation
Virginia Henderson (1964)	To help client gain independence as rapidly as possible	Henderson’s 14 basic needs
Dorothy Johnson (1968)	To reduce stress so that client can recover as quickly as possible	Adaptation model based on seven behavioral subsystems
Imogene King (1971)	To use communication to help client to reestablish positive adaptation to environment	Nursing process as dynamic interpersonal state between nurse and client
Dorothea Orem (1971)	To care for and help client to attain self-care	Self-care deficit theory
Betty Neuman (1972)	To assist individuals, families, and groups to attain and maintain maximal level of total wellness by purposeful interventions	Systems model of nursing practice having stress reduction as its goal; nursing actions is one of three levels: primary, secondary, or tertiary
Myra Levine (1973)	To use conservation activities aimed at optimal use of client resources	Adaptation model of human as integrated whole based on “four conservation principles of nursing”