Theory of Goal Attainment of Imogene King goal or goals are achieved, satisfaction will occur.

(4) If the
goal or goals are achieved, effective nursing care will
Some people consider their “success” after being occur. (5) If transactions are made in nurse-patient
hired in a great and well-known institution. But when interactions, growth and development will be enhanced. (6)
someone decides to pursue a career in nursing, one should If role expectations and role performance perceived by the
set his or her mind that they should be an instrument in nurse and patient are congruent, the transaction will occur.
helping patients get healthy. And to achieve that, it’s (7) If role conflict is experienced by either the nurse or the
important to set health goals with the patient, then take patient (or both), stress in the nurse-patient interaction will
steps to achieve those goals. occur. (8) If a nurse with special knowledge communicates
appropriate information to the patient, mutual goal-setting
Imogene M. King’s Theory of Goal and goal achievement will occur.
Attainment focuses on this process to guide and direct Assumptions
nurses in the nurse-patient relationship, going hand-in-hand Imogene King’s personal philosophy about
with their patients to meet good health goals. human beings and life influenced her assumptions about the
environment, health, nursing, individuals, and nurse-patient
King’s Theory of Goal Attainment was first interactions. King’s conceptual system and Theory of Goal
introduced in the 1960s. From the title itself, the model Attainment were “based on an overall assumption that the
focuses on the attainment of certain life goals. It explains focus of nursing is human beings interacting with their
that the nurse and patient go hand-in-hand in environment, leading to a state of health for individuals,
communicating information, set goals together, and then which is an ability to function in social roles.”
take actions to achieve those goals.
The assumptions are: (1) The focus of nursing is
King has interrelated the concepts of interaction, the care of the human being (patient). (2) The goal of
perception, communication, transaction, self, role, stress, nursing is the health care of both individuals and groups.
growth and development, time, and space into a goal (3) Human beings are open systems interacting with their
attainment theory. Her theory deals with a nurse-client environments constantly. (4) The nurse and patient
dyad, a relationship to which each person brings personal communicate information, set goals mutually, and then act
perceptions of self, role, and personal growth and to achieve those goals. This is also the basic assumption of
development levels. The nurse and client communicate, the nursing process. (5) Patients perceive the world as a
first in interaction and then in the transaction, to attain complete person making transactions with individuals and
mutually set goals. The relationship takes place in space things in the environment. (6) The transaction represents a
identified by their behaviors and occurs in forward-moving life situation in which the perceiver and the thing being
time. perceived are encountered. It also represents a life situation
in which a person enters the situation as an active
participant. Each is changed in the process of these
What is Theory of Goal Attainment? experiences.
The Theory of Goal Attainment states
that “Nursing is a process of action, reaction, and
interaction by which nurse and client share information Major Concepts and Subconcepts
about their perception in a nursing situation” and “a The following are the major concepts and subconcepts of
process of human interactions between nurse and client Imogene King’s Theory of Goal Attainment:
whereby each perceives the other and the situation, and
through communication, they set goals, explore means, and Nursing
agree on means to achieve goals.” Nursing is a process of action, reaction, and
interaction whereby nurse and client share information
In this definition, the action is a sequence of about their perceptions in the nursing situation. The nurse
behaviors involving mental and physical activity, and the and client share specific goals, problems, and concerns and
reaction is included in the sequence of behaviors described explore how to achieve a goal.
in action. King states that a nurse’s goal is to help
individuals maintain their health so they can function in Health
their roles. The domain of the nurse “includes promoting, Health is a dynamic life experience of a human
maintaining, and restoring health, and caring for the sick, being, which implies continuous adjustment to stressors in
injured and dying.” The function of a professional nurse is the internal and external environment through optimum use
“to interpret information in the nursing process to plan, of one’s resources to achieve maximum daily living
implement, and evaluate nursing care.” potential.

Propositions Individual
The following propositions are made in Imogene Individuals are social beings who are rational and
King’s Theory of Goal Attainment: (1) If perceptual sentient. Humans communicate their thoughts, actions,
interaction accuracy is present in nurse-patient interactions, customs, and beliefs through language. Persons exhibit
the transaction will occur. (2) If the nurse and patient make common characteristics such as the ability to perceive,
the transaction, the goal or goals will be achieved. (3) If the think, feel, choose between alternative courses of action, set
goals, select the means to achieve goals, and make Space includes that space exists in all directions, is the
decisions. same everywhere, and is defined by the physical area
known as “territory” and by the behaviors of those
Environment occupying it.
The environment is the background for human
interactions. It is both external to, and internal to, the Time is defined as “a duration between one event and
individual. another as uniquely experienced by each human being; it is
the relation of one event to another event.”
King (1986) added learning as a subconcept in the personal
system but did not further define it.
Action
Action is defined as a sequence of behaviors 2. Interpersonal Systems
involving mental and physical activity. The sequence is These are formed by human beings interacting.
first mental action to recognize the presenting conditions; Two interacting individuals form a dyad; three form a triad,
then physical action to begin activities related to those and four or more form small or large groups. As the
conditions; and finally, mental action to exert control over number of interacting individuals increases, so does the
the situation, combined with physical action seeking to complexity of the interactions. Understanding the
achieve goals. interpersonal system requires the concepts
of communication, interaction, role, stress, and transaction.
Reaction
The reaction is not specifically defined but might Interactions are defined as the observable
be considered in the sequence of behaviors described in behaviors of two or more individuals in mutual presence.
action. King (1990) defines communication as “a process
whereby information is given from one person to another
either directly in a face-to-face meeting or indirectly
Interacting Systems of Theory of Goal Attainment through telephone, television, or the written word.”
According to King, there are three interacting
systems in the Theory of Goal Attainment. These are King defines transactions as “a process of
the personal system, the interpersonal system, and interactions in which human beings communicate with the
the social system. Each system is given different concepts. environment to achieve goals that are valued… goal-
The personal system concepts are perception, self, growth directed human behaviors.
and development, body image, space, and time. The
concepts for the interpersonal system are interaction, The characteristics of the role include reciprocity.
communication, transaction, role, and stress. The social A person may be a giver at one time and a taker at another
system concepts are organization, authority, power, status, time, with a relationship between two or more individuals
and decision-making. functioning in two or more, learned, social, complex, and
situational roles.
1. Personal Systems
Each individual is a personal system. King designated an Stress is “a dynamic state whereby a human
example of a personal system as a patient or a nurse. King being interacts with the environment to maintain balance
specified the concepts of body image, growth, for growth, development, and performance, which involves
development, perception, self, space, and time to an exchange of energy and information between the person
comprehend human beings as persons. and the environment for regulation and control of
“The self is a composite of thoughts and feelings which stressors.”
constitute a person’s awareness of his individual existence,
his conception of who and what he is. A person’s self is the 3. Social Systems
total of all he can call his. The self includes, among other A more comprehensive interacting system consists of
things, a system of ideas, attitudes, values, and groups that make up society, referred to as the social
commitments. The self is a person’s total subjective system. Religious, educational, and health care systems are
environment. It is a distinctive center of experience and examples of social systems. An extended family’s
significance. The self constitutes a person’s inner world as influential behavior on an individual’s growth and
distinguished from the outer world consisting of all other development is another social system example. Within a
people and things. The self is the individual as known to social system, the concepts of authority, decision
the individual. It is that to which we refer when we say “I.” making, organization, power, and status guide system
understanding.
Growth and development can be defined as the processes
in people’s lives through which they move from a potential Power is the capacity to use resources in
for achievement to the actualization of self. organizations to achieve goals… is the process whereby
one or more persons influence other persons in a
King defines body image as to how one perceives both situation… is the capacity or ability of a person or a group
one’s body and others’ reactions to one’s appearance. to achieve goals… occurs in all aspects of life. Each person
has potential power determined by individual resources and
the environmental forces encountered. Power is a social Role
force that organizes and maintains society. Power is the The role is defined as “a set of behaviors expected of
ability to use and mobilize resources to achieve goals. persons occupying a position in a social system; rules that
define rights and obligations in a position; a relationship
Status is “the position of an individual in a group with one or more individuals interacting in specific
or a group concerning other groups in an organization,” It is situations for a purpose.”
identified that status is accompanied by “privileges, duties,
and obligation.” Stress
Stress is “a dynamic state whereby a human being interacts
Decision making is “a dynamic and systematic with the environment to maintain balance for growth,
process by which goal-directed choice of perceived development, and performance… an energy response of an
alternatives is made and acted upon by individuals or individual to persons, objects, and events called stressors.”
groups to answer a question and attain a goal” (King,
1990). Growth and Development
King (1986) added control as a subconcept in the social Growth and development can be defined as the “continuous
system but did not further define the concept. changes in individuals at the cellular, molecular, and
behavioral levels of activities… the processes that take
place in the life of individuals that help them move from
Dynamic Conceptual Systems potential capacity for achievement to self-actualization.”
The figure below demonstrates the conceptual system that Time
provided “one approach to studying systems as a whole Time is “a sequence of events moving onward to the
rather than as isolated parts of a system” and was “designed future… a continuous flow of events in successive order
to explain the organized wholes within which nurses are that implies a change, a past and a future… a duration
exKing has interrelated the concepts of interaction, between one event and another as uniquely experienced by
perception, communication, transaction, self, role, stress, each human being… the relation of one event to another.”
growth and development, time, and space into a goal Space
attainment theory. Her theory deals with a nurse-client Space exists in every direction and is the same in all
dyad, a relationship to which each person brings personal directions. Space includes that physical area called
perceptions of self, role, and personal growth and territory. Space is defined by the behaviors of those
development levels. The nurse and client communicate, individuals who occupy it.
first in interaction and then in the transaction, to attain pected to function.”
mutually set goals. The relationship takes place in space
identified by their behaviors and occurs in forward-moving
time.
Theory of Goal Attainment and The Nursing Process
She believed that her “framework differs from
other conceptual schemas in that it is concerned not with
Imogene King emphasizes the nursing process in
fragmenting human beings and the environment but with
her model of nursing. The steps of the nursing process
human transactions in different kinds of environments.”
are assessment, nursing
diagnosis, planning, implementations, and evaluation.
Process of Interaction
The figure above represents a process of human
The theory explains that assessment takes place
interactions that lead to transactions: A model of
during the interaction. The nurse uses his or her special
transaction. According to King, “The human process of
knowledge and skills while the patient delivers knowledge
interactions formed the basis for designing a model of
of him or herself and the perception of problems of concern
transactions that depicted theoretical knowledge used by
to the interaction. During this phase, the nurse gathers data
nurses to help individuals and groups attain goals.”
about the patient, including their growth and development,
Interaction
the perception of self, and current health status. Perception
Interaction is a process of perception and communication
is the basis for the collection and interpretation of data.
between a person and environment and between person and
Communication is required to verify the accuracy of the
person represented by verbal and nonverbal behaviors that
perception, as well as for interaction and translation.
are goal-directed.
Transaction
The next phase is the nursing diagnosis. This
The transaction is a process of interactions in which human
beings communicate with the environment to achieve phase is developed using the data collected in the
valued goals; transactions are goal-directed human assessment. In attaining goals, the nurse identifies
behaviors. problems, concerns, and disturbances about which the
Perception is “each person’s representation of reality.” patient is seeking help.
Communication
Communication is defined as “a process whereby The planning phase arises after the diagnosis.
information is given from one person to another either
directly in face-to-face meetings or indirectly through The nurse and other health care team members create a care
telephone, television, or the written word.” plan of interventions to solve the problems identified. This
phase is represented by setting goals and making decisions psychological, sociocultural, developmental, and spiritual.
about the means to achieve those goals. This part of the The client system consists of a basic or core structure that is
transaction and the patient’s participation are encouraged in protected by lines of resistance. The usual health level is
making decisions on the means to achieve the goals. identified as the normal defense line protected by a flexible
line of defense. Stressors are intra-, inter-, and extra
The actual activities done to achieve the goals personal in nature and arise from the internal, external, and
make up the implementation phase of the nursing process. created environments. When stressors break through the
Whereas in this model of nursing, it is the continuation of flexible line of defense, the system is invaded, and the lines
transaction. of resistance are activated. The system is described as
moving into illness on a wellness-illness continuum. If
Finally, in the evaluation phase, the nurse adequate energy is available, the system will be
evaluates the patient to determine whether the goals were reconstituted with the normal defense line restored at,
achieved. Evaluation involves determining whether or not below, or above its previous level.
goals were achieved. The explanation of evaluation in Nursing interventions occur through three
King’s theory addresses meeting goals and the prevention modalities. Primary prevention occurs before
effectiveness of nursing care. the stressor invades the system; secondary
prevention occurs after the system has reacted to an
In the healthcare field, the nurse-patient invading stressor; tertiary prevention occurs after
relationship‘s final goal is to help the patient achieve his or secondary prevention as reconstitution is being established.
her goals for getting healthy. Using the nursing process Assumptions
described in King’s Theory of Goal Attainment, a nurse can The following are the assumptions or “accepted
be more effective in working with a patient to achieve those truths” made by Neuman’s Systems Model:
goals and truly help patients.  Each client system is unique, a composite of
factors and characteristics within a given range of
responses.
 Many known, unknown, and universal stressors
exist. Each differs in its potential for disturbing a
client’s usual stability level or normal line of
defense. The particular interrelationships of client
Betty Neuman’s Nursing Theory variables at any point in time can affect the
Three words frequently used concerning stress degree to which a client is protected by the
are inevitable, painful, and intensifying. It is generally flexible line of defense against possible reaction
subjective and can be interpreted as the circumstances of to stressors.
conceivably threatening and out of their control. A nursing
 Each client/client system has evolved a normal
theory developed by Betty Neuman is based on the person’s
range of responses to the environment referred to
relationship to stress, response, and reconstitution factors
as a normal line of defense. The normal line of
that are progressive in nature. The Neuman Systems Model
defense can be used as a standard from which to
presents a broad, holistic, and system-based method to
measure health deviation.
nursing that maintains a factor of flexibility. It focuses on
the patient system’s response to actual or potential  When the flexible line of defense is no longer
environmental stressors and maintains the client system’s capable of protecting the client/client system
stability through primary, secondary, and tertiary nursing against an environmental stressor, the stressor
prevention interventions to reduce stressors. breaks through the normal line of defense.
What is the Neuman Systems Model?  Whether in a state of wellness or illness, the
Betty Neuman describes the Neuman Systems client is a dynamic composite of the variables’
Model as “a unique, open-system-based perspective that interrelationships. Wellness is on a continuum of
provides a unifying focus for approaching a wide range of available energy to support the system in an
concerns. A system acts as a boundary for a single client, a optimal system stability state.
group, or even several groups; it can also be defined as a  Implicit within each client system is internal
social issue. A client system in interaction with the resistance factors known as lines of resistance,
environment delineates the domain of nursing concerns.” which function to stabilize and realign the client
The Neuman Systems Model views the client as to the usual wellness state.
an open system that responds to stressors in the  Primary prevention relates to general knowledge
environment. The client variables are physiological, applied in client assessment and intervention in
 identifying and reducing or mitigating possible or of stability between the client system variables and
actual risk factors associated with environmental environmental stressors, focusing on conserving energy.
stressors to prevent a possible reaction. Open System
 Secondary prevention relates to symptomatology A system in which there is a continuous flow of
following a reaction to stressors, an appropriate input and process, output and feedback. It is a system of
ranking of intervention priorities, and treatment organized complexity, where all elements are in interaction.
to reduce their noxious effects. Basic Stricture and Energy Resources
 Tertiary prevention relates to the adjustive The basic structure, or central core, comprises
processes as reconstitution begins and those basic survival factors common to the species. These
maintenance factors move the client back in a factors include the system variables, genetic features, and
circular manner toward primary prevention. strengths and weaknesses of the system parts.
Client Variables
 The client as a system is in dynamic, constant
Neuman views the individual client holistically
energy exchange with the environment. (Neuman,
and considers the variables simultaneously and
1995)
comprehensively.
Major Concepts of Neuman Systems Model
This section will define the nursing  The physiological variable refers to the structure
metaparadigm and the major concepts in Betty Neuman’s and functions of the body.
Neuman Systems Model.  The psychological variable refers to mental
Human being processes and relationships.
The human being is an open system that interacts  The sociocultural variable refers to system
with internal and external environment forces or stressors. functions that relate to social and cultural
The human is constantly changing, moving toward a expectations and activities.
dynamic state of system stability or illness of varying  The developmental variable refers to those
degrees. processes related to development over the
Environment lifespan.
The environment is a vital arena that is germane  The spiritual variable refers to the influence of
to the system and its function. The environment may be spiritual beliefs.
viewed as all factors that affect and are affected by the Flexible line of defense
system. In Neuman Systems Model identifies three relevant A protective accordion-like mechanism that
environments: (1) internal, (2) external, and (3) created. surrounds and protects the normal line of defense from
 The internal environment exists within the client invasion by stressors.
system. All forces and interactive influences that Normal line of defense
are solely within the client system’s boundaries An adaptational level of health developed over
make up this environment. time and is considered normal for a particular individual
 The external environment exists outside the client client or system; it becomes a standard for wellness-
system. deviance determination.
 The created environment is unconsciously Lines of resistance
developed and is used by the client to support Protection factors are activated when stressors
protective coping. have penetrated the normal line of defense, causing reaction
Health symptomatology.
In Neuman’s nursing theory, Health is defined as Subconcepts of Neuman Systems Model
the condition or degree of system stability and is viewed as Stressors
a continuum from wellness to illness. When system needs A stressor is any phenomenon that might
are met, optimal wellness exists. When needs are not penetrate both the flexible and normal lines of defense,
satisfied, illness exists. When the energy needed to support resulting in either a positive or negative outcome.
life is not available, death occurs.  Intrapersonal stressors are those that occur
within the client system boundary and correlate
Nursing with the internal environment.
Nursing’s primary concern is to define the  Interpersonal stressors occur outside the client
appropriate action in situations that are stress-related or system boundary, are proximal to the system, and
concerning possible reactions of the client or client system impact the system.
to stressors. Nursing interventions aim to help the system  Extrapersonal stressors also occur outside the
adapt or adjust and retain, restore, or maintain some degree client system boundaries but are at a greater
 distance from the system than are interpersonal the basic structure will be unable to support the
stressors. An example is a social policy. system and its interventions, and death will occur.
Stability  Tertiary prevention occurs after the system has
A state of balance or harmony requiring energy been treated through secondary prevention
exchanges as the client adequately copes with stressors to strategies. Its purpose is to maintain wellness or
retain, attain, or maintain an optimal health level, thus protect the client system reconstitution by
preserving system integrity. supporting existing strengths and preserving
Degree of Reaction energy. Tertiary prevention may begin at any
The amount of system instability resulting from point after system stability has begun
stressor invasion of the normal line of defense. reestablished (reconstitution has begun). Tertiary
Entropy prevention tends to lead back to primary
A process of energy depletion and prevention. (Neuman, 1995)
disorganization moving the system toward illness or
possible death. Callista Roy’s Adaptation Model of Nursing

Negentropy The Adaptation Model of Nursing is a

An energy conservation process that increases prominent nursing theory aiming to explain or define the
organization and complexity, moving the system toward provision of nursing science. In her theory, Sister Callista
stability or a higher degree of wellness. Roy’s model sees the individual as a set of interrelated
systems that maintain a balance between various stimuli.
Input/Output
The matter, energy, and information exchanged The Roy Adaptation Model was first presented in
between the client and environment entering or leaving the the literature in an article published in Nursing Outlook in
system at any point in time. 1970 entitled “Adaptation: A Conceptual Framework for
Nursing.” In the same year, Roy’s Adaptation Model of
Reconstitution Nursing was adapted in Mount St. Mary’s School in Los
Following treatment of stressor reaction, the Angeles, California.
return and maintenance of system stability may result in a Roy’s model was conceived when nursing
higher or lower wellness level. theorist Dorothy Johnson challenged her students to
develop conceptual models of nursing during a
Prevention as Intervention seminar. Johnson’s nursing model was the impetus for the
Intervention modes for nursing action and development of Roy’s Adaptation Model.
determinants for both client and nurse entry into the health Roy’s model incorporated concepts from
care system. Adaptation-level Theory of Perception from renowned
 Primary prevention occurs before the system American physiological psychologist Harry Helson,
reacts to a stressor; it includes health Ludwig von Bertalanffy’s System Model, and Anatol
promotion and wellness maintenance. Primary Rapoport’s system definition.
prevention focuses on strengthening the flexible
line of defense through preventing stress and First, consider the concept of a system as applied
reducing risk factors. This intervention occurs to an individual. Roy conceptualizes the person in a holistic
when the risk or hazard is identified but before a perspective. Individual aspects of parts act together to form
reaction occurs. Strategies that might be used a unified being. Additionally, as living systems, persons are
include immunization, health education, exercise, in constant interaction with their environments. Between
and lifestyle changes. the system and the environment occurs an exchange of
 Secondary prevention occurs after the system information, matter, and energy. Characteristics of a system
reacts to a stressor and is provided in terms of include inputs, outputs, controls, and feedback.
existing symptoms. Secondary prevention focuses
on strengthening the internal lines of resistance Assumptions
and, thus, protects the basic structure through Scientific Assumptions
appropriate treatment of symptoms. The intent is  Systems of matter and energy progress to higher
to regain optimal system stability and conserve levels of complex self-organization.
energy in doing so. If secondary prevention is  Consciousness and meaning are constructive of
unsuccessful and reconstitution does not occur, person and environment integration.
  Awareness of self and The environment is defined as conditions,
environment is rooted in thinking and feeling. circumstances, and influences that affect humans’
 Humans, by their decisions, are accountable for development and behavior as an adaptive system. The
the integration of creative processes. environment is a stimulus or input that requires a person to
adapt. These stimuli can be positive or negative.
 Thinking and feeling mediate human action.
 System relationships include acceptance, Roy categorized these stimuli as focal,
protection, and fostering of interdependence. contextual, and residual. Focal stimuli are that confront the
 Persons and the earth have common patterns and human system and require the most attention. Contextual
integral relationships. stimuli are characterized as the rest of the stimuli present
 Persons and environment transformations are with the focal stimuli and contribute to its effect. Residual
created in human consciousness. stimuli are the additional environmental factors present
 Integration of human and environmental within the situation but whose effect is unclear. This can
meanings results in adaptation. include previous experience with certain stimuli.

Philosophical Assumptions Health

 Persons have mutual relationships with the world “Health is not freedom from the inevitability of
and God. death, disease, unhappiness, and stress, but the ability to
cope with them in a competent way.”
 Human meaning is rooted in the omega point
convergence of the universe.
Health is defined as the state where humans can
 God is intimately revealed in the diversity of continually adapt to stimuli. Because illness is a part of
creation and is the common destiny of creation. life, health results from a process where health and illness
 Persons use human creative abilities of can coexist. If a human can continue to adapt holistically,
awareness, enlightenment, and faith. they will maintain health to reach completeness and unity
 Persons are accountable for the processes of within themselves. If they cannot adapt accordingly, the
deriving, sustaining, and transforming the integrity of the person can be affected negatively.
universe.
Nursing
Major Concepts of the Adaptation Model “[The goal of nursing is] the promotion of
The following are Callista Roy’s Adaptation adaptation for individuals and groups in each of the four
Model’s major concepts, including the definition of the adaptive modes, thus contributing to health, quality of life,
nursing metaparadigm as defined by the theory. and dying with dignity.”

Person In Adaptation Model, nurses are facilitators of

“Human systems have thinking and feeling adaptation. They assess the patient’s behaviors for
capacities, rooted in consciousness and meaning, by which adaptation, promote positive adaptation by enhancing
they adjust effectively to changes in the environment and, in environment interactions and helping patients react
turn, affect the environment.” positively to stimuli. Nurses eliminate ineffective
coping mechanisms and eventually lead to better outcomes.
Based on Roy, humans are holistic beings that are
in constant interaction with their environment. Humans use Adaptation
a system of adaptation, both innate and acquired, to respond Adaptation is the “process and outcome whereby
to the environmental stimuli they experience. Human thinking and feeling persons as individuals or in groups use
systems can be individuals or groups, such as families, conscious awareness and choice to create human and
organizations, and the whole global community. environmental integration.”

Environment Internal Processes

“The conditions, circumstances and influences Regulator
surrounding and affecting the development and behavior of The regulator subsystem is a person’s
persons or groups, with particular consideration of the physiological coping mechanism. The body attempts to
mutuality of person and health resources that includes adapt via regulation of our bodily processes, including
focal, contextual and residual stimuli.” neurochemical and endocrine systems.
 The various modes and subsystems meet the
needs of the environment. These are usually stable
Cognator processes (e.g., breathing, spiritual realization, successful
The cognator subsystem is a person’s mental relationship).
coping mechanism. A person uses his brain to cope via self-
concept, interdependence, and role function adaptive Compensatory Process
modes. The cognator and regulator are challenged by the
environment’s needs but are working to meet the needs
Four Adaptive Modes (e.g., grief, starting with a new job, compensatory
The subsystem’s four adaptive modes are how the breathing).
regulator and cognator mechanisms are manifested; in other
words, they are the external expressions of the above and Compromised Process
internal processes. The modes and subsystems are not adequately
meeting the environmental challenge (e.g., hypoxia,
Physiological-Physical Mode unresolved loss, abusive relationships).
Physical and chemical processes are involved in
the function and activities of living organisms. These are Six-Step Nursing Process
the actual processes put in motion by the regulator A nurse’s role in the Adaptation Model is to
subsystem. manipulate stimuli by removing, decreasing, increasing, or
This mode’s basic need is composed of the needs altering stimuli so that the patient.
associated with oxygenation, nutrition, elimination, activity 1. Assess the behaviors manifested from the four
and rest, and protection. This model’s complex adaptive modes.
processes are associated with the senses, fluid 2. Assess the stimuli, categorize them as focal,
and electrolytes, neurologic function, and endocrine contextual, or residual.
function. 3. Make a statement or nursing diagnosis of the
person’s adaptive state.
Self-Concept Group Identity Mode 4. Set a goal to promote adaptation.
In this mode, the goal of coping is to have a sense 5. Implement interventions aimed at managing the
of unity, meaning the purposefulness in the universe, and a stimuli.
sense of identity integrity. This includes body image and 6. Evaluate whether the adaptive goal has been met.
self-ideals.
focuses specifically on the psychological and Johnson’s Behavioral System Model
spiritual aspects of the human system
Dorothy E. Johnson is well-known for
Role Function Mode her “Behavioral System Model,” which was first proposed
This mode focuses on the primary, secondary, in 1968. Her model was greatly influenced by Florence
and tertiary roles that a person occupies in society and Nightingale’s book, Notes on Nursing. It advocates
knowing where they stand as a member of society. fostering efficient and effective behavioral functioning in
the patient to prevent illness and stresses the importance of
Interdependence Mode research-based knowledge about the effect of nursing care
This mode focuses on attaining relational on patients.
integrity through the giving and receiving of love, respect Johnson’s Behavioral System Model is a nursing
and value. This is achieved with effective communication care model that advocates the fostering of efficient and
and relations. effective behavioral functioning in the patient to prevent
illness. The patient is identified as a behavioral system
Perception composed of seven behavioral subsystems: affiliative,
“Perception is the interpretation of a stimulus and the dependency, ingestive, eliminative, sexual, aggressive, and
conscious appreciation of it” (Pollock, 1993, p. 169). achievement. Each subsystem’s three functional
Perception links the regulator with the cognator and requirements include protection from noxious influences,
connects the adaptive modes. provision for a nurturing environment, and stimulation for
growth. An imbalance in any of the behavioral subsystems
Levels of Adaptation results in disequilibrium. It is nursing’s role to assist the
Integrated Process client in returning to a state of equilibrium.
 ‘drive’ has been stimulated or what ‘goal’ is being sought.”
(2) Each person has a “predisposition to act concerning the
What is Behavioral System Model? goal, in certain ways rather than the other ways.” This
Dorothy Johnson’s theory defined Nursing as “an predisposition is called a “set.” (3) Each subsystem has a
external regulatory force which acts to preserve the repertoire of choices called a “scope of action.” And (4)
organization and integration of the patient’s behaviors at The individual patient’s behavior produces an outcome that
an optimum level under those conditions in which the can be observed.
behavior constitutes a threat to the physical or social And lastly, there are three functional
health, or in which illness is found.” requirements for the subsystems.: (1) The system must be
protected from toxic influences with which the system
It also states that “each individual has patterned, cannot cope. (2) Each system has to be nurtured through the
purposeful, repetitive ways of acting that comprises a input of appropriate supplies from the environment. And
behavioral system specific to that individual.” (3) The system must be stimulated for use to enhance
growth and prevent stagnation.
Goals
Dorothy Johnson began her work on the model Major Concepts
with the premise that nursing was a profession that made a The following are the major concepts and
distinctive contribution to society’s welfare. Thus, nursing definitions of Johnson’s nursing model, including the
had an explicit goal of action in patient welfare. definition for its nursing metaparadigm:

According to the Behavior System Model, the Human Beings

goals of nursing are fourfold: (1) To assist the patient Johnson views human beings as having two
whose behavior is proportional to social demands. (2) To major systems: the biological system and the behavioral
assist the patient who can modify his behavior in ways that system. It is the role of medicine to focus on the biological
supports biological imperatives. (3) To assist the patient system, whereas nursing focuses on the behavioral system.
who can benefit to the fullest extent during illness from the The concept of a human being was defined as a
physician’s knowledge and skill. And (4) To assist the behavioral system that strives to make continual
patient whose behavior does not give evidence of adjustments to achieve, maintain, or regain balance to the
unnecessary trauma as a consequence of illness. steady-state adaptation.

Assumptions of the Behavioral System Model Environment

The assumptions made by Dorothy Johnson’s The environment is not directly defined, but it is
theory are in three categories: assumptions about implied to include all elements of the human system’s
system, assumptions about structure, and assumptions surroundings and includes interior stressors.
about functions.
Johnson identified several assumptions that are Health
critical to understanding the nature and operation of the Health is seen as the opposite of illness, and
person as a behavioral system: (1) There is “organization, Johnson defines it as “some degree of regularity and
interaction, interdependency and integration of the parts constancy in behavior. The behavioral system reflects
and elements of behaviors that go to make up the system.” adjustments and adaptations that are successful somehow,
(2) A system “tends to achieve a balance among the various and to some degree… adaptation is functionally efficient
forces operating within and upon it, and that man strives and effective.”
continually to maintain a behavioral system balance and
steady-state by more or less automatic adjustments and Nursing
adaptations to the natural forces occurring on him.” (3) A Nursing is seen as “an external regulatory force
behavioral system, which requires and results in regularity that acts to preserve the organization and integrate the
and constancy in behavior, is essential to man. It is patient’s behavior at an optimal level under those
functionally significant because it serves a useful purpose conditions in which the behavior constitutes a threat to
in social life and the individual. And (4) “System balance physical or social health or in which illness is found.”
reflects adjustments and adaptations that are successful in
some way and to some degree.” Behavioral system
The four assumptions about structure and Man is a system that indicates the state of the
function are that: (1) “From the form the behavior takes system through behaviors.
and the consequences it achieves can be inferred what
 Johnson’s Behavioral System Model

System Attachment or affiliative subsystem

That which functions as a whole under organized Attachment or affiliative subsystem is the “social
independent interaction of its parts. inclusion intimacy and the formation and attachment of a
strong social bond.” It is probably the most critical because
Subsystem it forms the basis for all social organizations. On a general
A mini system is maintained concerning the level, it provides survival and security. Its consequences are
entire system when it or the environment is not disturbed. social inclusion, intimacy, and the formation and
maintenance of a strong social bond.
Subconcepts
Dependency subsystem
Structure The dependency subsystem is the “approval,
The parts of the system that make up the whole. attention or recognition and physical assistance.” In the
broadest sense, it promotes helping behavior that calls for a
Variables nurturing response. Its consequences are approval, attention
Factors outside the system influence the system’s or recognition, and physical assistance. Developmentally,
behavior, but the system lacks the power to change. dependency behavior evolves from almost total dependence
on others to a greater degree of dependence on self. A
Boundaries certain amount of interdependence is essential for the
The point that differentiates the interior of the survival of social groups.
system from the exterior.
Ingestive subsystem
Homeostasis An ingestive subsystem is the “emphasis on the
Process of maintaining stability. meaning and structures of the social events surrounding the
occasion when the food is eaten.” It should not be seen as
Stability the input and output mechanisms of the system. All
Balance or steady-state in maintaining a balance subsystems are distinct subsystems with their own input
of behavior within an acceptable range. and output mechanisms. The ingestive subsystem “has to
do with when, how, what, how much, and under what
Stressor conditions we eat.”
A stimulus from the internal or external world
that results in stress or instability. Eliminative subsystem
Eliminative subsystem states that “human
Tension cultures have defined different socially acceptable
The system’s adjustment to demands, change or behaviors for excretion of waste, but the existence of such a
growth, or to actual disruptions. pattern remains different from culture to culture.” It
addresses “when, how, and under what conditions we
Instability eliminate.” As with the ingestive subsystem, the social and
State in which the system output of energy psychological factors influence the biological aspects of
depletes the energy needed to maintain stability. this subsystem and may conflict with the eliminative
subsystem.
Set
The predisposition to act. It implies that despite Sexual subsystem
having only a few alternatives to select a behavioral A sexual subsystem is both a biological and
response, the individual will rank those options and choose social factor that affects behavior. It has the dual functions
the option considered most desirable. of procreation and gratification. Including, but not limited
to, courting and mating, this response system begins with
Function the development of gender role identity and includes a
Consequences or purposes of action. broad range of sex-role behaviors.

7 Subsystems of the Behavior System Model Aggressive subsystem

Johnson identifies seven subsystems in the The aggressive subsystem relates to protection
Behavioral System Model. They are: and self-preservation, generating a defense response when
there is a threat to life or territory. Its function is protection It also includes seven nursing roles: Stranger role,
and preservation. Society demands that limits be placed on Resource role, Teaching role, Counseling role, Surrogate
self-protection modes and that people and their property be role, Active leadership, and Technical expert role.
respected and protected.
Description
Achievement subsystem Hildegard E. Peplau’s theory defined Nursing
The achievement subsystem provokes behavior as “An interpersonal process of therapeutic interactions
that tries to control the environment. It attempts to between an individual who is sick or in need of health
manipulate the environment. Its function is to control or services and a nurse especially educated to recognize,
mastery an aspect of self or environment to some standard respond to the need for help.” It is a “maturing force and
of excellence. Areas of achievement behavior include an educative instrument” involving an interaction between
intellectual, physical, creative, mechanical, and social two or more individuals with a common goal.
skills. In nursing, this common goal provides the
incentive for the therapeutic process in which the nurse and
Behavioral System Model and The Nursing Process patient respect each other as individuals, both of them
The nursing process of the Behavior System learning and growing due to the interaction. An individual
Model of Nursing begins with assessing and diagnosing the learns when she or he selects stimuli in the environment
patient. Once a diagnosis is made, the nurse and other and then reacts to these stimuli.
healthcare professionals develop a nursing care plan of Assumptions
interventions and setting them in motion. The process ends Hildegard Peplau’s Interpersonal Relations
with an evaluation, which is based on the balance of the Theory’s assumptions are: (1) Nurse and the patient can
subsystems. interact. (2) Peplau emphasized that both the patient and
Johnson’s Behavioral System Model is best nurse mature as the result of the therapeutic interaction. (3)
applied in the evaluation phase, during which time the Communication and interviewing skills remain
nurse can determine whether or not there is balance in the fundamental nursing tools. And lastly, (4) Peplau believed
subsystems of the patient. If a nurse helps a patient that nurses must clearly understand themselves to promote
maintain an equilibrium of the behavioral system through their client’s growth and avoid limiting their choices to
an illness in the biological system, they have been those that nurses value.
successful in the role.
Major Concepts of the Interpersonal Relations Theory
Hildegard Peplau’s Interpersonal Relations Theory The theory explains nursing’s purpose is to help
others identify their felt difficulties and that nurses should
Hildegard Peplau’s Interpersonal Relations apply principles of human relations to the problems that
Theory emphasized the nurse-client relationship as the arise at all levels of experience.
foundation of nursing practice. It emphasized the give-
and-take of nurse-client relationships that was seen by Man
many as revolutionary. Peplau went on to form an Peplau defines man as an organism that “strives
interpersonal model emphasizing the need for a partnership in its own way to reduce tension generated by needs.” The
between nurse and client as opposed to the client passively client is an individual with a felt need.
receiving treatment and the nurse passively acting out
doctor’s orders. Health
The four components of the theory are person, Health is defined as “a word symbol that implies
which is a developing organism that tries to forward movement of personality and other ongoing human
reduce anxiety caused by needs; environment, which processes in the direction of creative, constructive,
consists of existing forces outside of the person and put in productive, personal, and community living.”
the context of culture; health, which is a word symbol that
implies a forward movement of personality and nursing, Society or Environment
which is a significant therapeutic interpersonal process that Although Peplau does not directly address
functions cooperatively with another human process that society/environment, she does encourage the nurse to
makes health possible for individuals in communities. consider the patient’s culture and mores when the patient
The nursing model identifies four sequential adjusts to the hospital routine.
phases in the interpersonal
relationship: orientation, identification, exploitation,
and resolution.
Nursing  Advantages of services are used based on the
Hildegard Peplau considers nursing to be a needs and interests of the patients.
“significant, therapeutic, interpersonal process.” She  The individual feels like an integral part of the
defines it as a “human relationship between an individual helping environment.
who is sick, or in need of health services, and a nurse
 They may make minor requests or attention-
specially educated to recognize and to respond to the need
getting techniques.
for help.”
 The principles of interview techniques must be
Therapeutic nurse-client relationship used to explore, understand and adequately deal
A professional and planned relationship between with the underlying problem.
client and nurse focuses on the client’s needs, feelings,  Patient may fluctuate on independence.
problems, and ideas. It involves interaction between two or  Nurse must be aware of the various phases of
more individuals with a common goal. The attainment of communication.
this goal, or any goal, is achieved through a series of steps  Nurse aids the patient in exploiting all avenues of
following a sequential pattern. help, and progress is made towards the final step.
4. Resolution Phase
Four Phases of the therapeutic nurse-patient In the resolution phase, the client no longer needs
relationship: professional services and gives up dependent behavior. The
1. Orientation Phase relationship ends.
The nurse’s orientation phase involves engaging  Termination of professional relationship
the client in treatment, providing explanations and
 The patient’s needs have already been met by the
information, and answering questions.
collaborative effect of patient and nurse.
 Problem defining phase
 Now they need to terminate their therapeutic
 It starts when the client meets the nurse as a relationship and dissolve the links between them.
stranger.
 Sometimes may be difficult for both as
 Defining the problem and deciding the type of psychological dependence persists.
service needed
 The patient drifts away and breaks the nurse’s
 Client seeks assistance, conveys needs, asks bond, and a healthier emotional balance is
questions, shares preconceptions and expectations demonstrated, and both become mature
of past experiences. individuals.
 Nurse responds, explains roles to the client,
identifies problems, and uses available resources Subconcepts of the Interpersonal Relations Theory
and services. Peplau’s model has proved greatly used by later
Factors influencing orientation phase. Click to nurse theorists and clinicians in developing more
enlarge. sophisticated and therapeutic nursing interventions.
2. Identification Phase The following are the roles of the Nurse in the
The identification phase begins when the client Therapeutic relationship identified by Peplau:
works interdependently with the nurse, expresses feelings, Stranger: offering the client the same acceptance
and begins to feel stronger. and courtesy that the nurse would respond to any stranger
 Selection of appropriate professional assistance Resource person: providing specific answers to
 Patient begins to have a feeling of belonging and questions within a larger context
a capability of dealing with the problem, which Teacher: helping the client to learn formally or
decreases the feeling of helplessness informally
and hopelessness. Leader: offering direction to the client or group
3. Exploitation Phase Surrogate: serving as a substitute for another
In the exploitation phase, the client makes full such as a parent or a sibling
use of the services offered. Counselor: promoting experiences leading to
 In the exploitation phase, the client makes full health for the client such as expression of feelings
use of the services offered. Technical Expert: providing physical care for
the patient and operates equipment
 Use of professional assistance for problem-
Peplau also believed that the nurse could take on
solving alternatives
many other roles, but these were not defined in detail.
However, they were “left to the intelligence and The idea of a nurse-client interaction is limited to
imagination of the readers.” (Peplau, 1952) those individuals incapable of conversing, specifically
Additional roles include: those who are unconscious.
 Technical expert The concepts are highly applicable to the care of
 Consultant psychiatric patients considering Peplau’s background. But
it is not limited to those sets of individuals. It can be
 Health teacher
applied to any person capable and has the will to
 Tutor communicate.
 Socializing agent The phases of the therapeutic nurse-client are
 Safety agent highly comparable to the nursing process, making it vastly
 Manager of environment applicable. Assessment coincides with the orientation
phase; nursing diagnosis and planning with the
 Mediator
identification phase, implementation as to the exploitation
 Administrator
phase, and evaluation with the resolution phase.
 Recorder observer
 Researcher Orlando’s Deliberative Nursing Process Theory

Anxiety was defined as the initial response to a Ida Jean Orlando developed her theory from a
psychic threat. There are four levels of anxiety described study conducted at the Yale University School of Nursing,
below. integrating mental health concepts into a basic nursing
curriculum. She proposed that “patients have their own
Four Levels of Anxiety meanings and interpretations of situations and therefore
Mild anxiety is a positive state of heightened nurses must validate their inferences and analyses with
awareness and sharpened senses, allowing the person to patients before concluding.”
learn new behaviors and solve problems. The person can .
take in all available stimuli (perceptual field). Orlando’s nursing theory stresses the reciprocal
Moderate anxiety involves a decreased person relationship between patient and nurse. What the nurse and
can learn a new behavior or solve problems only with the patient say and do affects them both. She views
assistance. Another person can redirect the person to the nursing’s professional function as finding out and meeting
task. the patient’s immediate need for help.
Severe anxiety involves feelings of dread and
terror. The person cannot be redirected to a task; he or she She also described her model as revolving around
focuses only on scattered details and has physiologic the following five major interrelated concepts: the function
symptoms of tachycardia, diaphoresis, and chest pain. of professional nursing, presenting behavior, immediate
Panic anxiety can involve loss of rational reaction, nursing process discipline, and improvement. The
thought, delusions, hallucinations, and complete physical function of professional nursing is the organizing principle.
immobility and muteness. The person may bolt and run Presenting behavior is the patient’s problematic situation.
aimlessly, often exposing himself or herself to injury. The immediate reaction is the internal response. The
nursing process discipline is the investigation into the
Interpersonal Theory and Nursing Process patient’s needs. And lastly, improvement is the resolution
Peplau’s Interpersonal Relations Theory and the to the patient’s situation.
Nursing Process are sequential and focus on the therapeutic
relationship by using problem-solving techniques for the The Deliberative Nursing Process has five stages:
nurse and patient to collaborate on to meet the patient’s assessment, diagnosis, planning, implementation, and
needs. Both use observation communication and recording evaluation. Nurses use the standard nursing process in
as basic tools utilized by nursing. Orlando’s Nursing Process Discipline Theory to produce
Analysis positive outcomes or patient improvement. Orlando’s key
Peplau conceptualized clear sets of nurse’s roles focus was the definition of the function of nursing. The
that every nurse can use with their practice. It implies that a model provides a framework for nursing, but her theory
nurse’s duty is not just to care, but the profession does not exclude nurses from using other nursing theories
encompasses every activity that may affect the patient’s while caring for patients.
care. One important thing that nurses do is converse
with the patients and let them know what the plan of care
will be. However, regardless of how well thought out
a nursing care plan is for a patient, unexpected problems to 10. Patients enter into nursing care through medicine.
the patient’s recovery may arise at any time. With these, the 11. The patient cannot state the nature and meaning
nurse’s job is to know how to deal with those problems so of his or her distress without the nurse’s help or
the patient can continue to get back and reclaim his or her him or her first having established a helpful
well-being. Ida Jean Orlando developed her Deliberative relationship with the patient.
Nursing Process that allows nurses to formulate an 12. Any observation shared and observed with the
effective nursing care plan that can also be easily adapted patient is immediately helpful in ascertaining and
when and if any complexity comes up with the patient. meeting his or her need or finding out that he or
Ida Jean Orlando’s nursing theory stresses the she is not in need at that time.
reciprocal relationship between patient and nurse. It 13. Nurses are concerned with the needs the patient is
emphasizes the critical importance of the patient’s unable to meet on his or her own.
participation in the nursing process. Orlando also
considered nursing as a distinct profession. He separated it Major Concepts
from medicine, where nurses determining nursing action The nursing metaparadigm consists of four
rather than being prompted by physician’s orders, concepts: person, environment, health, and nursing. Of the
organizational needs, and past personal experiences. She four concepts, Ida Jean Orlando only included three in her
believed that the physician’s orders are for patients and not theory of Nursing Process Discipline: person, health, and
for nurses. nursing.
She proposed that “patients have their own
meanings and interpretations of situations and therefore Human Being
nurses must validate their inferences and analyses with Orlando uses the concept of human as she
patients before concluding.” emphasizes individuality and the dynamic nature of the
Goal nurse-patient relationship. For her, humans in need are the
Ida Jean Orlando’s goal is to develop a theory of focus of nursing practice.
effective nursing practice. The theory explains that the
nurse’s role is to find out and meet the patient’s immediate Health
needs for help. According to the theory, all patient behavior In Orlando’s theory, health is replaced by a sense
can be a cry for help. Through these, the nurse’s job is to of helplessness as the initiator of a necessity for nursing.
determine the nature of the patient’s distress and provide She stated that nursing deals with individuals who require
the help he or she needs. help.
Assumptions
Ida Jean Orlando’s model of nursing makes the Environment
following assumptions: Orlando completely disregarded the environment
1. When patients cannot cope with their needs on in her theory, only focusing on the patient’s immediate
their own, they become distressed by feelings of need, chiefly the relationship and actions between the nurse
helplessness. and the patient (only an individual in her theory; no
2. In its professional character, nursing adds to the families or groups were mentioned). The effect that the
distress of the patient. environment could have on the patient was never
3. Patients are unique and individual in how they mentioned in Orlando’s theory.
respond.
4. Nursing offers mothering and nursing analogous Nursing
to an adult who mothers and nurtures a child. Orlando speaks of nursing as unique and
5. The practice of nursing deals with people, the independent in its concerns for an individual’s need for
environment, and health. help in an immediate situation. The efforts to meet the
6. Patients need help communicating their needs; individual’s need for help are carried out in an interactive
they are uncomfortable and ambivalent about situation and in a disciplined manner that requires proper
their dependency needs. training.
7. People can be secretive or explicit about their
needs, perceptions, thoughts, and feelings. Subconcepts
8. The nurse-patient situation is dynamic; actions Ida Jean Orlando described her model as
and reactions are influenced by both the nurse revolving around the following five major interrelated
and the patient. concepts: the function of professional nursing, presenting
9. People attach meanings to situations and actions behavior, immediate reaction, nursing process discipline,
that aren’t apparent to others. and improvement.
 Automatic Nursing Actions are nursing actions decided
The function of Professional Nursing upon for reasons other than the patient’s immediate need.
The function of professional nursing is the
organizing principle. This means finding out and meeting Deliberative Nursing Actions are actions decided upon
the patient’s immediate needs for help. According to after ascertaining a need and then meeting this need.
Orlando, nursing is responsive to individuals who suffer or The following list identifies the criteria for
who anticipate a sense of helplessness. It is focused on the deliberative actions:
process of care in an immediate experience. It is concerned  Deliberative actions result from the correct
with providing direct assistance to a patient in whatever identification of patient needs by validating the
setting they are found to avoid, relieve, diminishing, or nurse’s reaction to patient behavior.
curing the patient’s sense of helplessness. The Nursing  The nurse explores the meaning of the action
Process Discipline Theory labels the purpose of nursing to with the patient and its relevance to meeting his
supply the help a patient needs for their needs to be met. If need.
the patient has an immediate need for help, and the nurse
 The nurse validates the action’s effectiveness
discovers and meets that need, the purpose of nursing has
immediately after completing it.
been achieved.
ADVERTISEMENTS  The nurse is free of stimuli unrelated to the
Presenting Behavior patient’s need when she acts.
Presenting behavior is the patient’s problematic Nursing Process Discipline
situation. Through the presenting behavior, the nurse finds The nursing process discipline is the investigation
the patient’s immediate need for help. To do this, the nurse into the patient’s needs. Any observation shared and
must first recognize the situation as problematic. explored with the patient is immediately useful in
Regardless of how the presenting behavior appears, it may ascertaining and meeting his or her need or finding out they
represent a cry for help from the patient. The patient’s have no needs at that time. The nurse cannot assume that
presenting behavior, which is considered the stimulus, any aspect of his or her reaction to the patient is correct,
causes an automatic internal response in the nurse, which in helpful, or appropriate until he or she checks its validity by
turn causes a response in the patient. exploring it with the patient. The nurse initiates this
exploration to determine how the patient is affected by
Distress what they say and do. Automatic reactions are ineffective
The patient’s behavior reflects distress when the because the nurse’s action is determined for reasons other
patient experiences a need that he cannot resolve, a sense of than the meaning of the patient’s behavior or the patient’s
helplessness occurs. immediate need for help. When the nurse doesn’t explore
the patient’s reaction with him or her, it is reasonably
Immediate Reaction certain that effective communication between nurse and
The immediate reaction is the internal response. patient stops.
The patient perceives objects with his or her five senses. The nurse decides on appropriate action to
These perceptions stimulate automatic thought, and each resolve the need in cooperation with the patient. This action
thought stimulates an automatic feeling, causing the patient is evaluated after it is carried out. If the patient’s behavior
to act. These three items are the patient’s immediate improves, the action was successful, and the process is
response. The immediate response reflects how the nurse completed. If there is no change or the behavior gets worse,
experiences his or her participation in the nurse-patient the process recycles with new efforts to clarify the patient’s
relationship. behavior or the appropriate nursing action.

Nurse Reaction The action process in a person-to-person contact

The patient’s behavior stimulated a nurse’s functioning in secret. The perceptions, thoughts, and
reaction, which marks the nursing process discipline’s feelings of each individual are not directly available to the
beginning. other individual’s perception through the observable action.

Nurse’s Action The action process in a person-to-person contact

When the nurse acts, an action process transpires. functioning by open disclosure. The perceptions, thoughts,
This action process by the nurse in a nurse-patient contact and feelings of each individual are directly available to the
is called the nursing process. The nurse’s action may other individual’s perception through the observable action.
be automatic or deliberative. Improvement
 Improvement is the resolution to the patient’s nurse as an independent nurse advocate for the patient. The
situation. In the resolution, the nurse’s actions are not nurse-patient interaction’s dynamic concept was justified
evaluated. Instead, the result of his or her actions is since the patient’s participation in the relationship was
evaluated to determine whether their actions served to help sought. The whole process is in constant revision through
the patient communicate his or her need for help and how it continuous validation of the nurse’s findings with that of
was met. In each contact, the nurse repeats learning how he the patient. Because the nurse has to explore her reactions
or she can help the patient. The nurse’s own individuality with the patient constantly, it prevents inaccurate diagnosis
and that of the patient require going through this each time or ineffective plans.
the nurse is called upon to render service to those who need Since the model is applied to an immediate
him or her. situation, its applicability to a long-term care plan is not
feasible.
5 Stages of the Deliberative Nursing Process The concept of interaction also limits it to
The Deliberative Nursing Process has five individuals capable of conversing, a shared limitation with
stages: assessment, diagnosis, planning, implementation, other nurse-client dynamic theories – this theory does not
and evaluation. cover unconscious patients.

Assessment Joyce Travelbee

In the assessment stage, the nurse completes a  States in her Human-to-Human Relationship
holistic assessment of the patient’s needs. This is done Model that the purpose of nursing was to help
without taking the reason for the encounter into and support an individual, family, or community
consideration. The nurse uses a nursing framework to to prevent or cope with the struggles of illness
collect both subjective and objective data about the patient. and suffering and, if necessary, to find
significance in these occurrences, with the
Diagnosis ultimate goal being the presence of hope.
The diagnosis stage uses the nurse’s clinical  Nursing was accomplished through human-to-
judgment about health problems. The diagnosis can then be human relationships.
confirmed using links to defining characteristics, related
 Extended the interpersonal relationship theories
factors, and risk factors found in the patient’s assessment.
of Peplau and Orlando.

Planning
Lydia Hall’s: Care, Core, Cure
The planning stage addresses each of the
problems identified in the diagnosis. Each problem is given
Lydia Hall used her knowledge of psychiatry and
a specific goal or outcome, and each goal or outcome is
nursing experiences in the Loeb Center to formulate her
given nursing interventions to help achieve the goal. By the
theory. Also known as “the Three Cs of Lydia Hall,” it
end of this stage, the nurse will have a nursing care plan.
contains three independent but interconnected circles: the
core, the care, and the cure.
Implementation
In the implementation stage, the nurse begins
The core is the patient receiving nursing care.
using the nursing care plan.
The core has goals set by him or herself rather than by any
other person and behaves according to their feelings and
Evaluation
values.
Finally, in the evaluation stage, the nurse looks at
the patient’s progress toward the goals set in the nursing
The cure is the attention given to patients by
care plan. Changes can be made to the nursing care plan
medical professionals. Hall explains in the model that the
based on how well (or poorly) the patient is progressing
nurse shares the cure circle with other health professionals,
toward the goals. If any new problems are identified in the
such as physicians or physical therapists. These are the
evaluation stage, they can be addressed, and the process
interventions or actions geared toward treating the patient
starts over again for those specific problems.
for whatever illness or disease they are suffering from.

Analysis
The care circle addresses the role of nurses and is
Compared to other nursing theories, which are
focused on performing the task of nurturing patients. This
task-oriented, Orlando gave a clear-cut approach to patient-
means the “motherly” care provided by nurses, which may
oriented nursing theory. It uplifts the integrity of
include comfort measures, patient instruction, and helping
individualized nursing care. This strengthens the role of the
the patient meet his or her needs when help is needed.
 Hall’s theory emphasizes the total patient rather Health
than looking at just one part and depends on all three Health can be inferred as a state of self-awareness
components of the theory working together. with a conscious selection of optimal behaviors for that
individual. Hall stresses the need to help the person explore
Nursing theory, in line with Lydia Hall, is the meaning of his or her behavior to identify and
nothing short of revolutionary. In the 1960s, she put down, overcome problems through developing self-identity and
in her own simple words, her thoughts about nursing. She maturity.
did not consider herself a nurse theorist but instead talked
about her transparent thoughts and remarkable nursing care Society and Environment
ideas as she learned them over the years. These lead to the The concept of society or environment is dealt
development of her “Care, Cure, Core Theory,” also with concerning the individual. Hall is credited with
known as the “Three Cs of Lydia Hall.” developing Loeb Center’s concept because she assumed
that the hospital environment during treatment of acute
Description illness creates a difficult psychological experience for the
Lydia Hall’s theory define Nursing as ill individual. Loeb Center focuses on providing an
the “participation in care, core and cure aspects of patient environment that is conducive to self-development. In such
care, where CARE is the sole function of nurses, whereas a setting, the focus of the nurses’ action is the individual.
the CORE and CURE are shared with other members of the Any actions taken concerning society or the environment
health team.” The major purpose of care is to achieve an are to assist the individual in attaining a personal goal.
interpersonal relationship with the individual to facilitate
the development of the core. Nursing
As Hall says, “To look at and listen to self is Nursing is identified as participating in the care,
often too difficult without the help of a significant figure core, and cure aspects of patient care.
(nurturer) who has learned how to hold up a mirror and
sounding board to invite the behaver to look and listen to Subconcepts
himself. If he accepts the invitation, he will explore the Lydia Hall’s theory has three components which
concerns in his acts. As he listens to his exploration are represented by three independent but interconnected
through the reflection of the nurse, he may uncover in circles. The three circles are the core, the care, and the cure.
sequence his difficulties, the problem area, his problem, The size of each circle constantly varies and depends on the
and eventually the threat which is dictating his out-of- state of the patient.
control behavior.”
Assumptions The Care Circle
Hall’s Care, Cure, Core Theory assumptions are According to the theory, nurses are focused on
as follows: (1) The motivation and energy necessary for performing the noble task of nurturing patients. This circle
healing exist within the patient rather than in the healthcare solely represents the role of nurses and is focused on
team. (2) The three aspects of nursing should not be viewed performing the task of nurturing patients. Nurturing
as functioning independently but as interrelated. And lastly, involves using the factors that make up the concept of
(3) The three aspects interact, and the circles representing mothering (care and comfort of the person) and provide for
them change the size, depending on the patient’s total teaching-learning activities.
course of progress. The care circle defines a professional nurse’s
primary role, such as providing bodily care for the patient
Major Concepts of Care, Core, Cure and helping the patient complete such basic daily biological
The following the major concepts of Lydia Hall’s functions as eating, bathing, elimination, and dressing.
Care, Core, Cure nursing theory, including their definitions. When providing this care, the nurse’s goal is the comfort of
the patient.
Individual Moreover, the nurse’s role also includes
The individual human who is 16 years of age or educating patients and helping a patient meet any needs he
older and past the acute stage of long-term illness focuses or she is unable to meet alone. This presents the nurse and
on nursing care in Hall’s work. The source of energy and patient with an opportunity for closeness. As closeness
motivation for healing is the individual care recipient, not develops, the patient can share and explore feelings with
the health care provider. Hall emphasizes the individual’s the nurse.
importance as unique, capable of growth and learning, and
requiring a total person approach. The Core Circle
 The core, according to Hall’s theory, is the Lydia Hall’s model is considered to be plain and
patient receiving nursing care. The core has goals set by simple in its presentation. However, the receptiveness and
him or herself rather than by any other person and behaves resilience necessary for its utilization and function may not
according to their feelings and values. This involves the be so simple for nurses whose personality, educational
therapeutic use of self and is shared with other members of preparation, and experience have not prepared them to
the health team. function with minimal structure. This and the self-imposed
This area emphasizes the patient’s social, age and illness requirements limit the generalizability.
emotional, spiritual, and intellectual needs concerning The age requirement for applying her theory 16
family, institution, community, and the world. This can years of age and above limits the theory since it cannot be
help the patient verbally express feelings regarding the disregarded that nurses are faced with pediatric clients now
disease process and its effects by using the reflective and then.
technique. Through such expression, the patient can gain The concept of a patient aggregate, such as
self-identity and further develop maturity. having families and communities as the focus of nursing
The professional nurse uses the reflective practice, was not tackled. It is purely on the individual
technique to act as a mirror to the patient to help the latter himself. Although, the role of the family or the community
explore his or her own feelings regarding his or her current within the patient’s environment was modestly discussed.
health status and related potential changes in lifestyle. Conclusion
Motivations are discovered through the process Lydia Hall used her knowledge of psychiatry and
of bringing into awareness the feelings being experienced. nursing experiences in the Loeb Center as a framework for
With this awareness, the patient can now make conscious formulating the Care, Core, and Cure Theory. Her model
decisions based on understood and accepted feelings and contains three independent but interconnected circles. The
motivation. three circles are the core, the care, and the cure.
The core is the patient. The cure refers to the
The Cure Circle medical and nursing interventions, and the care is the
As explained in this theory, the cure is nursing, nurturing provided by nurses. Nursing functions in all three
which involves the administration of medications and of the circles but shares them to different degrees with
treatments. Hall explains in the model that the nurse shares other disciplines.
the cure circle with other health professionals, such as Even though Hall confined her concepts for
physicians or physical therapists. patients with the age of 16 years and above, the concepts of
In short, these are the interventions or actions care, core and cure can still be applied to every age group,
geared toward treating the patient for whatever illness or but again, none was specified.
disease he or she is suffering from. During this aspect of This theory emphasizes the importance of the
nursing care, the nurse is an active advocate of the patient. total patient rather than looking at one part or aspect. There
Hall’s diagram showing interlocking circles that is also an emphasis on all three aspects of the theory, the
may change in size and overlap three Cs, functioning together.
As seen in the figure above, the three interlocking And for a nurse to successfully apply Hall’s
circles may change in size and overlap concerning the theory, the individual must pass an acute stage of illness. In
patient’s phase in the disease process. A nurse functions in this theory, no nursing contact with healthy individuals,
all three circles but to different degrees. families, or communities contradicts the concept of health
For example, in the care phase, the nurse gives maintenance and disease prevention.
hands-on bodily care to the patient about daily living
activities such as toileting and bathing. In the curing phase,
the nurse applies medical knowledge to the treatment of the
person. In the core phase, the nurse addresses the patient’s
social and emotional needs for effective communication
and a comfortable environment.
Strengths
Lydia Hall’s model appears to be completely and
simply logical. Her work may be viewed as the philosophy
of nursing.
The three Cs (care, core, and cure) in this theory
were unique. In all the model circles, the nurse is present,
although the nurse’s focus is on the care circle.
Weaknesses