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In depth

Nursing models and contemporary nursing 1: their development, uses and limitations  

Despite having fallen out of favour, nursing models may incorporate fundamental concepts, values and beliefs about contemporary nursing. It is time to revisit them

Authors

Fiona Murphy, PhD, MSc, BN, RGN, HV, NDN, RCNT, PGCE(FE), is a senior lecturer; Angela Williams, MSc, BN, RGN, PGCE, is a lecturer; Julia Ann Pridmore, MSc, BSc, DipN, RGN, PGCE, is a tutor; all in the School of Human and Health Science at Swansea University.

Abstract

Murphy F et al (2010) Nursing models and contemporary nursing 1: their development, uses and limitations. Nursing Times; 106: 23, early online publication.

This two-part series explores the value of nursing models and considers whether the fundamental concepts, beliefs and values about nursing in these models are relevant to current policy debates about the future of nursing.

This first article provides: an overview of nursing models; how and why they were developed; and some key criticisms. The second article will examine the models in the context of contemporary nursing practice, with particular reference to recent policy initiatives designed to modernise nursing and to raise standards of care.

Keywords: Nursing models, Caring, Health policy

  • This article has been double-blind peer reviewed

 

 

Practice points

  • Nursing models were developed to define what nursing is and could be.
  • They describe the beliefs, values, and goals of nursing and the knowledge and skills needed to practise nursing.
  • They offer a framework to guide practice and education.
  • Once in widespread use, they have fallen out of favour in recent years.
  • Extensive criticisms included that they were irrelevant, confusing and their implementation badly managed.
  • Despite having fallen out of favour, they may be relevant to contemporary nursing practice.

 

Introduction

Nursing models such as the “activities of living model” (Roper et al, 1990) and the “self-care model” (Orem, 1991) were in widespread use in British nursing in the 1980s and 1990s. They were supposed to be used extensively in practice, and to guide the education of nurses.

Many textbooks and journal articles were written to explain what the models were and how they could be used. However, they were heavily criticised and, in the past 10 years, they seem to have fallen out of favour.

In very simple terms, a model can be thought of as a way of representing reality. For example, model cars or aeroplanes are scaled representations that allow people to familiarise themselves with an object, understand it, and take it apart to see how it works. Models can also represent abstract and complex situations such as models of the economy, health beliefs, or grief and bereavement.

Initially, formal models of nursing were considered as ways of representing what nursing is, what it aimed to achieve and the different components of nursing that could then be taken apart, analysed and understood. The components of nursing – however it may be defined – are complex and, as a result, several models were developed. Each offered a different way of thinking about nursing and each presented a different way of guiding nursing practice.

So, a nursing model could be defined as “a picture or representation of what nursing actually is” (Pearson et al, 1996).

The development of nursing models

Nursing models originally came from the US in the 1960s, where several important social, technological, and cultural events were occurring at the time.

The 1960s was a time of staggering technological development, the most prime example of which was the Apollo space programme. This was a very visible example of the power of science and technology to transform lives. Some of this expertise and achievement spilled over into healthcare, with the advancement of medical technology.

Alongside these technological advances came the civil rights movement in the US, which included women’s rights. The consequences of this included the drive to ensure that more women – and therefore nurses – were educated in universities and an awareness and desire to develop nursing as a separate occupation and as a profession distinct from medicine.

At that time, the idea of what defined a “profession” was heavily influenced by Freidson (1988), who believed that one of the hallmarks was the possession of a unique body of knowledge. The early nurse theorists felt it was very necessary for nurses to be able to show that they had a body of knowledge specific to nursing, and models were one way of achieving this.

Historically, both the theory and practice of nursing had been heavily influenced and dictated by the goals of medicine (Pearson et al, 1996), a position perpetuated through the apprentice-style approach to nurse education.

The “medical model” focused on diagnosis, treatment, and cure of physical disease. Growing concerns among nurses about the suitability of the medical model added impetus to the development of models for nursing (Pearson et al, 1996).

It was anticipated that models of nursing would capture, represent, and articulate the particular concerns and purpose of nursing and develop that all important knowledge base characteristic of professional status (Hodgson, 1992). However, there were several difficulties in the development of such a model, not least of which was an apparent lack of a definition of nursing. This led to Henderson’s definition (Henderson, 1966) being frequently cited, and it formed the cornerstone of the debates at that time. Interestingly, there was also a return to the ideas of Florence Nightingale, one of the earliest and most influential writers on nursing.

In the endeavour to identify and build a body of knowledge unique to nursing, the early nurse theorists and model builders were highly influenced by conventional science. They used “scientific” techniques and shared the goal of trying to develop theories about, or for, nursing that could be “tested” by research. There was also an interest in systematically describing and analysing key concepts considered to be important in nursing practice, which can be seen in the work on the concept of care by Leininger (1988) and Watson (1988).

The arrival of nursing models and the nursing process in the UK can be seen from around the mid 1970s with the publication of influential texts on the nursing process and models (MacFarlane and Castledine, 1982; Aggleton and Chalmers, 1986).

The introduction in the 1970s of the idea of the nursing process as a four stage problem solving method to enhance the delivery of care to the individual was an important vehicle in the application of nursing models to clinical practice (Aggleton and Chalmers, 1986). The values, beliefs and theories for care within a given model of nursing could be used to guide the assessment, planning, implementation and evaluation of nursing care.

The nursing process, like nursing models, was not without its critics. Increasingly, it was questioned whether the proposed linear problem-solving approach to care delivery was a valid reflection of the nature of clinical decision-making, particularly for experienced nurses (Walsh, 1998).

The introduction of care pathways to the UK healthcare setting heralded a significant move away from the nursing process and a potential threat to the ideals of individualised care. However, the concept of a planned, standardised, multidisciplinary approach to care for groups of patients with the same health problem proved popular (Walsh, 1998) and continues to support the current emphasis on quality in healthcare provision (Currie and Harvey, 2000).

Components of nursing models

At a basic level, there are three key components to a nursing model:

  • A set of beliefs and values;
  • A statement of the goal the nurse is trying to achieve;
  • The knowledge and skills the nurse needs to practise (Pearson et al, 1996).

An important first step in the development of ideas about nursing was to try and identify the core concepts central to nursing, then to identify the beliefs and values around those. After extensive debate, there was some favour shown to the idea that nursing consists of four key concepts: person; health; environment; and nursing (see Box 1).

 

Box 1. Central concepts of all nursing models (Fawcett, 1995)

  • Person – the recipient of nursing actions
  • Environment – the recipient’s specific surroundings
  • Health – the wellness or illness state of the recipient
  • Nursing – actions taken by nurses on behalf of or in conjunction with a recipient

 

Nursing models may have these four concepts as their cornerstones but each describes them a little differently. For example, the sets of beliefs and values might be different and hence the goal of nursing and the knowledge and skills required might vary (Table 1).

The early theorists drew substantially on other disciplines to develop their ideas and to give their model a different perspective. For example, Neuman (1995) drew extensively on systems theories in thinking about people as a system that strives for stability. Illness is therefore a stressor which can destabilise an individual, and people then need help from nurses to regain stability.

Peplau (1988) drew on psychological theories to conceptualise nursing as an interpersonal process to help patients with mental health problems. In doing so, she contributed to the recognition of the therapeutic potential of nursing.

Arguably, the most influential and most commonly adopted model in the UK was that developed by Roper at al (1990). This described the person as being capable of performing activities of living along an independence/dependence continuum throughout their lifespan. In this model, the role of the nurse is to assist the individual if necessary to achieve as much independence as possible in these activities. Individuality is an important concept in carrying out the activities of living but this is set in the context of biological, psychological, sociocultural, environmental and politicoeconomic considerations.

There was no attempt to prescribe one model that would fit all of nursing, but each model offered a different picture of nursing. Practising nurses could select - and modify if necessary - a model to serve their needs and those of their patients.

Benefits of nursing models

The introduction and use of nursing models was thought to bring substantial benefits to nursing, nurses and patients. In terms of nursing, it was a serious and committed attempt to develop a knowledge base that would make it unique from other disciplines, in particular medicine. The hope was that, in devising models of and for nursing, theories of and for nursing could be generated, tested and, ultimately, added to the profession’s knowledge base.

Part of this knowledge base would be a set of clear ideas about what nursing is, what its values are, and what contribution it makes to healthcare (Draper, 1990).

While it might not be possible to come up with some kind of grand theory of nursing, it was hoped that there would be a working consensus of what nursing was. It was also hoped that these models would lead to the development of very practical theoretical tools to help nurses in their everyday practice.

Another benefit of nursing models was that they could offer a useful set of frameworks to guide practice and education. When teamed with the nursing process, a model could give shape and a structure to the nursing assessment, enabling a focus on the patient and allowing clear identification of the nursing problems and hence the nursing care the patient required. Such a framework would also guide the planning, implementation and evaluation phases of the process.

For example, using Orem’s model, nurses would assess patients for their individual self-care deficits and plan an appropriate set of interventions to help them to overcome and restore their self-care deficits as much as possible. In this example, the process of nursing would be clearly focused on the concerns of nursing and not other disciplines such as medicine.

Such was the importance of nursing models in the 1980s and 1990s that clinical areas had to be seen to be using a nursing model and some educational institutions structured their whole pre-registration curriculum around one. This was partly because the selection of a nursing model gave some guidance on the knowledge and skills required to deliver care.

For example, the use of Peplau’s model in a mental health programme would emphasise that nursing is potentially a therapeutic, interpersonal process; the curriculum would focus on the knowledge and skills needed by the nurse to provide that kind of nursing care. A general nurse training programme based on Neuman’s system model would emphasise the need to assess the patient for the stressors affecting them and provide appropriate interventions to offset the effects of these stressors. The use of a model would also potentially lead to a common language to allow nurses to discuss nursing practice.

Finally, for patients, it was considered that they would receive systematic nursing care, clearly focused on their needs, and in which the unique nursing contribution was clearly articulated and demarcated.

Criticisms of nursing models

Initially, nursing models such as the nursing process were vigorously endorsed in the UK (Aggleton and Chalmers, 1986; UKCC, 1986). However, despite the early enthusiasm associated with their development, models of nursing receive some significant criticism from a number of sources (Miller, 1984; Draper, 1990).

These criticisms can be categorised into intrinsic and extrinsic, depending on the nature of the criticism. Intrinsic criticisms relate to the model itself, which may include factors such as the language used in the model or the beliefs and values. Extrinsic criticisms are related to factors that are external to the model, such as the approach to implementation, attitudes to change, and the motives for developing nursing models.

Intrinsic factors

Nursing models received criticism for their frequent use of jargon and complex concepts, which did little to endear them to UK nurses (Kenny, 1993; Hodgson, 1992). As an example, Neuman (1995) uses the terms intra, inter and extra-personal stressors which have the potential to affect the system (or the person) which has a central core, lines of resistance and two lines of defence. In addition, Orem (1991) includes a number of complex terms such as health deviation, universal and developmental self-care requisites, self-care deficit, dependent-care deficit, and wholly, partly compensatory and supportive-educative nursing systems.

Such complex concepts and terminology had to be grasped and understood before the models could be used effectively in practice. Yet Hodgson (1992) concluded a significant problem was that models “leave us puzzling over the ridiculous use of English and ideas so embedded in terminology as to be inaccessible”.

Another criticism of nursing models was related to their origin in the US. Questions were raised about their underpinning philosophical beliefs and values, and their applicability and transferability to British nursing (Kenny, 1993; Draper, 1990). For example, the concept of self care in Orem’s model assumed a willingness and motivation on the part of individual patients to manage their healthcare needs to an extent, which sat well in the US healthcare system at that time.

However, the NHS historically has a less individually centred approach, with explicit financial responsibility for care costs and a greater emphasis on state or government responsibility for health. This meant the notion of self care as described by Orem was alien to British nurses and patients in the 1980s and 1990s.

Nursing models represented specific values and beliefs about nursing held by individual authors. Subsequent critical analyses have suggested these to be rather narrow perspectives that fail to capture what nursing is (Hardy, 1982).

The irony here is that one of the main reasons for the development of nursing models was to capture and articulate the nature and contribution of nursing as a discipline (Tierney, 1998). Yet Miller (1984) argued that models were idealised, lacked relevance to the reality of nursing practice and, as such, increased the gap between theory and practice.

Models of nursing also received criticism for the lack of research underpinning and supporting the relationships between the concepts and the effects on patient care (Fraser, 1996). As a result, models remained at a descriptive and explanatory level at best and failed to serve a practice-based discipline like nursing (Dickoff and James, 1968).

Draper (1990) also suggested that the application of theories from other disciplines undertaken by academic nurses to explain nursing was inadequate.

He and others argued for inductive theory generation derived from the practice of British nurses and the reality of contemporary British practice (Miller, 1985; Draper, 1990). Following this logic, the end theory would be more useful, valuable, and readily embraced by practitioners.

Extrinsic factors

While some of the criticisms focused on the nature of models themselves, the approach to implementation in the UK also received critical attention. Kenny (1993) highlighted the “top-down” strategy used to introduce nursing models, which prevented a sense of ownership by nurses and created a significant barrier to success.

Another contributing factor was the lack of educational preparation and in service training for practitioners in the use of models, which, together with resistance to change, posed significant barriers to their successful implementation (Kenny, 1993). Reflecting on the nature, approach, and attitude towards change and the bureaucratic environment of the NHS, Kenny (1993) also questioned whether nursing models stood any real chance of success.

Further scepticism of nursing models was derived from the perception that their purpose was primarily to advance the professionalisation of nursing (Hodgson, 1992) rather than improve patient care.

Conclusion

Models of nursing represented an important stage in the development of nursing theory and the development of nursing as a discipline.

The criticisms they generated were an important part of the professional debate and advancement of nurses and nursing. It could be argued that some of this criticism arose from a lack of clarity as to the aim and purpose of nursing models and their implementation, rather than the concepts and ideas within them.

Nursing models may therefore incorporate fundamental concepts, values and beliefs about nursing that are pertinent to contemporary nurses and the next article in the series examines this further.

Readers' comments (29)

  • Marjorie Lloyd

    Thank you for opening up this much needed debate in nursing I am looking forward to reading the next article. However you mention at one stage "nursing models such as the nursing process" which is not a model of course but a process. A lot of nurses get these mixed up which only adds to the confusion. In my book on care planning I suggest that a model is usually based on a theory while the process is just a framework that could be used to apply various models?
    Nursing models are therefore very important to the development of nursing theory but as you suggest if too difficult to apply in practice people simply give up.
    I am looking forward to reading how we can help people to identfiy nursing theory better so that it can be applied as evidence based practice.
    At a time when nurses are fighting to keep their jobs from going to unqualifed staff this is timely reminder of why we need nursing theory and models, more now than ever.
    Lloyd M (2010) A Practical Guide to Care Planning in Health and Social Care. Open University Press.

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  • rovergirl6@hotmail.com

    Well it seems to me that the models of nursing and the Nursing process ,worked for a long time,I know we need clarification as to what nursing is and how to nurse. Who do you think would be a good choice to write the

    NURSING IN MODERN TIMES. MANUAL.

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  • rovergirl6@hotmail.com

    Has anybody had the opportunity to visit
    www.rcn.org.uk

    On this site can be found a document called

    Defining nursing Nursing is.

    This definition is supposed to assist in developing policy and legislation ,using skill mix and resource management. Good luck if you can derive any form of help from this document.

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  • Florence Nightengale said "The tasks can all be done but the patient received on care". Models offer us a way of looking beyond the task to consider the patient as a whole. It seems to timely to have a discussion about the definition of nursing and what it means in a 21st century health care system. Are there now two classes, the mini doctor and plodders who get on with the job?

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  • Marjorie I am not sure that the article says the nursing process is a model. It define both and compares the way they were introduced.

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  • What next? A return to the Cardex system?

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  • I think nursing models were a move away from a Kardex approach rather than part of it.

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  • Hassan Sharifi

    I'm a MSc in medical surgical nursing and have work experience about 10 year in both theory and practice. I don't find any significant change in clinical areas with nursing theory. in my opinion, today nursing theory don't applicable in clinically hospital and only discuss in class.

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  • Martin Gray

    I amazed at the number of letters the authors of this article have after their names, and wonder just how much time they have spent as practising clinicians as ,to have obtained so many academic qualifications, the vast majority of their time must have been spent studying.

    How exactly do you apply a particular model to a ward or primary care environment when there are so many other factors to be considered? And why, Marjorie, do you beleive that nursing models and academic theories are going to stop nurses losing their jobs to ' non qualifed' staff? Perhaps because practicality in patient care is more important than writing endless care plans and trying to justify academic achievement as the way forward.

    I am glad to be retiring from a profession that has lost it's vocational origins in caring for people in favour of academic/scientific achievement of it's members in search of recoginition and equality with the medical profession.

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  • That was the point I was perhaps a little caustic in making Anonymous 17-Jun-2010 7:31 am. Unlike virtually every other profession who advance with newly acquired knowledge, we seem to be either forever reinventing the wheel or taking on board old technology that was shown to be unsuitable elsewhere.

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  • It is pleasing that the article has generated debate. As one of the contributing authors I feel I must defend the criticisms by Martin Grey levied against the aquisition of educational qualifications."letters after their names" and lack of clinical experience . I have been a practicing clniican since 1980 and still practice as a band 5 staff nurse today in addition to my educational practice. It is with the benefit of 28 years of experience combined with academic endeavour that I feel qualified to say that nurses do need a theoretical framework to guide, support and articulate their contribution. This is particularly so now that we face financial, demographic and societal change that will potentially"price the registered nurse out of the market".
    Without underpinning theory to explain
    what nursing is and does, it would be all too easy to relegate our role to being just about "basic tasks", when nusing is in fact a complex, dynamic and challenging role requiring the combination of knowledge ,skills, experience and theory.
    The use of nursing theory such as models should help us to make the distinction between the contributions of the medical, nursing and other health professionals and demonstrate our value. I urge Martin to read article 2 in the next edition.

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  • The point is that nursing models provide a basic on which we build personalised care for patients. They are NOT something we DO but provide us with a guiding principle or philosophy. They give us a framework for what we do and why we do it. Perhaps revisiting them will enable us to redefine what nursing is. We can decide whether it is a vocation, a caring profession or a adjunct to medicine.
    If we look at modlals, use them and embrace them we will return to the fundamental of nursing. This would make nursing a better place to be.

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  • I do wish 'basic' would be sustituted by 'essential'. One essential 'task' that is so much overlooked is mouthcare. Nursing models ensure we look at all aspects of care, but unfortunately seperate them into categories instead of the patient as a whole. I battled to introduce a patient goal as the subject of developing a care plan, ie. to be able to walk 5 yards so that I can return to my home. This encompasses a number of the activities of living, not categorising them, and promotes interdisciplinary working....another battle, still after all these years. By the way, if you attend 'meetings', check the agendas over the last 20 years...have they changed?

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  • This has provided me with some very interesting reading and I am wondering how I ever got by without having any knowledge of any models or the nursing process! My undersytanding has always been that these models strive to underpin a basis for nurse education and as suggested have had problems becoming embedded in practice due to a lack of inservice training. The patient has always been central to my philosophy of nursing and by listening and talking to patient's and developing an understanding of their unique needs and requirments must underpin all that we do. If by embracing a medical model of treatment and cure that nurses can undertake then surely that is the first line of care. If the management and support of a chronic long term condition is all we can offer then most often I have found that patients know what they want. Nurses just need to know how to navigate the health care system, be 'there' for the patient when they need to talk, fascilitate adaption to progressive illness and offer solutions to problems. I'm sorry to say it is all pretty 'basic' (or essential) stuff, but all too often missed as someone suggested with mouth care in our attempts to raise the profile of nursing.

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  • Martin Gray

    Julia, thank you for replying to my post and pointing out that nurses do need a theoretical framework; I totally agree with you on that point and later comments have supported what you and your co-authors have said.

    Perhaps my point was that we see so many nurses that DO have a lot of academic qualifications but do not work clinically AT ALL any longer, but rather sit in universities procrasternating on the way the profession needs to go in order to achieve recognition. I will further say that working for 1 day a week (not that I'm implying that's what you do but am generalising) does not, in my opinion, imply that people remain fully in tune with the whole reality oy nursing, as there are many different areas of care provision that are overlooked, such as community and practice nursing.

    Having been a nurse since 1976 I have worked in the armed forces, the prison service, elderly care in the private sector, A&E and general practice I feel I am also qualified to make the comments I have on this thread.

    Nursing models appear to be centered around the ward and hospital environments, it would be both interesting and informative to have another article on utilising nursing models in different areas and how they can be adapted to suit each area. Perhaps this could be your next project?

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  • Marjorie Lloyd

    Martin your comments on why we do not need nursing theory/models are so typical of people who are leaving the profession, having collected a nice pension on the way out. The fact that many newly qualified nurses need to develop their professional skills is very important in maintaining what I think is a very valued and significant contribution to health care. Even if Florence struggled to articulate it at the time.
    If we do not define (evidence) nursing practice and the underpinning theory the budget holders will consider it a waste of resources and employ unqualified staff to do the same job only cheaper.
    As an academic I am struggling to develop research that proves nursing is effective unlike many people who criticise me for not being on the shop floor.
    Those critics really make the job worthwhile and prove that many nurses were only ever in it for the money.

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  • Marjorie Lloyd

    to Anonymous 16th June - I did quote this bit from the paper but unable to give page numbers because it is online

    "Criticisms of nursing models
    Initially, nursing models such as the nursing process were vigorously endorsed in the UK (Aggleton and Chalmers, 1986; UKCC, 1986)".

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  • Has anyone ever thought that the time will come when they attempt time and motion into nursing.
    Computers are already here.It will not be the powers that be start to request a time sheet on how long it took to do that dressing or to change that catheter. lets wait and see.

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  • Martin Gray

    Marjorie I did NOT come into nursing for the money, noe did a great many others, as your post implies! and the pension I will receive is not 'nice' by any meansand I am having to sell my house because it will not pay the mortgage!

    Why is it you are having difficulty trying to develop research that proves nursing is effective? Surely that is something that requires no research at all, it's already a proven fact. You have admitted you are an academic that spends no time on the shop floor, which makes me wonder why you are in nursing at all. I can understand why you come under critism from your clinical colleagues.

    Nurses care for people, it is a vocational profession and not one entered for financial reward. To imply that it is I find, as I trust do others, quite insulting. If unqualified staff, which I very much doubt, were to take over the role of nurses it would not be long before the NHS was crippled by litigation cases. What is more likely to happen is that universities will lose students due to the proposed increace in fees and the pitiful bursary student nurses receive with which to live on.

    Nice free plug opportunity for your book though, but you wouldn't be getting any publishing royalties to supplement your income from that of course now would you?

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  • What is going on? Some of these postings are really quite offensive, unprofessional, immature and lack any insight into the value that nurses over the last few decades have contributed to the nursing role. Bashing experienced nurses again. Why do you do it? Thanks to us you have access to higher education. I personally, paid most of my own nursing education and still do to keep updating myself. To say that we went into nursing for money is so ridiculous as pay scales are far more generous (I am not saying adequate or good), nowadays than when I started. At least we get stuck in and work very hard for our patients.

    Anyway, back to the subject in hand. I am very sad that nursing models and theories have fallen by the wayside as they were an excellent basis for good, systematic and whole person nursing care. Technically, 'holistic'. As the theories developed it included more domains which early nursing (and let's face it, doctors as well), did not consider. Let's do bring them back and perhaps develop them further?

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