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joumal of Advanced Nursing. 1989, 14, 755-
Modelling and role-modelling: integrating
nursing theory into practice
Kathleen Kelley Walsh MS RN Director of Nursing (Resource Development), St Joseph's Hospital Flint. Michigan
Terry M. VandenBosch MS RN CS Nurse Specialist in Research, Catherine McAuley Health Center, and Adjunct Assistant Professor. The University of Michigan School of Nursing
and Susan Boehm PhD RN FAAN Associate Professor of Nursing, The University of Michigan School of Nursing. Ann Arbor, Michigan, USA
Accepted for publication I October 19&
WALSH KELLEY K., VANDENBOSCH T.M.& BOEHM S. (1989) Joumal of Advanced Nursing 14, 755- Modelling and role-modelling: integrating nursing theory into practice This article contrasts two clinical cases using a relatively new paradigm and theory, modelling and role-modelling. The concepts and linkages from modelling and role-modelling are presented and are the basis for analysing the outcomes of two patients. The case study approach communicates an understanding of the theory modelling and role-modelling and assists nurses to develop expertise in its use.
INTRODUCTION
Nursing is a profession which is simultaneously art and science. What makes our job of enhancing people's health both continually exciting and sometimes elusively frustrat- ing is this fusion of art and science. If our goal is to assist each client in their growth as people, we need to cultivate both our scientific foundations for action and our artful performance of them. We can heighten our ability to prac- tise both the art and science of nursing if our work is grounded in theory. The raw materials a nursing theorist works with are the concepts which our profession is con- cemed with: people, nursing, health and environment. These concepts are linked together and the resulting re- lationships are analysed and made explicit. Pre-existing facts and ideas are combined to look at the world in a new way. How a theory illustrates the world can then be tested to see how well it fits with reality. One fairly new theory has drawn together previously developed knowledge and added new ideas and ways of Correspondence: Kathleen Kelley VJalsh. 1217 Miatne, Flint. MI 48503, USA.
looking at nursing. It describes the scientific bases useful for our profession and our unique contribution to clients via the art and science of nursing practice. The theory, called modelling and role-modelling, was developed by Helen Erickson, Mary Ann Swain, and Evelyn Tomlin (Brickson et al. 1983). It is a complex theory because of the integration of several theories and ways of looking at man. Although the theory contains many levels of meaning, its basic con- cepts make sense, and can be readily applied to nursing practice. This article presents some of the concepts and linkages of modelling and role-modelling through case studies of two individuals.
C A S E N U M B E R l
Jim is a young man in his late twenties who has the con- genital bleeding disorder of haemophilia A (factor VIII deficiency). Like most severe haemophiliacs he has suffered from numerous spontaneous and trauma-induced episodes of bleeding into his joints and muscles. The repeated intemal bleeds have eroded the lining of several of his
K. Kelleu Wahh et al.
Informotion Esteem/self -esteem Love and belonging Sofely ond security Physiologicol Figure 1 Maslow's hierarchy of needs.
joints, resulting in arthritis and reduced mobility. The influence of haemophilia extends beyond the physical realm. Modelling and role-modelling (M & RM) states people are holistic. Jim's haemophilia, therefore, was ex- perienced by and caused effects on his total being. Using M & RM to explore these effects can give us insight into Jim's world. The theory emphasizes the importance of human development, and adds new links to pre-existing theories. This case study will illustrate some of the concepts and linkages explained in M & RM. The theories of Abraham Maslow (1968, 1970) and Eric Erikson {Erickson 1963) are important building blocks for M & RM. Diagrams of these levels and stages are included in Figures 1 and 2. M & RM links Maslow's theory of human needs with Erickson's theory of human develop- ment. The degree to which developmental tasks are resolved is dependent on the degree to which human needs are satisfied (Erickson et al. 1983). Integrating the concep- tual frameworks of Maslow and Erickson facilitates our understanding of how people grow to be both alike and different. Eor example, Erickson (1963) identified the initial con- flict every infant faces as they enter a strange new world as trust versus mistrust. Like other infants Jim took in nourish- ment when hungry, and thus leamed his mother could be trusted to provide for his needs. In Erickson's terms he was building the strength of trust. Having his basic physical needs met was helping him to feel safe and secure accord- ing to Maslow's heirarchy. Synthesizing the two theories tells us that having basic needs fulfulled provides Jim with the security and sustenance to work on the developmental task at hand. We might ask if the haemophilia had particular influences on Jim's infancy. Like many haemophiliacs, Jim was free of bleeding into joints and muscles for the first several months of his life. Physically he was unaffected for almost a year, except for excessive bleeding during circum- cision. This episode led to testing which substantiated the
diagnosis of haemophilia. His mother was then informed she carried the genetic trait which her son had inherited as haemophilia. This information impacted her basic need fulfilment, and therefore her ability to cope. She reacted with grief, guilt, and a determination to fight the haemo- philia and protect her son. Jim's physiologic needs were well attended to during infancy and throughout his life. Nevertheless, his mother's inability to cope adaptively with her feelings about having a son with haemophilia profoundly affected Jim, beginning in infancy. Unresolved morbid grief over transmitting the haemophilia impacted her ability to nurture Jim's development of strengths. Within a few months babies develop the physical mobility to actively explore the environment, and simul- taneously begin learning that they are a separate individual. Like all babies, as Jim began to realize he was separate from mother he would move away from her for a few minutes, retuming periodically for her assurance. M & RM labels the need to be both autonomous and dependent 'affiliated- individuation'. This concept describes the importance and coexistence of both the T and 'we' states of being. That is, all people need to experience freedom and acceptance in both states, being separate and being linked to others. This connection to others is our affiliation or attachment. A second theoretical linkage of M & RM is between this attachment to an object (a person, or in some cases an idea or thing) and basic need satisfaction. The degree to which needs are met by attachment depends on the availability of the object (i.e. mother) and the amount of comfort and security as opposed to threat and anxiety which it pro- vides. Thus, object-loss results in basic need deficits. Life entails ongoing losses, some of which are never completely resolved. The more important the object to basic need fulfilment the more likely that its loss will cause unresolved morbid grieving. With these concepts in mind let us retum to examining the stages of human development. Erickson's second stage involves a conflict which impacts an individual's sense of affiliated-individuation. Recall that affiliated-individuation is an intrapsychic phenomena in which the person perceives they are simul- taneously close to and yet separate from significant others. The person perceives freedom and acceptance whether de- pendant on or autonomous of the significant other. At Erickson's second developmental level, the child is grap- pling with autonomy versus doubt. The conflict involves recognizing self as separate from mother by exercising independence versus parental attempts to control or chan- nel behaviour in socially accepted ways. One important activity of this stage of development is toilet training. The child leams they have control over their body wastes, and
Kelleu Wahh ci al.
Equilibrium: Adaptive/ malQdoptive Stressor ^ Arousal
Impoverishment
Figure 3 Adaptive potential assessment model.
Equilibrium
Stressor
Stress Arousol -•- Impoverishment Figure 4 An illustration of the dynamic relationship among the states of the adaptive potential assessment model.
relationships with others. Without correcting this funda- mental need to feel in control, Jim's potential for healthy growth is stunted. Once again, the doubt and guilt are carried over when Jim reaches the next developmental level. His poor resol- ution of the previous task results in a higher residual of negative effects, and a lower residual of positive effects for that developmental task. According to Erickson, the basic strength that emerges from autonomy versus shame and doubt is self-control. Although Jim did not completely resolve this task, he did develop some strengths. Humour was a strength he developed which gives him control in some situations. One way Jim reveals his feelings and his sense of himself is through his use of a wry form of humour. On the other hand, the type of humour he chooses often reflects his low self-esteem and an inability to express feel- ings. Space limitations prohibit our walking through each of Erikson's stages and Maslow's levels in this article. Examine the chart and think for youself about how Jim is equipped to deal with the remaining developmental stages. Human beings are complex. Identifying enduring characteristics from development and basic need satisfac- tion provides some information in understanding human behaviour. Another mode! used in M & RM draws from Selye's (1974) general adaptation syndrome and Engel's (1962) responses to stressors theories. The authors of M &
RM synthesized these two and developed the adaptive potential assessment model (APAM) to assist in predicting an individual's potential to cope with stress (see Figures 3 and 4). Self-care knowledge, self-care resources and self- care action are important in the potential to mobilize re- sources for managing stressors (Erickson 1984). M & RM asserts 'At some level a person knows what has made him or her sick... or interfered with growth and what will help heal and optimize his or her effectiveness and promote his or her growth. This is the essence of self-care knowledge (Erickson et al. 1983). The strengths people develop and their support systems and social networks form the self- care resources they use to cope with the stresses of life. Self-care resources have both enduring characteristics and are fluid. They respond to the continual changes we are faced with in life. Using self-care knowledge and our ability to mobilize our resources is our self-care action. The third linkage in M & RM states, 'An individual's potential for mobilizing resources — the person's state of coping according to APAM — is directly associated with the person's need satisfaction level' (Erickson et al. 1983). Nu- merous basic need deficits limit potential for mobilizing self-care resources. The APAM model depicts three cate- gories or states. Each state represents a different potential for mobilizing resources at that point in time: arousal, equi- librium (adaptive or maladaptive), and impoverishment. Physiologic and psychologic data have been gathered to substantiate the three main states of adaption potential the model proposes (Erickson & Swain 1962). Assisting people in replenishing, developing and using their resources for movement in a healthier direction is a prime nursing responsibility.
The APAM is used when assessing an individual's potential for coping at a particular moment in time. It indi- cates their state. Currently Jim is in an impoverished state according to APAM. His coping abilities and strengths are limited by his basic need deficit. Two years ago he sustained serious injuries in an automobile accident and became even more withdrawn. The level of depression was such that some basic self-care activities were not per- formed. The change in his ability to cope is described in terms of the APAM model as a move from maladaptive equilibrium to impoverishment. Since the APAM reflects the current coping state, it must be continually reassessed. Jim has been moving back and forth between maladaptive equilibrium and impoverishment during the past 2 years.
C A S E N U M B E R T W O
Michael is in his late twenties and also has severe haemo- philia A, He experienced events in his infancy and early
Modelling and role-modelling
childhoodwhichclosely paralleled Jim's. Like Jim he devel- impoverished state will influence his ability to fight the
oped trust and had his basic needs for safety and security virus. met as an infant. Similarly, as he gained mobility, bleeding Michael's life has a different focus than Jim's. His episodes began impacting his life. The completely unpre- energieshavebeendirectedat establishing control through dictable occurrence of joint haemorrhages which suddenly action. He became addicted to narcotics during a time of interrupted activities, plans and comfort robbed Michael of severe pain when several operations were required to re- feeling in control of himself. To this point Jim and Michael place a joint and repair resulting complications. Disgusted had similar experiences. The difference was with the devel- by the side effects and lack of control the narcotic addiction opmental task of initiative versus guilt. Michael's parents imposed, Michael quit cold turkey. This extremely hard promoted safety but also gave him the freedom to take experience challenged his coping abilities enormously, and risks. He was allowed to try things out, test himself, and he pulled through. The sense of purpose, direction, and leam from his actions. For example, he leamed to operate self-esteem he gained in the initiative versus guilt stage farm equipment, and was allowed to run and play with the assisted him in this situation. Lack of control over severe neighbourhood children. Michael still has difficulty with joint dysfunction and pain are a continuing reality, and control issues, however his strength of taking initiative sometimes he despairs over his situation. Yet he retains his without oppressive guilt is a resource. strong sense of who he is. The intemal strengths Michael developed, coupled with Currently Michael is completing his PhD. He finds a supportive family, suggest his adaption potential is differ- focusing his attention on intellectual pursuits helps de- ent from Jim's. He continues to have positive expectations crease the perception of pain from his arthritic joints. and goals for his future. Using the APAM model we see he Michael struggles with the issue of how close to allow is in equilibrium. When stressors arouse him he mobilizes other persons. He openly describes his hesitancy to his resources and uses them effectively. In contrast, become involved with a woman because of his uncertain when Jim faces significant stress he lacks the strengths to fiiture. Prior to 2 years ago he had girlfi-iends, but since that maintain equilibrium and instead sinks further into time his concem over not exposing anyone to AIDS via impoverishment. sexual contact has resulted in a decision not to become involved with women in an intimate way. So developmen- tally we see he is struggling with the stage of intimacy PRESENT SITUATION FOR MICHAEL AND versus isolation. Although he knows of his exposure to JIM HIV, presently Michael shows no signs of immune system impairment. Civen these similarities and differences what is each man's life like today? The situations of each are not surprising. Both continue to struggle with controllssues as they face ^^opE^LING AND ROLE-MODELLING the stages of life presented to them. But the,rstmggles are ^^^ ^^^ NURSING PROCESS different trom one another. Jim never left home, found employment, or developed The central concept of M & RM states the nurse must intimate relationships with anyone other than his immedi- understand a client's world. The nurse models his world ate family. The adolescent conflict of identity versus role as it exists for him. Modelling contains both the art and dif^sion is one Jim has not yet resolved. In fact, he seems to science of nursing. It combines scientific aggregation and lack the energy necessary to deal with the issue of who he analysis of data with the image and understanding of the is. His self-esteem is very low and he is depressed. His world from the client's view. When one sees the world as interests, when he addresses them, are solitary pursuits, the client does, then one can role-model.'Role-modelling is Occasionally he paints (objects not people), and he dis- the facilitation of the individual in attaining, maintaining, plays affection towards his cat. He stays in his room, com- or promoting health through purposeful interventions' municating with others only when necessary. Presently he (Erickson et al. 1983). Role-modelling is science because it is incapable of choosing intimacy over isolation. His health draws on the theoretical bases of nursing practice. It is art has steadily deteriorated over the past few years. Like most because the nurse plans and intervenes within the person's severe haemophiliacs he has been exposed to the causative own unique model. The bedrock of the nurse's action is agent in AIDS, the HIV virus. Jim is beginning to have unconditional acceptance, positive regard, facilitation, and signs and symptoms that the virus is altering his immune nurturance of the individual. These attitudes permeate the system. Although not yet diagnosed with AIDS, his nurse's approach if the relationship is successfuL
Modelling and role-modelling
Table 1 Relationships among intervention goals, principles, and aims for intervention
Intervention goal (^) Principle Aim
- Develop a trusting and functional re- lationship between yourself and your client
- Facilitate a self-projection that is futuristic and positive
- Promote affiliated individuation with the minimum degree of ambivalence possible
- Promote a dynamic, adaptive, and holistic state of health
- (a) Promote (and nurture) coping mechan- isms that satisfy basic needs and permit growth-need satisfaction (b) Facilitate congruent actual and chrono- logical developmental stages
The nursing process requires that a trust- ing and functional relationship exists between nurse and client
Affiliated-individuation is contingent on the individual's perceiving that he or she is an acceptable, respectable, and worth- while human being
Human development is dependent on the individual's perceiving that he or she has some control over life (while concurrently sensing a state of affiliation)
There is an innate drive toward holistic health that is facilitated by consistent and systematic nurturance
Human growth is dependent on satisfac- tion of basic needs and is facilitated by growth-need satisfaction
Build trust
Promote client's positive orien- tation
Promote client's control
Affirm and strengths
promote client's
Set mutual goals that are health- directed
frustrating situations where our efforts did little to effect a positive outcome. M & RM provides the theoretical foundation to understand these experiences. It also pro- vides a scientific base to propel our nursing practice.
Acknowledgement
Figures 1, 2, 3, 4 and Table 1 are reprinted with permission from Erikson, Tomlin and Swain Modeling and Role- Modeling: A Theory and Paradigm for Nursing. Prentice-Hall Inc., Englewood Cliffs, New Jersey, 1983.
References
Campbell J., Finch D., Allport C, Erickson H.C. & Swain M.A. (1985) A theoretical approach to nursing assessment. Advanced Nursing 10, 111-115.
Engel G.S. (1962) Psychological Development in Health and Disease. Saunders, Philadelphia. Erikson E. (1963) Childhood and Society. W.W. Norton, New York. Erickson H.C. (1984) Self-care knowledge: relations among the concepts support, hope, control satisfaction with daily life and Physical Health Status. Unpublished doctoral thesis. University of Michigan. Erickson H.C, Tomlin E.M. & Swain M.A.P. (1983) Modeling and Role-Modeling: A Theory and Paradigm for Nursing. Prentice- Hall, Englewood Cliffs, New Jersey. Erickson H. & Swain M.A. (1982) A model for assessing potential adaptation to stress. Research in Nursing and Health 5, 93-101. Maslow A.H. (1968) Toward a Psychology of Being, 2nd edn. D. Van Nostrand, New York. Maslow A.H. (1970) Motivation and Personality, 2nd edn. Harper & Row, New York. Selye H. (1974) Stress Without Distress. Lippincott, Philadelphia.
