Psychological Models in Nursing Practice
Comprehensive notes on the Existential, Psychoanalytical, and Behavioral models
Introduction
Psychological models provide frameworks for understanding human behavior, cognition, and emotional processes. For nursing professionals, these models serve as essential tools for assessment, intervention planning, and therapeutic communication. This resource explores three major psychological frameworks—Existential, Psychoanalytical, and Behavioral models—with a special focus on their applications in nursing practice.
Learning Objectives
- Understand the foundational principles of each psychological model
- Distinguish between key concepts across different theoretical frameworks
- Apply psychological principles to nursing assessment and intervention
- Develop therapeutic communication strategies based on these models
- Recognize when and how to implement model-specific approaches in clinical settings
Table of Contents
1. Existential Model
2. Psychoanalytical Models
3. Behavioral Model
Existential Model
Overview
The Existential Model focuses on understanding the human experience through the lens of existence itself. It explores how individuals create meaning in their lives while confronting the fundamental realities of existence such as freedom, isolation, meaninglessness, and mortality.
“Man is nothing else but what he makes of himself.” — Jean-Paul Sartre
Rooted in existential philosophy, this approach emphasizes authentic living, personal responsibility, and making conscious choices in the face of life’s inherent uncertainties. Unlike models that focus on psychopathology, the existential perspective sees anxiety and distress as natural responses to the challenges of human existence.
Key Concepts
The Four Ultimate Concerns
Irvin Yalom identified four existential concerns that all humans must confront:
- Death: Awareness of mortality and finite nature of life
- Freedom: Responsibility for choices and constructing one’s life
- Isolation: Fundamental separation between self and others
- Meaninglessness: Search for purpose in a universe without inherent meaning
Authenticity vs. Bad Faith
Central to existential thinking is the concept of living authentically:
- Authenticity: Living according to one’s true values and accepting responsibility
- Bad Faith: Self-deception and denial of freedom and responsibility
- Being-in-the-world: Acknowledging one’s existence as part of the wider world
Existential Anxiety & Growth
The journey from comfort through existential anxiety toward authentic growth and meaning
MNEMONIC: “FIND” Existential Themes
- Freedom and responsibility for choices
- Isolation and connection with others
- Nonbeing (mortality) and awareness of death
- Discovery of meaning in a meaningless universe
Nursing Role in Existential Care
Core Nursing Responsibilities
When applying the existential model, nurses focus on presence, meaning-making, and supporting patients through existential crises. The therapeutic relationship becomes a space where patients can explore their authentic selves.
| Nursing Intervention | Purpose | Clinical Example |
|---|---|---|
| Authentic Presence | Being fully engaged with patients without pretense or professional distancing | Sitting with a terminal patient in silence, holding their hand without trying to offer false reassurance |
| Meaning-Focused Dialogue | Helping patients explore and articulate what gives their life meaning | Encouraging a patient with chronic illness to identify values and activities that provide purpose despite limitations |
| Supporting Choice & Autonomy | Respecting patient decisions and facilitating informed choices | Providing comprehensive information to a patient deciding between treatment options, without imposing one’s own values |
| Existential Reflection | Creating space for patients to reflect on existential questions | Asking open-ended questions about how a life-changing diagnosis has affected a patient’s view of themselves and their future |
| Normalization of Existential Anxiety | Helping patients understand that existential fears are natural human experiences | Reassuring a patient that feelings of uncertainty about the future after major surgery are normal and can be a catalyst for growth |
Assessment Techniques
- Listen for existential themes in patient narratives
- Assess for value conflicts or loss of meaning
- Identify how patients are coping with mortality awareness
- Explore how illness impacts the patient’s sense of identity
- Evaluate the quality of important relationships in the patient’s life
Therapeutic Communication
- Use open-ended questions about meaning and purpose
- Practice reflective listening without imposing solutions
- Validate existential struggles as normal human experiences
- Create safe spaces for expressions of fear, doubt, and hope
- Share authentic human-to-human connections while maintaining therapeutic boundaries
Clinical Applications
Case Scenario: End-of-Life Care
Mrs. Johnson, 68, was recently diagnosed with terminal pancreatic cancer. She expresses feeling that her life has lost meaning and questions “why this is happening to her.” She’s withdrawn from family and refuses to discuss her prognosis.
Existential Nursing Approach:
- Create a space of authentic presence, sitting with Mrs. Johnson without forcing conversation or offering platitudes
- Validate the normalcy of existential questioning when facing mortality
- Gently explore what has given her life meaning in the past, and what might provide meaning now
- Support her in communicating her fears and wishes to family members
- Help her identify choices she still has control over in her remaining time
This approach acknowledges Mrs. Johnson’s existential crisis while supporting her journey toward finding meaning and authenticity in her final chapter. The nurse serves as a compassionate witness to her suffering while empowering her to face mortality on her own terms.
Reflection Questions for Nurses
- • How do I create authentic human connections with patients while maintaining professional boundaries?
- • In what ways do I help patients find meaning in their illness experiences?
- • How comfortable am I sitting with a patient’s existential pain without trying to “fix” it?
- • What personal existential concerns might affect my nursing care, and how can I address them?
Psychoanalytical Models
Overview
Psychoanalytical models originate from Sigmund Freud’s pioneering work and subsequent developments by neo-Freudians and object relations theorists. These approaches focus on understanding how unconscious processes, early childhood experiences, and intrapsychic conflicts shape personality development and psychological functioning.
“The unconscious is the larger circle which includes within itself the smaller circle of the conscious.” — Carl Jung
While classic psychoanalysis has evolved significantly over time, the core emphasis on unconscious motivations, defense mechanisms, and the influence of early relationships remains fundamental to psychodynamic approaches in mental health care.
Key Concepts
Structure of the Mind
Freud proposed a tripartite model of the mind:
- Id: Primitive instincts, operates on pleasure principle
- Ego: Mediates between id and external reality, operates on reality principle
- Superego: Internalized moral standards and ideals
Levels of Consciousness
Mental processes occur at different levels of awareness:
- Conscious: Thoughts and feelings we’re aware of
- Preconscious: Material that can be readily accessed with attention
- Unconscious: Hidden wishes, memories, and impulses inaccessible to conscious awareness
Freud’s Structural Model of the Mind
The relationship between levels of consciousness and personality structures
Common Defense Mechanisms
| Defense Mechanism | Description | Clinical Example |
|---|---|---|
| Repression | Pushing distressing thoughts into the unconscious | A patient unable to recall traumatic medical experiences |
| Projection | Attributing unwanted thoughts/feelings to others | A patient accusing staff of hostility when experiencing their own anger |
| Denial | Refusing to accept reality or facts | A patient refusing to acknowledge a serious diagnosis despite clear evidence |
| Displacement | Redirecting emotions to a less threatening target | A patient being overly critical of hospital food after receiving distressing news |
| Rationalization | Creating logical explanations for unacceptable feelings/behaviors | A patient explaining non-adherence to treatment as “doing research” rather than fear |
MNEMONIC: “OPERA” for Freud’s Psychosexual Stages
- Oral Stage (0-18 months): Focus on oral gratification
- Personal boundaries in Anal Stage (18-36 months): Control and autonomy
- Emergence of gender identity in Phallic Stage (3-6 years): Oedipal/Electra complex
- Rest period in Latency Stage (6-12 years): Sexual drives dormant
- Adult sexuality in Genital Stage (12+ years): Mature sexual interests
Neo-Freudian & Object Relations Approaches
Later theorists expanded psychoanalytic thinking beyond Freud’s emphasis on biological drives:
- Erik Erikson: Psychosocial stages across the lifespan
- Carl Jung: Collective unconscious and archetypes
- Melanie Klein: Internal objects and splitting in early development
- Donald Winnicott: “Good enough” mothering and transitional objects
- John Bowlby: Attachment theory and its impact on development
Nursing Role in Psychoanalytical Care
Core Nursing Responsibilities
Applying psychoanalytical concepts in nursing requires attention to unconscious processes, transference/countertransference dynamics, and interpreting behavior as expressions of underlying conflicts. Nurses work to create therapeutic environments that support psychological insight.
Therapeutic Relationship Dynamics
- Transference: Patient projecting feelings about significant others onto the nurse
- Countertransference: Nurse’s emotional reactions to the patient
- Therapeutic use of self: Using self-awareness in interactions
- Boundaries: Maintaining professional limits while allowing for emotional exploration
Assessment Through a Psychoanalytic Lens
- Identifying patterns in relationships and attachment styles
- Recognizing defense mechanisms in patient behaviors
- Understanding symbolic meaning of symptoms
- Assessing for unconscious conflicts in presenting problems
- Analyzing dreams and parapraxes (Freudian slips)
Psychoanalytically-Informed Nursing Interventions
| Intervention | Purpose | Clinical Example |
|---|---|---|
| Containment | Providing a safe space for emotional expression | Creating a calm environment for a patient to express difficult feelings without judgment |
| Interpretation | Offering possible meanings of behaviors or patterns | Gently suggesting that a patient’s anger toward staff might relate to feelings of abandonment |
| Working Through | Supporting patients as they process insights | Consistently revisiting themes as a patient gradually accepts difficult realizations |
| Holding Environment | Creating reliable, consistent care | Maintaining consistent boundaries and routines for patients with attachment difficulties |
| Self-Reflection Promotion | Encouraging introspection about feelings and behaviors | Using journaling or guided questions to help patients connect current reactions to past experiences |
Clinical Considerations
- • Supervision: Regular clinical supervision is essential when working psychoanalytically to process countertransference and maintain therapeutic boundaries
- • Timing: Interpretations must be offered when the patient is ready to receive them, not prematurely
- • Integration: Psychoanalytic approaches can complement other modalities rather than replace them entirely
- • Cultural awareness: Consider cultural differences in expressing emotions and family dynamics when applying psychoanalytic concepts
Clinical Applications
Case Scenario: Post-Traumatic Stress
Michael, 35, is admitted following a car accident. He appears calm but becomes intensely angry when nurses attempt routine procedures. He frequently “forgets” appointments and denies needing pain medication despite visible discomfort. History reveals a previous traumatic hospitalization in childhood.
Psychoanalytical Nursing Approach:
- Recognize defense mechanisms: Michael’s denial of pain and “forgetting” appointments as avoidance of vulnerability
- Identify transference: His anger toward nurses may represent displaced feelings from previous medical trauma
- Establish a holding environment: Maintain consistency in care approach and boundaries
- Provide containment: Allow expression of feelings without judgment while maintaining safety
- Gentle interpretation: At appropriate times, help Michael connect current reactions to past experiences
This approach acknowledges the unconscious processes influencing Michael’s behavior. Rather than labeling him as a “difficult patient,” the nurse recognizes his defenses as protective mechanisms and creates a therapeutic relationship that gradually allows for more adaptive coping.
MNEMONIC: “AWARE” for Psychoanalytic Self-Reflection
Nurses can use this framework to examine their own countertransference:
- Affect: Identify your emotional reactions to the patient
- Who does this patient remind you of? (Recognize projection)
- Avoidance or over-involvement? (Notice boundary issues)
- Recurring patterns in your interactions with similar patients
- Explore these reactions in supervision or reflection
Behavioral Model
Overview
The Behavioral Model focuses on observable actions rather than internal mental processes. Rooted in the works of Ivan Pavlov, B.F. Skinner, and John Watson, this approach views behaviors as learned responses to environmental stimuli that can be modified through conditioning and reinforcement.
“Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I’ll guarantee to take any one at random and train him to become any type of specialist I might select.” — John B. Watson
Unlike models that emphasize unconscious processes or existential concerns, behavioral approaches concentrate on measurable, observable behaviors and the environmental factors that influence them. This makes behavioral interventions particularly amenable to empirical validation and measurement of outcomes.
Key Concepts
Classical Conditioning
Learning through association of stimuli:
- Unconditioned Stimulus (UCS): Naturally triggers response
- Unconditioned Response (UCR): Natural response to UCS
- Conditioned Stimulus (CS): Previously neutral stimulus paired with UCS
- Conditioned Response (CR): Learned response to CS
Operant Conditioning
Learning through consequences of behavior:
- Positive Reinforcement: Adding something desired to increase behavior
- Negative Reinforcement: Removing something aversive to increase behavior
- Positive Punishment: Adding something aversive to decrease behavior
- Negative Punishment: Removing something desired to decrease behavior
ABC Model of Behavior
Antecedents trigger behaviors, which lead to consequences that influence future behavior
Behavioral Learning Principles
| Principle | Description | Nursing Application |
|---|---|---|
| Extinction | Gradual decrease in behavior when reinforcement is removed | Not responding to attention-seeking behaviors in patients with borderline personality disorder |
| Shaping | Reinforcing successive approximations toward desired behavior | Gradually increasing physical activity goals for cardiac rehabilitation patients |
| Schedules of Reinforcement | Timing patterns for delivering reinforcement | Implementing token economy with intermittent reinforcement schedule in mental health units |
| Chaining | Breaking complex behaviors into sequence of smaller behaviors | Teaching self-care skills to patients with cognitive impairments through step-by-step reinforcement |
| Generalization & Discrimination | Applying learned responses to similar situations vs. distinguishing between situations | Teaching anxiety management techniques that can be used in multiple settings while identifying specific triggers |
MNEMONIC: “SPIN” for Operant Conditioning
- Strengthening with Positive reinforcement (add desired stimulus)
- Strengthening with Negative reinforcement (remove aversive stimulus)
- Inhibiting with Positive punishment (add aversive stimulus)
- Inhibiting with Negative punishment (remove desired stimulus)
Evolution to Cognitive-Behavioral Approaches
Modern behavioral approaches have integrated cognitive elements to address the role of thoughts in behavior:
- Cognitive-Behavioral Therapy (CBT): Examines how thoughts influence feelings and behaviors
- Dialectical Behavior Therapy (DBT): Combines behavioral techniques with mindfulness and acceptance
- Acceptance and Commitment Therapy (ACT): Focuses on psychological flexibility and valued action
- Behavioral Activation: Targets depression by increasing engagement in rewarding activities
Nursing Role in Behavioral Care
Core Nursing Responsibilities
Nurses applying behavioral principles focus on assessing, measuring, and modifying observable behaviors through environmental manipulation and reinforcement strategies. This approach emphasizes objective data collection and measurable outcomes.
Behavioral Assessment
- A-B-C Analysis: Documenting Antecedents, Behaviors, and Consequences
- Frequency counts: Tracking how often behaviors occur
- Duration recording: Measuring how long behaviors last
- Intensity scales: Rating the severity of behaviors
- Functional analysis: Determining the purpose behaviors serve
Behavioral Planning
- Setting specific, measurable behavioral goals
- Designing reinforcement schedules and token economies
- Creating behavior contracts with patients
- Developing stimulus control strategies
- Planning for generalization of skills to different settings
Behavioral Nursing Interventions
| Intervention | Purpose | Clinical Example |
|---|---|---|
| Contingency Management | Systematically applying reinforcers based on target behaviors | Implementing a point system for adolescents who complete hygiene routines independently |
| Systematic Desensitization | Gradually exposing patients to feared stimuli while in relaxed state | Working with a patient with needle phobia through progressive exposure combined with relaxation techniques |
| Behavioral Rehearsal | Practicing new behaviors through role-play and simulation | Helping patients practice assertive communication through supervised role-playing |
| Modeling | Demonstrating desired behaviors for patients to imitate | Demonstrating proper inhaler technique for asthma patients before asking them to practice |
| Environmental Modification | Altering settings to support desired behaviors | Removing distractions and creating structured routines for patients with attention deficits |
Behavioral Approach Steps for Nurses
- Identify target behaviors that are specific, observable, and measurable
- Establish baseline data through systematic observation and recording
- Analyze antecedents and consequences that maintain problematic behaviors
- Set concrete behavioral goals with the patient when possible
- Design and implement interventions based on behavioral principles
- Continuously measure outcomes and adjust interventions as needed
- Plan for maintenance and generalization of behavioral changes
Clinical Applications
Case Scenario: Medication Adherence
Mrs. Rodriguez, 72, has been hospitalized multiple times for complications related to irregular medication adherence for her heart failure. She reports forgetting doses and feeling overwhelmed by her complex medication regimen. Previous education attempts have been unsuccessful.
Behavioral Nursing Approach:
- Assessment: Conduct ABC analysis to identify specific barriers to adherence (e.g., complex schedule, forgetting, lack of immediate benefits)
- Intervention design: Create a simplified medication schedule with visual cues and alarms
- Environmental modification: Reorganize medication storage and set up prominent visual reminders
- Reinforcement system: Implement a medication tracking calendar with rewards for adherence
- Skill building: Use modeling and behavioral rehearsal to teach pill organization
- Data collection: Track adherence through pill counts and patient self-monitoring
This approach focuses on concrete, observable behaviors related to medication management rather than only providing information. By addressing specific barriers and implementing reinforcement strategies, the nurse supports the development of sustainable medication habits.
Pediatric Settings
- Token economies for procedure cooperation
- Positive reinforcement for health-promoting behaviors
- Systematic desensitization for medical fears
- Parent training in behavioral management
Mental Health Settings
- Behavioral activation for depression
- Exposure therapy for anxiety disorders
- Contingency management for substance use
- Skills training for emotional regulation
Rehabilitation Settings
- Shaping and chaining for relearning ADLs
- Scheduled reinforcement for exercise adherence
- Self-monitoring for pain management
- Behavioral contracting for home program compliance
MNEMONIC: “TRACE” Your Behavioral Nursing Skills
Use this self-assessment to evaluate your behavioral practice:
- Target behaviors clearly defined and measurable?
- Reinforcement plans appropriate and individualized?
- Assessment data objective and systematically collected?
- Consistency maintained in implementing behavioral interventions?
- Evaluation of outcomes based on behavioral metrics?
Comparative Analysis of Psychological Models
Each psychological model offers unique perspectives and tools for nursing practice. Understanding the strengths, limitations, and appropriate applications of each approach allows nurses to select the most effective framework for specific clinical situations.
| Existential Model | Psychoanalytical Models | Behavioral Model | |
|---|---|---|---|
| Focus | Meaning, authenticity, and facing existential realities | Unconscious processes and early developmental influences | Observable behaviors and environmental influences |
| View of Symptoms | Natural responses to existential challenges | Expressions of unconscious conflicts | Learned responses to environmental stimuli |
| Therapeutic Relationship | Authentic human-to-human encounter | Transference-countertransference dynamic | Collaborative, educational partnership |
| Change Process | Confronting anxiety to find authentic meaning | Gaining insight into unconscious processes | Learning new behavioral responses |
| Nursing Assessment Focus | Meaning, values, and existence concerns | Defense mechanisms and relationship patterns | Antecedents, behaviors, and consequences |
| Strengths | Profound for life-threatening illness, grief, and spiritual concerns | Addresses deep-rooted patterns and unconscious motivations | Concrete, measurable, and empirically validated interventions |
| Limitations | Less structured, difficult to measure outcomes | Time-intensive, requires specialized training | May oversimplify complex human experiences |
| Best Clinical Applications | End-of-life care, major life transitions, identity crises | Complex trauma, relationship difficulties, personality disorders | Phobias, habit disorders, skill development, health behavior change |
Integrative Nursing Approach
Rather than rigidly adhering to a single model, skilled nurses often incorporate elements from multiple psychological frameworks based on:
- Individual patient needs and preferences
- Specific presenting problems and goals
- Stage of treatment or recovery
- Evidence for specific interventions with particular conditions
- Cultural context and considerations
The most effective nursing care draws on behavioral techniques for concrete skill building, psychoanalytic insights for understanding patterns, and existential approaches for addressing meaning—tailored to the unique needs of each patient situation.
Conclusion
The Existential, Psychoanalytical, and Behavioral models represent fundamental frameworks for understanding human experience and behavior in nursing practice. Each offers unique insights and approaches to assessment, intervention, and therapeutic relationship development.
Integrating knowledge of these psychological models enhances nursing care by providing multiple lenses through which to understand patients’ experiences. This comprehensive understanding allows nurses to develop individualized, theory-based interventions that address the full spectrum of human needs—from concrete behavioral changes to deep existential concerns.
As nursing continues to evolve as a profession that blends science and art, familiarity with these psychological models provides a foundation for both evidence-based practice and the deeply human dimensions of care. By drawing on these theoretical frameworks, nurses can develop their own integrated approach to patient care that is both scientifically sound and profoundly compassionate.
References
- Frankl, V. E. (2006). Man’s search for meaning. Beacon Press.
- Yalom, I. D. (2020). Existential psychotherapy. Basic Books.
- Freud, S. (2010). The interpretation of dreams: The complete and definitive text. Basic Books.
- McLeod, S. (2019). Defense mechanisms. Simply Psychology. Retrieved from https://www.simplypsychology.org/defense-mechanisms.html
- Skinner, B. F. (2011). About behaviorism. Vintage.
- Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.
- Erikson, E. H. (1994). Identity and the life cycle. W. W. Norton & Company.
- Bowlby, J. (2008). A secure base: Parent-child attachment and healthy human development. Basic Books.
- Hays, J. S., & Larson, K. H. (1963). Interacting with patients. Macmillan.
- Peplau, H. E. (1991). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. Springer Publishing Company.