Nursing Models

Henderson’s Model (1960)

14 Basic Needs:1. Breath normally 2. Eat and drink adequately 3. Eliminate body wastes 4. Move and maintain desirable postures 5. Sleep and rest 6. Select suitable clothes - dress and undress 7. Maintain body temperature within normal range by adjusting clothing and modifying

the environment. 8. Keep the body clean and well groomed and protect the integument. 9. Avoid dangers in the environment and avoid injuring others. 10. Communicate with others in expressing emotions, needs, fears, or opinions.11. Worship according to one’s faith.12. Work in such a way that there is a sense of accomplishment.13. Play or participate in various forms of recreation. 14. Learn, discover, or satisfy the curiosity that leads to normal development and health and

use the available health facilities.

In collaboration with the patient work out which needs are not satisfied at present. Then decide what is causing the problems (physiological, psychological, social or spiritual) to be able to plan effective interventions.

Roper, Logan and Tierney Activities of Living Model (1976 - 1983)

12 Activities of Living1. Maintaining a safe environment2. Breathing3. Communication4. Mobilising5. Eating and Drinking6. Eliminating7. Personal cleansing and dressing8. Maintaining body temperature9. Working and playing10. Sleeping11. Expressing sexuality12. Dying

Johnson’s Behavioural Systems Model (1980)

7 Behavioural Subsystems (and Goals)1. Achievement - towards control over oneself and one’s environment. 2. Affiliative - towards relationships of intimacy with others.3. Aggressive - towards self-protection from threat and towards self-assertion. 4. Dependency - Towards conditions of security and dependency on others.5. Eliminative - towards the expulsion of biological waste. 6. Ingestive - towards maintaining the integrity of the organism and towards achieving

states of bodily pleasure.7. Sexual - Towards sexual gratification and towards caring for others.

The structure of each subsystem includes four elements:1. Drive or goal - the motivation for behaviour.2. Set - the individual's predisposition to act in certain ways to fulfil the function of the

subsystem.3. Choice - the individual's total behavioural repertoire for fulfilling subsystem functions,

which encompasses the scope of action alternatives from which the person can choose.

4. Action - the individual's actual behaviour in a situation. Action is the only structural element that can be observed directly; all other elements must be inferred from the individual's actual behaviour and from the consequences of that behaviour.

Behavioural subsystems can be thrown into disequilibrium by processes associated with disease or changes in personal requirements or patterns of daily living. During a nursing assessment, first, subsystems are examined in turn to detect those which are out of equilibrium. Second, possible causes of imbalance are identified.

4 types of intervention possible:1. Restrict behaviours by imposing external constraints and controls2. Defend the individual by offering protection against external stressors and threats.3. Attempt to inhibit the person by suppressing ineffective responses.4. Facilitate the person by offering nurturance and stimulation.

These rather controlling behaviours on the part of the nurse are central to this model and its application.

Roy’s Adaptation Model (1976)

3 principle systems make up each person, biological, psychological and social. Each system constantly interacts with the others and the environment. Roy suggests these systems strive for stability within itself and in relation to the others and the wider environment. Individuals strive to maintain these systems within a range of conditions unique to themselves, this makes up a person’s adaptation level.

Stimuli falling within the range of possibilities established by a person’s adaptation level lead to effective, coping responses.

Stimuli falling outside the range of possibilities lead to maladaptive and inefficient responses.

There are 3 types of stimuli:1. Focal stimuli, immediately surrounding a person (e.g. nurses or equipment delivering

care)2. Contextual stimuli, linked to the context in which focal stimuli are present (e.g.

environmental factors such as noise and temperature).3. Residual stimuli, such as beliefs, attitudes and values resulting from past patterns of

learning.

There are 4 types of response or adaptive modes:

Adaptive Mode Problems within this mode can be associated with:Physiological(concerned with maintaining balance of oxygenation, nutrition, elimination, activity/rest and protection against infection)

Hyperactivity, fatigueMalnutrition, vomitingConstipation, incontinenceOxygen deficit/excessInfection through loss of skin integrity

Self-concept(concerned with the need for psychological integrity, physical and personal self)

Sense of physical lossChange of body imageSense of anxietySense of powerlessnessSense of low self-esteemSense of inconsistency

Role-function(concerned with managing social interaction with others)

Sense of role failureSense of role conflict

Interdependency(concerned with emotional and affective behaviour)

Sense of alienationSense of rejectionSense of rivalrySense of lonelinessSense of dominance

Assessment using this model is carried out in 3 stages:1. Look at each adaptive mode in turn and seek to identify behaviours that suggest

coping mechanisms are strained (include observation, measurement and interviewing).

2. Conduct a more detailed assessment identifying specific focal, contextual and residual stimuli relating to the identified problems (should involve active participation of the patient).

3. Reach a nursing diagnosis of the patient’s adaptation status. Describe behaviours indicative of poor adaptation and the stimuli contributing to these behaviours.

Orem’s Self-Care Model (1971)

8 Universal self-care needs1. Sufficient intake of air2. Sufficient intake of water3. Sufficient intake of food4. Satisfactory eliminative functions5. Activity balanced with rest6. Balance between solitude and social interaction7. Prevention of hazards to human life, human functioning and human well-being8. Promotion of human functioning and development within social groups in

accordance with human potential, known human limitations and the desire for ‘normalcy’

A healthy person is likely to have sufficient self-care abilities to meet their universal self-care needs. An individual who is ill will have additional demands for self-care called ‘health deviation self-care needs’. A further set of needs are linked to particular stages of growth of development (e.g. ability of a child to understand what is said about their care), these are referred to as ‘developmental self-care needs’. Nursing interventions used to balance out these additional needs.

Orem rarely uses the term assessment and instead talks about preparing a ‘nursing history’ which is pretty much synonymous. All about identifying a self-care deficit by comparing demands with abilities individuals have to meet them. It is also necessary to identify whether the individuals state allows for safe involvement in self-care.

6 Methods of Helping1. Doing or acting for another2. Guiding or directing another3. Providing physical support4. Providing psychological support5. Providing an environment supportive of development6. Teaching another

Demands Ability to meet demands

Self-Care Abilities

Nursing Interventions

Nursing Interventions

Universal Self-Care Needs

Health Deviation Self Care Needs

Developmental Self-Care Needs

King’s Open Systems Model (1971)

3 dynamic and interacting systems:1. Personal – Perceptions of self, body image and of time and space. Influence the way

in which people present themselves and respond to others.2. Interpersonal – Communication and interaction, transactions with others, roles and

expected behaviour.3. Social – Interactions between larger groups, structured to ensure activities to

maintain life and health can take place within them e.g. communities, localities, workplaces, hospitals and other institutions.

King does not distinguish assessment clearly and instead favours use of a Goal Oriented Nursing Record (GONR). This has a database and problem list, in place of assessment, followed by a goal list, plan and progress notes. The database is made up of multidisciplinary information including a nursing history and health assessment; this is focused on the needs of the individual and aspects relevant to the context. A list of problems can then be compiled from the gathered data and used to set goals for the patient.

Peplau’s Development Model (1952)

Peplau’s understanding of people was based on Sullivan’s theory of human nature (1952):

According to Peplau people have biological, psychological and social qualities that motivate them towards self-maintenance, reproduction and growth. Extreme levels of anxiety can cause regression, with a person showing behaviour that lacks maturity and integration. Growth and development are facilitated by communication and good interpersonal relationships as both reduce anxiety.

Peplau does not use the term assessment often and instead refers to nurses and patients passing through an initial orientation phase in their relationships. During this nurses learn about the difficulties the patient is experiencing, help patients gain insight into the source of difficulties and patients learn how the nurse will participate in their care. Orientation has a greater emphasis on developing mutual trust and regard with potentially a more equal relationship between patient and nurse than assessment.

4 Phases to go through:1. Orientation phase – Nurse meets patient and familiarises them with nursing

knowledge relevant to meet needs. Develop trusting relationship. (Assessment)2. Identification phase – Patient identifies nurse as someone to help and begins to see

ways they can maintain control of the situation. (Planning and Goal Setting)3. Exploitation phase – Patient moves beyond receiving help and translates help into

effective personal action. Nurse provides resources and counselling. (Nursing Intervention)

4. Resolution phase – Not just when a medical issue is resolved but when a patient is able to be free from nursing assistance/support and act independently. Not just about whether goals have been met. (Evaluation/Reflection)

Neuman’s Systems Model (1989)

Within each person there are 5 variable areas or aspects which will be more or less developed in each individual and are determinants of behaviours:

1. The physiological2. The psychological3. The socio-cultural4. The developmental5. The spiritual

There are 3 environments to be considered:1. The internal environment – established by the boundaries of a client / client system2. The external environment – forces and influences external to client / client system3. The created environment – ‘unconscious mobilisation of all system variables…

towards system integration, stability and integrity…offer a protective coping shield’.

Neuman’s view of the person:

According to Neuman people have a number of physiological, psychological, socio-cultural and developmental qualities. Between them these contribute to a set of survival factors, unique to the individual but operating within a range of values shared with others. These can include mechanisms regulating body temperature to ego structure. A person’s core structure of survival factors in protected by a number of internal lines of resistance (to prevent maladaptation, restore adaptation or maintain adaptation). These help establish a normal line of defence (state of adaptation) which a person can maintain over time. Beyond this is a flexible line of defence (or resistance) which acts as a buffer and prevents stressors breaking through the normal line of defence (stressors can be intrapersonal, interpersonal or extrapersonal). The strength of this defence fluctuates and can be weakened by malnutrition, lack of sleep etc.

Assessment involves looking at potential and actual stressors affecting the individual. Identify whether intra, inter or extra personal. Reconcile any differences of perspective between nurse and patient.Riehl’s Interaction Model (1980) (later Riehl-Sisca)

Riehl’s model is unique in that it emphasises the capacity of people to give meaning to events and situations they encounter and interactions with others, this process is meaning-giving. Everyone uses their own stock of knowledge to give meaning by interpretation. The process of communication and negotiation taking place between nurse and patients leads to changes in perception and interpretation in both nurse and patients which is central to the process of care and of accepting a condition or becoming better. A central element of the model is role-taking. The nurse needs to develop insight into how the patient sees the world and their status in it (ill or well?) by taking the role of the other and trying to see things through their eyes. The ‘other’ will also be encouraged to understand things on the nurse’s terms.

Reihl does not use the term assessment extensively but early work advocated the FANCAP mnemonic for assessment.

Liquids, drinking Fluids Changeability, lability

Respiration Aeration Ventilation of feelings

Food, calorie intake Nutrition Cared for, not deprived

Sense organs, nervous system Communication Perception, interpretation

Physical exertion Activity Conversing, learning

Accompanying injury, lack of oxygen Pain Distress, grief, fear

This has been adapted to the tool:

Physiological Psychological Sociological Cultural EnvironmentalFluidsAerationNutritionCommunicationActivityPain

Regardless of framework the nurse’s aim is to develop insight into the individual subjective perception of the problems affecting them and the role flexibility a person has in order to anticipate coping and potential problems later on when encouraging the person to take on new roles.

Rogers’ Unitary Field Model (1970)

Rogers suggests that humans are best understood not as systems or discrete parts, but as unified fields of energy that interact with their environments. There is an emphasis on holism and the irreducibility of people to their bodily systems and parts. The human dynamic energy field is integral to the environmental energy field and it is the potential synergy (capacity of one to beneficially influence the other) between these two of which nurses need to be aware when thinking about human problems and needs. When two individuals interact a group energy field is likely to arise. Energy fields are open (subject to influence by other fields), infinite and integral to one another. They are constantly interacting and changing.

Human energy fields display a pattern of distinguishing characteristics. Patterns change with time and although not directly observable give rise to manifestations (behaviours or qualities of that individual). Rogers has an acceptance of the paranormal and encourages the understanding that human energy fields are in interaction through other dimensions that are not yet understood.

3 Principles of Homeodynamics (characterise the relationship between the human energy field and others):

1. Integrality – highlights the constant interaction with environmental energy fields2. Helicy – describes how human and environmental change occurs (usually in the

direction of innovation and increased complexity).3. Resonancy - tendency for human energy fields to change so that higher frequency

wave patterns appear over time (e.g. more frequent patterns of sleeping/waking in the elderly).

Need for nursing care arises when there is an imbalance between the unitary human energy field and the environmental energy field. Rogers does not often use ‘assessment’, ‘planning’ or ‘goal setting’ in her work. Instead the nurse must appraise the unitary energy field of the other, while recognising that both it and her own unitary field are integral to the environmental field.

Cowling (1990) developed a system for pattern appraisal in which efforts are made through observation and participation to access the perceptions, experience and reflections of the other unitary whole. Emphasis is on a process of mutual exploration as efforts are made to better understand the individual’s unitary energy field and its relationship with others. Techniques include empathetic conversation, professional closeness and therapeutic touch.