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Wound management: Using Levine'sconservation model to guide practice

Article in Ostomy/wound management · September 2006

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Name of Submitting Author:

Matthew Leach

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Publication Information:

Title of Journal Article:

Woun

d Management: Using Levine's Conservation Model to Guide Practice

Name of Journal:

Ostom

y Wound Management

Publisher:

H M P

Communications, LLC

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2006 Vol & Issue No:

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52, 8 Page Numbers:

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Matthew J. Leach; BN(Hons), ND, PhD

L

evine's

conservation model, initially construct-

ed as a teaching framework for medical-surgical

nursing,2 is based on the belief that nursing

interventions should be aimed at conserving func-

tion.3'4 Roberts and Taylor5 and Fawcett4 state that

nurses currently use Levine's model in practice by act-

ing to preserve Elient energy and integrity —

encour-

aging bed rest, maintaining pressure area care, and

preserving privacy. To clarify the relationship between

Levine's conservation model and wound manage-

ment, each of the four principles of Levine's model

will be examined. To enhance understanding of the

context in which Levine's conservation principles are

presented, the underlying assumptions, definitions,

and limitations of the model are discussed.

Levine's

conservation model' consists of four major

principles. The principles are defined as follows:

• conservation of energy

balancing

energy output

and input to avoid excessive fatigue4

• conservation of structural integrity —

maintaining

or restoring the body structure by preventing phys-

ical breakdown and promoting healing5

•

conservation of personal integrity

maintaining

or restoring the patient's sense of identity and self-

worth5 and. .

. acknowledging

uniqueness4

•

conservation of social integrity —

fostering aware-

ness that the patient. .

.

is

a social being who inter-

acts with others5 in their social environment.

Each of these principles —

the

reduction in energy

expenditure, the improvement in structural, personal

74

OstomyWound Management

Wound Management: Using

Conservation Mod&

Gifide Practice

Effective wound management is needed not only to generate positive patient outcomes, but also to reduce healthcare expenditure and

demand on healthcare services.

Implementing

Levine's four-principled conservation model — which addresses conservation of energy,

structural integrity, personal integrity, and social integrity — can provide clinical and financial benefits, as illustrated in the care of venous

leg ulceration. Using Levine's model as a theoretical framework for wound management also can contribute to good nursing practices,

enhancing a care approach that embraces wholeness and health along with cost effective care. Understanding how Levine's model can

improve patient care is further elucidated by discussing each of the principles in relation to wound management.

KEYWORDS: wounds, nursing care, nursing theory

Ostomy/ Wound Management 2006;52(8):74-80

Dr. Leach is Program. Director, University of South Australia, and a Registered Nurse, Royal District Nursing Service South

Australia. Please address correspondence to: Matthew J. Leach, BN(Hons), ND, PhD, School of Health Sciences, University of

South Australia, North Terrace Adelaide SA 5000; email: [email protected].


5/9

is

compatible with wound

for

many

Many nursing

scientif-

e, as a theoretical

nursing

Each of Levine's principles addresses the concept of

. .

defend,

sustain, maintain, and define the integrity of

for which it functions. Conservation can be

stability of the organism through .

.

.multiple,

.

The

universal concept of conservation also

describes the way complex systems are able to function

enged. 2 Therefore, conserva-

it

is only when the individual can no longer

Despite the comprehensiveness and wide applica-

to health; thus, nursing

interventions under Levine's theory have a present

and short-term focus and do not support health pro-

motion principles, even though health promotion is

an essential component of current nursing practice.'3

Thus, Levine's model does not add support to the use

of interventions that prevent ulcer occurrence and

reoccurrence in susceptible individuals.

Assumptions

An

underlying assumption of Levine's model is that

the nurse creates an environment in which healing can

occur and adaptation is promoted.'4 Individuals are con-

stantly interacting with an external environment; conse-

quently, they adapt and preserve their energy and

integrity in accordance with that environment. However,

when an individual can no longer maintain that energy

and integrity, health is adversely affected.5 This environ-

merit pertains not only to the external milieu, but also to

the individual's internal environment. For instance,

treating VLU externally with topical dressings, as well as

modifying the physiology of the venous

internal-

ly with external compression or venotonic agents, allows

the nurse to create an environment conducive to VLU

healing. Although Levine does not explicitly relate the

four conservation principles to the environment,'5 it

may be through effective wound care that nursing can

conserve energy and skin integrity'4 and as such lend

support to Levine's conservation model.

Conservation of Energy

Energy conservation is based on the belief that

patient activity is dependent on energy balance, that

illness increases energy demand, and that increased

August 2006 Vol. 52 Issue &

75

Wound Management

KEY POINTS

Theoretical frameworks help explain relationships

between concepts, observations, facts, and theories.

•

The author uses a conservation model to illustrate

potential relationships between venous ulcer care out-

comes and optimal patient well being.

•

This model may provide a basis for making wound

management choices and facilitate research to help

strengthen the evidence base of wound care practice.


6/9

energy demand can be measured

by the level of

fatigue.4 Even the most basic nursing procedures,

including rest and adequate nutrition,4 utilize the

principle of conserving energy.2

Nurses need to understand energy conservation as a

universal law applicable to all animate and inanimate

entities.'2 To maintain life activities, energy levels need to

be balanced and constantly renewed.2 Nurses often are

the people in contact with individuals in whom healing

and ageing challenge the ability to conserve energy.2

Therefore, nurses not only help conserve energy through

a reduction in activity, but

they also ensure energy

expenditure remains within the ..

. individual's

capabil-

ity, safety, and comfort. 4

In a normal healthy state, the body intentionally

utilizes a minimum level of energy to conserve ener-

gy. When the body's system

is disturbed, however,

energy is utilized and negative feedback systems are

activated until a normal state is obtained.3 For exam-

ple, the inflammatory and immune systems utilize

energy in order to restore homeostasis and promote

healing.3 In sick persons, energy expenditure often

becomes evident as the process of healing unfolds.

The unwell individual frequently manifests lethargy

and weakness, which subsequently reduces activity

and unnecessary energy expenditure; thus, energy can

be conserved and focused on healing.3 This energy

conservation also preserves functional integrity.'2

Nurses are in a position to conserve patient energy by

reducing the duration of leg ulceration. For instance,

nurses may select wound treatments

that restore skin

/ integrity

and minimize energy expenditure, ultimately

resulting in earlier discharge, reduced healthcare expen-

diture, and less emotional

However, in order to

assess the energy-conserving effect of

wound treat-

ments, energy needs to be measurable.

Levine3 claims that energy is measured in everyday

nursing practice via body temperature, blood gases,

pulse, and blood pressure; fluctuations determine

either energy expenditure or conservation. However,

it is unclear whether these aforementioned measure-

ments are valid and reliable indicators of changes

in

energy levels. Wound healing, on the other

hand, may

be an effective measure of energy conservation

because the conservation of structural integrity can-

not be maintained without conserving energy.

By

76

OstomyWo,,ud Management

conserving energy, the integrity of the individual ulti-

mately can be defended.'7

Conservation of Structural Integrity

Conserving structural integrity

is based on the

rationale that changes in structure ultimately affect

function, that structural integrity may be compromised

by pathophysiological processes, and that healing

restores structural integrity.4 Therefore, to regain struc-

ture and function, the body needs to restore

structural

integrity through repair and healing.'

Healing restores continuity and form through cell

replication; hence, conserving structural integrity.'2

Early detection and management of disease by nurses

reduces tissue destruction, which also conserves struc-

tural integrity.2 Specific nursing interventions that con-

serve structural integrity include

anatomic positioning

and range-of-motion exercises to prevent musculoskele-

tal deformities,'4 pressure area care to prevent pressure

ulcers, and early mobilization and chest physiotherapy

to prevent complications of bed rest.3 In

the example of

VLU; compression therapy may restore skin and venous

integrity. Through this conservation of structural

integrity, an individual can feel intact and whole and

subsequently manifest improvements in self-identity.'7

conservation of Personai Integrity

Conserving personal integrity is based on the belief

that individuals require privacy, are responsible for their

own decisions, and illness and

hospitalization compro-

mise personal integrity, self-identity, and self-respect.4

Nursing interventions aimed at conserving personal

integrity include protecting and respecting patient pri-

vacy, possessions, and defense

mechanisms4 and sup-

porting personal choice.2 The conservation of personal

integrity, therefore, aims to protect personal identity.1

Levine'2 argues that the fundamental goal of the nurse

is to provide knowledge and support so the individual

can resume a private independent

life. Personal integri-

ty, including self-identity and pride, is

compromised

when an individual becomes dependent.

Therefore,

interventions aimed at regaining individual independ-

ence ultimately conserve personal

integrity. The princi-

ple of conserving personal integrity is interdependent

with the principles of conserving energy and structural

integrity Without sufficient energy and, in the case

of


7/9

(

Venous leg ulceration

)

.1

Compression bandaging

(venous) environment

Primary dressing

eased physical and

energy expenditure

Conservation of structural integrity

depression,

and negative

Conservation of

integrity

Figure 1. Conceptual map outlining the relationship

effective wound management and positive patient outcomes through

Levine's

Conservation Model.

wound care, intact skin integrity, dependence on other

individuals is almost certain. Therefore, interventions

/that conserve energy and restore structural integrity

will arguably re-establish independence. Thus, dress-

ings and interventions that hasten ulcer healing

and

ultimately shorten ulcer duration may reduce client

dependency on others. Given that individuals with

VLU also experience depression, helplessness, anxiety,

and negative self-image,'82° effective wound manage-

ment also may restore patient self-worth and person-

al integrity.

Conservation

of Social Integrity

Conserving

social integrity is based on the premise

that individual life has meaning only in the context of

social life, individual behavior is influenced by the

ability to relate to various social groups, families often

78


are affected by an individual's

illness, and hospitaliza-

tion results in social isolation.4

Social factors such as family, friends, culture, reli-

gion, education, and socio-economic status all

deter-

mine how an individual defines him/herself.3 7 Thus, a

loss of these factors (eg, work, income, or family) may

arguably weaken an individual's social integrity.

Therefore, nursing strategies aimed at conserving

social integrity may include providing family support

and education, promoting family participation

in

care, and fostering patient

interaction with others.3

A change from an independent role to dependency

on the healthcare system creates

conflict for the indi-

vidual.3 For instance, patients with VLU often become

immobile,2 embarrassed, and socially, isolated and

experience financial difficulty.'8 By facilitating wound

healing, the nurse can indirectly restore the patient's

C

)

)

wound environment

Ulcer healing

)

(

)

C

Conservation of

energy

isolation,

and financial

C

Conservation of

social integrity

)


8/9

Furthermore, by decreasing VLU duration and

recur-

rence, effective wound management may inadvertent-

ly reduce healthcare expenditure and

demand on

healthcare services.

Nursing Implications

According to Levine, a nurse

can implement either

supportive or therapeutic interventions. Supportive

interventions prevent deterioration of health;

thera-

peutic interventions promote healing

and restore

health.'5 With regard to VLU

management, it is argued

that current practice, excluding

compression therapy,

is simply semi-therapeutic

— ie,

only the external

wound environment is supported without

imple-

menting therapy intended for internal effect.

In fact,

few dressings have been

proven to enhance venous

ulcer healing.2223 The exception is

compression thera-

py. Some evidence of efficacy is available,2' which

may

explain why this therapy prevails

as the primary treat-

ment of choice for VLU.25-2 One

reason why compres-

sion therapy may be effective is that

it adequately

addresses the underlying etiology of the

wound29

in

particular, the pathological

processes that lead to

venous

Hence, it

is argued that the

combination of appropriate primary dressings

and

compression therapy will provide

a complete thera-

peutic solution to VLU

management; subsequently,

increasing the rate of wound healing.

Levine's conservation model provides

a thoughtful

management

conse-

and quality

effective wound

conservation princi-

The conservation principles address

the integrity of

to death. Every activity

works with-

on it.

abilities,

life experi-

and desires of the self who makes the choices.

to which the individual belongs.'

References

1.

Levine ME. The conservation principles:

a model for

health. In: Schaefer KM, Pond JB (eds).

Levine's

Conservation Model: A Framework for Nursing Practice.

Philadelphia, Pa: F.A. Davis Company;1991.

2.

Artigue GS, Foli KJ, Johnson T, et al. Four conservation

principles.

In: Marriner-Tomey A (ed). Nursing

Theorists and Their Work, 3rd ed.

St. Louis, Mo:

Mosby; 1994.

3.

Levine ME. The conservation principles of nursing:

twenty years later. In: Riehl-Sisca J (ed). Conceptual

Models for Nursing Practice, 3rd ed. Norwalk, Conn:

Appleton & Lange;1989.

4.

Fawcett J. Analysis and Evaluation of Conceptual Models

of Nursing, 3rd ed.

Philadelphia, Pa:

F.A. Davis

Company; 1995.

5.

Roberts K, Taylor B. Nursing Research Processes: An

Australian Perspective. South Melbourne, Australia:

Nelson Thomson Learning;1999.

6.

Cox RA. A tradition of caring. In: Schaefer KM, Pond

JB (eds). Levine's Conservation Model: A Framework for

Nursing

Practice.

Philadelphia,

Pa:

RA.

Davis

Company;1991.

7.

Foreman MD. In: Schaefer KM, Pond JB (eds). Levine's



8.

Pasco A, Halupa D. Chronic pain management. In:

Schaefer KM, Pond JB (eds). Levine's Conservation

Model: A Framework for Nursing Practice. Philadelphia,

Pa: RA. Davis Company;1991.

9.

Pond JB. Ambulatory care of the homeless. In: Schaefer

KM, Pond JB (eds). Levine's Conservation Model: A

Framework for Nursing Practice. Philadelphia, Pa: F.A.

Davis Company; 1991.

10. Roberts JE, Fleming N, Giese D. Perineal integrity. In:

Schaefer KM, Pond JB (eds). Levine's Conservation

Model: A Framework for Nursing Practice. Philadelphia,

Pa: F.A. Davis Company;1991.

11. Schaefer KM. Care of the patient with congestive heart

failure.

In: Schaefer KM, Pond JB (eds). Levine's



12. Levine ME. Conservation and integrity. In: Parker ME

(ed). Nursing Theories in Practice. New York, NY:

National League for Nursing;1990.

13. Schaefer KM, Pond JB. Levine's conservation model

as

a

guide

to

nursing

practice.

Nurs

Sci

Q.

1994;7(2):53—54.

14. Meleis Al. Theoretical Nursing: Development and

Progress, 3rd ed. Philadelphia, Pa: Lippincott; 1997.

15. Leonard MK, Myra Estrin Levine. In: George JB (Ed).

August 2006

Vol. 52

Issue 8

79

ability

to

be

mobile, productive,

and

social.

Every activity is a product of the dynamic social

systems

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Documents

Wound Management - Using Levines Conservation Model - OWM