The Nursing Theories and Models

Summary

Jean Watson born in 1940 earned a diploma from Lewis Gale Hospital School of Nursing in Roanoke, VA. Watson furthered her education and attended the University of Colorado for her BSN, MSN in psychiatric-mental health nursing and Ph.D. in educational psychology and counseling. Watson has held numerous positions at the University of Colorado as both faculty and administrator. Watson served as faculty at the University of Colorado Health Science Center, dean of the School of Nursing, and fouding Dorector of the center for Human Caring.

Watson’s first publication was in 1979 and this was the introduction of the theory of Transpersonal Caring to the nursing profession. Watson’s theory focuses on preserving the dignity and wholeness of humanity. Transpersonal Caring theory evolved from Watson’s own personal values, beliefs, and perceptions regarding human life, health, and healing. (Walker, 1996, p. 144) Watson views nursing as a “collective caring-healing role and its mission in society as attending to, and helpting to sustain, humanity and wholeness” (Walker, 1996, p. 144). The thoery is meant to be a worldview or ethic by which nursing could know its traditions in health and healing. Watson views nursing as an human science academic discipline and as an clinical profession. The theory views nursing as a societal mission “to caring and healing work with others during their most vulnerable moments of life’s journey” (Walker, 1996, p. 145). The theory analyzes caring independently from curing. The discipline of caring and healing are derived from the arts and humanities.

Watson’s theory was based on Nightingale’s healing environment concept. The theory evolved from the belief that an individual’s environment affects their healing. The theory began as a philosophy and was never meant to be a testable theory. Watson’s goal for the theory is to move nursing from the belief that the human body is a machine to the belief that the “interdependent and nondiscrete nature of a world and the spiritual nature of humans is of paramount importance” (Watson, 1985, p. 1) Watson defines health as harmony, and illness as disharmony within the mind, body, and spirit. Eastern philosophy influenced Watson’s theory on health and illness. In Watson’s later works her influence was the Chaos Theory by Kellert and the quantum physics and mechanics by Pelletier (Walker, 1996, p. 191)

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Watson’s goal is to serve as a bridge by which nursing will transition from a biomedical/natural-science model to a postmodern/human-science perspective. Watson believes language is the key to transitiong nursing from the biomedical/natural-science model to the postmodern/human -science model (Walker, 1996, p. 146) Watson (1999) believed nursing is a discipline devoted to caring, health, and healing. Watson’s theory has continued to evolve in regards to her concepts. The main components of her origninal theory are: transpersonal caring relationship; ten carative factors; and caring occasion/caring moment. These components defined her orignial concept of transpersonal caring which was defined as a

human-to-human connectedness occurring in a nurse-patient encounter wherein each is touched by the human center of the other” (Watson, 1985). In Watson’s updated theory new dimensions evolved and included the concept that “the caring-healing modalities potentiate harmony, wholeness, and confort, and promote inner healing by releasing some of the disharmony and blocked energy that interfere with the natural healing processes” (Walker, 1996, p. 151)

The transpersonal caring relationship is a strong relationship between nurse and patient. The relationship is a unique relationship for the both the nurse and patient. A nurse enters “into the life space or phenomenal field of another person and is able to detect the other person’s condition of being (spirit, or soul level), feels this condition within self, and respons in such a way that the person being cared for has a release of feelings, thought , and tension” (Walker, 1996, p. 152). Watson believes the necessary knowledge and sensitivity a nurse needs to build a transpersonal caring relationship with their patient can be gained through work with other cultures, study of the humanities, and exploration of one’s own values, beliefs, and relationship with self (Walker, 1996, p. 153). Watson wanted the theory to apply to all nurses in any situation and make use of its carative factors in implements and delivering quality nursing care.

Weaknesses

The first limitation in Watson’s theory is the lack of relevancy to today’s nursing. Due to the acuity of illness and nurse patient ratios following Watson’s theory doesn’t seem practical. Watson’s model continuously focuses on the “spirit”, and has a lack of emphasis on the physical entities of an individual. Watson’s model would deem difficult to practice for nurses who focus care on the physical aspects and the treatment of illness. Watson’s theory focuses on the human care process and not on the therapeutic nature of care (Rafael, 2000, p. 402) Individuals who believe the physical is separate from the spiritual may find this theory unpractical. Watson continuously focuses on the psychosial aspects and need of patients, and this is a secondary concern in the current state of nursing practice.

Watson’s theory also deems itself to be impractical because it calls for a level of care that is simply impossible in an environment where there is a high acuity of illness, short hospital stays due to lack of insurance, and an increased level of technology which limits the amount of time needed to spend with a patient. In the current business focused era and a bureaucratic health care system, Watson’s model would prove to be extremely difficult for nurses to implement. “The broad gap between the nurse caring process and the clinical reality, have some authors suggesting that this gap reduces clinical relevance.” (Morse, Solberg, Neander, Bottorff, & Johnson, 1990, p. 8) Nurses would find current hospital policies and practices would limit their flexibility to implement this theory. The health system follows a different set of values and beliefs and would stand as a barrier for nurses whom choose to follow these principles. Implementation of Watson’s theory would require a change from the public and movement away from the idea of treatment and towards healing and caring. Watson’s theory would require the restructuring of our entire health system, and rebuilding into a healing focused health care system.

Strengths

Watson’s theory has been criticized by many, but is transformative and brings the caring aspect back to nursing. The theory guides the nurse to focus on the individual and requires the selective use of technology. The theory requires the use of technology only for the enhancement of healthcare practices, and not as the sole guiding factor in healthcare. Watson insists that the nurse focuses on the subjective experience of the patient, to facilitate “restoring inner harmony and potential healing” (Morse et al., 1990, p. 9) Watson calls the nurse to go beyond the duties of providing standard quality of care, but requires the nurse to provide soul satisfying care. Watson believes it is morally imperative and an obligation to care for the patient and their spiritual needs, regardless of the nurse’s experience or abilities. This notion also coincides with Leininger’s Culture Care theory in requiring the nurse to provide non-judgmental and non-biased culturally competent care.

Watson’s theory allows the nurse to be flexible in their practice. The theory doesn’t require the nurse to follow a set standard or tool. Transpersonal Caring theory focuses on the individual and not the disease or illness. The theory allows the nurse to utilize different interaction methods with different individuals. The theory grants the nurse the ability to adjust their approach and style of care based on the needs of each individual as separate entities and apart from their disease. The adjustment allows the nurse to have a transpersonal moment with their patient in which “one’s mind-bod- soul engages with another’s mind-body-soul in a lived moment. Here a spiritual union is felt with the other person” (Rafael, 2000, p. 402) Watson brings the patient back to focus and eliminates the other common distractors such as technology and illness. By eliminating these distractors Watson is allowing the nurse to meet each patient’s physical and spiritual needs.

Betty Neuman: The Neuman Systems Model

Summary

Betty Neuman born in 1924 in Ohio received her nursing diploma from Peoples Hospital in 1947 in Akron, Ohio. Neuman later received her B.S. in public health nursing in 1957 and her M.S. public-mental health in 1966 from UCLA. In 1985 she obtained her Ph.D. in clinical psychology from Pacific Western University. Neuman has worked as a bedside nurse, teach, author, lecturer, and consultant. Neuman was the first nurse licensed in California as a marriage and family counselor. The Neuman Systems Model was developed in 1970 in response to graduate students’ requests for a course that would provide an overview of the physiological, psychological, sociocultural, and developmental aspects of human beings (Fawcett, 2001, p. 211). The model was first published in 1972 and five editions have been published with the last edition in 2010.

The model was established during the period of general systems theory and is a holistic model based upon interactions and relationships. Neuman’s System Model consists of two major components stress and the reaction to stress (Neuman, 1995, p. 22). The model has four major concepts in relation to nursing which are: human being/individual, environment, health, and nursing. The model is an open system and defines the individual as a human being, the community, or a family. The goal of the system is to maintain balance and stability. Neuman allows the individual to maintain balance by utilizing resources within and outside of the system, or eliminate internal or external factors that affect the individual’s ability to maintain stability. Factors that disrupt an individual’s ability to maintain stability are called stressors. Neuman views stressors as either negative or positive and deem them capable of having this same effect on the individual. The model requires the individual to utilize and exchange with its environment. The individual may adjust itself according to the environment or adjust the environment as long as the ultimate goal of stability is met.

The physiological psychological, sociocultural, developmental and spiritual factors are considered the core of the model. If the individual has maintained stability then these factors functions harmoniously amongst each other in spite of environment and stressors. Neuman believes when these factors are working together harmoniously and optimal stability has been attained then the individual has also obtained a greater level of wellness. Neuman utilizes wellness and health interchangeably and identifies these factors as “optimal system stability, or the optimal state of wellness at a given time (Neuman, 1990, p. 129). The levels of health vary and is based upon the individual’s response to its environment and stressors. The model identifies illness and death as requiring more energy that what is available, and wellness as requiring less energy than what is available or generated (Neuman, 1990, p. 129)

Neuman utilizes prevention at the levels of primary, secondary, and tertiary to maintain stability (Fawcett, 2001, p. 213). Primary prevention is health promotion and maintenance and is utilized when a risk is identified and before its onset. Secondary prevention occurs after the risks onset and is utilized to prevent further injury and disability. If secondary prevention is unable to maintain stability the individual will move towards tertiary prevention. Tertiary prevention is maintaining maximum stability even with a disability to promote health and return to primary prevention.

Neuman defines nursing as helping the individual’s system “attain, maintain, or retain system stability” (Fawcett, 2001, p. 211). Neuman identifies the job of the nurse to accurately assess the individual and identify the stressors to their system, and assist the individual in making adjustments that will promote optimal health and wellness. By identifying and assisting the nurse stands as the linkage between the individual’s system, its environment, and health. The nurse’s interventions are aimed at helping the individual maintain a level of stability. The level of stability must be maintained under the conditions of the environment and possibly stressors if the factors are unable to be eliminated. The nurse must assist the individual in maintaining stability under these conditions and minimize the amount of energy consumed by the individual. The model identifies a three-step process for the nurse and consists of the nursing diagnosis, nursing goals, and nursing outcomes. The “Nursing Diagnosis” consists of the assessment and diagnosis of each individual. The second step “Nursing Goals” consists of the identification and planning phase. The final step “Nursing Outcomes” is the implementation and evaluation phase. (Fawcett, 2001, pp. 212-213)

Weaknesses

The major weakness identified in Neuman’s model is the ambiguity of the terms used in the model. Clarification is needed regarding the terms interpersonal stressors, extrapersonal stressors, and reaction. Gigliotti (2003) noted that “linking statements (relational propositions) between stressors and the environment should be clearer” (Gigliotti, 2003, p. 203). The reader can assume that interpersonal stressors occur between two people and extrapersonal stresors occur between a group or society and the person, but this is not clearly defined in Neuman’s literature. “Hoffman (1982) analyzed the NSM and explored its use for theory construction concluding that the concepts of the NSM were defined and proposed that concept interrelations be further investigated so that relational hypotheses could be formulated” (Gigliotti, 2003, p. 203). The differentiation between interpersonal and extrapersonal is not clear. The pictorial diagram of Neuman Systems Model includes the term reaction, but in the original model the term reaction is not clearly defined or discussed.

The second weakness identified in Neuman’s model is the inconsistence use of the concepts health, environment and nursing. Neuman’s literature identifies health, environment, and nursing as major concepts within the model, but these concepts do not appear in the model’s diagram. Neuman’s diagram is considered to be an important representation of her model, but major concepts are eliminated from the model. Gigliotti (2003) “noted that the definitions of essential concepts that Neuman had then supplied were adequate but the definitions of health, environment, and nursing needed clarification” (Gigliotti, 2003, p. 203). Major concepts stated and continuously used within Neuman’s literature should be identifiable and noted within the pictorial explanation of the model.

Strengths

A major strength in Neuman’s model is its ability to be widely used within nursing. Neuman reports that the model was designed for nursing but can be used by other health disciplines (Fawcett, 2001, p. 212). If all nurses and other disciplines utilize this model then a consistent approach to health care will be facilitated. If all disciplines utilize the same model, established by Neuman, perhaps redundancy and errors will be limited across health care disciplines. Redundancy would be eliminated and the patient would only have to explain their needs or story once to all health care disciplines, rather than, having to tell the same story many different times.

The second strength in Neuman’s model is not only can it be used across other health care disciplines, but can be utilized within all areas of nursing. Neuman’s model is flexible in the sense that it can be used in the areas of research, administration, education, and clinical practice all within nursing. The third edition of Neuman’s model highlights the use of the model in all areas of nursing throughout the United States, Australia, Canada, England, Holland, Sweden and Wales (Fawcett, 2001, p. 211). The widespread use of this model illustrates its universal applicability. Neuman highlights this applicability as crucial during the current state, in which, the nursing profession has an increased need for unity within the discipline. Neuman believes the “systematic Nursing Process format has been especially relevant as a guide for practice, despite all of the social and professional changes that nursing continues to experience” (Fawcett, 2001, p. 212).