joumal of Advanced Nursing. 1989, 14, 755-761

Modelling and role-modelling: integratingnursing theory into practice

Kathleen Kelley Walsh MS RNDirector of Nursing (Resource Development), St Joseph's Hospital Flint. Michigan

Terry M. VandenBosch MS RN CSNurse Specialist in Research, Catherine McAuley Health Center, and Adjunct AssistantProfessor. The University of Michigan School of Nursing

and Susan Boehm PhD RN FAANAssociate Professor of Nursing, The University of Michigan School of Nursing. Ann Arbor,Michigan, USA

Accepted for publication I October 19&8

WALSH KELLEY K., VANDENBOSCH T.M.& BOEHM S. (1989) Joumal of

Advanced Nursing 14, 755-761

Modelling and role-modelling: integrating nursing theory into practiceThis 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 andscience. What makes our job of enhancing people's healthboth continually exciting and sometimes elusively frustrat-ing is this fusion of art and science. If our goal is to assisteach client in their growth as people, we need to cultivateboth our scientific foundations for action and our artfulperformance of them. We can heighten our ability to prac-tise both the art and science of nursing if our work isgrounded in theory. The raw materials a nursing theoristworks 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-existingfacts and ideas are combined to look at the world in a newway. How a theory illustrates the world can then be testedto see how well it fits with reality.

One fairly new theory has drawn together previouslydeveloped 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 forour profession and our unique contribution to clients viathe art and science of nursing practice. The theory, calledmodelling and role-modelling, was developed by HelenErickson, Mary Ann Swain, and Evelyn Tomlin (Brickson etal. 1983). It is a complex theory because of the integrationof several theories and ways of looking at man. Althoughthe theory contains many levels of meaning, its basic con-cepts make sense, and can be readily applied to nursingpractice. This article presents some of the concepts andlinkages of modelling and role-modelling through casestudies 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 VIIIdeficiency). Like most severe haemophiliacs he has sufferedfrom numerous spontaneous and trauma-induced episodesof bleeding into his joints and muscles. The repeatedintemal bleeds have eroded the lining of several of his

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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. Theinfluence of haemophilia extends beyond the physicalrealm. Modelling and role-modelling (M & RM) statespeople 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'sworld. The theory emphasizes the importance of humandevelopment, and adds new links to pre-existing theories.This case study will illustrate some of the concepts andlinkages explained in M & RM.

The theories of Abraham Maslow (1968, 1970) and EricErikson {Erickson 1963) are important building blocks forM & RM. Diagrams of these levels and stages are includedin Figures 1 and 2. M & RM links Maslow's theory ofhuman needs with Erickson's theory of human develop-ment. The degree to which developmental tasks areresolved is dependent on the degree to which human needsare satisfied (Erickson et al. 1983). Integrating the concep-tual frameworks of Maslow and Erickson facilitates ourunderstanding of how people grow to be both alike anddifferent.

Eor example, Erickson (1963) identified the initial con-flict every infant faces as they enter a strange new world astrust versus mistrust. Like other infants Jim took in nourish-ment when hungry, and thus leamed his mother could betrusted to provide for his needs. In Erickson's terms he wasbuilding the strength of trust. Having his basic physicalneeds met was helping him to feel safe and secure accord-ing to Maslow's heirarchy. Synthesizing the two theoriestells us that having basic needs fulfulled provides Jim withthe security and sustenance to work on the developmentaltask at hand.

We might ask if the haemophilia had particularinfluences on Jim's infancy. Like many haemophiliacs, Jimwas free of bleeding into joints and muscles for the firstseveral months of his life. Physically he was unaffected foralmost a year, except for excessive bleeding during circum-cision. This episode led to testing which substantiated the

diagnosis of haemophilia. His mother was then informedshe carried the genetic trait which her son had inheritedas haemophilia. This information impacted her basic needfulfilment, and therefore her ability to cope. She reactedwith grief, guilt, and a determination to fight the haemo-philia and protect her son. Jim's physiologic needs werewell attended to during infancy and throughout his life.Nevertheless, his mother's inability to cope adaptivelywith her feelings about having a son with haemophiliaprofoundly affected Jim, beginning in infancy. Unresolvedmorbid grief over transmitting the haemophilia impactedher ability to nurture Jim's development of strengths.

Within a few months babies develop the physicalmobility 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 frommother he would move away from her for a few minutes,retuming periodically for her assurance. M & RM labels theneed to be both autonomous and dependent 'affiliated-individuation'. This concept describes the importance andcoexistence of both the T and 'we' states of being. That is,all people need to experience freedom and acceptance inboth states, being separate and being linked to others. Thisconnection to others is our affiliation or attachment. Asecond theoretical linkage of M & RM is between thisattachment to an object (a person, or in some cases an ideaor thing) and basic need satisfaction. The degree to whichneeds are met by attachment depends on the availability ofthe object (i.e. mother) and the amount of comfort andsecurity as opposed to threat and anxiety which it pro-vides. Thus, object-loss results in basic need deficits. Lifeentails ongoing losses, some of which are never completelyresolved. The more important the object to basic needfulfilment the more likely that its loss will cause unresolvedmorbid grieving.

With these concepts in mind let us retum to examiningthe stages of human development.

Erickson's second stage involves a conflict whichimpacts an individual's sense of affiliated-individuation.Recall that affiliated-individuation is an intrapsychicphenomena 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. AtErickson's second developmental level, the child is grap-pling with autonomy versus doubt. The conflict involvesrecognizing self as separate from mother by exercisingindependence versus parental attempts to control or chan-nel behaviour in socially accepted ways. One importantactivity of this stage of development is toilet training. Thechild leams they have control over their body wastes, and

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Figure 2 Erikson'sdevelopmental stages.

8 INTEGRITY versus DESPAIR

7. 6ENERATIVITY versus ABSORPTION

6. INTIMACY versus ISOLATION

5. lOENTITY versus ROLE CONFUSION

4 INDUSTRY versus INFERIORITY

3. INITIATIVE versus GUILT

2. AUTONOMY versus DOUBT

I, TRUST versus MISTRUST

TASK

RENUNCIATION

PRODUCTION

AFFILIATION

DEVOTION

METHOD

DIRECTION

SELF CONTROL

ORIVE

STRENGTH

WISDOM

CARE

LOVE

FIDELITY

COMPETENCE

PURPOSE

WILLPOWER

HOPE

VIRTUE

also learns how to use this control to elicit various reactionsfrom parents.

Where does Jim fit in here? By the time he was about 10months old the activities of crawling and walking wereresulting in painful episodes of bleeding into joints andmuscles. Attempts at exploring the world were somehowconnected with pain for reasons he could not understand.The episodes were irregularly spaced. Sometimes dayselapsed between bleeds, at best 2 to 3 weeks free of bleedspassed. His concemed mother tried curbing his actions,hoping to prevent bleeds. Unfortunately, people with hae-mophilia often bleed spontaneously into joints, and injuryis not necessarily a prerequisite. Swollen, restricted jointsare acutely painful, and the comfort of his mother could notcompletely relieve the hurting.

Twenty years ago, before the introduction of factor con-centrates, home care and speedy outpatient care, personswith haemophilia experienced frequent hospitalizations.Therefore, when bleeds occurred Jim was separated fromhis family. Jim's developing sense of affiliated individuationwas negatively impacted by the frequent separations, andhis mother's attempts to protect him from harm whichbecame quite restrictive. The pain and immobility he couldnot understand eroded the earlier achievement of feelingsafe, secure and trusting. In addition to impacts on Erickson'seight stages of development and Jim's sense of affiliationwas the impact on Jim's basic needs according to Maslow.Jim's basic needs were frequently threatened. A strongfoundation of basic need satisfaction provides the basis forhuman development. Without it healthy growth isinhibited by morbid grieving.

The bleeds continued as Jim moved into toddlerhoodwith autonomy versus doubt conflict and control issues.

When his actions resulted in pain for no apparent reason,his developing sense of control was negatively impacted.He built up more shame, fears and doubts than mostchildren, because his fledgling attempts to gain autonomywere frequently thwarted by his worried mother or by ableeding joint. The unpredictable bleeding episodes meantJim never felt much control over his environment, and evenover himself. Doubtful feelings built up, hampering hisability to experience independence.

For all people the outcomes of each stage contain vary-ing degrees of positive development and negative residualdevelopment. It is expected to have some negative residualdevelopment. However, more negative residual than posi-tive residual hampers the development of enduringstrengths and virtues that contribute to the character andhealth of an individual (see Figure 2). For Jim, the strengthof self-control and hope he developed were considerablylessened by the lack of control he experienced. Regardlessof the degree to which we positively resolve a develop-mental task, advancing age thrusts the next stage upon us.The degree to which we have resolved a stage, and thestrengths and fears which result, are carried over, afi-ectingour experience with the next stage.

Jim brings self-doubt to the next childhood task — thatof initiative versus guilt. He finds that his actions some-times coincide with a bleed. He feels guilty about his bleedsand assumes he is being punished. In attempting to protecttheir son from bleeds his parents stifle Jim's attempts totake initiative in activities. The overprotectiveness dimi-nishes self-learning which normally occurs through play.Instead of developing a sense of direction and purposein himself, he feels guilty which further inhibits hisgrowth. Jim as an adult rarely initiates new activities or

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Equilibrium:Adaptive/ malQdoptive

Stressor ^ Arousal

Impoverishment

Figure 3 Adaptive potential assessment model.

Equilibrium

Stressor

StressArousol -•- Impoverishment

Figure 4 An illustration of the dynamic relationship among thestates of the adaptive potential assessment model.

relationships with others. Without correcting this funda-mental need to feel in control, Jim's potential for healthygrowth is stunted.

Once again, the doubt and guilt are carried over whenJim reaches the next developmental level. His poor resol-ution of the previous task results in a higher residual ofnegative effects, and a lower residual of positive effects forthat developmental task. According to Erickson, the basicstrength that emerges from autonomy versus shame anddoubt is self-control. Although Jim did not completelyresolve this task, he did develop some strengths. Humourwas a strength he developed which gives him control insome situations. One way Jim reveals his feelings and hissense of himself is through his use of a wry form of humour.On the other hand, the type of humour he chooses oftenreflects his low self-esteem and an inability to express feel-ings. Space limitations prohibit our walking through eachof Erikson's stages and Maslow's levels in this article.Examine the chart and think for youself about how Jim isequipped to deal with the remaining developmental stages.

Human beings are complex. Identifying enduringcharacteristics from development and basic need satisfac-tion provides some information in understanding humanbehaviour. Another mode! used in M & RM draws fromSelye's (1974) general adaptation syndrome and Engel's(1962) responses to stressors theories. The authors of M &

RM synthesized these two and developed the adaptivepotential assessment model (APAM) to assist in predictingan individual's potential to cope with stress (see Figures 3and 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 & RMasserts 'At some level a person knows what has made himor her sick . . . or interfered with growth and what will helpheal and optimize his or her effectiveness and promote hisor her growth. This is the essence of self-care knowledge(Erickson et al. 1983). The strengths people develop andtheir 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 andare fluid. They respond to the continual changes we arefaced with in life. Using self-care knowledge and our abilityto mobilize our resources is our self-care action. The thirdlinkage in M & RM states, 'An individual's potential formobilizing resources — the person's state of copingaccording to APAM — is directly associated with theperson's need satisfaction level' (Erickson et al. 1983). Nu-merous basic need deficits limit potential for mobilizingself-care resources. The APAM model depicts three cate-gories or states. Each state represents a different potentialfor mobilizing resources at that point in time: arousal, equi-librium (adaptive or maladaptive), and impoverishment.Physiologic and psychologic data have been gathered tosubstantiate the three main states of adaption potential themodel proposes (Erickson & Swain 1962). Assisting peoplein replenishing, developing and using their resources formovement in a healthier direction is a prime nursingresponsibility.

The APAM is used when assessing an individual'spotential for coping at a particular moment in time. It indi-cates their state. Currently Jim is in an impoverished stateaccording to APAM. His coping abilities and strengthsare limited by his basic need deficit. Two years ago hesustained serious injuries in an automobile accident andbecame even more withdrawn. The level of depression wassuch that some basic self-care activities were not per-formed. The change in his ability to cope is described interms of the APAM model as a move from maladaptiveequilibrium to impoverishment. Since the APAM reflectsthe current coping state, it must be continually reassessed.Jim has been moving back and forth between maladaptiveequilibrium and impoverishment during the past 2 years.

CASE 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

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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. Hisepisodes began impacting his life. The completely unpre- energieshavebeendirectedat establishing control throughdictable occurrence of joint haemorrhages which suddenly action. He became addicted to narcotics during a time ofinterrupted 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. Disgustedhad similar experiences. The difference was with the devel- by the side effects and lack of control the narcotic addictionopmental task of initiative versus guilt. Michael's parents imposed, Michael quit cold turkey. This extremely hardpromoted safety but also gave him the freedom to take experience challenged his coping abilities enormously, andrisks. He was allowed to try things out, test himself, and he pulled through. The sense of purpose, direction, andleam from his actions. For example, he leamed to operate self-esteem he gained in the initiative versus guilt stagefarm equipment, and was allowed to run and play with the assisted him in this situation. Lack of control over severeneighbourhood children. Michael still has difficulty with joint dysfunction and pain are a continuing reality, andcontrol issues, however his strength of taking initiative sometimes he despairs over his situation. Yet he retains hiswithout 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 findsa 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 allowis in equilibrium. When stressors arouse him he mobilizes other persons. He openly describes his hesitancy tohis resources and uses them effectively. In contrast, become involved with a woman because of his uncertainwhen Jim faces significant stress he lacks the strengths to fiiture. Prior to 2 years ago he had girlfi-iends, but since thatmaintain equilibrium and instead sinks further into time his concem over not exposing anyone to AIDS viaimpoverishment. 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 toJIM HIV, presently Michael shows no signs of immune system

impairment.Civen these similarities and differences what is each man'slife like today? The situations of each are not surprising.Both continue to struggle with controllssues as they face

^^opE^LING AND ROLE-MODELLINGthe stages of life presented to them. But the,rstmggles are ^^^ ^^^ NURSING PROCESSdifferent trom one another.

Jim never left home, found employment, or developed The central concept of M & RM states the nurse mustintimate relationships with anyone other than his immedi- understand a client's world. The nurse models his worldate family. The adolescent conflict of identity versus role as it exists for him. Modelling contains both the art anddif^sion is one Jim has not yet resolved. In fact, he seems to science of nursing. It combines scientific aggregation andlack the energy necessary to deal with the issue of who he analysis of data with the image and understanding of theis. His self-esteem is very low and he is depressed. His world from the client's view. When one sees the world asinterests, when he addresses them, are solitary pursuits, the client does, then one can role-model.'Role-modelling isOccasionally 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 itis incapable of choosing intimacy over isolation. His health draws on the theoretical bases of nursing practice. It is arthas steadily deteriorated over the past few years. Like most because the nurse plans and intervenes within the person'ssevere haemophiliacs he has been exposed to the causative own unique model. The bedrock of the nurse's action isagent in AIDS, the HIV virus. Jim is beginning to have unconditional acceptance, positive regard, facilitation, andsigns and symptoms that the virus is altering his immune nurturance of the individual. These attitudes permeate thesystem. Although not yet diagnosed with AIDS, his nurse's approach if the relationship is successfuL

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The nursing process as visualized by M & RM is definedby the relationship to the client. The nurse brings his or herwhole self into an intensive, interpersonal relationship withthf client. The nursing process which results is continual andtherapeutic, as opposed to a rigid sequence of steps. Fromthe first moment of contact a nurse is intervening, simply bylistening and analysing data. She evaluates what she isperceiving in this give-and-take dialogue and respondsfurther. This dynamic process continues throughout therelationship. The more formal aspect of the nursing processis reflected in the theory and knowledge base she uses in heractions, her analysis and responses in the nurse—client re-lationship, and her documentation of what is occurring.

One important implication of this theory is focusing onthe client's perception. The client's concems preempt thenurse-identified concerns. If the need most central to theindividual is addressed, we know their holistic response willalso impact needs the nurse has identified, which the clientmay not have been aware of or focused on. Establishing trustand then positively impacting a client is only possible if whatis important to that individual receives attention.

To model the client's world the nurse gathers key infor-mation from the client and appropriate significant others.Areas the nurse addresses include how the individual viewstheir situation, their current and future expectations, theirstrengths and support systems, and finally their goals(Campbell et al. 1985). As the interpersonal relationshipcontinues to develop, the client will share those issuesimportant for them. The art of nursing is listening anddiscovering those issues. The science of nursing is heing ableto understand those issues within the framework of thetheory.

Using information

The next question one might ask is: how does the nurse usethe information as she relates to the client? The authors ofM & RM suggest five aims of nursing interventions whichreflect the theoretical bases and the linkages. The five aimsand their principles are presented in Table I.

Incorporating these principles into nursing practiceenables one to more readily perceive where the client is,and promote their healthy adaptation and role-modelgrowth. Masiow discussed the inability of humans to growunless the threatening aspects of growth can be minimizedand the appeal for growth is maximized, while the person'sneed to be safe is met. When people feel safe, secure andsupported they will choose health. A basic belief of M &RM is that people are bom with an inherent desire to growand fulfill their self-potential. That is what nursing is allabout. We work with people by nurturing their humanity,helping them to help themselves.

Interventions which reflect the client's world and pro-mote growth are not necessarily difficult to decide uponand act out. In fact they are often simple. For example, incommunicating unconditional positive regard and nurtur-ance, touch can be very useful. Of course, it must occurwithin the context of the model of the client's world. ForJim, who keeps people at arms length, the nurse graduallyprogressed in the use of touch. Initially she began with theclinically necessary act of gently palpating an extremitywith an intemal joint bleed, to playfully tweaking his bigtoe as a standard greeting when entering or leaving hishospital room (allows for his sense of personal space, not asthreatening as touching more centrally, such as his face), tositting on his bed to converse, to squeezing his hands.For each client and each nurse the use of touch will bepersonalized. This is the art of nursing.

Basic needs

In designing interventions identify the person's basic needsaccording to Maslow, and build on existing strengths.Whereas Jim has difficulty stating his needs, Michael is ableto identify what will help him. Michael's knowledge abouthaemophilia and its treatment is high. Like the majority ofadults with severe haemophilia, he is on a programmecalled home care. This means he has been taught to analysehis bleeds, calculate dosages, reconstitute and administerfactor VIII concentrate, perform venipuncture on himself,and keep a log of these episodes. Essentially he is in controlof his treatment. The haemophilia centre team is availableto help in acute situations, examine his logs; and evaluatehis health and development periodically to plan for thefuture.

When Michael enters the hospital he relinquishes muchof the control over his care he enjoys at home. Since main-taining control is important for Michael, an important in-tervention is to retum control to him to the extent possible.An example of retuming control and building on hisstrengths is to acknowledge Michael's expertise and facili-tate the continuation of his self-care activity in the hospital.Michael was allowed to perform his own venipuncturesand administer his factor concentrates during his last hospi-tal admission. He felt less threatened, more in control, andtook positive steps towards discharge when thesemeasures verifying ownership of his health and self wereinstituted.

A base for practice

All nurses have experienced the wonders of relating to aclient in a way which successfully enhances the client'sability to cope and grow. Conversely, we have endured

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Table 1 Relationships among intervention goals, principles, and aims for intervention

Intervention goal Principle Aim

1. Develop a trusting and functional re-lationship between yourself and yourclient

2. Facilitate a self-projection that is futuristicand positive

3. Promote affiliated individuation with theminimum degree of ambivalence possible

4. Promote a dynamic, adaptive, and holisticstate of health

5. (a) Promote (and nurture) coping mechan-isms that satisfy basic needs and permitgrowth-need satisfaction(b) Facilitate congruent actual and chrono-logical developmental stages

The nursing process requires that a trust-ing and functional relationship existsbetween nurse and client

Affiliated-individuation is contingent onthe individual's perceiving that he or she isan acceptable, respectable, and worth-while human being

Human development is dependent on theindividual's perceiving that he or she hassome control over life (while concurrentlysensing a state of affiliation)

There is an innate drive toward holistichealth that is facilitated by consistent andsystematic nurturance

Human growth is dependent on satisfac-tion of basic needs and is facilitated bygrowth-need satisfaction

Build trust

Promote client's positive orien-

tation

Promote client's control

Affirm andstrengths

promote client's

Set mutual goals that are health-directed

frustrating situations where our efforts did little to effecta positive outcome. M & RM provides the theoreticalfoundation 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 permissionfrom 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 lifeand Physical Health Status. Unpublished doctoral thesis.University of Michigan.

Erickson H.C, Tomlin E.M. & Swain M.A.P. (1983) Modeling andRole-Modeling: A Theory and Paradigm for Nursing. Prentice-Hall, Englewood Cliffs, New Jersey.

Erickson H. & Swain M.A. (1982) A model for assessing potentialadaptation 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.

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