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288424199-Myra-Levine-s-Conservation-Theory.pptx
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- 2. Myra Estrin Levine 19201996 (Group A, 2011) Introduction to Theorist
- 3. Education • 1944 • CookCounty School of Nursing, Chicago Diploma in Nursing • 1949 • University of Chicago Bachelor of Science in Nursing • 1962 • Wayne State University, Detroit Master of Science in Nursing • 1992 • Loyola University, Chicago Honorary Doctorate (Group A, 2011)
- 4. • Child duringGreat Depression • Young adult during WWII Life Experience • Oncology nurse • Civilian nurse at Gardiner General Hospital Clinical Experience • Director of Nursing at Drexel Nursing Home • Administrative Supervisor at University of Chicago Administrative Experience • Clinical Instructor at Bryan Memorial Hospital • Chairperson of clinical nursing at Cook County School of Nursing • Visiting professor at Tel Aviv University in Israel • Seventy-seven published articles Educational Experience (Meleis, 2012 and Group A, 2011) Experience
- 5. Beliefs Theory should influencepractice Acceptable use of adjunct science Conservation came from physics Patients give up independence when they enter health-care environment and should regain it when they leave (Levine, 1989, Levine, 1990, and Levine, 1996)
- 6. Theory Beginnings Began asnursing curriculum Gives rationale behind nursing actions Goals: Teach problem solving skills Teach individualized patient care Avoid procedure-oriented methods (Group A, 2011)
- 7. Internal environment adapts to externalenvironmental cues through conservation so that person maintains integrity Conservation Theory (Levine, 1969, Levine, 1989, Levine, 1990, Levine 1996 Levine, 1996)
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- 9. External Environment Perceptual Can besensed light, sound Conceptua l Can be thought about language, symbols Operation al Interacts with tissues without person being aware Radiation, microorganisms (Levine, 1989)
- 10. Adaptation • Process ofinteracting with environment • Process of change or of life • Can be equated with – Homeostasis – Stability – Equilibrium – Balance (Levine, 1989 and Levine, 1990)
- 11. Three Parts ofAdaptation Historicity • Refers to person’s genetic makeup • Happens at the cellular level Specificity • There is a system to deal with each task • Biologic systems model • Interacting sequences of events Redundancy • Person displays multiple responses to dysfunction • Multiple systems deal with threat (Levine, 1989 and Levine, 1996)
- 12. Types of responses •Quick response to threat or perceived threat Fight or flight • Restores physical wholeness (healing) Inflammatory-immune • Integrated response of person Stress • Focusing on specific aspects of environment Perceptual awareness (Levine, 1989)
- 13. Conservation • Product ofadaptation • Is how a system sustains itself even when challenged • Can be equated with a thermostat – Negative feedback systems – Efficient use of energy • Goal of conservation is health (Levine, 1989, Levine, 1990, and Levine, 1996)
- 14. • Recognition of self •Protection of personal space • Ability to function in groups • Self is developed in family and society • Physical healing • Physiologic activities • Protects functional integrity • Pacing activities to restore function Conservation of Energy Conservation of Structural Integrity Conservation of Personal Integrity Conservation of Social Integrity (Levine, 1990 and Levine, 1996) Principles of Conservation
- 15. Integrity • Same rootas health and whole • Independence • Control over own life (Levine, 1990 and Levine, 1996)
- 16. Internal Environment External Environmental Cues Adaptation Conservation Integrity (Levine, 1969,Levine, 1989, Levine, 1990, Levine 1996 Levine, 1996)
- 17. Nurse’s Role inSupporting Adaptation (Levine, 1969) • Therapeutically – Encourages favorable adaptation • Supportively – Maintains status quo cannot prevent decline
- 18. Interventions based onprinciples of conservation Conservation of energy Timing, spacing, and restriction of interventions Measured through vital signs, blood gases, patient behavior Conservation of Structural Integrity Limit injury Proper positioning and range of motion exercises Conservation of Personal Integrity Maintain Privacy Respect patient’s desire to withhold information Conservation of Social Integrity Include support system in treatment plan Assist with coping behaviors Help them adjust to health-care environment (Levine,, 1989 and Levine 1990)
- 19. Example Bed bath conservesenergy and promotes structural integrity The nurse also must look at personal integrity (privacy) and social integrity (visitors present) Can intervention be timed differently or done in a way to encourage conservation principles in ALL areas? (Levine, 1990)
- 20. Internal environment adapts to externalenvironmental cues through conservation so that person maintains integrity (Levine, 1969, Levine, 1989, Levine, 1990, Levine 1996 Levine, 1996)
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- 22. Purpose Describes rationale fornursing actions Written for hospital-based nursing, but can apply to all patient-care situations (Group A, 2011 and Levine, 1990)
- 23. Concepts Person Viewed holistically As havingintegrity Environment Internal and external Internal environment adapts External environment is manipulated Health Fitting into external environment through adaptation Integrity Wholeness Nursing Duty is to promote wholeness and adaptation Uses conservation principles to plan interventions Must use thorough observation and scientific method to arrive at nursing actions.
- 24. Definitions Specific definitions alreadycovered in detail Internal environment External environment Adaptation Conservation Integrity Multiple definitions derived from Latin/Greek roots Author was very careful in word selection Patient vs. client Integrity (Levine, 1991 and Levine, 1996)
- 25. Relationships Concepts are wellrelated Patient’s internal environment adapts to external environmental cues through conservation so that person maintains integrity (Levine, 1969, Levine, 1989, Levine, 1990, Levine 1996 Levine, 1996)
- 26. Structure Concepts are dividedinto subcomponents All concepts move toward end goal—integrity Does not lie in a linear fashion, rather ongoing process of events No internal diagram Has been depicted as mandala art
- 27. Assumptions Assumptions are implicit Valuesa patient-centered approach Patient is to be viewed as a whole Patient interacts with environment Nurse is provider of care Nurse is an active participant in patient’s environment Disease is a disruption which must be adapted to (Glass, 1989)
- 28. Clarity and Simplicity Wellorganized, easy to read, flows logically All concepts are divided and clearly defined Language is consistent throughout Succeeds in giving nurse rationale for interventions
- 29. Generalizability Broad purpose Theory appliesto all people. – Used with multiple patient populations – Used in multiple settings
- 30. Importance Supported with empiricaldata Results can be generalized to other populations Forward-looking theory for time written Many writings address current issues noncompliant patients (Levine, 1970) healthcare costs (Levine, 1969) May be able to look at issues in a renewed light (Levine, 1969, and Levine, 1970)
- 31. Contributions to Nursing/Healthcare Providednursing with a systematic way to view patient holistically and intervene accordingly Advocated for use of scientific process in nursing Now called…Evidence Based Practice
- 32. Application to Carefor Fatigue • According to Levine, fatigue is a manifestation of the body trying to heal itself. • Effects of exercise on fatigue during cancer treatment – Conservation principles addressed and measured during treatment – Theory of Conservation determined to be effective model for study design • Description of fatigue in congestive heart failure patients – Fatigue described by patients – Nursing interventions developed based on Conservation principles to foster adaptation and maintain wholeness of patient (Mock et. al., 2007 and Schaefer & Shober, 1993)
- 33. Nurse Consistency • Effectof nurse consistency during NICU stay on patient outcomes (Mefford & Alligood, 2011) – Consistent nurse more familiar with patient’s unique patterns of adaptation and tailor interventions accordingly – Consistency has positive impact on length of stay and patient outcomes • Translates to other areas of care (Mefford & Alligood, 2011)
- 34. Personal Evaluation Overall liketheory and viewing patient holistically Being familiar with theory has allowed insight into patient behavioral reactions—and allowed improved interventions Reminds nurse to care for the person
Editor's Notes
- #1 Hello and welcome to a presentation on Myra Levine’s Conservation Theory. This is a fairly complicated theory, so let’s get started.
- #2 Myra Levine was born in Chicago, Illinois in 1920, and was the oldest of three children. Her father had a chronic illness, and watching him deal with this was her inspiration for becoming a nurse. She died in Chicago in 1996 (Group A, 2011).
- #3 She received her diploma in nursing in 1944 at Cook County School of Nursing in Chicago. She received a Bachelor of Science in Nursing in 1949 from University of Chicago. She earned a Master of Science in 1962 from Wayne State University in Detroit, Michigan, and was awarded an Honorary Doctorate in 1992 from Loyola University in Chicago (Group A, 2011).
- #4 Levine was a child during the Great depression and a young adult during World War II. These were two significant time periods in US history which required both conservation and adaptation to the environment in order to survive. She had clinical, administrative, and educational experience (Meleis, 2012). She was an oncology nurse as well as a civilian nurse at the Army hospital—Gardiner General Hospital. She was the Director of Nursing at Drexel Nursing Home, and Administrative Supervisor at the University of Chicago. She was a clinical instructor at Bryan Memorial Hospital, Chairperson of Clinical Nursing at Cook County School of Nursing, a visiting professor at Tel Aviv University in Israel, and had 77 articles published (Group A, 2011).
- #5 Levine believed that theory should influence practice, but recognized the limitations of implementing a theoretical base for nursing interventions (Levine, 1989 and Levine 1990). In a time when using “borrowed science” was often looked down upon, she advocated for its usage. Her term for this was adjunct science, rather than borrowed science because she felt that findings were shared by all disciplines rather than owned by one or another (Levine, 1990). Her idea of conservation of energy itself came from the field of physics (Levine, 1990). You can also see psychology, sociology, and microbiology as influences to her theory. She felt that patients give up independence when they enter the health care environment and should regain this independence when they leave (Levine, 1996).
- #6 Myra Levine did not set out to write a nursing theory. She began by writing a nursing curriculum. She wanted this curriculum to give first-year nursing students a rationale behind nursing actions. Her goals were to teach problem solving skills, teach individualized patient care, and to avoid procedure-oriented methods which were common at that time (Group A).
- #7 The basic idea, or summary, of the Theory of Conservation is that the internal environment adapts to external environmental cues through conservation so that the person maintains integrity (Levine, 1969). We will look at each of these concepts as we move along.
- #8 The internal environment refers to the person. It is basically divided into four parts—energy, structural integrity, personal integrity, and social integrity. On a basic level, energy is the ability to do. Structural integrity refers to the persons body, or physiological functions. Personal integrity is a sense of self, and social integrity is the ability to interact in groups (Levine, 1996). These will be covered in greater detail later.
- #9 The external environment is divided into 3 parts, the perceptual, conceptual, and operational environment. The perceptual environment is experienced through the person’s senses—sight, sound, taste, smell, and feel. Sight, sound, taste, and smell are fairly straightforward. Feel is more complex in that it can be what a person is touching—items they are picking up, their sheets, a chair, etc. It can also refer to sensations they feel such as pain and temperature. This also refers to proprioception—balance and position sense (Levine, 1989). The conceptual environment can be thought about. It includes language, symbols, ideas, and concepts (Levine, 1989). The operational environment impacts the patient without them necessarily having knowledge of it. It is considered to be things such as radiation, microorganisms, pollutants, or anything that the person does not have sensory organs to sense (Levine, 1989).
- #10 Adaptation can be thought of as the process of interacting with the environment. It is a process of change or the process of life. It can be equated with homeostasis, stability, equilibrium, or balance. It is how the patient changes to fit into the environment (Levine, 1989 and Levine, 1990.
- #11 There are 3 parts to adaptation. Historicity refers to the person’s genetic makeup or innate ability to respond (Levine, 1989 and Levine, 1996). This happens at the cellular level. If you are thinking in terms of evolution, it is the accumulation of the person’s ancestry. It can be thought of, perhaps, as the predisposition to a disease. Specificity refers to biologic systems. There is a system to deal with each task—circulatory system, pulmonary system, integumentary system, immune system, etc. Each system does not act singularly, but responses occur as an interacting sequence of events (Levine, 1989 and Levine, 1996). Redundancy refers to a person’s ability to display multiple responses to dysfunction. Multiple systems deal with threat. Some systems deal with threat quickly such as an increased heart rate. Others correct imbalances more slowly, such as wound healing. Think of how the body protects you from the common cold. The skin acts as a barrier to microorganisms, the respiratory cilia and mucous protect from these microorganisms and attempt to expel them from the body, the immune system attacks whatever gets through. Each system has their own task, but they all act together.
- #12 There are four types of responses in adaptation (Levine, 1989). The fight or flight response is a quick response to a threat or a perceived threat. The inflammatory-immune response restores physical wholeness. It could also be referred to as healing. Stress is an integrated response of the person—all systems are involved. It can be thought of as a long-term response. Perceptual awareness refers to the ability of the person to focus on specific aspects of the environment. We are all familiar with how we can focus on something and not hear someone calling our name, or we think we are about to have a car accident and time seems to slow down.
- #13 Briefly, conservation is the product of adaptation (Levine, 1989, Levine, 1990, and Levine, 1996). It is how the system sustains itself even when it is challenged. It has been equated with a thermostat due to the use of negative feedback systems and efficient use of energy. The goal of conservation is health.
- #14 There are four principles of conservation (Levine 1990 and Levine, 1996). They coincide with the four parts of the person discussed earlier. Moving clockwise around our wheel here, the four conservation principles are the conservation of energy, structural integrity, personal integrity, and social integrity. The conservation of energy actually protects functional integrity, or the patient’s ability to perform activities. During illness, a person is using much of their energy in trying to heal. The conservation of structural integrity refers to physiologic activities or the actual act of healing. The conservation of personal integrity refers to recognition of self and the protection of personal space. During illness and hospitalization, a patient’s sense of self is threatened. If you think about someone who would normally be caring for their family, or who has cared for themselves independently; suddenly they are thrust into this completely dependent position, and are forced to come to terms with this new sense of who they are. This is why, often, patients are reluctant to develop a relationship with a nurse—they are protecting their personal space. The conservation of social integrity refers to the ability to function in groups. Self is developed and maintained in family and society. Again, if we look back on this new “sick role”, this person is no longer the caretaker. Their role in their family and perhaps in society is threatened. Or, if the patient is a child, they are not able to participate in important social events, and their social integrity is threatened as well as their personal integrity.
- #15 According to Levine (1990 and 1996), integrity is synonymous with health. It has the same root as health and whole. It refers to independence and control over one’s own life.
- #16 Here, we take a visual look at the concepts. The internal environment (which we now can equate with a person) adapts (or makes changes) to external environmental cues (which has 3 parts) through conservation and its four principles so that the person maintains integrity (or health).
- #17 The nurse’s role here is to support adaptation. This can be done in two ways—therapeutically or supportively (Levine, 1969). When interventions are therapeutic, favorable adaptation is encouraged. When interventions are supportive, the status quo is maintained. This is what happens when a decline cannot be prevented.
- #18 Here, we will look at interventions based on the four principles of conservation (Levine, 1989 and Levine, 1990). Interventions aimed at conservation of integrity will consider timing, spacing, and balancing interventions in order to balance energy consumption. This is not necessarily restricting activities—it is balancing them in order to promote efficient use of energy. Success of these interventions can be measured through vital signs, blood gasses, and patient behavior. Interventions aimed at conservation of structural integrity seek to limit injury to the patient. These can include proper positioning of the patient and range of motion exercises. This can also include fall prevention. Interventions aimed at conservation of personal integrity seek to maintain a person’s privacy. They can include respect for patient’s desire to withhold information. They can also include seeking to maintain the patient’s modesty in an immodest environment, and communicating with a patient prior to what could be embarrassing interventions. Interventions aimed at conservation of social integrity seek to ensure that the patient can still function in their family or support system. These interventions include assisting the patient with coping behaviors and including the support system in the treatment plan. If the patient is angry because of their diagnosis and prognosis, this is a threat to their personal integrity. However, if they are lashing out at their family and alienating them, this is a threat to their social integrity. Interventions in this case should aim to assist the patient recognize that they are angry, reasons for their anger, and appropriate behaviors to display this anger. Interventions could also include the family, and assisting them in understanding why the patient is lashing out at them.
- #19 One particular example we can look at in order to more fully understand this is a bed bath (Levine, 1990). If a patient is unable to perform hygiene functions on their own, a nurse may perform a bed bath in order to conserve the patient’s energy. This energy is then used by the patient for the healing process, or structural integrity. In considering this intervention, the nurse must also take into consideration the patient’s personal and social integrity. Do they have visitors present, or do they have visitors coming later in the day? Is it in the patient’s best interest for me to perform this bath now—in order to have it done before visitors arrive, or later—in order to avoid forcing visitors to leave the room? These questions look at social integrity. You also would not consider performing this bath with the door or curtain open, allowing everyone in the hallway to be able to see the patient’s body. This would compromise their personal integrity. All aspects must be considered in order to fully maintain the patient’s integrity.
- #20 Here we are again with the summary of the theory. Now we have gotten a really good look at how this applies to nursing interventions. The internal environment adapts to external environmental cues through conservation so that the person maintains integrity.
- #21 This theory was evaluated based on the Chinn & Kramer criteria model identified by Meleis (2012) in table 10-1 on page 184.
- #22 The original design of this theory was to function as a basis for a curriculum for first year nursing students. Levine’s intent was to teach the rationale behind nursing actions. (Group A, 2011). Since it was originally written for nursing students who functioned in a hospital environment, it is most easily applied there. Levine’s intent, however, was to include all patients in need of nursing care (Levine, 1990).
- #23 As a grand nursing theory, The Conservation Theory addresses the four metaparadigms of nursing: person, environment, health, and nursing. The person is viewed holistically as four subunits, and as having integrity. The person is also referred to as the internal environment, which must adapt. The environment is primarily viewed as the external environment, which is divided into three parts. It is the external environment which is manipulated. Health is viewed as fitting into the external environment through adaptation. It is viewed as integrity or wholeness of person. Nursing has a duty to promote wholeness and adaptation. A nurse uses the conservation principles to plan interventions, and must use thorough observation and scientific method to arrive at nursing actions. The concept central to the theory is conservation and its four principles. Sub-concepts include the internal and external environments, adaptation, and integrity. The further division of each concept helps to completely and adequately define it.
- #24 Although we have already covered many definitions of this theory at length during the overview, it is important to determine from where the theorist derived her definitions. Levine explicitly defines all terms used in her theory, and relationships are clearly stated. Word choices were made deliberately, and choices were often made based on Latin or Greek root words rather than popular definitions (Levine, 1991). We have seen that with her choice of the word integrity rather than health. Another place where you will find this important selection is in her choice of the word patient. At the time of theory writing, it was beginning to be in vogue to refer to the recipient of nursing care as a client. Levine felt that this was not necessarily the best choice because when looking at root words, a client is a follower. A patient is a sufferer. She felt that it was this suffering that would cause a person to seek out the care of a nurse, and then be willing to give up independence in order to rely upon the nurse for care (Levine, 1996). She also felt that when a person regained their independence, the need for a nurse-patient relationship no longer existed.
- #25 Concepts in this theory are well related. The patient is viewed holistically and is also referred to as the internal environment. The external environment is divided into three parts and exerts pressure on the internal environment. It includes the perceptual, conceptual, and operational environments (Levine, 1989). The patient must adapt, or change, in order to survive under this pressure. The product of adaptation is conservation, which occurs in four areas (Levine, 1990). Conservation of energy protects functional integrity. It is the pacing of activities to restore function. Conservation of structural integrity refers to physical healing. Conservation of personal integrity refers to the recognition of self and the protection of private, personal space. Conservation of social integrity refers to the patient’s ability to function within groups (Levine, 1996). Integrity is synonymous with health, which is the goal of conservation of all four areas of the person. The nurse’s role is to support adaptation either therapeutically, by moving the patient toward integrity, or supportively, by maintaining the status quo when a decline in function cannot be avoided (Levine, 1969).
- #26 Each concept is further defined by dividing it into subcomponents. Integrity is the end goal, and all concepts move toward integrity. However, the processes described do not lie in a linear fashion. It is an ongoing process of events. The theory does not have an internal diagram, but has been depicted by some as mandala art, which we will look at now.
- #27 Assumptions are implicit within this theory, and a patient centered approach is valued. Assumption include that the patient is to be viewed as a whole and interacts with the environment. The nurse is assumed to be the care provider, and will be an active participant in the patient’s environment. Disease is a disruption which must be adapted to (Glass, 1989).
- #28 The theory is presented in a well-organized fashion, is easy to read, and flows logically. It gives the nurse an understanding of the patient as a whole, while allowing logical interventions based on specific sub-areas or parts. There are multiple sub-concepts, but all concepts are divided and clearly defined. The theory succeeds in giving the nurse a rationale for nursing interventions. Language, as well as complexity of ideas is consistent throughout.
- #29 The purpose of this theory is sufficiently broad, and the four metaparadigms of nursing are adequately addressed. This theory can be applied in multiple settings, with multiple populations (Schaeffer & Pond, 1991).
- #30 The theory is supported with empirical data from studies performed, and results from them can be generalized to other populations as well. For the time in which it was written, this theory was forward-looking. For example, viewing the patient holistically was a novel concept at that time, but is a common view of the patient today. Many of Levine’s writings address current nursing issues such as noncompliant patients (Levine 1970) and healthcare costs (Levine, 1969). Studying and implementing this theory will allow a nurse today to effectively care for her patients.
- #31 Among Levine’s most important contributions to the science of nursing are these things. Her theory provides nurses with a systematic way to view the patient holistically, and the rationale to intervene accordingly. She was a pioneer in this area. Levine also advocated for the use of the scientific process in nursing. I think we are all familiar with this, it is now called evidence based practice. These things seem commonplace today, but were very forward thinking for the 1960s and 1970s. To read her writing today, the reader feels like they are reading a current issue, rather than a writing from 40 or 50 years ago.
- #32 In the 1973 edition of her textbook, Levine states that fatigue is a manifestation of the body trying to heal itself (as cited in Schaefer & Shober, 1993). One study looked at the effects of exercise on fatigue during cancer treatment (Mock et al., 2007). The conservation principles were addressed and measured during treatment, and the theory was determined to be an effective model for a study design. Another study used the Levine Model to describe fatigue in congestive heart failure patients (Schaefer & Shober, 1993). Fatigue was described by the patients and nursing interventions were developed based on the principles of conservation to foster adaptation and maintain the wholeness of the patient.
- #33 Mefford and Alligood (2011) also used the Levine Model to study the effect of nurse consistency on patient outcomes during a NICU stay. They determined that a consistent nurse became more familiar with the infant’s unique patterns of adaptation and was then able to tailor their interventions accordingly. Care became more patient-focused. The consistency of the nurse assignment had a positive impact on outcomes and length of stay for the infants. On average, the infants were able to take oral feedings earlier and were discharged from the hospital earlier with more consistent nursing care. This nurse consistency and improved outcomes can also translate to other areas of care.
- #34 Overall, I have grown to like this theory and I utilize it in my practice on a daily basis. Many times, a patient has made a comment, which I have then equated with a need for an intervention in one of the four areas. I think that, as nurses, we often focus on the energy and structural integrity of a patient. Even though we claim to view our patients holistically, we often forget to consider their personal and social integrity. We forget that they have a life outside the hospital doors—which affects, and is affected by, the care they receive inside. Studying this theory has allowed me a greater insight, especially into these two areas. It has afforded me the opportunity to understand that when a patient is overly anxious or noncompliant with their regimen, they are often experiencing a disruption in one of these other two areas. If I am able to intervene in a manner which addresses those issues, it brings greater integrity to the patient. This, in a sense, frees them up to further participate in their plan of care.