SUMMARY OF THE THEORY PART I

MA. THERESA SALINDA,MSN, RN

PhDNS(Student)
 1. Florence Nightingale: Environmental Theory

• M-other of modern nursing she cares to wounded soldiers at

• L-ady with the lamp night
• D-evelop nursing practice
• A-dvocate nursing knowledge
• S-ervice in Crimean war
 Environmental Theory

“the act of utilizing the patient’s environment to assist him

in his recovery.”

nurse’s initiative to configure environmental settings

appropriate for the gradual restoration of the patient’s

health

external factors associated with the patient’s surroundings

affect the life
 CANONS OF THE ENVIRONMENTAL
THEORY
1. HEALTH OF HOUSES Once air is stagnant, sickness
• ‘badly constructed houses do for the is certain to follow’
healthy what badly constructed hospitals (Nightingale, 1859)

do for sick.
cleanliness outside the house affected the inside
2. VENTILATION AND
keep the air he breathes as pure as
WARMTH
te external air, without chilling him.”

bringing
3. LIGHT 4 NOISE 5.VARIETY the patient brightly colored flowers
or plants
 CANONS OF THE ENVIRONMENTAL THEORY

6.BED AND BEDDINGS 10.CHATTERING HOPES

AND ADVICES

7. CLEANLINESS 11.OBSERVATION OF THE

SICK

8.PERSONAL ways to assure that

12. PETTY
CLEANLINESS “what
MANAGEMENT
you do when you are
9.NUTRITION AND TAKING there, shall be done
FOOD when you are not
there.
 MAJOR ASSUMPTIONS

NURSING PERSON HEALTH ENVIRONMENT

• trained • being well and using create

• Patient every power (resource) and maintain a
nurses
• Nurses to
• scientific principles to
performed tasks to
therapeutic
be applied the fullest extent in living
and for the patient environment that
• skilled in observing life.
and reporting patients’
and controlled the
• prevention would enhance
patient’s
health status while
environment of disease via the comfort and
providing care as the
patient recovered.
to enhance recovery environmental control recovery of the
and social responsibility. patient.
 2. Patricia Benner’s Stages of Nursing Expertise

nurse “knowing how” without “knowing that

development of knowledge in fields such as nursing is made up of the

extension of knowledge through research and understanding through clinical
experience.

FOCUS: profession's understanding of what it means to

be an expert, placing this designation not on the nurse with the most
highly paid or most prestigious position, but on the nurse who provided
"the most exquisite nursing care.
 Stages of Nursing Expertise

NOVICE ADVANCED PROFICIENT EXPERT

COMPETENT
BEGINNER

Nurse with 2-3 year’s

experience on the job Perceives and
Demonstrates Has intuitive grasp
Beginner with in the understands
acceptable of clinical
no experience same area or in situations as whole
performance situations
similar day-to-day parts
situations
Principles, based on
Ex. “Tell me perspective from Learns from Performance is
experiences, begin planning own actions
what I need to experiences what to now fluid, flexible,
to be formulated to based on conscious,
do and I’ll do expect in certain and highly-
guide
it.” abstract, and situations and proficient
actions
analytical thinking how to modify plans
 Metaparadigm

Situation /
Nursing Person Health
Environment

• what is assessed, • situation

• caring
whereas well- conveys social
relationship and self- interpreting being is the environment with social
condition and being and human definition and
connection. experience of
Caring is
effortless meaningfulness.
health or
nonreflective • person engaged
primary because wholeness.
interaction, interpretation
caring self is set understanding of • Well-being and
being ill are and understanding
possibility of the self in the understood as of situation.
giving help and world distinct ways of
receiving help.
being in the world.
3.JEAN WATSON’S THEORY OF
TRANSPERSONAL CARING

FOCUS/concerned : how nurses express care to their

Patients

stresses humanistic aspects of nursing as they intertwine with scientific knowledge and
nursing practice

caring is central to nursing practice, and promotes health better than a simple medical
cure
“Transpersonal Caring Relationship” as foundation to her theory;
it is a “special king of human care relationship-a union with another person-high
regard for the whole person and their being-in-the-world.
 Carative Factors and Caritas Processes
is Latin word which means “to cherish, to appreciate, to give special attention, if
not loving attention.

Formation of a Humanistic Altruistic System

Systematic Use of the Scientific
of Values Problem-Solving Method for Decision Making

Instillation of Faith-Hope Promotion of Interpersonal Teaching-Learning

Cultivation of Sensitivity to Self Provision for a Supportive, Protective, and

Corrective Mental, Physical, Sociocultural, and
and Others Spiritual Environment

Development of a Helping-Trust Assistance with Gratification of Human

Relationship Needs
Allowance for Existential-Phenomenological
Promotion and Acceptance of the Expression of Forces
Positive and Negative Feelings
 Metaparadigm

Nursing Person Health Environment

• consist of • “a unity of • “healing spaces can be

“knowledge, mind/body/spirit/nat • “The used to help others
thought, values, ure and she says positive state of transcend illness, pain,
philosophy, that personhood is physical, mental, andsuffering,”emphasizin
tied to notions that and social well-
commitment, g the environment and
one’s soul possess being with the
and action inclusion of person connection
a body that is not
with some three elements: • patient’s room, a
confined by
degrees of objective time and . magnetic field of
passion. space. expectation is created”.
4.VIRGINIA HENDERSON’S NURSING NEEDS THEORY

“Modern-Day Mother of
Nursing” and “The 20th Century Florence Nightingale”

NURSING NEEDS THEORY-increasing the patient’s independence to hasten their

progress in the hospital

basic human needs -as the central focus of nursing practice

“nurses care for a patient until a patient can care for him or herself,”
 14 components that make up the basic nursing care
(fundamental needs)

1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes-dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and modifying environment
8. Keep the body clean and well-groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others.
1O. Communicate with others in expressing emotions, needs, fears, or opinions.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the
available health facilities.
 Metaparadigm

Nursing Person Health Environment

• Individual • balance in all

• “the unique • everything that is outside
achieveswholeness realms of human
function of the life. It is equated of the patient but is
by maintaining
nurse is to assist physiological and with the connected to the patient is
the individual, emotional balance. independence or considered the
sick or well. • patient as ability to perform environment & the
• To help him gain someone who activities without environment should
independence needs nursing care any aid in the 14 support the 14
as rapidly as but did not limit components or fundamental needs.
possible. nursing to illness basic human
care needs.
5.FAYE GLENN ABDELLAH’S TYPOLOGY OF 21 NURSING PROBLEMS

“Twenty-One Nursing Problems Theory” that has interrelated

the concepts of health, nursing problems, and problem-solving.

used Henderson’s 14 basic human needs and nursing research to

establish the classification of nursing problems

The patient-centered approach to nursing was developed from

Abdellah’s practice, and the theory is considered a human needs theory

21 nursing problem-the clinical practitioner could assess the patient,

make a nursing diagnosis and plan interventions
 Abdellah’s Typology of 21 Nursing
Problems
Needs of patients are further
divided into four categories

BASIC NEEDS-needs of an Remedial care needs to identify and accept

individual patient to maintain good positive and negative expressions,
hygiene and physical comfort; feelings, and reactions; identify and accept
the interrelatedness of emotions
promote optimal health through and organic illness;
healthy activities
Restorative care needs include the
SUSTENAL CARE NEEDS-maintenance of a
acceptance of the optimum possible goals
supply of oxygen to all body cells; facilitate the
in light of limitations, both physical and
maintenance of nutrition of all body cells; facilitate
emotional; the use of community
the maintenance of elimination; facilitate the
resources as an aid to resolving problems
maintenance of fluid and electrolyte balance; that arise from illness
ten steps to identify the patient’s
problem and 11 nursing skills used to develop a treatment typology.

1Learn to know the patient.

2. Sort out relevant and significant data.
3. Make generalizations about available data in relation to similar
nursing problems presented by other patients.
4. Identify the therapeutic plan.
5. Test generalizations with the patient and make additional
generalizations.
ten steps to identify the patient’s
problem and 11 nursing skills used to develop a treatment typology.

6.Validate the patient’s conclusions about his nursing problems.

7. Continue to observe and evaluate the patient over a period of time
to identify any attitudes and clues affecting this behavior.
8. Explore the patient’s and family’s reaction to the therapeutic plan
and involve them in the plan.
9. Identify how the nurse feels about the patient’s nursing problems.
10.Discuss and develop a comprehensive nursing care plan.
The 11 nursing skills

1. observation of health status

2. skills of communication
3. application of knowledge
4. teaching of patients and families
5. planning and organization of work
6. use of resource materials
7. use of personnel resources
8. problem-solving
9. direction of work of others
10.therapeutic uses of the self
11.nursing procedure
 Metaparadigm

Nursing Person Health Environment

• The client’s health • Recipients of

• the purpose of • Society is included in
needs can be nursing as
viewed as problems, individuals (and nursing services. “planning for optimum
which may be families) • In Patient - health on local, state,
overt as an • people as having Centered and
apparent condition, physical, Approaches to international levels.”
or covert as a emotional, and Nursing • the focus of
hidden or concealed sociological • state mutually nursing service is
one. needs. exclusive of
clearly the individual
illness
6. DOROTHEA ELIZABETH OREM’S SELF-CARE DEFICIT
NURSING THEORY (OREM MODEL OF NURSING

Focuses: on each “individual’s ability to perform s elf- care, defined as ‘the

practice of activities that individuals initiate and perform on their own behalf
in maintaining life, health, and well-being.”

SCDNT represents a caring approach

that uses experiential and specialized knowledge (Science) to design
and produce nursing care (Art).
 SELF CARE THEORY

Self-care Therapeutic Self-

Self-care agency care Demand
Nursing Agency

the performance totality of “self-

complex property or
or practice of care actions to be
the human’s performed for some
attribute of people
activities that educated and trained as
ability or power duration in order to
individuals nurses that enables them
initiate and to engage in meet known self- to act, to know, and to
perform on their self-care and is care requisites by help others meet their
own behalf to affected by basic using valid methods therapeutic self-care
maintain life, conditioning and related sets of demands by exercising
health, and well- factors. actions and or developing their own
operations.” self-care agency.
being.
Self-Care Requisites. Actions directed towards provision of self-care.

Three categories of self-care requisites

Universal self-care requisites

• Associated with life processes and maintenance of the integrity of human
structure and functioning.

Developmental self-care requisites (DSCRs

Health deviation self-care requisites

 Theory of Dependent care
Dependent- Dependent- Dependent-care
Dependent-
care care deficit
care demand
agency
Acquired ability of a
care that is person to Summation of care
know and meet the Relationship that measures at a
provide to a exists when the
person who, therapeutic self-care specific point in time or
demand of the dependent-care
because of age or over a duration of time
dependent provider’s agency is
related factors, is for meeting the
person and/or not adequate to meet
unable to perform the therapeutic self-
dependent’s therapeutic,
regulate the self-care demand when
the self-care development and care demand of the
needed to person receiving his or her self-care
exercise of the
maintain life, dependent’s self dependent-care. agency is not adequate
or operation
care agency.
 SELF CARE THEORY

Self-care Therapeutic Self-

Self-care agency care Demand
Nursing Agency

the performance totality of “self-

complex property or
or practice of care actions to be
the human’s performed for some
attribute of people
activities that educated and trained as
ability or power duration in order to
individuals nurses that enables them
initiate and to engage in meet known self- to act, to know, and to
perform on their self-care and is care requisites by help others meet their
own behalf to affected by basic using valid methods therapeutic self-care
maintain life, conditioning and related sets of demands by exercising
health, and well- factors. actions and or developing their own
operations.” self-care agency.
being.
 Theory of Self-Care Deficit

Inoperable or
relationship between an
inadequate for knowing
individual’s therapeutic
and meeting some
self-care demand and his or
her powers of self-care agency or all components of the
in which the constituent- existent or projected
developed self-care capabilities therapeutic self-care
within self-care agency demand (Orem, 2001,
p.522).
 Theory of Nursing Systems

Partially
Compensatory Supportive-educative
Wholly System. The patient System. The patient
Compensatory can meet some can meet self-care
System. The needs. Needs nursing requisites, but needs
patient is assistance. Both the assistance with decision
dependent. nurse and the patient making or knowledge
engage in meeting self- and skills to lean self-
care needs. care.
 Metaparadigm

Nursing Person Health Environment

• structurally and
• an art, a helping
• A total being functionally
service, and a • environmental
with universal, whole or
technology.
- Actions developmental sound. factors,
deliberately selected needs and - Wholeness environmental
and performed by capable of or integrity elements, conditions,
nurses to help continuous self- includes that and developmental
individuals or groups care. which makes a environment.
under their care person human
operating
 7.BETTY NEUMAN’S SYSTEMS MODEL

conceptual model of nursing focuses attention on the

response of the client system to actual or potential environmental stressors, and the
use of primary, secondary, and tertiary nursing prevention interventions for retention,
attainment, and maintenance of optimal client system wellness.”

Neuman’s model is based on the general systems theory and reflects

the nature of living organisms as open systems (Bertalanfly, 1968, cited
in Alligood, 2018) in interaction with
each other and the environment.
Neuman Systems Model is classified as a systems model or a
systems category of knowledge.

unique, open-systems-based perspective that provides a unifying focus

for approaching a wide range of concerns.

system acts as a boundary for a single reactions of the client-client

client, a group, or even a number of system- field primarily
groups. It can also be defined as a social concerned stressor-related
issue.
situation

client and environment may Forces as stressors, and suggests that possible
be positively or negatively reactions and actual reactions with identifiable
signs or symptoms may be mitigated
affected by each other through appropriate early interventions
 Neuman Systems Model views the client as
an open system that responds to stressors in client variables
the environment.

client system consists of a basic or core protected by lines of resistance.

structure

health level is identified as the normal

defense line protected by a flexible line STRESSORS

of defense.

stressors break through the flexible line of

defense, the system is invaded, and the lines of
resistance are activated.
The system is described as moving into If adequate energy is available, the system will be
illness on a wellness-illness continuum reconstituted with the normal defense line
restored at, below, or above its previous level.
 Sub concepts of Neuman Systems Model

Stressors Lines of Degree of

Reaction resistance
•Intrapersonal stressors are those that Entropy
occur within the client system boundary and A process of energy depletion and
correlate with the internal environment. disorganization moving the system toward
illness or possible death.
•Interpersonal stressors occur outside the Negentropy
client system boundary, are proximal to the An energy conservation process that
system, and impact the system. increases organization and complexity,
•Extrapersonal stressors also occur outside the moving the system toward stability or a
client system boundaries but are at a greater higher degree of wellness.
distance from the system than are interpersonal
stressors. An example is a social policy.
 BASIC TERMINOLOGY

Input/Out Reconstitu Stability Open System

put -tion
• The matter, • treatment of A system in which there is
A state of balance or
energy, and stressor harmony requiring a continuous flow of input
information reaction, the energy exchanges as and process, output and
exchanged return and the client adequately feedback. It is a system of
between the client maintenance of copes with stressors
organized complexity,
and environment system stability to retain, attain, or
maintain an optimal where all elements are in
entering or leaving may result in a health level, thus interaction.
the system at any higher or lower preserving system
point in time. wellness level. integrity.
 BASIC TERMINOLOGY

Basic Stricture Flexible Normal line

and Energy Lines of
Resources line of of defense
resistance
defense
An adaptational level
• A protective of health developed
accordion-like over time and is
Protection factors are
• central core activated when stressors
mechanism that considered normal
• system variables, for a particular have penetrated the
surrounds and
genetic features, individual client or normal line of defense,
protects the
and strengths and system; it becomes a causing reaction
normal line of standard for
weaknesses of the symptomatology.
defense from wellness-deviance
system parts.
invasion by determination.
stressors.
 Flexible line of defense is no longer
capable of protecting the client-client system against an environmental stressor,
the stressor breaks through the normal line of defense.
VARIABLES-physiological, psychological, sociocultural, developmental, and
spiritual—determine the nature and degree of system reaction or possible reaction
to the stressor.
Wellness is on a continuum of
client, whether in a state of wellness or available energy to support
illness the system in an optimal state of
system stability

client system are internal resistance

factors know as lines of
resistance, which function to stabilize and
return the client to the usual wellness state
 Prevention as Intervention

Primary prevention occurs before the system focuses on strengthening the flexible line of
reacts to a stressor; it includes health defense through preventing stress and
promotion and wellness maintenance. reducing risk factors

Secondary prevention occurs after the system reacts • Focuses on strengthening the internal
lines of resistance and, thus, protects the
to a stressor and is provided in terms of existing basic structure through appropriate
symptoms treatment of symptoms.
• To regain optimal system stability and
conserve energ

Tertiary prevention occurs after the system to maintain wellness or protect the client
system reconstitution by supporting existing
has been treated through secondary strengths and preserving energy.
prevention strategies. • begin at any point after system stability has
begun reestablished
 Metaparadigm

Nursing Person Health Environment

• open client • internal and external

system in • continuum of factors that surround
• unique profession in reciprocal
wellness to and influence the
that it is concerned interaction with
with all the variables the environment. illness that is client
affecting an The client may be dynamic in system.
individual’s response an individual, nature and is • Stressors
to stress family, group, constantly (intrapersonal,
community or
changing. interpersonal and
social issue.
extrapersonal
9.MARTHA ROGERS SCIENCE OF UNITARY HUMAN BEINGS

FOCUS of model = the role of the nurse is to serve people.

Proposal = noninvasive modalities for nursing, such as therapeutic
touch, humor, music, meditation and guided imagery, and even the use
of color.

interventions of nurses =coordinate the rhythm between the human

and environmental fields, help the patient in the process of change, and
to help patients move toward better health
NURSING PRACTICE =Focused on pain management, and supportive
psychotherapy for rehabilitation.
KEY POINTS: Look at both the patient as a whole person, and the
patient’s environment when treating the patient for an injury or illness.

Science of Unitary Human Beings

addresses the importance of

the environment as an integral art of nursing to ensure
part of the patient, and uses patients have a smooth
that knowledge to help nurses recovery and can get back to
blend the science the best health possible.
 “unitary who cannot be patients have the capacity
to participate knowingly in
human divided into parts,
the process of change.
but have to be
beings” humans are viewed as
looked at as a whole integral with the universe

the patient and his

also irreducible, and or her environment
environment coexists with unitary are one.
human beings.
Rogers’ Theory of Unitary Human Beings-
belief of the coexistence of the human and the environment has greatly
influenced the process of change toward better health. In short, a patient can’t
be separated from his or her environment when addressing health and
treatment.

Human-unitary human beings

A person is defined as an indivisible, pan-dimensional energy field identified by a pattern
and manifesting characteristics specific to the whole. That can’t be predicted from
knowledge of the parts
Energy fields are the “fundamental view the patient and his or her
unit” for both the living and nonliving environment as wholes, and it
and are two types, human and continuously changes in
environmental. intensity, density, and extent
 CONCEPT

ENERGY FIELD-constitutes the fundamental unit of both the living and

the nonliving. Field is a unifying concept, and energy signifies the
dynamic nature of the field.

Unitary human being (human environmental field is defined as

field) is defined as an irreducible, an irreducible,
indivisible, pandimensional energy field
pandimensional energy field
identified by pattern and manifesting
characteristics that are
identified by
specific to the whole and that cannot be pattern and integral with the
predicted from knowledge of the part human field.
universe of open systems holds that energy fields are infinite, open,
and Integral with one another (Rogers, 1983). The
human and environmental fields are in continuous process and are open
systems.

Pattern identifies energy fields. It is the distinguishing characteristic of

an energy field and is perceived as a single wave. The nature of
the pattern changes continuously and innovatively, and these changes
give identity to the energy field.
pandimensionality as a nonlinear (NOT ONLY 3 DIMENSION BUT 4 DIMENSION)
domain without spatial or temporal attributes, or as Phillips (2010) notes: “essentially
a spaceless and timeless reality” (p. 56). The term
pandimensional provides for an infinite domain without limit.
 Metaparadigm

Nursing Person Health Environment

• learned profession • • change is continuously

and is both a • Human beings innovative,
science and an art.
Passive
“Man is a unified unpredictable, and
• concern with people health
whole possessing characterized by
and the world in his own integrity symbolizes increasing diversity.
which and manifesting wellness and 4. Environmental and
they live- a natural fit characteristics the absence human fields are identified
for nursing care, as different from the by wave patterns
it encompasses
of disease
sum of his parts and major manifesting continuous
people and
their environments. illness change.
Dorothy Johnson’s(1960,1980)
Behavioral Systems Model

Ma. Theresa Salinda,MSN

Phd NS (student)
 Dorothy E. Johnson was born August 21 1919,
in Savannah Georgia
MAJOR CONCEPTS AND DEFINITIONS MAJOR CONCEPTS AND DEFINITIONS
1. Behavior 3. Behavioral System
q as expressed by behavioral and q encompasses the patterned, repetitive
biological scientist-that is, the output and purposely ways of behaving
of intraorganismic structures and q interaction between the person and his or
processes as they are coordinated her environment and establishes the
and articulated by and responsive relationship
to changes in sensory stimulation. 4. Subsystems
2. System q minisystemwith its own particular goal and
q is a whole that functions as a whole function that can be maintained as long as
virtue of the independence of its parts. its relationship to other subsystems or
the environment is not disturbed”
 Seven subsystems of behavior which are as
follows
1.Attachment –affiliative subsystem: “social inclusion, intimacy, and the
formation and attachment of a strong social bond.”
2.Dependency subsystem: “approval, attention or recognition, and
physical assistance (helping or nurturing).
3.Ingestive subsystem: “the emphasis is on the meaning and structures of the
social events surrounding the occasion when the foodis eaten, itsfunction is
appetite satisfaction.
4. Eliminative subsystem: human cultures have defined different socially
acceptable behaviors for excretionof waste but the existence of such a
pattern remains different from culture to culture
 Seven subsystems of behavior which are as
follows
5.Sexual subsystem: “both biological and social factor affect thebehavior in
the sexual subsystem.” E.g., role identity, courting, mating. The function
is procreation and gratification.
6.Aggressive-Protective subsystem: “related to the behavior concerned with
protection and self-preservation: one that generates defensive response
from the individual when life or territory is being threatened.
7.Achievement subsystem: “provokes behavior that attempts to control the
environment; intellectual, physical, creative, mechanical and social skills;
(efforts to gain and control).
 Key points
qEquilibrium -a stabilized but more or qTension-be constructive in adaptive
less transitory, resting state in which change or destructive in inefficient
the individual is in harmony with use of energy. Hindering adaptation
himself and with his environment” and causing potential structural
damage.
qRegulation/Control-
qStressorInternal or external stimuli that
vRegulation implies that deviations will
produce tension and result in a degree
be detected and corrected.
of instability are called stressors.
vFeedback is, therefore, a “Stimuli may be positive in that they
requirement of effective control. are present; or negative in that
vThere is self-regulation by the client. something desired or required is
absent.
 4 assumptions of the Behavioral System model:
1.There is “organization, interaction, interdependency, and integration of
the parts and elements of behaviors that make up the system
2. A system tends to achieve a balance among the various forces
operating within and upon it, and that man continually strive to
maintain a behavioral system balance and steady state
3. A behavioral system, which both requires and results is some degree
of regularity and constancy in behavior is essential to man
4. The final assumption states “system balance reflects adjustments and
adaptations that are successful in some ways and to some degree.”
 Four Structural Characteristics:
1. Goal of a subsystem is defined as “the ultimate consequence of behaviors”
(Grubbs,1974.p.226)
qThe basis for the goal is a universal drive, the existence of which is
supported by existing theory or research.•
2. set-is a tendency to act in a certain way in a given situation.
qSet formation is influenced by societal norms and variables as culture,
family, values, perception, and perseveratory sets.•
3.Choice-refers to the alternate behaviors the person considers in any given
situation. Options are influence by such variables as age, sex. Culture, and
socioeconomic status.
4. action-is the observable behavior of the person.
 metaparadigm
1. NURSING. Has a primary goal that is to foster equilibrium within the
individual.
2. PERSON. A behavioral system is comprised of subsystem constantly trying to
maintain a steady state.
3. HEALTH. As an elusive, dynamic state influenced by biological,
psychological, and social factors. Health is reflected by the organization,
interaction, interdependence, and integration of the subsystems of the
behavioral system (Johnson, 1980
4. ENVIRONMENT-consists of all the factors that are not part of the
individual’s behavioral system, but that influence the system. The nurse
may manipulate some aspects of the environment so the goal of health or
behavioral system balancecan be achieved.