On Levine & Watson: Comparing Two Nursing Frameworks and Their Application to the Field

Throughout the years, there have been a significant amount of attempts to both define and examine the field of nursing. As a result, a variety of theories have emerged - each with different assessments of what is means to assist and support individuals. The field has continually faced the almost insurmountable task of classifying broad and intricate theories. In an effort to categorize the theories, the field derived two specific terms noted as grand theory and middle-range theory. The former is an all-encompassing presentation on the complexities that nursing deals with, while the latter is a smaller and less broad category that observes the many situations and scenarios that nurses deal with on a daily basis.

According to Nursing Theory (2013), the vast amount of theories pertaining to nursing "are developed by nurses, but at times other healthcare professionals [in an attempt] to explain, predict and describe elements of nursing care and practice" (p.1). These individuals in their creation of the theories outline them on the basis of the circumstances they have encountered. There are theories, however, that have emerged over the years that are extensions of prior theories with incorporations of research studies and conjecture that have been woven into new theories. Nursing Theory (2013) goes on to state that the theories of nursing underscore the profession and that most, if not all nurses utilize the theories when they practice. Additionally, there is no one nursing theory that the field prefers over the other. It is rather a matter of deciding upon which theory best fits a given situation with a patient. The theories assist nurses in bettering their analytical and critical thinking skills, as well as comprehension of the core concepts of nursing (p.1). Essentially, nursing theories strongly influence the development, education, and training of all nurses and to a certain extent healthcare professionals. With an ever-evolving field, there will inevitably be new theories that will, in essence, guide the profession towards better practices in dealing with patients. Two theories that guide the field of nursing that warrant analysis and examination are Jean Watson's caring science model and Myra Levine's conservation model.

Nursing Theory #1 – Jean Watson’s Caring Science Model

Jean Watson's Caring Science Model per Watson Caring Science Institute & International Caritas Consortium (2013) is defined as a phenomenon that includes different facets of science. Further, Watson's theory denotes significant areas that must be embraced by the nursing profession that incorporate ethics, philosophy, and history. Also, Watson's theory draws on the principle that individuals have a responsibility to their fellow man and to that extent, nurses should or rather need to have empathy and benevolence when dealing with goal-oriented patient care. There are ten processes of caring that are the foundation for the theory. These are:

“Embrace altruistic values and practice loving kindness with self and others.

Instill faith and hope and honor others.

Be sensitive to self and others by nurturing individual beliefs and practices.

Develop helping-trusting-caring relationships.

Promote and accept positive and negative feelings as you authentically listen to another's story.

Use creative scientific problem-solving methods for caring decision making.

Share teaching and learning that addresses the individual needs and comprehension styles.

Create a healing environment for the physical and spiritual self which respects human dignity.

Assist with basic physical, emotional, and spiritual human needs.

Open to mystery and Allow miracles to enter” (p.1).

On the surface, the theory is very easy to understand, but when delved into further, it becomes quite complex. The simple foundation of the theory is that every nurse should have a caring attitude toward their patients. Watson relays that individual nurses should have a vested interest in their patients and in order to successfully do this is to inject feelings into the situation. Lachman (2012) asserts that Watson's model is one that crosses the boundaries of the patient-nurse relationship and argues that for Watson, this is necessary in order for the patient to heal. Moreover, the caring association engenders a more aware nurse in that the particular individual that is caring for the patient is wholeheartedly committed to the deep connection with the patient and has opted to discover the root cause of the patient's issue. Also, nurses should have a consciousness of caring irrespective of the patient's situation because each respective scenario is distinctively different (p.112-113). Watson's theory then enforces an obligatory measure to the field of nursing by stating that caring should be a habit and that nurses have an onus to both socially and spiritually share in the connection of the ailment or illness of the patient.

One of the often discussed aspects of Watson's model is the reflective/meditative approach. Watson (2010) identifies a set of questions that the nurse must ask themselves when using the caring model. The basic premise of each of the questions is that the nurse understands the patient's situation and expresses that to the patient in an effort to make a proverbial difference in the patient on an array of levels (p.1-2). Lachman (2012) writes that most nurses have been afforded the opportunity to ascertain the philosophical reasoning of Watson's caring model, but have not explored it as significantly as they can (p.114). As such, when a nurse makes the decision to become a nurse, they should be doing so on the basis of caring for the patient by any means necessary. Watson's caring model is useful in the sense that it creates an essence for the field to be responsible for the patients and to have a kind of mandatory bedside manner. In other words, becoming a nurse is not simply a professional decision, it is a personal one also.

Nursing Theory #2 – Myra Levine’s Conservation Model

Nursing Theory (2013) expresses that the conservation model created by Myra Levine has an assortment of objectives or principles that operate on the focus of "promoting adaptation and maintaining wholeness" (p.1). The theory makes several assumptions:

“The nurse creates an environment in which healing can occur.

A human being is more than the sum of his or her parts.

Human beings respond in a predictable way.

Human beings are unique in their responses.

Human beings know and appraise objects, conditions, and situations.

Human beings sense, reflect, reason, and understand.

Human beings' actions are self-determined, even when emotional.

Human beings are capable of prolonging reflection through strategies such as asking questions” (p.1).

These assumptions are created from what Levine noted as four principles of conservation: conservation of structural integrity, conservation of personal integrity, conservation of energy and conservation of social integrity. The particular principles assist nurses in accomplishing the specific objectives that they have in the profession. Levine's theory goes on to state what each principle is composed of: conservation of energy is defined as the balance of energy in the patient (i.e. getting proper rest, eating right and exercising); conservation of structural integrity expresses the continual maintenance of the body; personal integrity is identified as the patient being respected and being recognized by the nurse; and conservation of social integrity relates to the patient being recognized as someone who matters to the world and should be treated as such (Nursing Theory, 2013). Levin’s conservation model is more or less a framework for the nurse to have compassion and respect for the patients that they care for. Levine presents a compelling theory in that it puts a significant responsibility on the nurse to both treat the patient and subsequently, care for them. Levine’s theory goes on to discuss the environment and dissects the concept from both an internal and external context.

Nursing Theory (2013) adds that the model "explains the environment as completing the wholeness of the patient, who is seen as a holistic being who strives to preserve wholeness and integrity. The internal environment has two components - homeostasis and homeorrhesis" (p.1). Homeostasis is the synchronization of the mental, emotional and physical dynamics, while homeorrhesis describes the patient's body's capacity to sustain its well-being over a certain amount of time in spite of the environmental effects (Nursing Theory, 2013). The external environment per Levine's model has a total of three precise components: conceptual, preconceptual and operational. Conceptual refers to the cultural aspects that motivate or characterize the beliefs and attitudes of the patient. Preconceptual is noted as the patient's ability to incorporate the world around them into their mind and operational incorporates the various elements of how the patient is affected by their environment (Nursing Theory, 2013). Levine’s conservation model deals primarily with the patient and their environment and because of this rationale, it puts a notable emphasis not only on the nursing profession to treat and care for them but the patient as well. Many of the dynamics that are associated with the patient and their environment have to contend that this is how the patient will in effect deal with the many issues and dilemmas when they are being treated.

Monsen et al. (2010) argue that the conservation model is useful in the application of family home visiting. Nurses essentially can assess the unique characteristics of the environments in which they visit and decide the best approach to confront the specific predicaments that the patient is dealing with. The model is also unique in the sense that it is the driving factor behind the projected outcome of the patient care in that it presupposes that the nurse will be able to confront the obstacle that the patient is dealing with and subsequently heal that patient. Moreover, family home visiting allows for continuous surveillance of the types of externals that are contributing to the patient and their families. In using the Levine model is quite helpful because it puts the resources of the profession where they should and need to be (p.1036).

In addition to family home visiting, Levine’s conservation model is helpful in hospitals and clinical environments because it ensures that the nurse will be equipped to assess the patient, the respective environment and the adaptability of the patient to that environment. Much like Callista Roy's Adaption Model, Nursing Theory (2013) contends that Levine's conservation model requires a nurse to perform what is known as an organismic response on the patient. There are a total of four response types: fight or flight; stress; perceptual; and inflammatory. Furthermore, Levine's theory also states that each nurse should also perform what is referred to as a guided assessment of the patients that they see. This assessment includes: "vital signs, body movement, and positioning, ministration of personal hygiene, pressure gradient system, nutritional needs, pressure gradient system in the interventions of nursing, local application of heat and cold, administration of medicine and establishing an aseptic environment" (p.1). Even though Levine’s model is useful in its application in the field of nursing, one particular criticism of it is that it centers on a given period of time as far as the evaluation aspect. In other words, the criticism portrays the theory as a short-term one that should guide the field of nursing as opposed to something in the long term ("Levine's Four Conservation Principles," 2013). While this criticism is valid to a certain extent, reasoning suggests that because Levine's theory is based on the patient's adaptation to their predicament (i.e. environment), that the initial assessment/evaluation of the patient, in the beginning, would not necessarily be significantly different in the long-term as far as the emotional and mental dynamics. Essentially, the patient's beliefs about their dilemma will remain the same throughout, for example.

In order to better understand Watson’s model and Levine’s framework of conservation, there is a need to distinguish the two theories on the basis of whether they are grand theories or middle-range theories. Due to the expansive natures of both theories in terms of how extensive the concepts and principles are, they each are undoubtedly grand theories. In an article published by Sharon L. Dudley Brown entitled, "The evaluation of nursing theory: a method for our madness," there is a considerable argument surrounding the characteristics of what a grand theory must be composed of. In addition to the aforementioned reasons, there should be both consistency and fruitful component to them (p.78-80). Watson's theory both helps the profession to adopt an attitude of having a spirit of helpfulness toward the patients and allows for minimal objections on the basis of its structure. Levin's model equally describes the persistence of the nursing profession to examine the patient on factors that do not change. In other words, the knowledge obtained from both theories/models is consistent and fruitful to guide the field of nursing and each individual that opts to become a nurse.

Comparison and Contrast of Watson’s Theory and Levine’s Model

While the models are distinctively different, they are similar in some respects as well. First, Watson's model relays that nurses should have an emotional association with the patient on the reasoning that this allows them to better understand the patient and their problems, and to delineate a conclusion on how best to treat them. Levine's model of conservation has a similar premise in that it speaks to the nurse doing what they can to solve the issue that the patient is dealing with by assessing their environment. Levine's model of conservation uses the modus operandi of promoting the wellbeing of the patient through addresses the four principles, while Watson's theory also deals with promoting the physical and emotional wellbeing of the patient on the basis of the nurse's caring attitude and behavior toward the patient.

Second, they both deal with the environment of the patient. Watson's model contends that the nurse should encompass a caring nature and the promotion of certain teaching and learning methods in order to allow for a loving approach to the patient. The fundamentals of Levine's model relays that it is the environment that creates the wellbeing (both on an internal and external level). The patient's health is centered on the complexities of their body and how it responds to the environment. In the Levine model, the nurse is responsible for observing the patient and deriving facts and hypotheses on how best to treat the patient while Watson's model also puts the challenge on the nurse to both observe the best approach to the patient on how to handle the patient. The personal integrity component of the Levine model relates to the individual's self-worth and validation of who they are. In essence, how the patient feels about themselves and their illness. The nurse plays a pivotal role in that once the patient is diagnosed with their issue. Watson's theory proposes that the nurse also plays a crucial role in how the patient feels about themselves and their illness and diagnoses that it is the caring element or component that should be intertwined with the application of what to do.

Third, there is a notable emotional component with both models. Watson Caring Science Institute & International Caritas Consortium (2013) finds that transpersonal relationships "are the foundation of the work, conveying a concern for the inner life world and subjective meaning of another" and that this relationship is "influenced by the caring consciousness and intentionally of the nurse as she or he enters into the living space or phenomenal field of another person and is able to detect the other person's condition of being" (p.1). In essence, transpersonal is an emotional element that the nurse transcends when using the caring model of Watson in his/her operation. Moreover, the nurse according to the model is able to have what are known as caring occasions and caring moments with the patient. Watson Caring Science Institute & International Caritas Consortium (2013) states that a caring occasion is when the nurse and the individual come together in a particular association. The caring moment is the choice and following action by the individual patient and the nurse (p.1). Therefore, these particular instances unlock the emotional aspects of the individual who is treating the patient and in turn, ensure that the caring consciousness is at work.

As far as Levine's model of conservation, the emotional component in that framework deals with the overall assumptions that can be made from the theory. Also, each of the principles refers to the nurse having an emotional unification with the patient in that they have to monitor items such as adequate rest, nutrition and assess the familial aspects and belief systems of the patient in their assessment. Further, the model conceptualizes that the patient reacts to their environment on the basis of emotion in how they intercept their world, how they have dealt with the values and beliefs of the environment in which they live and the perceptions of the various forms of physical elements that have affected them.

Fourth, each model has an assessment component to it. Regarding Watson's model, the nurse is seen as becoming a caring individual with the intention of healing. In order to carry this objective out successfully, the nurse in approaching the transaction should hone in on the spirit of the patient and engage them. Given that Watson's model is essentially grounded in factors regarding having a loving, kind demeanor, the nurse in their assessment of the patient should relay this to the patient in trying to understand their needs. Further, each respective plan or regimen that is then created to address the patient's issue also must have an assessment component because the nurse has to ensure that the caring approach is guiding the execution of that plan by the patient. With Levine's model, the nurse uses an assessment to guide them in determining the best course of action in helping the patient achieve wellbeing. Given that the field of nursing involves tremendous interaction and communication with humans, the model suggests that each specific step within the assessment requires one or the other, or a combination thereof. Further, the guided assessment allows the nurse to also create a plan or regimen associated with the relationship that they have formed with the patient pre, post and during that assessment. These are the main similarities between the two models. There are also distinct differences between the two frameworks.

First, the basis of the model provided by Watson is that everyone is interconnected and that the nurse should have this perspective when treating patients. This perspective also draws on a spiritual component in its foundation. The structure of Watson's model is spiritual - and presupposes that the nurse should draw upon the creator/God/a supernatural force in their application toward the patient. In doing this, the nurse can then achieve a decision on how best to treat the patient by following the Caritas processes. The spiritual component also assists with how best to teach and instruct the patient in assessing the individual's beliefs and subsequent cultural practices. Basically, the nurse assesses the patient's attitudes and belief systems and forms their approach to addressing the ailment and/or illness. The spirituality of the patient then becomes the central focus of how the nurse addresses the patient.

Levine's model is quite different. Where Watson draws upon spirituality, Levine makes no mention of it. Instead, Levine discusses the attitudes and beliefs but does not indicate that the nurse should incorporate/integrate spirituality in dealing with the patient. Levine's framework is focused on the environment that the patient is both on an internal and external level and the effects associated with said statement. For Levine, wholeness is not spiritual but exists on the basis of an individual adapting to their environment. The nurse can, in essence, help the patient achieve this wholeness by stabilizing their environment as best as possible. This environment relies on a host of principles. Where Watson's model is an injection of something (spirituality) in order to achieve the desired outcome, Levine's model is a response-type examination of what has occurred prior in order to achieve a promising conclusion.

Secondly, Watson's theory tends to be thought of as a theory that should be used over a longer period of time. This particular theory is often used as a guide for situations and scenarios related to life transitions and the like (Goldin & Kautz, 2010). The Levine model, while potentially, used as a guide for ease of life transition, contends that an individual's environment is what drives them wellbeing and how the nurse will treat their predicament. Additionally, as previously mentioned, criticism of Levine's theory is that it is a short term guidance system for nurses in terms of how best to help patients achieve hope for the future. Third, Watson's theory has also been criticized as being difficult to utilize in practice due to the factors strictly pertaining to the spiritual aspects of the individual, and the nurse. Critics appear to denote that the ten factors of the theory do not address the biophysical needs (i.e. inner environment and outer environmental responses) of the individual. Instead, the focus is mainly on the context of the patient, their spirituality and how best to encourage them to get well via faith and hope.

Conclusion

Due to the broad dynamics of grand theories, it can be stated that both Levine's and Watson's models can be examined again and again as far as their viability in approaching how best to cure patients that nurses see. Grand theories are difficult to analyze and examine because there tend to be concepts between concepts within them. This is why both theories can be utilized, and have been utilized in nursing practice - and continually face criticism. Despite the specifics of the theories in terms of what their basic foundation is - the language within them is quite intricate. Each model is logical and relatively simple to understand, but both are noted as having drawbacks and limitations in their usage in the profession.

Moreover, upon evaluation of the theories, data from research studies and the like tends to generate additional hypotheses and potentially more theories. This is precisely why both theories are characteristic of grand theories, in spite of the straightforward concepts that they encompass. There isn't necessarily a decision as to one of the models being better than the other. Each has their respective useful application in the field and provide additional understanding of why nursing is such a profound field, to begin with. Nursing theories since their emergence and the subsequent impact on the field have redefined how the profession evolves to the point where the field would have a difficult time operating without them.

References

Dudley-Brown, S. L. (1997). The evaluation of nursing theory: A method for our madness. International Journal of Nursing Studies, 34(1), 76-83.

Goldin, M., & Kautz, D. D. (2010). Applying Watson’s caring theory and Caritas processes to ease life transition. International Journal for Human Caring, 14, 11-14.

Lachman, V. D. (2012, March). Applying the Ethics of Care to Your Nursing Practice. Medical-Surgical Nursing, 21(2), 112-116.

Levine's four conservation principles. (2013, September 9). Current Nursing. Retrieved from http://currentnursing.com/nursing_theory/Levin_four_c onservation_principles.html

Monsen, K. A., Banerjee, A., & Das, P. (2010, August 11). Discovering client and intervention patterns in home visiting data. Western Journal of Nursing Research, 32(8), 1031-1054. doi:10.1177/0193945910370970

Nursing theory. (2013). Retrieved from http://nursing-theory.org/articles/nursing-theory-definition.php

Watson Caring Science Institute & International Caritas Consortium. (2013). Retrieved from http://watsoncaringscience.org/about-us/caring-science-definitions-processes-theory/

Watson, J. (2010). Core concepts of Jean Watson’s Theory of Human Caring/Caring Science. Watson Caring Science Institute. Retrieved from http://watsoncaringscience.org/files/Cohort%206/watsons-theory-of-human-caring-core-concepts-and-evolution-to-caritas-processes-handout.pdf