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Levine’s Conservation Model: A Framework for Advanced Gerontology Nursing Practice Ibrahim Mahmoud Abumaria, MS, RN, ANP, Marie Hastings-Tolsma, PhD, CNM, FACNM, and Teresa J. Sakraida, PhD, RN Ibrahim Mahmoud Abumaria, MS, RN, ANP, is Adult Nurse Practitioner, El Paso, TX; Marie Hastings-Tolsma, PhD, CNM, FACNM, is Professor, College of Nursing, University of Colorado Denver, Aurora, CO; and Teresa J. Sakraida, PhD, RN, is Assistant Professor, College of Nursing, University of Colorado Denver, Aurora, CO. Keywords Advanced gerontology nursing practice, Levine’s Conservation Nursing Model, nursing homes, older adults Correspondence Teresa J. Sakraida, PhD, RN, College of Nursing, University of Colorado Denver, Aurora, CO E-mail: teresa.sakraida @ucdenver.edu
Abumaria
PURPOSE. Growing numbers of older adults place increased demands on already burdened healthcare systems. The cost of managing chronic illnesses mandates greater emphasis on management and prevention. This article explores the adaptation of Levine’s Conservation Model as a structure for providing care to the older adult by the adult-gerontology primary care nurse practitioner (AGNP). CONCLUSION. The AGNP role, designed to provide quality care to adult and older adult populations, offers the opportunity to not only manage health care of the elderly, but to also advocate, lead in collaborative care efforts, conduct advanced planning, and manage and negotiate health delivery systems. The use of nursing models can foster the design of effective interventions that promote health of the older adult, particularly in the long-term care environment. PRACTICE IMPLICATION. Levine’s Conservation Model provides a useful structure for older adult care in the long-term care setting. As an ideal care manager, the AGNP would be well served to consider use of the model to guide advanced nursing practice. Recommendations for clinical practice, research, and health policy.
Hastings-Tolsma
Sakraida
Introduction Aging is a global health phenomenon. According to the World Health Organization, the number of individuals age 60 years and older has doubled since 1980,
and those 80 years and older are estimated to reach nearly 395 million by 2050 (“Are You Ready?,” 2012). The burgeoning numbers of the elderly require specialized nursing services. This change in demographics presents a pressing need to shift healthcare emphasis 179
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
Levine’s Conservation Model from treatment to management and prevention (Greenberg & Greenberg, 2007) as added risks to the health of the elderly have emerged (Vincent & Velkoff, 2010). To meet the needs of the U.S. aging population, increased numbers of adult-gerontology nurse practitioners (AGNPs) will be required to increase system efficiency, improve quality, reduce hospitalizations, and meet evidence-based care mandates. These advanced practice providers will be vital in the provision of sustainable cost-effective primary healthcare services for those most burdened with escalating healthcare costs. An important foundation for AGNP care is the synthesis of theoretical, scientific, and contemporary knowledge that can guide care and promote the wellbeing of an aging population (American Association of Colleges of Nursing [AACN], 2010). Levine’s conservation model (1967) offers a valuable theoretical lens for moving AGNPs forward as primary care providers of gerontology care, particularly within the long-term care environment. Overview of Levine’s Model The Levine (1967) conservation model describes how adaptation leads to the wholeness of an individual through the conservation of energy, structural integrity, personal integrity, and social integrity. Figure 1 presents the major concepts of Levine’s model. As shown, adaptation occurs in an ever-changing internal and external environment. Conservation is the product of adaptation, and wholeness is the ultimate result of conservation. Adaptation is a way by which a person maintains integrity within the environment. It is characterized by redundancy, historicity, and specificity. Redundancy is the multilayered options that exist for adapting to the environment and is an important concept that humans rely on for survival. In medicine, this translates into the freedom to choose from several options when it comes to a health decision. If all redundant options fail, the person also fails. Historicity of adaptation refers to survival instincts and mechanisms that are hidden in the genetic code. Specificity is the uniqueness of each individual; no two people will have the exact same redundancy and historicity. Levine defines health as wholeness (Levine, 1996). Wholeness occurs when there is a balanced adaptation between the evolving needs of the organism and the stresses of the ever-changing environment. Organisms exist in an open environ180 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
I. M. Abumaria et al. ment that is the sum of internal and external elements. The internal environment consists of physiological and pathophysiological elements, as well as the interaction of bodily functions. The external environment is categorized into three levels: perceptual, operational, and conceptual (Schaefer, 2010b). The perceptual environment includes elements that the person experiences through the senses, such as smell and touch. The operational environment includes elements that surround the person but for which no awareness by the person exists, for example, air pollution. The conceptual environment consists of factors that the person experiences by learning and appreciation, such as language, ways of thinking, values, beliefs, morality, and history. All of the above elements harmonize when the principles of conservation are observed. Levine defines the person as a “spiritual being” (Schaefer, 2010b, p. 88). She posits that the person is a spiritual, holistic, unique being that remembers the past but is focused on the future. However, the individual should not be considered in isolation. She states that the “individual life has meaning only in the context of social life” (Schaefer, 2010b, p. 88). According to Levine, nursing is a science that excels in the skill of “human interaction” and is a partnership of the human experience with the patient (Schaefer, 2010b, p. 89). During this relationship, the nurse uses the scientific process to interpret the patient’s altered health status and organismic response to develop a nursing judgment or trophicognosis (Schaefer, 2010a, p. 228). The organismic response is the change that an organism makes during adaptation to a new environment. The nurse then applies the conservation principles and proposes a hypothesis to address the patient’s condition. The resulting nursing intervention is then coupled with patient participation in order to restore wholeness. Conservation is the central concept of Levine’s model. When it is achieved, the person is in harmony, and adaptation is accomplished. The conservation model has four main elements: the conservation of energy, structural integrity, personal integrity, and social integrity. Energy is an abstract concept that relies on free exchange between the internal and the external environment. A person’s energy is conserved if a balance of energy input and output is achieved. Structural integrity is the task of keeping the person whole (Levine, 1967). Behaviors such as hygiene, health provider visits, and medicines are examples by which structural integrity is maintained. Personal integrity
HEALTH
Culture
State of Wholeness
Ever-changing ENVIRONMENT • Internal • External
Imbalance with Environment
Balance
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015 - Balance with environment achieved - Optimum conservation of energy for patient
ENVIRONMENT
Balance with Environment not yet Achieved
ADAPTATION Adapts to new environment • Redundancy • Historicity • Specificity
Intervention n
Organismic Responses Fight orr Flight Flight Inflammatory Response I fl f t R Stress Perceptual
New Environmental o onmental t te State
Nursing Assessment
Scientific Process
Human being appraises condition and situation
PATIENT åa
Strives to preserve wholeness and integrity
Self-determined actions, even in emotional states
Nursing Plan
Se Selects best solutions -Conservation of Energy -C åaIntegrity -S -Structural -Personal Integrity -P -Social Integrity -S
NURSE
Nursing Diagnosis (Trophicognosis)
Coupled Cou upled e
Figure 1. Levine’s Traditional Conservation Model
Human being reflects and understands
Physician’s Medical Plan
Nursing Hypothesis
I. M. Abumaria et al. Levine’s Conservation Model
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Levine’s Conservation Model includes respect, self-awareness, humanness, selfhood, and self-determination. Social integrity refers to the patient’s role in the community, family, ethnic group, culture, and religion.
Utility of Levine’s Nursing Model in Advanced Practice Older adults or seniors frequently struggle with a variety of health problems, particularly chronic diseases and cognitive issues, such as dementia, which are frequent triggers for needing long-term care nursing services. Dementia increases dramatically with age, and it is estimated that the number of Americans with dementia may rise to as high as 19 million by 2050 (Sloane et al., 2002). Similarly, chronic diseases and the need to manage the impact on daily living and quality of life are significant causes of morbidity and mortality, and create a substantial burden on both the family and healthcare system. It is estimated that 43% of Medicare beneficiaries have three or more chronic diseases (Federal Interagency Forum on Aging-Related Statistics, 2010). Such health issues are also primary factors in decreased social interactions. Models that are useful in effectively addressing the health concerns of the elderly and their dependency needs are requisite. Levine’s conservation model focuses on the promotion of adaptation and maintaining wholeness by conserving energy, structure, and person and social integrity (Levine, 1967). Targeted interventions that promote energy and integrity are the foundation for advanced practice. Individualized care focused on conservation balance fosters improved outcomes (Agency for Healthcare Research and Quality, 2011).
Application of Levine’s Model to the AGNP Practice Levine’s model can guide AGNP care in the promotion of adaptation on three levels (see Figure 2). The first level is an environment where homeostasis is maintained by constant adjustments in the internal physiology of the body along with external environmental factors (e.g., eating, warmer clothes). In this fluid state, the individual has the potential to shift from a state of wholeness, to imbalance, and back again often without being aware of the fluctuation. The second level focuses on how the person 182 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
I. M. Abumaria et al. responds when he or she becomes self-aware of the disease. The third level is reached when the patient seeks health care. A case exemplar illustrates the model applied in the care of Mrs. Martinez, an 87-year-old with Hispanic ancestry who is bilingual and with a well-controlled type 2 diabetes. Mrs. Martinez resides in an assisted living facility. Currently, she requires basic support that includes medications, bathing, and foot care. She ambulates with the aid of a walker and regularly socializes by playing cards with her friends at the facility. Promoting health among seniors starts by fostering a state of wholeness. With every alteration in the environment, whether internal or external, there is the potential for imbalance, and thus illness. The older person may not recognize the body’s physiological efforts to maintain homeostasis. For example, the body of a healthy individual who consumes a large meal responds to the increase in blood glucose by secreting more insulin. Insulin, in turn, returns the patient to a euglycemic state, with little awareness by the individual other than feeling satiated. In certain conditions, the individual may recognize that his or her body is working to maintain homeostasis. For example, the patient with diabetes will likely be more aware of the shifts in his or her internal physiological state from fluctuating blood glucose levels. Recognition of the imbalance is dependent upon personal and cultural factors as the body attempts to adapt using redundancy (coping mechanisms), historicity (previous exposure), and specificity (unique adaptations). Each of these processes reflects physiological effort to maintain homeostasis in adapting to internal and external environmental influences. Levine’s ideas of nursing were influenced by the western view of care and caring, and have not been examined across cultures where care for older adults is part of the family dynamic. Mrs. Martinez feels tired as she sat on the edge of her couch. She checks her blood glucose, and it reads 83 mg/dl. She decides a nap would help since she did not get enough sleep the previous night. In level two, the body is unable to silently resolve environmental imbalances. Here, the older adult becomes aware of the imbalance, self-identifies as being sick, and typically seeks advice and information about his or her condition. The sources of information
Levine’s Conservation Model
I. M. Abumaria et al.
Figure 2. Levine’s Conservation Model Adapted to the Adult-Gerontology Nurse Practitioner (AGNP) Practice Key • Boxes: Biologic state of patient • Ovals: Voluntary state • Arrows: Actions • Levine’s conservation model
Imbalance With Environment
Data analysis based on experience and training ADAPTATION Adapts to new environment • Redundancy • Historicity • Specificity
LEVEL 3: AGNP • Patient seeks medical att attention from AGNP • AG AGNP selects best so solution guided by åa evidence-based evi pra practice
History and Physical
Patient seeks medical advice LEVEL 1:
Ever-changing environment • Internal • External
ENVIRONMENT
Balance
-Patient feels well -Minor fluctuations in environment
New Environmental State • Organismic response • Patient attempts to conserve Energy Structure Personal/social integrity
Culture
State of Wholeness
• Balance with environment achieved • Optimum conservation of energy for patient
Advanced Nursing Plan
Intervention Interventio ntion
Partnership
Patient Plan
P Patient Pa culturallyy iinterprets nterprets imbala imbalance annce as iillness/disease llness/disease
LEVEL 2: PERSON, LE PARENT, and GUARDIAN Patie Patient is aware of illness. Ponders illness. Seeks Po su support from family, society, religion, and past personal experiences
Patient Selfidentifies as Being “Sick”
Diagnosis
Advice from Other Disciplines
Chooses best solution based on advice, experience, and patient’s emotions
Patient Hypothesis about Symptoms
HEALTH Strives to preserve wholeness and integrity
Direction and Collection
Social Spirit
may be categorized as social (e.g., family, friends), spiritual (e.g., praying for guidance), experiential (e.g., recalling similar episodes in the past), emotional (i.e., feelings about the best course of action), and medical (i.e., previous contact with health providers). A hypothesis will be reached by analyzing all the information provided by these sources (e.g., taking these actions is most likely to result in improved health). Once a hypothesis has been reached, an appropriate course of action is planned to enact the hypothesis. When imbalance from disease exceeds the ability of the patient to self-treat, the third level is reached, and
Past
Emotions
Analysis
Self-obtained information (e.g., Internet)
medical intervention is sought. The use of health resources, such as laboratory testing and medications, is common as efforts are undertaken to restore balance. In the afternoon, Mrs. Martinez feels like she is not her usual self. Her muscles are aching, and she has a dry cough. She feels warm and suspects she has a fever. She knows from previous experience that a fever will elevate her blood sugar. She calls one of her friends and tells her that she is worried.
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Levine’s Conservation Model In the third level, the AGNP is instrumental in the promotion of balance, wholeness, and health. The AGNP utilizes education, experience, and critical thinking to assess patient balance, and then formulate a diagnosis and plan of care to effectively promote wholeness. Throughout the process, the patient is in partnership with the AGNP, an expert in detailing effective interventions to promote health. Where partnership with the patient is limited by cognitive limitations, the family and community become important surrogates for inclusion. Strategies to promote balance are tailored to include patient beliefs, cultural practices, education, and socioeconomic background. Mrs. Martinez checks her blood glucose again, and it is high at 154 mg/dl. Her cough is worse. She is not sure what to do. She calls Michael, the AGNP who supports her care management. For example, if the older adult is unable to remember an appointment set with his or her primary care provider due to decline in memory, this can lead to disruption of the structural integrity by worsening of a condition. Comorbidities that accompany the aging process, especially those that affect the cognition, can often threaten both the person’s personal and social integrities. The person may not be able to recognize the self or others, or may even rely on others for survival. Michael visits Mrs. Martinez and obtains a more detailed history and physical. He determines that she is eating slightly less, yet covering her calorie requirements. He asks to see her diary for previous blood glucose readings. Although she is tired, she is able to maintain her usual activities of daily living. Michael considers conservation of energy, structural integrity, and personal integrity as guiding principles. In partnership with Mrs. Martinez, a plan of care is developed. Where the long-term care environment challenges the older patient, the AGNP is able to utilize conservation principles to promote adaptation and balance. Physiological changes of aging represent a threat to conservation of energy, as well as structural, personal, and social integrity. Specifically, conservation of energy can be addressed through attention to factors such as nutritional quality, facility layout and access to ser184 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
I. M. Abumaria et al. vices, and mobility assistance. Conservation of structural integrity mandates efforts to provide a safe environment that promotes healing and health (e.g., safety equipment, protocols to prevent falls and development of pressure ulcers, and attention to colors and noise). Conservation of personal integrity merits particular attention as it is frequently overlooked when providing institutional care. The older adult in long-term care requires interventions that foster respect, humanness, self-awareness, and self-determination. Providing privacy and opportunities to engage in favored activities and encouraging the older adult to make decisions regarding care are fundamental considerations. Finally, conservation of social integrity is requisite to achieving wholeness and health. Opportunities for the older adult to regularly engage with family and others in their social network (e.g., worship participation, social networking) need to be established or maintained. The composite use of these conservation principles provides a framework for the development of key interventions for health. The rapid test is positive for the flu. Michael, after discussing the results with Mrs. Martinez, initiates treatment with oseltamivir phosphate and acetaminophen. At this time, no adjustment is made to her diabetes regimen; however, he asks her to continue self-monitoring her blood sugar. He discussed the importance of rest and energy-conserving measures, hydration, and proper nutrition. Recommendations for Clinical Practice, Research, and Health Policy Levine’s model has been broadly applied to varying populations, as well as individuals, communities, and populations. However, the model has particular clinical, theoretical, research, and health policy relevance in the care of older adults in long-term care settings (see Table 1). Much of health care today is consumed by the elderly at all healthcare levels, including hospital, home, and long-term care settings (Bednash, Mezey, & Tagliareni, 2011). The substantial shift in the numbers of older adults that has occurred over the past 15 years has stimulated a reexamination of the assumption that all entry-level and advanced practice nurses (APNs) are competent to care for the elderly population. The shift in population demographics underscores the need and importance of a geriatric
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Table 1. Implications for Use of Levine’s Conservation Model in Long-Term Care Clinical practice • Incorporate the main concepts of wholeness, adaptation, and conservation into the organization’s mission statement • Promotion of those interventions that foster social interaction and individual uniqueness • Restructuring of the AGNP practice to promote homeorrhesis (striving for around a trajectory or promoting self-righting tendencies) and the external environment (perceptual, operational, and conceptual environments) • Multidisciplinary engagement with the AGNP as leader Clinical theory and research • Contribute to model development and promulgation by demonstrating application of the model in presentation and publication venues • Test interventions to promote patient adaptation and use of conservation principles to the nursing home environment • Engage in quality outcome assessments to promote evidence-based practice Public policy • Serve as leader in refining best practices in care standards • Policies promoting controlled use of resources, including cost-effectiveness of AGNP care • Reimbursement policies that target the promotion of individual adaptation within the nursing home environment AGNP, adult-gerontology nurse practitioner.
specialty both at the practice and the academic levels (Bednash et al., 2011). Older adults represent the most medically challenging with multifactorial complexities that nurses at all levels encounter (Bednash et al., 2011), and this recognition has been influential in the development of the AGNP primary care nurse practitioner competencies (AACN, 2010). The use of APNs in long-term care settings has led to the improvement in patient outcomes. For example, onsite services and telephone consultation using APNs more than twice per month have improved falls outcomes, increased activity level, and improved behavioral symptoms (Bourbonniere et al., 2009). These improvements give credence to APN leadership for quality of care in residential, onsite health services in long-term care facilities for older
Levine’s Conservation Model adults. The AGNP is not only able to provide extensive and holistic primary care for residents, but can also provide care that is more cost-effective; such care may prevent exacerbation of disease requiring hospitalization and the increased use of increasingly scarce healthcare resources. The presence of ANPs on a continuous basis in long-term care facilities serves to allow for prompt assessment and intervention, improving the quality of life for both patient and family. Work by Krichbaum, Pearson, and Hanscom (2000) demonstrated a reduction in the incidence of pressure ulcers, and better outcomes related to incontinence, depression, and aggressive behavior outcomes, where AGNP care was employed. Similarly, another study that examined the effectiveness of APNs showed that affect deterioration was slowed in cognitively impaired residents (Ryden et al., 2000). A long-term facility managed by APNs can reduce the use of physical restraints in combative patients by providing education to increase staff awareness of the harmful effects of, as well as strategies to avoid, the use of restraints (Evans et al., 1997). Such improvements in patient outcomes render the AGNP ideal as a care manager for the older adult in the long-term care setting. Michael asks Mrs. Martinez to restrict visits from others until symptoms abate, and to practice good hand hygiene. She is instructed to call him if symptoms worsen or persist. He informs the staff to keep a close eye on Mrs. Martinez. An important aspect of Levine’s conservation model, consistent with AGNP core competencies (AACN, 2010), is the role of the AGNP as a leader in coordinating care among patient, family, and healthcare providers. AGNPs and physicians have parallel but diverse skills and knowledge that can serve in understanding the importance of integrating collaborative practice models, which in turn can improve the care outcomes of the elderly in long-term care settings (American Medical Directors Association Ad Hoc Work Group on the Role of the Attending Physician Advanced Practice Nurse, 2011). The emphasis of Levine’s model on the conservation of the wholeness and the health of the individual corresponds well to the needs of the older adult population. The changes brought about with the aging process and the dynamic changes in the family system, which take place as the individual moves from one 185
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
Levine’s Conservation Model stage to the next, reflect the model’s conservation principles. Threats to conservation and balance can be encountered and dealt with by the AGNP in ways that incorporate the individual, the family, and the community as participants, and facilitate adaptation (Schaefer & Shober Potylycki, 1993). The AGNP role mandates the execution of competencies, which ensure the health of the older adult (see Table 2). The older adult in their illness experience have increased dependency upon healthcare and caregiver services. The AGNP is uniquely positioned to enhance quality
I. M. Abumaria et al. of care and nurse-family partnership by recommending evidence-based standards of care and by formulating meaningful health policy.
Five days later, Michael visits Mrs. Martinez, and finds that her temperature has decreased, the cough has improved, and blood sugar readings are stable. In partnering with Michael, Mrs. Martinez is recovering and achieving adaptation.
Table 2. Relationship of Adult-Gerontology Nurse Practitioner (AGNP) Core Competencies to Conservation Principles Conservation principle
Core competency
Actions to meet competency
Health promotion, health protection, disease prevention, and treatment
• Assessment of health status • Diagnosis of health status • Plan of care and implementation
Energy Structural integrity
Nurse practitioner–patient relationship
• Interpersonal transaction • Provides therapeutic and culturally appropriate communication • Therapeutic relationships • Enhances safety, dignity, autonomy, and worth • Advocates for individual and family
Social integrity Personal integrity
Teaching–coaching function
• • • •
Social integrity Personal integrity
Professional role
• Directs and collaborates care with formal and informal caregivers • Demonstrates leadership to achieve optimal care outcomes • Coordinates comprehensive care • Participates in community and professional organizations • Promotes use of professional standards for evidence-based care • Advocates and promotes AGNP role
Structural integrity Personal integrity Social integrity
Managing and negotiating health delivery systems
• Oversees and directs delivery of clinical services • Plans and leads disease prevention and health promotion efforts
Monitoring and ensuring the quality of healthcare practice
• Collaborates and consults for care • Monitors practice outcomes • Engages in improvement processes
Cultural and spiritual competence
• Provides spiritually and culturally appropriate care • Provides health resources respectful of cultural and spiritual needs
Energy Structural integrity Social integrity Personal integrity Energy Structural integrity Social integrity Personal integrity Social integrity Personal integrity
Collaborates with patient, family Educates for self-management Provides education Adapts teaching-learning based on psychological-physiological abilities
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I. M. Abumaria et al. Summary Fawcett (1992) has emphasized the need to use nursing models to guide practice. However, a notable criticism of models is the lack of evidence to show beneficial effects on nursing outcomes (Draper, 1993). AGNPs are challenged to consider the usefulness of nursing models in addressing the chronic illnesses, functional decline, and geriatric syndromes that threaten the well-being of older adults (McMahon & Fleury, 2012). Levine (1996) identified that despite the cost-driven nature of our healthcare system, nursing will manage the resources to assure quality of care. While interventions specific to Levine’s model have not been explicated (Leach, 2006), it does provide clear structure for older adult care in the longterm care setting. Use of the model fosters personcentered care that is central to the focus of gerontological nursing. Mission statements of organizations must be given careful attention as such statements inform the healthcare team and stakeholders about the framework for practice. Levine’s model provides core values that are useful in long-term care settings. It is worthwhile to examine the application of this model to national aging population shifts, as well as its application to international agencies that serve older adults. Studies to examine Levine’s model are indicated, with particular emphasis on the diversity and the crosscultural perspectives present in aging adults and their families. Further research is warranted to demonstrate evidence of its utility in facilitating best practice and in supporting cost-effectiveness. References Agency for Healthcare Research and Quality. (2011). Comparison of characteristics of nursing homes and other residential long-term care settings for people with dementia. Rockville, MD: Author. Retrieved from http://effectivehealthcare .ahrq.gov/ehc/products/327/832/Dementia_Protocol _20111103.pdf American Association of Colleges of Nursing. (2010, March). Adult-gerontology primary care nurse practitioner. Washington, DC: Author. Retrieved from http://www .aacn.nche.edu/geriatric-nursing/adultgeroprimcare NPcomp.pdf American Medical Directors Association Ad Hoc Work Group on the Role of the Attending Physician Advanced Practice Nurse. (2011). Collaborative and supervisory relationships between attending physicians and advanced practice nurses in long-term care facilities. Geriatric Nursing, 32(1), 7–17. doi:10.1016/j.gerinurse.2010.12.010
Levine’s Conservation Model Are you ready? What you need to know about ageing. (2012). Retrieved from http://www.who.int/world -health-day/2012/toolkit/background/en/index.html Bednash, G., Mezey, M., & Tagliareni, E. (2011). The Hartford Geriatric Nursing Initiative experience in geriatric nursing education: Looking back, looking forward. Nursing Outlook, 59(4), 228–235. doi:10.1016/j.outlook .2011.05.012 Bourbonniere, M., Mezey, M., Mitty, E. L., Burger, S., Bonner, A., Bowers, B., . . . Nicholson, N. R. (2009). Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: Expert panel recommendations. Policy, Politics & Nursing Practice, 10(1), 64–70. doi:10.1177/ 1527154409332289 Draper, P. (1993). A critique of Fawcett’s “conceptual models and nursing practice: The reciprocal relationship.” Journal of Advanced Nursing, 18(4), 558–564. Evans, L. K., Strumpf, N. E., Allen-Taylor, S. L., Capezuti, E., Maislin, G., & Jacobsen, B. (1997). A clinical trial to reduce restraints in nursing homes. Journal of the American Geriatrics Society, 45(6), 675–681. Fawcett, J. (1992). Conceptual models and nursing practice: The reciprocal relationship. Journal of Advance Nursing, 17(2), 224–228. Federal Interagency Forum on Aging-Related Statistics. (2010). Older American 2010: Key indicators of wellbeing. Washington, DC: U.S. Government Printing Office. Greenberg, J., & Greenberg, H. (2007). More physicians are not the answer. American Journal of Cardiology, 99, 1476–1478. Krichbaum, K. E., Pearson, V., & Hanscom, J. (2000). Better care in nursing homes: Advanced practice nurses’ strategies for improving staff use of protocols. Clinical Nurse Specialist, 14(1), 40–46. Leach, M. J. (2006). Wound management: Using Levine’s conservation model to guide practice. Ostomy Wound Management, 52(8), 74–80. Levine, M. E. (1967). The four conservation principles of nursing. Nursing Forum, 6(1), 45–59. doi:10.1111/j.17446198.1967.tb01297.x Levine, M. E. (1996). The conservation principles: A retrospective. Nursing Science Quarterly, 9(1), 38–41. doi:10.1177/089431849600900110 McMahon, S., & Fleury, J. (2012). Wellness in older adults: A concept analysis. Nursing Forum, 47(1), 39– 51. Ryden, M. B., Snyder, M., Gross, C. R., Savik, K., Pearson, V., Krichbaum, K., & Mueller, C. (2000). Valueadded outcomes: The use of advanced practice nurses in long-term care facilities. Gerontologist, 40(6), 654–662. Schaefer, K. M. (2010a). The conservation model. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 225–241). Maryland Heights, MO: Mosby Elsevier. Schaefer, K. M. (2010b). Myra Levine’s conservation model. In M. E. Parker & M. C. Smith (Eds.), Nursing theories and nursing practice (3rd ed., pp. 83–103). Philadelphia: F.A. Davis Company. 187
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Levine’s Conservation Model Schaefer, K. M., & Shober Potylycki, M. J. (1993). Fatigue associated with congestive heart failure: Use of Levine’s conservation model. Journal of Advanced Nursing, 18(2), 260–268. Sloane, P. D., Zimmerman, S., Suchindran, C., Reed, P., Wang, L., Boustani, M., & Sudha, S. (2002). The public health impact of Alzheimer’s disease, 2000–2050:
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I. M. Abumaria et al. Potential implication of treatment advances. Annual Review of Public Health, 23, 213–231. Vincent, G. K., & Velkoff, V. A. (2010). The next four decades, the older population in the United States: 2010 to 2050. Current Population Reports, P25-1138. Washington, DC: U.S. Census Bureau.
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Levine’s Conservation Model: A Framework for Advanced Gerontology Nursing Practice Ibrahim Mahmoud Abumaria, MS, RN, ANP, Marie Hastings-Tolsma, PhD, CNM, FACNM, and Teresa J. Sakraida, PhD, RN Ibrahim Mahmoud Abumaria, MS, RN, ANP, is Adult Nurse Practitioner, El Paso, TX; Marie Hastings-Tolsma, PhD, CNM, FACNM, is Professor, College of Nursing, University of Colorado Denver, Aurora, CO; and Teresa J. Sakraida, PhD, RN, is Assistant Professor, College of Nursing, University of Colorado Denver, Aurora, CO. Keywords Advanced gerontology nursing practice, Levine’s Conservation Nursing Model, nursing homes, older adults Correspondence Teresa J. Sakraida, PhD, RN, College of Nursing, University of Colorado Denver, Aurora, CO E-mail: teresa.sakraida @ucdenver.edu
Abumaria
PURPOSE. Growing numbers of older adults place increased demands on already burdened healthcare systems. The cost of managing chronic illnesses mandates greater emphasis on management and prevention. This article explores the adaptation of Levine’s Conservation Model as a structure for providing care to the older adult by the adult-gerontology primary care nurse practitioner (AGNP). CONCLUSION. The AGNP role, designed to provide quality care to adult and older adult populations, offers the opportunity to not only manage health care of the elderly, but to also advocate, lead in collaborative care efforts, conduct advanced planning, and manage and negotiate health delivery systems. The use of nursing models can foster the design of effective interventions that promote health of the older adult, particularly in the long-term care environment. PRACTICE IMPLICATION. Levine’s Conservation Model provides a useful structure for older adult care in the long-term care setting. As an ideal care manager, the AGNP would be well served to consider use of the model to guide advanced nursing practice. Recommendations for clinical practice, research, and health policy.
Hastings-Tolsma
Sakraida
Introduction Aging is a global health phenomenon. According to the World Health Organization, the number of individuals age 60 years and older has doubled since 1980,
and those 80 years and older are estimated to reach nearly 395 million by 2050 (“Are You Ready?,” 2012). The burgeoning numbers of the elderly require specialized nursing services. This change in demographics presents a pressing need to shift healthcare emphasis 179
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Levine’s Conservation Model from treatment to management and prevention (Greenberg & Greenberg, 2007) as added risks to the health of the elderly have emerged (Vincent & Velkoff, 2010). To meet the needs of the U.S. aging population, increased numbers of adult-gerontology nurse practitioners (AGNPs) will be required to increase system efficiency, improve quality, reduce hospitalizations, and meet evidence-based care mandates. These advanced practice providers will be vital in the provision of sustainable cost-effective primary healthcare services for those most burdened with escalating healthcare costs. An important foundation for AGNP care is the synthesis of theoretical, scientific, and contemporary knowledge that can guide care and promote the wellbeing of an aging population (American Association of Colleges of Nursing [AACN], 2010). Levine’s conservation model (1967) offers a valuable theoretical lens for moving AGNPs forward as primary care providers of gerontology care, particularly within the long-term care environment. Overview of Levine’s Model The Levine (1967) conservation model describes how adaptation leads to the wholeness of an individual through the conservation of energy, structural integrity, personal integrity, and social integrity. Figure 1 presents the major concepts of Levine’s model. As shown, adaptation occurs in an ever-changing internal and external environment. Conservation is the product of adaptation, and wholeness is the ultimate result of conservation. Adaptation is a way by which a person maintains integrity within the environment. It is characterized by redundancy, historicity, and specificity. Redundancy is the multilayered options that exist for adapting to the environment and is an important concept that humans rely on for survival. In medicine, this translates into the freedom to choose from several options when it comes to a health decision. If all redundant options fail, the person also fails. Historicity of adaptation refers to survival instincts and mechanisms that are hidden in the genetic code. Specificity is the uniqueness of each individual; no two people will have the exact same redundancy and historicity. Levine defines health as wholeness (Levine, 1996). Wholeness occurs when there is a balanced adaptation between the evolving needs of the organism and the stresses of the ever-changing environment. Organisms exist in an open environ180 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
I. M. Abumaria et al. ment that is the sum of internal and external elements. The internal environment consists of physiological and pathophysiological elements, as well as the interaction of bodily functions. The external environment is categorized into three levels: perceptual, operational, and conceptual (Schaefer, 2010b). The perceptual environment includes elements that the person experiences through the senses, such as smell and touch. The operational environment includes elements that surround the person but for which no awareness by the person exists, for example, air pollution. The conceptual environment consists of factors that the person experiences by learning and appreciation, such as language, ways of thinking, values, beliefs, morality, and history. All of the above elements harmonize when the principles of conservation are observed. Levine defines the person as a “spiritual being” (Schaefer, 2010b, p. 88). She posits that the person is a spiritual, holistic, unique being that remembers the past but is focused on the future. However, the individual should not be considered in isolation. She states that the “individual life has meaning only in the context of social life” (Schaefer, 2010b, p. 88). According to Levine, nursing is a science that excels in the skill of “human interaction” and is a partnership of the human experience with the patient (Schaefer, 2010b, p. 89). During this relationship, the nurse uses the scientific process to interpret the patient’s altered health status and organismic response to develop a nursing judgment or trophicognosis (Schaefer, 2010a, p. 228). The organismic response is the change that an organism makes during adaptation to a new environment. The nurse then applies the conservation principles and proposes a hypothesis to address the patient’s condition. The resulting nursing intervention is then coupled with patient participation in order to restore wholeness. Conservation is the central concept of Levine’s model. When it is achieved, the person is in harmony, and adaptation is accomplished. The conservation model has four main elements: the conservation of energy, structural integrity, personal integrity, and social integrity. Energy is an abstract concept that relies on free exchange between the internal and the external environment. A person’s energy is conserved if a balance of energy input and output is achieved. Structural integrity is the task of keeping the person whole (Levine, 1967). Behaviors such as hygiene, health provider visits, and medicines are examples by which structural integrity is maintained. Personal integrity
HEALTH
Culture
State of Wholeness
Ever-changing ENVIRONMENT • Internal • External
Imbalance with Environment
Balance
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015 - Balance with environment achieved - Optimum conservation of energy for patient
ENVIRONMENT
Balance with Environment not yet Achieved
ADAPTATION Adapts to new environment • Redundancy • Historicity • Specificity
Intervention n
Organismic Responses Fight orr Flight Flight Inflammatory Response I fl f t R Stress Perceptual
New Environmental o onmental t te State
Nursing Assessment
Scientific Process
Human being appraises condition and situation
PATIENT åa
Strives to preserve wholeness and integrity
Self-determined actions, even in emotional states
Nursing Plan
Se Selects best solutions -Conservation of Energy -C åaIntegrity -S -Structural -Personal Integrity -P -Social Integrity -S
NURSE
Nursing Diagnosis (Trophicognosis)
Coupled Cou upled e
Figure 1. Levine’s Traditional Conservation Model
Human being reflects and understands
Physician’s Medical Plan
Nursing Hypothesis
I. M. Abumaria et al. Levine’s Conservation Model
181
Levine’s Conservation Model includes respect, self-awareness, humanness, selfhood, and self-determination. Social integrity refers to the patient’s role in the community, family, ethnic group, culture, and religion.
Utility of Levine’s Nursing Model in Advanced Practice Older adults or seniors frequently struggle with a variety of health problems, particularly chronic diseases and cognitive issues, such as dementia, which are frequent triggers for needing long-term care nursing services. Dementia increases dramatically with age, and it is estimated that the number of Americans with dementia may rise to as high as 19 million by 2050 (Sloane et al., 2002). Similarly, chronic diseases and the need to manage the impact on daily living and quality of life are significant causes of morbidity and mortality, and create a substantial burden on both the family and healthcare system. It is estimated that 43% of Medicare beneficiaries have three or more chronic diseases (Federal Interagency Forum on Aging-Related Statistics, 2010). Such health issues are also primary factors in decreased social interactions. Models that are useful in effectively addressing the health concerns of the elderly and their dependency needs are requisite. Levine’s conservation model focuses on the promotion of adaptation and maintaining wholeness by conserving energy, structure, and person and social integrity (Levine, 1967). Targeted interventions that promote energy and integrity are the foundation for advanced practice. Individualized care focused on conservation balance fosters improved outcomes (Agency for Healthcare Research and Quality, 2011).
Application of Levine’s Model to the AGNP Practice Levine’s model can guide AGNP care in the promotion of adaptation on three levels (see Figure 2). The first level is an environment where homeostasis is maintained by constant adjustments in the internal physiology of the body along with external environmental factors (e.g., eating, warmer clothes). In this fluid state, the individual has the potential to shift from a state of wholeness, to imbalance, and back again often without being aware of the fluctuation. The second level focuses on how the person 182 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
I. M. Abumaria et al. responds when he or she becomes self-aware of the disease. The third level is reached when the patient seeks health care. A case exemplar illustrates the model applied in the care of Mrs. Martinez, an 87-year-old with Hispanic ancestry who is bilingual and with a well-controlled type 2 diabetes. Mrs. Martinez resides in an assisted living facility. Currently, she requires basic support that includes medications, bathing, and foot care. She ambulates with the aid of a walker and regularly socializes by playing cards with her friends at the facility. Promoting health among seniors starts by fostering a state of wholeness. With every alteration in the environment, whether internal or external, there is the potential for imbalance, and thus illness. The older person may not recognize the body’s physiological efforts to maintain homeostasis. For example, the body of a healthy individual who consumes a large meal responds to the increase in blood glucose by secreting more insulin. Insulin, in turn, returns the patient to a euglycemic state, with little awareness by the individual other than feeling satiated. In certain conditions, the individual may recognize that his or her body is working to maintain homeostasis. For example, the patient with diabetes will likely be more aware of the shifts in his or her internal physiological state from fluctuating blood glucose levels. Recognition of the imbalance is dependent upon personal and cultural factors as the body attempts to adapt using redundancy (coping mechanisms), historicity (previous exposure), and specificity (unique adaptations). Each of these processes reflects physiological effort to maintain homeostasis in adapting to internal and external environmental influences. Levine’s ideas of nursing were influenced by the western view of care and caring, and have not been examined across cultures where care for older adults is part of the family dynamic. Mrs. Martinez feels tired as she sat on the edge of her couch. She checks her blood glucose, and it reads 83 mg/dl. She decides a nap would help since she did not get enough sleep the previous night. In level two, the body is unable to silently resolve environmental imbalances. Here, the older adult becomes aware of the imbalance, self-identifies as being sick, and typically seeks advice and information about his or her condition. The sources of information
Levine’s Conservation Model
I. M. Abumaria et al.
Figure 2. Levine’s Conservation Model Adapted to the Adult-Gerontology Nurse Practitioner (AGNP) Practice Key • Boxes: Biologic state of patient • Ovals: Voluntary state • Arrows: Actions • Levine’s conservation model
Imbalance With Environment
Data analysis based on experience and training ADAPTATION Adapts to new environment • Redundancy • Historicity • Specificity
LEVEL 3: AGNP • Patient seeks medical att attention from AGNP • AG AGNP selects best so solution guided by åa evidence-based evi pra practice
History and Physical
Patient seeks medical advice LEVEL 1:
Ever-changing environment • Internal • External
ENVIRONMENT
Balance
-Patient feels well -Minor fluctuations in environment
New Environmental State • Organismic response • Patient attempts to conserve Energy Structure Personal/social integrity
Culture
State of Wholeness
• Balance with environment achieved • Optimum conservation of energy for patient
Advanced Nursing Plan
Intervention Interventio ntion
Partnership
Patient Plan
P Patient Pa culturallyy iinterprets nterprets imbala imbalance annce as iillness/disease llness/disease
LEVEL 2: PERSON, LE PARENT, and GUARDIAN Patie Patient is aware of illness. Ponders illness. Seeks Po su support from family, society, religion, and past personal experiences
Patient Selfidentifies as Being “Sick”
Diagnosis
Advice from Other Disciplines
Chooses best solution based on advice, experience, and patient’s emotions
Patient Hypothesis about Symptoms
HEALTH Strives to preserve wholeness and integrity
Direction and Collection
Social Spirit
may be categorized as social (e.g., family, friends), spiritual (e.g., praying for guidance), experiential (e.g., recalling similar episodes in the past), emotional (i.e., feelings about the best course of action), and medical (i.e., previous contact with health providers). A hypothesis will be reached by analyzing all the information provided by these sources (e.g., taking these actions is most likely to result in improved health). Once a hypothesis has been reached, an appropriate course of action is planned to enact the hypothesis. When imbalance from disease exceeds the ability of the patient to self-treat, the third level is reached, and
Past
Emotions
Analysis
Self-obtained information (e.g., Internet)
medical intervention is sought. The use of health resources, such as laboratory testing and medications, is common as efforts are undertaken to restore balance. In the afternoon, Mrs. Martinez feels like she is not her usual self. Her muscles are aching, and she has a dry cough. She feels warm and suspects she has a fever. She knows from previous experience that a fever will elevate her blood sugar. She calls one of her friends and tells her that she is worried.
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Levine’s Conservation Model In the third level, the AGNP is instrumental in the promotion of balance, wholeness, and health. The AGNP utilizes education, experience, and critical thinking to assess patient balance, and then formulate a diagnosis and plan of care to effectively promote wholeness. Throughout the process, the patient is in partnership with the AGNP, an expert in detailing effective interventions to promote health. Where partnership with the patient is limited by cognitive limitations, the family and community become important surrogates for inclusion. Strategies to promote balance are tailored to include patient beliefs, cultural practices, education, and socioeconomic background. Mrs. Martinez checks her blood glucose again, and it is high at 154 mg/dl. Her cough is worse. She is not sure what to do. She calls Michael, the AGNP who supports her care management. For example, if the older adult is unable to remember an appointment set with his or her primary care provider due to decline in memory, this can lead to disruption of the structural integrity by worsening of a condition. Comorbidities that accompany the aging process, especially those that affect the cognition, can often threaten both the person’s personal and social integrities. The person may not be able to recognize the self or others, or may even rely on others for survival. Michael visits Mrs. Martinez and obtains a more detailed history and physical. He determines that she is eating slightly less, yet covering her calorie requirements. He asks to see her diary for previous blood glucose readings. Although she is tired, she is able to maintain her usual activities of daily living. Michael considers conservation of energy, structural integrity, and personal integrity as guiding principles. In partnership with Mrs. Martinez, a plan of care is developed. Where the long-term care environment challenges the older patient, the AGNP is able to utilize conservation principles to promote adaptation and balance. Physiological changes of aging represent a threat to conservation of energy, as well as structural, personal, and social integrity. Specifically, conservation of energy can be addressed through attention to factors such as nutritional quality, facility layout and access to ser184 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 3, July-September 2015
I. M. Abumaria et al. vices, and mobility assistance. Conservation of structural integrity mandates efforts to provide a safe environment that promotes healing and health (e.g., safety equipment, protocols to prevent falls and development of pressure ulcers, and attention to colors and noise). Conservation of personal integrity merits particular attention as it is frequently overlooked when providing institutional care. The older adult in long-term care requires interventions that foster respect, humanness, self-awareness, and self-determination. Providing privacy and opportunities to engage in favored activities and encouraging the older adult to make decisions regarding care are fundamental considerations. Finally, conservation of social integrity is requisite to achieving wholeness and health. Opportunities for the older adult to regularly engage with family and others in their social network (e.g., worship participation, social networking) need to be established or maintained. The composite use of these conservation principles provides a framework for the development of key interventions for health. The rapid test is positive for the flu. Michael, after discussing the results with Mrs. Martinez, initiates treatment with oseltamivir phosphate and acetaminophen. At this time, no adjustment is made to her diabetes regimen; however, he asks her to continue self-monitoring her blood sugar. He discussed the importance of rest and energy-conserving measures, hydration, and proper nutrition. Recommendations for Clinical Practice, Research, and Health Policy Levine’s model has been broadly applied to varying populations, as well as individuals, communities, and populations. However, the model has particular clinical, theoretical, research, and health policy relevance in the care of older adults in long-term care settings (see Table 1). Much of health care today is consumed by the elderly at all healthcare levels, including hospital, home, and long-term care settings (Bednash, Mezey, & Tagliareni, 2011). The substantial shift in the numbers of older adults that has occurred over the past 15 years has stimulated a reexamination of the assumption that all entry-level and advanced practice nurses (APNs) are competent to care for the elderly population. The shift in population demographics underscores the need and importance of a geriatric
I. M. Abumaria et al.
Table 1. Implications for Use of Levine’s Conservation Model in Long-Term Care Clinical practice • Incorporate the main concepts of wholeness, adaptation, and conservation into the organization’s mission statement • Promotion of those interventions that foster social interaction and individual uniqueness • Restructuring of the AGNP practice to promote homeorrhesis (striving for around a trajectory or promoting self-righting tendencies) and the external environment (perceptual, operational, and conceptual environments) • Multidisciplinary engagement with the AGNP as leader Clinical theory and research • Contribute to model development and promulgation by demonstrating application of the model in presentation and publication venues • Test interventions to promote patient adaptation and use of conservation principles to the nursing home environment • Engage in quality outcome assessments to promote evidence-based practice Public policy • Serve as leader in refining best practices in care standards • Policies promoting controlled use of resources, including cost-effectiveness of AGNP care • Reimbursement policies that target the promotion of individual adaptation within the nursing home environment AGNP, adult-gerontology nurse practitioner.
specialty both at the practice and the academic levels (Bednash et al., 2011). Older adults represent the most medically challenging with multifactorial complexities that nurses at all levels encounter (Bednash et al., 2011), and this recognition has been influential in the development of the AGNP primary care nurse practitioner competencies (AACN, 2010). The use of APNs in long-term care settings has led to the improvement in patient outcomes. For example, onsite services and telephone consultation using APNs more than twice per month have improved falls outcomes, increased activity level, and improved behavioral symptoms (Bourbonniere et al., 2009). These improvements give credence to APN leadership for quality of care in residential, onsite health services in long-term care facilities for older
Levine’s Conservation Model adults. The AGNP is not only able to provide extensive and holistic primary care for residents, but can also provide care that is more cost-effective; such care may prevent exacerbation of disease requiring hospitalization and the increased use of increasingly scarce healthcare resources. The presence of ANPs on a continuous basis in long-term care facilities serves to allow for prompt assessment and intervention, improving the quality of life for both patient and family. Work by Krichbaum, Pearson, and Hanscom (2000) demonstrated a reduction in the incidence of pressure ulcers, and better outcomes related to incontinence, depression, and aggressive behavior outcomes, where AGNP care was employed. Similarly, another study that examined the effectiveness of APNs showed that affect deterioration was slowed in cognitively impaired residents (Ryden et al., 2000). A long-term facility managed by APNs can reduce the use of physical restraints in combative patients by providing education to increase staff awareness of the harmful effects of, as well as strategies to avoid, the use of restraints (Evans et al., 1997). Such improvements in patient outcomes render the AGNP ideal as a care manager for the older adult in the long-term care setting. Michael asks Mrs. Martinez to restrict visits from others until symptoms abate, and to practice good hand hygiene. She is instructed to call him if symptoms worsen or persist. He informs the staff to keep a close eye on Mrs. Martinez. An important aspect of Levine’s conservation model, consistent with AGNP core competencies (AACN, 2010), is the role of the AGNP as a leader in coordinating care among patient, family, and healthcare providers. AGNPs and physicians have parallel but diverse skills and knowledge that can serve in understanding the importance of integrating collaborative practice models, which in turn can improve the care outcomes of the elderly in long-term care settings (American Medical Directors Association Ad Hoc Work Group on the Role of the Attending Physician Advanced Practice Nurse, 2011). The emphasis of Levine’s model on the conservation of the wholeness and the health of the individual corresponds well to the needs of the older adult population. The changes brought about with the aging process and the dynamic changes in the family system, which take place as the individual moves from one 185
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Levine’s Conservation Model stage to the next, reflect the model’s conservation principles. Threats to conservation and balance can be encountered and dealt with by the AGNP in ways that incorporate the individual, the family, and the community as participants, and facilitate adaptation (Schaefer & Shober Potylycki, 1993). The AGNP role mandates the execution of competencies, which ensure the health of the older adult (see Table 2). The older adult in their illness experience have increased dependency upon healthcare and caregiver services. The AGNP is uniquely positioned to enhance quality
I. M. Abumaria et al. of care and nurse-family partnership by recommending evidence-based standards of care and by formulating meaningful health policy.
Five days later, Michael visits Mrs. Martinez, and finds that her temperature has decreased, the cough has improved, and blood sugar readings are stable. In partnering with Michael, Mrs. Martinez is recovering and achieving adaptation.
Table 2. Relationship of Adult-Gerontology Nurse Practitioner (AGNP) Core Competencies to Conservation Principles Conservation principle
Core competency
Actions to meet competency
Health promotion, health protection, disease prevention, and treatment
• Assessment of health status • Diagnosis of health status • Plan of care and implementation
Energy Structural integrity
Nurse practitioner–patient relationship
• Interpersonal transaction • Provides therapeutic and culturally appropriate communication • Therapeutic relationships • Enhances safety, dignity, autonomy, and worth • Advocates for individual and family
Social integrity Personal integrity
Teaching–coaching function
• • • •
Social integrity Personal integrity
Professional role
• Directs and collaborates care with formal and informal caregivers • Demonstrates leadership to achieve optimal care outcomes • Coordinates comprehensive care • Participates in community and professional organizations • Promotes use of professional standards for evidence-based care • Advocates and promotes AGNP role
Structural integrity Personal integrity Social integrity
Managing and negotiating health delivery systems
• Oversees and directs delivery of clinical services • Plans and leads disease prevention and health promotion efforts
Monitoring and ensuring the quality of healthcare practice
• Collaborates and consults for care • Monitors practice outcomes • Engages in improvement processes
Cultural and spiritual competence
• Provides spiritually and culturally appropriate care • Provides health resources respectful of cultural and spiritual needs
Energy Structural integrity Social integrity Personal integrity Energy Structural integrity Social integrity Personal integrity Social integrity Personal integrity
Collaborates with patient, family Educates for self-management Provides education Adapts teaching-learning based on psychological-physiological abilities
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I. M. Abumaria et al. Summary Fawcett (1992) has emphasized the need to use nursing models to guide practice. However, a notable criticism of models is the lack of evidence to show beneficial effects on nursing outcomes (Draper, 1993). AGNPs are challenged to consider the usefulness of nursing models in addressing the chronic illnesses, functional decline, and geriatric syndromes that threaten the well-being of older adults (McMahon & Fleury, 2012). Levine (1996) identified that despite the cost-driven nature of our healthcare system, nursing will manage the resources to assure quality of care. While interventions specific to Levine’s model have not been explicated (Leach, 2006), it does provide clear structure for older adult care in the longterm care setting. Use of the model fosters personcentered care that is central to the focus of gerontological nursing. Mission statements of organizations must be given careful attention as such statements inform the healthcare team and stakeholders about the framework for practice. Levine’s model provides core values that are useful in long-term care settings. It is worthwhile to examine the application of this model to national aging population shifts, as well as its application to international agencies that serve older adults. Studies to examine Levine’s model are indicated, with particular emphasis on the diversity and the crosscultural perspectives present in aging adults and their families. Further research is warranted to demonstrate evidence of its utility in facilitating best practice and in supporting cost-effectiveness. References Agency for Healthcare Research and Quality. (2011). Comparison of characteristics of nursing homes and other residential long-term care settings for people with dementia. Rockville, MD: Author. Retrieved from http://effectivehealthcare .ahrq.gov/ehc/products/327/832/Dementia_Protocol _20111103.pdf American Association of Colleges of Nursing. (2010, March). Adult-gerontology primary care nurse practitioner. Washington, DC: Author. Retrieved from http://www .aacn.nche.edu/geriatric-nursing/adultgeroprimcare NPcomp.pdf American Medical Directors Association Ad Hoc Work Group on the Role of the Attending Physician Advanced Practice Nurse. (2011). Collaborative and supervisory relationships between attending physicians and advanced practice nurses in long-term care facilities. Geriatric Nursing, 32(1), 7–17. doi:10.1016/j.gerinurse.2010.12.010
Levine’s Conservation Model Are you ready? What you need to know about ageing. (2012). Retrieved from http://www.who.int/world -health-day/2012/toolkit/background/en/index.html Bednash, G., Mezey, M., & Tagliareni, E. (2011). The Hartford Geriatric Nursing Initiative experience in geriatric nursing education: Looking back, looking forward. Nursing Outlook, 59(4), 228–235. doi:10.1016/j.outlook .2011.05.012 Bourbonniere, M., Mezey, M., Mitty, E. L., Burger, S., Bonner, A., Bowers, B., . . . Nicholson, N. R. (2009). Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: Expert panel recommendations. Policy, Politics & Nursing Practice, 10(1), 64–70. doi:10.1177/ 1527154409332289 Draper, P. (1993). A critique of Fawcett’s “conceptual models and nursing practice: The reciprocal relationship.” Journal of Advanced Nursing, 18(4), 558–564. Evans, L. K., Strumpf, N. E., Allen-Taylor, S. L., Capezuti, E., Maislin, G., & Jacobsen, B. (1997). A clinical trial to reduce restraints in nursing homes. Journal of the American Geriatrics Society, 45(6), 675–681. Fawcett, J. (1992). Conceptual models and nursing practice: The reciprocal relationship. Journal of Advance Nursing, 17(2), 224–228. Federal Interagency Forum on Aging-Related Statistics. (2010). Older American 2010: Key indicators of wellbeing. Washington, DC: U.S. Government Printing Office. Greenberg, J., & Greenberg, H. (2007). More physicians are not the answer. American Journal of Cardiology, 99, 1476–1478. Krichbaum, K. E., Pearson, V., & Hanscom, J. (2000). Better care in nursing homes: Advanced practice nurses’ strategies for improving staff use of protocols. Clinical Nurse Specialist, 14(1), 40–46. Leach, M. J. (2006). Wound management: Using Levine’s conservation model to guide practice. Ostomy Wound Management, 52(8), 74–80. Levine, M. E. (1967). The four conservation principles of nursing. Nursing Forum, 6(1), 45–59. doi:10.1111/j.17446198.1967.tb01297.x Levine, M. E. (1996). The conservation principles: A retrospective. Nursing Science Quarterly, 9(1), 38–41. doi:10.1177/089431849600900110 McMahon, S., & Fleury, J. (2012). Wellness in older adults: A concept analysis. Nursing Forum, 47(1), 39– 51. Ryden, M. B., Snyder, M., Gross, C. R., Savik, K., Pearson, V., Krichbaum, K., & Mueller, C. (2000). Valueadded outcomes: The use of advanced practice nurses in long-term care facilities. Gerontologist, 40(6), 654–662. Schaefer, K. M. (2010a). The conservation model. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 225–241). Maryland Heights, MO: Mosby Elsevier. Schaefer, K. M. (2010b). Myra Levine’s conservation model. In M. E. Parker & M. C. Smith (Eds.), Nursing theories and nursing practice (3rd ed., pp. 83–103). Philadelphia: F.A. Davis Company. 187
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Levine’s Conservation Model Schaefer, K. M., & Shober Potylycki, M. J. (1993). Fatigue associated with congestive heart failure: Use of Levine’s conservation model. Journal of Advanced Nursing, 18(2), 260–268. Sloane, P. D., Zimmerman, S., Suchindran, C., Reed, P., Wang, L., Boustani, M., & Sudha, S. (2002). The public health impact of Alzheimer’s disease, 2000–2050:
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I. M. Abumaria et al. Potential implication of treatment advances. Annual Review of Public Health, 23, 213–231. Vincent, G. K., & Velkoff, V. A. (2010). The next four decades, the older population in the United States: 2010 to 2050. Current Population Reports, P25-1138. Washington, DC: U.S. Census Bureau.
