130 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
■ Summary
This chapter provided an overview of Orem’s blocks of these theories are six major concepts
self-care deficit nursing theory. Orem created and one peripheral concept. Orem’s SCDNT
this general theory of nursing to address the has been applied extensively in nursing practice
proper objective of nursing through the ques- throughout the United States and internation-
tion, What condition exists in a person when ally in diverse settings and with diverse popu-
judgments are made that a nurse(s) should be lations. SCDNT continues to be used as a
brought into the situation (i.e., that a person framework for research with specific patient
should be under nursing care; Orem, 2001, populations throughout the world. Collabora-
p. 20)? The grand theory comprises four inter- tion among scholars, researchers, and practi-
related theories: the theory of self-care, theory tioners is necessary to provide the science of
of dependent care, theory of self-care deficit, self-care useful to improve nursing practice
and theory of nursing systems. The building into the future (Taylor & Renpenning, 2011).
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Imogene King’s Theory 9Chapter
of Goal Attainment
CHRISTINA L. SIELOFF AND
MAUREEN A. FREY
Introducing the Theorist Introducing the Theorist
Overview of the Conceptual System
(King’s Conceptual System and Theory of Imogene M. King was born on January 30,
1923, in West Point, Iowa. She received a
Goal Attainment) diploma in nursing from St. John’s Hospital
Applications of the Theory In Practice School of Nursing, St. Louis, Missouri (1945);
Practice Exemplar by Mary B. Killeen a bachelor of science in nursing education
(1948); a master of science in nursing from
Summary St. Louis University (1957); and a doctor of
References education (EdD) from Teachers College,
Columbia University, New York (1961). She
Imogene M. King held educational, administrative, and leader-
ship positions at St. John’s Hospital School
of Nursing, the Ohio State University, Loyola
University, the Division of Nursing in the
U.S. Department of Health, Education, and
Welfare, and the University of South Florida.
King’s hallmark theory publications include:
“A Conceptual Frame of Reference for Nurs-
ing” (1968), Towards a Theory for Nursing:
General Concepts of Human Behaviour (1971),
and A Theory for Nursing: Systems, Concepts,
Process (1981). Since 1981, King has clarified
and expanded her conceptual system, her
middle-range theory of goal attainment, and
the transaction process model in multiple book
chapters, articles in professional journals, and
presentations. After retiring as professor
emerita from the University of South Florida
in 1990, King remained an active contributor
to nursing’s theoretical development and
worked with individuals and groups in devel-
oping additional middle range theories, apply-
ing her theoretical formulations to various
populations and settings and implementing
the theory of goal attainment in clinical prac-
tice. King received recognition and numerous
133
134 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
awards for her distinguished career in nursing review of nursing literature provided me with
from the American Nurses Association, the ideas to identify five comprehensive concepts
Florida Nurses Association, the American as a basis for a conceptual system for nursing.
Academy of Nursing, and Sigma Theta Tau The overall concept is a human being, com-
International. King died in December 2007. monly referred to as an “individual” or a “per-
Her theoretical formulations for nursing con- son.” Initially, I selected abstract concepts of
tinue to be taught at all levels of nursing edu- perception, communication, interpersonal re-
cation and applied and extended by national lations, health, and social institutions (King,
and international scholars.1 1968). These ideas forced me to review my
knowledge of philosophy relative to the nature
Overview of the Conceptual of human beings (ontology) and to the nature
System (King’s Conceptual of knowledge (epistemology).
System and Theory of Goal
Attainment) Philosophical Foundation
Theoretical Evolution in King’s In the late 1960s, while auditing a series of
Own Words courses in systems research, I was introduced
to a philosophy of science called general system
My first theory publication pronounced the theory (von Bertalanffy, 1968). This philoso-
problems and prospect of knowledge devel- phy of science gained momentum in the
opment in nursing (King, 1964). More than 1950s, although its roots date to an earlier pe-
30 years ago, the problems were identified as riod. This philosophy refuted logical positivism
(1) lack of a professional nursing language, and reductionism and proposed the idea of iso-
(2) a theoretical nursing phenomena, and morphism and perspectivism in knowledge
(3) limited concept development. Today, the- development. Von Bertalanffy, credited with
ories and conceptual frameworks have iden- originating the idea of general system theory,
tified theoretical approaches to knowledge defined this philosophy of science movement
development and utilization of knowledge in as a “general science of wholeness: systems of
practice. Concept development is a continu- elements in mutual interaction” (von Bertalanffy,
ous process in the nursing science movement 1968, p. 37).
(King, 1988).
My philosophical position is rooted in gen-
My rationale for developing a schematic eral system theory, which guides the study of
representation of nursing phenomena was in- organized complexity as whole systems. This
fluenced by the Howland systems model philosophy gave me the impetus to focus on
(Howland, 1976) and the Howland and knowledge development as an information-
McDowell conceptual framework (Howland processing, goal-seeking, and decision-making
& McDowell, 1964). The levels of interaction system. General system theory provides a ho-
in those works influenced my ideas relative to listic approach to study nursing phenomena as
organizing a conceptual frame of reference for an open system and frees one’s thinking from
nursing. Because concepts offer one approach the parts-versus-whole dilemma. In any dis-
to structure knowledge for nursing, a thorough cussion of the nature of nursing, the central
ideas revolve around the nature of human be-
For additional information about the theorist, publica- ings and their interaction with internal and ex-
tions and research using King’s conceptual model and ternal environments. During this journey, I
the theory of goal attainment (Tables 9-1 to 9-15), began to conceptualize a theory for nursing.
please go to bonus chapter content available at However, because a manuscript was due in the
http://davisplus.fadavis.com. Some tables are specifically publisher’s office, I organized my ideas into a
referenced throughout the text to further guide the conceptual system (formerly called a “concep-
reader. tual framework”), and the result was the pub-
lication of a book titled Toward a Theory of
Nursing (King, 1971).
CHAPTER 9 • Imogene King’s Theory of Goal Attainment 135
Design of a Conceptual System Process for Development of Concepts
A conceptual system provides structure for or-
ganizing multiple ideas into meaningful wholes. “Searching for scientific knowledge in nursing
From my initial set of ideas in 1968 and 1971, is an ongoing dynamic process of continuous
my conceptual framework was refined to show identification, development, and validation of
some unity and relationships among the con- relevant concepts” (King, 1975, p. 25). What
cepts. The conceptual system consists of indi- is a concept? A concept is an organization of
vidual systems, interpersonal systems, and social reference points. Words are the verbal symbols
systems and concepts that are important for un- used to explain events and things in our envi-
derstanding the interactions within and be- ronment and relationships to past experiences.
tween the systems (Fig. 9-1). Northrop (1969) noted: “[C]oncepts fall into
different types according to the different
The next step in this process was to review sources of their meaning. . . . A concept is a
the research literature in the discipline in term to which meaning has been assigned.”
which the concepts had been studied. For ex- Concepts are the categories in a theory.
ample, the concept of perception has been
studied in psychology for many years. The lit- The concept development and validation
erature indicated that most of the early studies process is as follows:
dealt with sensory perception. Around the
1950s, psychologists began to study interper- 1. Review, analyze, and synthesize research
sonal perception, which related to my ideas literature related to the concept.
about interactions. From this research literature,
I identified the characteristics of perception and 2. From the review, identify the characteris-
defined the concept for my framework. I con- tics (attributes) of the concept.
tinued searching literature for knowledge of
each of the concepts in my framework. An up- 3. From the characteristics, write a concep-
date on my conceptual system was published tual definition.
in 1995 (King, 1995).
4. Review literature to select an instrument
Social systems or develop an instrument.
(society)
5. Design a study to measure the character-
Interpersonal systems istics of the concept.
(group)
6. Select the population to be sampled.
Personal 7. Collect data.
systems 8. Analyze and interpret data.
(individuals) 9. Write results of findings and conclusions.
10. State implications for adding to nursing
Fig 9 • 1 King’s conceptual system.
knowledge.
Concepts that represent phenomena in
nursing are structured within a framework and
theory to show relationships.
Multiple concepts were identified from my
analysis of nursing literature (King, 1981). The
concepts that provided substantive knowledge
about human beings (self, body image, percep-
tion, growth and development, learning, time,
and personal space) were placed within the
personal system, those related to small groups
(interaction, communication, role, transac-
tions, and stress) were placed within the inter-
personal system, and those related to large
groups that make up a society (decision mak-
ing, organization, power, status, and authority)
were placed within the social system (King,
1995). However, knowledge from all of the
136 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
concepts is used in nurses’ interactions with in- Lo and behold, a theory of goal attainment was
dividuals and groups within social organiza- developed (King, 1981, 1992). More recently,
tions, such as the family, the educational others have derived theories from my conceptual
system, and the political system. Knowledge of system (Frey & Sieloff, 1995).
these concepts came from my synthesis of re-
search in many disciplines. Concepts, when Theory of Goal Attainment
defined from research literature, give nurses
knowledge that can be applied in the concrete Generally speaking, nursing care’s goal is to
world of nursing. The concepts represent basic help individuals maintain health or regain
knowledge that nurses use in their role and health (King, 1990). Concepts are essential
functions either in practice, education, or ad- elements in theories. When a theory is derived
ministration. In addition, the concepts provide from a conceptual system, concepts are se-
ideas for research in nursing. lected from that system. Remember my ques-
tion: What is the essence of nursing? The
One of my goals was to identify what I call concepts of self, perception, communication,
the essence of nursing. That brought me back interaction, transaction, role, growth and de-
to the question: What is the nature of human velopment, stress, time, and personal space
beings? A vicious circle? Not really! Because were selected for the theory of goal attainment.
nurses are first and foremost human beings who
give nursing care to other human beings, my Transaction Process Model
philosophy of the nature of human beings
has been presented along with assumptions I A transaction model, shown in Figure 9-2, was
have made about individuals (King, 1989a). developed that represented the process in
Recognizing that a conceptual system repre- which individuals interact to set goals that re-
sents structure for a discipline, the next step in sult in goal attainment (King, 1981, 1995).
the process of knowledge development was to
derive one or more theories from this structure. The model is a human process that can be
observed in many situations when two or more
people interact, such as in the family and in
Feedback
PERCEPTION REACTION INTERACTION TRANSACTION
JUDGMENT
ACTION
NURSE
ACTION
JUDGMENT
PATIENT
PERCEPTION
Feedback
Fig 9 • 2 Transaction process model. (From King, I. M. [1981]. A theory for nursing: Systems, concepts, process
[p. 145]. New York: Wiley.)
CHAPTER 9 • Imogene King’s Theory of Goal Attainment 137
social events (King, 1996). As nurses, we bring designing critical paths, various care plans, and
knowledge and skills that influence our percep- other types of forms when, with knowledge of
tions, communications, and interactions in per- this system, the nurse documents nursing care
forming the functions of the role. In your role directly on the patient’s chart? Why do we use
as a nurse, after interacting with a patient, sit multiple forms to complicate a process that is
down and write a description of your behavior knowledge-based and also provides essential
and that of the patient. It is my belief that you data to demonstrate outcomes and to evaluate
can identify your perceptions, mental judg- quality nursing care?
ments, mental action, and reaction (negative or
positive). Did you make a transaction? That is, Federal laws have been passed that indicate
did you exchange information and set a goal that patients must be involved in decisions
with the patient? Did you explore the means about their care and about dying. This trans-
for the patient to use to achieve the goal? Was action process provides a scientifically based
the goal achieved? If not, why? It is my opinion process to help nurses implement federal laws
that most nurses use this process but are not such as the Patient Self-Determination Act
aware that it is based in a nursing theory. With (Federal Register, 1995).
knowledge of the concepts and of the process,
nurses have a scientific base for practice that Goal Attainment Scale
can be clearly articulated and documented to
show quality care. How can a nurse document Analysis of nursing research literature in the
this transaction model in practice? 1970s revealed that few instruments were de-
signed for nursing research. In the late 1980s,
Documentation System the faculty at the University of Maryland, ex-
perts in measurement and evaluation, applied
A documentation system was designed to im- for and received a grant to conduct conferences
plement the transaction process that leads to to teach nurses to design reliable and valid in-
goal attainment (King, 1984). Most nurses use struments. I had the privilege of participating
the nursing process to assess, diagnose, plan, in this 2-year continuing education confer-
implement, and evaluate, which I call a ence, where I developed a Goal Attainment
method. My transaction process provides the Scale (King, 1989b). This instrument may be
theoretical knowledge base to implement this used to measure goal attainment. It may also
method. For example, as one assesses the be used as an assessment tool to provide pa-
patient and the environment and makes a tient data to plan and implement nursing care.
nursing diagnosis, the concepts of perception,
communication, and interaction represent Vision for the Future
knowledge the nurse uses to gather informa-
tion and make a judgment. A transaction is My vision for the future of nursing is that
made when the nurse and patient decide mu- nursing will provide access to health care for
tually on the goals to be attained, agree on the all citizens. The United States’ health-care sys-
means to attain goals that represent the plan tem will be structured using my conceptual
of care, and then implement the plan. Evalua- system. Entry into the system will be via
tion determines whether or not goals were nurses’ assessment so that individuals are di-
attained. If not, you ask why, and the process rected to the right place in the system for
begins again. The documentation is recorded nursing care, medical care, social services in-
directly in the patient’s chart. The patient’s formation, health teaching, or rehabilitation.
record indicates the process used to achieve My transaction process will be used by every
goals. On discharge, the summary indicates practicing nurse so that goals can be achieved
goals set and goals achieved. One does not to demonstrate quality care that is cost-effective.
need multiple forms when this documentation My conceptual system, theory of goal attain-
system is in place, and the quality of nursing ment, and transaction process model will con-
care is recorded. Why do nurses insist on tinue to serve a useful purpose in delivering
professional nursing care. The relevance of
evidence-based practice, using my theory, joins
138 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
the art of nursing of the 20th century to the purpose of this part of the chapter is to provide
science of nursing in the 21st century. an updated review of the state of the art in
terms of the application of King’s conceptual
Concepts and Middle-Range Theory system (KCS) and middle-range theory in a
Development Within King’s variety of areas: practice, administration, edu-
Conceptual System or the Theory cation, and research. Publications, identified
of Goal Attainment from a review of the literature, are summarized
and briefly discussed. Finally, recommenda-
Concept development within a conceptual tions are made for future knowledge develop-
framework is particularly valuable, as it ment in relation to KCS and middle-range
often explicates concepts more clearly than theory, particularly in relation to the impor-
a theorist may have done in his or her origi- tance of their application within an evidence-
nal work. Concept development may also based practice environment.
demonstrate how other concepts of interest
to nursing can be examined through a nurs- In conducting the literature review, the
ing lens. Such explication further assists authors began with the broadest category
the development of nursing knowledge by of application—application within KCS to
enabling the nurse to better understand the nursing care situations. Because a conceptual
application of the concept within specific framework is, by nature, very broad and
practice situations. Examples of concepts abstract, it can serve only to guide, rather than
developed from within King’s work include to prescriptively direct, nursing practice.
the following: collaborative alliance relation-
ship (Hernandez, 2007); decision making Development of middle-range theories is a
(Ehrenberger, Alligood, Thomas, Wallace, & natural extension of a conceptual framework.
Licavoli, 2007), empathy (May, 2007), holis- Middle-range theories, clearly developed from
tic nursing (Li, Li, & Xu, 2010), managerial within a conceptual framework, accomplish two
coaching (Batson & Yoder, 2012), patient goals: (1) Such theories can be directly applied
satisfaction with nursing care (Killeen, to nursing situations, whereas a conceptual
2007), sibling closeness (Lehna, 2009), and framework is usually too abstract for such direct
whole person care (Joseph, Laughon, & application, and (2) validation of middle-range
Bogue, 2011).2 theories, clearly developed within a particular
conceptual framework, lends validation to the
Applications of the Theory conceptual framework itself. King (1981) stated
in Practice that individuals act to maintain their own
health. Although not explicitly stated, the
Since the first publication of King’s work converse is probably true as well: Individuals
(1971), nursing’s interest in the application of often do things that are not good for their
her work to practice has grown. The fact that health. Accordingly, it is not surprising that the
she was one of the few theorists who generated KCS and related middle-range theory are often
both a framework and a middle range theory directed toward patient and group behaviors
further expanded her work. Today, new pub- that influence health.
lications related to King’s work are a frequent
occurrence. Additional middle-range theories In addition to the middle-range theory of
have been generated and tested, and applica- goal attainment (King, 1981), several other mid-
tions to practice have expanded. After her re- dle-range theories have been developed from
tirement, King continued to publish and within King’s interacting systems framework. In
examine new applications of the theory. The terms of the personal system, Brooks and
Thomas (1997) used King’s framework to derive
2See Table 9-2 in the bonus chapter content available at a theory of perceptual awareness. The focus was
http://davisplus.fadavis.com. to develop the concepts of judgment and action
as core concepts in the personal system. Other
concepts in the theory included communication,
perception, and decision making.
CHAPTER 9 • Imogene King’s Theory of Goal Attainment 139
In relation to the interpersonal system, reproductive health and related quality of life
several middle-range theories have been among Indian women in mining communities”
developed regarding families. Doornbos (p. 1963).
(2007), using her family health theory, ad-
dressed family health in terms of families of Nursing Process and Nursing
adults with persistent mental illness. Thoma- Terminologies, Including
son and Lagowski (2008) used concepts from Standardized Nursing Languages
King along with other nursing theorists to
develop a model for collaboration through Within the nursing profession, the nursing
reciprocation in health-care organizations. process has consistently been used as the basis
In relation to social systems, Sieloff and for nursing practice. King’s framework and
Bularzik (2011) revised the “theory of group middle-range theory of goal attainment (1981)
power within organizations” to the “theory have been clearly linked to the process of nurs-
of group empowerment within organiza- ing. Although many published applications
tions” to assist in explaining the ability have broad reference to the nursing process,
of groups to empower themselves within several deserve special recognition. First, King
organizations.3 herself (1981) clearly linked the theory of goal
attainment to nursing process as theory and to
Review of the literature identified instru- nursing process as method. Application of
ments specifically designed within King’s King’s work to nursing curricula further
framework. King (1988) developed the Health strengthened this link.
Goal Attainment instrument, designed to de-
tail the level of attainment of health goals by In addition, the steps of the nursing process
individual clients. The Nurse Performance have long been integrated within the KCS
Goal Attainment (NPGA) was developed by and the middle-range theory of goal attain-
Kameoka, Funashima, and Sugimori (2007). ment (Daubenmire & King, 1973; D’Souza,
Somayaji, & Suybrahmanya, 2011; Woods,
Applications in Nursing Practice 1994). In these process applications, assess-
ment, diagnosis, and goal-setting occur, fol-
There have been many applications of King’s lowed by actions based on the nurse–client
middle-range theory to nursing practice be- goals. The evaluation component of the nurs-
cause the theory focuses on concepts relevant ing process consistently refers back to the orig-
to all nursing situations—the attainment of inal goal statement(s). In related research, Frey
client goals. The application of the middle- and Norris (1997) also drew parallels between
range theory of goal attainment (King, 1981) the processes of critical thinking, nursing, and
is documented in several categories: (1) general transaction.
application of the theory, (2) exploring a par-
ticular concept within the context of the theory Over time, nursing has developed nursing
of goal attainment, (3) exploring a particular terminologies that are used to assist the pro-
concept related to the theory of goal attain- fession to improve communication both
ment, and (4) application of the theory in non- within, and external to, the profession. These
clinical nursing situations. For example, King terminologies include the nursing diagnoses,
(1997) described the use of the theory of goal nursing interventions, and nursing outcomes.
attainment in nursing practice. Short-term With the use of these standardized nursing
group psychotherapy was the focus of theory languages (SNLs), the nursing process is fur-
application for Laben, Sneed, and Seidel (1995). ther refined. Standardized terms for diagnoses,
D’Souza, Somayaji, and Subrahmanya (2011) interventions, and outcomes also potentially
used the theory to “examine determinants of improve communication among nurses.
See Table 9-5 in the bonus chapter content available at Using SNLs also enables the development
http://davisplus.fadavis.com. of middle-range theory by building on con-
cepts unique to nursing, such as those concepts
of King that can be directly applied to the
nursing process: action, reaction, interaction,
140 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
transaction, goal setting, and goal attainment. Dalri (2006), and Palmer (2006) implemented
Biegen and Tripp-Reimer (1997) suggested nursing diagnoses within the context of King’s
middle-range theories be constructed from the framework.4
concepts in the taxonomies of the nursing lan-
guages focusing on outcomes. Alternatively, Applications in Client Systems
King’s framework and theory may be used as a
theoretical basis for these phenomena and may KCS and middle-range theory of goal attain-
assist in knowledge development in nursing in ment have a long history of application with
the future. large groups or social systems (organizations,
communities). The earliest applications in-
With the advent of SNLs, “outcome volved the use of the framework and theory to
identification” is identified as a step in the guide continuing education (Brown & Lee,
nursing process after assessment and diagnosis 1980) and nursing curricula (Daubenmire,
(McFarland & McFarland, 1997, p. 3). King’s 1989; Gulitz & King, 1988). More contempo-
(1981) concept of mutual goal setting is anal- rary applications address a variety of organiza-
ogous to the outcomes identification step, tional settings. For example, the framework
because King’s concept of goal attainment served as the basis for the development of a
is congruent with the evaluation of client middle-range theory relating to practice in a
outcomes. nursing home (Zurakowski, 2007). Nwinee
(2011) used King’s work, along with Peplau’s,
In addition, King’s concept of perception to develop the sociobehavioral self-care man-
(1981) lends itself well to the definition of agement nursing model (p. 91). In addition,
client outcomes. Moorhead, Johnson, and the theory of goal attainment has been pro-
Maas (2013) define a nursing-sensitive patient posed as the practice model for case manage-
outcome as “an individual, family or commu- ment (Hampton, 1994; Tritsch, 1996). These
nity state, behaviour or perception that is latter applications are especially important be-
measured along a continuum in response to cause they may be the first use of the frame-
nursing intervention(s)” (p. 2). This is fortu- work by other disciplines.
itous because the development of nursing
knowledge requires the use of client outcome Applicable to administration and manage-
measurement. The use of standardized client ment in a variety of settings, a middle-range
outcomes as study variables increases the ease theory of group power within organizations
with which research findings can be compared has been developed and revised to the theory
across settings and contributes to knowledge of group empowerment within organizations
development. Therefore, King’s concept of (Sieloff, 1995, 2003, 2007; Sieloff & Dunn,
mutually set goals may be studied as “expected 2008; Sieloff & Bularzik, 2011). Educational
outcomes.” Also, by using SNLs, King’s settings, also considered as social systems,
(1981) middle-range theory of goal attainment have been the focus of application of King’s
can be conceptualized as the “attainment of ex- work (George, Roach, & Andfrade, 2011;
pected outcomes” as the evaluation step in the Greef, Strydom, Wessels, & Schutte, 2009;
application of the nursing process. Ritter, 2008).5
In summary, although these terminologies, Multidisciplinary Applications
including SNLs, were developed after many of
the original nursing theorists had completed Because of King’s emphasis on the attainment
their works, nursing frameworks such as the of goals and the relevancy of goal attainment
KCS (1981) can still find application and use to many disciplines, both within and external
within the terminologies. In addition, it is this to health care, it is reasonable to expect that
type of application that further demonstrates
the framework’s utility across time. For exam- 4See Table 9-4 in the bonus chapter content available at
ple, Chaves and Araujo (2006), Ferreira De http://davisplus.fadavis.com.
Sourza, Figueiredo De Martino, and Daena 5See Table 9-8 in the bonus chapter content available at
De Morais Lopes (2006), Goyatá, Rossi, and http://davisplus.fadavis.com.
CHAPTER 9 • Imogene King’s Theory of Goal Attainment 141
King’s work can find application beyond Undoubtedly, the strongest evidence for the
nursing-specific situations. Two specific ex- cultural utility of King’s conceptual framework
amples of this include the application of and midrange theory of goal attainment (1981)
King’s work to case management (Hampton, is the extent of work that has been done in
1994; Sowell & Lowenstein, 1994) and to other cultures. Applications of the framework
managed care (Hampton, 1994). Both case and related theories have been documented in
management and managed care incorporate the following countries beyond the United
multiple disciplines as they work to improve States: Brazil (Firmino, Cavalcante, & Celia,
the overall quality and cost-efficiency of the 2010), Canada (Plummer & Molzahn, 2009),
health care provided. These applications also China (Li, Li, & Xu, 2010), India (D’Souza,
address the continuum of care, a priority in Somayaji, & Subrahmanya, 2011; George
today’s health-care environment. Specific re- et al., 2011), Japan (Kameoka et al., 2007),
searchers (Fewster-Thuente & Velsor- Portugal (Chaves & Araujo, 2006; Goyatá
Friedrich, 2008; Khowaja, 2006) detailed et al., 2006; Pelloso & Tavares, 2006), Slovenia
their research related to multidisciplinary ac- (Harih & Pajnkihar, 2009), Sweden (Rooke,
tivities and interdisciplinary collaborations, 1995a, 1995b), and West Africa (Nwinee,
respectively.6 2011). In Japan, a culture very different from
the United States with regard to communica-
Multicultural Applications tion style, Kameoka (1995) used the classifica-
tion system of nurse–patient interactions
Multicultural applications of KCS and re- identified within the theory of goal attainment
lated theories are many. Such applications (King, 1981) to analyze nurse–patient interac-
are particularly critical because many theo- tions. In addition to research and publications
retical formulations are limited by their regarding the application of King’s work to
culture-bound nature. Several authors specif- nursing practice internationally, publications by
ically addressed the utility of King’s frame- and about King have been translated into other
work and theory for transcultural nursing. languages, including Japanese (King, 1976,
Spratlen (1976) drew heavily from King’s 1985; Kobayashi, 1970). Therefore, perception
framework and theory to integrate ethnic and the influence of culture on perception were
cultural factors into nursing curricula and identified as strengths of King’s theory.
to develop a culturally oriented model for
mental health care. Key elements derived Research Applications in Varied
from King’s work were the focus on percep- Settings and Populations
tions and communication patterns that mo-
tivate action, reaction, interaction, and KCS has been used to guide nursing practice
transaction. Rooda (1992) derived proposi- and research in multiple settings and with
tions from the midrange theory of goal multiple populations. For example, Harih and
attainment as the framework for a conceptual Pajnkihar (2009) applied King’s model in
model for multicultural nursing. treating elderly diabetes patients. Joseph et al.
(2011) examined the implementation of
Cultural relevance has also been demon- whole-person care.7 As stated previously, dis-
strated in reviews by Frey, Rooke, Sieloff, eases or diagnoses are often identified as the
Messmer, and Kameoka (1995) and Husting focus for the application of nursing knowledge.
(1997). Although Husting identified that cul- Maloni (2007) and Nwinee (2011) conducted
tural issues were implicit variables throughout research with patients with diabetes, and
King’s framework, particular attention was women with breast cancer were the focus of
given to the concept of health, which, accord- the work of Funghetto, Terra, and Wolff
ing to King (1990), acquires meaning from (2003). In addition, clients with chronic
cultural values and social norms.
6See Table 9-14 in the bonus chapter content available 7See Table 9-11 in the bonus chapter content available
at http://davisplus.fadavis.com. at http://davisplus.fadavis.com.
142 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
obstructive pulmonary disease were involved in obesity (Ongoco, 2012). Gender-specific work
research by Wicks, Rice, and Talley (2007). included Sharts-Hopko’s (2007) use of a middle-
Clients experiencing a variety of psychiatric range theory of health perception to study the
concerns have also been the focus of work, health status of women during menopause
using King’s conceptualizations (Murray & transition and Martin’s (1990) application
Baier, 1996; Schreiber, 1991). Clients’ con- of the framework toward cancer awareness
cerns ranged from psychotic symptoms among males.
(Kemppainen, 1990) to families experiencing
chronic mental illness (Doornbos, 2007), to Several of the applications with adults have
clients in short-term group psychotherapy targeted the mature adult, thus demonstrating
(Laben, Sneed, & Seidel, 1995).8 The theory contributions to the nursing specialty of geron-
has also been applied in nonclinical nursing tology. Reed (2007) used a middle-range the-
situations. Secrest, Iorio, and Martz (2005) ory to examine the relationship of social
used the theory in examining the empower- support and health in older adults. Harih and
ment of nursing assistants. Li et al. (2010) ex- Pajnkihar (2009) applied “King’s model in the
plored the “development of the concept of treatment of elderly diabetes patients” (p. 201).
holistic nursing” (p. 33).9 Clearly, these applications, and others, show
how the complexity of King’s framework and
Research Applications with Clients Across midrange theory increases its usefulness for
the Life Span nursing.10
Additional evidence of the scope and usefulness Research Applications to Client Systems
of King’s framework and theory is its use with
clients across the life span. Several applications In addition to discussing client populations
have targeted high-risk infants (Frey & Norris, across the life span, client populations can be
1997; Syzmanski, 1991). Frey (1993, 1995, identified by focus of care (client system)
1996) developed and tested relationships among and/or focus of health problem (phenomenon
multiple systems with children, youth, and of concern). The focus of care, or interest, can
young adults. Lehna (2009) explicated the con- be an individual (personal system) or group
cept of sibling closeness in a study of siblings (interpersonal or social system). Thus, applica-
experiencing a major burn trauma. Interestingly, tion of King’s work, across client systems, can
these studies considered personal systems (in- be divided into the three systems identified
fants), interpersonal systems (parents, families), within the KCS (1981): personal (the individ-
and social systems (the nursing staff and hospi- ual), interpersonal (small groups), and social
tal environment). Clearly, a strength of King’s (large groups/society).
framework and theory is its utility in encom-
passing complex settings and situations. Use with personal systems has included
both patients and nurses. LaMar (2008) exam-
KCS and the midrange theory of goal at- ined nurses in a tertiary acute care organization
tainment have also been used to guide practice as the personal system of interest. Nursing stu-
with adults (young adults, adults, mature dents as personal systems were the focus of
adults) with a broad range of concerns. Goyatá Lockhart and Goodfellow’s research (2009).
et al. (2006) used King’s work in their study of When the focus of interest moves from an in-
adults experiencing burns. Additional exam- dividual to include interaction between two
ples of applications focusing on adults include people, the interpersonal system is involved.
individuals with hypertension (Firmino et al., Interpersonal systems often include clients and
2010) and perceptions of students toward nurses. An example of an application to a
nurse–client dyad is Langford’s (2008) study
8See Table 9-8 and 9-11 in the bonus chapter content of the perceptions of transactions with nurse
available at http://davisplus.fadavis.com. practitioners and obese adolescents. In relation
9See Table 9-3 in the bonus chapter content available at
http://davisplus.fadavis.com. 10 See Table 9-7 in the bonus chapter content available
at http://davisplus.fadavis.com.
CHAPTER 9 • Imogene King’s Theory of Goal Attainment 143
to interpersonal systems, or small groups, the outcome of concern in practice applications
many publications focus on the family. Frey by Smith (1988). Several applications used
and Norris (1997) used both KCS and the the- health-related terms. For example, DeHowitt
ory of goal attainment in planning care with (1992) studied well-being, and D’Souza et al.
families of premature infants. Alligood (2010) (2011) examined the determinants of health.
described “family health care with King’s the-
ory of goal attainment” (p. 99). Health promotion has also been an em-
phasis for the application of King’s ideas.
Research Applications Focusing on Sexual counseling was the focus of work by
Phenomena of Concern to Clients Villeneuve and Ozolins (1991). Health be-
haviors were Hanna’s (1995) focus of study,
Within King’s work, it is critically important and Plummer and Molzahn (2009) explored
for the nurse to focus on, and address, the the “quality of life in contemporary nursing
phenomenon of concern to the client. With- theory” (p. 134). Frey (1996, 1997) examined
out this emphasis on the client’s perspective, both health behaviors and illness manage-
mutual goal setting cannot occur. Hence, a ment behaviors in several groups of children
client’s phenomenon of concern was selected with chronic conditions as well as risky
as neutral terminology that clearly demon- behaviors (1996). Recently, researchers have
strated the broad application of King’s work explored weight loss and obesity (Langford,
to a wide variety of practice situations. A topic 2008; Ongoco, 2012).
that frequently divides nurses is their area of
specialty. However, by using a consistent Research Applications in Varied Work
framework across specialties, nurses may be Settings
able to focus more clearly on their common-
alities, rather than highlighting their differ- An additional potential source of division
ences.11 A review of the literature clearly within the nursing profession is the work sites
demonstrates that King’s framework and re- where nursing is practiced and care is deliv-
lated theories have application within a variety ered. As the delivery of health care moves from
of nursing specialties.12 This application is ev- the acute care hospital to community-based
ident whether one is reviewing a “traditional” agencies and clients’ homes, it is important to
specialty, such as surgical nursing (Bruns, highlight commonalities across these settings,
Norwood, Bosworth, & Gill, 2009; Lockhart and it is important to identify that King’s
& Goodfellow, 2009; Sivaramalingam, 2008), framework and middle-range theory of goal
or the nontraditional specialties of forensic attainment continue to be applicable. Al-
nursing (Laben et al., 1991) and/or nursing though many applications tend to be with
administration (Gianfermi & Buchholz, 2011; nurses and clients in traditional settings, suc-
Joseph et al., 2011). cessful applications have been shown across
other, including newer and nontraditional set-
Health is one area that certainly binds tings. From hospitals (Bogue, Jospeh, &
clients and nurses. Improved health is clearly Sieloff, 2009; Firmino et al., 2010; Kameoka
the desired end point, or outcome, of nursing et al., 2007) to nursing homes (Zurakowski,
care and something to which clients aspire. 2007), King’s framework and related theories
Review of the outcome of nursing care, as provide a foundation on which nurses can
addressed in published applications, tends to build their practice interventions. In addition,
support the goal of improved health directly the use of the KCS and related theories are ev-
and/or indirectly, as the result of the applica- ident within quality improvement projects
tion of King’s work. Health status is explicitly (Anderson & Mangino, 2006; Durston, 2006;
Khowaja, 2006).13 Nurses also use the theory
11See Table 9-9 in the bonus chapter content available at
http://davisplus.fadavis.com. 13See Table 9-11 in the bonus chapter content available
12See Table 9-10 in the bonus chapter content available at http://davisplus.fadavis.com.
at http://davisplus.fadavis.com.
144 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
of goal attainment (King, 1981) to examine 2009; Gemmill et al., 2011; Mardis, 2011),
concepts related to the theory. This application nurse administrators (Sieloff & Bularzik,
was demonstrated by Smith (2003), by Jones 2011), and client-consumers (Killeen, 2007)
and Bugge (2006), by Sivaramalingam (2008) as part of evolving evidence-based nursing
in a study of patients’ perceptions of nurses’ practice.14
roles and responsibilities, and by Mardis
(2012) in a study of patients’ perceptions of Recommendations for Future
minimal lift equipment. Applications Related to King’s
Framework and Theory
Relationship to Evidence-Based Practice
Obviously, new nursing knowledge has resulted
From an evidence-based practice and King from applications of King’s framework and the-
perspective, the profession must implement ory. However, nursing is evolving as a science.
three strategies to apply theory-based research Additional work continues to be needed. On
findings effectively. First, nursing as a disci- the basis of a review of the applications previ-
pline must agree on rules of evidence in evalu- ously discussed, recommendations for future
ation of quality research that reflect the unique applications continue to focus on (1) the need
contribution of nursing to health care. Second, for evidence-based nursing practice that is the-
the nursing rules of evidence must include oretically derived; (2) the integration of King’s
heavier weight for research that is derived work in evidence-based nursing practice; (3) the
from, or adds to, nursing theory. Third, the integration of King’s concepts within SNLs;
nursing rules of evidence must reflect higher (4) analysis of the future effect of managed care,
scores when nursing’s central beliefs are af- continuous quality improvement, and technol-
firmed in the choice of variables. This third ogy on King’s concepts; (5) identification, or de-
strategy, for the use of concepts central to velopment and implementation, of additional
nursing, has clear relevance for evidence-based relevant instruments; and (6) clarification of ef-
practice when using King’s (1981) concepts as fective nursing interventions, including identi-
reformulated within interventions or out- fication of relevant Nursing Interventions
comes. Outcomes, as in King’s concept of goal Classifications, based on King’s work.
attainment, provide data for evidence-based
practice. As part of its mission, the King International
Nursing Group (KING) (www.kingnursing
Currently, safety and quality initiatives in .org) continuously monitors the latest publica-
organizations, with evidence-based practice tions and research based on King’s work and
as the innovation, use many concepts initially related theories, providing updates to mem-
defined by King and found in middle-range bers. To further assist in the dissemination of
theories (Sieloff & Frey, 2007). King’s such research, KING also conducts a biannual
(1981) work on the concepts of client and research conference. The following Exemplar
nurse perceptions, and the achievement of illustrates the application of the theory of goal
mutual goals has been assimilated and ac- attainment to an interdisciplinary team, quality
cepted as core beliefs of the discipline of improvement, and evidence-based practice.
nursing. Research conducted with a King
theoretical base is well positioned for appli- 14See Table 9-12 in the bonus chapter content available
cation by nurse caregivers (Bruns et al., at http://davisplus.fadavis.com.
CHAPTER 9 • Imogene King’s Theory of Goal Attainment 145
Practice Exemplar
Provided by Mary B. Killeen, PhD, The following are the questions and the
RN, NEA-BC conclusions that Claire and her colleagues
discussed:
Claire Smith, RN, BSN, is a recent nursing
graduate in her first position on a medical in- 1. How does King’s theory of goal attainment help
tensive care unit in a suburban community the unit’s quality improvement (QI) committee?
hospital. Claire’s manager suggests that she Goal attainment theory is derived from
should join the unit’s interdisciplinary quality KCS, which includes personal, interpersonal,
improvement committee to develop her lead- and social systems. The QI committee is a
ership skills. The goal of the committee is to type of interpersonal system. An interpersonal
improve patient care by using the best avail- system encompasses individuals in groups in-
able evidence to develop and implement prac- teracting to achieve goals. The QI committee
tice protocols. is engaged in the committee’s goal attainment
for the benefit of patients. “Role expectations
At the first meeting, Claire was asked if and role performance of nurses and clients in-
she had any burning clinical questions as a fluence transactions” (King, 1981, p. 147).
new graduate. She stated that she was taught When used in interdisciplinary teams, the
to avoid use of normal saline for tracheal suc- transaction process in King’s theory facilitates
tioning. However, she noticed many respira- mutual goal setting with nurses, and ulti-
tory therapists and some nurses routinely mately patients, based on each member of the
using normal saline with suctioning. When team’s specific knowledge and functions.
asked about this practice, she was told Multidisciplinary care conferences, an ex-
that normal saline was useful to break up se- ample of a situation where goal-setting
cretions and aid in their removal. The com- among professionals occurs, is a label for an
mittee affirmed Claire’s observation of indirect nursing intervention within the
contradictory practices between what is Nursing Interventions Classification (NIC;
taught and what is done in practice. After Bulechek, Butcher, & Dochterman, 2008).
discussion, the group formulated the follow- Some of the activities listed under this NIC
ing clinical question: Does instilling normal reflect King’s (1981) concepts: “establish mu-
saline decrease favorable patient outcomes tually agreeable goals; solicit input for patient
among patients with endotracheal tubes or care planning; revise patient care plan, as
tracheostomies? necessary; discuss progress toward goals; and
provide data to facilitate evaluation of patient
Claire suggests to the committee that care plan” (p. 501).
King’s theory of goal attainment might be
useful as a theoretical guide for this project 2. How does King define goals and goal attain-
because the question is focused on patient ment and how are these related to quality
outcomes, or according to King’s theory, patient outcomes?
goals. The nursing members are familiar According to King’s theory of goal at-
with King’s theory, and all members value tainment (1981), goals are mutually agreed
using theory to guide practice. Claire’s pro- upon, and through a transaction process,
posal is accepted. Claire experienced work- are attained. Goals are similar to outcomes
ing on EBP group projects as a student, so that are achieved after agreement on the
she feels comfortable volunteering to develop definitions and measurement of the out-
a draft of the theoretical foundation for the comes. Quality improvement has shown
project. Two other committee members agreement that evaluation of care must in-
agree to work on the plan and present it at clude process and outcomes. Outcomes are
the next meeting.
Continued
146 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Practice Exemplar cont. question and the theoretical concepts as key
words. Second, the theoretical formulation of
the results of interventions or processes. the study helps organize the implementation
The term “outcome” assumes that a process is and evaluation plans so they are attainable.
central to effective care. An outcome is de-
fined as a change in a patient’s health status. 4. What key words would you use for the search con-
Effectiveness of care can be measured by sidering the clinical question and King’s theory?
whether the patient goals (i.e., outcomes) Key words used are endotracheal tubes,
have been attained. The QI Committee en- tracheostomies, normal saline, suctioning, out-
gages in goal attainment through communi- comes, King’s theory of goal attainment, and
cation by setting goals, exploring means, and goal attainment.
agreeing on means to achieve goals. In this
example, members will gather information, 5. How does a theoretical foundation, such as
examine data and evidence, interpret the in- King’s theory of goal attainment, apply to a
formation, and participate in developing a quality improvement or EBP project?
protocol for patients to achieve quality patient Claire used these criteria from her nurs-
outcomes, that is, goals. ing program to develop a theoretical foun-
dation for the project.
3. How does King’s theory of goal attainment The theoretical foundation for the proj-
provide a theoretical foundation for the clini- ect was presented to the committee and
cal problem of using normal saline with accepted (Fig. 9–3).
suctioning?
First, the use of King’s theory will help 6. What were the results of the committee’s
guide the literature search to include studies work?
that address interventions or processes that The search strategy included MEDLINE,
lead to favorable patient outcomes or goals CINAHL, Cochrane Library, Joanna Briggs
among patients similar to the population on Institute, and TRIP databases. All types of
the unit. Claire’s subgroup enlisted the help evidence (nonexperimental, experimental,
of the hospital librarian in searching the qualitative studies, systematic reviews) were
literature using the elements of the clinical
Clinical Problem King’s Application to
Elements Concepts the Project
Population: patients Clients and nurses Members of the
with endotracheal Interdisciplinary
tubes or tracheostomies Committee
Intervention: normal Transaction Clinical problem
saline with suctioning process: formulated and relevance
Disturbance to unit discussed.
Outcomes Goals explored Evidence sought and
examined to select
measurable goals/
outcomes.
Outcomes Explore means to Implementation plan
achieve goals devised.
Outcomes Agree on means Implementation plan
to achieve goals accepted by members.
Fig 9 • 3 Theoretical foundation for a quality improvement project using
Imogene King’s theory of goal attainment derived from King’s conceptual
system (1981).
CHAPTER 9 • Imogene King’s Theory of Goal Attainment 147
Practice Exemplar cont. small samples, hemodynamic alterations and
infections were not selected as outcomes.
included. The evidence was evaluated by the The committee devised a theory-based im-
QI committee and included physiological plementation plan to discontinue normal
and psychological effects of instillation of saline for suctioning using the five Ws (who,
normal saline. The collective evidence, rele- what, where, when, why) and how as the
vant to their unit’s practice problem, did not outline for the plan. Change processes were
support the routine use of normal saline with employed in the plan. Evaluation of the at-
suctioning (similar to Halm & Kriski- tainment of outcomes will address the effec-
Hagel, 2008). From the evidence, the com- tiveness of the plan using the measurable
mittee selected the specific outcomes to track outcomes and the degree to which they were
for the project: sputum recovery, oxygena- attained.
tion, and subjective symptoms of pain, anx-
iety, and dyspnea. Owing to anticipated
■ Summary
An essential component in the analysis of con- because interaction is a part of every nursing
ceptual frameworks and theories is the consid- encounter. Although previous evaluations of
eration of their adequacy (Ellis, 1968). the scope of King’s framework and middle-
Adequacy depends on the three interrelated range theory have resulted in mixed reviews
characteristics of scope, usefulness, and com- (Austin & Champion, 1983; Carter &
plexity. Conceptual frameworks are broad in Dufour, 1994; Frey, 1996; Jonas, 1987;
scope and sufficiently complex to be useful for Meleis, 2012), the nursing profession has
many situations. Theories, on the other hand, clearly recognized their scope and usefulness.
are narrower in scope, usually addressing less In addition, the variety of practice applications
abstract concepts, and are more specific in evident in the literature clearly attests to the
terms of the nature and direction of relation- complexity of King’s work. As researchers con-
ships and focus. tinue to integrate King’s theory and framework
with the dynamic health-care environment, fu-
King fully intended her conceptual system ture applications involving evidence-based
for nursing to be useful in all nursing situa- practice will continue to demonstrate the ade-
tions. Likewise, the middle-range theory of quacy of King’s work in nursing practice.
goal attainment (King, 1981) has broad scope
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Sister Callista Roy’s 10Chapter
Adaptation Model
PAMELA SENESAC AND Introducing the Theorist
SISTER CALLISTA ROY
Introducing the Theorist Sister Callista Roy is a highly respected nurse
Overview of the Roy Adaptation Model theorist, writer, lecturer, researcher, and
Applications of the Theory teacher. She is currently Professor and Nurse
Theorist at the Connell School of Nursing at
Practice Exemplar Boston College. Roy holds concurrent ap-
Summary pointments as Research Professor in Nursing
at her alma mater, Mt. Saint Mary’s College,
References Los Angeles, CA, and as Faculty Senior Sci-
entist, Yvonne L. Munn Center for Nursing
Sister Callista Roy Research, Massachusetts General Hospital,
Boston, MA. Roy has been a member of the
Sisters of St. Joseph of Carondolet for more
than 50 years.
Roy is recognized worldwide in the field of
nursing and considered to be among nursing’s
great living thinkers. As a theorist, Roy often
emphasizes her primary commitment to define
and develop nursing knowledge and regards
her work with the Roy adaptation model as a
rich source of knowledge for improving nurs-
ing practice for individuals and for groups.
In the first decade of the 21st century, Roy
provided an expanded, values-based concept
of adaptation based on insights related to the
place of the person in the universe and in so-
ciety. A prolific thinker, educator, and writer,
she has welcomed the contributions of others
in the development of the work; she notes that
her best work is yet to come and likely will be
done by one of her students.
Roy credits the major influences of her fam-
ily, her religious commitment, and her teachers
and mentors in her personal and professional
growth. Born in Los Angeles, California, in
1939, Roy is the oldest daughter of a family of
seven boys and seven girls. A deep spirit of
faith, hope, love, commitment to God, and
153
154 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
service to others was central in the family. Her She has received many other awards, including
mother was a licensed vocational nurse and in- the National League for Nursing Martha
stilled the values of always seeking to know Rogers Award for advancing nursing science;
more about people and their care and of selfless the Sigma Theta Tau International Founders
giving as a nurse. Award for contributions to professional prac-
tice; and four honorary doctorates. Sigma
Roy was awarded a bachelor of arts degree Theta Tau International, Honor Society of
with a major in nursing from Mount St. Mary’s Nursing included Roy as an inaugural inductee
College, Los Angeles; a master’s degree in pe- to the Nurse Researcher Hall of Fame.1
diatric nursing and a master’s degree and a PhD
in sociology from the University of California, Overview of the Roy Adaption
Los Angeles. Roy completed a 2-year postdoc- Model
toral program as a clinical nurse scholar in neu-
roscience nursing at the University of California, The Roy adaptation model (Roy, 1970, 1984,
San Francisco. She was a Senior Fulbright 1988a, 1988b, 2009, 2011a, 2011b, 2014; Roy
Scholar in Australia. Important mentors in & Andrews, 1991, 1999; Roy & Roberts,
her life have included Dorothy E. Johnson, 1981; Roy, Whetzell & Fredrickson, 2009) has
Ruth Wu, Connie Robinson, and Barbara been in use for more than 40 years, providing
Smith Moran. direction for nursing practice, education, and
research. Extensive implementation efforts
Roy is best known for developing and con- around the world and continuing philosophical
tinually updating the Roy adaptation model as and scientific developments by the theorist
a framework for theory, practice, and research have contributed to model-based knowledge
in nursing. Books on the model have been for nursing practice. The purpose of this chap-
translated into many languages, including ter is to describe the model as the foundation
French, Italian, Spanish, Finnish, Chinese, for knowledge-based practice. The develop-
Korean, and Japanese. Two publications that ments of the model, including assumptions
Roy considers significant are The Roy Adapta- and major concepts are described. The reader
tion Model (Roy, 2009) and Nursing Knowledge is introduced to the knowledge that the model
Development and Clinical Practice (Roy & provides as the basis for planning nursing care
Jones, 2007). Another important work is a along with applications in practice and three
two-part project analyzing research based on practice exemplars.
the Roy adaptation model and using the find-
ings for knowledge development. The first was Historical Development
a critical analysis of 25 years of model-based
literature, which included 163 studies pub- Under the mentorship of Dorothy E. Johnson,
lished in 46 English-speaking journals, as well Roy first developed a description of the adap-
as dissertations and theses. It was published as tation model while a master’s student at the
a research monograph by Sigma Theta Tau In- University of California at Los Angeles. The
ternational and entitled The Roy Adaptation first publication on the model appeared in 1970
Model-based Research: Twenty-five Years of Con- (Roy, 1970) while Roy was on the faculty of the
tributions to Nursing Science (Boston-Based baccalaureate nursing program of a small liberal
Adaptation Research in Nursing Society, 1999). arts college. There, she had the opportunity to
The research literature of the next 15 years was lead the implementation of this model of nurs-
analyzed and used to create middle range theo- ing as the basis of the nursing curriculum. Dur-
ries as evidence for practice. Including 172 stud- ing the next decade, more than 1500 faculty
ies and currently in press, this work is entitled and students at Mount St. Mary’s College
Generating Middle Range Theory: Evidence for 1For additional information please see the bonus chapter
Practice (Buckner & Hayden, in press). content available at http://davisplus.fadavis.com
Roy was honored as a Living Legend by the
American Academy of Nursing and the Mas-
sachusetts Association of Registered Nurses.
CHAPTER 10 • Sister Callista Roy’s Adaptation Model 155
helped to clarify, refine, and develop this ap- Roy, the word offered the notion of the root-
proach to nursing. The constant influence of edness of all knowledge being one. Veritivity is
practice was important during this develop- the principle within the Roy Adaptation Model
ment. One example of data from practice used of human nature that affirms a common pur-
in model development was the derivation of posefulness of human existence. Veritivity is
four adaptive modes from 500 samples of pa- the affirmation that human beings are viewed
tient behaviors described by nursing students. in the context of the purposefulness of their ex-
istence, unity of purpose of humankind, activity
The mid-1970s to the mid-1980s saw the and creativity for the common good, and the
expansion of the use of the model in nursing value and meaning of life.
education. Roy and the faculty at her home
institution consulted on curriculum in more Currently, Roy views the 21st century as a
than 30 schools across the United States and time of transition, transformation, and need
Canada. By 1987, it was estimated that more for spiritual vision. The further development
than 100,000 students had graduated from of the philosophic assumptions focuses on
curricula based on the Roy model. Theory de- people’s mutuality with others, the world, and
velopment was also a focus during this time, a God-figure. The development and expansion
and 91 propositions based on the model were of the major concepts of the model show the
identified. These described relationships be- influence of the theorist’s scientific and philo-
tween and among concepts of the regulator sophic background and global experiences.
and the cognator and the four adaptive modes For nursing in the 21st century, Roy (1997)
(Roy & Roberts, 1981). In the 1980s, Roy also provided a redefinition of adaptation and a re-
was influenced by postdoctoral work in neu- statement of the assumptions that are founda-
roscience nursing and an increasing number tional to the model, which led to expanded
of commitments in other countries. Roy fo- philosophical and scientific assumptions in
cused on contemporary movements in nursing contemporary society and to adding cultural
knowledge and the continued integration of assumptions. These assumptions are listed in
spirituality with an understanding of nursing’s Table 10-1 and further described in the basic
role in promoting adaptation. The first decade work on the model (Roy, 2009). Roy also uses
of the 21st century included a greater focus on the idea of cosmic unity that stresses her vision
philosophy, knowledge for practice, and global for the future and emphasizes the principle
concerns. that people and Earth have common patterns
and integral relationships. Rather than the sys-
Philosophical, Scientific, and Cultural tem acting to maintain itself, the emphasis
Assumptions shifts to the purposefulness of human existence
in a creative universe.
Assumptions provide the beliefs, values, and
accepted knowledge that form the basis for the Model Concepts
work. For the Roy adaptation model, the con-
cept of adaptation rests on scientific and philo- The underlying assumptions of the Roy adap-
sophic assumptions that Roy has developed tation model are the basis for and are evident
over time. The scientific assumptions initially in the specific description of the major con-
reflected von Bertalanffy’s (1968) general sys- cepts of the model. The major concepts include
tems theory and Helson’s (1964) adaptation- people as adaptive systems (both individuals
level theory. Later beliefs about the unity and and groups), the environment, health, and the
meaningfulness of the created universe were in- goal of nursing.
cluded (Young, 1986). Early identification of
the philosophic assumptions for the model People as Adaptive Systems
named humanism and veritivity. In 1988, Roy
introduced the concept of veritivity as an option Roy describes people, both individually and in
to total relativity. Veritivity was a term coined groups, as holistic adaptive systems, complete
by Roy, based on the Latin word veritas. For with coping processes acting to maintain adap-
tation and to promote person and environment
156 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Table 10 • 1 Assumptions of the Roy Adaptation Model for the 21st Century
Philosophic Assumptions
Persons have mutual relationships with the world and the God-figure.
Human meaning is rooted in an omega point convergence of the universe.
God is intimately revealed in the diversity of creation and is the common destiny of creation.
Persons use human creative abilities of awareness, enlightenment, and faith.
Persons are accountable for entering the process of deriving, sustaining, and transforming the
universe.
Scientific Assumptions
Systems of matter and energy progress to higher levels of complex self-organization.
Consciousness and meaning are consistent of person and environment integration.
Awareness of self and environment is rooted in thinking and feeling.
Human decisions are accountable for the integration of creative processes.
Thinking and feeling mediate human action.
System relationships include acceptance, protection, and fostering interdependence.
Persons and the Earth have common patterns and integral relations.
Person and environment transformations created human consciousness.
Integration of human and environment meanings result in adaptation.
Cultural Assumptions
Experiences within a specific culture will influence how each element of the Roy adaptation
model is expressed.
Within a culture, there may be a concept that is central to the culture and will influence some or
all of the elements of the Roy adaptation model to a greater or lesser extent.
Cultural expressions of the elements of the Roy adaptation model may lead to changes in prac-
tice activities such as nursing assessment.
As Roy adaptation model elements evolve within a cultural perspective, implications for educa-
tion and research may differ from experience in the original culture.
transformations. As with any type of system, and comes to a new decision about where and
people have internal processes that act to how to cross the street safely.
maintain the integrity of the individual or
group. These processes have been broadly cat- The coping processes for the group relate to
egorized as a regulator subsystem and a cognator stability and change. The stabilizer subsystem
subsystem for the person related to a stabilizer has structures, values, and daily activities to
subsystem and an innovator subsystem for accomplish the primary purpose of the group.
the group. The regulator uses physiological Thus a family group is structured to earn a
processes such as chemical, neurological, and living and to provide for the nurturance and ed-
endocrine responses to cope with the changing ucation of children. Family values also influence
environment. For example, when an individual how the members respond to the environment
sees a sudden threat, such as an oncoming car to fulfill their responsibilities to maintain the
approaching when stepping off the curb, an in- family. Groups also have processes to respond
crease of adrenal hormones provides immedi- to the environment with innovation and change
ate energy enabling him or her to escape harm. by way of the innovator subsystem. For exam-
The cognator subsystem involves the cognitive ple, organizations use strategic planning activi-
and emotional processes that interact with the ties and team-building sessions. When the
environment. In the example of the individual innovator is functioning well, the group creates
who escapes from an oncoming car, the cogna- new goals and growth, achieving new mastery
tor acts to process the emotion of fear. The per- and transformation. Nurses can use innovator
son also processes perceptions of the situation subsystems to create organizational change in
practice.
CHAPTER 10 • Sister Callista Roy’s Adaptation Model 157
Both the cognator-regulator and stabilizer- of the individual, the role function mode focuses
innovator coping processes are manifested in on the roles that the individual occupies in so-
four particular ways of adapting in each indi- ciety. A role, as the functioning unit of society,
vidual and in groups of people. These four is defined as a set of expectations about how a
ways of categorizing the effects of coping person occupying one position behaves toward
activity are called adaptive modes. These four a person occupying another position. The basic
modes, initially developed for human systems need underlying the role function mode for the
as individuals, were expanded to encompass individual has been identified as social in-
groups. These are termed the physiological– tegrity, the need to know who one is in rela-
physical, self-concept–group identity, role func- tion to others in order to act. The underlying
tion, and interdependence modes. These four processes include developing roles and role
major categories describe responses to and taking.
interaction with the environment and are how
adaptation can be observed. Behavior related to interdependent rela-
tionships of individuals and groups is the
For individuals, the physiological mode in the interdependence mode, the final adaptive mode
Roy adaptation model is associated with the Roy describes. For the individual, the mode
way people as individuals interact as physical focuses on interactions related to the giving
beings with the environment. Behavior in this and receiving of love, respect, and value. The
mode is the manifestation of the physiological basic need of this mode is termed relational
activities of all the cells, tissues, organs, and integrity, the feeling of security in nurturing re-
systems comprising the human body. The lationships. Two specific relationships are the
physiological mode has nine components: the focus within the interdependence mode for the
five basic needs of oxygenation, nutrition, individual: significant others, persons who are
elimination, activity and rest, and protection the most important to the individual, and
and four complex processes that are involved support systems, others contributing to meet-
in physiological adaptation, including the ing interdependence needs. Interdependence
senses; fluid, electrolyte, and acid–base bal- processes include affectional adequacy and de-
ance; neurological function; and endocrine velopmental adequacy.
function. The underlying need for the physio-
logical mode is physiological integrity. For people in groups it is more appropriate
to use the term physical in referring to the first
The category of behavior related to the adaptive mode. At the group level, this mode
personal aspects of individuals is termed the relates to the manner in which the human
self-concept. The basic need underlying the self- adaptive system of the group manifests adap-
concept mode has been identified as psychic and tation relative to basic operating resources, that
spiritual integrity; one needs to know who one is, participants, physical facilities, and fiscal re-
is to be or exist with a sense of unity. Self- sources. The basic need associated with the
concept is defined as the composite of beliefs physical mode for the group is resource ade-
and feelings that a person holds about him- or quacy, or wholeness achieved by adapting to
herself at a given time. Formed from internal change in physical resource needs. Processes in
perceptions and perceptions of others, self- this mode for groups include resource manage-
concept directs one’s behavior. Components of ment and strategic planning.
the self-concept mode are the physical self, in-
cluding body sensation and body image; and Group identity is the relevant term used for
the personal self, including self-consistency, the second mode related to groups. Identity in-
self-ideal, and moral–ethical–spiritual self. tegrity is the need underlying this group adap-
Processes in the mode are the developing self, tive mode. The mode comprises interpersonal
perceiving self, and focusing self. relationships, group self-image, social milieu,
and culture.
Behavior relating to positions in society is
termed the role function mode for both the in- A nurse can have a self-concept of seeing self
dividual and the group. From the perspective as physically capable of the work involved. In
addition, the nurse feels comfortable meeting
158 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
self-expectations of being a caring professional. complex relationships among modes further
In a social system, such as a nursing care unit, demonstrate the holistic nature of humans as
an associated culture can be described. There is adaptive systems. The adaptive modes and
a social environment experienced by the nurses, coping processes for individuals and groups of
administrators, and other staff that is reflected individuals are described by the Roy adapta-
by those who are part of the nursing care group. tion model (Roy, 2009).
The group feels shared values and counts on
each other. As such, the self-concept–group iden- Environment
tity mode can reflect adaptive or ineffective be-
haviors associated with an individual nurse or The Roy adaptation model defines environ-
the nursing care unit as an adaptive system. As ment as all the conditions, circumstances, and
we note later in the chapter, two processes iden- influences surrounding and affecting the de-
tified in this mode are group shared identity and velopment and behavior of individuals and
family coherence. groups. Given the model’s view of the place of
the person in the evolving universe, environ-
Roles within a group are the vehicles ment is a biophysical community of beings
through which the goals of the social system with complex patterns of interaction, feedback,
are actually accomplished. They are the action growth, and decline, constituting periodic and
components associated with group infrastruc- long-term rhythms. Individual and environ-
ture. Roles are designed to contribute to the mental interactions are input for the individual
accomplishment of the group’s mission, or the or group as adaptive systems. This input in-
tasks or functions associated with the group. volves both internal and external factors. Roy
The role function mode includes the functions used the work of Helson (1964), a physiolog-
of administrators and staff, the management ical psychologist, to categorize these factors as
of information, and systems for decision mak- focal, contextual, and residual stimuli.
ing and maintaining order. The basic need as-
sociated with the group role function mode is The focal is the stimulus most immediately
termed role clarity, the need to understand and confronting the individual and holding the
commit to fulfil expected tasks, to achieve focus of attention; contextual stimuli are those
common goals. Processes involve socializing factors also acting in the situation; and resid-
for role expectations, reciprocating roles, and ual are possible factors that as yet have an
integrating roles. unknown affect. A specific internal input
stimulus is an adaptation level that represents
For groups, the interdependence mode per- the individual’s or group’s coping capacities.
tains to the social context in which the group This changing level of ability has an internal
operates. It involves private and public contacts effect on adaptive behaviors. Roy defined
both within the group and with those outside three levels of adaptation: integrated, com-
the group. The components of group interde- pensatory, and compromised. Integrated adap-
pendence include context, infrastructure, and tation occurs when the structures and functions
resources. The processes for group interde- of the adaptive modes are working as a whole
pendence include relational integrity, develop- to meet human needs. The compensatory adap-
mental adequacy, and resource adequacy. tation level occurs when the cognator and
regulator or stabilizer and innovator are acti-
The four adaptive modes are interrelated, vated by a challenge. Compromised adaptation
which can be illustrated by drawing the modes occurs when integrated and compensatory
as overlapping circles. The physiological–physical processes are inadequate, creating an adapta-
mode is intersected by each of the other three tion problem.
modes. Behavior in the physiological–physical
mode can have an effect on or act as a stimulus Health
for one or all of the other modes. In addition,
a given stimulus can affect more than one Roy’s concept of health is related to the con-
mode, or a particular behavior can be indicative cept of adaptation and the idea that adaptive
of adaptation in more than one mode. Such responses promote integrity. Individuals and
CHAPTER 10 • Sister Callista Roy’s Adaptation Model 159
groups are viewed as adaptive systems that Theory Development for Practice
interact with the environment and grow,
change, develop, and flourish. Health is the re- To lead to middle-range theories within the
flection of personal and environmental inter- model, Roy identified the major life processes
actions that are adaptive. According to the Roy within each adaptive mode. For example, in
adaptation model, health is defined as (1) a the physiological mode, there are processes
process, (2) a state of being, and (3) becoming and patterns for the need for oxygenation that
whole and integrated in a way that reflects in- include ventilation, patterns of gas exchange,
dividual and environment mutuality. transport of gases, and compensation for inad-
equate oxygenation. Similarly, the self-concept
Goal of Nursing mode has three processes identified to meet the
person’s need for psychic and spiritual in-
When Roy began her theoretical work, the tegrity: the developing self, the perceiving self,
goal of nursing was the first major concept of and the focusing self. On the group level, two
her nursing model to be described. She began examples of processes identified to meet the
by attempting to identify the unique function need for a shared self-image are group shared
of nursing in promoting health. As a number identity and family coherence. The group iden-
of health-care workers have the goal of pro- tity mode reflects how people in groups perceive
moting health, it seemed important to iden- themselves based on environmental feedback
tify a unique goal for nursing. While she was about the group. Persons in a group have per-
working as a staff nurse in pediatric settings, ceptions about their shared relations, goals,
Roy noted the great resiliency of children in and values. The social milieu and the culture
responding to major physiological and psy- provide feedback for the group. The social mi-
chological changes. Yet nursing intervention lieu refers to the human-made environment in
was needed to support and promote this pos- which the group is embedded, including eco-
itive coping. It seemed, then, that the con- nomic, political, religious, and family struc-
cept of adaptation, or positive coping, might tures. Ethnicity and socioeconomic status in
be used to describe the goal or function of particular make up the social culture, a specific
nursing. From this initial notion, Roy devel- part of the milieu or environment of the group.
oped a description of the goal of nursing: the
promotion of adaptation for individuals and The belief systems of the milieu and social
groups in each of the four adaptive modes, culture act as stimuli for the group and also affect
thus contributing to health, quality of life, other groups with which the group interacts. The
and dying with dignity. family is most often the first group with which a
person identifies. The group self-image and
Basis for Practice—Theory and Process shared responsibility for goal achievement is
central to group identity. Identity integrity is the
The assumptions and concepts of the model basic need underlying the group identity mode.
provide the basis for theory building for Nursing care uses the understanding of these
nursing practice, as well as a specific ap- processes to evaluate the adaptation level and to
proach to the nursing process. As early as provide care to promote integrated processes at
the 1970s, human life processes and patterns the highest level of adaptation possible.
were identified as the common focus of
nursing knowledge (Donaldson & Crowley, To develop knowledge for practice from the
1978). In a more recent article, a central uni- grand theory, Roy described a five-step process
fying focus of nursing has extended this view for developing middle or practice level theory
to include nursing concepts categorized as fa- and nursing knowledge:
cilitating humanization, meaning, choice,
quality of life, and healing, living, and dying 1. Select a life process.
(Willis, Grace, & Roy, 2008). Adaptation is 2. Study the life process in the literature and
a significant life process that leads to these
ideals. in people.
3. Develop an intervention strategy to en-
hance the life process.
160 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
4. Derive a proposition for practice. however, the process is ongoing and the steps
5. Test the proposition in research. can be simultaneous. For example, the nurse
may be intervening in one adaptive mode and
Processes can also be identified by using assessing in another at the same time.
qualitative research to identify and describe
human experiences. Applications of the Theory
Nursing Process for Care Senesac (2003) reviewed published projects
that have implemented the Roy adaptation
The nursing process based on the model stems model in institutional practice settings and
from the assumptions and concepts of the identified seven distinct projects ranging from
model. First-level assessment of behavior in- an ideology basis for a single unit to hospital-
volves gathering data about the behavior of the wide projects. In some cases the published proj-
person or group as an adaptive system in each ect developed from a unit implementation to a
of the adaptive modes. Second-level assess- full agency implementation, as in one of the
ment is the assessment of stimuli, that is, the early projects reported by Mastal et al. (1982).
identification of internal and external stimuli Gray (1991) discussed involvement in five proj-
that influence the adaptive behaviors. Stimuli ects. She reported that not all implementation
are classified as focal, contextual, and residual. projects were completed due to changes in hos-
The nurse uses the first- and second-level as- pital management, philosophy, or direction.
sessment to make a nursing judgment called a
nursing diagnosis. In collaboration with the Gray’s initial work was at a 132-bed acute
person or group, the data are interpreted in care, not-for-profit children’s hospital. Other
statements about the adaptation status of the projects varied from a 100-bed proprietary hos-
person, including behavior and most relevant pital to a 248-bed nonprofit, community-owned
stimuli. The adaptation level is then classified hospital. The main focus of the implementation
as integrated, compensatory, or compromised. projects was to improve patient care through
quality nursing care plans and in some cases to
Also, in collaboration with the person or develop performance standards. Two implemen-
group, the nurse sets goals, establishing clear tation projects in Colombia were reported on by
statements of the behavioral outcomes for nurs- Moreno-Ferguson and Alvarado-Garcia (2009).
ing care. Interventions then involve the deter- One project was in an ambulatory rehabilitation
mination of how best to assist the person in service (Moreno-Ferguson, 2001) and the other
attaining the established goals. These may in- a pediatric intensive care unit of a cardiology in-
volve changing stimuli or strengthening coping stitute (Monroy, 2003). As hospitals in the
ability. The aim is to promote an integrated United States work toward certification of Mag-
adaptation level. Evaluation involves judging the net Status, more nursing groups are requesting
effectiveness of the nursing intervention in rela- information about application of the Roy adap-
tion to the resulting behavior in comparison with tation model in institutional health-care settings.
the goal established. The steps of the nursing
process have been given in sequential order;
Practice Exemplar
Family coherence is an indicator of positive the health and social services system, health-
adaptation and refers to a state of unity or a care decision making, the availability of social
consistent sequence of thought that connects support for caregivers, and may have implica-
family members who share group identity, tions for the psychosocial experience of family
goals, and values (Roy, 2009). When interact- caregivers and the clients. Roy’s group identity
ing with families of other cultures, health-care mode provides a useful conceptual framework
providers need to assess cultural norms and be- that guides health-care providers working with
liefs that determine patterns of interaction with families of diverse ethnic backgrounds.
CHAPTER 10 • Sister Callista Roy’s Adaptation Model 161
Practice Exemplar cont. David provides primary financial support
for his family. As his mother’s cognitive func-
Introduction to the Practice tion deteriorated, David became overwhelmed
Exemplar—the Wang Family by caring for his mother while being respon-
sible for managing the restaurant. His wife
The Wang family includes David Wang; his quit her job to attend to her mother-in-law’s
wife, Teresa Wang; their 7-year old daughter, care. When David and his wife tried to find
Vivian Wang; and extended family including someone in the Chinese community to pro-
David’s mother, Uncle Frank Wang; his vide respite care for their mother, they heard
daughter Lisa Wang, 32; and her husband some strong negative reactions. Some consid-
and their 5-year-old son (Zhan, 2003). ered his mother’s dementia as “insanity” or “a
David’s parents immigrated to the United mental disorder.” Some talked about dementia
States when he was ten years old. The Wang as contagious or believed his mother’s demen-
family opened a small Chinese restaurant, tia was being caused by bad Feng Shui, an an-
which David has managed since his father’s cient Chinese belief in which Feng (the force
retirement. David’s parents participate regu- of wind) and Shui (the flow of water) are
larly in activities organized by Chinatown’s viewed as living energies that flow around
Council on Aging. one’s home and affect one’s life and well-
being. If Feng Shui flows gently and peacefully,
David and his parents have a shared self- it brings happiness and health to one’s family.
image as Chinese immigrants and a shared If Feng Shui stagnates, one can be ill, poor, and
group identity as the Wang family. The Wang unfortunate (Beattie, 2000). The perception
family shares a strong cultural commitment to of dementia triggered a strong negative re-
the value of filial piety. To family members, sponse from the Chinese community, and his
this means to be good to one’s parents and mother’s friends stopped visiting her. David’s
take care of them; to engage in good conduct daughter began to miss school, and her grades
and bring a good name to parents and ances- were declining. Both David and his wife were
tors; to perform one’s job well to support par- feeling overwhelmed and depressed.
ents and carry out sacrifices to the ancestors;
and to show love, respect, and support. The Analysis of the Practice Exemplar
term filial denotes the respect and obedience
that a child, primarily a son, should show to In the case of the Wang family, the focus of
his parents, especially to his father. nursing practice is on the relational system of
the family. To begin planning nursing care,
David’s father suffered a stroke and died at the family is addressed as an adaptive system.
the age of 78. His mother began to show de- Assessment of behaviors
cline in memory, experiencing difficulty find- The nurse met with David and Teresa to assess
ing her way in familiar places, misplacing family structure, function, relationships, and
objects, becoming disoriented and easily irri- consistency, and their employment status, liv-
tated. David took his mother for a physical ing arrangements, and the division of family
examination; she was diagnosed as having caregiving responsibilities. The nurse assessed
dementia and referred to a specialist. Recog- how decisions are made in the family, from
nizing that his mother was unable to live small daily decisions to larger, health-care-
independently, David arranged for her to live related decisions. The nurse observed that
with his family. David and his wife took on David and his wife show love, respect, and
the family caregiver role while trying to keep loyalty to David’s mother and to each other.
their respective jobs. David’s cousin visited Although the mother’s needs for care are met,
them regularly and helped with household individual needs of both David and his wife,
chores. David was glad that he was able to
keep the family together despite the passing of Continued
his father and the cognitive impairment of his
mother.
162 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Practice Exemplar cont. orientations by sharing their thinking and feel-
ings. David and his wife openly share their
Teresa are unmet. Alternating care for David’s feelings and frustrations. Lisa and her father
mother, maintaining their jobs, and attending express their willingness to share responsibility
to Vivian’s schoolwork and growth needs is and help out.
challenging. The nurse finds out that the Goal setting
Wang family holds a strong Chinese tradition At the next meeting, the nurse helps the
of filial piety and that they feel a moral obliga- Wang family set up attainable short-term
tion to take care of their mother. The strong goals based on shared cognitive and emotional
stigma attached to dementia in the Chinese orientations and common values. Attaining
community takes an emotional toll on them. goals requires shared responsibilities and some
Assessment of stimuli division of labor. Their goals include (1) work-
The nurse conducts a second level of assess- ing together with home health aides; (2) sup-
ment by meeting with the extended Wang porting each other through shared feelings and
family to identify influencing factors, or stim- thoughts and the shared responsibilities of
uli, related to group identity and family coher- caregiving based on each individual’s desire,
ence. The major stimuli are the demands they skill, and availability; and (3) communicating
face and the problems posed for them to solve. with the Chinese community about the stigma
David’s mother requires medical and personal toward dementia and finding ways to demys-
care. David needs to work to ensure health in- tify dementia.
surance for his family and to secure income
to pay for the cost of personal care. Finding The Wang family decides to have Lisa
Chinese-speaking home health aides is chal- Chang, a social worker in a community hospi-
lenging. The social stigma toward dementia is tal, lead the search for home health aides.
strong in the Chinese community, bringing David Wang convenes family meetings as
shame to the Wang family and isolating needed, and Frank Wang leads the talk with
David’s mother from her ethnic community. key players in the Chinese community. Despite
The Wang family agrees that the stigma and the stressors they have encountered, family
reaction from the external social environment members feel a sense of unity through com-
have become stressors to family caregiving. pensatory adaptation process.
Nursing diagnosis Intervention
The nurse identifies three tentative diagnoses. Nursing intervention involves focusing on the
First, the Wang family has a strong ethnic her- stimuli affecting the behavior and managing
itage related to the group’s responsibility to the stimuli by altering, increasing, or decreas-
maintain values and goals. Second, family con- ing, removing, or maintaining stimuli. The
flict exists as the demands of family caregiving nurse (1) assesses the Wang family with re-
for the mother increase. Third, strong stigma spect to shared values, shared goals, shared re-
attached to dementia in the Chinese commu- lations, group identify, and social environment
nity creates prejudice against the Wang family and stimuli; (2) works with the Wang family
and causes some family members to feel dis- to write down shared goals, values, and expec-
tressed and ambivalent. tations; and (3) encourages the family to ex-
plore additional resources. The nurse also helps
The nurse continues to assess behaviors of the Wang family to use effective coping strate-
shared identity and cohesion in the Wang gies to strengthen compensatory processes by
family, looking for common perceptions, feel- acknowledging that the family is transcending
ings, and experiences of caregiving for the the crisis, identifying additional resources in
loved one with dementia. The nurse learns that support of family caregiving, and by reinforc-
David, as the only son, has a moral responsi- ing their shared goals, values, relations, and
bility to care for his mother and considers group identity.
himself solely responsible. The nurse asks each
member of the Wang family to find common
CHAPTER 10 • Sister Callista Roy’s Adaptation Model 163
Practice Exemplar cont. and how caregiving is supported. To reduce
stigma in promotion of effective adaptation
Evaluation of family caregivers and health-care providers,
The nurse evaluates the effectiveness of the families and the community need to work
nursing intervention. Lisa Chang called her together toward better understanding of
social work network and found appropriate dementia, its diagnosis, treatment, and care
home health aides to provide personal care to options. Educational and service outreach is
David’s mother. This allows David to attend the first step to reduce the stigma in the
to his work and allows his wife to spend more Chinese community. Educational materials
time with their daughter, attending to her and service need to be linguistically appropri-
schoolwork and personal needs. Vivian has not ate and adaptable to Chinese patients and
been absent from school again. their families. Elderly Chinese immigrants
often read Chinese newspapers to connect
David Wang hired a manager to help op- themselves to their culture and people. Pub-
erate the restaurant so that he has time to take lishing dementia information and related
his mother to appointments and to maintain educational articles in widely circulated
a stable income. David’s mother’s old friend Chinese newspapers is a way to reach out to
visited her briefly. Frank Wang, an activist in Chinese families. Bilingual professional staff
the Chinese community, began to talk with and linguistically appropriate oral and written
other Chinese about dementia. instructions on dementia are helpful (Valle,
1998).
The strong stigma attached to dementia
in the Chinese community influenced the Reprinted from: Roy, C. & Zhan, l. (2010).
adaptation problem experienced by the Sister Callista Roy’s Adaptation Model. In Nurs-
Wang family. Social stigma can be pervasive, ing Theories and Nursing Practice (3rd. Ed.).
distorting the perceptions of individuals,
affecting the perception of a disease and how
a dementia diagnosis and services are sought,
■ Summary
This chapter focused on the Roy adaptation middle- and practice-level theory that is tested
model as a foundation for knowledge-based in research. In particular, the effects of the Roy
practice. The background of the theorist and adaptation model on practice were articulated
the historical development of the model were from a general summary of major practice
presented briefly. Roy’s most recent theoretical projects and through a practice exemplar. The
developments were the main focus of the de- exemplar illustrates the use of the self-identity
scription of the model assumptions and major adaptive mode as an example of using theory-
concepts (. The process for theory becoming based knowledge to provide care for a Chinese
the basis for developing knowledge for practice family dealing with a parent diagnosed with
was introduced by outlining how to develop dementia.
References Buckner, E. B., & Hayden, S. (2014). Synthesis of
middle range theory of adapting in chronic health
Beattie, A. (2000). Using Feng Shui. Vancouver: conditions. In C. Roy with the Roy Adaptation
Raincoast Books. Association, Generating middle range theory: Evidence
for practice (pp. 277–308). New York, NY: Springer
Boston-Based Adaptation Research in Nursing Society. Publishing Company.
(1999). Roy adaptation model-based research: 25 years
of contributions to nursing science. Indianapolis, IN:
Centre Nursing Press.
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Donaldson, S. K., & Crowley, D. (1978). The discipline Roy, S. C. (2011a). Extending the Roy adaptation model
of nursing. Nursing Outlook, 26, 113–120. to meet changing global needs. Nursing Science
Quarterly, 24(4), 345–351. nsq.sagepub.com
Gray, J. (1991). The Roy adaptation model in nursing
practice. In C. Roy & H. A. Andrews (Eds.), Roy, S. C. (2011b). Research based on the Roy adapta-
tion model: Last 25 years. Nursing Science Quarterly,
The Roy adaptation model: The definitive statement 24(4), 312–320. nsq.sagepub.com
(pp. 429–443). Norwalk, CT: Appleton & Lange.
Helson, H. (1964). Adaptation level theory. New York: Roy, C.with the RAA. (Ed.). (2014). Generating middle
Harper & Row. range theory: Evidence for practice. New York, NY:
Mastal, M. F., Hammond, H., & Roberts, M. P. Springer Publishing Company.
(1982). Theory into hospital practice: A pilot imple-
mentation. The Journal of Nursing Administration, 12, Roy, C., & Andrews, H. A. (1991). The Roy adaptation
9–15. model: The definitive statement. East Norwalk, CT:
Monroy, P. (2003). Aproximación a la experiencia de Appleton & Lange.
aplicación del Modelo de Callista Roy en la Unidad
de cuidado intensivo pediátrico. Enfermería Hoy, Roy, C., & Andrews, H. A. (1999). The Roy adaptation
1(1), 17–20. model (2nd ed.). Stamford, CT: Appleton & Lange.
Moreno-Ferguson, M. E. (2001). Aplicacion del modelo
de adaptacion en un servicio de rehabilitacion ambu- Roy, C., & Jones, D. (Eds.). (2007). Nursing knowledge
latoria, Aquichan, 1(1), 14–17. development and clinical practice. New York: Springer.
Moreno-Ferguson, M. E., & Alvardo-Garcia, A. M.
(2009). Aplicacion del modelo de adaptacion de Roy, C., & Roberts, S. (1981). Theory construction in
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literatura. Aquichan, 9(1), 62–72. Prentice-Hall.
Roy, C. (1970). Adaptation: A conceptual framework
for nursing. Nursing Outlook, 18, 42–45. Roy, C., Whetsell, M.V., & Frederickson, K. (2009).The
Roy, C. (1984). Introduction to nursing: An adaptation Roy adaptation model and research: Global Perspec-
model (2nd ed.). Englewood Cliffs, NJ: Prentice- tive Nursing Science Quarterly, 22(3), 209–211.
Hall.
Roy, C. (1988a). Altered cognition: An information Senesac, P. (2003). Implementing the Roy adaptation
processing approach. In P. H. Mitchell, L. C. model: From theory to practice. Roy Adaptation
Hodges, M. Muwaswes, & C. A. Walleck (Eds.), Association Review, 4(2), 5.
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Human responses to neurological health problems (pp. dementing illness and ethnically diverse populations.
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Betty Neuman’s Systems 11Chapter
Model
LOIS WHITE LOWRY AND Introducing the Theorist
PATRICIA DEAL AYLWARD
Betty Neuman developed the Neuman systems
Introducing the Theorist model (NSM) in 1970 to “provide unity, or a
Overview of the Neuman Systems Model focal point, for student learning” (Neuman,
2002b, p. 327) at the School of Nursing, Uni-
Applications of the Theory versity of California at Los Angeles (UCLA).
Practice Exemplar Neuman recognized the need for educators
Summary and practitioners to have a framework to view
References nursing comprehensively within various con-
texts. Although she developed the model
Betty Neuman strictly as a teaching aid, it is now used globally
as a nursing conceptual model to guide cur-
riculum development, research studies, and
clinical practice in the full array of health-care
disciplines.
Neuman’s autobiography, touched on
briefly here, is presented more fully in the lat-
est edition of her book focusing on the model
(Neuman & Fawcett, 2011). Neuman was
born in southeastern Ohio on a 100-acre fam-
ily farm on September 11, 1924. Her father
died at age 37 when she was 11, and she, her
mother, and two brothers worked hard to keep
the farm.
Neuman idealized nursing because her fa-
ther had praised nurses during his 6 years of
intermittent hospitalizations. In gratitude, she
developed a strong commitment to become an
excellent bedside nurse. She also attributed her
decisions about her life’s work to the important
influence of her mother’s charity experiences
as a self-taught rural midwife.
Betty Neuman graduated from high school
soon after the onset of World War II. Al-
though she had dreamed of attending nearby
Marietta College, she lacked the financial
means and instead became an aircraft instru-
ment repair technician. After the Cadet Nurse
165
166 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Corps Program became available, she entered possible harm from internal and external stres-
the 3-year diploma nurse program at People sors, while caregivers and clients form a partner-
Hospital, Akron, Ohio (currently General ship relationship to negotiated desired outcome
Hospital Medical Center). goals for optimal health retention, restoration,
and maintenance. This philosophic base pervades
She completed her baccalaureate degree in all aspects of the model.
nursing and earned a master’s degree, with a —BETTY NEUMAN (2002c, p. 12)
major in public health nursing, from UCLA.
During her master’s program, she worked on As its name suggests, the Neuman systems
special projects, as a relief psychiatric head model is classified as a systems model or a sys-
nurse and as a volunteer crisis counselor. Be- tems category of knowledge. Neuman (1995)
cause of these experiences, Neuman became defined system as a pervasive order that holds
one of the first California Nurse Licensed together its parts. With this definition in
Clinical Fellows of the American Association mind, she writes that nursing can be readily
of Marriage and Family Therapy. conceptualized as a complete whole, with
identifiable smaller wholes or parts. The com-
In 1967, Neuman became a faculty member plete whole structure is maintained by interre-
at UCLA and assumed the role of chair of the lationships among identifiable smaller wholes
program from which she had graduated. She or parts through regulations that evolve out of
expanded the master’s program, focusing on the dynamics of the open system. In the system
interdisciplinary practice in community mental there is dynamic energy exchange, moving ei-
health. ther toward or away from stability. Energy
moves toward negentropy, or evolution, as a
In 1970, she developed the NSM as a guide system absorbs energy to increase its organiza-
for graduate nursing students. The model was tion, complexity, and development when it
first published in the May–June 1972 issue of moves toward a steady or wellness state. An
Nursing Research. Since 1980, several impor- open system of energy exchange is never at
tant changes have enhanced the model. A rest. The open system tends to move cyclically
nursing process format was designed, and in toward differentiation and elaboration for fur-
1989, Neuman introduced the concepts of the ther growth and survival of the organism.
created environment and the spiritual variable. With the dynamic energy exchange, the sys-
In collaboration with Dr. Audrey Koertve- tem can also move away from stability. Energy
lyessy, Neuman developed a theory of client can move toward extinction (entropy) by grad-
system stability. Along with the Neuman Sys- ual disorganization, increasing randomness,
tems Trustees Group, she continues to clarify and energy dissipation.
concepts and components of the model.
The NSM illustrates a client–client system
Neuman completed a doctoral degree in clin- and presents nursing as a discipline concerned
ical psychology in 1985 from Pacific Western primarily with defining appropriate nursing
University. She received honorary doctorates actions in stressor-related situations or in pos-
from Neumann College in Aston, Pennsylvania, sible reactions of the client–client system. The
and Grand Valley State University in Allendale, client and environment may be positively or
Michigan. She is an honorary fellow in the negatively affected by each other. There is a
American Academy of Nursing. tendency within any system to maintain a
steady state or balance among the various dis-
Overview of the Neuman ruptive forces operating within or upon it.
Systems Model Neuman has identified these forces as stressors
and suggests that possible reactions and actual
The philosophic base of the Neuman Systems reactions with identifiable signs or symptoms
Model encompasses wholism, a wellness orienta- may be mitigated through appropriate early in-
tion, client perception and motivation, and a dy- terventions (Neuman, 1995).
namic systems perspective of energy and variable
interaction with the environment to mitigate
Unique Perspectives of the Neuman CHAPTER 11 • Betty Neuman’s Systems Model 167
Systems Model
6. The client, whether in a state of wellness or
Neuman (2002c, p. 14; 2011a, p. 14) has iden- illness, is a dynamic composite of the inter-
tified 10 unique perspectives inherent within relationships of variables—physiological,
her model. They describe, define, and connect psychological, sociocultural, developmental,
concepts essential to understanding the con- and spiritual. Wellness is on a continuum
ceptual model that is presented in the next sec- of available energy to support the system in
tion of this chapter. an optimal state of system stability.
1. Each individual client or group as a client 7. Implicit within each client system are in-
system is unique; each system is a compos- ternal resistance factors known as lines of
ite of common known factors or innate resistance, which function to stabilize and
characteristics within a normal, given return the client to the usual wellness
range of response contained within a basic state (normal line of defense) or possibly
structure. to a higher level of stability after an envi-
ronmental stressor reaction.
2. The client as a system is in a dynamic, con-
stant energy exchange with the environment. 8. Primary prevention relates to general
knowledge that is applied in client assess-
3. Many known, unknown, and universal en- ment and intervention in identification
vironmental stressors exist. Each differs in and reduction or mitigation of possible
its potential for disturbing a client’s usual or actual risk factors associated with envi-
stability level, or normal line of defense. ronmental stressors to prevent possible
The particular interrelationships of client reaction. The goal of health promotion
variables—physiological, psychological, so- is included in primary prevention.
ciocultural, developmental, and spiritual—
at any point in time can affect the degree 9. Secondary prevention relates to sympto-
to which a client is protected by the flexi- matology after a reaction to stressors,
ble line of defense against possible reaction appropriate ranking of intervention
to a single stressor or a combination of priorities, and treatment to reduce their
stressors. noxious effects.
4. Each individual client–client system has 10. Tertiary prevention relates to the adaptive
evolved a normal range of response to the processes taking place as reconstitution
environment that is referred to as a normal begins and maintenance factors move the
line of defense, or usual wellness/stability client back in a circular manner toward
state. It represents change over time through primary prevention.
coping with diverse stress encounters. The
normal line of defense can be used as a The Conceptual Model
standard from which to measure health
deviation. Neuman’s original diagram of her model is illus-
trated in Figure 11-1. The conceptual model was
5. When the cushioning, accordion-like ef- developed to explain the client–client system as
fect of the flexible line of defense is no an individual person for the discipline of nursing.
longer capable of protecting the client– Neuman chose the term client to show respect for
client system against an environmental collaborative relationships that exist between the
stressor, the stressor breaks through the client and the caregiver in Neuman’s model, as
normal line of defense. The interrelation- well as the wellness perspective of the model. The
ships of variables—physiological, psycho- model can be applied to an individual, a group,
logical, sociocultural, developmental, and a community, or a social issue and is appropri-
spiritual—determine the nature and degree ate for nursing and other health disciplines
of system reaction or possible reaction to (Neuman, 1995, 2002c, 2011a, p.15).
the stressor.
The NSM provides a way of looking at the
domain of nursing: humans, environment,
health, and nursing.
168 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Stressors Basic structure
Identified Basic factors common to
Classified as knowns all organisms, i.e.:
or possibilities, i.e., Normal temperature
Loss range
Pain Genetic structure
Sensory deprivation
Cultural change Stressor Response pattern
Organ strength or
Inter Personal Stressor weakness
Intra factors Ego structure
Extra Knowns or commonalities
Flexible Line of Defense
Primary prevention Normal LoifnReeosfisDtaenfecnese
Reduce possibility of Lines
encounter with stressors
Strengthen flexible line Degree of BASIC
of defense Reaction STRUCTURE
Secondary prevention ENERGY
Early case-finding and RESOURCES
Treatment of symptoms
Reaction Reconstitution
Tertiary prevention Stressors
Readaptation More than one stressor
Reeducation to prevent could occur
future occurrences simultaneously*
Maintenance of stability Same stressors could vary
as to impact or reaction
Reaction Normal defense line varies
Individual intervening with age and development
variables, i.e.:
Basic structure NOTE:
idiosyncrasies
Natural and learned *Physiological, psychological,
resistance sociocultural, developmental, and
Time of encounter spiritual variables are considered
with stressor simultaneously in each client
concentric circle.
Inter Personal Reconstitution
Intra factors Could begin at any degree
Extra or level of reaction
Range of possibility may
Interventions extend beyond normal line
Can occur before or after resistance of defense
lines are penetrated in both reaction
and reconstitution phases Inter Personal
Interventions are based on: Intra factors
Degree of reaction Extra
Resources
Goals
Anticipated outcome
Fig 11 • 1 The Neuman systems model. (Original diagram copyright 1970 by Betty Neuman. A holistic
view of a dynamic open client–client system interacting with environmental stressors, along with client
and caregiver collaborative participation in promoting an optimum state of wellness.) (From Neuman, 1995,
p. 17, with permission.)
Client–Client System CHAPTER 11 • Betty Neuman’s Systems Model 169
The client–client system (see Fig. 11-1) con- Flexible Line of Defense
sists of the flexible line of defense, the nor-
mal line of defense, lines of resistance, and Stressors must penetrate the flexible line of de-
the basic structure energy resources (shown fense before they are capable of penetrating the
at the core of the concentric circles in rest of the client system. Neuman described
Fig. 11-2). Five client variables—physiological, this line of defense as accordion-like in func-
psychological, sociocultural, developmental, and tion. The flexible line of defense acts like a pro-
spiritual—occur and are considered simulta- tective buffer system to help prevent stressor
neously in each concentric circle that makes invasion of the client system and protects the
up the client–client system (Neuman, 1995, normal line of defense. The client has more
2002c, 2011a). protection from stressors when the flexible line
expands away from the normal line of defense.
Basic structure The opposite is true when the flexible line
Basic factors common to moves closer to the normal line of defense. The
all organisms, i.e.: effectiveness of the buffer system can be re-
Normal temperature duced by single or multiple stressors. The flex-
range ible line of defense can be rapidly altered over
Genetic structure a relatively short time period by states of emer-
Response pattern gency, or short-term conditions, such as loss of
Organ strength or sleep, poor nutrition, or dehydration (Neuman,
weakness 1995, 2002c; 2011a, p. 17). Consider the latter
Ego structure examples. What are the effects of short-term
Knowns or commonalities loss of sleep, poor nutrition, or dehydration on
a client’s normal state of wellness? Will these
Flexible Line of Defense situations increase the possibility for stressor
NoLrmineasl LoifnRe eosfiDsteafnecnese penetration? The answer is that the possibility
for stressor penetration may be increased. The
BASIC actual response depends on the accordion-like
STRUCTURE function previously described, along with the
other components of the client system.
ENERGY
RESOURCES Normal Line of Defense
NOTE: The normal line of defense represents what the
Physiological, psychological, sociocultural, client has become over time, or the usual state
developmental, and spiritual variables occur of wellness. The nurse should determine the
and are considered simultaneously in each client’s usual level of wellness to recognize a
client concentric circle. change. The normal line of defense is consid-
ered dynamic because it can expand or contract
Fig 11 • 2 Client–client system. The structure of over time. The usual wellness level or system
the client-client system, including the five vari- stability can decrease, remain the same, or im-
ables that are occurring simultaneously in each prove after treatment of a stressor reaction. The
client concentric circle. (From Neuman, 1995, p. 26, normal line of defense is dynamic because of
with permission.) its ability to become and remain stabilized with
life stressors over time, protecting the basic
structure and system integrity (Neuman, 1995,
2002c, 2011, p. 18).
Lines of Resistance
Neuman identified the series of concentric
broken circles that surround the basic structure
170 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
as lines of resistance for the client. When the Developmental: Refers to life-developmental
normal line of defense is penetrated by environ- processes
mental stressors, a degree of reaction, or signs
and/or symptoms, will occur. Each line of re- Spiritual: Refers to spiritual beliefs and
sistance contains known and unknown internal influence
and external resource factors. These factors sup-
port the client’s basic structure and the normal Neuman elaborated that the spiritual vari-
line of defense, resulting in protection of system able is an innate component of the basic
integrity. Examples of the factors that support structure. Although it may or may not be ac-
the basic structure and normal line of defense knowledged or developed by the client or client
include the body’s mobilization of white blood system, Neuman views the spiritual variable as
cells and activation of the immune system being on a continuum of development that
mechanisms. There is a decrease in the signs or penetrates all other client system variables and
symptoms, or a reversal of the reaction to stres- supports the client’s optimal wellness. The
sors, when the lines of resistance are effective. client–client system can have a complete lack of
The system reconstitutes itself, and system sta- awareness of the spiritual variable’s presence and
bility is returned. The level of wellness may be potential, deny its presence, or have a conscious
higher or lower than it was before the stressor and highly developed spiritual understanding
penetration. When the lines of resistance are in- that supports the client’s optimal wellness.
effective, energy depletion and death may occur
(Neuman, 1995, 2002c, 2011a, p. 18). Neuman explained that the spirit controls
the mind, and the mind consciously or uncon-
Basic Structure sciously controls the body. She used an analogy
of a seed to clarify this idea.
The basic structure or central core consists
of factors that are common to the human It is assumed that each person is born with
species. Neuman offered the following exam- a spiritual energy force, or “seed,” within the
ples of basic survival factors: temperature spiritual variable, as identified in the basic struc-
range, genetic structure, response pattern, ture of the client system. The seed or human
organ strength or weakness, ego structure, and spirit with its enormous energy potential lies on
knowns or commonalities (Neuman, 1995, a continuum of dormant, unacceptable, or un-
2002c, 2011a, p. 16). developed to recognition, development, and
positive system influence. Traditionally, a seed
Five Client Variables must have environmental catalysts, such as tim-
ing, warmth, moisture, and nutrients, to burst
Neuman (1995, p. 28; 2002c, p. 17; 2011a, forth with the energy that transforms into a liv-
p. 16) identified five variables that are con- ing form that then, in turn, as it becomes fur-
tained in all client systems: physiological, psy- ther nourished and develops, offers itself as
chological, sociocultural, developmental, and sustenance, generating power as long as its own
spiritual. These variables are considered simul- source of nurture exists (Neuman, 2002c, p. 16;
taneously in each client concentric circle. They 2011, Box 1-1, p. 17).
are present in varying degrees of development
and in a wide range of interactive styles and po- The spiritual variable affects or is affected
tential. Neuman offers the following definitions by a condition and interacts with other vari-
for each variable: ables in a positive or negative way. Neuman
gave the example of grief or loss (psychologi-
Physiological: Refers to bodily structure and cal state), which may inactivate, decrease,
function initiate, or increase spirituality. There can
be movement in either direction of a contin-
Psychological: Refers to mental processes and uum (Neuman, 1995, 2002c, 2011a, p. 17).
relationships Neuman believes that spiritual variable con-
siderations are necessary for a truly holistic
Sociocultural: Refers to combined social and perspective and for a truly caring concern for
cultural functions the client–client system.
Fulton (1995) has studied the spiritual vari- CHAPTER 11 • Betty Neuman’s Systems Model 171
able in depth. She elaborated on research studies
that extend our understanding of the following • Created environment: Intra-, inter-, and
aspects of spirituality: spiritual well-being, spir- extrapersonal factors (Neuman, 1995, p. 31;
itual needs, spiritual distress, and spiritual care. 2002c, pp. 18–19; 2011a, pp. 20–21)
She suggested that spiritual needs include (1) the
need for meaning and purpose in life, (2) the The internal environment consists of all
need to receive love and give love, (3) the need forces or interactive influences contained
for hope and creativity, and (4) the need for for- within the boundaries of the client–client
giving, trusting relationships with self, others, system. Examples of intrapersonal forces are
and God or a deity or a guiding philosophy. presented for each variable.
Environment • Physiological variable: autoimmune re-
sponse, degree of mobility, range of body
A second concept identified by Neuman is the function
environment, as illustrated in Figure 11-3. She
defined environment broadly as “all internal • Psychological and sociocultural variables:
and external factors or influences surrounding attitudes, values, expectations, behavior pat-
the identified client or client system” (Neu- terns, coping patterns, conditioned responses
man, 1995, p. 30; 2002c, p. 18; 2011,
pp. 20–21), including: • Developmental variable: age, degree of nor-
malcy, factors related to the present situation
• Internal environment: intrapersonal factors
• External environment: Inter- and extraper- • Spiritual variable: hope, sustaining forces
(Neuman, 1995; 2002c; 2011, p. 17)
sonal factors
The external environment consists of all
forces or interactive influences existing out-
side the client–client system. Interpersonal
factors in the environment are forces between
Stressors Stressor Stressor Basic structure
Identified Basic factors common to
Classified as knowns Flexible Line of Defense all organisms, i.e.:
or possibilities, i.e.: Normal temperature
Loss NoLrimneasl LoifnReeosfisDtaenfecnese range
Pain Genetic structure
Sensory deprivation Response pattern
Cultural change Organ strength or
weakness
Ego structure
Knowns or commonalities
Inter Personal
Intra factors
Extra
BASIC
STRUCTURE
ENERGY
RESOURCES
Stressors
More than one stressor
could occur simultaneously
Same stressors could vary
as to impact or reaction
Normal defense line varies
with age and development
Fig 11 • 3 Environment. Internal and external factors surrounding the client–client system. (From Neuman,
1995, p. 27, with permission.)
172 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
people or client systems. These factors recognizes the value of the client-created
include the relationships and resources of environment and purposefully intervenes, the
family, friends, or caregivers. Extrapersonal interpersonal relationship can become one of
factors include education, finances, employ- important mutual exchange (Neuman, 1995,
ment, and other resources (Neuman, 1995, 2002c, 2011a). de Kuiper (2011) added her
2002c). perspective of the created environment and
guidelines for nursing practice.
Neuman (1995, 2002c, 2011a, pp. 20–21)
identified a third environment as the “created Health
environment.” The client unconsciously mo-
bilizes all system variables, including the Health is a third concept in Neuman’s model.
basic structure of energy factors, toward sys- She believes that health (or wellness) and ill-
tem integration, stability, and integrity to ness are on opposite ends of the continuum.
create a safe environment. This safe, created Health is equated with optimal system stability
environment offers a protective perceptive (the best possible wellness state at any given
coping shield that helps the client to func- time). Client movement toward wellness exists
tion. A major objective of this environment when more energy is built and stored than ex-
is to stimulate the client’s health. Neuman pended. Client movement toward illness and
pointed out that what was originally created death exists when more energy is needed than
to safeguard the health of the system may is available to support life. The degree of well-
have a negative effect because of the binding ness depends on the amount of energy required
of available energy. This environment repre- to return to and maintain system stability. The
sents an open system that exchanges energy system is stable when more energy is available
with the internal and external environments. than is being used. Health is seen as varying
The created environment supersedes or goes levels within a normal range, rising and falling
beyond the internal and external environ- throughout the life span. These changes are in
ments while encompassing both; it provides response to basic structure factors and reflect
an insulating effect to change the response satisfactory or unsatisfactory adjustment by
or possible response of the client to environ- the client system to environmental stressors
mental stressors. Neuman (1995, 2002c, (Neuman, 1995, 2002c, 2011a, p. 23).
2011) gave the following examples of re-
sponses: use of denial or envy (psychological), Nursing
physical rigidity or muscle constraint (physi-
ological), life-cycle continuation of survival Nursing is a fourth concept in Neuman’s model
patterns (developmental), required social and is depicted in Figure 11-4. Nursing’s major
space range (sociocultural), and sustaining concern is to keep the client system stable by
hope (spiritual). (1) accurately assessing the effects and possible
effects of environmental stressors and (2) as-
Neuman believes the caregiver, through as- sisting client adjustments required for optimal
sessment, will need to determine (1) what has wellness. Nursing actions, which are called pre-
been created (nature of the created environ- vention as intervention, are initiated to keep the
ment), (2) the outcome of the created environ- system stable. Neuman created a typology for
ment (extent of its use and client value), and her prevention as intervention nursing actions
(3) the ideal that has yet to be created (the pro- that includes primary prevention as interven-
tection that is needed or possible, to a lesser or tion, secondary prevention as intervention, and
greater degree). This assessment is necessary to tertiary prevention as intervention. All of these
best understand and support the client’s created actions are initiated to best retain, attain, and
environment (Neuman, 1995, 2002c, 2011a). maintain optimal client health or wellness.
Neuman suggested that further research is Neuman (1995, 2002c) believes the nurse cre-
needed to understand the client’s awareness ates a linkage among the client, the environ-
of the created environment and its relationship ment, health, and nursing in the process of
to health. She believes that as the caregiver keeping the system stable.
CHAPTER 11 • Betty Neuman’s Systems Model 173
Primary prevention
Reduce possibility of
encounter with stressors
Strengthen flexible line
of defense
Secondary prevention Inter Personal
Early case-finding and Intra factors
Treatment of symptoms Extra
Tertiary prevention Interventions
Readaptation Can occur before or after resistance
Reeducation to prevent lines are penetrated in both reaction
future occurrences and reconstitution phases
Maintenance of stability Interventions are based on:
Degree of reaction
Resources
Goals
Anticipated outcome
Fig 11 • 4 Nursing. Accurately assessing the effects and possible effects of
environmental stressors (inter-, intra-, and extrapersonal factors) and using
appropriate prevention by interventions to assist with client adjustments for
an optimal level of wellness. (From Neuman, 1995, p. 29, with permission.)
Prevention as Intervention Once a reaction from a stressor occurs, the
nurse can use secondary prevention as inter-
The nurse collaborates with the client to estab- vention to treat the symptoms within the
lish relevant goals. These goals are derived only nurse’s scope of practice, reduce the degree of
after validating with the client and synthesiz- reaction to the stressors, and protect the basic
ing comprehensive client data and relevant structure by strengthening the lines of resist-
theory to determine an appropriate nursing di- ance. The goal of secondary prevention as in-
agnostic statement. With the nursing diagnos- tervention is to attain optimal client system
tic statement and goals in mind, appropriate stability or wellness and energy conservation.
interventions can be planned and implemented The nurse uses as much of the client’s existing
(Neuman, 1995, 2002c, 2011a, pp. 25–29). internal and external resources (lines of resist-
ance) as possible to stabilize the system.
Primary prevention as intervention involves
the nurse’s actions that promote client wellness Reconstitution represents the return and
by stress prevention and reduction of risk fac- maintenance of system stability after nursing
tors. These interventions can begin at any point intervention for stressor reaction. The state of
a stressor is suspected or identified, before a re- wellness may be higher, the same, or lower
action has occurred. They protect the normal than the state of wellness before the system
line of defense by reducing the possibility of an was stabilized. Death occurs when secondary
encounter with a stressor and strengthening prevention as intervention fails to protect the
the flexible lines of defense. Health promotion basic structure and thus fails to reconstitute the
is a significant intervention. The goal of pri- client (Neuman, 1995, 2002c).
mary prevention as intervention is to retain op-
timal stability or wellness. Ideally, the nurse Tertiary prevention as intervention can
should consider primary prevention along with begin at any point in the client’s reconstitu-
secondary and tertiary preventions as interven- tion. This includes interventions that pro-
tions when actual client problems exist. mote (1) readaptation, (2) reeducation to
174 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
prevent further occurrences, and (3) mainte- The Client Assessment and Nursing Diag-
nance of stability. These actions are designed nosis tool with primary, secondary, and tertiary
to maintain an optimal wellness level by sup- prevention as intervention was developed to
porting existing strengths and conserving convey appropriate nursing actions with each
client system energy. Tertiary prevention typology of prevention. There are clear instruc-
tends to lead back toward primary prevention tions for writing appropriate nursing actions
in a circular fashion. Neuman pointed out (Neuman, 2002a, p. 354; 2011b, pp. 343–350),
that one or all three of these prevention which students are encouraged to review
modalities give direction to, or may be used before writing these nursing actions. Keep in
simultaneously for, nursing actions with pos- mind that the nature of stressors and their
sible synergistic benefits (Neuman, 1995, threat to the client–client system are first de-
2002, 2011, pp. 28–29). termined for each type of prevention before
any other nursing actions are initiated. The
Nursing Tools for Model same stressors could produce variable effects or
Implementation reactions. Nursing outcomes are determined
by the accomplishment of the interventions
Neuman designed the NSM nursing process and evaluation of goals after intervention.
format and the NSM Assessment and Inter-
vention Tool: Client Assessment and Nursing Applications of the Theory
Diagnosis to facilitate implementation of the
Neuman model. These tools are presented in Because the model is flexible and adaptable to
all the editions of The Neuman Systems Model a wide range of groups and situations, people
(Neuman, 1982, 1989, 1995, 2002c; 2011a; have used it globally for more than three
Neuman & Lowry, 2011). decades. Neuman’s first book, The Neuman
Systems Model: Application to Nursing Education
The NSM nursing process format reflects a and Practice, was published in 1982 as a response
process that guides information processing and to requests for data and support in applying the
goal-directed activities. Neuman uses the nurs- model in practice settings and as a guide for
ing process within three categories: nursing di- entire nursing curricula. The second and third
agnosis, nursing goals, and nursing outcomes. In editions (1989, 1995) present examples of the
1982, doctoral students validated the Neuman use of the model in practice and education, pri-
nursing process format. The format’s validity and marily. The fourth edition (2002c) includes
social utility have been supported in a wide integrative reviews of practice, educational,
variety of nursing education and practice areas. and research literature and discussions of prac-
tice and educational tools. The fifth edition
The Neuman Systems Model Assessment (Neuman & Fawcett, 2011) continues the tra-
and Intervention Tool dition of including contributions that reflect the
broad applicability of the model. Guidelines and
The Client Assessment and Nursing Diagnosis available tools for NSM-based practice, educa-
tool is used to guide the nursing process. The tional programs, and research are summarized.
nurse collects holistic, comprehensive data to
determine the effect or possible effect of envi- Application of the Neuman Systems
ronmental stressors on the client system then Model to Nursing Practice
validates the data with the client before formu-
lating a nursing diagnosis. Selected nursing “The function of a conceptual model in nursing
diagnoses are prioritized and related to rele- practice is to provide a distinctive frame of ref-
vant knowledge. Nursing goals are determined erence that guides approaches to patient care”
mutually with the caregiver–client–client sys- (Amaya, 2002, p. 43). There is a critical need for
tem, along with mutually agreed on prevention meaningful definitions and conceptual frames of
as intervention strategies. Mutually agreed on reference for nursing practice if the profession is
goals and interventions are consistent with cur- to be established as a science (Neuman, 2002c).
rent mandates within the health-care system
for client rights related to health-care issues.
The NSM is being used in diverse practice CHAPTER 11 • Betty Neuman’s Systems Model 175
settings globally such as critical care nursing,
psychiatric mental health nursing, gerontolog- long, the potential of using the model for cur-
ical nursing, perinatal nursing, community riculum development was recognized at all
nursing, occupational health nursing, rehabil- levels of nursing education in the United
itation, and advanced nursing practice (Amaya, States, Canada, and globally. The NSM was
2002; Bueno & Sengin, 1995; Chiverton selected because it is a systems approach, com-
& Flannery, 1995; McGee, 1995; Peirce & prehensive, and holistic and focuses on health
Fulmer, 1995; Groesbeck, 2011; Merks, van and prevention. Programs adopting the model
Tilburg, & Lowry, 2011; Russell, Hileman, in the 1980s used it in its entirety. Through
& Grant, 1995; Stuart & Wright, 1995; the years, some programs moved to a more
Trepanier, Dunn, & Sprague, 1995; Ware & eclectic approach that combines the model
Shannahan, 1995). concepts of stress, systems, and primary pre-
vention with concepts from other models.
The model is used to guide practice in clients Appendix F in Neuman and Fawcett (2011)
with acute and chronic health-care problems summarizes 28 programs currently using the
(e.g., hypertension, chronic obstructive pul- NSM at the time of publication. Two bac-
monary disease, renal disease, cardiac surgery, calaureate programs at Newberry College,
cognitive impairment, mental illness, multiple Newberry, SC, and Cedar Crest College,
sclerosis, pain, grief, pediatric cancers, perinatal Allentown, PA, adopted the model in 2007
stressors); to meet family needs of clients in crit- and 2009, respectively. The department of
ical care; to provide stable support groups for Psychiatric Nursing at Douglas College,
parents with infants in neonatal intensive care British Columbia, Canada, follows a Neuman-
units; and to meet the needs of home caregivers, based curriculum for advanced practice psychi-
with emphasis on clients with cancer, HIV/ atric nurses (Tarko & Helewka, pp. 216–220).
AIDS, and head trauma (Beddome, 1995; MacEwan University in Edmonton, Alberta,
Beynon, 1995; Craig, 1995; Damant, 1995; Canada, is planning for the adoption of the
Davies & Proctor, 1995; Engberg, Bjalming, & model for their curriculum in fall of 2011
Bertilson, 1995; Felix, Hinds, Wolfe, & Martin, (personal communication, Betty Neuman,
1995; Vaughan & Gough, 1995; Verberk, January, 2013).
1995). An excellent example of how the com-
prehensive NSM can be used to gather and Educators have developed tools with NSM
analyze individual client system data is found terminology to guide student learning and
in Tarko and Helewka (2011, pp. 37–69). examine student progress in courses within
Ume-Nwangbo, DeWan, and Lowry (2006) Neuman-based nursing programs (Newman
provided two examples of using the model to et al., 2011). The Lowry-Jopp Neuman Model
provide care: first, for an individual client; sec- Evaluation Instrument (LJNMEI) has been
ond, for a family client. “Nurses who conduct used by two associate-degree nursing programs,
their practice from a nursing theory base, while one at Cecil Community College and the other
assisting individuals and families to meet their at Indiana University—Ft. Wayne. The objec-
health needs, are more likely to provide com- tive of the evaluation instrument is to assess the
prehensive, individualized care that exemplifies efficacy of being educated within a Neuman-
best practices” (p. 31). based curriculum. Participants were assessed at
graduation and 7 months after graduation.
Application of the Neuman Systems Findings indicate that graduates internalized
Model to Nursing Education the Neuman concepts well and continued to
practice from the model perspective if they
Neuman originally designed the model “as a were encouraged by their colleagues. Graduates
focal point for student learning” (2011, who were employed in institutions that did not
p. 332) because it considered four variables of encourage use of the model for assessments
human experience: physiological, psychologi- often did not continue to use it (Beckman,
cal, sociocultural and developmental. Before Boxley-Harges, Bruick-Sorge, & Eichenauer,
1998; Lowry, 1998).
176 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
The LJNMEI instrument was adapted for other Magnet criteria to achieve quality health
use by the practicing nurses at the Emergis care and national recognition. Nursing research
Psychiatric Institute in Zeeland, Holland, in in these institutions is reported in publications
2002. Data have been collected for a decade and at the Biennial International Neuman
to track the efficacy of using the NSM for de- Systems Model Symposia.
livering quality patient care within this psychi-
atric health-care system. Other disciplines in Application of the Neuman Systems
the institution became interested in using the Model to Nursing Research
model as well with no significant difference for
knowledge of the NSM among nurses, psychi- Each edition of The Neuman Systems Model
atrists, and psychologists. Having all disciplines from the second to the fifth (1989–2011) pro-
practicing from one theoretical perspective en- vides a chapter that summarizes the research
ables an integrated approach to motivate and based on the model completed in the years be-
stimulate clients to reach their levels of opti- tween the editions. Through the years, the
mum stability (Merks et al., 2011). growth of Neuman-based research is evident.
In the early years, most of the research was de-
Application of the Neuman Systems scriptive, focusing on one concept from the
Model to Nursing Administration model, such as stressor reactions or primary
and Management prevention interventions. Many of the early
studies were completed by master’s and doc-
Although there is less evidence of the use of the toral students as fulfillment of their advanced
NSM in administration compared with prac- degrees (Fawcett, 2011, pp. 393–404). To date
tice and education, the available literature is in- there are 132 master’s theses, 110 doctoral dis-
creasing and emphasizes how complex systems sertations, and 109 Neuman-based studies
are greatly benefitted by using a systems ap- completed by researchers.
proach as a guide to management (Pew Health
Professions Commission, 1995; Sanders & Neuman-based research has progressed
Kelley, 2002). For example, the purpose of the developmentally through the decades as re-
Magnet recognition program is to promote searchers become more sophisticated and in-
quality patient care within a culture that sup- formed about processes that lead to sound
ports professional nursing practice (McClure, conceptual model-based studies. Conceptual
2005). This is the gold standard for work envi- models provide the broad framework for or-
ronments in health care. One of the attributes ganizing the phenomena to be studied through
of Magnet status is practicing from a profes- research and are critical because they are pre-
sional model of care. Nurses and administrators cursors for theory development. The models
with knowledge of the NSM are poised to as- provide the concepts and propositions (con-
sume leadership roles within these hospital sys- necting statements) that explain the model.
tems. The model emphasizes comprehensive For example, the NSM provides the context
patient care to facilitate the delivery of primary, and structure for research. Because the con-
secondary and tertiary interventions, within a cepts are abstract, the model cannot be tested
culture supporting professional nursing prac- in a single research study. Thus, midrange the-
tice. Some examples of magnet hospitals using ories must be derived from the NSM concepts,
the NSM are Allegiance Health, Michigan and these theories can then be tested in indi-
(Burnett & Johnson-Crisanti, 2011); Riverside vidual studies.
Methodist Hospital, Ohio (Kinder, Napier,
Rupertino, Surace, & Burkholder, 2011); Fawcett (1989) developed a structure that is
Abingdon Memorial Hospital, Philadelphia used by researchers when developing a research
(Breckenridge, 2011); and the South Jersey study from a conceptual model. This conceptual-
Healthcare System (Boxer, 2008). These exem- theoretical-empirical (CTE) framework pres-
plars describe how nurses combine their pro- ents the model concepts to be studied at the
fessional model of care (the NSM) with the upper level, then the more observable concepts
being studied at the second level, and the in-
struments that will be used to collect data
about the second level concepts at the third CHAPTER 11 • Betty Neuman’s Systems Model 177
level. This CTE diagram shows explicit vertical
linkages. Then a narrative explanation is neces- physiological, psychological, and sociocultu-
sary to clarify the concepts and propositions dis- ral stressors. Each item in each of these cat-
played in the CTE diagram. Examples of studies egories is a descriptor of something physical,
developed from CTE frameworks can be found psychological, and sociocultural. A second
in research chapters in two editions of Neuman example is the “Client System Perception
and Fawcett (2002, 2011). Guides” for structured interviews. The items
listed in the guide were developed from the
A second major contribution of Fawcett NSM for measuring spirituality (Clark, Cross,
to model-based research is the publishing of Deane, & Lowry, 1991), dialysis treatment
guidelines for the development of research stud- (Breckenridge, 1997), and elder abuse (Kottwitz
ies (Fawcett, 1995, table 32-1). These rules are & Bowling, 2003). To date, 25 instruments
applicable to any health-care discipline and have have been directly derived from the NSM and
been refined over the years. The latest rendition can measure stressors, client systems percep-
is given in Neuman and Fawcett (2011, p. 162, tions, client system needs, the five system vari-
table 10-1). These rules can apply to both quan- ables, coping strategies, the lines of defense and
titative and qualitative studies. An excellent resistance, and client system responses.
example of a CTE structure for a quantitative
study of multiple role stress in mothers at- Four reviews of NSM-based studies from
tending college (Gigliotti, 1997, 1999) is dis- the 1980s and 1990s focused on how the stud-
played in Neuman and Fawcett (2002, p. 290, ies reflected the research rules. Gigliotti (2001)
Figure 21-1). Note that the midrange theory presented an integrative review of 10 studies
concepts are specific attributes of the NSM to determine the extent of support for Neuman
concepts but do not include all model concepts. propositions that link various concepts of the
An excellent example of a CTE for a qualitative model. Gigliotti reported her difficulty inter-
study is found in Neuman and Fawcett (2002, preting the results due to investigators’ failures
p. 179, Figure 10-3). Note that this diagram to link the research concepts to the NSM in
moves from the Neuman model concepts their designs. Fawcett and Giangrande (2002)
(Level 1) to empirical research methods (Level 3), presented a full integrative-review project that
from which Level 2 midrange theory concepts linked all the available NSM-based research.
have been derived from patient interviews. If the The authors found that about one-half of pub-
guidelines for conducting model-based research lished research journal articles and book chap-
are followed, resulting studies will be logically ters included conceptual linkages between
consistent and will advance nursing knowledge NSM propositions and the study variables.
by helping to explain the effects of using the Master’s theses and doctoral dissertations
NSM (Louis, Gigliotti, Neuman, & Fawcett, (about two-thirds) did not make the concep-
2011; Gigliotti). The ultimate goal of all re- tual linkages. Researchers are reminded to pay
search is to develop conceptual model-based more attention to conceptual aspects of their
middle-range theories (Fawcett & Garrity, studies and make explicit references to these so
2009; Gigliotti, 2012). that nursing theoretical knowledge is ad-
vanced. Throughout this chapter, one can find
The fourth step of the research guidelines the network of researchers who have con-
is research methodology. Appropriate re- ducted model-based studies.
search instruments for data collection must
be selected. This means that the items in Fawcett and Giangrande (2002) presented a
each instrument are either derived from the literature review of 212 studies and identified the
NSM or are compatible with concepts within instruments used for data collection that are
the NSM. For example, Loescher, Clark, compatible with the NSM concepts and propo-
Atwood, Leigh, and Lamb (1990) created sitions as well as the middle-range theory meas-
the Cancer Survivors Questionnaire, which ured by each instrument. Compatible with the
collects data on the client’s perception of NSM concepts are 75 instruments, such as the
State-Trait Anxiety Inventory, used to measure
anxiety; the Beck Depression Inventory, used to
178 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
measure depression; and the Norbeck Social Kaskel, 2012; Bruick-Sorge, Beckman, Boxley-
Support Questionnaire, used to measure client’s Harges, & Salmon, 2010). If the NSM is to be
perception of social support in their lives. When used for assessment of the spiritual variable,
using an instrument not deducted directly from then caregivers must be confident that the Neu-
the model, researchers must describe the link- man definition is congruent with client beliefs
ages between the concepts in the instruments (Lowry, 2012). Several studies have addressed
and those from the NSM to demonstrate logical the importance of spirituality to quality care
congruence between the NSM and the instru- (Clark, Cross, Deane & Lowry, 1991), to aging
ment. The evidence of validity and reliability of persons (Lowry, 2002, 2012), and to adults liv-
the instruments selected must be provided in the ing with HIV (Cobb, 2012). Finally, Burkhart,
study. The ultimate goal is to accumulate a group Schmidt, and Hogan (2012) published a new
of instruments that measure the complete spec- spiritual care inventory instrument within the
trum of NSM concepts, such as the five vari- context of the NSM to measure spiritual in-
ables; the central core; the four environments; terventions that facilitate health and wellness.
client system stability; reconstitution; variances
from wellness; primary, secondary, and tertiary The Neuman Systems Model Research
prevention interventions; and client perceptions. Institute
Finally, Gigliotti and Manister (2012) presented
an article to guide novice researchers through At the 2003 Biennial International Neuman
the writing of the conceptual model-based the- Systems Model Symposium in Philadelphia,
oretical rationale. This is a must-read for every PA, the NSM Trustees formally approved the
beginning researcher. formation of a Research Institute to test and
generate midrange theories derived from the
Focus of Current Research NSM (Gigliotti & Fawcett, 2011). Activities
of this institute include the funding of two dis-
Neuman concepts of stressors, and the three pre- tinct types of fellowships for novice researchers:
ventions as intervention have been the foci most the John Crawford Awards (up to 10 per bien-
frequently studied by descriptive methodology. nium) and the Patricia Chadwick Research
Gigliotti (1999, 2004, 2007) has a program of Grant (one per biennium). For more informa-
research on the subject of women’s maternal- tion, see http://www.neumansystemsmodel
student role stress in which she tests the NSM .org/NSMdocs/research_institute.htm.
flexible line of defense. Spirituality is the vari-
able that has been researched most recently. Each biennium, the Neuman Systems Model
Neuman (1989) claimed that spirituality is the Trustees Group conducts an international sym-
unifying variable of all personal systems. She posium where the recipients of the fellowships
states that the “spirit controls the mind, and the can join other scholars and present their find-
mind controls the body” (pp. 29–30). A spiritual ings. All researchers, educators, and nurses who
encounter occurs between clients and caregivers, practice from the NSM perspective are welcome
thus, nurses must assess spirituality as part of to attend these events to share new insights and
their data collection. These beliefs have influ- to advance understanding of various model
enced the development of spirituality studies. concepts. The networking among these scholars
Some of the studies focus on the development helps to integrate the growing body of knowl-
of spirituality in students, and others aim to un- edge about the use of the model in education,
derstand the concept of spirituality. Because research, practice, and administration of nursing
student nurses must learn to assess the spiritual services.
variable, it is imperative that they develop spir-
itually. A team of faculty from Indiana Purdue– Value of the Neuman Systems Model
Ft. Wayne are studying the evolution of student for the Future
nurses’ awareness of the concept of spirituality
(Beckman, Boxley-Harges, Bruick-Sorge, & Theory development is the hallmark of any pro-
Salmon, 2007; Beckman, Boxley-Harges, & fession. The NSM continues to be researched
and validated through studies; thus, it becomes
more valuable as the basis for quality patient care
and for the advancement of the nursing profes- CHAPTER 11 • Betty Neuman’s Systems Model 179
sion. The addition of the spiritual variable to the
client system in 1989 accentuated the impor- Networking to Enhance Applications
tance of this dimension. The plethora of research of the Model
on spirituality and the recognition of the impor-
tance of the concept are increasingly being There are opportunities to network with others
recognized by the health-care community. The using the model in a variety of applications and
development of middle-range theories from the settings. One way is to attend the Neuman
NSM is imperative because it is the integration Systems Model International Symposium,
of theories from other disciplines that are com- which is held every 2 years, in the odd year.
patible with Neuman concepts. The concepts of International scholars gather to share ideas,
holism, wellness, and prevention interventions insights, innovations, practice, and research
used to attain, retain, and maintain client system from the model. The Neuman Systems Model
stability are as viable today in our complex website provides the latest information: www
health-care system as they were in 1970. Our .neumansystemsmodel.org.
global colleagues find that these philosophical
beliefs are congruent with beliefs in their own The Neuman Archives were established
health-care systems. More than 12 countries to preserve and protect the work of Betty
have been introduced to the model over two Neuman and others working with the model.
decades, with Belgium being the most recent in The archives, previously located at Newmann
2012. Holland has adopted the model most University in Aston, PA, are now housed
widely due to its translation into Dutch and in the Barbara Bates Center for the Study of
hosts the annual International Neuman Systems the History of Nursing at the University of
Model Association symposium (Merks, Verberk, Pennsylvania (http://www.nursing.upenn
de Kuiper, & Lowry, 2012). .edu/history/Pages/default.aspx). Contact
Gail Farr, MA, CA, for information and
an appointment to access the collection
([email protected]).
Practice Exemplar
A nurse guided by the Neuman systems model strong tolerance for the caregiving situation
met Gloria Washington while providing care and served to mediate strain. Caregivers who
for her mother in Gloria’s home. Gloria’s voiced a lack of support from family, especially
74-year-old mother has Alzheimer’s disease, siblings, had much anger and resentment.
and Gloria has been her caregiver for 4 years.
The nurse was aware that, according to Neu- The nurse used this new knowledge to en-
man, the family client system includes Gloria hance the nursing process with Gloria. By
and her mother. This nurse uses practice-based using the Neuman systems model Assessment
research to guide her work (best practice). She and Intervention Tool, she learned that Gloria
recently read Jones-Cannon and Davis’s is a 52-year-old divorced African American
(2005) research study that examined the cop- woman who is employed full-time by a com-
ing strategies of African American daughters pany for which she enjoys working. She also
who have functioned as caregivers. In their has a teenage daughter who lives with her and
study, African American caregivers of a family a grown son who lives away from home. Glo-
member with dementia or a stroke believed ria attends the Baptist church in her neighbor-
that attending support groups and knowing hood 2 or 3 times a week and attributes this
that their parent needed them influenced their experience to her ability to care for her mother.
caregiving experience positively. Most care-
givers identified that religion gave them a The nurse assessed for stressors as they were
perceived by Gloria and by herself. The nurse
assessed for discrepancies between their
Continued
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Nursing Theories & Nursing Practice
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