Nursing Theories

"Ethical behaviour is not the display of one's moral rectitude in times of crisis, it is the day-to-day expression of one's commitment to other persons and the ways in which human beings relate to one another in their daily interactions." - Levine, Myra (1972)

Biography

Myra E. Levine was born in 1920 in Chicago, the first child in a family of three siblings. Her experience during her father’s frequent illness contributed to her interest in and dedication to nursing. She received a diploma from Cook County School of Nursing in 1944, an SB from the University of Chicago in 1949, and a Masters of Science in nursing from Wayne State University in 1962. Her career in nursing has been varied. Clinically, she held position as private duty nurse, a civilian nurse for the U.S. Army, surgical supervisor, and director of nursing. She held faculty positions at Cook County School of Nursing, Loyola University, Rush University, University of Illinois, Chicago. Levine filled visiting professorship at Tel-aviv University and Recanati School of Nursing, Ben Gurion University of the Negev, both in Israel.

Levine is a charter fellow in the American Academy of Nursing and has been honored by the Illinois Nurses Association. She was the first recipient of Sigma Theta Tau’s Elizabeth Russell Belford Award for teaching excellence. She was granted an honorary doctorate by Loyola University, Chicago, in 1992.

Myra Levine has said that she had no intention of developing a theory when she first began putting her ideas about nursing into writing (Trench, Wallace, & Coberg, 1987). In fact, more than two decades after the initial publication of Introduction to Clinical Nursing (Levine, 1969) she has referred to her work as a theory but prefers to identify at as a conceptual model. She states r=that she was looking in three quarters and for a way to generalize the content, to move away from a procedurally oriented educational process. She was interested in helping nurses realize that every nurse-patient contact leads to a puzzle in relation to nursing care that needs to be solved in an individualized manner. Her work has evolved over the years, with the most recent comprehensive update of the theory published in 1989 and additional discussions in 1990 1991.

Levine (1990) believes that entry into the health care system is associated with giving up some measure of personal independence. To designate the person who has entered the health care system a client reinforces the state of dependency, for a client is a follower. She supports the term patient because patient means sufferer, and dependency is associated with suffering.

It is the condition of suffering that makes it possible to set independence aside and accept the services of another person. It is the challenge of the nurse to provide the individual with appropriate care without losing sight of the individual’s integrity, to honor the care that the patient has placed in the nurse, and to encourage the participation of the individual in his or her own welfare. The patient comes in trust and dependence only for as long as the services of the nurse are needed. The nurse’s goal is always to impart knowledge and strength so that the individual can…walk away…as an independent individual. (p. 199)

It is Levine’s intent that such dependency be very temporary state of affairs (Trench, Wallace, & Coberg, 1987).

In her writings, Levine ( 1989. 1990, 1991) is careful to credit the scientists’ works upon which she was built. In discussing physiological mechanisms, she drew upon Cannon’s (1963) descrioption of the flight and fight response. Selye’s (1956) stress theories provided further information about protection from the hazards of living. Gibson’s (1966) perceptual systems about how people are actively involved in gathering information from their environment to aid them in moving safely through those environments were drawn upon. Erikson’s (1969, 1975) discussions of the influence of environment on development further expanded Levine’s information about the person-environment interaction. Bate’s (1967) description of three types of environment was also important. The works of Dubos (1966), Cohen (1968) and Goldstein (1963) contributed to Levine’s concept of adaptation.

Definition of Nursing, Health and Environment

Nursing is a human interaction designed to promote "wholeness" through adaptation. it course at the interface between the open and fluid boundaries of the person and his environment. nursing care is seen as both supportive and therapeutic. the supportive aspect is designed to maintain a state of wholeness in the face o a client's failing health.

Nursing

"Nursing is a profession as well as an academic discipline, always practiced and studied in concert with all of the disciplines that together from the health sciences"
The human interaction relying on communication ,rooted in the organic dependency of the individual human being in his relationships with other human beings
Nursing involves engaging in "human interactions"

Goal of Nursing

A theory of nursing must recognized the importance of detail of care for a single patient with in an empiric framework that successfully describe the requirement of the all patient
A human being is a social animal
A human being is an constant interaction with an ever changing society
To promote wholeness, realizing that every individual requires a unique and separate cluster of activities
The individual integrity is his abiding concern and it is the nurse’s responsibility to assist him to defend and to seek its realization
Human being make decision through prioritizing course of action
Human being must be aware and able to contemplate objects, condition and situation
Human being are agents who act deliberately to attain goal
Adaptive changes involve the whole individual
A human being has unity in his response to the environment
Every person possesses a unique adaptive ability based on one’s life experience which creates a unique message
There is an order and continuity to life change is not random
A human being respond organismically in an ever changing manner
Change is inevitable in life
Nursing needs existing and emerging demands of self care and dependant care
Nursing is associated with condition of regulation of exercise or development of capabilities of providing care

Nursing Process

I. Assessment

Collection of provocative facts through observation and interview of challenges to the internal and external environment using four conservation principles
Nurses observes patient for organismic responses to illness, reads medical reports. talks to patient and family
Assesses factors which challenges the individual

II. Trophicognosis

Nursing diagnosis-gives provocative facts meaning
A nursing care judgment arrived at through the use of the scientific process
Judgment is made about patient’s needs for assistance

III. Hypothesis

Planning
Nurse proposes hypothesis about the problems and the solutions which becomes the plan of care
Goal is to maintain wholeness and promoting adaptation

IV. Interventions

Testing the hypothesis
Interventions are designed based on the conservation principles
Mutually acceptable
Goal is to maintain wholeness and promoting adaptation

V. Evaluation

Observation of organismic response to interventions
It is assesses whether hypothesis is supported or not supported
If not supported, plan is revised, new hypothesis is proposed

Definition of Health

Health is a state of being "whole" and just not the absence of a disease. health is socially determined and modified by person's interaction or relationship with other people, particularly family and peers.

Health

Health is a wholeness and successful adaptation
It is not merely healing of an afflicted part ,it is return to daily activities, selfhood and the ability of the individual to pursue once more his or her own interest without constraints
Disease: It is unregulated and undisciplined change and must be stopped or death will ensue

Definition of Environment

The environment is where a person is constantly and actively involved. each individual has his own environment, both internal and external. the internal environment involves the physiologic element, while the external includes three levels: Perception, Operation, and conceptual

I. Internal Environment

Homeostasis: A state of energy sparing that also provide the necessary baselines for a multitude of synchronized physiological and psychological factors
A state of conservation
Homeorrhesis: A stabilized flow rather than a static state
Emphasis the fluidity of change within a space-time continuum
Describe the pattern of adaptation, which permit the individual’s body to sustain its well being with the vast changes which encroach upon it from the environment

II. External Environment

Preconceptual: Aspect of the world that individual are able to intercept
Operational: Elements that may physically affects individuals but not perceived by hem: radiation, micro-organism and pollution
Conceptual: Part of person's environment including cultural patterns characterized by spiritual existence, ideas, values, beliefs and tradition

Person and the Environment

Adaptation

Historicity: Adaptations are grounded in history and await the challenges to which they respond
Specificity: Individual responses and their adaptive pattern varies on the base of specific genetic structure
Redundancy: Safe and fail options available to the individual to ensure continued adaptation

Organismic Response

A change in behavior of an individual during an attempt to adapt to the environment
Help individual to protect and maintain their integrity
They co-exist
There are four types:

           1. Flight or fight: An instantaneous response to real or imagined threat, most primitive response
           2. Inflammatory: response intended to provide for structural integrity and the promotion of healing
           3. Stress: Response developed over time and influenced by each stressful experience encountered by person
           4. Perceptual: Involves gathering information from the environment and converting it in to a meaningful experience

Nine Models of Guided Assessment

Vital’s signs
Body movement and positioning
Ministration of personal hygiene needs
Pressure gradient system in nursing interventions
Nursing determination in provision of nutritional needs
Pressure gradient system in nursing
Local application of heat and cold
Administration of medicine
Establishing an aseptic environment

Assumption

The nurse creates an environment in which healing could occur
A human being is more than the sum of the part
Human being respond in a predictable way
Human being are unique in their responses
Human being know and appraise objects ,condition and situation
Human being sense ,reflects, reason and understand
Human being action are self determined even when emotional
Human being are capable of prolonging reflection through such strategists raising questions

Key Concepts

Conservational Principle

1. Conservation of Energy
Each person requires a balance of energy but there are factors within the person and the external environment that may cause depletion of energy. Refers to balancing energy input and output to avoid excessive fatigue and includes adequate rest, nutrition and exercise.

Example:

Availability of adequate rest
Maintenance of adequate nutrition

2. Conservation of Structural Integrity

For a person to function he has to cover his structural integrity. this is preserving the anatomical structure of the body. Refers to maintaining or restoring the structure of body preventing physical breakdown And promoting healing

Example:

Assist patient in ROM exercise
Maintenance of patient’s personal hygiene

3. Conservation of Personal Integrity

Each person has his own sense of identity and self worth. how do you value yourself. Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and self determination

Example:

Recognize and protect patient’s space needs

4. Conservation of Social Integrity

Involves the presence and recognition of the human interaction, particularly with the client's significant others who comprise his support system. An individual is recognized as some one who resides with in a family, a community ,a religious group, an ethnic group, a political system and a nation

Example:

Position patient in bed to foster social interaction with other patients
Avoid sensory deprivation
Promote patient’s use of news paper, magazines, radio, and TV
Provide support and assistance to family

Theoretical Assumptions and Uses

1. Conservational Models

Conservational model provides the basis for development of two theories

Theory of redundancy
Theory of therapeutic intention

Theory of Redundancy

Untested ,speculative theory that redefined aging and everything else that has to do with human life
Aging is diminished availability of redundant system necessary for effective maintenance of physical and social well being

Theory of Therapeutic Intention

Goal: To seek a way of organizing nursing interventions out of the biological realities which the nurse has to confront.

Therapeutic regimens should support the following goals:

Facilitate healing through natural response to disease
Provide support for a failing auto regulatory portion of the integrated system
Restore individual integrity and well being
Theory of therapeutic intention
Provide supportive measure to ensures comfort
Balance a toxic risk against the threat of disease
Manipulate diet and activity to correct metabolic imbalance and stimulate physiological process
Reinforce usual response to create a therapeutic changes

2. Uses

Critical, acute or long term care unit
Neonates, infant and young children, pregnant young adult and elderly care unit
Primary health care
OT
Community setting

3. Utility of Theory

Nursing research
Nursing education
Nursing administration
Nursing practice

Nursing Research

Principles of conservation have been used for data collection in various researches
Conservational model was used by Hanson et al.in their study of incidence and prevalence of pressure ulcers in hospice patient
Newport used principle of conservation of energy and social integrity for comparing the body temperature of infant’s who had been placed on mother’s chest immediately after birth with those who were placed in warmer

Nursing Education

Conservational model was used as guidelines for curriculum development
It was used to develop nursing undergraduate program at Allentown college of St.Francis de sales, Pennsylvania
Used in nursing education program sponsored by Kapat Holim in Israel

Nursing Administration

Taylor described an assessment guide for data collection of neurological patients which forms basis for development of comprehensive nursing care plan and thus evaluate nursing care
McCall developed an assessment tool for data collection on the basis of four conservational principles to identify nursing care needs of epileptic patients
Family assessment tool was designed by Lynn-Mchale and Smith for families of patient in critical care setting

Nursing Practice

Conservational model has been used for nursing practice in different settings
Bayley discussed the care of a severely burned teenagers on the basis of four conservational principles and discussed patient’s perceptual, operational and conceptual environment
Pond used conservation model for guiding the nursing care of homeless at a clinic, shelters or streets

Nursing Management Utilizing Myra Levine's Conservation Model

CASE 1

Mrs. RL is a 47-year-old female rushed to the emergency room due to onset of sudden severe chest pain radiating to the left arm and left angle of the jaw associated with diaphoresis, nausea, vomiting, and shortness of breath. Initial vital signs as follows: T=37.0 °C, CR=110 bpm, RR=30 rpm, BP=140/90 mmHg. Oxygen was administered at 2-4 lpm via nasal cannula. Morphine 4mg was administered intravenously as ordered. 12-lead ECG shows ST-elevation consequently a medical diagnosis of Acute Coronary Syndrome ST-segment elevation Myocardial Infarction was made. Intravenous fluid resuscitation was initiated with PNSS 1L at KVO regulation. Metoclopramide 1 ampule was administered intravenously for nausea and vomiting. She was instructed nothing per orem temporarily.
Aside from the chief complaint, a non-healing wound was noticed on Mrs. RL’s right foot. Medical history confirms Diabetes Mellitus Type II. Capillary blood glucose reads 314 mg/dl and a rescue dose of Humulin R 10 units was administered intravenously as ordered.

Nursing Management:
Conservation of Energy
Energy must be conserved to prevent precipitation of the clinical distress brought about by the medical condition of Mrs. RL. Our client is prone to activity intolerance therefore provision of complete bed rest with commode privileges for 24 to 48 hours may address this problem. The goal is to prevent further myocardial tissue injury, maximize tissue perfusion, and reduce tissue demands. Energy is conserved to promote oxygenation and tissue perfusion. Instructions must be given to the patient regarding avoidance of over fatigue. Oxygen therapy must be ensured at appropriate regulation and tolerance. Position the client in Semi-Fowler’s to allow greater diaphragm expansion thereby lung expansion and better carbon dioxide-oxygen exchange. Assist the client in feeding and performing self-hygiene to minimize the efforts provided by the patient in such activities. Most importantly, anticipate the needs of the client.
Conservation of Structural Integrity
Daily wound care must be rendered over the non-healing wound of Mrs. RL on her right foot. Prevention of infection is the goal to minimize further damage. Healing should be promoted as soon as possible. Cleanse the wound properly and apply prescribed topical medications by the physician. Keep wound dressing intact over the affected area. Administer prescribed antibiotics ordered. Aside from focusing on the wound per se, capillary blood glucose levels must be under tight controls. Determine the signs and symptoms of hypoglycemia and hyperglycemia and respond accordingly with appropriate insulin therapy

Conservation of Personal Integrity
Hospitalization is a great stressor to the well-being of an individual. Promote relief of anxiety and well-being by providing an opportunity for Mrs. RL to explore concerns and to identify alternative methods of coping as necessary. Promote a positive attitude and active participation of Mrs. RL in her care during her stay in the hospital. Build up a constructive nurse-patient relationship. Use an emphatic approach when caring. Deal with the Mrs. RL as a person with specific needs rather than a patient requiring merely medical help. Make her feel more comfortable with the nurse by calling her by her name rather than bed number. Help her feel that she is respected and treated with dignity. Provide privacy through proper draping and screening when performing commode activities such as perineal hygiene, diaper change, changing of hospital gown, bed bath, and the like. Promote independence and autonomy in the course of her hospitalization. In short, “put yourself into the shoes of your client” to maintain effectively his/ her personal integrity.
Conservation of Social Integrity
Encourage friends and relatives to visit the patient during visiting hours. This provides Mrs. RL of a sense of security in an unfamiliar environment and would relieve the anxiety brought about by present hospitalization.

Submitted by:
Group E
Jennifer Remo

Jonas Aspuria
Joseph Mari Mendoza
Joy Noja
Joy Ruth Pidlaoan
Joy Ruth Pidlaoan
Juaymah Go
Kathleen Rose Cruz
Katrina Cruz
Katrina Dominguez
Kim Bernard Cabalagnan
Kris Colleen Pedro
Kristinna Marie Jadulco
Lady Anne Margotte Brown
Leilani Ipapo
Leopoldo Galan
Leorebeck Gorres
Lito Rama
Lourenne Ayco
Ma. Bernadette Daza
Ma. Haifa Villamil
Ma. Queenna Lynn Obispo
Ma.Magdalena Babaran
Marie Chrysallis Ramos