Nursing Theory

1. Class Presentation
on
Application of non-nursing
theories to clinical practice:
Erikson: Theory of Psychosocial
Development
and
Bowen: Family Theory
PRESENTERS:
ARELIS GONZALEZ
ALAN HIPPLEHEUSER
BRIGITTE KINDA
March 11, 2016

2. Introduction
 Origin of Bowen’s Family Theory:
 This theory was developed from psychiatric research
 It is a theory backed up by a growing body of empirical
research
 It is the foundation for Bowen concept that the primary source
of human emotional experience is the extended family unit.
 For Bowen the degree of differentiation determines the
capacity of a person to manage his or her emotion, thinking,
individuality and connections to others (Brown, 2012)
 Origin of Erikson’s Psychosocial Development Theory:
 This theory emerged as an expansion of Freud’s concept of
ego.
 In Erikson’s theory, special stages of a person’s life from birth
to death are formed by social influences that interact with the
physical/psychological, maturing, organism.
 Erikson developed the concept of ego to incorporate qualities
that expanded the Freudian concept. He believed the ego is the
most powerful of the three parts of the personality (id, ego, and
superego) and described the ego as being robust and resilient
(McEwen and Wills, 2014, p. 310).

3. The Nursing Metaparadigm
Bowen’s Family Theory
 Person: Each individual goes through developmental stages throughout their lifespan
 Nursing: A better understanding of the stages of development help nurses to give a
nursing diagnosis related to the patient psychosocial development based on his or her
stage of development.
 Health: A positive resolution through the developmental stages influence how an
individual reaction to stress situation.
 Environment: Social interaction of an individual throughout his or her lifespan
influences his or her stages of development.
Erikson’s Psychosocial Development Theory
 Person: Allow each member to have their own emptiness and period of pain, without
rushing to resolve or protect them from the pain and thus prohibit growth.
Differentiation of the person from the family members lead to optimal family
development.
 Nursing: Adjusted families are aware of influences from outside the family, such as
emotional processes, as well as from within the family.
 Health: Family who are adjusted view emotional problems as coming largely from the
greater system but as having some components in the individual member.
 Environment: Adjusted families are balance in terms of their togetherness and
separateness, and can adapt to changes in the environment

4. Bowen’s Key Concepts
Triangles –
Three-person relationship system.
Building block of large emotional system
Pattern in a triangle change with increasing tension
Contribute significantly to the development of clinical problems
Differentiation of self –
Individuals vary in their susceptibility to a “group think”, feel, and act,
but individuals vary in the amount of pressure they exert for conformity
The less develop a person’s “self,” the more impact others have on his
or her functioning and more he or she tries to control, actively or
passively, the functioning of others. A person with a well-differentiated
“self” recognizes his or her realistic dependence on others, but he or
she can stay calm and clear headed enough in the face of conflict,
criticism, and rejection to distinguish thinking rooted in a careful
assessment of the facts from thinking clouded by emotionality
Family emotional –
Clinical problems or symptoms usually develop during periods of heightened
and prolonged family tension
Four basic patterns: marital conflict, dysfunction in one spouse, impairment
of one or more children, emotional distance

5. Bowen’s Key Concepts (cont.)
Family projection process –
The projection process follows three steps:
(1) the parent focuses on a child out of fear that something is wrong with the child;
(2) the parent interprets the child’s behavior as confirming the fear; and
(3) the parent treats the child as if something is really wrong with the child.
Multigenerational transmission –
The combination of parents actively shaping the development of their offspring, offspring
innately responding to their parents’moods, attitudes, and actions, and the long dependency
period of human offspring results in people developing levels of differentiation of self-similar
to their parents’levels
Emotional cutoff –
People reduce the tensions of family interactions by cutting off, but risk making their new
relationships too important. For example, the more a man cuts off from his family of origin,
the more he looks to his spouse, children, and friends to meet his needs
Sibling position –
The sibling or rank positions are complementary in the first case and each spouse is familiar
with living with someone of the opposite sex
The sibling positions of a person’s parents are also important to consider
Societal emotional –
Human societies undergo periods of regression and progression in their history. The current
regression seems related to factors such as the population explosion, a sense of diminishing
frontiers, and the depletion of natural resources (Bowen center, 2016).

6. Erikson’s Key Concepts
Stage 1- (0-1 year) – trust vs. mistrust,
Occurs between birth and one year of age and is the most fundamental stage in life.
Based on the development and quality of the child’s caregivers
Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable
Leads to hope
Stage 2 – (1 – 3 years) – Autonomy vs shame and doubt,
Focused on children developing a greater sense of personal control
Toilet training
Leads to will, which is the belief that children can act with intention, within reason and limits
Stage 3 – (3 – 6 years) – Initiative vs guilt,
Independence
Responsibility
Letting children do things on their own
Leads to purpose
Stage 4 (6 – 12 years) – Industry vs. inferiority
Through social interactions, children begin to develop a sense of pride in their accomplishments
Encouragement is key
Leads to competence

7. Erikson’s Key Concepts (cont.)
Stage 5- (12 – 19 years) – Identity vs. confusion
Children explore their independence and develop a sense of self
Leads to fidelity, which Erikson described as an ability to live by society’s standards and expectations
Stage 6 – (20 – 25 year) – Intimacy vs. isolation
People are exploring personal relationships
Forms committed and secure relationships
A strong sense of personal identity is important for development intimate relationships
Leads to love
Stage 7- (26 – 64 years) – Generativity vs. stagnation
Continuing to build our lives, focusing on our career and family
Contributing to the world
Leads to care
Stage 8 – (65 – Death years) – Integrity vs. despair
Reflecting back on life
Feel a sense of integrity if successful, if unsuccessful may feel as if their life was a waste
Looking back with few regrets and a general feeling of satisfaction
Leads to wisdom, even when confronting death (Shic, A., & Burdalic, A., 2013)

8. An example of a client situation where the Bowen’s Family Theory and Erikson’s
Psychosocial Developmental Theory may be applied is a follows:
 A person with Alzheimer lives alone and has two
children. The oldest child lives 15 minutes away and
the youngest child lives two hours away. The
daughter who lives closer is frequently visiting her
mother and finds herself providing 24/7 care as the
primary caregiver, which allows her mother to stay
home. Despite being obvious that she needs help, it
seems that her younger sister is unwilling to help
their mother even on weekends, which would
provide the older the sister some much-needed
relief. The older sister is upset with the younger
sister because she offers advice but does not help
with the mother’s care. The younger sister thinks the
older sister is being unreasonable by not taking her
advice to place their mother in a long-term care
facility. She thinks that they should just place their
mother in a facility so that neither of them would be
overwhelmed with daily caregiving. Therefore, since
the older sister will not place their mother in a long-
term care facility, she refuses to help. Now the
caregiving sister has lost her job and is living with
her mother to provide full-time to care.
Client Situation

9. Theory Specific Diagnosis for each Theory
 Bowen’s Family Theory is a theory of
human behavior that views the family
as an emotional unit and uses systems
thinking to describe the complex
interactions in the unit. It is the nature
of a family that its members are
intensely connected emotionally. Two
main variables is: 1) Degree of anxiety
and 2) Degree of integration of self.
 Using the “Triangle” concept, I would
use Anxiety relating to Caregiver Role
Strain as a Diagnosis for the child who
has taken the role of the caregiver.
(The Bowen Theory Education CTR, 2016)
 According to Erikson’s Psychosocial
Development Theory in each stage,
the person confronts, and hopefully
masters, new challenges. Each stage
builds upon the successful completion
of earlier stages. The challenges of
stages not successfully completed may
be expected to reappear as problems
in the future.
 Erikson’s Psychosocial Crisis of
Integrity vs. Despair is used best to
relate to the mother with Alzheimer’s
Disease with a Diagnosis of Impaired
memory related to Alzheimer's
Disease evidenced by memory loss.
(McLeod, 2013)

11. Bowen’s Family Theory can be used to
design Nursing Interventions by:
 Bowen’s Family Theory can be used to design an
intervention by first implementing a care plan to
resolve/support the nursing diagnosis identified
by the nursing assessment to meet the clients'
needs.
 Using the Triangle concept of Bowen’s Theory
and the diagnosis for Anxiety relating to
Caregiver Role Strain as an example we can
provide goals or desired outcomes for the
caregiver such as: Family will report low or no
feelings of burden or distress measured by relief
stated by family.
 Nursing interventions or orders are instructions
for the specific activities that will perform to help
the patient achieve the health care goal.
 Ultimately evaluating the client’s progress
towards the goals effectiveness of the nursing care
plan.
(McLeod, 2013)
 Bowen’s Family Theory helps the reader
understand that a family is composed of a
unit, and any change in one person’s
functioning predicted to cause changes in
the functioning of others.
 One person inevitably affects the other and
vice-versa. Because of this tension stress
is experienced. To relieve the stress
another member must reveal new and
more effective options for solving that
which is causing tension.

13. Erikson’s Psychosocial Developmental Theory can
be used to design Nursing Interventions by:
 Nurses help identify a client’s faulty
behavior based on past experiences and
stages and help the client seek
psychological assistance such as a
counselor.
 Nurses use Erikson’s developmental
model as an important part of patient
assessment. Analysis the behavior
patterns identify age-appropriate or
arrested development of normal
interpersonal skills
(McEwen & Wills, 2014)
 Erikson’s developmental framework
helps the nurse know what types of
interventions are most likely to be
effective.
 For example, elderly patients respond to
a life review strategy that focuses on the
integrity of their life as a tapestry of
experience.
 During the assessment process the nurse
can determine age appropriateness or
arrested development.
 By assessing the developmental stage of
an adult and elderly person, data can be
collected about interpersonal skills and
behaviors that need to be addressed in
client care.
(McLeod, 2013)

14. Components of Bowen’s Theory and Erikson’s Theory that
need more research before it can be applied to clinical
practice is:
 Erikson’s Theory can relate to many people in various stages of the life cycle
through their own experiences. However, Erikson is rather vague about the
causes of development. What kinds of experiences must people have in order to
successfully resolve various psychosocial conflicts and move from one stage to
another; or what about those adults who rediscover themselves and develop a
different understanding of their lives due to life's changes and experiences? It
may be possible for an individual to change throughout life despite the need to
resolve one stage before moving on to the other.
(McLeod, 2013)
 Bowen’s Theory consist of the family as a unit, a family system. Once the
research view shifts from the individual to the family, the scene looks entirely
different and research doesn’t employ cause-effect linear models. This makes
research from a systems perspective somewhat complex. If a person does
clinical outcome research and only measures the presence or absence of a
symptom in one family member, the systems view has been lost. Multiple
variables affect the system. Researchers guided by systems thinking holds
multiple variables and their interactions with each other, simultaneously in their
thinking.
(Kerr, 2000)
(The Bowen Theory Education CTR, 2016)

15. Diagram 1:
Concepts that apply to practice
Practice area: Hospital in-patient ICU,
PCU, Med-Surge areas
Stage Assessment
Current research for
specific illness/stage
Design care around
stage and stage
strengths
Talk with patient about
life stage
Recognize
underlying family
system anxieties
Apply skills to help
strengthen triangles
Improve
differentiation
through tea
ERIKSON STAGES

16. Diagram 2:
Areas needing future refinement or research
Practice area: Hospital in-patient ICU,
PCU, Med-Surge areas
Research how to use assessment to determine Erikson
stage, strengths and weakness, and application and how
to use the assessment in client communication
Research specific illnesses for specific
Erkson stages: design care plans
based on research.
How family anxiety can be relieved and teaching,
learning, and integration can take place in an ICU
with Bowman’s Theory
ERIKSON STAGES
Research how to teach nurses to
interact better in family systems

17. How applying theory to clinical practice has
increased our use of current literature and
research findings.
 The client’s developmental strength. Looking for ways to
serve clients from different Erikson development ages and
how identification of a patient’s strengths during assessment
can improve communication and teaching of patient family:
conducting literature searches.
 Example: Research by Nyman and Szymcznska (2016)
indicates that patients with dementia can benefit through
Erikson’s generativity vs stagnation by storytelling, re-
identification of leisure time activities, therapeutic life
review, spiritual and religious activities for death
preparation, hope for new creative activities, and
intergenerational contribution.

18. Specific examples of how applying theory
helped us to evaluate our clinical practice
and approach to patient care.
 Using Erikson stage in assessment. Using
Erikson’s theory, we question as to how family
theory and psychosocial theory can be used to
impact the overall health of the patient including
the psyche, and the effect of care that considers a
patient’s psychosocial stage, and accomplishments
with the stages as well as a person’s relationship
to their family in terms of Bowen’s triad.
 This question helped us evaluate our current
assessment of the developmental life stage, it’s
significance to the individual’s health and/or
illness, where the patient has developmental
strengths and how these strengths can be applied
to help the individual to make health life choices
(McEwen and Wills, 2014, p. 310).

19. Specific examples of how applying theory
helped us to evaluate our clinical practice
and approach to patient care (cont.)
Using Bowman’s Family Theory to communicate.
Next, we take research from Tarnowski and Hanson
(1999) for critical care and improve nurse-family
communication through understanding and interacting in
the whole family system, as proposed by Bowman.
This requires recognizing triangling and family roles,
reducing family anxiety through increasing family
awareness of individuality and family member roles.
Even small gains in this area can make a great difference
as families relieve stress and understand the critical care
system better.

20. summary
 Clinical examples include assessing for Erikson
stage and active listening to help patients use their
developmental strengths to cope, heal, learn and
change.
 Further research areas include study of how to
assess for Erikson stages and apply the
information to improved in-hospital stays, and
how to teach nurses about Bowman Systems
theory to reduce family stress in critical situations.
 Erikson's theory offers a useful framework for
analyzing developmental histories making the
nurse more aware of the client’s inability to cope
with problems as an adult, in turn helping the
client seek psychological assistance such as a
counselor, or merely being more compassionate.
 According to Bowen, persons are reasonably
adaptable to anxiety. Tension develops either
within the person or in the unit/the family. The
tension produced by enduring anxiety precipitates
symptoms, dysfunction or sickness. The
characteristics can be impulsiveness, withdrawal
or social misbehavior in a person; or by emotional
or behavioral dysfunction.

21. References
Brown, J. (2012). What is Bowen Theory? Who is Dr Murray Bowen? Retrieved March 8,
2016, from http://www.thefsi.com.au/us/bowen-theory/
Goodell, T., & Hanson, S. (1999). Nurse-family interactions in adult critical care: a Bowen
family systems perspective. Journal Of Family Nursing, 5(1), 72-91.
doi:10.1177/107484079900500105
Kerr, M.E. (2000). “One Family’s Story: A Primer on Bowen Theory.” The Bowen Center
for the Study of the Family. Retrieved from http://www.thebowencenter.org
Kerr, M. E., & Bowen, M. (1988). Family evaluation. New York: W. W. Norton.
Mansour, M. (1994). Cultural circles: application of family systems theory in staff
development. Journal Of Nursing Staff Development, 10(1), 22-26 5p.
McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing. (4th ed).Philadelphia:
Wolters Kluwer/Lippincott Williams & Wilkins.
Nyman, S. R. and Szymczynska, P. (2016). Meaningful activities for improving the
wellbeing of people with dementia: beyond mere pleasure to meeting fundamental
psychological needs. Perspectives in Public Health 136, 99-107.
doi:10.1177/1757913915626193
Öhlén, J. and Segesten, K. (1998), The professional identityof the nurse: concept analysis
and development. Journal of Advanced Nursing, 28, 720–727.
doi:10.1046/j.1365-2648.1998.00704.x
Shic, A., & Burdalic, A. (2013, September 16). Erik Erikson Theory of Develop-ment.
Retrieved March 08, 2016, from https://erikedevelopazra.wordpress.com/
The Bowen Theory Education Center. (2016). A Brief History of the Bowen Theory.
Retrieved from http://www.bowentheoryeducationcenter.org/the-bowen-theory

22. References (cont.)
Wadensten, B. (2006). An analysis of psychosocial theories of ageing and their relevance to
practical gerontological nursing in Sweden Scandinavian Journal of Caring Science 20 (3),
347–354. doi:10.1111/j.1471-6712.2006.00414.xWanta, B. (1998).
The relationship between family communication about death and dying, in terms of Bowen's
family systems theory, and physicians' knowledge of preference for cardiopulmonary
resuscitation (Doctoral dissertation). Retrieved from CINAHL. (Accession. No.10987210).