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Population Health for Nurses

C | Theories and Models Applicable to Practice

Population Health for NursesC | Theories and Models Applicable to Practice

Nurse scholars have developed theories of nursing to define the profession and guide data collection and interpretation using a structured approach. The use of theory when planning nursing care guides the nurse in planning effective interventions and connects theory to nursing practice and research. Historically, many nurse theorists sought an individual approach to change. Theorists in public health take a broader approach, including the social, economic, and environmental factors that impact the development of health problems at the population, community, or family levels. For example, when planning care for a community that treats a high percentage of children with asthma in the local school systems, an individual approach would include specific medications to treat symptoms and planning for self-care. However, a broader perspective may consider how symptoms may be linked to environmental factors, such as allergens or irritants, as well as the quality of housing (e.g., the presence of pet dander, rugs, food additives, cigarette or cigar smoke, fragrances, temperature, humidity, dust mites or cockroaches, or air pollution).

C.1 Relevance of Theories and Models

Population health nurses use theory to plan and implement care at the family, local, regional, or national level. For example, a public health nurse may work within a local community to assess a virus outbreak in a school, while a nurse epidemiologist might assess a communicable disease incidence in a larger population. This appendix reviews a sample of nursing theories related to the individual, family, community, and population levels of care.

C.2 Nursing Theories at the Individual Level

While community-based models generally focus on the family, community, and population levels of care, serious illness care programs are often driven by the goals and priorities of the person directly affected and their family. Therefore, Table C1 in this section includes individual-level theories. Services should be culturally and linguistically responsive, and careful attention must be paid to social risks such as poverty, mental illness, insecure housing, food, and transportation, which create unique challenges, as do past or present traumatic events. Comprehensive assessments at the individual level offer insight into collaboration with colleagues and community partners.

Theorist/Year Focus Concepts Nursing’s Role
Orem’s Self-Care Deficit
1971
Nursing care is required if a client cannot fulfill biological, psychological, developmental, or social needs. Assumes that people can exert purposeful control over their environments in the pursuit of health.

Three related constructs:
  1. Theory of self-care (dependent care)
  2. Theory of self-care deficit
  3. Nursing systems


Includes six major concepts and one peripheral concept.
Patient self-care is accomplished with assistance that compensates for the patient’s limitations when the patient cannot perform these functions independently. Nurses support and protect the patient.

Example:
A home care client who has become paraplegic following a spinal cord injury may require that nurses assist in performing intermittent urinary catheterization and ensuring that the client has supplies at home until the patient and/or family are able to independently address this health care need.
Pender’s Health Promotion Model
1982
Health is “a positive dynamic state, not merely the absence of disease.” Each person has unique characteristics and experiences that affect subsequent actions. Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential.

Health protection is behavior motivated by a desire to avoid illness.

Behavior-specific cognitions and affect are perceived benefits of action, barriers to action, self-efficacy, activity-related affect, interpersonal influences, and situational influences.

Behavioral outcomes are a commitment to a plan of action.
The community health care setting is the best avenue for promoting health and preventing illnesses. The focus is on activities that can improve people’s well-being. Health promotion and disease prevention can more easily be carried out in the community.

Example:
An older client who successfully recovered following an acute care hospital admission for an acute respiratory infection has scheduled an RSV vaccination at a local clinic and wears an N95 mask when in public spaces where close interpersonal contact is anticipated. The client states, “I am now more selective about my social engagements due to the risk of exposure.”
Bandura’s Social Cognitive Theory (SCT)
1986
Not specific to nursing.
Opportunities for social support become available by instilling expectations, self-efficacy, and observational learning. This will achieve behavior change.
Describes individual health behaviors as influenced by the actions of others and by environmental factors.

Key components that relate to individual behavior change:
  1. Self-efficacy
  2. Behavioral capability
  3. Expectations
  4. Expectancies
  5. Self-control
  6. Observational learning
  7. Reinforcements
Nurses and other health professionals utilize the SCT framework in a wide variety of settings and populations to guide behavioral change by creating an understanding of the influences of the social determinants of health and the individual’s past experiences on current behavior.

Example: A senior-level college student who is the first person in the family to graduate college applies for opportunities post-graduation in job roles that include a comprehensive health insurance program, relocation expenses and subsidized housing, and a support plan that includes tuition remission for graduate school.
Neuman’s Systems Model
1995
A broad, holistic, and system-based method to nursing. Nursing care is based on the person’s relationship to stress, response, and reconstitution factors that are progressive in nature. The client as a system is in dynamic, constant energy exchange with the environment in which there is a continuous flow of input and process and output and feedback. All elements are in interaction.
  • Intrapersonal stressors occur within the client system boundary and correlate with the internal environment.
  • Interpersonal stressors occur outside the client system boundary, are proximal to the system, and impact the system.
  • Extra-personal stressors also occur outside the client system boundaries but are at a greater distance from the system than are interpersonal stressors. An example is a social policy.
Nursing’s primary concern is to define the appropriate action in situations that are stress-related or concerning possible reactions of the client or client system to stressors. Nursing interventions aim to help the system adapt or adjust and retain, restore, or maintain some degree of stability between the client system variables and environmental stressors, focusing on conserving energy.

Example: A nurse struggled with the demands of working in an inner-city emergency department following treating clients who were involved in a mass shooting. One of the clients that the emergency room treated that day was a young member of the nurse’s suburban community who unfortunately passed away due to the injuries sustained. The nurse spoke with the nurse manager and obtained mental health services and was granted time away from work to rest and recover from the trauma. The nurse subsequently returned to work with a renewed perspective of service and commitment to the many members of the community that are effectively treated annually in the emergency department.
Table C1 Nursing Theories at an Individual Level

C.2 Nursing Theories at the Family/Community/Population Level

Table C2 in this section includes family/community/population-level theories.

Theorist/Year Focus Concepts Nursing’s Role
Nightingale’s Environmental Theory
1860
The goal of nursing is to put the patient in the best possible condition for nature to act. Nursing is “the activities that promote health in any caregiving situation. Nursing is the act of utilizing the patient’s environment to assist him in his recovery.” Seven environmental factors that affect health:
  1. Fresh air
  2. Pure water
  3. Efficient drainage
  4. Bed and bedding
  5. Cleanliness/sanitation
  6. Nutrition and food
  7. Light/direct sunlight
Nurses can modify patients’ environments according to their 10 canons (nursing interventions) to restore health/recovery:
  1. Ventilation and warming
  2. Light and noise
  3. Cleanliness of the area
  4. Health of houses
  5. Bed and bedding
  6. Personal cleanliness
  7. Variety
  8. Offering hope/advice
  9. Food
  10. Observation

Example:
Collaboration with the community to ensure that a migrant population has access to clean and healthy housing, bedding, access to sanitation services, and culturally congruent foods will offer hope for a brighter future.
Milio’s
Framework for Prevention
1976
Health deficits often result from an imbalance between a population’s health needs and health-sustaining resources.
  1. Health status is the result of deprivation and/or excess of critical health-sustaining resources.
  2. Behavior patterns of populations are a result of limited choices, and these habits of choice are related to
    1. actual and perceived options available; and
    2. beliefs and expectations developed and refined over time by socialization, education, and experience.
  3. Organizational behavior (governmental /nongovernmental) dictates the range of options available to individuals
  4. Individual choices concerning health-promoting or health-damaging selections are affected by their effort to maximize valued resources.
  5. Social change occurs as a result of changes in patterns in the choice-making of significant numbers of people within a population.
  6. Health education can have little impact on personal choice-making of groups of people without the availability of alternative health-promoting options for investing personal resources.
Nurses must examine the determinants of a community’s health and attempt to influence those determinants through public policy.
Use an upstream approach toward preventing diseases and conditions rather than waiting until illness occurs and then treating it.

Example:
Ensuring access to vaccinations and sanitary facilities to wash hands and making sure people use masks correctly to prevent the spread of airborne viruses and bacteria will improve the health of communities.
Roy’s Adaptation Model
1976
Adaptation occurs when people respond positively to environmental changes, and it is the process and outcome of individuals and groups who use conscious awareness, self-reflection, and choice to create human and environmental integration. Concepts within the model are made of four components:
  1. Health
  2. Person
  3. Environment
  4. Nursing
Ten explicit assumptions:
  1. The person is a bio-psycho-social being.
  2. The person is in constant interaction with a changing environment.
  3. To cope with a changing world, a person uses coping mechanisms, which are biological, psychological, and social in origin.
  4. Health and illness are inevitable dimensions of a person’s life.
  5. In order to respond positively to environmental changes, a person must adapt.
  6. A person’s ability to adapt is a function of the stimulus they are exposed to and their adaptation level.
  7. The person’s adaptation level comprises a zone indicating the range of stimulation that will lead to a positive response.
  8. Each person has four modes of adaptation: physiologic needs, self-concept, role function, and interdependence.
  9. Nursing values others’ opinions and perspectives. Interpersonal relations are an integral part of nursing.
  10. The objective for existence is achieving dignity and integrity.
The goal of nursing is to promote adaptation in the four adaptive modes. Nurses promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity, by assessing behaviors and factors that influence adaptive abilities and by intervening to enhance environmental interactions.

Example:
Health concerns change across the lifespan. Providing communities with knowledge regarding the options to change when health concerns change is an important aspect of awareness, self-reflection, and personal choices.
Salmon White’s Construct for Public Health Nursing
1982
Public health is an organized societal effort to protect, promote, and restore people’s health, and public health nursing is focused on achieving and maintaining public health. Three practice priorities:
  1. Prevention of disease and poor health
  2. Protection against disease and external agents
  3. Promotion of health
Scope of prevention spans individual, family, community, and global care.
Targeted interventions are in four categories:
  1. Human/biological
  2. Environmental
  3. Medical/technological/ organizational
  4. Social
Nursing Interventions
  1. Education is directed toward voluntary change in the attitudes and behaviors of the subjects.
  2. Engineering is directed at managing risk-related variables.
  3. Enforcement is directed at mandatory regulation to achieve health.
Block & Josten’s Ethical Theory of Population-Focused Nursing Foundational values and beliefs reflected in the community health nursing process:
  1. Caring
  2. Principles of primary health care
  3. Multiple ways of knowing
  4. Individual and community partnerships and empowerment
Population-focused nursing’s three essential elements:
  1. Obligation to population
  2. Primacy of prevention
  3. Centrality of relationship-based care
Relationship-based care is central to the provision of community-based nursing care. Public health nursing care will improve outcomes by understanding and by developing community-based relationships when providing care for a family, community, or population.

Example:
A nurse realized that health care in her home community was lacking in both primary and tertiary care. The nurse learned that there were not enough registered nurses in the region to care for the community. For many years, the nurse traveled back home to perform stroke screenings and maintained relationships with many members of the community. Several years later, this same nurse completed a doctoral degree and became the director of a bachelor’s degree program. Given this experience, the nurse was asked to consult with a local university and community health partners to develop a successful Bachelor of Science Nursing program and obtained a grant to assist students with tuition and other support resources.
Social Ecological Model of Health: World Health Organization
1947
Not specific to nursing; the focus is the complex interplay between individual, relationship, community, and societal factors. Health is affected by the interaction between the individual, the group/community, and the physical, social, and political environments. Create engaged partnerships and identify a comprehensive list of factors that contribute to poor health among individuals. Encourage the possibility of interpersonal relationships and community resources and for society to eliminate harm from the environment.

Example:
The Nightingale Initiative for Global Health (NIGH) was created to engage and empower the world’s 27 million nurses and student nurses to advocate for global health by efforts. NIGH seeks to reach the United Nations (UN) Sustainable Development Goals and to promote the UN Declaration on the Rights of Indigenous Peoples. NIGH encourages self-care by working together in the global community.
https://www.nighvision.net/our-vision-mission--values.html
PRECEED
PROCEED Model (PPM)
Crosby & Noar
2011
Designed for creating, implementing, and evaluating public health programs.
PRECEDE = Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation

PROCEED = Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development
An ecological approach to health promotion. Two key aspects of intervention are planning and evaluation. The planning process is arranged by objectives and sub-objectives. This is a medical perspective to public health even though its focus is health promotion rather than treatment of disease.
County Health Rankings Model Explores the measures that influence the quality and quantity of life by showing how policies and programs influence health factors that affect a community’s health outcomes. The physical environment accounts for 10 percent (air and water quality, housing, and transit). Social and economic factors account for 40 percent (education, employment, income, family and social support, and community safety).
Clinical care accounts for 20 percent (access to and quality of care). Health behaviors account for 30 percent (tobacco use, diet and exercise, alcohol and drug use, and sexual activity).
Not nursing-specific but helps nurses to define the factors in the county that affect health outcomes.
Table C2 Nursing Theories at the Family/Community/Population Level
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