Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain:
Modeling and Role-Modeling
Modeling and role-modeling (MRM) is considered by its authors to be a theory and a paradigm. They constructed the theory from a multiplicity of resources that explain nurses’ interactions with clients.
MAJOR ASSUMPTIONS, CONCEPTS, AND RELATIONSHIPS
Assumptions
Assumptions about adaptation and nursing are proposed in the MRM theory; the au- thors state that adaptation “is an innate drive toward holistic health, growth, and devel- opment. Self-healing, recovery and renewal, and adaptation are all instinctual despite the aging process or inherent malformations” (Erickson et al., 1983, p. 47).
When describing nursing, it is assumed that (1) “nursing is the nurturance of holistic self-care”; (2) “nursing is assisting persons holistically to use their adaptive strengths to attain and maintain optimum biopsychosocial-spiritual functioning”; (3) “nursing is helping with self-care to gain optimum health”; and (4) “nursing is an integrated and in- tegrative helping of persons to better care for themselves” (Erickson et al., 1983, p. 50).
Concepts
The MRM theory contains a detailed set of concepts, and a glossary is provided in their work that assists in its comprehension. Table 8-4 provides definitions for some of the major concepts.
Relationships
The active potential assessment model (APAM) directs nursing assessment in the MRM theory. The APAM is a synthesis of Selye’s general adaptation syndrome and
TABLE 8-4Major Concepts of the Modeling and Role-Modeling Theory
Concept Definition
Holism The idea that “human beings have multiple interacting subsystems including genetic make up and spiritual drive, body, mind, emotion, and spirit are a total unit and act together, affecting and controlling one another interactively” (Erickson et al., 1983, p. 44).
Health “The state of physical, mental, and social well-being, not merely the absence of disease or infirmity” (p. 46).
Lifetime growth Lifetime growth and development are continuous processes. When needs are met, and development growth and development promote health.
Affiliated-individuation The dependence on support systems while maintaining the independence of the individual.
Adaptation The individual’s response to external and internal stressors in a health-and growth-directed manner. The opposite is maladaptation, which is the taxing of the system when the individual is “unable to engage constructive coping methods or mobilize appropriate resources to contend with the stressor(s)” (p. 47).
Self-care Knowledge, resources, and action of the client, knowledge considers what has made the client sick, what will make him or her well, and “the mobilization of internal resources, and acquisition of additional resources to gain, maintain, or promote an optimal level of holistic health” (p. 48).
Nursing “The holistic helping of persons with their self-care activities in relation to their health—an interactive, interpersonal process that nurtures strengths to achieve a state of perceived holistic health” (p. 49).
Modeling The process by which the nurse seeks to understand the client’s unique model of the world.
Role-modeling The process by which the nurse understands the client’s unique model within the context of scientific theories and uses the model to plan interventions that promote health for the client.
Source: Erickson et al. (1983).
Engles’ response to stressors (Erickson et al., 1983). The APAM assists the nurse in predicting a client’s potential to cope and is used to assess three states: equilibrium, arousal, and impoverishment. Equilibrium has two facets: adaptive and maladaptive.
People in equilibrium have potential for mobilizing resources; those in maladaptive equilibrium have fewer resources.
Both arousal and impoverishment are considered to be states of stress in which mo- bilizing resources are expected. Persons in impoverishment have diminished or depleted abilities for mobilizing resources. People move between the states as their capacities to meet stress change. The APAM is considered dynamic rather than unidirectional and depends on the person’s abilities to mobilize resources. Nursing interventions influence the person’s ability to mobilize resources and move from impoverishment to equilib- rium within the APAM (Erickson et al., 1983).
From the data collected, a client model is developed, with a description of the functional relationship among the factors. Etiologic factors are analyzed, and possible therapeutic interventions are devised recognizing possible conflicts with treatment plans of other health professionals. Diagnoses and goals are established to complete the planning process (Erickson et al., 1983).
The success of the process is predicated on nurse’s coming to know client. The five aims of nursing interventions are building trust, promoting the client’s positive orien- tation, promoting the client’s control, affirming and promoting the client’s strength, and setting health-directed mutual goals while meeting the client’s needs (e.g., bio- physical, safety and security, love and belonging, esteem and self-esteem) (Erickson et al., 1983; Erickson, 2006).
USEFULNESS
Currently the model is the basis for a series of conferences incorporating MRM into re- search, practice settings, and curricula. Adherents of the theory state that it is used in courses or in the curricula of several universities. These include Humboldt State Univer- sity School of Nursing in Arcata, California; Metropolitan State University in St. Paul, Minnesota; and the University of Texas at Austin, Alternate Entry Program where gradu- ate nursing students use MRM as a unifying model (MRM website, 2008); St. Catherine’s University, Associate Degree Program Minneapolis, MN; Washetnaw Community Col- lege AD-N Program, Ypsilanti MI; Portland Health Science Center, Portland, OR; Hard- ing University, Search, AR; and East Carolina University, Greensboro, NC (retrieved December 30, 2008 from http://www.mrmnursingtheory.org).
Several institutions use the model for practice. The University of Texas Medical Branch at Galveston uses the model to structure the academic/service model. The Uni- versity of Michigan Medical Center, Brigham and Women’s Hospital in Boston, and the University of Pittsburgh (PA) hospitals all used the MRM as a theoretical basis for prac- tice (Erickson et al., 1998). Several examples demonstrate how MRM has been applied in nursing practice. One in particular, Baldwin (2004), used the model to describe effec- tive nursing interventions to promote independence for clients with interstitial cystitis.
TESTABILITY
Modeling and role-modeling provides assumptions and relationships that are amenable to testing and have been and continue to be tested in research. The model has been used by nurses who have studied with Erickson, Tomlin, and Swain, and many theses and dissertations have incorporated elements of the model. Box 8-2 lists some of the current works using MRM in research.
PARSIMONY
The MRM theory is not parsimonious. Its complexity, however, reflects human be- ings, to whom it applies. MRM incorporates several borrowed theories that are syn- thesized for use in nursing science. The many linkages among the concepts and multiple levels need to be addressed, and considerable explanation is needed to enh- ance understanding of the tenets of the theory for nursing practice and for client care activities.
VALUE IN EXTENDING NURSING SCIENCE
In addition to the uses of MRM in nursing education, practice, and research, three middle range nursing theories have been based on MRM. Acton (1997) developed a model describing affiliated-individuation, Irvin and Acton (1996) described caregiver stress, and Rogers (1996) discussed the concept of facilitative affiliation.
MRM theory is used in education, practice, and research. The Society for Promoting MRM Theory has been formed to promote understanding and use of the theory. This group meets annually and maintains a website at http://www.mrmnursingtheory.org.
Research has been completed with people of all ages and with those who are suffering from many different health problems. According to those who espouse the theory, its major attraction is that it is practical, reflects the domain of nursing, and is a realistic model for guiding research, practice, and education.
Imogene M. King: King’s Conceptual System and Theory of Goal Attainment and Transactional Process
King’s theory evolved from early writings about theory development. In her first book in 1971, she synthesized scholarship from nursing and related disciplines into a theory for nursing (King, 1971). She wrote the Theory of Goal Attainment in 1980.
The most recent edition (King, 1995a) contains further refinements and more det- ailed explanation of the general nursing framework and the theory.
BACKGROUND OF THE THEORIST
Imogene King graduated from St. John’s Hospital School of Nursing in St. Louis, Missouri, with a diploma in nursing in 1945. She received a bachelor of science in nurs- ing education from St. Louis University in 1948, and a master of science in nursing Beery, T., Baas, L. S., & Henthorn, C. (2007). Self
reported adjustment to implanted cardiac de- vices. Journal of Cardiovascular Nursing, 22(6), 516–524.
Beery, T., Baas, L. S., Mathews, H., Burrough, J.,
& Henthorn, R. (2005). Development of the im- planted devices adjustment scale. Dimensions of Critical Care Nursing, 24(50), 242–248.
Nash, K. (2007). Evaluation of the empower peer support and education program for middle school-aged adolescents. Journal of Holistic Nursing, 25(1), 26–36.
Mitchel, J. B. (2007). Enhancing patient connect- edness: Understanding the nurse–patient relationship. International Journal for Human Caring, 11(4), 79–82.
BOX 8-2
Examples of Research Studies Using Modeling and Role-Modeling Theory
from the same school in 1957. In 1961, she received the doctor of education degree from Teacher’s College, Columbia University, in New York (Sieloff, 2006). She held a variety of staff nursing, educational, research, and administrative roles throughout her professional life. She worked as a research consultant for the Division of Nursing in the Department of Health, Education, and Welfare from 1964 to 1966 (King, personal communication, October, 2005). King moved to Tampa, Florida in 1980, assuming the position of professor at the University of South Florida College of Nursing (Sieloff, 2006). She remained active in professional organizations for many years. She died in 2008 and has been celebrated by a plethora of her colleagues (Mensik, 2008;
Mitchell, 2008; Smith, Wright, & Fawcet, 2008; Stevens & Messmer, 2008).
PHILOSOPHICAL UNDERPINNINGS OF THE THEORY
The von Bertalanffy General Systems Model is acknowledged to be the basis for King’s work. She stated that the science of wholeness elucidated in that model gave her hope that the complexity of nursing could be studied “as an organized whole”
(King, 1995b, p. 23).
MAJOR ASSUMPTIONS, CONCEPTS, AND RELATIONSHIPS
King’s conceptual system and theory contain many concepts and multiple assumptions and relationships. A few of the assumptions, concepts, and relationships are presented in the following sections. The scholar wishing to use King’s model or theory is re- ferred to the original writings as both the model and theory are complex (Figure 8-2).
Assumptions
The Theory of Goal Attainment lists several assumptions relating to individuals, nurse–client interactions, and nursing. When describing individuals, the model shows that (1) individuals are social, sentient, rational, reacting beings and (2) are control- ling, purposeful, action oriented, and time oriented in their behavior (King, 1995b).
Perception
Judgment
Action
Reaction Interaction Transaction
Action
Judgment
Perception Action Nurse
Patient
Feedback
Feedback
FIGURE 8-2A model of nurse–patient interactions. (Source: King, I. M. (1981). A theory for nursing: Systems, concepts, process, p. 61 [Reprinted with permission of Sage Publications, Inc.].)
Regarding nurse–client interactions, King (1981) believed that (1) perceptions of the nurse and client influence the interaction process; (2) goals, needs, and values of the nurse and client influence the interaction process; (3) individuals have a right to knowledge about themselves; (4) individuals have a right to participate in decisions that influence their lives, health, and community services; (5) individuals have a right to accept or reject care; and (6) goals of health professionals and goals of recipients of health care may not be congruent.
With regard to nursing, King (1981, 1995b) wrote that (1) nursing is the care of human beings; (2) nursing is perceiving, thinking, relating, judging, and acting vis-a- visthe behavior of individuals who come to a health care system; (3) a nursing situa- tion is the immediate environment in which two individuals establish a relationship to cope with situational events; and (4) the goal of nursing is to help individuals and groups attain, maintain, and restore health. If this is not possible, nurses help individ- uals die with dignity.
Concepts
King’s Theory of Goal Attainment defines the metaparadigm concepts of nursing as well as a number of additional concepts. Table 8-5 lists some of the major concepts.
Relationships
The Theory of Goal Attainment encompasses a great many relationships, many of them complex. King organized them into useful propositions that enhance the understanding
TABLE 8-5Major Concepts of the Theory of Goal Attainment
Concept Definition
Nursing A process of action, reaction, and interaction whereby nurse and client share information about their perceptions in the nursing situation. The nurse and client share specific goals, problems, and concerns and explore means to achieve a goal.
Health A dynamic life experience of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living.
Individuals Social beings who are rational and sentient. Humans communicate their thoughts, actions, customs, and beliefs through language. Persons exhibit common characteristics such as the ability to perceive, to think, to feel, to choose between alternative courses of action, to set goals, to select the means to achieve goals, and to make decisions.
Environment The background for human interactions. It is both external to, and internal to, the individual.
Perception The process of human transactions with environment. It involves organizing, interpreting, and transforming information from sensory data and memory.
Communication A process by which information is given from one person to another either directly in face-to-face meetings or indirectly. It involves intrapersonal and interpersonal exchanges.
Interaction A process of perception and communication between person and environment and between person and person represented by verbal and nonverbal behaviors that are goal-directed.
Transaction A process of interactions in which human beings communicate with the environment to achieve goals that are valued; transactions are goal-directed human behaviors.
Stress A dynamic state in which a human interacts with the environment to maintain balance for growth, development, and performance; it is the exchange of information between human and environment for regulation and control of stressors.
Source: King (1981).
of the relationships of the theory. A review of some relationships among the theory’s concepts follows:
■ Nurse and client are purposeful interacting systems.
■ Nurse and client perceptions, judgments, and actions, if congruent, lead to goal directed transactions.
■ If perceptual accuracy is present in nurse–client interactions, transactions will occur.
■ If nurse and client make transactions, goals will be attained.
■ If goals are attained, satisfaction will occur.
■ If goals are attained, effective nursing care will occur.
■ If transactions are made in nurse–client interactions, growth and development will be enhanced.
■ If role expectations and role performance as perceived by nurse and client are congruent, transactions will occur.
■ If role conflict is experienced by nurse or client or both, stress in nurse–client interactions will occur.
■ If nurses with special knowledge and skills communicate appropriate informa- tion to clients, mutual goal setting and goal attainment will occur (King, 1981, pp. 61, 149).
USEFULNESS
King’s Theory of Goal Attainment has enhanced nursing education. For example, it served as a framework for the baccalaureate program at the Ohio State University School of Nursing, where it determined the content and processes taught at each level of the program (Daubenmire, 1989). Similarly, in Sweden, King’s model was used to organize nursing education (Frey, Rooke, Sieloff, Messmer, & Kameoka, 1995). In more recent years King’s model has been useful in nursing education programs in Sweden, Portugal, Canada, and Japan (Sieloff, 2002, 2006).
King’s conceptual system is an organizing guide for nursing practice. Palmer (2006) found King’s model important to educating older adult clients in a plastic surgery practice, noting that anxiety and disruption may affect their ability to recall information. Similarly, Page (2008) found the theory of goal attainment assisted clients with sarcoidosis to cope and to remain strong in the face of this debilitating immune system disease.
Hughes, Lloyd, and Clarke (2008) found King’s model “a radical approach to process of nursing . . . in the United Kingdom” (p. 48). They found King’s transac- tion process especially suited to nursing information systems.
TESTABILITY
Parts of the Theory of Goal Attainment have been tested, and a number of research studies reported in the literature used the model as a conceptual framework. For exam- ple, recent research by Falcao, Guedes, and da Silva (2006), who employed the theory of goal attainment, studied arterial hypertension and adherence to prescribed therapy in Brazil. Khowaja (2006) tested clinical pathways in transurethral resection of the prostate at Aga Khan University Hospital in Karachi, Pakistan. Findings indicated a sig- nificant improvement in outcomes with the clinical pathway using King’s interacting systems framework. A study in South America by Souza, De Martino, and Lopes (2007) identified nursing diagnoses of hemodialysis patients with King’s conceptual system as the referent. The results of the sample of 20 patients with chronic renal
disease in dialysis centers indicated three nursing diagnoses were most prevalent: risk of infection, altered protection, and altered comfort.
PARSIMONY
The conceptual system and theory were presented together in several versions of King’s writings and remain largely as written in 1981. The theory is not parsimonious, having numerous concepts, multiple assumptions, many statements, and many rela- tionships on a number of levels. This complexity, however, mirrors the complexity of human transactions for goal attainment. The model is general and universal and can be the umbrella for many midrange and practice theories.
VALUE IN EXTENDING NURSING SCIENCE
In addition to application in practice and research described previously, King’s work has been the basis for development of several middle range nursing theories. For ex- ample, the Theory of Goal Attainment was used by Rooda (1992) to develop a model for multicultural nursing practice. King’s Systems Framework was reportedly used by Alligood and May (2000) to develop a theory of personal system empathy, and by Doornbos (2000) to derive a middle range theory of family health. Several Magnet status hospitals in the United States are using King’s conceptual system in practice (King, personal communication, October, 2005).
King’s conceptual system and theory have been used internationally in Australia, Brazil, Canada, Pakistan, and Sweden, as well as in numerous university nursing pro- grams in the United States and have provided a foundation for many research studies.
Her work has extended nursing science by its usefulness in education, practice, and re- search across international boundaries (King, 2001; Sieloff, 2006).
Roper, Logan, and Tierney: Model of Nursing Based on Activities of Living
The Activities of Living (ALs) Model as initially described by Roper in the mid-1970s has been revised several times. The model was developed from the nursing education experiences of the authors as they analyzed data from numerous hospitals and other clinical practicum locations to identify a core of nursing knowledge across specialties (Roper, Logan, & Tierney, 2000).
BACKGROUND OF THE THEORISTS
Nancy Roper spent 15 years as a principal tutor at a school of nursing in England. In the 1960s, she moved to Edinburgh, Scotland, where she was also an editor for Churchill-Livingstone Publishers. In the early 1970s she studied and achieved the M.Phil degree. Her thesis, “Clinical Experience on Nurse Education,” became the basis for her later work on the model (Roper et al., 2000, p. v). Roper has worked as a nursing research officer for the Scottish Home and Health Department and carried out assignments for the World Health Organization (WHO) European Office. She has had a distinguished career as a nurse educator and speaker.
Winifred Logan began her nursing education in Edinburgh, and she earned an M.A. in Nursing from Columbia University in 1966. She held a high-level position in the Department of Nursing Studies at the University of Edinburgh for 12 years in the