Myra Estrin Levine
1921 to 1996
“Nursing is human interaction”
(Levine, 1973, p. 1).
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Credentials and background of the theorist*
Myra Estrin Levine enjoyed a varied career. She was a private duty nurse (1944), a civilian nurse in the U.S. Army (1945), a preclinical instructor in the physical sciences at Cook County (1947 to 1950), director of nursing at Drexel Home in Chicago (1950 to 1951), and surgical supervisor at both the University of Chicago Clinics (1951 to 1952) and the Henry Ford Hospital in Detroit (1956 to 1962). Levine worked her way up the academic ranks at Bryan Memorial Hospital in Lincoln, Nebraska (1951), Cook County School of Nursing (1963 to 1967), Loyola University (1967 to 1973), Rush University (1974 to 1977), and the University of Illinois (1962 to 1963, 1977 to 1987). She chaired the Department of Clinical Nursing at Cook County School of Nursing (1963 to 1967) and coordinated the graduate nursing program in oncology at Rush University (1974 to 1977). Levine was director of the Department of Continuing Education at Evanston Hospital (March to June 1974) and consultant to the department (July 1974 to 1976). She was adjunct associate professor of Humanistic Studies at the University of Illinois (1981 to 1987). In 1987, she became a Professor Emerita, Medical Surgical Nursing, at the University of Illinois at Chicago. In 1974, Levine went to Tel-Aviv University, Israel, as a visiting associate professor and returned as a visiting professor in 1982. She also was a visiting professor at Recanati School of Nursing, Ben Gurion University of the Negev, at Beer Sheva, Israel (March to April, 1982).
Levine received numerous honors, including charter fellow of the American Academy of Nursing (1973), honorary member of the American Mental Health Aid to Israel (1976), and honorary recognition from the Illinois Nurses Association (1977). She was the first recipient of the Elizabeth Russell Belford Award for excellence in teaching from Sigma Theta Tau (1977). Both the first and second editions of her book, Introduction to Clinical Nursing (Levine, 1969a; 1973) received American Journal of Nursing Book of the Year awards, and her book, Renewal for Nursing, was translated into Hebrew (Levine, 1971a). Levine was listed in Who’s Who in American Women (1977 to 1988) and in Who’s Who in American Nursing (1987). She was elected fellow of the Institute of Medicine of Chicago (1987 to 1991). The Alpha Lambda Chapter of Sigma Theta Tau recognized Levine for her outstanding contributions to nursing in 1990. In January 1992, she was awarded an honorary doctorate of humane letters from Loyola University, Chicago (Mid-Year Convocation, Loyola University, 1992). Levine was an active leader in the American Nurses Association and the Illinois Nurses Association. After her retirement in 1987, she remained active in theory development and encouraged questions and research about her theory (Levine, 1996).
A dynamic speaker, Levine was a frequent presenter of programs, workshops, seminars, and panels, and a prolific writer regarding nursing and education. She also served as a consultant to hospitals and schools of nursing. Although she never intended to develop theory, she provided an organizational structure for teaching medical-surgical nursing and a stimulus for theory development (Stafford, 1996). “The Four Conservation Principles of Nursing” was the first statement of the conservation principles (Levine, 1967a). Other preliminary work included “Adaptation and Assessment: A Rationale for Nursing Intervention,” “For Lack of Love Alone,” and “The Pursuit of Wholeness” (Levine, 1966b, 1967b, 1969b). The first edition of her book using the conservation principles, Introduction to Clinical Nursing, was published in 1969 (Levine, 1969a). Levine addressed the consequences of the four conservation principles in Holistic Nursing (Levine, 1971b). The second edition of Introduction to Clinical Nursing was published in 1973 (Levine, 1973). After that, Levine (1984) presented the conservation principles at nurse theory conferences, some of which have been audiotaped, and at the Allentown College of St. Francis de Sales (now DeSales University) Conference.
Levine (1989) published a substantial change and clarification about her theory in “The Four Conservation Principles: Twenty Years Later.” She elaborated on how redundancy characterizes availability of adaptive responses when stability is threatened. Adaptation processes establish a body economy to safeguard individual stability. The outcome of adaptation is conservation.
She explicitly linked health to the process of conservation to clarify that the Conservation Model views health as one of its essential components (Levine, 1991). Conservation, through treatment, focuses on integrity and the reclamation of oneness of the whole person.
Levine died on March 20, 1996, at 75 years of age. She leaves a legacy as an administrator, educator, friend, mother, nurse, scholar, student of humanities, and wife (Pond, 1996). Dr. Baumhart, President of Loyola University, said the following of Levine (Mid-Year Convocation, Loyola University, 1992):
Mrs. Levine is a renaissance woman …. who uses knowledge from several disciplines to expand the vision of health needs of persons that can be met by modern nursing. In the Talmudic tradition of her ancestors, [she] has been a forthright spokesperson for social justice and the inherent dignity of [the] human person as a child of God (p. 6).
From Beland’s (1971) presentation of the theory of specific causation and multiple factors, Levine learned historical viewpoints of diseases and learned that the way people think about disease changes over time. Beland directed Levine’s attention to numerous authors who became influential in her thinking, including Goldstein (1963), Hall (1966), Sherrington (1906), and Dubos (1961, 1965). Levine uses Gibson’s (1966) definition of perceptual systems, Erikson’s (1964) differentiation between total and whole, Selye’s (1956) stress theory, and Bates’ (1967) models of external environment. Levine was proud that Rogers (1970) was her first editor. She acknowledged Nightingale’s contribution to her thinking about the “guardian activity” of observation used by nurses to “save lives and increase health and comfort” (Levine, 1992, p. 42).
Use of empirical evidence
Levine (1973) believed that specific nursing activities could be deducted from scientific principles. The scientific theoretical sources have been well researched. She based much of her work on accepted science principles.
Introduction to Clinical Nursing is a text for beginning nursing students that uses the conservation principles as an organizing framework (Levine, 1969a, 1973). Although she did not state them specifically as assumptions, Levine (1973) valued “a holistic approach to care of all people, well or sick” (p. 151). Her respect for the individuality of each person is noted in the following statements:
Ultimately, decisions for nursing interventions must be based on the unique behavior of the individual patient …. Patient centered nursing care means individualized nursing care …. and as such he requires a unique constellation of skills, techniques, and ideas designed specifically for him (1973, p. 6).
Schaefer (1996) identified the following statements as assumptions about the model:
Levine (1973) stated the following about nursing:
Nursing is a human interaction (p. 1). Professional nursing should be reserved for those few who can complete a graduate program as demanding as that expected of professionals in any other discipline …. There will be very few professional nurses (Levine, 1965, p. 214).
Nursing practice is based on nursing’s unique knowledge and the scientific knowledge of other disciplines adjunctive to nursing knowledge (Levine, 1988b), as follows:
It is the nurse’s task to bring a body of scientific principles, on which decisions depend, into the precise situation that she shares with the patient. Sensitive observation and the selection of relevant data form the basis for her assessment of his nursing requirements.
The nurse participates actively in every patient’s environment and much of what she does supports his adjustments as he struggles in the predicament of illness (Levine, 1966b, p. 2452).
The essence of Levine’s theory is as follows:
…. when nursing intervention influences adaptation favorably, or toward renewed social well-being, then the nurse is acting in a therapeutic sense; when the response is unfavorable, the nurse provides supportive care (1966b, p. 2450).
The goal of nursing is to promote adaptation and maintain wholeness (1971b, p. 258).
Person is described as a holistic being; wholeness is integrity (Levine, 1991). Integrity means that the person has freedom of choice and movement. The person has a sense of identity and self-worth. Levine also described person as a “system of systems, and in its wholeness expresses the organization of all the contributing parts” (pp. 8–9). Persons experience life as change through adaptation with the goal of conservation. According to Levine (1989), “The life process is the process of change” (p. 326).
Health is socially determined by the ability to function in a reasonably normal manner (Levine, 1969b). Social groups predetermine health. Health is not just an absence of pathological conditions. Health is the return to self; individuals are free and able to pursue their own interests within the context of their own resources. Levine stressed the following:
It is important to keep in mind that health is also culturally determined—it is not an entity on its own, but rather a definition imparted by the ethos and beliefs of the groups to which individuals belong
(M. Levine, personal communication, February 21, 1995).
Even for a single individual, the definition of health will change over time.
Environment is conceptualized as the context in which individuals live their lives. It is not a passive backdrop. “The individual actively participates in his environment” (Levine, 1973, p. 443). Levine discussed the importance of the internal and external environment to the determinant of nursing interventions to promote adaptation. “All adaptations represent the accommodation that is possible between the internal and external environment” (p. 12).
Levine (1991) provided some thoughts about two theories in their early stages of development. The theory of therapeutic intention is intended to provide the basis of nursing interventions that focus on biological realities of the patient. Although not planned as such, the theory naturally flows from the conservation principles. The theory of redundancy expands the redundancy domain of adaptation and offers explanations for redundant options such as those found in aging and the physiological adaptation of a failing heart.
Levine primarily uses deductive logic. In developing her model, Levine integrates theories and concepts from the humanities and the sciences of nursing, physiology, psychology, and sociology. She uses the information to analyze nursing practice situations and describe nursing skills and activities. With the assistance of many of her students and colleagues, and through her own personal health encounters, Levine has experienced the Conservation Model and its principles operating in practice.
Applications to the nursing community
Levine helps define what nursing is by identifying the activities it encompasses and giving the scientific principles behind them. Conservation principles, levels of integration, and other concepts can be used in numerous contexts (Fawcett, 2000; Levine, 1990, 1991). Hirschfeld (1976) has used the principles of conservation in the care of the older adult. Savage and Culbert (1989) used the Conservation Model to establish a plan of care for infants. Dever (1991) based her care of children on the Conservation Model. Roberts, Fleming, and Yeates-Giese (1991) designed interventions for women in labor based on the Conservation Model. Mefford (2000; Mefford & Alligood, 2011a, 2011b) tested a Middle Range Theory of Health Promotion for Preterm Infants based on Levine’s Conservation Model of nursing and found a significant inverse relationship between the consistency of the caregiver and the age at which the infant achieved health, and an inverse relationship between the use of resources by preterm infants during the initial hospital stay and the consistency of caregivers. Cooper (1990) developed a framework for wound care focusing on structural integrity while integrating all the integrities. Leach (2007) published a white paper on use of the Conservation Model to guide wound care practices. Webb (1993) used the Conservation Model to provide care for patients undergoing cancer treatment. Roberts, Brittin, and deClifford (1995) and Roberts, Brittin, Cook, and deClifford (1994) used the Conservation Model to study the boomerang pillow technique effect on respiratory capacity. Jost (2000) used the model to develop an assessment of the needs of staff during the experience of change.
Conservation principles have been used as a framework for numerous practice settings in cardiology, obstetrics, gerontology, acute care (neurology), pediatrics, long-term care, emergency care, primary care, neonatology, critical care, and in the homeless community (Savage & Culbert, 1989; Schaefer & Pond, 1991).
Levine (1973) wrote Introduction to Clinical Nursing as a textbook for beginning students. It introduced new material into the curricula. She presented an early discussion of death and dying and believed that women should be awakened after a breast biopsy and consulted about the next step.
Introduction to Clinical Nursing provides an organizational structure for teaching medical-surgical nursing to beginning students (Levine, 1969a, 1973). In both the 1969 and 1973 editions, Levine presents a model at the end of each of the first nine chapters. Each model contains objectives, essential science concepts, and nursing process to give nurses a foundation for nursing activities. These models are not part of the Conservation Model. The Conservation Model is addressed in the Introduction and in Chapter 10 of the introductory text. The teachers’ manual that accompanies the text remains a timely source of educational principles that may be helpful to both beginning and seasoned teachers (Levine, 1971c).
Although the text is labeled introductory, beginning students would have benefited from a background in physical and social sciences to use it. An emphasis of scientific principles in the second edition bridged this gap. Evidence supporting the model has been integrated successfully into undergraduate and graduate curricula (Grindley & Paradowski, 1991; Schaefer, 1991a).
Levine’s Model has been successfully used to develop nursing knowledge (Schaefer & Pond, 1991). However, Fawcett (1995) states that to establish credibility, “more systematic evaluations of the use of the model in various clinical situations are needed, as are studies that test conceptual-theoretical-empirical structures directly derived from or linked with the conservation principles” (p. 208). Many research questions can be generated from Levine’s model (Radwin & Fawcett, 2002; Schaefer, 1991b). Graduate students and clinical researchers have used the conservation principles as a framework to guide their research (Ballard, Robley, Barrett, et al., 2006; Cox, 1988; Gagner-Tjellesen, Yurkovich, & Gragert, 2001; Mefford, 2000; Mefford & Alligood, 2011a, 2011b; Moch, St. Ours, Hall, et al., 2007). Ballard and colleagues used the model to frame their phenomenological study of how participants reconstructed their lives with paraplegia. They found that structural integrity, along with all the other integrities, was used as a basis for defining their new lives.
One of the most important questions to be asked about the model is: What are the human experiences not explained by the model? This question can provide guidance for continued testing of the model’s application in nursing practice. For example, as health care providers use information from the human genome project, nurse researchers will want to test the ability of the model to explain comprehensive nursing care of the client undergoing genetic counseling. Based on the outcome of testing, hypotheses can be developed and tested to support the prescriptive basis of theories developed from the model.
Levine and others have worked on using the conservation principles as the basis for a nursing diagnosis taxonomy (Stafford, 1996; Taylor, 1989). Additional work has been done on the use of Levine’s model in administration and with the frail elderly. The model was used to develop and test the Theory of Health Promotion in Preterm Infants based on Levine’s Conservation Model (Mefford, 2000; Mefford & Alligood, 2011a, 2011b) and has great potential for studies of sleep disorders and in the development of collaborative and primary care practices (Fawcett, 2000). The philosophical, ethical, and spiritual implications of the model are research challenges yet to be realized (Stafford, 1996).
Levine’s model possesses clarity. Fawcett (2000) states, “…. Levine’s Conservation Model provides nursing with a logically congruent, holistic view of the person” (p. 189). George (2002) affirms, “this theory directs nursing actions that lead to favorable outcomes” (p. 237). The model has numerous terms; however, Levine adequately defines them for clarity.
Although the four conservation principles appear simple initially, they contain subconcepts and multiple variables. Nevertheless, this model is still one of the simpler ones developed.
The four conservation principles can be used in all nursing contexts.
Levine used deductive logic to develop her model, which can be used to generate research questions. As she lived her Conservation Model, she verified the use of inductive reasoning to further develop and inform her model (M. Levine, personal communication, May 17, 1989).
The four conservation principles defined in Levine’s model are recognized as one of the earliest nursing models used to organize and clarify elements of nursing practice. Furthermore, the model continues to demonstrate evidence of its utility for nursing practice and research and is receiving increased recognition in the twenty-first century.
Levine developed her Conservation Model to provide a framework within which to teach beginning nursing students. In the first chapter of her book, she introduces her assumptions about holism, and that the conservation principles support a holistic approach to patient care (Levine, 1969a, 1973). The model is logically congruent, is externally and internally consistent, has breadth as well as depth, and is understood, with few exceptions, by professionals and consumers of health care. Nurses using the Conservation Model can anticipate, explain, predict, and perform patient care. However, its ability to predict outcomes must be tested further. Levine (1990) said, “…. everywhere that nursing is essential, the rules of the conservation and the integrity hold” (p. 195).