Fundamentals - Principles, part 5: Theoretical Foundations - Kohlberg, Maslow, Erikson, and Piaget

When you were little, did you have an imaginary friend or a stuffed animal with magic powers? Read on to find out why, and how understanding human perception, needs and motives can make you a better nurse. In this article, we've outlined the key theoretical frameworks in nursing that you will need to know for your nursing school exams—Kohlberg, Maslow, Erikson, and Piaget. These are the frameworks which are most commonly found on exams and can give you a good theoretical foundation.

The Fundamentals of Nursing video series follows along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Why do nurses need to know theoretical foundations?

The theoretical foundations that you will need to know for your nursing exams explain different methods of understanding human thinking, reasoning, decision-making, types of needs, internal conflict, perception and cognition. Considering these frameworks in the context of patient behavior will help nurses better understand their patients, and oftentimes themselves, which can lead to better caregiving. Knowing Maslow's hierarchy can also help with determining nursing priorities.

Understanding patients motives, needs and perceptions can enhance nursing communication and the nurse/patient relationship.

What is psychosocial?

Throughout this article, we will use the term psychosocial when referring to different aspects of each framework. Psychosocial simply means involving both psychological and social aspects, or the interrelation of mental health and the social environment.

Kohlberg's Theory of Moral Development

Kohlberg’s Theory of Moral Development is a theory that focuses on thinking, reasoning, and decision-making across the lifespan. The three stages in Kohlberg's Theory are preconventional, conventional, and postconventional.

Preconventional stage

Kohlberg's Theory says that from birth to age 5, children are in the preconventional stage, when actions are taken with the goal of avoiding consequences or to get a reward. If you are familiar with the metaphor for "carrot vs. stick," where the carrot is a reward and the stick is a punishment, you can think of that for Kohlberg's preconventional stage.

Kohlberg's Theory about the preconventional stage can help explain why sticker charts are effective for very young children, as the sticker functions as a reward for good behavior.

On the NCLEX, you might see a question like "A patient makes a decision in order to get a reward. The nurse understands this is which stage of Kohlberg's theory of moral development?" — the answer would be preconventional.

Conventional stage

Kohlberg's Theory defines the conventional stage from age 6 to 12 when children start to think about how their actions affect other people, and that can influence their decision making. Children in this stage begin to understand and follow social norms and desire the approval of others.

Postconventional stage

Kohlberg's Theory says that the postconventional stage begins around age 13, and that this is when abstract ideas and other perspectives begin to impact decision making.

Maslow's Hierarchy of Needs

Maslow's Hierarchy of Needs is the most popularly known example of these theoretical frameworks, so you may already know about it! Maslow defined human needs and organized them hierarchically by how important they are. Maslow's Hierarchy is often shown in the form of a pyramid, indicating which needs are the most basic and important, as the foundation that the other needs are built on.

The key takeaway from Maslow's Hierarchy is that our psychosocial, higher-level needs can't be met until our basic and physiological needs are met. As a nurse, you will want your patients to fulfill their self-actualization needs, but per Maslow's Hierarchy, they can't do that if they are in severe pain or don't know where their next meal is coming from.

Maslow's Hierarchy can be used to help determine your priority nursing actions. For example, when prioritizing a nursing diagnosis for a patient with an eating disorder, inadequate nutrition (a physiological need) takes priority over working on body image (a psychosocial need).

If you encounter a test question where you need to establish your nursing priorities, and there are both physiological and psychosocial options, you can usually eliminate the psychosocial options first.

Physiological Needs

Physiological needs are the base of Maslow's Hierarchy. This means that our biological survival needs are the most important: water, food, and shelter.

Safety

Second from the bottom in Maslow's Hierarchy is safety, which includes security, employment and access to resources.

Love and Belonging

Third from the bottom in Maslow's Hierarchy is love and belonging, which includes relationships with friends, family, and significant others.

Self-Esteem

Fourth from the bottom in Maslow's Hierarchy is self esteem, which includes achievement and respect. We desire to be respected by others and ourselves (self-respect).

Self-Actualization

Near the top of Maslow's hierarchy is self actualization, which includes pursuing inner talents and fulfillment (e.g., hobbies) and achieving personal goals.

Erikson’s Stages of Psychosocial Development

Erikson’s Stages of Psychosocial Development is the name for a theory that describes key stages in human development and the "psychosocial crisis" encountered during each stage. A psychosocial crisis in this context is a conflict that can involve mental health and the social environment. For each stage of human development, Erikson posited that people have a main conflict that they are concerned with, whether they are aware of it or not.

Infancy: Trust vs. Mistrust

Erikson theorized that from birth to 1 year of age, we are learning what we can trust and what we cannot. For example, if you (a baby) cry, does someone attend to your needs?

Toddler: Autonomy vs. Shame and Doubt

Erikson theorized that from 1 to 3 years of age, we are learning our own autonomy in the world and that we can act on the world around us, but we can also internalize shame and doubt if our autonomy is suppressed. For example, if a three year old wants to dress herself, she is exhibiting autonomy, but if she were prevented from doing so by a strict parent or authority figure, she might learn to doubt her abilities.

Preschooler: Initiative vs. Guilt

Erikson theorized that from 3 to 6 years of age, children take initiative in the world and assert themselves through their social and physical interactions on the environment. However, if a child is prevented from doing so, they may internalize guilt.

School Age: Industry vs. Inferiority

Erikson theorized that from 6 to 12 years of age, we become more part of "industry" by attending school, making crafts, learning, participating in sports, and competing with peers. However, this can also have the effect of stack ranking us against our peers, and inferiority complexes can develop.

If a child was hospitalized during this time, they are away from their peers and the learning environment. Nurses can remember this Erikson stage (and its related needs) and give the child some crafts to do, or ensure they get their homework and other projects sent to them from their school.

Adolescence: Identity vs. Role Confusion

Erikson posited that from 12 to 18 years of age, we are forming our own identity in the world with our beliefs, actions, values, and choices (e.g., what clothes to wear). However, at this time we may also become confused about our place in the world. Teens may ask themselves, "What do I want to do with my life?"

Young Adulthood: Intimacy vs. Isolation

Erikson theorized that once we arrive at adulthood at age 18, all the way to age 40, we seek intimacy with others through friendships, acquaintances, family, and romantic relationships. However, we are also susceptible to isolation if we do not succeed (or think we don't) in these intimate relationship efforts.

Adulthood: Generativity vs. Stagnation

Erikson suggests that between the ages of 40 and 65 years old, our new task becomes generativity — to find our life's work and live into its purpose (e.g., career, raising a family, etc.). However, if we do not master this task we risk stagnation — feeling stuck or like we are not having an impact on the world around us.

During this time, life changes may be occurring — kids are grown and leave the home, some people become grandparents. This is a big shift and can be a crisis for some. People in this stage may either try to hold onto their youth, or part ways with it freely.

Older Age: Integrity vs. Despair

Erikson's theory states that once we reach old age (65 years old and older), we might reflect on our lives and feel pride and integrity at what we've accomplished. Alternatively, if we don't believe we have accomplished our life's goals, we may feel despair.

Piaget's Theory of Cognitive Development

Piaget’s Theory of Cognitive Development is a theory that describes perception and cognition across the lifespan. Piaget's Theory is made up of stages of how children perceive and explore the world before entering adulthood.

Sensorimotor stage

Piaget's theory states that during the sensorimotor stage, which is from birth to 2 years old, humans learn through senses and movement. During this stage, we also develop object permanence.

When children are born, they do not have object permanence, which means when something disappears from their sight, it ceases to exist to them. That's why peekaboo is such a fun game for babies and young toddlers— when you cover your face, they think you have completely disappeared...only to—SURPRISE!—come right back!

Preoperational stage

Piaget's theory defines the preoperational stage between ages 2 and 7 as the time when magical thinking occurs. Magical thinking is defined as thinking that magic is real, and that things can happen in the child's environment because of magic.

The preoperational stage also features animism, which means that we attribute human-like characteristics to inanimate objects. This could be anything from a stuffed animal to a decoration in the house. Children might be afraid of these things, or really like these things, because they believe the things are alive. If a child has an imaginary friend, that is also an example of animism.

Concrete operational stage

Piaget states that in the concrete operational stage, from ages 7 through 11, children gain an increased understanding of cause and effect, and the concept of conservatism starts to be understood. Conservatism is the understanding that matter does not change when its form is altered.

As an example, if you have 100ml of liquid and pour it into a short, fat glass, then pour it into a tall, skinny glass, a child who had not mastered conservatism would think that those were different amounts of liquid. An understanding of conservatism is evident when the child knows the volume of liquid didn't change.

Formal operational stage

Piaget's formal operational stage begins at age 11 and continues beyond, and this is where children develop abstract thinking, deductive reasoning, and logic-based problem solving. Abstract thinking is the ability to think of concepts (e.g., "dogs" in general as opposed to the child's actual, specific pet dog) and abstract ideas (things that exist but you can't touch, e.g. love, freedom, or poverty).