Chapter 08

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 8Chapter 8
Grand Nursing Theories Based onGrand Nursing Theories Based on
Interactive ProcessInteractive Process

Myra Levine
““Nursing is a humanitarian enterprise.”Nursing is a humanitarian enterprise.”

Myra Levine—(cont.)
• Born in Chicago in 1920
• Diploma from Cook County School of Nursing (1944)
• BS from University of Chicago (1949)
• MS in Nursing from Wayne State University (1962)
• Held a number of faculty positions including Cook County
School of Nursing, Loyola University, Rush University,
and the University of Illinois, Chicago
• Retired in 1987 but remained active in speaking

The Conservation Model
• The Conservation Model was developed from
Nightingale’s idea of creating an environment to assist
healing.
• The model was developed in the late 1960s as a teaching
tool for medical/surgical nursing students to de-
emphasize “procedures.”
• The nurses are seen as part of the environment and uses
skill, knowledge, and compassion to assist each client to
confront environmental challenges in resolving problems.
• Effectiveness of interventions is determined by
maintenance of client integrity.

The Conservation Model—(cont.)
• Model focuses on multiple factorial interactions between
the nursing and the client.
• Three major concepts
– Wholeness (holism)—“wholeness emphasizes a
sound, organic, progressive, mutuality between
diversified functions and parts within an entirety”;
wholeness is integrity
– Adaptation—“process of change whereby the
individual retains his integrity within the realities of
his internal and external environment”; conservation
is the outcome
– Conservation—“the way complex systems are able to
continue to function even when severely challenged”

Question
The Conservation Model focuses on holism, conservation,
and which other major concept?
A.Adaptation
B.Compensatory health
C.Health promotion
D.Nursing therapeutics

Answer
A. Adaptation
Rationale: In the Conservation Model, adaptation is the
process of change whereby the individual retains his
integrity within the realities of his internal and external
environment. Conservation is the outcome.

• Four conservation principles form the basis of the model.
– Principle of the conservation of energy
– Principle of the conservation of structural integrity
– Principle of the conservation of personal integrity
– Principle of the conservation of social integrity

• Conservation
– Through conservation, individuals confront obstacles,
adapt, and maintain their uniqueness.
– The goal of conservation is health.
– Focus of conservation is keeping together the
wholeness of the individual.
– Stresses nursing interactions and interventions are
based on the conservation principles
– Nursing interventions are based on conservation of
the client’s integrity in each of the conservation
domains.

• Conservation of energy
– Individuals require a constant renewal of energy to
maintain life activities.
– Healing and aging challenge the energy balance.
– Conservation of energy is part of most basic of
nursing procedures.

• Conservation of structural integrity
– Healing is a process of restoring structural and
functional integrity.
– Disabled are guided to new level of adaptation.
– Nurses can limit threats to structural integrity by
early recognition of functional changes and
appropriate interventions.

• Conservation of personal integrity
– Self-worth and identity are important.
– Anxiety and erosion of privacy threaten personal
integrity.
– Includes the sanctity of life and recognition of the
holiness of each person
– Nurses should give knowledge and assist in regaining
and maintaining personal integrity.

Conservation of social integrity
 Life gains meaning through social communities.
 Health is socially determined.
 Nurses provide for family members, assist with
religious needs, and use interpersonal relationships
to conserve social integrity.

• The first edition of her book—Introduction to Clinical
Nursing (1969) addressed the four conservation
principles in “holistic nursing.”
• In the second edition, she added detail and began
presenting the principles as the Conservation Model.
• Model was revised in 1989 and 1991.
• Levine died in 1996 (age 75 years).

Sister Callista Roy

Sister Callista Roy—(cont.)
• Callista Roy was born in 1939 in Los Angeles.
• Mom was an LVN.
• Earned a BS in Nursing in 1963 from Mount St. Mary’s
College, Los Angeles
• MSN in 1966 (UCLA)
• PhD in sociology 1977 (UCLA)

• She is a member of the Sisters of St. Joseph of
Carondelet.
• Pediatric nurse by practice working in several Carondelet
hospitals.
• Currently Professor and Nurse Theorist at Boston College
School of Nursing

• Became interested in nursing theory during a seminar
with theorist Dorothy Johnson
• She developed basic concepts for the model while a
graduate student at UCLA in the mid-1960s; it was
developed as a curriculum framework for nursing
programs.

• Roy focused on the concept of adaptation because of her
interest in resiliency of children and their ability to adapt
to major physical and psychological changes.
• RAM is based on the work of Dorothy Johnson, Helson’s
adaptation theory, Selye’s stress and adaptation works,
von Bertalanffy’s systems theory, and Lazarus’s coping
model.

Question
Tell whether the following statement is true or false:
Roy’s observations of the resiliency of children with regard
to their health led her to focus her theory on the concept of
adaptation.

Answer
True
Rationale: Roy’s background work in pediatrics led her to
focus on the concept of adaptation. She included the works
of several other theorists while focusing on stress, coping,
and adaptation.

• The Roy Adaptation Model (RAM) was first published in
Nursing Outlook in 1970.
• Books and book chapters describing and updating the
model were published in 1976, 1980, 1984, 1989, 1999,
and 2009.

Roy Adaptation Model
• Major concepts
– Adaptation
– Focal stimuli
– Contextual stimuli
– Residual stimuli
– Cognator subsystem
– Regulator subsystem
– Coping mechanisms
– Adaptive and ineffective responses

Roy Adaptation Model—(cont.)
• Major concepts
– Four adaptive modes
• Physiologic–physical mode
• Self-concept–group identity mode
• Role function mode
• Interdependence mode

Diagrammatic representation of human adaptive systems.
(Source: Roy, C., & Andrews, H. A. [1998]. The Roy adaptation model [2nd ed.,
p. 114). Stamford, CT: Appleton & Lange [Reprinted with permission of Pearson
Education, Inc, Upper Saddle River, NJ].)

• Nurses assess behaviors and stimuli that influence
adaptation.
• Goal of nursing is promotion of adaptation in each of the
four adaptive modes; this contributes to health, quality of
life, and dying with dignity.

• The person is an open system that receives input or
stimuli from both the environment and the self.
• Adaptation level is determined by the combined effect of
the focal, contextual, and residual stimuli.
• Adaptation occurs when the person responds positively to
environmental change; this promotes integrity leading to
health.

• Two interrelated subsystems
– Functional or control process subsystem
• Regulator and cognator
– Effector subsystem (four adaptive modes)
• Physiologic functions
• Self-concept
• Role function
• Interdependence

• Functional or control process subsystem
– Regulator—influences the physiologic mode responds
automatically through neural, chemical, and
endocrine coping processes
– Cognator—influences the self-concept, role function,
and interdependence modes through perceptual
information processing, learning, judgment, and
emotion

• Six-step nursing process
– Assess behaviors in four adaptive modes.
– Assess focal, contextual, and residual stimuli.
– Make statement of diagnosis of person’s adaptive
state.
– Set goals to promote adaptation.
– Implement interventions to manage stimuli to
promote adaptation.
– Evaluate whether goals have been met.

• Among the most widely used models in nursing education
—curricular framework for all levels of nursing programs
• Among the most widely used models in nursing research
(more than 170 studies)

Roy Adaptation Model—Resources
• http://www.bc.edu/schools/son/faculty/featured/theorist/Ro
• http://currentnursing.com/nursing_theory/Roy_adaptation_

Erickson, Tomlin, and Swain

Erickson, Tomlin, and Swain—(cont.)
• Helen Erickson
– Diploma from Saginaw General Hospital in Saginaw,
MI (1957)
– BSN (1974) and MSN (1976) in psychiatric and
medical surgical nursing, PhD in educational
psychology (1984) from the University of Michigan
– ER nurse in Midland, TX
– Worked in Puerto Rico
– Independent practitioner
– Faculty at several schools, including University of
Michigan and University of South Carolina, and is
professor emeritus from University of Texas at Austin

• Evelyn Tomlin
– Diploma from Los Angeles General Hospital and BSN
from University of Southern California
– Masters in Psychiatric Nursing from University of
Michigan (1976)
– Clinical practice in Afghanistan
– Areas of practice include critical care, home health,
and nursing education
– Retired and lives in Illinois

• Mary Ann Swain
– Education in psychology (BA, MS, and doctorate) (not
a nurse) from University of Michigan
– Taught research methods and statistics to graduate
nursing students at DePauw University and University
of Michigan
– Currently an administrator (Provost) at SUNY—
Binghamton

Modeling and Role-Modeling
• Based on works of Maslow, Erickson, Piaget, Selye, and
Lazarus among others
• Nursing is a process between the nurse and client.
• Nursing requires an interpersonal and interactive nurse–
client relationship.
• The focus of the model is the ability of the individual to
mobilize resources when confronted with stressors.
• Initially published in 1983; revised in 1990.

Modeling and Role-Modeling—(cont.)
• Nurses assess (model), plan (role-model), and intervene
(five aims of intervention) based on the client’s
perspective of the world.
• The nurse always acknowledges the uniqueness and
individuality of the client and appreciates that all
individuals have self-care knowledge (what works for
them).

• Important concepts
– Holism—Humans have multiple interacting
subsystems (genetics, spiritual drive, body, mind,
emotion) that act together, affecting and controlling
one another.
– Affiliated individuation—dependence on support
systems while maintaining independence

– Adaptation—individual’s responses to external and
internal stressors
– Maladaptation—taxing of the system in which the
individual is unable to engage constructive coping
methods or mobilize appropriate resources to
contend with the stressor

– Self-care—knowledge, resources, and actions of the
client
– Nursing is the holistic helping of persons with their
self-care activities in relation to health; it is an
interactive, interpersonal processes to achieve
perceived holistic health.

– Modeling—the process by which the nurse seeks to
understand the client’s unique model of the world
– Role-modeling—the process by which the nurse
understand the client’s unique model within the
context of scientific theories and uses the model to
plan interventions that promote health for the client

Question
In the Modeling and Role-Modeling Theory, which of the
following is considered the interactive, interpersonal
processes to holistically assist persons with their self-care
activities in relation to health?
A. Affiliated individuation
B. Modeling
C. Nursing
D. Role-modeling

Answer
C. Nursing
Rationale: Nursing is seen as an interactive, interpersonal
process that nurtures strengths to achieve a state of
holistic health.

• Five aims of intervention
– Build trust—Nursing requires a trusting relationship.
– Promote positive orientation—Affiliated nursing
care should promote the client’s self-worth and hope
for the future.
– Promote perceived control—Nurses should assist
clients have control over what happens to them.
– Promote strengths—Nurses should identify and
promote strengths to mobilize resources.
– Set mutual goals—Nurses should use the
individual’s innate drive to be as healthy as he/she
can be; goals are to meet basic needs.

• Nurses promote self-care by helping clients with
– Self-care knowledge—knowledge of what will
improve health
– Self-care resources—recognition of internal and
external resources that will hope promote holistic
health
– Self-care action—development and use of self-care
knowledge and self-care resources

• Adaptive potential—ability to mobilize resources to cope
with stressors
– Equilibrium
• Adaptive equilibrium
• Maladaptive equilibrium
– Arousal
– Impoverishment

• Human beings are holistic with interacting
subsystems (biophysical, psychological, social and
cognitive) and inherent genetic bases and
spiritual drive.

• Through an interactive and interpersonal relationship,
nurses use three activities:
– Facilitation
– Nurturance
– Unconditional acceptance

• MRM is newer and not as well known as other nursing
theories.
• MRM has been used as the basis for curricula at a
number of schools in the United States.
• A series of conferences discussing the models use in
research and practice were conducted in the 1990s.

Modeling and Role-Modeling—Resource
• http://www.mrmnursingtheory.org/

Jean Watson

Jean Watson
• Jean Watson was born in 1940 in West Virginia.
• Diploma from Lewis Gale Hospital School of Nursing in
Roanoke, VA
• BSN (1964) and MSN (1966) in psychiatric–mental health
nursing and PhD in Educational Psychology and
Counseling (1973) from the University of Colorado
• Faculty at the University of Colorado since 1973
• In 1992, she founded the Center for Human Caring and is
still the director.

Theory of Human Science and Human
Caring
• Initially published in 1979 as the Philosophy and Science
of Caring
• In 1985, Nursing: Human Science and Human Care: A
Theory of Nursing was published; it was revised in
1988.
• Caring Science as Sacred Science (2nd ed.) (2012) is
her most recent work.

Caring—(cont.)
• Describes caring as the essence of nursing
• Caring is perceived to be a moral ideal rather than a
task-oriented behavior.
• Her work is focused on humanities with a
phenomenologic, existential, and spiritual orientation.

Caring—(cont.)
• She used works of Leininger, Peplau, Rogers,
Nightingale, Maslow, Heidegger, Selye, Lazarus, and
Sarte among others in her work.

Caring—(cont.)
• Main concepts
– Transpersonal caring relationship
– Ten carative factors
– Caring occasion/caring moment

Caring—(cont.)
• Ten “carative factors” for nursing practice
1. Formation of humanistic–altruistic system of values
2. Instillation of faith–hope
3. Cultivation of sensitivity to self and others
4. Development of a helping–trusting relationship
5. Promotion and acceptance of the expression of
positive and negative feelings

Caring—(cont.)
• Ten “carative factors” for nursing practice—(cont.)
6. Systematic use of the scientific problem-solving
method for decision making
7. Promotion of interpersonal teaching–learning
8. Provision for supportive, protective, and corrective
mental, physical, sociocultural, and spiritual
environment
9. Assistance with gratification of human needs
10. Allowance for existential-phenomenologic forces

Evolution of the Theory
• Carative factors became clinical caritas processes.
• Caritas (Greek) meaning to cherish, appreciate, and
to give special attention to
• Clinical caritas is an emerging model of transpersonal
caring.

Clinical Caritas Processes
1. Practice of loving-kindness an equanimity within
context of caring consciousness
2. Being authentically present . . . sustaining the deep
belief system and subjective life world of self and one
being cared for
3. Cultivation of one’s spiritual practices and
transpersonal self (going beyond self)
4. Developing and sustaining a helping–trusting, caring
relationship
5. Being . . . supportive of the expression of positive and
negative feeling and connection with the spirit of
self . . .

Clinical Caritas Processes—(cont.)
6. Creative use of self . . . as part of the caring process
7. Engaging in teaching learning experience that attends
to unity of being and meaning . . .
8. Creating healing environment at all levels . . .
9. Assisting with basic need and intention caring
consciousness . . . tending to both embodied spirit and
evolving spiritual emergence
10. Opening an attending to spiritual-mysterious and
existential dimension of one’s own life death care for
self

Caring—(cont.)
• Nursing consists of knowledge, thoughts, values,
commitment, and action; it is related to human care
transactions within the lived world of the person.
• Nursing involves transpersonal human-to-human
attempts to protect, enhance, and preserve humanity by
helping a person find meaning in illness, suffering, pain,
and existence; it involves helping others gain self-
knowledge, control, and self-healing wherein a sense of
inner harmony is restored.

Caring—(cont.)
• Goals of nursing
– Enhance mental–spiritual growth for self and others.
– Find meaning in one’s own existence and
experiences.
– Discover inner power and control.
– Encourage transcendence and self-healing.

Caring—(cont.)
• Widely recognized, but not well understood (opinion)
• Used sparingly in nursing education
• Used as a framework in qualitative research studies; also
elements of the study have been tested by Watson and
colleagues

Caring—Resources
• http://watsoncaringscience.org/
• http://www.humancaring.org/

Chapter 08

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