Myra Estrin Levine (The Conservation Model)

Influence by:

 Goldstein (1963)
 Hall (1966)
 Dubos (1961;1965)
 Gibson’s (1866) definition of Perceptual Systems
 Erikson’s (1964;1968) differentiation of Total and Whole
 Selye’s (1956) Stress theory
 Bates (1967) Model of External Environment
 Nightingale’s contributions- Levines’s idea of guardian activity

CONCEPTS & DEFINITIONS

• HEALTH comes from “hal” – whole (Anglo Saxon)

• INTEGRITY – wholeness of the individual and the sense of independence & selfhood

“Conservation of integrity of the individual is the hallmark of nursing intervention”

• HEALING – defense of wholeness

- avenue of the return to the daily activities compromised by ill health
- a return to selfhood

Adaptation
• Critical for conserving wholeness in the midst of changing environments
• It is the bridge that allows movement from one environmental reality to another
• Allows individuals to fit in the environment they live in

“The goal of adaptive change is to conserve wholeness and integrity.”

- will be focused ore on holistic wellness of the person

3 Characteristics of Adaptation:
• HISTORICITY – genetic patterns
• SPECIFICITY - unique adaptive responses
• REDUNDANCY – availability of multiple responses

• Presence and interaction of internal environment & external environment

• Claude Bernard’s conceptualization of internal environment

“Man carried the essentials with him, safely packaged inside his skin”- internal
environment, within oneself

• Bates (1973) description of the external environment to have 3 components:

• PERCEPTUAL – aspects of the world precepted by the senses (nararamdaman ng
senses natin)
 • OPERATIONAL – environmental components physically affects individual
although they are not directly precepted(pressure, temperature, can’t be physically seen
pero may factor)
• CONCEPTUAL – recognized through cultural patterns, spirituality and aspects
mediated through language, thought, & history

Organismic response
“The human being responds to forces in his environment in a singular yet integrated
fashion... in a way which is peculiar to him and him alone.” (different responses)

• Nursing care focuses in the on the management of the levels of integrated organismic
(holistic) responses

4 levels of protective organismic response:

• RESPONSE TO FEAR (FIGHT OR FLIGHT) – most primitive and is the response
conducted when individual feels threatened whether or not threat really exists
- Primary response: being alert
• INFLAMMATORY-IMMUNE RESPONSE – protects organisms from irritants and
pathogens but it is draining
- A way of healing; a reparative process
• RESPONSE TO STRESS – derived from Selye’s (1956) model of adaptive stress
response characterized by behavioral and biological responses to nonspecific life
stressors
- There is adaptive energy meant to respond to stressors
- Possibilities of long term effects
• SENSORY RESPONSE – generated through perceptual awareness via sensory stimuli
- Sensory inputs are continuous
• A conservative function
• Actively support the patient’s adaptive efforts to achieve the best environment fit for
their overall wellness
• Highly individualized patient care
• Patient – receiver of care

2 types of nursing interventions:

• THERAPEUTIC INTERVENTIONS – enhancing adaptation and improving well-being
of patient
• SUPPORTIVE INTERVENTIONS – when nursing care is unable to improve adaptive
response
• “conservatio” – to keep together (Latin)
• It is a natural law that describes the way complex systems are able to continue to
function even when severely challenged
• Includes confronting of challenges, adapting accordingly and maintaining uniqueness

CONSERVATION MODEL

The core of the conservation model is to improve a person’s physical and emotional well-
being by considering the four domains of conservation Levine has set out. Nursing’s role
in conservation is to help the person with the process of “keeping together” the total
person through the least amount of effort. The conservation principles do not, of course,
operate singly and in isolation from each other. They are joined within the individual as a
cascade of life events, churning and changing as the environmental challenge is
confronted and resolved in each individual’s unique way (Levine, 1989).

THE FOUR CONSERVATION PRINCIPLES

CONSERVATION OF ENERGY

● It is a must to balance energy and rest to maintain life activities

● Energy Balance – critical focus of nursing care for patients with chronic illness as well
acute illnesses
● Applies equally for perfectly healthy and ill patients
● Adaptation

“The development of chronic disease is always accompanied by a period

during which relearning and readjustment must take place.”
CONSERVATION OF STRUCTURAL INTEGRITY

● Structure and Integrity are interrelated

● Nursing care should maintain a continual rehabilitative focus to minimize structural
damage and prevent disabilities

“Every infection is an assault on structural integrity.”

CONSERVATION OF PERSONAL INTEGRITY

● Valuing self-identity, self-worth and self-respect

● Seen through patient’s unique psychological and behavioral responses to challenges
● Includes recognition of the holiness of each person
● Nursing interventions: teach patients, promote patient participation in decisions and
treatments plans, protecting patient privacy and supporting their cultural practices

“The body does not exist separately from the minds, emotions and soul.”

CONSERVATION OF SOCIAL INTEGRITY

● Reflected among dynamic relationships among human beings

● Nursing intervention: encompasses care of family, promote social connectedness,
minimize sensory deprivation

“Family is a critical social unit and the life of each individual is “woven in the fabric” of
family.”
Nursing- Both a profession and a scientific discipline as nursing is based on a nurse’s
unique knowledge and the scientific knowledge of other disciplines. Their main goal is to
promote adaptation and maintain wholeness. “Trophicognosis.”
Person- A holistic being. He/she has a sense of identity and self- worth. They are
described as “system of systems”. They undergo series of changes. “Any individual who
enters into the dependence of health care is a patient.”
Health- Determined by the ability to function in a reasonably normal manner. It is
achieved through holism.
Environment- Context of how the individual lives their lives. It is not a passive
background.

How was the CONSERVATION MODEL interpreted?

EMPIRICAL EVIDENCES

Levine (1973) has based much of her work on accepted and well-researched scientific
principles. She believed that specific nursing activities could be deduced from scientific
principles.

LOGICAL FORM

Levine primarily used deductive logic. She integrated theories and concepts from
humanities, and the sciences of nursing, physiology, psychology and sociology.

THEORETICAL ASSERTIONS

The major assertions from Levine’s work is that nursing intervention is based on the
conservation of her 4 conservation principles.

Levine provided ideas on the early development of the following theories:

• THEORY OF THERAPEUTIC INTERVENTION – provide basis of nursing

interventions that focus on the patient’s biological realities
• THEORY OF REDUNDANCY – expands redundancy of domain of adaptation and
offers explanations for redundant options (e.g. aging and physiological adaptations of a
failing heart)
How was the CONSERVATION MODEL utilized?

APPLICATION OF CONSERVATION MODEL IN THE NURSING PRACTICE

❑ Practice

• Neonates
• Children
• Women in Labor
• Women with chronic illnesses
• African American women with fibromyalgia
• Older adults
• Cancer patients
• Patients with neurological dysfunction
• Patients with sepsis
• The homeless
• Fatigue in heart failure
• Sleep disturbance following coronary artery bypass surgery
• Testing respiratory capacity
• Critical and cardiac care
• Wound care and enterostomal therapy nursing
• Perioperative nursing
• Life transitions in serious illness
• Management and nursing staff

❑Education

• Levine’s textbook entitled “Introduction to Clinical Nursing” serves as an organizational

structure for teaching medical-surgical nursing to beginner students.
• She also authored “Renewal for Nursing” which is a text for nurses returning to active
practice after a period of inactivity.

❑ Research

• Confusion in hospitalized older adults

• Critical Care
• Use of musical therapy in acute care
• Neonatal nursing
• Fatigue in cancer patients
• Parents adjusting to an ostomy
• Perioperative nursing
• Low back pain
• Effects of exercise
• Violence against women
Are there further developments based on the CONSERVATION MODEL?

• A basis for a nursing diagnosis taxonomy (Stafford, 1996; Taylor, 1974, 1989)
• Mefford (2004) developed a middle range theory of health promotion for preterm
infants tested by Mefford and Alligood (2011a, 2011b)

STRENGTHS

▪ Provides logical explanations

▪ Shows how adaptation, conservation and integrity is interrelated in a different view

WEAKNESSES
▪ Comparatively unspecified concept relationships
▪ Unspecified assumptions

CASE-ON POINT

Yolanda is a 55-year-old married African American mother of two adult children who has
a history of breast cancer. She was diagnosed with fibromyalgia 2 years ago, after years
of unexplained muscle aches and what she thought was arthritis. The diagnosis was a
relief for her; she was able to read about it and learn how to care for herself. Over the past
2 months, Yolanda has stoppped taking all of her medicine, because she was seeing a new
primary care provider and wanted to start her care at “ground zero.” In addition to her
family responsibilities, she is completing her degree as an English major. At the time of
her clinic appointment, she told the nurse practitioner that she was having the worst pain
possible.

PHYSICAL EXAMINATION

Assessment:

➢ External Environment
▪ Perceptual Factors
▪ Operational Factors
▪ Conceptual Environment
➢ Conservation of Energy
➢ Conservation of Structural Integrity
➢ Conservation of Personal Integrity
➢ Conseervationof Social Integrity
Clarity- Even though there were numerous terms, they were given definition.
Simplicity- Model appears simple. Even with various subconcepts and variables, it is
easy to understand.
Generality- Model can be used in all nursing contexts..
Accessibility- Verified the use of inductive reasoning to further develop and inform her
model.
Importance- This particular model is one of the earliest nursing models to clarify and
organize elements of patient care for nursing practice.

Dorothea E. Orem (Self-Care Deficit Theory of Nursing)

MAJOR ASSUMPTIONS

01 People should be self-reliant, and responsible for their care, as well as others in their
family who need care.

02 People are distinct individuals.

03 Nursing is a form of action. It is an interaction between two or more people.

04 Successfully meeting universal and development self-care requisites is an

important component of primary care prevention and ill health.

05 A person’s knowledge of potential health problems is needed for promoting self-care

behaviors.
06 Self-care and dependent care are behaviors learned within a socio- cultural context.

METAPARADIGM OF OREM’S THEORY

PERSON- Orem views a person as a physical, social, and psychological character with
inconsistent degrees of self care abilities. Person is the recipient of care needed, and has
potentials for learning and development, and also has the abilities to learn how to meet
self care needs.
HEALTH- Health is the major metaparadigm, which Orem views as physical, mental, and
social well being. It is the integrity of human structure and the crucial goal of Orem’s
theory.

ENVIRONMENT- Orem’s describe it as a stat that a person exists in an environment.

Orem asserted that person and environment are separate entities in our minds which
required sophistication to conceptualize them as a single unit

NURSING- Orem presented nursing as a unique field of knowledge and an action

system, which is professional practice. According to her nursing is the intervention to
meet the
required need for self care and need for medical care of patients.

CONCEPTUAL THEORIES

1. Theory of Self-care- focuses on the performance or practice of activities that

individuals initiate and perform on their own behalf to maintain life, health, and well-
being

• Self-Care Agency
• Self-Care Requisites
• Therapeutic Self-Care Demand

• SELF-CARE AGENCY
- is a human ability which is "the ability for engaging in self care“ and is affected by
basic conditioning factors.

Basic Conditioning Factors

• Age
• Gender
• developmental state
• health state
• socio-cultural orientation
• health care system factors
• family system factors
• patterns of living
• environmental factors
• resource adequacy and availability.

• SELF-CARE REQUISITES
- Associated with life processes and the maintenance of the integrity of human structure
and functioning.
- Common to all

It is presented in three categories:

1. Universal Self-Care Requisites
- Associated with life processes and the maintenance of the integrity of human structure
and functioning
Identifies these requisites as:
• Maintenance of sufficient intake of air, water, food
• Provision of care assoc with elimination process
• Balance between activity and rest, between solitude and social interaction
• Prevention of hazards to human life well being and
• Promotion of human functioning

2. Developmental self-care requisites- Associated with developmental processes/ derived

from a condition or associated with an event.

3. Health deviation self-care requisites- required in conditions of illness, injury, or disease

or may result from medical measures required to diagnose and correct the condition.

• THERAPEUTIC SELF-CARE DEMAND

- is the totality of “self-care actions to be performed for some duration to meet
known self-care requisites by using valid methods and related sets of actions and
operations.”

Nursing Agency is a complex property or attribute of people educated and trained as

nurses that enables them to act, know, and help others meet their therapeutic self-care
demands by exercising or developing their own self-care agency.

2. The Self-Care Deficit

Theory

This theory delineates when nursing is needed. Nursing is required when an adult is
incapable of or limited in providing continuous effective self- care. Orem identified 5
methods of helping:

• Acting for and doing for others

• Guiding others
• Supporting another
• Providing an environment promoting personal development about meet future demands
• Teaching another

3. The Theory of Nursing Systems

Describes how the patient’s self care needs will be met by the nurse , the
patient, or both. Identifies 3 classifications of nursing system to meet the self care
requisites of the patient:

• Wholly Compensatory Nursing System

• Partial Compensatory Nursing System
• Supportive-Educative System

• Wholly Compensatory Nursing System - represented by a situation in which the

individual is unable “to engage in those self-care actions requiring self-directed and
controlled ambulation and manipulative movement or the medical prescription to refrain
from such activity.

Example: care of a newborn, care of client recovering from surgery in a post-

anesthesia care unit

• Partial Compensatory Nursing System - represented by a situation in which “both nurse

and perform care measures or other actions involving manipulative tasks or ambulation.

Example: Nurse can assist the postoperative client in ambulating, Nurse can bring a meal
tray for a client who can feed himself

• Supportive-Educative System - also known as a supportive-developmental system. The

person “can perform or can and should learn to perform required measures of externally
or internally oriented therapeutic self-care but cannot do so without assistance.”

Example: Nurse guides a mother on how to breastfeed her baby, Counseling a

psychiatric client on more adaptive coping strategies.

Dorothea Orem’s Theory and The Nursing Process

Assessment

• Diagnosis and prescription; determine why nursing is needed. Analyze and interpret by
making a judgment regarding care.
• Design of a nursing system and plan for delivery of care.
• Production and management of nursing systems.

Step 1 – Collect Data in Six Areas

1. The person’s health status
2. The physician’s perspective of the person’s health status
3. The person’s perspective of his or health health
4. The health goals within the context of life history, lifestyle, and health status.
5. The person’s requirements for self-care
6. The person’s capacity to perform self-care

Nursing Diagnosis & Care Plans

Step 2
• The nurse designs a system that is wholly or partly compensatory or supportive-
educative.
• The two actions are: (1) Bringing out a good organization of the components of patients’
therapeutic self-care demands. (2) Selection of a combination of helping methods will be
effective and efficient in compensating for/overcoming the patient’s self-care deficits.

Implementation & Evaluation

Step 3
• A nurse assists the patient or family in self-care matters to identify and describe health
and health-related results. Collecting evidence in evaluating results achieved against
results specified in the nursing system design.
• The etiology component of nursing diagnosis directs actions.

Analysis of the Self-Care Deficit Theory

• Orem’s goal of letting the readers view nursing care to assist people was apparent in
every concept presented.
• From the definition of health which is sought to be rigid, it can now be refined by
making it suitable to the general view of health as a dynamic and ever-changing state.
• The role of the environment in the nurse-patient relationship, although defined by Orem,
was not discussed.
• Orem set nurses’ role in maintaining health for the patient with great coherence
following every individual’s life-sustaining needs.
• Although Orem viewed the parent’s or guardians’ importance in providing for their
dependents, the definition of self-care cannot be directly applied to those who need
complete care or assistance with self-care activities such as the infants and the aged.

CRITIQUES OF OREM’S THEORY

Strengths
• A major strength of Dorothea Orem’s theory is that it is applicable for nursing by the
beginning practitioner and the advanced clinicians.
• Orem’s theory provides a comprehensive basis for nursing practice. It has utility for
professional nursing in the areas of nursing practice, nursing education, and
administration.
• The terms self-care, nursing systems, and self-care deficit are easily understood by the
beginning student nurse and can be explored in greater depth as they gain more
knowledge and experience.
• She specifically defines when nursing is needed: Nursing is needed when the individual
cannot maintain continuously that amount and quality of self-care necessary to sustain
life and health, recover from disease or injury, or cope with their effects.
• Her self-care approach is contemporary with the concepts of health promotion and
health maintenance.
• Three identifiable nursing systems were clearly delineated and are easily understood.

Limitations
• Orem’s theory, in general, is viewed as a single whole thing, while Orem defines a
system as a single whole thing.
• Orem’s theory is simple yet complex. The use of self-care in multitudes of terms, such
as self-care agency, self-care demand, self-care deficit, self- care requisites, and universal
self-care, can be very confusing to the reader.
• Orem’s definition of health was confined to three static conditions, which she refers to
as a “concrete nursing system,” which connotes rigidity.
• Throughout her work, there is a limited acknowledgment of the individual’s emotional
needs.
• Health is often viewed as dynamic and ever-changing.

CONCLUSION

Orem’s theory is relatively simple but generalizable to apply to a wide variety of patients.
It explains the terms self-care, nursing systems, and self-care deficit essential to students
who plan to start their nursing careers.

Moreover, this theory signifies that all patients want to care for themselves. They can
recover more quickly and holistically by performing their own self-care as much as
they’re able. This theory is particularly used in rehabilitation and primary care or other
settings where patients are encouraged to be independent. Though this theory greatly
influences every patient’s independence, the definition of self-care cannot be directly
applied to those who need complete care or assistance with self-care activities such as
infants and the aged.

Imogene M. King (Conceptual System and Middle-Range Theory of Goal Attainment)

Concepts for Personal System

 Perception – a process of organizing, interpreting, and transforming information from

sense data and memory that gives meaning to one’s image of reality and influences
one’s behavior.
 Self – a composite of thoughts and feelings that constitute a person’s awareness of
 individual existence, of who and what he or she is.
 Growth & development – cellular, molecular, and behavioral changes in human
beings that are a function of genetic endowment, meaningful and satisfying
experiences, and an environment conductive to helping individuals move toward
maturity.
 Body image – a person’s perceptions of his or her body.
 Time – the duration between the occurrence of one event and the occurrence of
another event.
 Space – the physical area called territory that exists in all directions.
 Learning – gaining knowledge

Concepts for Interpersonal System

 Interaction – the acts of two or more persons in mutual presence; a sequence of

verbal and nonverbal behaviors that are goal directed.
 Communication – the vehicle by which human relations are developed and
maintained; encompasses intrapersonal, interpersonal, verbal and nonverbal
communication.
 Transaction – a process of interaction in which human beings communicate with the
environment to achieve goals that are valued;goal – directed human behaviors.
 Role a set of behaviors expected of a person occupying a position in a social system.
 Stress—a dynamic state whereby a human being interacts with the environment to
maintain balance for growth, development, and performance, involving an exchange
of energy and information between the person and the environment for regulation
and control of stressors.
 Coping—a way of dealing with stress.

Concepts for Social System

 Organization—composed of human beings with prescribed roles and positions who

use resources to accomplish personal and organizational goals.
 Authority—a transactional process characterized by active, reciprocal relations in
which members' values, backgrounds, and perceptions play a role in defining,
validating, and accepting the authority of individuals within an organization.
 Power—the process whereby one or more persons influence other persons in a
situation.
 Status—the position of an individual in a group or a group in relation to other groups
in an organization.
 Decision making—a dynamic and systematic process by which goal- directed choice
of perceived alternatives is made and acted upon by
 individuals or groups to answer a question and attain a goal.
 Control—being in charge.

Theory Assertions

8 propositions in King's Theory of Goal

Attainment

1. If perceptual interaction accuracy is present in nurse-client interactions, transaction

will occur.
2. If nurse and client make transaction, goal will be attained
3. If goal is attained, satisfaction will occur
4. If goal is attained, effective nursing care will occur
5. If transactions are made in nurse-client interactions, growth & development will be
enhanced
6. If role expectations and role performance as perceived by nurse & client are congruent,
transaction will occur
7. If role conflict is experienced by nurse or client or both, stress in nurse-client
interaction will occur
8. If nurse with special knowledge skill communicate appropriate information to client,
mutual goal setting and goal attainment will occur.

NURSE-PATIENT MODEL OF TRANSACTION

 Action is defined as a sequence of behaviors involving mental and physical action.

 The sequence is first mental action to recognize the presenting conditions; then the
physical action to begin activities related to those conditions; and finally, mental
action to exert control over the situation, combined with physical action seeking to
achieve goals.
 Reaction is not specifically defined but might be included in the sequence of
behaviors described in action.
 Interaction is a process of perception and communication between person and
environment and between person and person represented by verbal and nonverbal
behaviors that are goal-directed
 Transaction is a process of interactions in which human beings communicate with
environment to achieve goals that are valued; transactions are goal-directed human
behavior.

Metaparadigm according to Imogene King's Theory of Goal Attainment

Person

 King described a person existing in an open system as a spiritual being and rational
thinker who makes choices, selects alternative courses of action, and can record their
history through their own language and symbols, unique, holistic and have different
needs, wants and goals.
1. The need for health information that is unable at the time when it is needed and can be
used.
2. The need for care that seek to prevent illness.
3. The need for care when human beings are unable to help themselves.

Health

 Health involves dynamic life experiences of a human being, which implies

continuous adjustment to stressors in the internal and external environment through
optimum use of one’s resources to achieve maximum potential for daily living.

Environment

 King defined Environment as the process of balance involving internal and external
interactions inside the social system. Reaction from interaction between the internal
and external environment can be biological, psychological, physical, social or
spiritual.
1. Internal environment: transforms energy to enable person to adjust to continuous
external environmental changes.
2. External environment: involves formal and informal organizations. Nurse is a part of
the patient’s environment.

Nursing

 Nursing is a process of action, reaction, and interaction whereby nurse and client
share information about their perceptions in nursing situation.
 The nurse and client share specific goals, problems, and concerns and explore means
to achieve a goal.

In addition, king discussed:

a) Goal of nurse: “To help individuals to maintain their health so they can function in
their roles.”
b) Domain of nurse: “includes promoting, maintaining, and restoring health, and caring
for the sick, injured and dying.
c) Function of professional nurse: “To interpret information in nursing process to plan,
implement and evaluate nursing care.

APPLICATION OF THEORY OF GOAL ATTAINMENT IN NURSING PROCESS

ASSESSMENT

 Assessment occurs during interaction.

 The nurse brings special knowledge and skills whereas client brings knowledge of
self and perception of problems of concern, to this interaction.
 During assessment nurse collects data regarding client (his/her growth &
development, perception of self and current health status, roles etc.)
 Perception is the base for collection and interpretation of data.
 Communication is required to verify accuracy of perception, for interaction and
transaction.

NURSING DIAGNOSIS

 The data collected by assessment are used to make nursing diagnosis in nursing
process.
 In process of attaining goal, the nurse identifies the problems, concerns, and
disturbances about which person seek help.

PLANNING

 After diagnosis, planning for interventions to solve those problems is done.

 In goal attainment, planning is represented by setting goals and making decisions
about and being agreed on the means to achieve goals.
 This part of transaction and client’s participation is encouraged in making decision
on the means to achieve the goals.

IMPLEMENTATION

 In nursing process implementation involves the actual activities to achieve the goals.
 In goal attainment it is the continuation of transaction.

EVALUATION
 It involves to finding out whether goals are achieved or not.
 In king description evaluation speaks about attainment of goal and effectiveness of
nursing care.