alligood 8th edition_Neat

182 UNIT II Nursing Philosophies

caring administration, and interdisciplinary research. people’s conception of health (1998; Lindholm &
Eriksson’s caritative caring theory has been tested and Eriksson, 1998) and Bondas’ study of women’s health
further developed in various contexts with different during the perinatal period (2000; Bondas & Eriksson,
methodological approaches, both within the depart- 2001) led to doctoral dissertations.
ment’s own research projects and in doctoral disserta- The ontological health model subsequently formed
tions that have been published at the department. the basis for several studies. Wärnå (2002), in her study
Eriksson has always emphasized the importance concerning the worker’s health, related Aristotle’s the-
of basic research as necessary for clinical research, ory of virtue to Eriksson’s ontological health model.
and her main thesis is that substance should direct The study opened a new line of thought in preventive
the choice of research method. In her book, Pausen health service in working environments; continued
(The Pause) (Eriksson, 1987b), she describes how the research and development are now in progress in a
research object is structured, starting from the carita- number of factories in the wood-processing industry
tive theory of caring. In her book, Broar (Bridges) in Finland.
(Eriksson, 1991), she describes the research paradigm Since the mid-1980s, when suffering as the basic
and various methodological approaches based on a category in caring was made explicit in Eriksson’s
human science perspective. During the first few years, theory, examples of research related to suffering have
the emphasis lay on basic research, with the focus on been legion. One is Wiklund’s (2000) study of suffer-
development of the basic concepts and assumptions ing as struggle and drama, among both patients
of the theory and on the fundamentals of history and who had undergone coronary bypass surgery and
the history of ideas. An especially strong point in patients addicted to drugs. In several clinical studies,
Eriksson’s research is the clearly formulated theoreti- Råholm focused on suffering and alleviation of suffer-
cal perspective that confers explicitness and greater ing in patients undergoing coronary bypass surgery
depth to the generation of knowledge. Development (Råholm, Lindholm, & Eriksson, 2002; Råholm, 2003).
of the theory and research have always moved hand in The manifestation of suffering in a psychiatric context
hand with the focus on various dimensions of the has been studied by Fredriksson, who illustrates the
theory, and, in this connection, we wish to illustrate possibilities of the caring conversation in the allevia-
some central results of the research. tion of suffering (Fredriksson, 2003; Fredriksson
Eriksson has emphasized the necessity of an exhaus- & Eriksson, 2003; Fredriksson & Lindström, 2002).
tive and systematic analysis of basic concepts, and Nyback (2008) studied suffering in the Chinese cul-
developed her own model of concept development ture, and Lindholm (2008) focused on suffering and
(Eriksson, 1991, 1997b), which proved fruitful and is its connection to domestic violence. In a Norwegian
used by many researchers, including Nåden (1998) in study, Nilsson (2004) studied suffering in patients in
his study of the art of caring, von Post (1999) in her psychiatric noninstitutional care units with a high
study of the concept of natural care, Sivonen (2000) in degree of ill health and found that the experience of
studies of the concepts of soul and spirit, and Kasén loneliness is of basic importance. Caspari (2004) in her
(2002) in her study of the concept of the caring relation- study illustrated the importance of aesthetics for
ship. Other studies focused on the concept of dignity health and suffering.
(Edlund, 2002), the concepts of power and authority In a cooperative project between researchers in
(Rundqvist, 2004), and the concept of the body in a Sweden and Finland, the suffering of women with
perioperative context (Lindwall, 2004). breast cancer was studied. This project comprised in-
Continued development of Eriksson’s concept of tervention studies in which the importance of different
health took place in the research project Den Mång- forms of care for the alleviation of suffering was illus-
dimensionella Hälsan (Multidimensional Health), trated (Arman, Rehnsfeldt, Lindholm, & Hamrin,
during the years 1987 to 1992 and resulted in the on- 2002; Arman-Rehnsfeldt & Rehnsfeldt, 2003; Lindholm,
tological health model (Eriksson, 1994a; Eriksson, Nieminen, Mäkelä, & Rantanen-Siljamäki, 2004).
Bondas-Salonen, Fagerström, et al., 1990; Eriksson & Arman-Rehnsfeldt, in her dissertation, illustrated how
Herberts, 1992). The project resulted in a number of the drama of suffering is formed among these women
master’s theses. Of these, Lindholm’s study of young (Arman, 2003).

CHAPTER 11 Katie Eriksson 183

Continuous research has been carried out since the different depending on what object of knowledge con-
1970s, with a view toward developing caring science as stitutes the focus of research (Eriksson & Lindström,
an academic discipline, and a theory of science for car- 2003). Another central area of interest for Eriksson
ing science has been formulated (Eriksson, 1988, 2001; (2003) is formed by the development of caritative car-
Eriksson & Lindström, 2000, 2003; Lindström, 1992). ing ethics. Continued development of the caritative
Eriksson has developed subdisciplines of caring science, theory of caring also occurs, as has emerged before,
which means that researchers of caring science and through continued implementation and testing in
other scientific disciplines enter into dialogues with various clinical contexts.
each other, and constitute a research area. An example
of this is the development of caritative caring ethics Critique
(Andersson, 1994; Eriksson, 1991, 1995; Fredriksson &
Eriksson, 2001; Råholm & Lindholm, 1999; Råholm, Clarity
Lindholm, & Eriksson, 2002). Another interesting sub- The strong point of Eriksson’s theory is the overall
discipline that Eriksson has developed is caring theol- logical structure of the theory, in which every new
ogy, within which she has articulated spiritual and concept becomes a part of an ever more comprehensive
doctrinal questions in caring with a scientific group of whole in which an element of internal logic can be seen
themes, and in this respect has cleared the way for new clearly. Her main thesis has always been that basic con-
thinking. Caring theology has aroused great interest ceptual clarity is needed before developing the contex-
among caregivers in clinical practice that can be studied tual features of the theory. Eriksson has used concept
in academic courses. analysis and analysis of ideas as central methods, which
has led to semantic and structural clarity. It has at the
same time meant that the concepts may have assumed
Further Development dimensions that have been regarded as strange to those
Eriksson continues developing her thinking and the who are not familiar with the theoretical perspective in
caritative caring theory with unabated energy and which the development of the theory has taken place.
constantly finds new ways, recreating and deepening We, who have for many years had the opportunity to
what has been stated before. Systematic research and follow Eriksson’s work, have realized that her way of
the development of caritative caring theory, as well as thinking forms a logical whole, where the abstract sci-
the discipline of caring science, take place chiefly entific reveals the concrete in a new understanding
within the scope of the research programs in her own (i.e., provides an experience of evidence and verifies
department with her own staff and the postdoctoral the convincing force of the theory).
group. The dissertation topics of doctoral candidates
are connected with the research programs and form Simplicity
an important contribution of knowledge to the ongo- The theoretical clarity of Eriksson’s theory reflects the
ing development of Eriksson’s thinking. simplicity of the theory by showing the general in a
During the last few years, Eriksson has emphasized clear and logical conceptual entirety. The hermeneutic
the necessity of basic research in clinical caring sci- approach has deepened the understanding of the sub-
ence, where she has especially stressed the under- stance and thus contributed to the simplicity of the
standing of the research object, caring reality. She theory (Gadamer, 1960/1994). The simplicity also can
describes the object of research from three points of be understood as an expression of Gadamer’s concept
view: the experienced world, praxis as activity, and the of theory by making it comprehensible that theory and
real reality. In the real reality, which carries the attri- practice belong together and reflect two sides of the
butes of mystery, one finds something of the deepest same reality. Eriksson agrees with Gadamer’s thought
potential of caring, and it is a reality that can be under- that understanding includes application, and the the-
stood in Gadamer’s sense, in the old Greek meaning ory opens the way to deeper participation and com-
of praxis, as a way of living, a mode of being, that is, munion. Eriksson (2003) formulates this process by
an ontology (Gadamer, 2000). The development of the statement that “ideals reach reality and reality
knowledge in caring science becomes fundamentally reaches the ideals” (p. 26).

184 UNIT II Nursing Philosophies
Generality level developing concepts and theory, the theory is
Eriksson’s theory is general in the sense that it aims at rooted in clinical reality and teaching. The whole cari-
creating an ontological and ethical basis of caring, tative theory and the caring that are built up around
while at the same time it constitutes the core of the the theoretical core get their distinctive character
discipline and thus involves epistemology as well. and deeper meaning. The ultimate goal of caring is to
Eriksson’s theory is also general as a result of the wide alleviate suffering and serve life and health.
convincing force it receives through its theoretical Knowledge formation, which Eriksson sees as a her-
core concepts and its theoretical axioms and theses. meneutic spiral, starts from the thought that ethics pre-
There may be a risk that a too-general theory be- cedes ontology. In a concrete sense, this implies that the
comes diffuse in relation to different caring contexts. thought of human holiness and dignity is always kept
Eriksson, however, has always stressed the impor- alive in all phases of the search for knowledge. Ethics
tance of describing the core concepts on an optimal precedes ontology in theory as well as in practice.
level of abstraction in order to include all of the com- Eriksson’s caring science tradition and discipline
plex caring reality that simultaneously carries a wealth of caring science form a basis for the activity at the
of signification that opens up understanding in vari- Department of Caring Science at Åbo Akademi Univer-
ous caring contexts. sity. Eriksson’s caritative caring theory and the discipline
of caring science have inspired many in the Nordic
Accessibility countries, and they are used as the basis for research,
Eriksson’s thinking as a whole has reached an under- education, and clinical practice. Many of her original
standing that extends to other disciplines and profes- textbooks, published mainly in Swedish, have been
sions. She has developed a language and a rhetoric translated into Finnish, Norwegian, and Danish.
that has reached researchers as well as practitioners in
the human scientific field. The empirical precision of
Eriksson’s theory demonstrated in multiple deductive CASE STUDY
testings manifests a combination of the clarity, sim-
plicity, and generality of the theory combined with a The case presented is a philosophy of practice, by Ulf
rich substance and clearly formulated ethos. Donner, leader of the Foundation Home at the psy-
chiatric nursing home in Finland that for 15 years
Importance has based its practice on Eriksson’s caritative theory
Eriksson’s work on developing her caritative caring of caring.
theory for 30 years has been successful, and particularly Even at an early stage in our serving in caring
in the Nordic countries there is abundant evidence that science, we caregivers recognized ourselves in the
her thinking is of great importance to clinical practice, caring science theory, which stresses the healing
research, and education, and also to the development of force of love and compassion in the form of tend-
the caring discipline. By her development of the carita- ing, playing, and learning in faith, hope, and char-
tive theory of care, Eriksson created her own caring ity. The caritative culture is made visible with
science tradition, a tradition that has grown strong and the help of rituals, symbols, and traditions, for
has set the tone for nursing advancement and caring instance, with the stone that burns with the light
science. of the Trinity and the daily common time for
spiritual reflection. In every meeting with the suf-
fering human being, the attributes of love and
Summary charity are striven for, and the day involves discus-
Eriksson has been a guide and visionary who has gone sions of reconciliation, forgiveness, and how we as
before and “ploughed new furrows” in theory develop- caregivers can tend by nourishing and cleansing
ment for many years. Eriksson’s caritas-based theory on the level of becoming, being, and doing. In the
and her whole caring science thinking have developed struggle in love and compassion to reach a fellow
over the course of 30 years. Characteristic of her human being who, because of suffering, has with-
thinking is that while she is working at an abstract drawn from the communion to find common

CHAPTER 11 Katie Eriksson 185


horizons, the sacrifice of the caregiver is con- we often recognize the importance of teaching the
stantly available. patient to be able to mourn disappointments and
We work with people who often have the feeling affirm the possibilities of forgiveness in the move-
that they do not deserve the love they encounter ment of reconciliation.
and who, in various ways, try to convince us care- We also try to bring about the open invitation to
givers of this. We experience patients’ disappoint- the suffering human being to join a communion
ment in their destructive acts, and we constantly with the help of myths, legends, and tales con-
have to remember that it may be broken promises cerned with human questions about evil versus
that produce such dynamics. Sometimes, it may be good and about eternity and infinity. Reading aloud
difficult to recognize that suffering expressed in this with common reflective periods often provides us
way in an abstract sense seeks an embrace that does caregivers a possibility of getting closer to patients
not give way but is strong enough to give shelter to without getting too close, and opens the door for
this suffering, in a way that makes a becoming the suffering the patient bears.
movement possible. In recognizing what is bad and In the act of caring, we strive for openness with
what is difficult, horizons in the field of force are regard to the patient’s face and a confirmative attitude
expanded, and the possibility of bringing in a ray of that responds to the appeal that we can recognize that
light and hope is opened. the patient directs to us. When we as caregivers
As caregivers, we constantly ask ourselves respond to the patient’s appeal for charity, we are
whether the words, the language we use, bring faced with the task of confirming the holiness of the
promise, and how we can create linguistic foot- other as a human being. Our constant effort is to
holds in the void by means of images and sym- make it possible for the patient to reestablish his or
bols. In our effort to nourish and cleanse, that her dignity, accomplish his or her human mission,
which constitutes the basic movement of tending, and enter true communion.


CRITICAL THINKING ACTIVITIES
1. Reflect on the meaning of caritas as the ethos of 3. How have you recognized the elements of
caring. caring—faith, hope, love and tending, playing,
a. How is caritas culture formed in a care setting? and learning—in a concrete caring situation?
b. How do caritative elements appear in caring? Give examples.
c. What is the nature of nursing ethics based on 4. Suffering as a consequence of lack of caritative
caritas? caring is a violation of a human being’s dignity.
2. Health and suffering are each other’s preconditions. Think about a situation in which you saw this
Think of what this meant in the life of a patient occur, and consider what can be done to prevent
you cared for recently. suffering related to care.


POINTS FOR FURTHER STUDY
n Eriksson, K. (2007). Becoming through suffering— n Eriksson, K. (2010). Concept determination as
The path to health and holiness. International Jour- part of the development of knowledge in caring
nal for Human Caring, 11(2), 8–16. science. Scandinavian Journal of Caring Sciences,
n Eriksson, K. (2007). The theory of caritative caring: 24, 2–11.
A vision. Nursing Science Quarterly, 20(3), 201–202. n Eriksson, K. (2010). Evidence—To see or not to
n Eriksson, K. (2006). The suffering human being. see. Nursing Science Quarterly, 23(4), 275–279.
Chicago: Nordic Studies Press. [English transla- n For further literature and information visit
tion of Den Lidande Människan. Stockholm: Liber our website at: http://www.abo.fi/institution/
Förlag, 1994.] vardvetenskap

186 UNIT II Nursing Philosophies

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Möten med lidanden. Vårdforskningar 4/1993 (s. 1–27). academic discipline. Caring research 7/2001. Vaasa,
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hälsan—Verklighet och visioner. Slutrapport. Vaasa, (s. 1–14). Vaasa, Finland: Institutionen för vårdvetenskap,
Finland: Vasa sjukvårdsdistrikt kf. och Institutionen Åbo Akademi. [The history of ideas as a sub-discipline
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den. Vårdforskningar 4/1993 (s. 29–54). Vaasa, Finland: Science, Åbo Akademi.
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Eriksson, K., Herberts, S., & Lindholm, L. (1993). Bilder vårdvetenskap, Åbo Akademi. [The theory of science
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kaplig forskning. I K. Eriksson (red.), Möten med lidan- basic features. In K. Eriksson, U. Å. Lindström, D.
den. Vårdforskningar 4/1993 suffering (s. 55–78). Vaasa, Matilainen & L. Lindholm (Eds.), Dawn III. Caring
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Finland, Åbo Akademi University Press.] University Press.]
Rydenlund, K. (2012). Vårdandets imperativ i de yttersta Wiklund, L. (2000). Lidandet som kamp och drama. Doktor-
livsrummen. Hermeneutiska vårdande samtal inom savhandling, Turku, Finland, Åbo Akademis Förlag.
den rättspsykiatriska vården. Doktorsavhandling, [Suffering as struggle and as drama. Doctoral dissertation,
Turku, Finland, Åbo Akademis förlag. [The imperative Turku, Finland, Åbo Akademi University Press.]
of caring in extreme living-spaces—Hermeneutical car- Wärnå, C. (2002). Dygd och hälsa. Doktorsavhandling,
ing conversations in forensic psychiatric care. Doctoral Turku, Finland, Åbo Akademis Förlag. [Virtue and
dissertation, Turku, Finland, Åbo Akademi University health. Doctoral dissertation, Turku, Finland, Åbo
Press.] Akademi University Press.]

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III

UNIT













Nursing Conceptual Models





n Nursing conceptual models are concepts and their relationships that specify a
perspective and produce evidence among phenomena specific to the discipline.

n Conceptual models address broad metaparadigm concepts (human beings,
health, nursing, and environment) that are central to their meaning in the
context of the particular framework and the discipline of nursing.

n Nursing conceptual models provide perspectives with different foci for
critical thinking about persons, families, and communities, and for making
knowledgeable nursing decisions.

12

CHAP TER



















Myra Estrin Levine
1921 to 1996


The Conservation Model


Karen Moore Schaefer



“Nursing is human interaction”
(Levine, 1973, p. 1).




University of Illinois (1962 to 1963, 1977 to 1987).
Credentials and Background of the She chaired the Department of Clinical Nursing at
Theorist* Cook County School of Nursing (1963 to 1967) and
Myra Estrin Levine enjoyed a varied career. She was coordinated the graduate nursing program in oncology
a private duty nurse (1944), a civilian nurse in the at Rush University (1974 to 1977). Levine was director
U.S. Army (1945), a preclinical instructor in the of the Department of Continuing Education at Evanston
physical sciences at Cook County (1947 to 1950), di- Hospital (March to June 1974) and consultant to the
rector of nursing at Drexel Home in Chicago (1950 to department (July 1974 to 1976). She was adjunct as-
1951), and surgical supervisor at both the University sociate professor of Humanistic Studies at the Univer-
of Chicago Clinics (1951 to 1952) and the Henry Ford sity of Illinois (1981 to 1987). In 1987, she became a
Hospital in Detroit (1956 to 1962). Levine worked her Professor Emerita, Medical Surgical Nursing, at the
way up the academic ranks at Bryan Memorial Hospi- University of Illinois at Chicago. In 1974, Levine went
tal in Lincoln, Nebraska (1951), Cook County School to Tel-Aviv University, Israel, as a visiting associate
of Nursing (1963 to 1967), Loyola University (1967 professor and returned as a visiting professor in 1982.
to 1973), Rush University (1974 to 1977), and the She also was a visiting professor at Recanati School of


*The information in this section is informed by Levine’s autobiographical chapter (1988a), her curriculum vitae, and the program
from the Mid-Year Convocation, Loyola University, Chicago (1992).
Previous authors: Karen Moore Schaefer, Gloria S. Artigue, Karen J. Foil, Tamara Johnson, Ann Marriner Tomey, Mary Carolyn
Poat, LaDema Poppa, Roberta Woeste, and Susan T. Zoretich.

204

CHAPTER 12 Myra Estrin Levine 205

Nursing, Ben Gurion University of the Negev, at Beer the conservation principles at nurse theory confer-
Sheva, Israel (March to April, 1982). ences, some of which have been audiotaped, and at
Levine received numerous honors, including charter the Allentown College of St. Francis de Sales (now
fellow of the American Academy of Nursing (1973), DeSales University) Conference.
honorary member of the American Mental Health Aid Levine (1989) published a substantial change and
to Israel (1976), and honorary recognition from the clarification about her theory in “The Four Conserva-
Illinois Nurses Association (1977). She was the first tion Principles: Twenty Years Later.” She elaborated on
recipient of the Elizabeth Russell Belford Award for how redundancy characterizes availability of adaptive
excellence in teaching from Sigma Theta Tau (1977). responses when stability is threatened. Adaptation pro-
Both the first and second editions of her book, Introduc- cesses establish a body economy to safeguard individual
tion to Clinical Nursing (Levine, 1969a; 1973) received stability. The outcome of adaptation is conservation.
American Journal of Nursing Book of the Year awards, She explicitly linked health to the process of conser-
and her book, Renewal for Nursing, was translated into vation to clarify that the Conservation Model views
Hebrew (Levine, 1971a). Levine was listed in Who’s health as one of its essential components (Levine, 1991).
Who in American Women (1977 to 1988) and in Who’s Conservation, through treatment, focuses on integrity
Who in American Nursing (1987). She was elected fel- and the reclamation of oneness of the whole person.
low of the Institute of Medicine of Chicago (1987 to Levine died on March 20, 1996, at 75 years of age.
1991). The Alpha Lambda Chapter of Sigma Theta Tau She leaves a legacy as an administrator, educator,
recognized Levine for her outstanding contributions friend, mother, nurse, scholar, student of humanities,
to nursing in 1990. In January 1992, she was awarded and wife (Pond, 1996). Dr. Baumhart, President of
an honorary doctorate of humane letters from Loyola Loyola University, said the following of Levine (Mid-
University, Chicago (Mid-Year Convocation, Loyola Year Convocation, Loyola University, 1992):
University, 1992). Levine was an active leader in the Mrs. Levine is a renaissance woman . . . who uses
American Nurses Association and the Illinois Nurses knowledge from several disciplines to expand the
Association. After her retirement in 1987, she remained vision of health needs of persons that can be met
active in theory development and encouraged questions by modern nursing. In the Talmudic tradition of
and research about her theory (Levine, 1996). her ancestors, [she] has been a forthright spokes-
A dynamic speaker, Levine was a frequent pre-
senter of programs, workshops, seminars, and panels, person for social justice and the inherent dignity of
[the] human person as a child of God (p. 6).
and a prolific writer regarding nursing and education.
She also served as a consultant to hospitals and
schools of nursing. Although she never intended to Theoretical Sources
develop theory, she provided an organizational struc- From Beland’s (1971) presentation of the theory of
ture for teaching medical-surgical nursing and a stim- specific causation and multiple factors, Levine learned
ulus for theory development (Stafford, 1996). “The historical viewpoints of diseases and learned that the
Four Conservation Principles of Nursing” was the way people think about disease changes over time.
first statement of the conservation principles (Levine, Beland directed Levine’s attention to numerous authors
1967a). Other preliminary work included “Adaptation who became influential in her thinking, including
and Assessment: A Rationale for Nursing Interven- Goldstein (1963), Hall (1966), Sherrington (1906),
tion,” “For Lack of Love Alone,” and “The Pursuit of and Dubos (1961, 1965). Levine uses Gibson’s (1966)
Wholeness” (Levine, 1966b, 1967b, 1969b). The first definition of perceptual systems, Erikson’s (1964) dif-
edition of her book using the conservation principles, ferentiation between total and whole, Selye’s (1956)
Introduction to Clinical Nursing, was published in stress theory, and Bates’ (1967) models of external
1969 (Levine, 1969a). Levine addressed the conse- environment. Levine was proud that Rogers (1970) was
quences of the four conservation principles in Holistic her first editor. She acknowledged Nightingale’s contri-
Nursing (Levine, 1971b). The second edition of Intro- bution to her thinking about the “guardian activity” of
duction to Clinical Nursing was published in 1973 observation used by nurses to “save lives and increase
(Levine, 1973). After that, Levine (1984) presented health and comfort” (Levine, 1992, p. 42).

206 UNIT III Nursing Conceptual Models

MAJOR CONCEPTS & DEFINITIONS
The three major concepts of the Conservation of failed redundancy of physiological and psycho-
Model are (1) wholeness, (2) adaptation, and (3) logical processes” (p. 6).
conservation.
Environment
Wholeness (Holism) Levine (1973) also views individuals as having their
“Whole, health, hale are all derivations of the Anglo- own environment, both internally and externally.
Saxon word hal” (Levine, 1973, p. 11). Levine based Nurses can relate to the internal environment as
her use of wholeness on Erikson’s (1964, 1968) the physiological and pathophysiological aspects
description of wholeness as an open system. Levine of the patient. Levine uses Bates’ (1967) definition of
(as cited in 1969a) quotes Erikson, who states, the external environment and suggests the following
“Wholeness emphasizes a sound, organic, progres- three levels:
sive mutuality between diversified functions and 1. Perceptual
parts within an entirety, the boundaries of which are 2. Operational
open and fluent” (p. 94). Levine (1996) believed that 3. Conceptual
Erikson’s definition set up the option of exploring These levels give dimension to the interactions
the parts of the whole to understand the whole. between individuals and their environments. The
Integrity means the oneness of the individuals, perceptual level includes aspects of the world that
emphasizing that they respond in an integrated, individuals are able to intercept and interpret with
singular fashion to environmental challenges. their sense organs. The operational level contains
things that affect individuals physically, although
Adaptation they cannot directly perceive them, things such as
“Adaptation is a process of change whereby the indi- microorganisms. At the conceptual level, the envi-
vidual retains his integrity within the realities of his ronment is constructed from cultural patterns,
internal and external environment” (Levine, 1973, characterized by a spiritual existence and mediated
p. 11). Conservation is the outcome. Some adapta- by the symbols of language, thought, and history
tions are successful and some are not. Adaptation is (Levine, 1973).
a matter of degree, not an all-or-nothing process.
There is no such thing as maladaptation. Organismic Response
Levine (1991) speaks of the following three char- The capacity of individuals to adapt to their envi-
acteristics of adaptation: ronmental conditions is called the organismic re-
1. Historicity sponse. It is divided into the following four levels
2. Specificity of integration:
3. Redundancy 1. Fight or flight
She states, “. . . every species has fixed patterns 2. Inflammatory response
of responses uniquely designed to ensure success 3. Response to stress
in essential life activities, demonstrating that 4. Perceptual awareness
adaptation is both historical and specific” (p. 5). Treatment focuses on the management of these
In addition, adaptive patterns may be hidden in responses to illness and disease (Levine, 1969a).
individuals’ genetic codes. Redundancy represents
the fail-safe options available to individuals to Fight or Flight
ensure adaptation. Loss of redundant choices The most primitive response is the fight or flight
through trauma, age, disease, or environmental syndrome. Individuals perceive that they are
conditions makes it difficult for individuals to threatened, whether or not a threat actually exists.
maintain life. Levine (1991) suggests that “the Hospitalization, illness, and new experiences elicit
possibility exists that aging itself is a consequence a response. Individuals respond by being on the

CHAPTER 12 Myra Estrin Levine 207

MAJOR CONCEPTS & DEFINITIONS—cont’d
alert to find more information and to ensure their nursing is required (Levine, 1973, pp. 193–195). The
safety and well-being (Levine, 1973). primary focus of conservation is keeping together
the wholeness of individuals. Although nursing
Inflammatory Response interventions may deal with one particular conser-
This defense mechanism protects the self from vation principle, nurses also must recognize the
insult in a hostile environment. It is a way of heal- influence of the other conservation principles
ing. The response uses available energy to remove (Levine, 1990).
or keep out unwanted irritants and pathogens. It is Levine’s (1973) model stresses nursing interac-
limited in time because it drains the individual’s tions and interventions that are intended to promote
energy reserves. Environmental control is impor- adaptation and maintain wholeness. These interac-
tant (Levine, 1973). tions are based on the scientific background of the
conservation principles. Conservation focuses on
Response to Stress achieving a balance of energy supply and demand
Selye (1956) described the stress response syndrome within the biological realities unique to each indi-
to predictable, non–specifically induced organismic vidual. Nursing care is based on scientific knowl-
changes. The wear and tear of life is recorded on the edge and nursing skills. There are four conservation
tissues and reflects long-term hormonal responses principles.
to life experiences that cause structural change. It is
characterized by irreversibility and influences the Conservation Principles
way patients respond to nursing care. The goals of the Conservation Model are achieved
through interventions that attend to the conservation
Perceptual Awareness principles.
This response is based on the individual’s perceptual
awareness. It occurs only as individuals experience Conservation of Energy
the world around them. Individuals use responses The individual requires a balance of energy and a
to seek and maintain safety. It is the ability to gather constant renewal of energy to maintain life activi-
information and convert it to a meaningful experi- ties. Processes such as healing and aging challenge
ence (Levine, 1967a, 1969b). that energy. This second law of thermodynamics
applies to everything in the universe, including
Trophicognosis people.
Levine (1966a) recommended trophicognosis as an Conservation of energy has long been used in
alternative to nursing diagnosis. It is a scientific nursing practice, even with the most basic proce-
method of reaching a nursing care judgment. dures. Nursing interventions “scaled to the indi-
vidual’s ability are dependent upon providing care
Conservation that makes the least additional demand possible”
Conservation is from the Latin word conservatio, (Levine, 1990, pp. 197–198).
which means “to keep together” (Levine, 1973).
“Conservation describes the way complex systems Conservation of Structural Integrity
are able to continue to function even when severely Healing is a process of restoring structural and func-
challenged” (Levine, 1990, p. 192). Through conser- tional integrity through conservation in defense of
vation, individuals are able to confront obstacles, wholeness (Levine, 1991). The disabled are guided to
adapt accordingly, and maintain their uniqueness. a new level of adaptation (Levine, 1996). Nurses can
“The goal of conservation is health and the strength limit the amount of tissue involved in disease by early
to confront disability” as “. . . the rules of conserva- recognition of functional changes and by nursing
tion and integrity hold” in all situations in which interventions.

Continued

208 UNIT III Nursing Conceptual Models

MAJOR CONCEPTS & DEFINITIONS—cont’d

Conservation of Personal Integrity manifested through holiness, a testament to spiritu-
Self-worth and a sense of identity are important. ality in all people. “The conservation of personal
The most vulnerable become patients. This begins integrity includes recognition of the holiness of
with the erosion of privacy and the creation of each person” (Levine, 1996, p. 40).
anxiety. Nurses can show patients respect by calling
them by name, respecting their wishes, valuing per- Conservation of Social Integrity
sonal possessions, providing privacy during proce- Life gains meaning through social communities,
dures, supporting their defenses, and teaching and health is socially determined. Nurses fulfill
them. “The nurse’s goal is always to impart knowl- professional roles, provide for family members,
edge and strength so that the individual can resume assist with religious needs, and use interpersonal
a private life—no longer a patient, no longer depen- relationships to conserve social integrity (Levine,
dent” (Levine, 1990, p. 199). The sanctity of life is 1967b, 1969a).





Use of Empirical Evidence • “Every self-sustaining system monitors its own
Levine (1973) believed that specific nursing activities behavior by conserving the use of the resources
could be deducted from scientific principles. The sci- required to define its unique identity” (Levine,
entific theoretical sources have been well researched. 1991, p. 4).
She based much of her work on accepted science • Human beings respond in a singular, yet integrated,
principles. fashion (Levine, 1971a).

Nursing
Major Assumptions Levine (1973) stated the following about nursing:
Introduction to Clinical Nursing is a text for beginning Nursing is a human interaction (p. 1). Professional
nursing students that uses the conservation principles nursing should be reserved for those few who can
as an organizing framework (Levine, 1969a, 1973). complete a graduate program as demanding as
Although she did not state them specifically as as- that expected of professionals in any other disci-
sumptions, Levine (1973) valued “a holistic approach pline . . . There will be very few professional nurses
to care of all people, well or sick” (p. 151). Her respect (Levine, 1965, p. 214).
for the individuality of each person is noted in the
following statements: Nursing practice is based on nursing’s unique
knowledge and the scientific knowledge of other dis-
Ultimately, decisions for nursing interventions ciplines adjunctive to nursing knowledge (Levine,
must be based on the unique behavior of the 1988b), as follows:
individual patient. . . . Patient centered nursing
care means individualized nursing care . . . and It is the nurse’s task to bring a body of scientific
as such he requires a unique constellation of principles, on which decisions depend, into the
skills, techniques, and ideas designed specifically precise situation that she shares with the patient.
for him (1973, p. 6).
Sensitive observation and the selection of rele-
Schaefer (1996) identified the following statements vant data form the basis for her assessment of his
as assumptions about the model: nursing requirements.
• The person can be understood only in the context The nurse participates actively in every patient’s
of his or her environment (Levine, 1973). environment and much of what she does supports

CHAPTER 12 Myra Estrin Levine 209

backdrop. “The individual actively participates in his
his adjustments as he struggles in the predicament environment” (Levine, 1973, p. 443). Levine discussed
of illness (Levine, 1966b, p. 2452).
the importance of the internal and external environ-
The essence of Levine’s theory is as follows: ment to the determinant of nursing interventions to
promote adaptation. “All adaptations represent the
. . . when nursing intervention influences adap- accommodation that is possible between the internal
tation favorably, or toward renewed social well- and external environment” (p. 12).
being, then the nurse is acting in a therapeutic
sense; when the response is unfavorable, the
nurse provides supportive care (1966b, p. 2450). Theoretical Assertions
The goal of nursing is to promote adaptation
and maintain wholeness (1971b, p. 258). Although many theoretical assertions can be generated
from Levine’s work, the four major assertions follow:
1. “Nursing intervention is based on the conserva-
Person tion of the individual patient’s energy” (Levine,
Person is described as a holistic being; wholeness is 1967a, p. 49).
integrity (Levine, 1991). Integrity means that the per- 2. “Nursing intervention is based on the conserva-
son has freedom of choice and movement. The person tion of the individual patient’s structural integrity”
has a sense of identity and self-worth. Levine also (Levine, 1967a, p. 56).
described person as a “system of systems, and in its 3. “Nursing intervention is based on the conserva-
wholeness expresses the organization of all the con- tion of the individual patient’s personal integrity”
tributing parts” (pp. 8–9). Persons experience life as (Levine, 1967a, p. 56).
change through adaptation with the goal of conserva- 4. “Nursing intervention is based on the conservation
tion. According to Levine (1989), “The life process is of the individual patient’s social integrity” (Levine,
the process of change” (p. 326). 1967b, p. 179).
Levine (1991) provided some thoughts about two
Health theories in their early stages of development. The the-
Health is socially determined by the ability to func- ory of therapeutic intention is intended to provide the
tion in a reasonably normal manner (Levine, 1969b). basis of nursing interventions that focus on biological
Social groups predetermine health. Health is not just realities of the patient. Although not planned as such,
an absence of pathological conditions. Health is the the theory naturally flows from the conservation prin-
return to self; individuals are free and able to pursue ciples. The theory of redundancy expands the redun-
their own interests within the context of their own dancy domain of adaptation and offers explanations
resources. Levine stressed the following: for redundant options such as those found in aging
and the physiological adaptation of a failing heart.
It is important to keep in mind that health is also
culturally determined—it is not an entity on its
own, but rather a definition imparted by the Logical Form
ethos and beliefs of the groups to which individu- Levine primarily uses deductive logic. In developing
als belong her model, Levine integrates theories and concepts
(M. Levine, personal communication, from the humanities and the sciences of nursing,
February 21, 1995).
physiology, psychology, and sociology. She uses the
Even for a single individual, the definition of information to analyze nursing practice situations
health will change over time. and describe nursing skills and activities. With the
assistance of many of her students and colleagues,
Environment and through her own personal health encounters,
Environment is conceptualized as the context in Levine has experienced the Conservation Model and
which individuals live their lives. It is not a passive its principles operating in practice.

210 UNIT III Nursing Conceptual Models

Applications to the Nursing Community early discussion of death and dying and believed that
women should be awakened after a breast biopsy and
Practice consulted about the next step.
Levine helps define what nursing is by identifying the Introduction to Clinical Nursing provides an orga-
activities it encompasses and giving the scientific nizational structure for teaching medical-surgical
principles behind them. Conservation principles, nursing to beginning students (Levine, 1969a, 1973).
levels of integration, and other concepts can be used In both the 1969 and 1973 editions, Levine presents a
in numerous contexts (Fawcett, 2000; Levine, 1990, model at the end of each of the first nine chapters.
1991). Hirschfeld (1976) has used the principles of Each model contains objectives, essential science con-
conservation in the care of the older adult. Savage cepts, and nursing process to give nurses a foundation
and Culbert (1989) used the Conservation Model for nursing activities. These models are not part of
to establish a plan of care for infants. Dever (1991) the Conservation Model. The Conservation Model
based her care of children on the Conservation Model. is addressed in the Introduction and in Chapter 10
Roberts, Fleming, and Yeates-Giese (1991) designed of the introductory text. The teachers’ manual that
interventions for women in labor based on the Con- accompanies the text remains a timely source of edu-
servation Model. Mefford (2000; Mefford & Alligood, cational principles that may be helpful to both begin-
2011a, 2011b) tested a Middle Range Theory of Health ning and seasoned teachers (Levine, 1971c).
Promotion for Preterm Infants based on Levine’s Although the text is labeled introductory, beginning
Conservation Model of nursing and found a signifi- students would have benefited from a background in
cant inverse relationship between the consistency of physical and social sciences to use it. An emphasis of
the caregiver and the age at which the infant achieved scientific principles in the second edition bridged this
health, and an inverse relationship between the use gap. Evidence supporting the model has been integrated
of resources by preterm infants during the initial hos- successfully into undergraduate and graduate curricula
pital stay and the consistency of caregivers. Cooper (Grindley & Paradowski, 1991; Schaefer, 1991a).
(1990) developed a framework for wound care focus-
ing on structural integrity while integrating all the Research
integrities. Leach (2007) published a white paper on Levine’s Model has been successfully used to develop
use of the Conservation Model to guide wound care nursing knowledge (Schaefer & Pond, 1991). However,
practices. Webb (1993) used the Conservation Model Fawcett (1995) states that to establish credibility, “more
to provide care for patients undergoing cancer treat- systematic evaluations of the use of the model in vari-
ment. Roberts, Brittin, and deClifford (1995) and ous clinical situations are needed, as are studies that
Roberts, Brittin, Cook, and deClifford (1994) used test conceptual-theoretical-empirical structures di-
the Conservation Model to study the boomerang pil- rectly derived from or linked with the conservation
low technique effect on respiratory capacity. Jost principles” (p. 208). Many research questions can be
(2000) used the model to develop an assessment of generated from Levine’s model (Radwin & Fawcett,
the needs of staff during the experience of change. 2002; Schaefer, 1991b). Graduate students and clinical
Conservation principles have been used as a researchers have used the conservation principles as a
framework for numerous practice settings in cardiol- framework to guide their research (Ballard, Robley,
ogy, obstetrics, gerontology, acute care (neurology), Barrett, et al., 2006; Cox, 1988; Gagner-Tjellesen,
pediatrics, long-term care, emergency care, primary Yurkovich, & Gragert, 2001; Mefford, 2000; Mefford &
care, neonatology, critical care, and in the homeless Alligood, 2011a, 2011b; Moch, St. Ours, Hall, et al.,
community (Savage & Culbert, 1989; Schaefer & 2007). Ballard and colleagues used the model to frame
Pond, 1991). their phenomenological study of how participants re-
constructed their lives with paraplegia. They found that
Education structural integrity, along with all the other integrities,
Levine (1973) wrote Introduction to Clinical Nursing was used as a basis for defining their new lives.
as a textbook for beginning students. It introduced One of the most important questions to be asked
new material into the curricula. She presented an about the model is: What are the human experiences

CHAPTER 12 Myra Estrin Levine 211

not explained by the model? This question can pro- Accessibility
vide guidance for continued testing of the model’s Levine used deductive logic to develop her model,
application in nursing practice. For example, as health which can be used to generate research questions. As
care providers use information from the human she lived her Conservation Model, she verified the
genome project, nurse researchers will want to test use of inductive reasoning to further develop and in-
the ability of the model to explain comprehensive form her model (M. Levine, personal communication,
nursing care of the client undergoing genetic counsel- May 17, 1989).
ing. Based on the outcome of testing, hypotheses can
be developed and tested to support the prescriptive Importance
basis of theories developed from the model. The four conservation principles defined in Levine’s
model are recognized as one of the earliest nursing
models used to organize and clarify elements of nurs-
Further Development ing practice. Furthermore, the model continues to
Levine and others have worked on using the conser- demonstrate evidence of its utility for nursing practice
vation principles as the basis for a nursing diagnosis and research and is receiving increased recognition in
taxonomy (Stafford, 1996; Taylor, 1989). Additional the twenty-first century.
work has been done on the use of Levine’s model in
administration and with the frail elderly. The model
was used to develop and test the Theory of Health Summary
Promotion in Preterm Infants based on Levine’s Con- Levine developed her Conservation Model to provide
servation Model (Mefford, 2000; Mefford & Alligood, a framework within which to teach beginning nursing
2011a, 2011b) and has great potential for studies of students. In the first chapter of her book, she intro-
sleep disorders and in the development of collabora- duces her assumptions about holism, and that the
tive and primary care practices (Fawcett, 2000). The conservation principles support a holistic approach to
philosophical, ethical, and spiritual implications of patient care (Levine, 1969a, 1973). The model is logi-
the model are research challenges yet to be realized cally congruent, is externally and internally consis-
(Stafford, 1996). tent, has breadth as well as depth, and is understood,
with few exceptions, by professionals and consumers
Critique of health care. Nurses using the Conservation Model
can anticipate, explain, predict, and perform patient
Clarity care. However, its ability to predict outcomes must be
Levine’s model possesses clarity. Fawcett (2000) states, tested further. Levine (1990) said, “. . . everywhere
“. . . Levine’s Conservation Model provides nursing that nursing is essential, the rules of the conservation
with a logically congruent, holistic view of the person” and the integrity hold” (p. 195).
(p. 189). George (2002) affirms, “this theory directs
nursing actions that lead to favorable outcomes”
(p. 237). The model has numerous terms; however, CASE STUDY*
Levine adequately defines them for clarity. Yolanda is a 55-year-old married African-American
mother of two adult children who has a history
Simplicity of breast cancer. She was diagnosed with fibromyal-
Although the four conservation principles appear sim- gia 2 years ago, following years of unexplained
ple initially, they contain subconcepts and multiple muscle aches and what she thought was arthritis.
variables. Nevertheless, this model is still one of the The diagnosis was a relief for her; she was able to
simpler ones developed. read about it and learn how to care for herself.
Over the past 2 months, Yolanda stopped taking
Generality all of her medicine, because she was seeing a new
The four conservation principles can be used in all physician and wanted to start her care at ground
nursing contexts. zero. In addition to her family responsibilities, she
Continued

212 UNIT III Nursing Conceptual Models


is completing her degree as an English major. At gas results have always been within normal limits.
the time of her appointment, she told the nurse Most diagnostic study values are within normal
practitioner that she was having the worst pain limits in patients with fibromyalgia, making treat-
possible. ment difficult.
Using Levine’s Conservation Model, the nurse Conservation of structural integrity involves
practitioner completed a comprehensive assess- maintaining the structure of the body to promote
ment in preparation for developing a plan of care healing. Because there is no known cause of fibro-
in consultation with the physician. Nursing care is myalgia, treatment focuses on reducing symptoms.
organized according to the conservation princi- Yolanda’s symptoms could not be traced to any
ples, with consideration of how the individual physical or structural alteration, yet she reports
adapts to the internal and external environments. severe pain and fatigue. The nurse practitioner
Yolanda’s diagnosis of fibromyalgia was based on knows that it is important to acknowledge the reality
the exclusion of other illnesses with a cluster of of the symptoms and work with the client to deter-
symptoms, including pain, fatigue, and sleepless- mine if activities of daily living result in changes in
ness (e.g., systemic lupus erythematosus, multiple the pattern of illness. In addition, Yolanda thinks she
sclerosis). Laboratory and other diagnostic results is going through menopause, and she is having
all were within normal limits. trouble determining if her symptoms are caused by
The external environment includes perceptual, menopause or fibromyalgia.
operational, and conceptual factors. Perceptual With continued questioning, the nurse practitio-
factors are those that are perceived through the ner learns that Yolanda was diagnosed with irritable
senses. Yolanda reported a history of unexplained bowel syndrome several years earlier. She is not
fatigue and pain for years. She recently stopped worried about constipation but is concerned about
her medications “to clean my body out.” However, sudden diarrhea. She is afraid to go to school; she
she reported that the pain became unbearable and fears embarrassment because she might have an
was making it difficult for her to sleep. She noted “accident.” Yolanda was taking several medications
that when she sleeps at least 6 hours a night, her for her discomfort. One of them made her feel so
pain is less intense. With the current insomnia, “hung over” that she stopped taking it after 2 weeks.
her pain is very intense. She was given amitriptyline (Elavil) for sleep. It was
Operational factors are threats to the environment the only medicine that helped her get 6 hours of
that the client cannot perceive through the senses. continuous sleep.
Yolanda reported severe pain in response to both the Personal integrity involves the maintenance of
cold weather and changes in barometric pressure. one’s sense of personal worth and self-esteem.
The conceptual environment includes cultural Yolanda reported that she lost control when she
and personal values about health care, the meaning was diagnosed with breast cancer. A dear friend
of health and illness, knowledge about health care, convinced her to go to church and encouraged her
education, language use, and spiritual beliefs. In to use prayer. When feeling sorry for herself, she
response to breast cancer, Yolanda developed her would go into her bedroom and read her Bible, cry
spirituality through prayer and reading the Bible. by herself, and pray. She believes that prayer and
She believes that this is how she gets through the Bible reading helped her heal. She continues to
painful moments of her current illness. pray and read her Bible to gain the strength she
Conservation of energy focuses on the balance needs to live with her illness. She also believes that
of energy input and output to prevent excessive she needs to be able to laugh at herself; humor
fatigue. Yolanda complains of a fatigue that just helps her to feel better. She actively seeks health
“comes over me.” She has difficulty doing house- information, as indicated by her quest to learn
work. One day of work usually means one day in about her new diagnosis of fibromyalgia. She is
bed because of extreme fatigue. Her hemoglobin most upset about not being able to walk like
level and hematocrit are normal; her arterial blood she used to walk. One of her favorite pastimes

CHAPTER 12 Myra Estrin Levine 213


was shopping for shoes at the mall, which now is prayer, Bible reading, and humor to help her feel
difficult for her. better, (3) discuss medication therapy and what
Social integrity acknowledges that the patient is a might help her achieve restful sleep, (4) refer her
social being. Yolanda is a married mother of three for blood work to assess hormone levels, and
grown children. She keeps a lot of her feelings from (5) assist her with determining the meaning of
her children but does share them with her husband. the symptoms (e.g., menopause or fibromyalgia).
He is a major source of support for her. He takes her Yolanda indicated that when she was able to get
food shopping and makes sure that she gets to her 6 hours of uninterrupted sleep, her pain was less
appointments on time. She shared at the time of intense and she felt better. Finding both medication-
her visit that she wants to have a picnic for her induced and nonpharmaceutical approaches to
birthday, but the only way she can do it is to ask her improve sleep is a high priority.
grandchildren to help her husband clean the yard. The nurse practitioner will assess the outcome
Yolanda is a middle-aged woman with a history of Yolanda’s care based on the organismic re-
of severe pain, sleeplessness, and fatigue. Diagnostic sponses. The following predicted responses suggest
studies have been unrevealing, with the exception adaptation:
of multiple tender points. The history of pain and n Reports comfort as a result of prayer, Bible
positive tender points supported the diagnosis of reading, and humor
fibromyalgia. She has stopped taking all medications n Distinguishes symptoms of menopause from
and reports that she may be going through meno- symptoms of fibromyalgia
pause. She reports severe pain and fatigue that make n Reports feeling rested after 6 hours of unin-
it difficult for her to sleep and to do normal house- terrupted sleep
work. Her husband and grandchildren are available n Reports a perceived reduction in pain and
to help with chores at home, and she seeks the sup- fatigue
port of prayer and reading her Bible to ease her n Collaborates with health care providers to
discomfort. She also finds that humor helps her to manage symptoms of menopause
feel better. *This case study is based on raw data from a completed study (Schaefer,
The initial plan of care includes (1) validate the 2005). Yolanda is a fictitious name used to protect the privacy and anonymity
illness experience, (2) encourage continued use of of the participant.



CRITICAL THINKING ACTIVITIES
1. Keep a reflective journal about a personal health appropriate interventions using Levine’s conserva-
or illness experience or that of someone very close. tion principles.
Reflect on its consistency with the Conservation 4. Watch one of the following movies: City of Joy,
Model—how to modify, expand, or delimit the Soul Food, The Secret Garden, Courageous, or
model to provide a context for explanation. The Descendents. Use examples from the movie
2. Levine stated, “Health is culturally determined; it to support or refute Levine’s propositional
is not an entity on its own, but rather a definition statements.
imparted by the ethos and beliefs of groups to 5. Apply the Conservation Model to a pathography
which the individual belongs” (M. Levine, such as Love and Other Infectious Diseases by
personal communication, February, 21, 1995). Molly Haskell, and explain life with illness.
3. Visit a museum, and evaluate how artistic expres- 6. Identify what may be missing in simulation expe-
sion captures the beliefs of different ethnic groups. riences of nursing practice from the perspective
Then explore how these beliefs shape definitions of this nursing model. Suggest how you might
of health and illness. On the basis of an ethnically develop your style of nursing practice to encom-
derived definition of health, propose ethnically pass the total patient experience.

214 UNIT III Nursing Conceptual Models

POINTS FOR FURTHER STUDY
n Cardinal Stitch University Library; Nursing n Mayo Clinic—Nursing Theorist—Myra Levine at:
Theorist: Myra Levine at: http://library.stitch.edu/ http://www.mayo.edu/education/nursing-research/
research/subjects/nursingtheorists/levine.htm levine.html
n Hahn School of Nursing and Health Science, n Nursing for Nurses—Levine Conservation Model
University of San Diego at: http://www.sandiego. (Blog) at: http://allnurses.com/forums/f76/levine-
edu/nursing/theory/ conservation-model-48040-print.html
n Karen Schaefer’s chapter, “Levine’s Conservation n Nursing Theories Group E-Levine’s Conservation
Nursing Model in Nursing Practice” (Chapter Model Concept at: http://nursingtheories.
10) in a companion Elsevier text, Alligood blogspot.com2011/07/group-e-levines-
(2010). Nursing theory: Utilization & application, n The nursing theorist: Portraits of excellence. Myra
4th edition. Levine (video, CD, or electronically), by Oakland:
n Leach, M. J. Using Levine’s conservation model Studio III, Oakland, CA. Now available at Fitne,
to guide practice (white paper) at: http://www. Inc., 5 Depot Street, Athens, Ohio 45701
om.com/article/6024


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13

CHAP TER



















Martha E. Rogers
1914 to 1994


Unitary Human Beings


Mary E. Gunther



“Professional practice in nursing seeks to promote symphonic interaction between man and environ-
ment, to strengthen the coherence and integrity of the human field, and to direct and redirect pat-
terning of the human and environmental fields for realization of maximum health potential”
(Rogers, 1970, p. 122).




included an MA degree in public health nursing
Credentials and Background of the supervision from Teachers College, Columbia Uni-
Theorist versity, New York (1945), and an MPH (1952) and
Martha Elizabeth Rogers, the eldest of four children an ScD (1954) from Johns Hopkins University in
of Bruce Taylor Rogers and Lucy Mulholland Keener Baltimore.
Rogers, was born May 12, 1914, in Dallas, Texas. Rogers’ early nursing practice was in rural public
Soon after her birth, her family returned to Knoxville, health nursing in Michigan and in visiting nurse
Tennessee. She began her college education (1931 to supervision, education, and practice in Connecticut.
1933) studying science at the University of Tennessee. Rogers subsequently established the Visiting Nurse
Receiving her nursing diploma from Knoxville Gen- Service of Phoenix, Arizona. For 21 years (from 1954
eral Hospital School of Nursing (1936), she quickly to 1975), she was professor and head of the Division
obtained a BS degree from George Peabody College of Nursing at New York University. After 1975, she
in Nashville, Tennessee (1937). Her other degrees continued her duties as professor until she became


Photo credit: Kathleen Leininger, Shiner, TX.
Previous authors: Kaye Bultemeier, Mary Gunther, Joann Sebastian Daily, Judy Sporleder Maupin, Cathy A. Murray, Martha Carole
Satterly, Denise L. Schnell, and Therese L. Wallace. Earlier editions of this chapter were critiqued by Dr. Lois Meier and Dr. Martha
Rogers.

220

CHAPTER 13 Martha E. Rogers 221

Professor Emerita in 1979. She held this title until her humorous, blunt, and ethical. Rogers remains a widely
death on March 13, 1994, at 79 years of age. recognized scholar honored for her contributions and
Rogers’ publications include three books and more leadership in nursing. Butcher (1999) noted, “Rogers,
than 200 articles. She lectured in 46 states, the District like Nightingale, was extremely independent, a deter-
of Columbia, Puerto Rico, Mexico, the Netherlands, mined, perfectionist individual who trusted her vision
China, Newfoundland, Columbia, Brazil, and other despite skepticism” (p. 114). Colleagues consider her
countries (M. Rogers, personal communication, March one of the most original thinkers in nursing as she syn-
1988). Rogers received honorary doctorates from such thesized and resynthesized knowledge into “an entirely
renowned institutions as Duquesne University, Univer- new system of thought” (Butcher, 1999, p. 111). Today
sity of San Diego, Iona College, Fairfield University, she is thought of as “ahead of her time, in and out of this
Emory University, Adelphi University, Mercy College, world” (Ireland, 2000, p. 59).
and Washburn University of Topeka. The numerous
awards for her contributions and leadership in nursing
include citations for Inspiring Leadership in the Field of Theoretical Sources
Intergroup Relations by Chi Eta Phi Sorority, In Recog- Rogers’ grounding in the liberal arts and sciences
nition of Your Outstanding Contribution to Nursing by is apparent in both the origin and the development
New York University, and For Distinguished Service to of her conceptual model, published in 1970 as An
Nursing by Teachers College. In addition, New York Introduction to the Theoretical Basis of Nursing (Rogers,
University houses the Martha E. Rogers Center for the 1970). Aware of the interrelatedness of knowledge,
Study of Nursing Science. In 1996, Rogers was inducted Rogers credited scientists from multiple disciplines
posthumously into the American Nurses Association with influencing the development of the Science of
Hall of Fame. Unitary Human Beings. Rogerian science emerged
In 1988, colleagues and students joined her in from the knowledge bases of anthropology, psychol-
forming the Society of Rogerian Scholars (SRS) and ogy, sociology, astronomy, religion, philosophy, history,
immediately began to publish Rogerian Nursing Sci- biology, physics, mathematics, and literature to create a
ence News, a members’ newsletter, to disseminate the- model of unitary human beings and the environment
ory developments and research studies (Malinski as energy fields integral to the life process. Within
2009). In 1993, the SRS began to publish a refereed nursing, the origins of Rogerian science can be traced
journal, Visions: The Journal of Rogerian Nursing Sci- to Nightingale’s proposals and statistical data, placing
ence. The society includes a foundation that maintains the human being within the framework of the natural
and administers the Martha E. Rogers Fund. In 1995, world. This “foundation for the scope of modern nurs-
New York University established the Martha E. Rogers ing” began nursing’s investigation of the relationship
Center to provide a structure for continuation of Ro- between human beings and the environment (Rogers,
gerian research and practice. 1970, p. 30). Newman (1997) describes the Science of
A verbal portrait of Rogers includes such descriptive Unitary Human Beings as “the study of the moving,
terms as stimulating, challenging, controversial, idealistic, intuitive experience of nurses in mutual process with
visionary, prophetic, philosophical, academic, outspoken, those they serve” (p. 9).


MAJOR CONCEPTS & DEFINITIONS

In 1970, Rogers’ conceptual model of nursing rested Rogers postulates that human beings are dynamic
on a set of basic assumptions that described the energy fields that are integral with environmental
life process in human beings. Wholeness, openness, fields. Both human and environmental fields are
unidirectionality, pattern and organization, sen- identified by pattern and characterized by a universe
tience, and thought characterized the life process of open systems. In her 1983 paradigm, Rogers pos-
(Rogers, 1970). tulated four building blocks for her model: energy
Continued

222 UNIT III Nursing Conceptual Models

MAJOR CONCEPTS & DEFINITIONS—cont’d
field, a universe of open systems, pattern,and four- human and environmental fields change continu-
dimensionality. ously, creatively, and integrally (Rogers, 1994a).
Rogers consistently updated the conceptual model
through revision of the homeodynamic principles. Universe of Open Systems
Such changes corresponded with scientific and tech- The concept of the universe of open systems holds
nological advances. In 1983, Rogers changed her that energy fields are infinite, open, and integral
wording from that of unitary man to unitary human with one another (Rogers, 1983). The human and
being, to remove the concept of gender. Additional environmental fields are in continuous process and
clarification of unitary human beings as separate are open systems.
and different from the term holistic stressed the
unique contribution of nursing to health care. In Pattern
1992, four-dimensionality evolved into pandimension- Pattern identifies energy fields. It is the distinguishing
ality. Rogers’ fundamental postulates have remained characteristic of an energy field and is perceived as a
consistent since their introduction; her subsequent single wave. The nature of the pattern changes con-
writings served to clarify her original ideas. tinuously and innovatively, and these changes give
identity to the energy field. Each human field pattern
Energy Field is unique and is integral with the environmental field
An energy field constitutes the fundamental unit of (Rogers, 1983). Manifestations emerge as a human-
both the living and the nonliving. Field is a unifying environmental mutual process. Pattern is an abstrac-
concept, and energy signifies the dynamic nature of tion; it reveals itself through manifestation. A sense
the field. Energy fields are infinite and pandimen- of self is a field manifestation, the nature of which is
sional. Two fields are identified: the human field and unique to each individual. Some variations in pat-
the environmental field. “Specifically human beings tern manifestations have been described in phrases
and environment are energy fields” (Rogers, 1986b, such as “longer versus shorter rhythms,” “pragmatic
p. 2). The unitary human being (human field) is versus imaginative,” and time experienced as “fast”
defined as an irreducible, indivisible, pandimen- or “slow.” Pattern is changing continually and may
sional energy field identified by pattern and mani- manifest disease, illness, or well-being. Pattern change
festing characteristics that are specific to the whole is continuous, innovative, and relative.
and that cannot be predicted from knowledge of
the parts. The environmental field is defined as Pandimensionality
an irreducible, pandimensional energy field identi- Rogers defines pandimensionality as a nonlinear
fied by pattern and integral with the human field. domain without spatial or temporal attributes, or as
Each environmental field is specific to its given Phillips (2010) notes: “essentially a spaceless and
human field. While not necessarily quantifiable, timeless reality” (p. 56). The term pandimensional
an energy field has the inherent ability to create provides for an infinite domain without limit. It best
change (Todaro-Franceschi, 2008). In this case, both expresses the idea of a unitary whole.




Use of Empirical Evidence apparent of these are the nonlinear dynamics of quan-
Being an abstract conceptual system, the Science tum physics and general system theory.
of Unitary Human Beings does not directly identify Evident in her model are the influence of Einstein’s
testable empirical indicators. Rather, it specifies a (1961) theory of relativity in relation to space-time
worldview and philosophy used to identify the phe- and Burr and Northrop’s (1935) electrodynamic the-
nomena of concern to the discipline of nursing. As ory relating to electrical fields. By the time von
was mentioned previously, Rogers’ model emerged Bertalanffy (1960) introduced the general system
from multiple knowledge sources; the most readily theory, theories regarding a universe of open systems

CHAPTER 13 Martha E. Rogers 223

were beginning to affect the development of knowl- Nursing exists for the care of people and the life
edge within all disciplines. With the general system process of humans.
theory, the term negentropy was brought into use
to signify increasing order, complexity, and heteroge- Person
neity in direct contrast to the previously held belief Rogers defines person as an open system in continuous
that the universe was winding down. Rogers, how- process with the open system that is the environment
ever, refined and purified the general system theory (integrality). She defines unitary human being as an
by denying hierarchical subsystems, the concept of “irreducible, indivisible, pandimensional energy field
single causation, and the predictability of a system’s identified by pattern and manifesting characteristics
behavior through investigations of its parts. that are specific to the whole” (Rogers, 1992, p. 29).
Introducing quantum theory and the theories of Human beings “are not disembodied entities, nor are
relativity and of probability fundamentally challenged they mechanical aggregates. . . . Man is a unified
the prevailing absolutism. As new knowledge escalated, whole possessing his own integrity and manifesting
the traditional meanings of homeostasis, steady state, characteristics that are more than and different from
adaptation,and equilibrium were questioned seriously. the sum of his parts” (Rogers, 1970, pp. 46–47).
The closed-system, entropic model of the universe was Within a conceptual model specific to nursing’s con-
no longer adequate to explain phenomena, and evi- cern, people and their environment are perceived as
dence accumulated in support of a universe of open irreducible energy fields integral with one another and
systems (Rogers, 1994b). Continuing development continuously creative in their evolution.
within other disciplines of the acausal, nonlinear dy-
namics of life validated Rogers’ model. Most notable Health
of this development is that of chaos theory, quantum Rogers uses the term health in many of her earlier
physics’ contribution to the science of complexity (or writings without clearly defining the term. She uses
wholeness), which blurs the boundaries between the the term passive health to symbolize wellness and the
disciplines, allowing exploration and deepening of the absence of disease and major illness (Rogers, 1970).
understanding of the totality of human experience. Her promotion of positive health connotes direction
in helping people with opportunities for rhythmic
Major Assumptions consistency (Rogers, 1970). Later, she wrote that well-
ness “is a much better term . . . because the term
Nursing health is very ambiguous” (Rogers, 1994b, p. 34).
Nursing is a learned profession and is both a science Rogers uses health as a value term defined by the
and an art. It is an empirical science and, like other culture or the individual. Health and illness are mani-
sciences, it lies in the phenomenon central to its festations of pattern and are considered “to denote
focus. Rogerian nursing focuses on concern with behaviors that are of high value and low value” (Rogers,
people and the world in which they live—a natural fit 1980). Events manifested in the life process indicate the
for nursing care, as it encompasses people and their extent to which a human being achieves maximum
environments. The integrality of people and their health according to some value system. In Rogerian
environments, operating from a pandimensional uni- science, the phenomenon central to nursing’s concep-
verse of open systems, points to a new paradigm and tual system is the human life process. The life process
initiates the identity of nursing as a science. The pur- has its own dynamic and creative unity that is insepa-
pose of nursing is to promote health and well-being rable from the environment and is characterized by
for all persons. The art of nursing is the creative use of the whole (Rogers, 1970). Using this definition as a
the science of nursing for human betterment (Rogers, foundation for their research, Gueldner, and colleagues
1994b). “Professional practice in nursing seeks to (2005) postulate that a human being’s sense of well-
promote symphonic interaction between human and being (wellness) manifests itself by higher frequency
environmental fields, to strengthen the integrity of and increasing pattern diversity.
the human field, and to direct and redirect patterning In “Dimensions of Health: A View from Space,”
of the human and environmental fields for realization Rogers (1986b) reaffirms the original theoretical asser-
of maximum health potential” (Rogers, 1970, p. 122). tions, adding philosophical challenges to the prevailing

224 UNIT III Nursing Conceptual Models

perception of health. Stressing a new worldview that of the parts. Each environmental field is specific to its
focuses on people and their environment, she lists given human field. Both change continuously and cre-
iatrogenesis, nosocomial conditions, and hypochron- atively” (p. 3). Environmental fields are infinite, and
driasis as the major health problems in the United change is continuously innovative, unpredictable, and
States. Rogers (1986b) writes, “A new world view com- characterized by increasing diversity. Environmental
patible with the most progressive knowledge available and human fields are identified by wave patterns
is a necessary prelude to studying human health and manifesting continuous mutual change.
to determining modalities for its promotion whether
on this planet or in the outer reaches of space” (p. 2).
Theoretical Assertions
Environment The principles of homeodynamics postulate a way
Rogers (1994a) defines environment as “an irreduc- of perceiving unitary human beings. The evolution
ible, pandimensional energy field identified by pattern of these principles from 1970 to 1994 is depicted in
and manifesting characteristics different from those Table 13–1. Rogers (1970) wrote, “The life process is



TABLE 13-1 Evolution of Principles of Homeodynamics: 1970, 1983, 1986, and 1992
An Introduction to Science of Unitary Human Dimensions of Nursing Science
the Theoretical Basis Nursing: A Science Beings: A Paradigm for Health: A View and the Space Age,
of Nursing, 1970 of Unitary Man, 1980 Nursing, 1983 From Space, 1986 1992
Resonancy
Continuously propa- Continuous change Continuous change from Continuous change Continuous change
gating series of from lower- to higher- lower- to higher-frequency from lower- to from lower- to
waves between frequency wave wave patterns in the higher-frequency higher-frequency
man and environ- patterns in the human human and environmental wave patterns in wave patterns in
ment and environmental fields the human and the human and
fields environmental fields environmental fields
Helicy
Continuous, innova- Nature of change be- Continuous innovative, Continuous, innova- Continuous, innova-
tive change growing tween human and probabilistic, increasing tive, probabilistic, tive, unpredictable,
out of mutual inter- environmental fields diversity of human and increasing, and increasing diversity
action of man and is continuously innova- environmental field environmental of human and
environment along a tive, probabilistic, and patterns, characterized diversity character- environmental
spiraling longitudinal increasingly diverse, by nonrepeating ized by nonrepeating field patterns
axis bound in manifesting nonre- rhythmicities rhythmicities
space-time peating rhythmicities
Reciprocy
Continuous mutual — — — —
interaction between
the human and
environmental fields
Synchrony
Change in the human Continuous, mutual, Continuous, mutual Continuous, mutual Continuous, mutual
field and simultane- simultaneous interac- human field and human field and human field and
ous state of envi- tion between human environmental field environmental field environmental field
ronmental field and environmental process process process
at any given point fields
in space-time
Conceptualized by J. S. Daily; revised by D. Schnell & T. Wallace; updated by C. Murray.

CHAPTER 13 Martha E. Rogers 225

homeodynamic. . . . these principles postulate the Rogers explains nursing by referring to broader
way the life process is and predict the nature of its principles that explain human beings. She explains
evolving” (p. 96). Rogers identified the principles of human beings through principles that characterize
change as helicy, resonancy, and integrality. The helicy the universe, based on the perspective of a whole
principle describes spiral development in continuous, that organizes the parts.
nonrepeating, and innovative patterning. Rogers’ Rogers’ model of unitary human beings is deductive
articulation of the principle of helicy describing the and logical. The theory of relativity, the general system
nature of change evolved from probabilistic to unpre- theory, the electrodynamic theory of life, and many
dictable, while remaining continuous and innovative. other theories contributed ideas for Rogers’ model.
According to the principle of resonancy, patterning Unitary human beings and environment, the central
changes with the development from lower to higher components of the model, are integral with one
frequency, that is, with varying degrees of intensity. another. The basic building blocks of her model are
Resonancy embodies wave frequency and energy field energy field, openness, pattern, and pandimensionality
pattern evolution. Integrality, the third principle providing a new worldview. These concepts form the
of homeodynamics, stresses the continuous mutual basis of an abstract conceptual system defining nursing
process of person and environment. The principles of and health. From the abstract conceptual system,
homeodynamics (nature, process, and context of Rogers derived the principles of homeodynamics,
change) support and exemplify the assertion that “the which postulate the nature and direction of human
universe is energy that is always becoming more beings’ evolution. Although Rogers invented the
diverse through changing, continuous wave frequen- words homeodynamics (similar state of change and
cies” (Phillips, 2010, p. 57). In addition, Todaro- growth), helicy (evolution), resonancy (intensity of
Franceschi (2008) reminds us that this changing change), and integrality (wholeness), all definitions
nature is intrinsic to, not outside of, fields. are etymologically consistent and logical.
In 1970, Rogers identified the following five assump-
tions that are also theoretical assertions supporting Acceptance by the Nursing Community
her model derived from literature on human beings,
physics, mathematics, and behavioral science: Practice
1. “Man is a unified whole possessing his own integ- The Rogerian model is an abstract system of ideas
rity and manifesting characteristics more than from which to approach the practice of nursing.
and different from the sum of his parts” (energy Rogers’ model, stressing the totality of experience
field) (p. 47). and existence, is relevant in today’s health care sys-
2. “Man and environment are continuously exchang- tem, where a continuum of care is more important
ing matter and energy with one another” (open- than episodic illness and hospitalization. This model
ness) (p. 54). provides the abstract philosophical framework from
3. “The life process evolves irreversibly and unidirec- which to view the unitary human-environmental
tionally along the space-time continuum” (helicy) field phenomenon. Within the Rogerian framework,
(p. 59). nursing is based on theoretical knowledge that
4. “Pattern and organization identify man and reflect guides nursing practice. The professional practice of
his innovative wholeness” (pattern and organiza- nursing is creative and imaginative and exists to
tion) (p. 65). serve people. It is rooted in intellectual judgment,
5. “Man is characterized by the capacity for abstrac- abstract knowledge, and human compassion.
tion and imagery, language and thought, sensation, Historically, nursing has equated practice with
and emotion” (sentient, thinking being) (p. 73). the practical and theory with the impractical. More
appropriately, theory and practice are two related
components in a unified nursing practice. Alligood
Logical Form (1994) articulates how theory and practice direct and
Rogers uses a dialectic method as opposed to a logis- guide each other as they expand and increase unitary
tical, problematic, or operational method, that is, nursing knowledge. Nursing knowledge provides the

226 UNIT III Nursing Conceptual Models

framework for the emergent artistic application of The Rogerian model provides a challenging and
nursing care (Rogers, 1970). innovative framework from which to plan and imple-
Within Rogers’ model, the critical thinking pro- ment nursing practice, which Barrett (1998) defines
cess directing practice can be divided into three as the “continuous process (of voluntary mutual pat-
components: pattern appraisal, mutual patterning, terning) whereby the nurse assists clients to freely
and evaluation. Cowling (2000) states that pattern choose with awareness ways to participate in their
appraisal is meant to avoid, if not transcend, reduc- well-being” (p. 136).
tionistic categories of physical, mental, spiritual,
emotional, cultural, and social assessment frame- Education
works. Through observation and participation, the Rogers clearly articulated guidelines for the education
nurse focuses on human expressions of reflection, of nurses within the Science of Unitary Human Beings.
experience, and perception to form a profile of the Rogers discusses structuring nursing education pro-
patient. Mutual exploration of emergent patterns grams to teach nursing as a science and as a learned
allows identification of unitary themes predominant profession. Barrett (1990b) calls Rogers a “consistent
in the pandimensional human-environmental field voice crying out against antieducationalism and de-
process. Mutual understanding implies knowing par- pendency” (p. 306). Rogers’ model clearly articulates
ticipation but does not lead to the nurse’s prescribing values and beliefs about human beings, health, nursing,
change or predicting outcomes. As Cowling (2000) and the educational process. As such, it has been
explains, “A critical feature of the unitary pattern used to guide curriculum development in all levels of
appreciation process, and also of healing through nursing education (Barrett, 1990b; DeSimone, 2006;
appreciating wholeness, is a willingness on the part Hellwig & Ferrante, 1993; Mathwig, Young, & Pepper,
of the scientist or practitioner to let go of expecta- 1990). Rogers (1990) stated that nurses must commit
tions about change” (p. 31). Evaluation centers on the to lifelong learning and noted, “The nature of the prac-
perceptions emerging during mutual patterning. tice of nursing (is) the use of knowledge for human
Noninvasive patterning modalities used within betterment” (p. 111).
Rogerian practice include, but are not limited to, Rogers advocated separate licensure for nurses
acupuncture, aromatherapy, touch and massage, prepared with an associate’s degree and those with a
guided imagery, meditation, self-reflection, guided baccalaureate degree, recognizing that there is a dif-
reminiscence, humor, hypnosis, dietary manipula- ference between the technically oriented and the
tion, transcendent presence, and music (Alligood, professional nurse. In her view, the professional nurse
1991a; Jonas-Simpson, 2010; Larkin, 2007; Levin, must be well rounded and educated in the humani-
2006; Lewandowski, et al., 2005; Malinski & ties, sciences, and nursing. Such a program would
Todaro-Franceschi, 2011; Siedliecki & Good, 2006; include a basic education in language, mathematics,
Smith, Kemp, Hemphill, & Vojir, 2002; Smith & Kyle, logic, philosophy, psychology, sociology, music, art,
2008; Walling, 2006; Yarcheski, Mahon, & Yarcheski, biology, microbiology, physics, and chemistry; elec-
2002). Barrett (1998) notes that integral to these mo- tive courses could include economics, ethics, political
dalities are “meaningful dialogue, centering, and science, anthropology, and computer science (Barrett,
pandimensional authenticity (genuineness, trustwor- 1990b). With regard to the research component of the
thiness, acceptance, and knowledgeable caring)” curriculum, Rogers (1994b) stated the following:
(p. 138). Nurses participate in the lived experience of
health in a multitude of roles, including “facilitators Undergraduate students need to be able to identify
and educators, advocates, assessors, planners, coor- problems, to have tools of investigation and to do
dinators, and collaborators,” by accepting diversity, studies that will allow them to use knowledge for
recognizing patterns, viewing change as positive, and the improvement of practice, and they should
accepting the connectedness of life (Malinski, 1986, be able to read the literature intelligently. People
p. 27) These roles may require the nurse to “let go with master’s degrees ought to be able to do
of traditional ideas of time, space, and outcome” applied research. . . . The theoretical research, the
(Malinski, 1997, p. 115). fundamental basic research is going to come out of

CHAPTER 13 Martha E. Rogers 227

doctoral programs of stature that focus on nursing Principles of Homeodynamics
as a learned field of endeavor (p. 34).

Resonancy Helicy Integrality
Barrett (1990b) notes that with increasing use of
technology and increasing severity of illness of hospi-
talized patients, students may be limited to observa-
tional experiences in these institutions. Therefore, the
acquisition of manipulative technical skills must be
accomplished in practice laboratories and at alterna-
tive sites, such as clinics and home health agencies. Midrange theories
Other sites for education include health promotion
programs, managed care programs, homeless shelters, Bultemeier Barrett Floyd
and senior centers. (1993) (1990a) (1983)
FIGURE 13-1 Theory development within the Science of
Research Unitary Human Beings.
Rogers’ conceptual model provides a stimulus and
direction for research and theory development in
nursing science. Fawcett (2000), who insists that the her overview of Rogerian science–based theories,
level of abstraction affects direct empirical observation Malinski (2009) identifies work within specific concepts:
and testing, endorses the designation of the Science of (1) self-transcendence (Reed, 2003), enlightenment
Unitary Human Beings as a conceptual model rather (Hills & Hanchett, 2001), and spirituality (Malinski,
than a grand theory. She states clearly that the purpose 1994; Smith, 1994); (2) turbulence (Butcher, 1993)
of the work determines its category. Conceptual mod- and dissonance (Bultemeier, 2002); (3) aging (Alligood
els “identify the purpose and scope of nursing and & McGuire, 2000; Butcher, 2003); (4) intentionality
provide frameworks for objective records of the effects (Ugarizza, 2002; Zahourek, 2005); and (5) unitary
of nursing” (Fawcett, 2005, p. 18). caring (Watson & Smith, 2002). Other middle-range
Emerging from Rogers’ model are theories that ex- theories encompass the phenomena of human field
plain human phenomena and direct nursing practice. motion (Ference, 1986), as well as creativity, actualiza-
The Rogerian model, with its implicit assumptions, tion, and empathy (Alligood, 1991b).
provides broad principles that conceptually direct the- Rogers (1986a) maintains that research in nurs-
ory development. The conceptual model provides a ing must examine unitary human beings as integral
stimulus and direction for scientific activity. Relation- with their environment. Therefore, the intent of
ships among identified phenomena generate both grand nursing research is to examine and understand a
(further development of one aspect of the model) and phenomenon and, from this understanding, design
middle-range (description, explanation, or prediction patterning activities that promote healing. To obtain
of concrete aspects) theories (Fawcett, 1995). a clearer understanding of lived experiences, the
Two prominent grand nursing theories grounded person’s perception and sentient awareness of what
in Rogers’ model are Newman’s health as expanding is occurring are imperative. The variety of events
consciousness and Parse’s human becoming (Fawcett, associated with human phenomena provides the
2005). Numerous middle-range theories have emerged experiential data for research that is directed toward
from Rogers’ three homeodynamic principles as fol- capturing the dynamic, ever-changing life experi-
lows: (1) helicy, (2) resonancy, and (3) integrality ences of human beings. Selecting the correct method
(Figure 13–1). Exemplars of middle-range theories for examining the person and the environment as
derived from homeodynamic principles include health-related phenomena is the challenge of the
power-as-knowing-participation-in-change (helicy) Rogerian researcher. Both quantitative and qualita-
(Barrett, 2010), the theory of perceived dissonance tive approaches have been used in the Science
(resonancy) (Bultemeier, 2002), and the theory of of Unitary Human Beings research, although not
interactive rhythms (integrality) (Floyd, 1983). In all researchers agree that both are appropriate.

228 UNIT III Nursing Conceptual Models

Researchers do agree that ontological and epistemo- respects the inherent interconnectedness of phenom-
logical congruence between the model and the ena. A pattern profile is composed through a synopsis
approach must be considered and reflected by and synthesis of the data (Barrett, Cowling, Carboni,
the research question (Barrett, Cowling, Carboni, et al., 1997). Other innovative methods of recording
& Butcher, 1997). Quantitative experimental and and entering the human-environmental field phenom-
quasi-experimental designs are not appropriate, be- enon include photo-disclosure (Bultemeier, 1997),
cause their purpose is to reveal causal relationships. descriptive phenomenology (Willis & Griffith, (2010),
Descriptive, explanatory, and correlational designs hermeneutic text interpretation (Alligood & Fawcett,
are more appropriate, because they acknowledge 1999), and measurement of the effect of dialogue
diversity, universality, and patterned change. combined with noninvasive modalities (Leddy &
Specific research methods emerging from middle- Fawcett, 1997).
range theories based on the Rogerian model capture Rogerian instrument development is extensive
the human-environmental phenomena. As a means of and ever-evolving. A wide range of instruments for
capturing the unitary human being, Cowling (1998) measuring human-environmental field phenomena
describes the process of pattern appreciation using the have emerged (Table 13–2). The continual emergence
combined research and practice case study method. of middle-range theories, research approaches, and
Case study attends to the whole person (irreducibil- instruments demonstrates recognition of the impor-
ity), aims at comprehending the essence (pattern), and tance of Rogerian science to nursing.




TABLE 13-2 Research Instruments and Practice Tools Derived From the Science of
Unitary Human Beings
Human Field Motion Test (HFMT) (Ference, 1986; Measures human field motion by means of semantic differential ratings of
the concepts My Motor Is Running and My Field Expansion.
Perceived Field Motion Scale (PFM) (Yarcheski & Measures the perceived experience of motion by means of semantic
Mahon, 1991) differential ratings of the concept My Field Motion.
Human Field Rhythms (HFR) (Yarcheski & Measures the frequency of rhythms in the human-environmental energy
Mahon, 1991) field mutual process by means of a one-item visual analogue scale.
The Well-being Picture Scale (Gueldner et al., A non–language-based pictorial scale that measures concepts of frequency,
2005) (Terwilliger, Gueldner, & Bronstein, 2012) awareness, action, and power of energy field (general well-being) in
adults. Evaluated in children in 2012.
Power as Knowing Participation in Change Tool Measures the person’s capacity to participate knowingly in change by
(PKPCT) (Barrett, 1990a, 2010) means of semantic differential ratings of the concepts Awareness,
Choices, Freedom to Act Intentionally, and Involvement in Creating
Changes.
Diversity of Human Field Pattern Scale (DHFPS) Measures diversity of human field pattern, or degree of change in the evo-
(Hastings-Tolsma, 1993) lution of human potential throughout the life process, by means of Likert
scale ratings of 16 items.
Human Field Image Metaphor Scale (HFIMS) Measures the individual’s awareness of the infinite wholeness of the
(Johnston, 1993, 1994) human field by means of Likert scale ratings of 14 metaphors that
represent perceived potential and 11 metaphors that represent per-
ceived field integrality.
Temporal Experience Scale (TES) (Paletta, 1990) Measures subjective experience of temporal awareness by means of Likert
scale ratings of 24 metaphors representing the factors of time dragging,
time racing, and timelessness.
Assessment of Dream Experience (ADE) Measures dreaming as a beyond waking experience by means of Likert
(Watson, 1999) scale ratings of the extent to which 20 items describe what the individual’s
dreams have been like during the past 2 weeks.

CHAPTER 13 Martha E. Rogers 229

TABLE 13-2 Research Instruments and Practice Tools Derived From the Science of
Unitary Human Beings—cont’d
Person-Environment Participation Scale (PEPS) Measures the person’s experience of continuous human-environment
(Leddy, 1995, 1999) mutual process by means of semantic differential ratings of 15 bipolar
adjectives representing the content areas of comfort, influence, continuity,
ease, and energy.
Leddy Heartiness Scale (LHS) (Leddy, 1996) Measures the person’s perceived purpose and power to achieve goals by
means of Likert scale ratings of 26 items representing meaningfulness,
ends, choice, challenge, confidence, control, capability to function, and
connections.
McCanse Readiness for Death Instrument (MRDI) Measures physiological, psychological, sociological, and spiritual aspects
(McCanse,1995) of healthy field pattern, as death is developmentally approached by
means of a 26-item structured interview questionnaire.
Mutual Exploration of the Healing Human- Measures nurses’ and clients’ experiences and expressions of changing
Environmental Field Relationship (Carboni, 1992) configurations of energy field patterns of the healing human-environmental
field relationship using semi-structured and open-ended items. Forms
for a nurse and a single client and for a nurse and two or more clients
are available.
Practice Tool and Citation Description
Nursing Process Format (Falco & Lobo, 1995) Guides use of a Rogerian nursing process, including nursing assessment,
nursing diagnosis, nursing planning for implementation, and nursing
evaluation, according to the homeodynamic principles of integrality,
resonancy, and helicy.
Assessment Tool (Smith et al., 1991) Guides use of a Rogerian nursing process, including assessment, diagno-
sis, implementation, and evaluation, according to the homeodynamic
principles of complementarity (i.e., integrality), resonancy, and helicy,
for patients hospitalized in a critical care unit and their family members,
using open-ended questions.
Critical Thinking for Pattern Appraisal, Mutual Provides guidance for the nurse’s application of pattern appraisal, mutual
Patterning, and Evaluation Tool (Bultemeier, patterning, and evaluation, as well as areas for the client’s self-reflection,
2002) patterning activities, and personal appraisal.
Nursing Assessment of Patterns Indicative Guides assessment of patterns, including relative present, communication,
of Health (Madrid & Winstead-Fry, 1986) sense of rhythm, connection to environment, personal myth, and system
integrity.
Assessment Tool for Postpartum Mothers Guides assessment of mothers experiencing the challenges of their first
(Tettero et al., 1993) child during the postpartum period.
Assessment Criteria for Nursing Evaluation of the Guides assessment of the functional status of older adults living in their
Older Adult (Decker, 1989) own homes, including demographic data, client prioritization of problems,
sequential patterning (e.g., family of origin culture, past illnesses), rhyth-
mical patterning (e.g., health care usage, medication usage, social
contacts, acute illnesses), and cross-sectional patterning (e.g., current
living arrangements and health concerns, cognitive and emotional status).
Holistic Assessment of the Chronic Pain Client Guides holistic assessment of clients living in their own homes and experi-
(Garon, 1991) encing chronic pain, including the environmental field, the community, and
all systems in contact with the client; the home environment; client needs
and expectations; client and family strengths; the client’s pain experi-
ence—location, intensity, cause, meaning, effects on activities, life, and
relationships, relief measures, and goals; and client and family feelings
about illness and pain.
Continued

230 UNIT III Nursing Conceptual Models

TABLE 13-2 Research Instruments and Practice Tools Derived From the Science of
Unitary Human Beings—cont’d
Human Energy Field Assessment Form Used to record findings related to human energy field assessment as
(Wright, 1991) practiced in therapeutic touch, including location of field disturbance
on a body diagram and strength of the overall field and intensity of the
field disturbance on visual analogue scales.
Family Assessment Tool (Whall, 1981) Guides assessment of families in terms of individual subsystem consider-
ations, interactional patterns, unique characteristics of the whole family
system, and environmental interface synchrony.
An Assessment Guideline for Work with Families Guides assessment of the family unit, in terms of definition of family,
(Johnston, 1986) family organization, belief system, family developmental needs, eco-
nomic factors, family field and environmental field complementarity,
communication patterns, and supplemental data, including health
assessment of individual family members, developmental factors,
member interactions, and relationships.
Nursing Process Format for Families (Reed, 1986) Guides the use of a developmentally oriented nursing process for families.
Community Health Assessment (Hanchett, 1988) Guides assessment of a community in areas of diversity; rhythms, including
frequencies of colors, rhythms of light, and patterns of sound; motion;
experience of time; pragmatic-imaginative-visionary worldviews; and
sleep-wake beyond waking rhythms.
Adapted from Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (pp. 337–339). Philadelphia:
F. A. Davis. Used with permission.



Further Development of operational definitions, and inadequate tools
Rogers (1986a) believed that knowledge develop- for measurement (Butterfield, 1983). However, the
ment within her model was a “never-ending process” model has passed the test of time for the development
using “a multiplicity of knowledge from many of nursing science as nursing matured as a science.
sources . . . to create a kaleidoscope of possibilities” Rogers’ ideas continue to demonstrate clarity for
(p. 4). Explorations by Rogerian scholars into tran- nursing research with human beings of all ages
scendence and universality exemplify this belief in (Terwilliger, Gueldner, & Bronstein, 2012).
a unifying wholeness (Phillips, 2010).
Fawcett (2005) identified the following three rudi- Simplicity
mentary theories developed by Rogers from the Science Ongoing studies and work within the model have
of Unitary Human Beings: served to simplify and clarify some of the concepts and
1. Theory of accelerating evolution relationships. However, when the model is examined in
2. Theory of rhythmical correlates of change total perspective, some still classify it as complex. With
3. Theory of paranormal phenomena its continued use in practice, research, and education,
Continued explication and testing of these theories nurses will come to appreciate the model’s elegant
and the homeodynamic principles by nurse researchers simplicity. As Whall (1987) noted, “With only three
contributes to nursing science knowledge. principles, a few major concepts, and five assumptions,
Rogers has explained the nature of man and the life
Critique process” (p. 154).
Clarity Generality
There were early criticisms of the model with com- Rogers’ conceptual model is abstract and therefore gen-
ments such as difficult-to-understand principles, lack eralizable and powerful. It is broad in scope, providing

CHAPTER 13 Martha E. Rogers 231

a framework for the development of nursing knowledge
through the generation of grand and middle-range CASE STUDY
theories. Charlie Dee is a 56-year-old male client with a
30-year history of smoking two packs of cigarettes
Accessibility per day. He is seeing nurse practitioner Sandra Gee
Drawing on knowledge from a multitude of scientific for the first time after being diagnosed with chronic
fields, Rogers’ conceptual model is deductive in logic obstructive pulmonary disease. Pattern appraisal
with an inherent lack of immediate empirical support begins with eliciting the client’s description of his
(Barrett, 1990b). As Fawcett (1995) points out, failure to experience with this disease, his perceptions of his
properly categorize the work as a conceptual model health, and how the disease is expressed (symp-
rather than as a theory leads to “considerable misunder- toms). Mr. Dee states that he has a productive
standings and inappropriate expectations” (p. 29), cough that is worse in the morning, gets short of
which can result in the work being labeled inadequate. breath whenever he is physically active, and always
As noted earlier, the development of the model by feels tired. Through specific questions, the nurse
Rogerian scientists has resulted in the generation of practitioner discovers that Mr. Dee has experienced
testable theories accompanied by tools of measurement. a change in his sleep patterns and nutritional intake.
He is sleeping for shorter periods and eating less.
Importance She also learns that Mr. Dee’s wife smokes, and that
Rogers’ science has the fundamental intent of under- they have indoor cats for pets. He does not think
standing human evolution and its potential for human that his wife will be amenable to changing her hab-
betterment. The science “coordinates a universe of its or getting rid of the cats. During this appraisal,
open systems to identify the focus of a new paradigm the nurse seeks to discover what is important to
and initiate nursing’s identity as a science” (Rogers, Mr. Dee and how he defines healthy.
1989, p. 182). Mutual patterning involves sharing knowledge
Although all the metaparadigm concepts are ex- and offering choices. Upon completion of the ap-
plored, the emphasis is on the integrality of human- praisal, the nurse summarizes what she has been
environmental field phenomena. Rogers suggested told and how she understands it. In this way, the
many ideas for future studies; on the basis of this and nurse and the client can reach consensus about
the research of others, it can be said that the concep- what activities would be acceptable to Mr. Dee.
tual model is useful. Such utility has been proven Ms. Gee provides information about the disease
in the arenas of practice, education, administration, and suggestions that will increase his comfort. Non-
and research. invasive interventions include breathing retraining,
recommendations for a high-protein high-calorie
diet, eating smaller meals more frequently, sleeping
Summary with the head elevated, and using progressive relax-
The Rogerian model emerged from a broad historical ation exercises at bedtime. The nurse recommends
base and has moved to the forefront as scientific knowl- that the Dees buy a HEPA filter and humidifier to
edge has evolved. Understanding the concepts and assist in removing environmental pollutants and
principles of the Science of Unitary Human Beings maintaining proper humidity in the home.
requires a foundation in general education, a willing- Because Mr. Gee has expressed a desire to quit
ness to let go of the traditional, and an ability to perceive smoking, the nurse suggests that he use forms of
the world in a new and creative way. Emerging from a centering, such as guided imagery and meditation,
strong educational base, this model provides a challeng- to supplement the nicotine patches prescribed by
ing framework from which to provide nursing care. The his physician. She also provides him with written
abstract ideas expounded in the Rogerian model and material about the disease that he can share with
their congruence with modern scientific knowledge his wife. At the end of the visit, Mr. Dee states that
spur new and challenging theories that further the he feels better knowing that he has the power to
understanding of the unitary human being. change some things about his life.