2425TFNPRELIMLEC.docx

**Definition of Nursing** **1. [The International Council for Nurses (ICN, 2002)] states that "Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings" Nursing includes the promotion of health, prevention o...

**Definition of Nursing** **1. [The International Council for Nurses (ICN, 2002)] states that "Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings" Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles** **2. [ American Nurses Association] (ANA) states, "nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations".** **[3. The Philippine Nursing Act of 2002 (RA 9173)]** **Scope of Nursing: A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting.** **It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, pre-school, school age, adolescence, adulthood and old age.** **As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness.** **As members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death** **4. The Association of Deans of Philippine Colleges of Nursing (ADPCN)** **Nursing is a "dynamic discipline. It is an art and a science of caring for individuals, families, groups, and communities geared toward promotion of health, prevention of illness, alleviation of suffering and assisting clients to face death with dignity and peace. It is focused on assisting the client as he or she responds to health -- illness situations, utilizing the nursing process and guided by ethico -- legal responsibilities.** **Definition of Theory** **What is a theory? How often have you used this term to explain an event or a situation?** **Or even emotions, or behavior. We often say that everything happens for a reason especially when we cannot really explain how things happen. In your high school days, you have encountered many theories but most of them still seem abstract to you. This is the nature of a theory. That is why, it is explained in many different ways by different authors. Below are some definitions of theory:** **A theory is a set of concepts and propositions that provide an orderly way to view phenomena** **It is an organized system of accepted knowledge that is composed of concepts, propositions, definitions and assumptions intended to explain a set of fact, event or phenomena.** **A theory is a group of related concepts that propose action that guide practice.** **Theory is \"a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena".** **A theory makes it possible to \"organize the relationship among the concepts to describe, explain, predict, and control practice\"** **You will observe that some authors define theory in terms of its components. Some define it in terms of characteristics. Now, let us define them one by one...** **The following are the components of a theory mentioned in the definition:** **1. Purpose answers the question, "why is the theory formulated?". It specifies the context and situation within which the theory is formulated. The purpose of a theory may not always be stated specifically but it can be identified. In your study of the different theories, always remember to identify the purpose of each one.** **2. Concepts are the building blocks of theory. They are Ideas, mental images of a phenomenon, an event or object that is derived from an individual's experience and perception. It refers to a "complex mental formulation of our Perceptions of the world."** **A concept labels or names a phenomenon, an observable fact that can be perceived through the senses and explained. A concept assists us in formulating a mental image about an object or situation. Concepts help us to name things and occurrences in the world around us and assist us in communicating with each other about the world.** **Examples: Independence, self-care, caring, love...** **An idea formulated by the mind or an experience perceived and observed. What are other concepts running in your mind right now. I am sure you have already a lot of concepts that you are aware of. Take note that different persons have different concepts since we have different perceptions and experiences.** **Concepts can be classified as:** **A. Discrete: Identify categories or classes of phenomenon e.g\... patient, nurse, & environment** **B. Continuous: Allows the classification of dimensions/ of an observation or phenomenon across a continuum e.g\... temperature, pain** **3. Definitions give meaning to concepts; make them clearer, and more understandable** **There are two types of definition:** **A. Descriptive (conceptual) -- refers to the accepted meaning of the term already used like the definition we find on the dictionaries** **B. Operational (stipulative) -- refers to the specific use or definition of the term within the theory. It is how a word or concept is used in the theory and how it is defined by a particular theorist in his/her theory.** **4. Propositions are expressions of relational statements between and among concepts. Propositional statements in a theory represent the theorist's particular view of which concepts fit together and, in most theories, establish how concepts affect one another. They provide links and connections between and among concepts. Propositions can be expressed as statements, paradigm or figure** **5. Assumptions are accepted "truths" that are basic and fundamental to the theory; also called givens. They are judgments regarding unknown factors & the future which are made in analyzing alternative course of action. Also, the major points, ideas or statements of a theory** **They can be:** **A. Factual assumptions -- knowable or potentially knowable by empirical experience.** **B. Value assumptions -- asserts or implies what is right, good or ought to be** **Characteristics of a theory:** **Characteristics of a theory can also be derived from its definitions. What are these?** **1. Systematic, logical and coherent** **There must be an orderly reasoning and no contradictions between and among concepts. There must be proper sequencing of ideas and theoretical assertions** **2. Creative structuring of ideas** **We said that concepts are the building blocks of a theory and that they are the mental images resulting from one's experiences and perceptions. Therefore, when these concepts are interrelated, they created different ways of looking at a particular event phenomenon, event or object** **3. Tentative in nature** **A theory can change overtime implying that it is evolving, and dynamic. As more researches and studies are done, and as they are enriched by practice, theory can change, However, there are also theories that remain valid despite the passage of time.** **Classification of Nursing Theories** There are different ways to categorize nursing theories. They are classified depending on their function, levels of abstraction, or goal orientation. [By Abstraction] There are three major categories when classifying nursing theories based on their level of abstraction: grand theory, middle-range theory, and practice-level theory. Grand Nursing Theories Grand theories are abstract, broad in scope, and complex, therefore requiring further research for clarification. Grand nursing theories do not provide guidance for specific nursing interventions but rather provide a general framework and ideas about nursing. Grand nursing theorists develop their works based on their own experiences and the time they were living explaining why there is so much variation among theories. Address the nursing metaparadigm components of person, nursing, health, and environment. Middle-Range Nursing Theories More limited in scope (as compared to grand theories) and present concepts and propositions at a lower level of abstraction. They address a specific phenomenon in nursing. Due to the difficulty of testing grand theories, nursing scholars proposed using this level of theory. Most middle-range theories are based on the works of a grand theorist but they can be conceived from research, nursing practice, or the theories of other disciplines. Practice-Level Nursing Theories Practice nursing theories are situation specific theories that are narrow in scope and focuses on a specific patient population at a specific time. Practice-level nursing theories provide frameworks for nursing interventions and suggest outcomes or the effect of nursing practice. Theories developed at this level have a more direct effect on nursing practice as compared to more abstract theories. These theories are interrelated with concepts from middle-range theories or grand theories. [By Goal Orientation] Theories can also be classified based on their goals, they can be Descriptive Theories or Prescriptive Descriptive theories are the first level of theory development. They describe the phenomena and identify its properties and components in which it occurs. Descriptive theories are not action oriented or attempt to produce or change a situation. There are two types of descriptive theories: *factor-isolating theory* and *explanatory theory*. Factor-Isolating Theory Also known as category-formulating or labeling theory. Theories under this category describe the properties and dimensions of phenomena. Explanatory Theory Explanatory theories describe and explain the nature of relationships of certain phenomena to other phenomena. Prescriptive Theories Address the nursing interventions for a phenomenon, guide practice change, and predict consequences. Includes propositions that call for change. In nursing, prescriptive theories are used to anticipate the outcomes of nursing interventions. **Definition of Phenomenon (Plural, Phenomena)** **A phenomenon can be defined as sets of empirical data or experiences that can be physically observed or tangible such as crying or grimacing when in pain. It is concerned with how an individual person reacts using the human senses concerning their surroundings and assessing the different behaviors and factors that affect such behaviors** **In Nursing, phenomena can be:** **1. Clinical or environmental setting of nursing -- health center, community** **2. Disease process -- COVID 19** **3. Client's behavior -- fear, anxiety, physical symptoms** **4. Interventions -- care of the client to relieve symptoms, fear and anxiety** **5. Practices that are utilized in nursing theories and paradigm** **Theory Development**  **According to Meleis as cited by Corcega (2005), there are four strategies of theory development in nursing.** **1. Theory → Practice → Theory implies that theory development in nursing is based on theories developed by other disciplines and used in nursing situations.** **Ex. Peplau's theory of Interpersonal Relations was based on the Interpersonal Theory of Sullivan which she used in her practice of Mental Health and Psychiatric Nursing. After observations and researches done in her practice, she developed her own theory.** **2. Practice → Theory strategy were based and evolved from clinical practice. The development of a theory is done through actual observations and experiences in the clinical area of the theorist. She then develops her own theory.** **Ex. Orlando's Nursing Process Theory** **3. Research → Theory strategy was based on research findings done through observations of others like behavior.** **Ex. Johnson's Behavior Systems Model** **4. Theory → Research → Theory strategy utilizes other theories developed by other disciplines but given a unique nursing perspective. Conceptual or theoretical frameworks in nursing research studies are adapted from these theories.** **Ex. Stages of Change theory** **Uses of theory** **What are the uses of theory in nursing?** **1. Theory guides nursing practice** **Theory helps to identify the goals and means of nursing practice. As theory evolves, nurses become mor efficient and effective because their actions are based on tested theory** **2. Theory guides research** **The primary use to theory is to guide research with the use of hypothesis and statistical analysis. It is also a very rich source of research problem. In your future research works, you can use theory as the source of your research problem.** **3. Theory contributes to the development of the discipline's body of knowledge** **Theory in nursing describes, explains, predicts and controls phenomena or events to achieve desired outcome. It also shows relationships between and among concepts to create a different way of understanding a nursing phenomenon** **4. Theory enhances communication** **Nursing is explained and understood trough common concepts. Therefore, communication among nurse practitioners, educators, administrators and researchers is important.** **Historical Development of Nursing Theories** **The writings of Florence Nightingale** **Beginning of the scientific practice of nursing** **Her work paved the way for modern nursing (written in the mid nineteenth century) which reflected her beliefs, observations and practice of nursing.** **1952** **Nursing Research journal was published that encouraged the nurses to pursue research, thus developing questioning attitudes and inquiries that set the stage for conceptualization of nursing practice** **Peplau developed the first theory of nursing in her book (Interpersonal Relations in Nursing** **Scientific era (1960s)** **Debate on the nature of nursing practice as nursing leaders recognized the need to define nursing practice, develop a nursing theory, and create a substantive body of knowledge** **Literature on the philosophy of nursing, as well as conceptual models proliferated. Peplau, Abdellah and Hall developed their theories\ ** **1968** **The writings on "Theory in a Practice Discipline" (Dickoff, James and Wiedenbach) influenced the development of theoretical thinking in nursing; presented a definition of nursing theory and goals for theory development in nursing** **1969** **The first conference on nursing theory was held** **1970s** **Analysis and debate on metatheoretical issues related to theory development** **1980s -- acceptance of the significance of theory in nursing** **1980s up to present -- publication of numerous books and articles on analysis, application evaluation and further development of nursing theories** **Journal of Nursing Research was published** **Graduate schools of nursing developed courses on how to analyze and apply nursing theories** **Further acceptance of nursing theory and its incorporation in the nursing curricula; publication of several nursing journals** **1990s** **Nursing as a basic science, an applied science, or a practical science** **2. Significance of nursing theories to the discipline and to the profession:** 1. **Nursing theories aim to describe, predict and explain the phenomenon of nursing** 2. **Provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future** 3. **Help to distinguish what should form the basis of practice by explicitly describing nursing** 4. **Help provide better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education** 5. **Analyze and explain what nurses do** 6. **Establish a unique body of knowledge** 7. **Maintain professional boundaries in nursing** **B. History and Philosophy of Science** ***"Why should nurses be interested in the history and philosophy of science? The history and philosophy of science is important as a foundation for exploring whether scientific results are actually truth. As nurses our practice should be based upon truth and we need the ability to interpret the results of science. Nursing science provides us with knowledge to describe, explain and predict outcomes. The legitimacy of any profession is built on its ability to generate and apply theory."* *(McCrae, as cited by Bishop, 2017)*** **The development of nursing science has evolved since the 1960s as a pursuit to be understood as a scientific discipline. Being a scientific discipline means identifying nursing's unique contribution to the care of patients, families, and communities. It means that nurses can conduct clinical and basic nursing research to establish the scientific base for the care of individuals across the life span (Hardin, 2017)** **Definition of Science** **Science means knowledge coming from the Latin word *scientia*. It refers to any systematic knowledge or practice in a discipline of study. It refers to a system of acquiring knowledge based on the scientific method.** **Science is logical, systematic, and coherent way to solve problems and answer questions. It is a collection of facts known in area and the process used to obtain knowledge** **The scientific method involves acquiring knowledge through critical observation, formation of hypothesis or informed guess and experimenting to see whether the results match the hypothesis. Results that match the hypothesis become theories and theories that pass the test of time become scientific laws.** **Definition of philosophy** **Philosophy studies concepts that structure thought processes, foundations, and presumptions. It is an approach for thinking about the nature of people, the methods that should be used to create a scientific knowledge and the ethics involved. It gives meaning to phenomena through analysis, reasoning and logical arguments.** **1. Rationalism is the philosophy that knowledge comes from logic and a certain kind of intuition---when we immediately know something to be true without deduction, such as "I am conscious."** **Rationalists hold that the best way to arrive at certain knowledge is using the mind's rational abilities. Rationalism is an idea about where knowledge comes from** **Math provides a good illustration of rationalism: to a rationalist, you don't have to observe the world or have experiences in order to know that 1+1=2. You just have to understand the concepts "one" and "addition," and then you can know that it's true.** **2. Empiricism is the theory that the origin of all knowledge is sense experience. It emphasizes the role of experience and evidence, especially sensory perception, in the formation of ideas, and argues that the only knowledge humans can have is a posteriori (i.e. based on experience). Most empiricists also discount the notion of innate ideas or innatism (the idea that the mind is born with ideas or knowledge and is not a \"blank slate\" at birth).** **Empiricists, point out that we can only rely on mathematical equations based on some experience of the world, for example having one cookie, being given another, and then having two.** **RATIONALISM** **EMPIRICISM** ------------------------------------------------------------------ ------------------------------------------------------------------------------------------------- Rationalism is the belief in innate ideas, reason, and deduction **Empiricism is the belief in sense perception, induction, and that there are no innate ideas** Reason is the main source of knowledge Sense perception is the main source of knowledge Ideas are only acquired through innate ideas Ideas are only acquired through experience, Plato, Descartes, G.W. Leibniz, Noam Chomsky are rationalists Locke, Berkeley, and Hume are empiricist **3. Early Twentieth Century Views** **Philosophers focused on the analysis of theory structure, whereas scientists focused on empirical research** **Positivism (imposed on the mind by experience) is the philosophy of science that information is derived from logical and mathematical treatments and reports of sensory experience is the exclusive source of all authoritative knowledge** **4. Emergent Views of Science and Theory in the late 20^th^ century** **Empiricists argue that for science to maintain its objectivity, data collection and analysis must be independent of a theory** **Brown argues that the new epistemology challenged the empiricist view of perception by acknowledging that theories play a significant role in determining what the scientist will observe and how it will be interpreted. He identified 3 different views of the relationship between theories and observation:** **1. Scientists are merely passive observers of occurrences in the empirical world. Observable data are objective truth waiting to be discovered** **2. Theories structure what the scientists perceived in the empirical world** **3. Presupposed theories and observable data interact in the process of scientific investigation** **Interdependence between Theory and Research** **A theory should be judged based on scientific consensus** **The acceptance of scientific hypothesis through research depends on the appraisal of the coherence of theory** **When is scientific consensus necessary?** **1 On the boundaries of the theory, the phenomenon it addresses and what it excludes** **2. On the logic used in constructing the theory to further understanding from a similar perspective** **3. That the theory fits the data collected and analyzed through research** **Issues in Nursing Philosophy and Science Development** **[Four fundamental patterns of knowing in Nursing] (Carper, 1978)** **Empirical knowing - the principal form relating factual and descriptive knowing aimed at the expansion of abstract and theoretical explanations; any scientific, researched based, theoretical and factual information that the nurse makes use of.** **Example; nursing student answers questions posed by the clinical instructor based on what he learned from the school.** **Ethical knowing - requires knowledge of different philosophical positions regarding what is good and right in making moral actions and decisions, particularly in the theoretical and clinical components of nursing; involves in the judgment of right and wrong in relation to intentions, reasons and attributes of individuals and situations.** **Example: Nurse Severina presents herself as a patient advocate and defends her client's right to choose treatment.** **Esthetic or aesthetics knowing -- related to understanding what is of significance to particular patients such as feelings, attitudes, points of view; also the manifestation of the creative and expressive styles of the nurse (Kenney,1996); used in the process of giving appropriate nursing care through understanding the uniqueness of every patient, thus emphasizing use of creative and practical styles of care.** **Example: nurse Moses places himself in the "patient's shoes" (empathy) when communicating, giving judgment and providing care** **Personal knowing - encompasses knowledge of the self in relation to others and to self. It involves entirety of the nurse-patient relationship; focused on realizing, meeting and defining the real, true self (self-awareness).** **Example: a nursing student, undergoes psychological counselling and self- awareness sessions before his Psychiatric nursing rotation** **[Progress in the Discipline of Nursing] (Meleis)** **Practice** **Education and Administration** **Research** **Development of Nursing Theory** **Post -- positivism focuses on discovering the patterns that may describe a phenomenon** **Interpretive paradigm tends to promote understanding by addressing the meanings of the participants' social interaction that emphasize situation, context and multiple cognitive constructions that individuals create on everyday events.** **Critical paradigm for knowledge development in nursing provides a framework for inquiring about the interaction between the social, political, economic, gender and cultural factors and experiences of health and illness** **C. Structure of Nursing Knowledge** 'What is nursing knowledge?' According to Hall, (2005) it is a complex question, the answer to which helps define nurses as a profession. It is also difficult to answer because nursing is dynamic, evolving and a relatively new profession. However, as knowledge is central to the issue of professional accountability it is vital to attempt to answer the question. **Nurses use a wide range of theoretical and practical knowledge in their work. In recent years they have needed a considerable amount of new knowledge to provide the appropriate level of care for patients.** **Their knowledge may be acquired by different means - some is 'hidden' in practice, but from whatever source it originates it should be evaluated, and hopefully that which is without merit will be discarded. The key to success in such activity is to question beliefs from all sources.** **Nursing knowledge is the means by which the whole purpose of caring for patients is achieved because it underpins what we actually do. It is what defines us as nurses as opposed to similar professions such as doctors or physiotherapists, and helps to differentiate us from lay careers or care support workers. Knowledge is basically what classifies us as a profession because having a 'unique body of knowledge' is one of the things that defines a profession in society.** **Structure of nursing knowledge** Because of the importance of nurses to the nation's health, early in the twentieth century, studies of nursing were legislated and conducted by sociologists who recommended that nursing be developed as a profession. The criteria for a profession provided guidance in this process (Kalish & Kalish, as cited by Alligood, 2017). The criterion that called for specialized nursing knowledge and knowledge structure was a particularly important driving force in recognition of nursing as a profession The types of knowledge, levels, and examples of each are included in the following table:** ** **Structure Level** **Example** ---------------------------- -------------------------------------------------------------------------------------------------------------------------- **Metaparadigm** **Person, Health, Environment and Nursing** **Philosophy** **Theory of Nightingale** **Conceptual Models** **Neuman's systems model** **Theory** **Theory of Leininger** **Middle -- range theory** **Maintaining optimal client stability with structured activity (body recall) for healthy aging in a community setting** **A. Metaparadigm** **Metaparadigms are global concepts that identify the phenomenon of central interests to a discipline, the global propositions that describe the concepts, and the global propositions that state the relations between or among concepts** **A metaparadigm** **is a set of theories or ideas that provide structure for how a discipline should function. For a nursing discipline, these theories consist of four basic concepts that address the patient as a whole, the patient's health and well-being, the patient's environment and the nursing responsibilities.** **The Nursing Metaparadigm embodies the knowledge base, theory, philosophy, research, practice, and educational experience and literature identified with the profession. These given concepts vary in accordance to the experiences and views of different nursing theorists.** **The following are definitions of the 4 concepts in the nursing paradigm. Take note that each one of the nursing theorists has her own definition of these based on their views, expertise and experiences.** Person - The recipient of nursing care; Recipient of care, including physical, spiritual, psychological, and sociocultural components; Individual, family, or community **Health -** **Degree of wellness or illness experienced by the person** **Environment -** **All internal and external conditions, circumstances, and influences affecting the person** **Nursing -** **The attributes, characteristics, and actions of the nurse providing care to person** **Philosophy -** **As previously defined, the original meaning of the word philosophy comes from the Greek roots philo- meaning \"love\" and -sophos, or \"wisdom.\"** **It refers to the rational investigation of questions about existence and knowledge and ethics** **Philosophy is a belief (or system of beliefs) accepted as authoritative by some group or school, and any personal belief about how to live or how to deal with a situation** **Philosophy is the next knowledge level which specifies the definition of metaparadigm concepts in each of the conceptual models of nursing. It sets forth the meaning of phenomena through analysis, reasoning and logical argument** **A philosophy of nursing is a statement, sometimes written, that declares a nurse's beliefs, values, and ethics regarding their care and treatment of patients** **Philosophies have contributed to the knowledge development in nursing by forming a basis for subsequent developments especially in area of human science** **Examples: the works of Nightingale, Watson and Benner** **Conceptual Model** **A conceptual model is a representation of a system that uses concepts and ideas to form said representation.** **Conceptual modeling is used as a way to describe physical or social aspects of the world in an abstract way.** **Conceptual models or frameworks are representations of an idea or body of knowledge based on the understanding or perception of a person or a researcher on a certain topic, phenomena or theory. They can be represented through a diagram or in narrative form which shows how concepts are interrelated** **Use/purpose of conceptual models:** **1. To provide an organizing structure for the research design and methods** **2. To guide the development and testing of interventions and hypotheses based on the tenets of the theory** **3. To explain the study results and place the findings within the context of science in a specific field of investigation.** **A conceptual model or theoretical framework provides a coherent, unified and orderly way of envisioning related events or processes relevant to a discipline (Fawcett 2005)** **Conceptual Framework vs. Theoretical Framework** ------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------- **CONCEPTUAL** **THEORETICAL** **It is a structure of concepts or theories which are pulled together as a map for the study** **It is a structure of concepts which exist or tested in the literature, a ready -- made map for the study**  **Example of a conceptual framework** **Example of a Theoretical Framework** **Theory** **As earlier defined, a theory is a set of concepts and propositions that provide an orderly way to view phenomena; an organized system of accepted knowledge that is composed of concepts, propositions, definitions and assumptions intended to explain a set of fact, event or phenomena.** **Nursing theory is a group of interrelated concepts that are developed from various studies of disciplines and related experiences. This aims to view the essence of nursing care. Theories are specifically contributed by different theorists from difference times and ages** **Nursing theory provides a perspective from which to define the what of nursing, to describe the who of nursing (who is the client) and when nursing is needed, and to identify the boundaries and goals of nursing's therapeutic activities.** **Middle -- Range Theory - Middle-Range Nursing Theories** **Middle -- Range theories are more limited in scope (as compared to grand theories) and present concepts and propositions at a lower level of abstraction. They are less complex. They address a specific phenomenon in nursing.** **Due to the difficulty of testing grand theories, nursing scholars proposed using this level of theory.** **Most middle-range theories are based on the works of a grand theorist but they can be conceived from research, nursing practice, or the theories of other disciplines.** **Example of middle -- Range Theories: Peplau's Interpersonal Relations theory** **A. Nursing Philosophies** **1. Environmental Theory by Florence Nightingale** **2. Theory of Human Caring by Jean Watson** ***"Nursing ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, light, and the proper selection and administration of diet -- all at the least expense of vital power to the patient..." Florence Nightingale*** **Florence Nightingale (mid 1800s) developed and described the fist theory of nursing, "Notes on Nursing: What It Is, What It IS Not." She focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act (nursing and the patient environment relationships).** **She believed that in the nursing environment, the body could repair itself. Client's environment is manipulated to include appropriate noise, nutrition, hygiene, light, comfort, socialization and hope.** **She provided the nursing profession the "Legacy of Caring."** **"*Caring in Nursing conveys physical acts, but embraces the mind, body -- spirit as it reclaims the embodied spirt as its focus of attention*..." Margaret Jean Watson** **Jean Watson (1979 -- 1985) conceptualized the Human Caring Model (Nursing: Human Science and Human Care). She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind -- body -- soul harmony, which generates self -- knowledge, self -- control, self -- care, and self -- healing. She included health promotion and treatment of illness in nursing. She believed that a person is valued being to be cared for, respected, nurtured, understood and assisted; a fully functional, integrated self.** **1. Environmental Theory by Florence Nightingale** **Florence Nightingale was born on May 12, 1820 in Florence, Italy to a wealthy and well -- traveled parents. From the start she was expected to behave like a lady learning music, embroidery, reading and other things fit for a perfect hostess.** **However, she had other intentions having great compassion and concern for all types of people. As she grew older, she believed she had been called to serve mankind.** **In spite of her family's objection, she took up nursing in the Institute of Protestant Deaconesses in Kaiserwerth, Germany for 3 years.** **She served the wounded soldiers during the Crimean War. She was the first Nursing Theorist known as "The Lady with the Lamp". She established a School of Nursing at St. Thomas Hospital in England and wrote many manuscripts about hospital reform and nursing care. She died on August 13, 1910.** The Crimean War began and soon reports in the newspapers were describing the desperate lack of proper medical facilities for wounded British soldiers at the front. Nightingale was asked to oversee the care of soldiers and bring a team of nurses in the military hospitals in Turkey. In 1854 she led an expedition of 38 women to take over the management of the barrack hospital at Scutari where she observed the disastrous sanitary conditions. Nightingales' Environmental Theory revolutionized nursing practices to create sanitary conditions for patients to get care inspired by her observations during her work in the Crimean War. **What inspired her to develop the Environmental Theory?** **The writings of Florence Nightingale which included philosophy and directions were inspired from a need to defined nursing and reform hospital environments rather than give nursing new knowledge. She worked entirely during her lifetime to effect all types of reforms in nursing. Nightingale strongly advocated that "nursing knowledge is distinct from medical knowledge".** **The major concepts of Nightingale's theory** Human Being/Person Human being is not defined by Nightingale specifically. A person is the one receiving care. Persons are defined in relation to their environment and the impact of the environment upon them. People are multidimensional, composed of biological, psychological, social and spiritual components Health Nightingale (1859/1992) did not define health specifically. She stated, "We know nothing of health, the positive of which pathology is negative, except for the observation and experience. She wrote **Health is "not only to be well, but to be able to use well every power we have". Disease is considered as dys-ease or the absence of comfort.** Disease & Illness is a reparative process instituted by mother nature if the person will not attend to his personal health concerns **Environment** The physical environment is stressed by Nightingale in her writing. In her theory, Nightingale's writings reflect a community health model in which all that surrounds human beings is considered in relation to their state of health. Nursing "What nursing has to do... is to put the patient in the best condition for nature to act upon him" (Nightingale, 1859/1992 **Nursing is the \"activities that promote health (as outlined in canons) which occur in any caregiving situation. They can be done by anyone.\"** She defined different types of nursing as "nursing proper" (nursing the sick), "general nursing" (health promotion) and "midwifery nursing". **The Key Concepts of Nightingale's Theory (13 Canons)** Health of Houses "Badly constructed houses do for the healthy what badly constructed hospitals do for the sick. Once ensure that the air is stagnant and sickness is certain to follow." Ventilation and Warming "Keep the air he breathes as pure as the external air, without chilling him." Nightingale believed that the person who repeatedly breathed his or her own air would become sick or remain sick. She was very concerned about "noxious air" or "effluvia" and foul odors that came from excrement. She also criticized "fumigations," for she believed that the offensive source, not the [[smell]](https://nurseslabs.com/special-senses-anatomy-physiology/), must be removed The importance of room temperature was also stressed by Nightingale. The patient should not be too warm or too cold. The temperature could be controlled by an appropriate balance between burning fires and ventilation from windows. Light Nightingale believed that second to fresh air, the sick needed light. She noted that direct sunlight was what patients wanted. Noise She stated that patients should never be "waked intentionally" or accidentally during the first part of [[sleep]](https://nurseslabs.com/helping-our-patients-to-sleep-will-reduce-their-pain/). She asserted that whispered or long conversations about patients are thoughtless and cruel. She viewed unnecessary noise, including noise from female dress, as cruel and irritating to the patient. Variety She discussed the need for changes in color and form, including bringing the patient brightly colored flowers or plants. She also advocated rotating 10 or 12 paintings and engravings each day, week, or month to provide variety for the patient. Nightingale also advocated reading, needlework, writing, and cleaning as activities to relieve the sick of boredom. Bed and Bedding Nightingale noted that an adult in health exhales about three pints of moisture through the [[lungs]](https://nurseslabs.com/respiratory-system/) and skin in a 24-hour period. This organic matter enters the sheets and stays there unless the bedding is changed and aired frequently. She believed that the bed should be placed in the lightest part of the room and placed so the patient could see out of a window. She also reminded the caregiver never to lean against, sit upon, or unnecessarily shake the bed of the patient. Personal Cleanliness **"**Just as it is necessary to renew the air round a sick person frequently to carry off morbid effluvia from the lungs and skin, by maintaining free ventilation, so it is necessary to keep pores of the skin free from all obstructing excretions." "Every nurse ought to wash her hands very frequently during the day." **Nutrition and Taking Food** Nightingale noted in her Environmental Theory that individuals desire different foods at different times of the day and that frequent small servings may be more beneficial to the patient than a large breakfast or dinner. She urged that no business be done with patients while they are eating because this was a distraction. **Chattering Hopes and Advice** Florence Nightingale wrote in her Environmental Theory that to falsely cheer the sick by making light of their illness and its danger is not helpful. She encouraged the nurse to heed what is being said by visitors, believing that sick persons should hear the good news that would assist them in becoming healthier. **Social Considerations** Nightingale supported the importance of looking beyond the individual to the social environment in which he or she lived. **Environmental Factors** In Florence Nightingale's Environmental Theory, she identified five (5) environmental factors: fresh air, pure water, efficient drainage, cleanliness or sanitation, and light or direct sunlight. Pure fresh air -- "to keep the air he breathes as pure as the external air without chilling him." Pure water -- "well water of a very impure kind is used for domestic purposes. And when epidemic disease shows itself, persons using such water are almost sure to suffer." Effective drainage -- "all the while the sewer maybe nothing but a laboratory from which epidemic disease and ill health is being installed into the house." Cleanliness -- "the greater part of nursing consists in preserving cleanliness." Light (especially direct sunlight) -- "the usefulness of light in treating disease is very important." **Assumptions of the Environmental Theory** The assumptions of Florence Nightingale in her Environmental Theory are as follows: - - - - **Strengths** The language Florence Nightingale used to write her books was cultured and flowing, logical in format, and elegant in style. Nightingale's Environmental Theory has broad applicability to the practitioner. Her model can be applied in most complex hospital intensive care environment, the home, a work site, or the community at large. Reading Nightingale's Environmental Theory raises consciousness in the nurse about how the environment influences client outcomes. **Weaknesses** In Nightingale's Environmental Theory, there is scant information on the psychosocial environment when compared to the physical environment. The application of her concepts in the twentieth century is in question. **Application of Nightingale\'s theory in practice:** **\"Patients are to be put in the best condition for nature to act on them, it is the responsibility of nurses to reduce noise, to relieve patients' anxieties, and to help them sleep.\"** **As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.** 1. Patients should have clean air and a temperature-controlled environment 2. Patients should have access to direct sunlight and not be subjected to unnecessary noise, especially when sleeping 3. Rooms should be kept clean 4. Hospital facilities should be well-constructed 5. Bedding should be changed and aired frequently 6. Patients should be kept clean and nurses should wash hands frequently 7. Patients should be offered a variety of scenery, such as new books or flowers, to prevent boredom 8. Nurses should be positive but not offer false hope to patients or make light of their illness 9. Offer a variety of small meals instead of large ones, and do not do patient care while patient is eating as it is distracting 10. Consider not only the individual patient but the context of where he or she lives **2. Theory of Transpersonal Caring by Margaret Jean Watson** Jean Watson was born Margaret Jean Harmon and grew up in the small town of Welch, West Virginia, in the Appalachian Mountains on June 10, 1940. Watson attended high school in West Virginia and then the Lewis Gale School of Nursing in Roanoke, Virginia, where she graduated in 1961. She then took up the following degrees: **BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD, University of Colorado, 1973.** After her graduation in 1961, Jean Watson married her husband, Douglas, and moved west to his native state of Colorado. In 1997, she experienced an accidental injury that resulted in the loss of her left [eye](https://nurseslabs.com/special-senses-anatomy-physiology/) and soon after, in 1998, her husband, whom she considers as her physical and spiritual partner, and her best [friend](https://nurseslabs.com/8-reasons-why-your-nurse-best-friends-are-just-the-best/) passed away and left Watson and their two grown daughters, Jennifer and Julie, and five grandchildren **She is a distinguished Professor of Nursing and Chair in Caring Science at the University of Colorado Health Sciences Center, a fellow of the American Academy of Nursing. She became the Dean of Nursing at the University Health Sciences Center and President of the National League for Nursing. She has six (6) Honorary Doctoral Degrees. Her research has been has been in the area of human caring and loss.** **In 1988, her theory was published in "Nursing: Human Science and Human Care".** Watson's Philosophy and Science of Caring is concerned on how nurses express care to their patients. Her theory stresses humanistic aspects of nursing as they intertwine with scientific knowledge and nursing practice. **Factors that influence the development of the Theory** **Jean Watson is a nursing theorist who has evolved her work around theory, science, philosophy, research, and most importantly has centered her focus on a theory about caring. Watson's theory is focused on holistic human.** **Watson's theory was deeply influenced by personal issues; the death of her husband by suicide and the tragic loss of her eye in a golfing incident.** **The Theory of Human Caring was developed in 1979 with the focus on bringing meaning and focus to nursing as a distinct health profession.** **Watson's belief is that the focus should be on connecting with the patient's inner self by the use of healing, caring, spirituality, science, and philosophy instead of the focus being on illness and disease.** **As Watson formulated her theory, she found inspiration in Florence Nightingale's focus on caring.** **Florence Nightingale states, "It is the surgeon who saves a person's life.......it is the nurse who helps this person live** **Major concepts** **Human being** **Watson defined human being as a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. Human is viewed as greater than and different from the sum of his or her parts.** **Health** **Health is defined as a high level of overall physical, mental, and social functioning; a general adaptive-maintenance level of daily functioning; and the absence of illness, or the presence of efforts leading to the absence of illness.** **Health refers to unity and harmony within the mind, body and soul. Associated with the degree of congruence between self as perceived and as experienced** **Environment** **According to Watson, a person's environment provides values that determine how one should behave and what goals one should strive toward ( social,cultural, spiritual)** **Nursing** **Watson viewed nursing as a science of persons and health-illness experience that are mediated by professional, personal, scientific, and ethical care interactions.** **Nursing have to move educationally in the two areas of stress and developmental conflicts to provide holistic care** **Key concepts:** **Transpersonal caring relationship -- human-to-human connectedness occurring in a nurse-patient encounter, each touched by the human center of the other.** **Focus on the uniqueness of the persons in relationship, and the uniqueness of the phenomena wherein the coming together can be mutual and reciprocal, conveys a spiritual dimension** **Caring occasion/ caring moment --occurs when a nurse and others come together with their unique life histories and phenomenal field in a human-to-human transaction and is "focal point in space and time, has a greater field of itself that become part of the life history of each person, as well as of some larger, deeper, complex of life" ( Watson 1985/1988** **The ten primary carative factors** **Watson devised 10 caring needs specific carative factors critical to the caring human experience that need to be addressed by nurses with their patients when in a caring role.** **The first three carative factors form the "philosophical foundation" for the science of caring. The remaining seven carative factors spring from the foundation laid by these first three.** **1. The formation of a humanistic- altruistic system of values.** **Begins developmentally at an early age with values shared with the parents** **Mediated through one's own life experiences, the learning one gains and exposure to the humanities.** **Is perceived as necessary to the nurse's own maturation which then promotes altruistic behavior towards others.** **2. Installation of Faith and hope** **Is essential to both the carative and the curative processes.** **When modern science has nothing further to offer the person, the nurse can continue to use faith-hope to provide a sense of well-being through beliefs which are meaningful to the individual.** **3. Cultivation of sensitivity to one's self and to others** **Explores the need of the nurse to begin to feel an emotion as it presents itself.** **Development of one's own feeling is needed to interact genuinely and sensitively with others.** **Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in both the nurse and those with whom the nurse interacts.** **The nurses promote health and higher- level functioning only when they form person to person relationship.** **4. Establishing a helping-trust relationship** **The strongest tool is the mode of communication, which establishes rapport and caring.** **Characteristics needed to in the helping-trust relationship are:** **Congruence** **Empathy** **Warmth** **Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding.** **5. Promoting the expression of feelings, both positive and negative** **"Feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship".** **Awareness of the feelings helps to understand the behavior it engenders.** **6. Use of the scientific problem-solving method for decision making** **The scientific problem- solving method is the only method that allows for control and prediction, and that permits self-correction.** **The science of caring should not be always neutral and objective.** **7. Promotion of interpersonal teaching-learning** **The caring nurse must focus on the learning process as much as the teaching process.** **Understanding the person's perception of the situation assist the nurse to prepare a cognitive plan.** **8. Provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment** **Watson divides these into external and internal variables, which the nurse manipulates in order to provide support and protection for the person's mental and physical well-being.** **The external and internal environments are interdependent.** **Nurse must provide comfort, privacy and safety as a part of this carative factor.** **9. Assisting with the gratification of human needs** **It is based on a hierarchy of need similar to that of the Maslow's.** **Each need is equally important for quality nursing care and the promotion of optimal health.** **All the needs deserve to be attended to and valued.** **Watson's ordering of needs:** **a. Lower order needs (biophysical needs)** **The need for food and fluid** **The need for elimination** **The need for ventilation** **b. Lower order needs (psychophysical needs)** **The need for activity-inactivity** **The need for sexuality** **c. Higher order needs (psychosocial needs)** **The need for achievement** **The need for affiliation** **d. Higher order need (intrapersonal-interpersonal need)** **The need for self-actualization** **10. Allowing for existential-phenomenological forces** **Phenomenology is a way of understanding people from the way things appear to them, from their frame of reference.** **Existential psychology is the study of human existence using phenomenological analysis.** **This factor helps the nurse to reconcile and mediate the incongruity of viewing the person holistically while at the same time attending to the hierarchical ordering of needs.** **Assumptions** **Watson's model makes seven assumptions:** **(1) Caring can be effectively demonstrated and practiced only interpersonally.** **(2) Caring consists of carative factors that result in the satisfaction of certain human needs.** **(3) Effective caring promotes health and individual or family growth.** **(4) Caring responses accept the patient as he or she is now, as well as what he or she may become.** **(5) A caring environment is one that offers the development of potential while allowing the patient to choose the best action for him or herself at a given point in time.** **(6) A science of caring is complementary to the science of curing.** **(7) The practice of caring is central to nursing** **Strengths** **Although some consider Watson's theory complex, many find it easy to understand. The model can be used to guide and improve practice as it can equip healthcare providers with the most satisfying aspects of practice and can provide the client with holistic care.** **Watson considered using nontechnical, sophisticated, fluid, and evolutionary language to artfully describe her concepts, such as caring-love, carative factors, and Caritas. Paradoxically, abstract and simple concepts such as caring-love are difficult to practice, yet practicing and experiencing these concepts leads to greater understanding.** **Also, the theory is logical in that the carative factors are based on broad assumptions that provide a supportive framework. The carative factors are logically derived from the assumptions and related to the hierarchy of needs.** **Watson's theory is best understood as a moral and philosophical basis for nursing. The scope of the framework encompasses broad aspects of health-illness phenomena. In addition, the theory addresses aspects of health promotion, preventing illness and experiencing peaceful death, thereby increasing its generality. The carative factors provide guidelines for nurse-patient interactions, an important aspect of patient care.** **Weakness** **The theory does not furnish explicit direction about what to do to achieve authentic caring-healing relationships. Nurses who want concrete guidelines may not feel secure when trying to use this theory alone. Some have suggested that it takes too much time to incorporate the Caritas into practice, and some note that Watson's personal growth emphasis is a quality "that while appealing to some may not appeal to others.** **Application to Nursing Practice** **The theory of Watson can best be applied in situations through love and caring.** **Sharing something of a nurse's self with patients helps to establish a connection, an intimacy which will allow that person to related to the nurse. Creating a healing environment at all levels, physical as well as non -- physical subtle environment of energy and consciousness whereby wholeness, beauty, comfort, dignity and peace are rendered more effective.** **"*Nursing is concerned with the social sentient body that dwells in finite human world; that gets sick and recovers; that is altered during illness, pain and suffering; and that engages with the world differently upon recovery*..." Patricia Benner** **Dr Patricia Benner introduced the concept that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a** **multitude of experiences. She proposed that one could gain knowledge and skills (\"knowing how\") without ever learning the theory (\"knowing that\").** **She further explains that the development of knowledge in applied disciplines such as medicine and nursing is composed of the extension of practical knowledge (know how) through research and the characterization and understanding of the \"know how\" of clinical experience. She conceptualizes in her writing about nursing skills as experience is a prerequisite for becoming an expert.** **3. Patricia Benner's Stages of Nursing Expertise (From Novice to Expert)** **Patricia Benner was born in Hampton, Virginia in August of 1942. Benner earned her Bachelor of Arts degree in nursing from Pasadena College in 1964. She was given a Master of Science in Medical-Surgical Nursing from the University of California at San Francisco in 1970, and a Ph.D. from the University of California at Berkeley in 1982** **In the late 1960s, Benner worked in the nursing field. This included working as a Head Nurse of the Coronary Care Unit at the Kansas City General Hospital and an Intensive Care Staff Nurse at the Stanford University Hospital and Medical Center. From 1970 until 1975, she was a Research Associate at the University of California at San Francisco School of Nursing.** **Following that, she was a Research Assistant to Richard S. Lazarus at the University of California at Berkeley. From 1979 until 1981, she was the Project Director at the San Francisco Consortium/University of San Francisco for a project achieving methods of intra - professional consensus, assessment, and evaluation. Since 1982, Benner has been working in research and teaching at the University of California at San Francisco School of Nursing.** **Factors that influenced the development of Benner's theory** **The Novice to expert Model was introduced into nursing by Dr. Patricia Benner in 1982 and discussed how nurses develop skills and understanding of patient care over time. The model was derived from the Dreyfuss Model of Skill Acquisition and adapted to provide a more objective way for evaluating progress of nursing skills and subjects. The model essentially discusses how an individual begins in the novice stage, as new skills and knowledge are gained, progresses through and number of stages to end in expert realm.** **Major Concepts of the Theory** **Person** **Benner stated that a "*self-interpreting being, that is the person does not come into the world predefined but gets defined in the course of living a life, A person also an effortless and non -- reflective understanding of the self in the world. The person is viewed as a participant in common meanings*."** **Benner believed that there are significant aspects that make up a person. She had conceptualized the major aspects of understanding that the person must deal with as:** **1. The role of the situation** **2. The role of the body** **3. The role of personal concerns** **4. The role of temporality** **Health** **Benner focused "on the lived experience of being healthy and ill." She defined health as what can be assessed, while well -- being is the human experience of health or wholeness. Well -- being and being ill are recognized as different ways of being in the world. Health is described as not just the absence of disease and illness. Also, a person may have a disease and not experience illness because illness is the human experience of loss or dysfunction, whereas disease is what can be assessed at a physical level.** **Environment** **Benner used the term "situation" instead of "environment", because it suggests a social environment with a social definition and meaning. She used the phenomenological terms of being situated and situated meaning which are defined by the person's engaged interaction, interpretation and understanding of the situation.** **Nursing** **Benner described nursing as an "enabling condition of connection and concern", which shows a high level of emotional involvement in the nurse -- client relationship. She viewed nursing practice as the care and study of the lived experience of health, illness, and disease and the relationships among these three elements** **Key Concepts of the Theory** **Benner proposed that a nurse could gain knowledge and skills without actually learning a theory. She describes this as a nurse "knowing how" without "knowing that." She further explains that the development of knowledge in fields such as nursing is made up of the extension of knowledge through research and understanding through clinical experience.** **The theory identifies five levels of nursing experience: novice, advanced beginner, competent, proficient, and expert.** **Novice** A novice is a beginner with no experience. They are taught general rules to help perform tasks, and their rule-governed behavior is limited and inflexible. In other words, they are told what to do and simply follow instruction. The rules are **context-free, independent of specific cases, and applied universally. The rule -governed behavior is limited and inflexible** **Ex. "Tell me what I need to do and I'll do it."** Advanced Beginner The advanced beginner shows acceptable performance, and has gained prior experience in actual nursing situations. This helps the nurse recognize recurring meaningful components so that principles, based on those experiences, begin to formulate in order to guide actions. Competent A competent nurse generally has two - three years' experience on the job in the same field. The experience may also be similar day-to-day situations. These nurses are more aware of long-term goals, and they gain perspective from planning their own actions, which helps them achieve greater efficiency and organization. **Example -- a nurse having two or three years in intensive care unit gain more knowledge and skill from situations they encounter in their everyday experiences.** **Proficient** **A proficient nurse perceives and understands situations as whole parts. He or she has a more holistic understanding of nursing, which improves decision-making. These nurses learn from experiences what to expect in certain situations, as well as how to modify plans as needed.** **Expert** **Expert nurses no longer rely on principles, rules, or guidelines to connect situations and determine actions. They have a deeper background of experience and an intuitive grasp of clinical situations. Their performances are fluid, flexible, and highly-proficient. Benner's writings explain that nursing skills through experience are a prerequisite for becoming an expert nurse.** **These different levels of skills show changes in the three aspects of skilled performance: movement from relying on abstract principles to using past experiences to guide actions; change in the learner's perception of situations as whole parts rather than separate pieces; and passage from a detached observer to an involved performer, engaged in the situation rather than simply outside of it.** **The levels reflect movement from reliance on past principles to the use of past experience and change in the perception of the situation as a complete whole with certain relevant parts. Each step builds on the previous step as principles are refined and expanded by experience and clinical expertise.** **Assumptions** **Discovering assumptions, expectations, and sets can uncover an unexamined area of practical knowledge that can then be systematically studied and extended or refuted"** ** Clinical knowledge is embedded in perceptions rather that precepts.** **Perceptual awareness is central to good nursing judgment and... (for the expert) begins with vague hunches and global assessments that initially bypass critical analysis; conceptual clarity follows more often than in precedes" (Benner, 1984a, p.8)** ** Formal rules are limited and discretionary judgment is needed in actual clinical situations** **Clinical knowledge develops over time and each clinician develops a personal repertoire of practice knowledge that can be shared in dialogue with other clinicians.** **Expertise develops when the clinician tests and refines propositions, hypotheses, and principal - based expectations in actual practice situations"** **Strengths** **One of the greatest strengths of Benner's theory is that it focuses on the behavior of nurses depending on their level of understanding with nursing practice -- novice, advanced beginner, competent, proficient, expert.** **Her theory highlights the importance of clinical experience in developing expertise.** **Limitations** **Benner's theory proposes that the road from novice to expert nurse encompasses five stages (novice, advance beginner, competent, proficient, and expert). However, these stages are poorly defined in the literature, and some of the evidence from nursing practice presented to support their existence is weak.  ** **In addition, the criteria used for assigning nurses to stages (number of years of experience and supervisors' judgements) are not reliable and in fact have been shown to not always correlate with expertise.** **Moreover, establishing the reality of stages is a difficult matter, requiring a wealth of quantitative data, which are lacking in this case.** **Also, the very status of these stages is unclear. If they are meant to imply that individuals can be categorized in one stage, there are plenty of evidences showing that individuals, while fluent in one sub-field, may perform much less fluidly in another sub-field of the same domain.** **Application of the theory to Nursing practice, education** **As observed today, her theory is widely used as it provides a foundation to use for assigning clinical competence.** **Benner's model has been used in the nursing profession to make innovative changes in how knowledge is acquired and developed, continuing education's rationale, and serve as a foundation for how nurses build and improve skills based on acquiring experience** **Performance and learning needs of staff nurses can be identified and classified based on her five levels of skill acquisition.** **This process can serve to identify experts that could serve in a teaching and mentoring** **role to those staff members that are still in the novice to beginner phase. Having an** **understanding of the skill level of each nurse would better prepare the nurse in the** **educator role.** **Education of staff is an ongoing process that should never cease. Acquiring skills and** **knowledge takes time and mentoring.** **Benner's concept of reflection can be used to bridge the gap between theory and actual** **skill. This can be appropriate for nurses and patient families performing a return** **demonstration, further proving they have the knowledge and know how when faced** **with a situation or task. Deeper meaning and skill can be enhanced by reflection in** **practice, leadership, and education** **4. Eriksson's Caritative Caring Theory** **Katie Eriksson, one of the pioneers of caring science in the Nordic countries was born on November 18, 1943 in Jakobstad, Finland. She belongs to the Finland-Swedish minority in Finland, and her native language is Swedish.** **After taking nursing in 1965 to be able to practice nursing, she became a nursing instructor at Helsinki Swedish Medical Institute.** **She currently works as a professor of health sciences at Abo Akademi University in Vaasa, where she built a master's degree program in health sciences, and a four-year postgraduate studies program leading to a doctoral degree in health sciences.** **With her staff and researchers, Eriksson has further developed the caritative theory of caring and caring science as an academic discipline. The department has a leading position in the Nordic countries with students and researchers. In addition to her work with teaching, research, and supervision, Eriksson has been the dean of the Department of Caring Science. One of her central tasks has been to develop Nordic and international contacts within caring science.** **Eriksson has been a very popular guest and keynote speaker, not only in Finland, but in all the Nordic countries and at various international congresses.** **Eriksson has been a yearly keynote speaker at the annual congresses for nurse managers and, since 1996, at the annual caring science symposia in Helsinki, Finland.** **She has received many awards and honors for her professional and academic accomplishments** **Influences on the theory** **Ever since the mid - 1970s, Eriksson's leading thoughts have been not only to develop the substance of caring, but also to develop caring science as an independent discipline.** **Eriksson has found inspirations and was influenced by the works of many philosophers and scholars. Among them were the following:** **1. Greek classics by Plato, Socrates, and Aristotle, from whom she found her inspiration for the development of both the substance and the discipline of caring science. From her basic idea of caring science as a humanistic science, she developed a meta-theory that she refers to as "the theory of science for caring science"** **2. When developing caring science as an academic discipline, Swedish theologian Anders Nygren and Hans-Georg Gadamer. Nygren and later Tage Kurtén (1987) provided her with support for her division of caring science into systematic and clinical caring science. Eriksson introduces Nygren's concepts of motive research, context of meaning, and basic motive, which give the discipline structure. The aim of motive research is to find the essential context, the leading idea of caring. The idea of motive research applied to caring science is to show the characteristics of caring** **3. The basic motive in caring science and caring for Eriksson is caritas, which constitutes the leading idea and keeps the various elements together. It gives both the substance and the discipline of caring science a distinctive character. In development of the basic motive, St. Augustine and Soren Kierkegaard became important sources.** **4. In further development of the discipline, Eriksson's thinking was influenced by sources such as Thomas Kuhn and Karl Popper,** **5. American philosopher Susan Langer (1942) and Finnish philosophers Eino Kaila (1939) and Georg von Wright (1986), all of whom support the human science idea that science cannot exist without values.** **6. For many years, Eriksson collaborated with Hakan Tornebohm holder of the first Nordic professorial chair in the theory of science at the University of Gothenburg, Sweden. It is especially Tornebohm's research in and development of paradigms related to various scientific cultures that inspired Eriksson** **7. The thought that concepts have both meaning and substance has been prominent in Eriksson's scientific work. This appears through a systematic analysis of fundamental concepts with the help of a semantic method of analysis rooted in the idea of hermeneutics, which professor Peep Koort developed. Koort was Eriksson's mentor and unmistakably the most important source of inspiration in her scientific work. Building on the foundation of his methodology, Eriksson subsequently developed a model for concept development that has been of great importance to many researchers in their scientific work.** **8. In her formulation of the caritas-based caring ethic, which Eriksson conceives as an ontological ethic, Emmanuel Lévinas') idea that ethics precedes ontology has been a guiding principle** **Major Concepts** **Human Being** **The conception of the human being in Eriksson's theory is based on the axiom that the human being is an entity of body, soul, and spirit. She emphasizes that the human being is fundamentally a religious being, but all human beings have not recognized this dimension. The human being is fundamentally holy, and this axiom is related to the idea of human dignity, which means accepting the human obligation of serving with love and existing for the sake of others.** **The human being is seen as in constant becoming; he is constantly in change and therefore never in a state of full completion. He is understood in terms of the dual tendencies that exist within him, engaged in a continued struggle and living in a tension between being and nonbeing.** **According to Eriksson, the human being we meet in care is creative and imaginative, has desires and wishes, and is able to experience phenomena; therefore, a description of the human being only in terms of his needs is insufficient. When the human being is entering the caring context, he or she becomes a patient in the original sense of the concept---a suffering human being** **Health** **Eriksson defines health as soundness, freshness, and well-being. health implies being whole in body, soul, and spirit. Health means as a pure concept wholeness and holiness** **She sees health as both movement and integration. The health premise is a movement comprising various partial premises: health as movement implies a change; a human being is being formed or destroyed, but never completely; health is movement between actual and potential; health is movement in time and space; health as movement is dependent on vital force and on vitality of body, soul, and spirit; the direction of this movement is determined by the human being's needs and desires; the will to find meaning, life, and love constitutes the source of energy of the movement; and health as movement strives toward a realization of one's potential** **Environment** **Eriksson uses the concept of ethos. Ethos originally refers to home, or to the place where a human being feels at home. It symbolizes a human being's innermost space, where he appears in his nakedness.** **Nursing** **Eriksson believes that love and charity, or caritas, as the basic motive of caring. The history of ideas indicates that the foundation of the caring professions through the ages has been an inclination to help and minister to those suffering).** **Caritas constitutes the motive for caring, and it is through the caritas motive that caring gets its deepest formulation. Caritas constitutes the inner force that is connected with the mission to care. A carer beams forth caritas, or the strength and light of beauty.** **Key concepts** Caritas **Caritas means love and charity. In caritas, eros and agapé are united, and caritas is by nature unconditional love. Caritas, which is the fundamental motive of caring science, also constitutes the motive for all caring. It means that caring is an endeavor to mediate faith, hope, and love through tending, playing, and learning.** **Caring communion** **Caring communion constitutes the context of the meaning of caring and is the structure that determines caring reality. Caring gets its distinctive character through caring communion It is a form of intimate connection that characterizes caring. Caring communion requires meeting in time and space, an absolute, lasting presence** **Caring communion is characterized by intensity and vitality, and by warmth, closeness, rest, respect, honesty, and tolerance. It cannot be taken for granted but pre-supposes a conscious effort to be with the other. Caring communion is seen as the source of strength and meaning in caring.** The act of caring ***The act of caring* contains the caring elements (faith, hope, love, tending, playing, and learning), involves the categories of *infinity* and *eternity,* and invites to deep communion. The act of caring is the art of making something very special out of something less special.** Caritative caring ethics ***Caritative caring ethics* comprises the ethics of caring, the core of which is determined by the caritas motive. Eriksson makes a distinction between caring ethics and nursing ethics. She also defines the foundations of ethics in care and its essential substance.** **Caring ethics deals with the basic relation between the patient and the nurse---the way in which the nurse meets the patient in an ethical sense. It is about the approach we have toward the patient.** **Nursing ethics deals with the ethical principles and rules that guide my work or my decisions. Caring ethics is the core of nursing ethics. The foundations of caritative ethics can be found not only in history, but also in the dividing line between theological and human ethics in general** **Ethical caring is what we actually make explicit through our approach and the things we do for the patient in practice. An approach that is based on ethics in care means that we, without prejudice, see the human being with respect, and that we confirm his or her absolute dignity. It also means that we are willing to sacrifice something of ourselves.** **The ethical categories that emerge as basic in caritative caring ethics are human dignity, the caring communion, invitation, responsibility, good and evil, and virtue and obligation. In an ethical act, the good is brought out through ethical actions** Dignity ***Dignity* constitutes one of the basic concepts of caritative caring ethics. Human dignity is partly absolute dignity, partly relative dignity. Absolute dignity is granted the human being through creation, while relative dignity is influenced and formed through culture and external contexts. A human being's absolute dignity involves the right to be confirmed as a unique human being.** Invitation **Invitation refers to the act that occurs when the carer welcomes the patient to the caring communion. The concept of invitation finds room for a place where the human being is allowed to rest, a place that breathes genuine hospitality, and where the patient's appeal for charity meets with a response.** Suffering ***Suffering* is an ontological concept described as a human being's struggle between good and evil in a state of becoming. Suffering implies in some sense dying away from something, and through reconciliation, the wholeness of body, soul, and spirit is re-created, when the human being's holiness and dignity appear. Suffering is a unique, isolated total experience and is not synonymous with pain** Suffering related to illness, to care, and to life **These are three different forms of suffering. *Suffering related to illness* is experienced in connection with illness and treatment. When the patient is exposed to suffering caused by care or absence of caring, the patient experiences *suffering related to care*, which is always a violation of the patient's dignity. Not to be taken seriously, not to be welcome, being blamed, and being subjected to the exercise of power are various forms of suffering related to care. In the situation of being a patient, the entire life of a human being may be experienced as *suffering related to life.*** The suffering human being **The *suffering human being* is the concept that Eriksson uses to describe the patient. The patient refers to the concept of *patiens* (Latin), which means "suffering." The patient is a suffering human being, or a human being who suffers and patiently endures** Reconciliation **Reconciliation refers to the drama of suffering. A human being who suffers wants to be confirmed in his or her suffering and be given time and space to suffer and reach reconciliation.** **Reconciliation implies a change through which a new wholeness is formed of the life the human being has lost in suffering. In reconciliation, the importance of sacrifice emerges** **Having achieved reconciliation implies living with an imperfection with regard to oneself and others but seeing a way forward and a meaning in one's suffering. Reconciliation is a prerequisite of caritas** Caring culture ***Caring culture* is the concept that Eriksson uses instead of *environment*. It characterizes the total caring reality and is based on cultural elements such as traditions, rituals, and basic values. Caring culture transmits an inner order of value preferences or ethos, and the different constructions of culture have their basis in the changes of value that ethos undergoes. If communion arises based on the ethos, the culture becomes inviting.** **Respect for the human being, his or her dignity and holiness, forms the goal of communion and participation in a caring culture. The origin of the concept of culture is to be found in such dimensions as reverence, tending, cultivating, and caring; these dimensions are central to the basic motive of preserving and developing a caring culture** **Major assumptions** **Eriksson distinguishes between two kinds of major assumptions: axioms and theses. She regards axioms as fundamental truths in relation to the conception of the world; theses are fundamental statements concerning the general nature of caring science, and their validity is tested through basic research.** **The axioms are as follows:** **  The human being is fundamentally an entity of body, soul, and spirit.** **  The human being is fundamentally a religious being.** **  The human being is fundamentally holy. Human dignity means accepting the human obligation of serving with love, of existing for the sake of others.** **  Communion is the basis for all humanity. Human beings are fundamentally interrelated to an abstract and/or concrete other in a communion.** **  Caring is something human by nature, a call to serve in love.** **  Suffering is an inseparable part of life. Suffering and health are each other's prerequisites.** **  Health is more than the absence of illness. Health implies wholeness and holiness.** **  The human being lives in a reality that is characterized by mystery, infinity, and eternity.** **The theses are as follows:** **  Ethos confers ultimate meaning on the caring context.** **  The basic motive of caring is the *caritas* motive.** **  The basic category of caring is suffering.** **  Caring communion forms the context of meaning of caring and derives its origin from the ethos of love, responsibility, and sacrifice, namely, caritative ethics.** **  Health means a movement in becoming, being, and doing while striving for wholeness and holiness, which is compatible with endurable suffering.** **  Caring implies alleviation of suffering in charity, love, faith, and hope. Natural basic caring is expressed through tending, playing, and learning in a sustained caring relationship, which is asymmetrical by nature.** **Strengths** **1. Holism** **2. Acknowledges willingness of person, caregiver or patient** **3. Nurse willingness to act without prejudice** **4. Altruistic** **Limitations** 1. **Abstract** 2. **Spiritually based** 3. **Lack of international use in nursing education** 4. **Nurse willingness to self -- sacrifice** **Application to Nursing Practice, Education and Research** Since the 1970s, Eriksson's nursing care process model was systematically used, tested, and developed as a basis of nursing care and documentation at Helsinki University Central Hospital. In various studies, Eriksson's theory has been tested, and the results have been presented in doctoral and master's theses and published in professional and scientific journals. The study, "In the Patient's World II: Alleviating the Patient's Suffering---Ethics and Evidence" led to recommendations for the care of patients and is an ongoing research project that will become a handbook for clinical caring science. Since the 1970s, Eriksson's theory has been integrated into the education of nurses at various levels, and her books have been included continuously in the examination requirements in various forms of nursing education in the Nordic countries. Eriksson has always emphasized the importance of basic research as necessary for clinical research, in her book, Broar (Bridges, 1991), she describes the research paradigm and various methodological approaches based on a human science perspective. During the first few years, the emphasis lay on basic research, with the focus on development of the basic concepts and assumptions of the theory and on the fundamentals of history and the history of ideas. Development of the theory and research have always moved hand in hand with the focus on various dimensions of the theory, and, in this connection, we wish to illustrate some central results of the research.