Wound Management: Using Levine’s Conservation Model to Guide Practice
Levine’s conservation model,1 initially constructed as a teaching framework for medical-surgical nursing,2 is based on the belief that nursing interventions should be aimed at conserving function.3,4 Roberts and Taylor5 and Fawcett4 state that nurses currently use Levine’s model in practice by acting to preserve client energy and integrity — encouraging bed rest, maintaining pressure area care, and preserving privacy. To clarify the relationship between Levine’s conservation model and wound management, 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 model1 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 physical 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 awareness that the patient…is a social being who interacts with others5 in their social environment.
Each of these principles — the reduction in energy expenditure, the improvement in structural, personal and social integrity, and the reclaiming of individual wholeness and health — is compatible with wound management.1 Levine’s principles are also specific and testable; hence, they already have been utilized as a framework for many studies.6-11 Many nursing researchers and practitioners adopt Levine’s model because the conservation principles provide a scientific and research-oriented approach to the majority of nursing interventions.3 Furthermore, as a theoretical framework, the rules of conservation and integrity are applicable to all aspects of nursing, from clinical practice to administration.12 As such, the conservation principles help anticipate and predict all fields of nursing practice by placing independent information into an organized framework.12
Each of Levine’s principles addresses the concept of conservation, defined by the author1 as preserving individual wholeness. The purpose of conservation is to “…defend, sustain, maintain, and define the integrity of the system for which it functions.”1 Conservation can be compared to the process of homeostasis in that it maintains the stability of the organism through “…multiple, interacting, and synchronized negative feedback systems….”3 The universal concept of conservation also “describes the way complex systems are able to function even when severely challenged.”12 Therefore, conservation aims to maintain an equilibrium conducive to health; accordingly, many nursing interventions use conservation principles to maintain patient wholeness.13 Meleis14 claims that all individuals strive for conservation — it is only when the individual can no longer adapt to adverse stimuli that the nurse becomes the individual’s conservator. To illustrate, when an individual can no longer maintain adequate venous tone and function, venous leg ulceration (VLU) potentially will develop. As a conservator, the nurse can help the client resolve the disequilibrium by applying external compression therapy to improve venous function and skin integrity.
Despite the comprehensiveness and wide application of Levine’s theory, the model is not without limitation. For example, Levine’s conservation model focuses on illness as opposed to health; thus, nursing interventions are limited to addressing only the presenting condition of an individual.15 Hence, nursing interventions under Levine’s theory have a present and short-term focus and do not support health promotion principles, even though health promotion is an essential component of current nursing practice.15 Thus, Levine’s model does not add support to the use of interventions that prevent ulcer occurrence and reoccurrence in susceptible individuals.
An underlying assumption of Levine’s model is that the nurse creates an environment in which healing can occur and adaptation is promoted.14 Individuals are constantly interacting with an external environment; consequently, 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 environment 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 system internally 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,15 it may be through effective wound care that nursing can conserve energy and skin integrity14 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 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.12 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 capability, safety, and comfort.”14
In a normal healthy state, the body intentionally utilizes a minimum level of energy to conserve energy. 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 example, 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.12
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 expenditure, and less emotional trauma.16 However, in order to assess the energy-conserving effect of wound treatments, 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 measurements 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 cannot be maintained without conserving energy. By conserving energy, the integrity of the individual ultimately can be defended.17
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 structure and function, the body needs to restore structural integrity through repair and healing.1
Healing restores continuity and form through cell replication; hence, conserving structural integrity.12 Early detection and management of disease by nurses reduces tissue destruction, which also conserves structural integrity.2 Specific nursing interventions that conserve structural integrity include anatomic positioning and range-of-motion exercises to prevent musculoskeletal deformities,14 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.17
Conservation of Personal Integrity
Conserving personal integrity is based on the belief that individuals require privacy, are responsible for their own decisions, and illness and hospitalization compromise personal integrity, self-identity, and self-respect.4 Nursing interventions aimed at conserving personal integrity include protecting and respecting patient privacy, possessions, and defense mechanisms4 and supporting personal choice.2 The conservation of personal integrity, therefore, aims to protect personal identity.4
Levine12 argues that the fundamental goal of the nurse is to provide knowledge and support so the individual can resume a private independent life. Personal integrity, including self-identity and pride, is compromised when an individual becomes dependent.3 Therefore, interventions aimed at regaining individual independence ultimately conserve personal integrity. The principle of conserving personal integrity is interdependent with the principles of conserving energy and structural integrity. Without sufficient energy and, in the case of 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, dressings 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,18-20 effective wound management also may restore patient self-worth and personal 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 are affected by an individual’s illness, and hospitalization results in social isolation.4
Social factors such as family, friends, culture, religion, education, and socio-economic status all determine how an individual defines him/herself.3,17 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 individual.3 For instance, patients with VLU often become immobile,21 embarrassed, and socially isolated and experience financial difficulty.18 By facilitating wound healing, the nurse can indirectly restore the patient’s ability to be mobile, productive, and social. Furthermore, by decreasing VLU duration and recurrence, effective wound management may inadvertently reduce healthcare expenditure and demand on healthcare services.
According to Levine, a nurse can implement either supportive or therapeutic interventions.11 Supportive interventions prevent deterioration of health; therapeutic interventions promote healing and restore health.15 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 implementing therapy intended for internal effect. In fact, few dressings have been proven to enhance venous ulcer healing.22,23 The exception is compression therapy. Some evidence of efficacy is available,24 which may explain why this therapy prevails as the primary treatment of choice for VLU.25-28 One reason why compression therapy may be effective is that it adequately addresses the underlying etiology of the wound29 — in particular, the pathological processes that lead to venous insufficiency.30 Hence, it is argued that the combination of appropriate primary dressings and compression therapy will provide a complete therapeutic solution to VLU management; subsequently, increasing the rate of wound healing.
Levine’s conservation model provides a thoughtful basis for making effective wound management choices in order to improve wound healing and consequently ameliorate individual well being and quality of life. The relationship between effective wound management and positive patient outcomes (see Figure 1) draws on Levine’s four conservation principles, about which she states:
The conservation principles address the integrity of the individual…from birth to death. Every activity requires an energy supply because nothing works without it. Every activity must respect the structural wholeness of the individual because well-being depends on it. Every activity is chosen out of the abilities, life experience, and desires of the “self”’ who makes the choices. Every activity is a product of the dynamic social systems to which the individual belongs.1