The conservation model was originally an organizing framework for teaching undergraduate nursing students (Levine, 1973a). Levine’s book Introduction to Clinical Nursing (1973a) addressed the “whys” of nursing actions. Levine taught the skill of nursing and the rationale for the actions. She demonstrated high regard for the contribution of the adjunctive sciences to a theoretical basis of nursing in a clear voice for discipline development and attention to the rhetoric of nursing theory (Levine, 1988, 1989b,c, 1994, 1995).

The universality of the conservation model is supported by its use with a variety of patients of varied ages in a wide range of settings, including critical care (Langer, 1990; Litrell & Schumann, 1989; Lynn-McHale & Smith, 1991; Taylor, 1989; Tribotti, 1990), acute care (Foreman, 1991; Molchany, 1992; Roberts, Brittin, Cook, et al., 1994; Roberts, Brittin, & deClifford, 1995; Schaefer, 1991; Schaefer, Swavely, Rothenberger, et al., 1996), and long-term care (Burd, Olson, Langemo, et al., 1994; Clark, Fraaza, Schroeder, et al., 1995; Cox, 1991). It is also used with neonates (Tribotti, 1990), infants (Deiriggi & Miles, 1995; Mefford, 1999, 2004; Mefford & Alligood, 2011a,b; Newport, 1984), young children (Dever, 1991; Savage & Culbert, 1989), pregnant women (Oberg, 1988; Roberts, Fleming, & Yeates-Giese, 1991),young adults (Pasco & Halupa, 1991), women with chronic illness (Schaefer, 1996), long-term ventilator patients (Delmore, 2003), and the elderly (Cox, 1991; Foreman, 1991; Happ, Williams, Strumpf, et al., 1996). It has been successfully used in communities (Dow & Mest, 1997; Pond, 1991), emergency departments (Pond & Taney, 1991), extended care facilities (Cox, 1991; R. Cox, personal communication, February 21, 1995), critical care units (Molchany, 1992), primary care clinics (Schaefer & Pond, 1994), and operating rooms (Crawford-Gamble, 1986; Piccoli & Galvao, 2001) as well as for wound care and enterostomal therapy (Cooper, 1990; Leach, 2006; Neswick, 1997), care of intravenous sites (Dibble, Bostrom-Ezrati, & Ruzzuto, 1991), management of patients on long-term ventilation (Higgins, 1998), and care of patients undergoing treatment for cancer (Mock, St. Ours, Hall, et al., 2007; O’Laughlin, 1986; Webb, 1993).

The model is used for quantitative and qualitative research addressing practice issues. Melacon and Miller (2005) found massage therapy effective as complementary support for patients, reducing their low back pain intensity and preventing further decline. Mock, Pickett, Ropka, and colleagues (2001) used the model to study the effect of exercise on fatigue in patients with cancer. Coyne and Rosenzweig (2006) studied fatigue and functional status in women with cancer metastasis, using the model to assess energy and structural, personal, and social integrity. Hanna, Avila, Meteer, and colleagues (2008) found that comprehensive exercise for patients with cancer results in significant improvements in functional status, fatigue, and mood in treatment and recovery. Zalon (2004) found that pain, depression and fatigue, and return of functional status in older adults after major abdominal surgery were significantly related to patient perception of functional status and recovery.

Chang (2007) studied swaddling guided by Levine’s model and found swaddling conserved energy because the heart rates of swaddled infants increased less than those of the control group. Watanabe and Nojima (2005) proposed a middle-range theory describing the “calm delivery” and conservation of social integrity relationship based on key indicators of parental relationships, person-environment relationship, family function, dyadic relationship between parents, and dyadic relationship between the generations. Gregory (2008) found premature infants who did not receive fortified enteral breast milk feedings developed necrotizing enterocolitis when respiratory support was increased to maintain oxygenation. Mefford (2004; Mefford & Alligood, 2011a) developed and tested a theory of health promotion for preterm infants.

Ballard, Robley, Barrett, and colleagues (2006) applied the conservation model for a phenomenological study of patients’ recollections of therapeutic paralysis in intensive care. They found that patients reconstruct their lives in concert with care given by nurses who modified physiological stress to reduce chances of mortality and maintain wholeness. Delmore (2006) studied fatigue and protein calorie malnutrition in adult long-term ventilated patients during the weaning process, and found patients experienced moderate to severe fatigue during weaning and prealbumin levels affected the level of fatigue experienced. Jost (2000) studied staff nurse productivity, burnout, and satisfaction issues.

According to Levine (1973a), “Nursing is human interaction” (p. 1). “The nurse enters into a partnership of human experience where sharing moments in time—some trivial, some dramatic—leaves its mark forever on each patient” (Levine, 1977, p. 845). As a human science, the profession of nursing integrates the adjunctive sciences (e.g., chemistry, biology, anatomy and physiology, psychology, sociology, anthropology, philosophy, medicine) to develop the practice of nursing.

Three major concepts form the basis of the model and its assumptions: (1) conservation, (2) adaptation, and (3) wholeness. Conservation is a natural law fundamental to many sciences. Levine (1973a) explains that individuals continuously defend their wholeness.

Conservation is the keeping together of the life system. To keep together means to maintain a proper balance between active nursing interventions and patient participation, in which the patient participates within the safe limits of his or her ability. Individuals defend that system in constant interaction with their environments and choose the most economical, frugal, energy-sparing options available to safeguard their integrity. Energy sources cannot be directly observed but the consequences (clinical manifestations) of their exchange are predictable, manageable, and recognizable (Levine, 1991). Conservation is about achieving balance between energy supply and demand within the unique biological realities of the individual.

Adaptation is an ongoing process of change in which individuals retain their integrity within the realities of their environments (Levine, 1989a). Change is the life process, and adaptation is the method of change. The achievement of adaptation is “the frugal, economic, contained, and controlled use of environmental resources by the individual in his or her best interest” (Levine, 1991, p. 5). Individuals possess a range of adaptive responses unique to them. The ranges vary with ages and are challenged by illness. For example, the hypoxic drive stimulates breathing in individuals with chronic obstructive pulmonary disease. History, specificity, and redundancy characterize adaptations that await the challenges to which they respond (Levine, 1995). The severity of responses and the adaptive patterns vary based on specific genetic structures and influences of social, cultural, spiritual, and experiential factors.

Redundancy represents the fail-safe anatomical, physiological, and psychological options available to individuals to ensure continued adaptation (Levine, 1991). Levine (1991) proposed that “[a]chieving health is predicated on the deliberate selection of redundant options” (p. 6). Survival depends on redundant options that are challenged and limit illness, disease, and aging.

Wholeness exists when interactions with and adaptations to the environment permit assurance of integrity (Levine, 1991). Nurses use of the conservation principles to promote wholeness. Recognition of an open, fluid, constantly changing interaction between the individual and the environment is basic to holistic thought. Wholeness is health; health is integrity. Health is the pattern, and well-being is the goal of adaptive change.

Levine (1988) referred to the metaparadigm concepts of person, environment, health, and nursing as commonplaces of the discipline because they are necessaryfor any description of nursing. Persons are holistic beings who are sentient, thinking, future-oriented, and aware of their past. Wholeness (integrity) of individuals demands that “isolated aspects…have meaning outside of the context within which the individual experiences his or her life” (Levine, 1973a, pp. 325, 326). Persons are in constant interaction with the environment, responding to change in an orderly, sequential pattern, adapting to forces that shape and reshape their essence. According to Levine (1973a), the person can be defined as an individual, a group (family), or a community of groups and individuals (Pond, 1991).

The environment completes the wholeness of the person. Each individual has his or her own internal and external environments. The internal environment includes physiological and pathophysiological aspects of the patient that are challenged by changes in the external environment. External environmental factors impinge on and challenge the individual. Acknowledging the complexity of environment, Levine (1973a) adopted three levels of environment identified by Bates (1967): (1) perceptual, (2) operational, and (3) conceptual. Perceptual environment includes aspects of the world that individuals intercept or interpret through the senses. Operational environment includes elements that physically affect individuals but are not directly perceived (e.g., radiation, microorganisms). Conceptual environment includes cultural patterns that affect behavior characterized by spiritual existence and mediated by symbols of language, thought, and history (e.g., values, beliefs).

Health and disease are patterns of adaptive change with the goal of well-being (Levine, 1971b). Health is socially defined by the following question (Levine, 1984): “Do I continue to function in a reasonably normal fashion?” Health (wholeness) is the goal of nursing and implies the unity and integrity of the individual. Illness is adaptation to noxious environmental forces. Levine (1971a) proposes that “[d]isease represents the individual’s effort to protect self-integrity, such as the inflammatory system’s response to injury” (p. 257). Disease is unregulated and undisciplined change that must be stopped to prevent death (Levine, 1973a).

Nursing involves engaging in “human interaction” (Levine, 1973a, p. 1). Individuals seek nursing care when they are no longer able to adapt. The goal of nursing is to promote adaptation and maintain wholeness. This goal is accomplished through the conservation of energy and structural, personal, and social integrity.

Energy conservation depends on free exchange with environment so living systems can constantly replenish their supply (Levine, 1991). Conservation of energy is integral to individual ranges of adaptive responses. Conservation of structural integrity depends on the defense system that supports repair and healing in response to challenges from internal and external environments. Conservation of personal integrity recognizes individual wholeness in response to environment as the individual strives for recognition, respect, self-awareness, humanness, holiness, independence, freedom, selfhood, and self-determination.

Conservation of social integrity recognizes individual functioning in a society that helps establish the boundaries of the self. Social integrity is created with family and friends, workplace and school, religion, personal choices, and cultural and ethnic heritage (Levine, 1996). With political and economic control, the health care system is part of the social system of individuals. Levine (1991) contends that“[c]onservation of integrity is essential to assuring wholeness and providing the strength needed to confront illness and disability” (p. 3).

Levine (1973a) stresses that patient understanding of plans of care and diagnostic studies is vital. To this understanding the nurse contributes knowledge of nursing science, a careful history of the patient’s illness, the patient’s perception of the current predicament, information gained from family and friends, and acute observation of the patient and his or her interactions with others (Levine, 1966a). This integrated approach to patient-centered care provides the basis for collaborative care and the establishment of partnerships in the delivery of comprehensive care. Treatment focuses on the management of the organismic responses, including the following:

The model provides a basis for the following four theories for practice (Mefford, 2004):

The Theory of Conservation, rooted in the universal principle of conservation, is foundational for the model (Alligood, 1997, 2006, 2010). The purpose of conservation is to “keep together.” According to Levine (1973a), “To keep together means to maintain a proper balance between active nursing interventions coupled with patient participation on the one hand and the safe limits of the patient’s abilities to participate on the other” (p. 13). The patient interacts with the environment in a singular but integrated fashion. The person represents a system that is more than the sum of its parts and reacts as a whole being. As part of the patient’s environment the nurse supports patient responses. All nursing acts of conservation are devoted to restoring symmetry of response with the goal of maintaining wholeness (Levine, 1969).

In developing the Theory of Therapeutic Intention, Fawcett (2005) cites Levine’s model for its capacity to organize nursing interventions using biologicalrealities that nurses confront and proposed therapeutic regimens to support the following goals (Fawcett, 2000):

Levine’s Theory of Redundancy, grounded in adaptation, has the capacity to expand our understanding of aging (Fawcett, 2005). Redundancy is predicated on the ability of a human to “monitor its own behavior by conserving the use of resources required to define its unique identity” (Levine, 1991, p. 4). Inherent in the ability to select from the environment is availability of options from which choices are made.

Mefford (2000; Mefford & Alligood, 2011a,b) tested the validity of her Middle Range Theory of Health Promotion for Preterm Infants and found that consistency of nurse caregivers mediated the infant’s integrity at birth and the age that health was obtained, and an inverse relationship between the use of resources by preterm infants during their initial hospital stay and consistency of caregivers. Watanabe and Nojima (2005) developed a middle-range theory with substruction using Levine’s Conservation Model to describe, “calm delivery.” Literature review identified 22 concepts related to the four integrities of the model. Conservation of social integrity was the integrity related to a cluster of five concepts, including social support; dyadic relationships between parents, generations, and environment; and family function. They identified significant cues for researchers to conduct studies in this area.

Anecdotal reports are supportive of the theories in practice. For example, a patient with diabetes who follows a diet and exercise program is more likely to control his or her blood sugar levels (therapeutic intention) than one who does not follow the same program. Patients with emphysema who space activities to conserve energy will be more satisfied with daily life than patients who do not space activities (conservation). Patients with chronic illness manage their lives better when given options for treatment than patients who are not provided with options (redundancy). According to Levine (1991), failure of redundant options (loss of hearing in one ear) helps explain aging. The Theory of Redundancy might explain the process of aging because as one ages organ function declines, in some cases as a part of the aging process. If a kidney fails, the Theory of Redundancy no longer is valid because only one kidney remains. This is also true if a patient can only hear from one ear; the option to hear with both ears no longer exists. Of course, a hearing aid may help restore hearing in the ear with less than optimal function, supporting the Theory of Redundancy through the use of technology.

Levine (1973a,b) proposes that nurses use their scientific and creative abilities to provide nursing care to patients using a process incorporating ability to think critically. Table 10-1 describes Levine’s nursing process using critical thinking the nurse used to guide Debbie’s care.

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