Modeling and Role-Modeling:

A Theory and Paradigm for Nursing.

            Erickson, Helen Cook (1936-)

            Modeling and role-modeling

            Bibliography: p. 256-283

            Includes index

1. Nursing-Philosophy.  2. Values-Study and teaching. I Tomlin, Evelyn Malcolm (date-) II. Swain, Mary Ann Price , (date-). III. Modeling and Role-modeling: A theory and paradigm for nursing. {DNLM: 1. Nursing. 2. Nurse-patient relations. 3. Role-Nursing texts. WY 87E68m]  RT84.5.E74  1983    610.73   82-13286

ISBN 0-9763385-0-5

Copyrighted 1983 by Prentice-Hall, Inc. Englewood Cliffs, N.J. 07632

Copyright assigned February 18, 1988, by Appleton and Lange to:

EST Company

All rights reserved. No part of this book may be reproduced in any form or by any means without permission in writing from the authors.

Published and distributed by EST Company, 406 Trail Ridge Dr., Cedar Park TX 78613

Email: mrmbook1@yahoo.com

Related work: http://www.mrmnursingtheory.org/References.htm

Contents

5

 

2

25

Theoretical Bases: How People Are

Developmental Tasks and Basic-Needs

Modeling and Role-Modeling: A Paradigm

How Does One Aggregate, Analyze,

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Foreword

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        I feel deeply honored to be writing the foreword for this book, as my close association with the authors has provided me with my most meaningful experiences in the development of my nursing practice. Each author, in her own unique way, has stimulated me to become the best nurse I could possibly be, while collectively they have been a continual inspiration.

I first became associated with Mary Ann Swain during my early efforts with nursing research. I remember so clearly the number of times my research partner and I sat in her office worrying that our data did not demonstrate the significant differences we had expected related to our specific nursing interventions. Yet Mary Ann kept saying, “But look what you do have. Look at the number of times patients said (on the questionnaire) that the nurse was the most helpful factor in their hospital experience. What do you suppose that means?” she would ask. “What were you doing that was helpful? Why was it meaningful?”

We certainly did not know then. The health teaching and pain medications we had instituted were not mentioned as helpful. But Mary Ann continued to ask. Over the years she has listened closely to all my efforts to understand my practice, and has the unique ability of finding and developing the central themes in what I have said.

        Moreover, Mary Ann has provided the environment, both the physical space and the milieu, to help me and others carry out nursing research. She has provided the opportunity, as well as the research knowledge and support to help us develop and understand our nursing practice.

 Helen Erickson’s very special contribution to this volume, as well as to helping me with my own practice, is her extensive knowledge of great teachers and scholars such as Abraham Maslow, Erik Erikson, and Milton Erickson, as well as the others whose work appears here. More importantly, however, she has taken their work, added nursing theory, synthesized it all with a nursing perspective, and demonstrated how the resulting overall theory supports an effective paradigm (or design) to use in nursing practice.

Helen has explained many times to me the ideas and concepts presented by these scholars, and related the theory and paradigm that she and her colleague authors have developed until I came to understand. Everything Helen has said over the years has been so clear, so practical, that I am often surprised to find myself saying to her such things as, “Can we go over the story of Sue again? Why was it right for the nurses to let her be dependent on them for care?” Each time I listened, I understood more and gained new insights. Although I don’t intend to stop asking and discussing, I am glad to have this volume finally available to me for as much rereading as I like.

Evelyn Tomlin and her nursing practice are a clear validation that the theory and paradigm presented in this book work, not only most of the time, but beyond my highest expectations. Evelyn has been my role model, mentor, colleague, and friend. She has often been my nurse, and sometimes even my client.

Sharing an office for the past five years has afforded us many opportunities for meaningful discussions during which we have articulated and refined our ideas about nursing. It has been Evelyn’s strong practice component with example after example of clients’ positive response to her nursing care that finally helped me internalize these concepts and apply them to both my practice and my teaching.

My own growth in nursing related to this theory and paradigm can be demonstrated in three clinical experiences which I would like to share with the reader. I was asked one day to provide diabetic education to Greg, a 21-year-old man whose chart described him as “hostile and aggressive.” I soon discovered that he was certainly very bitter, and also that he knew a great deal about diabetes and did not need instruction. The clinic nurse had thought that more education would help him manage his insulin reactions and thus he would be able to hold a job. The doctors believed he was using his illness as an excuse to stay on welfare.

Greg’s bitter attitude softened as he talked to me. He realized that I cared about him, even though he also knew I couldn’t help him. I honestly tried, but I was at a loss. I even wrote a paper about this man later, to try to gain insight, but learned little. Within a few weeks, I heard that he had been committed to a state hospital.

            Edith was a 50-year-old woman with vulvectomy surgery, who was described by the nursing staff as “unreasonable, manipulative, and a malingerer.” She refused to participate in her care, ate little, and would not get out of bed. One nurse tried to do some contracting with her, while another tried to have the doctors provide parenteral nutrition. Most of the nurses, however, were furious with her, believing she was trying to manipulate them. I kept saying that she was really ill and simply could not do what was asked of her.

            When Edith developed septicemia and died, one nurse said, "Well, you were right. She was ill." But I was puzzled. The septicemia had not been present at the start of her postoperative course. Physiologically, she had been in fine condition, which was why everyone insisted that she do her own care. I had been right, but I didn't know why. I did not understand why we failed some of our patients so utterly. I knew that persons often responded well to my approach, recognizing that I cared about them. But it was not enough, and the good feelings they had for a little while did not last.

            The answers came gradually over the years as I worked with Mary Ann, Helen, and Evelyn. Thus I share my third example. Karen was a young woman recovering from surgery. She had struggled to cope with a disease, surgery, and family concerns all at once. She was angry a good part of the time and often refused to speak to us. Since I had admitted her and performed much of her postoperative care, we did have some rapport.

            One morning, I was greeted by her physician who said, "Well, you'll have your hands full with Karen today. She's refusing to cough, and has announced she won't get out of bed. You've got to make her understand that if she doesn't do as she's told, the result will be pneumonia." He was obviously exasperated. I went to Karen. She turned away from me with lips set and arms folded tightly across her chest, refusing to acknowledge my greeting. I said, "I think you are unhappy, Karen. Can we talk about it?" She was quiet for another moment and then, still without looking at me, blurted out, "I'm not getting out of bed and nothing you can say will make me!" I replied that she was certainly right about that, and I was not going to try to make her get up. However, I told her that I was puzzled, as she had been walking all around and feeling good just yesterday. Very gently I touched her arm and she didn't pull away. Gradually she began to cry, saying she hated this place and just wanted to go home. She missed her family so much.

            Karen, of course, had been well instructed on the necessities of postoperative care and its goal of discharge as soon as possible. She had even indicated, the day before, that she knew that the frequent ambulation was making her stronger. I did not know what in particular had caused her current distress, but I was no longer perplexed by this kind of response. Her posture was relaxing, so I took her hand, and said: "I don't wonder you're tired of this place, and it is lonely when your family can't visit very often. Besides that, some days after surgery are just rough. You're entitled to feel rotten! After all, your body has been through a lot. Why don't I let you rest for a while, say a half hour, and then we'll start planning how to get you home faster."

            When I returned, Karen was up and making her bed. She smiled as she sat down, and let me finish the bed. "I don't know why I behaved that way. It was stupid. After you left I told myself to get moving or I never would be strong enough to go home."

            Later that morning I told the physician that Karen was fine and doing all her care. He was amazed, asking me what in the world I had said to her. I replied that, since she considered me trustworthy, when I pointed out some of her strengths and my positive expectations for her, she believed me. He looked puzzled. After all, he had been trustworthy also. But then he shrugged and said that it probably didn’t matter as long as she was back on track.

 But it does matter. It matters terribly. Most nurses can share with me the knowledge that an attitude like Karen’s that morning can become a major problem, or even a disaster. The words and touch I used were planned from a nursing framework. I helped her remember that she was stronger than she thought at the moment, but that it was okay to have a brief relapse. I indicated that she was going to do well and that together we could plan ways to achieve her goal of leaving the hospital more quickly. Her self-care abilities came forward, and no mention of pneumonia or more instruction was ever made.

The principles suggested in the care of Karen and a great deal more are described in this volume. And so I invite the readers to join me in an exciting nursing adventure as we read and reread this book. It is the book that nurses have been waiting for. Read it and become!

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Preface

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    Introduction

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Modeling and Role-Modeling:

A Paradigm for Nursing Practice

OVERVIEW

In the preceding chapters we presented our philosophy, definition of nursing, theoretical bases from which we work, and our own theoretical statements about the relationships among these theory bases. We now describe our paradigm for the practice of professional nursing, emphasizing two major concepts: modeling and role-modeling. Since these terms have several connotations, we will be very specific about our definitions. We will describe each explicitly and then we will summarize the relationship between the two (1).

MODELING

The term modeling is often defined as the act of imitating a standard or copying a representation of something. The word model often refers to the standard or representation to be copied. In Chapter 5 we stated that each individual has a unique model of his or her world. One perceives one’s environment from one’s own perspectives, based on one’s experiences, past learnings, state of life, and so forth. The act of modeling, then, is the process the nurse uses as she develops an image and understanding of the client’s world—an image and understanding developed within the client’s framework and from the client’s perspective.

            Modeling contains the art and the science of nursing. That is, the art of modeling is the development of a mirror image of the situation from the client’s perspective. It requires communication skills basic to nursing. These skills will help the nurse put one foot into a word foreign to herself. The science of modeling is the scientific aggregation and analysis of the data collected about the client’s model. The science of modeling requires keeping the other foot firmly planted in the theoretical bases discussed above.

 ROLE-MODELING

 Role-modeling cannot occur until the nurse has modeled her client’s world and has aggregated and analyzed the constructs of that world. Role-modeling is the facilitation of the individual in attaining, maintaining, or promoting health through purposeful interventions. These interventions are planned based on the data analyses.           

Role-modeling is also both an art and a science. The art of role-modeling occurs when the nurse plans and implements interventions that are unique for her client. The science of role-modeling occurs as the nurse plans interventions with respect to her theoretical base for the practice of nursing. For example, a client might have basic unmet security needs and be working on the stage of autonomy. Scientifically, the nurse would plan interventions that would promote perceived trust and control, but these interventions would have to be designed based on the individual’s personal perceptions and beliefs—the individual’s model of the world.

            Role-modeling is, in our minds, the essence of nurturance. It is the basis for the predictive and prescriptive component of nursing practice. Role-modeling requires an unconditional acceptance of the person as the person is while gently encouraging and facilitating growth and development at the person’s own pace and within the person’s own model.

MODELING AND ROLE-MODELING

One author had a client whose developmental history resulted in nonresolution of all of the developmental tasks. Her basic-need deficits were multiple and severe; she had experienced those deficits throughout her 28 years. Her recurrent mode of trying to satisfy those basic needs (modeling) was to alternate between showering others with gifts (“I don’t need anything. I’ll give to you”) and becoming gravely ill, necessitating hospitalization (“You take complete care of me”). Her basic-need deficits were seen graphically in her inability to identify any personal strengths. In an attempt to move this client toward a healthier state, the nurse gave this client gifts of her strengths (role-modeling). That is, the nurse wrote down strengths she had identified in this client, wrapped them attractively, and presented them as gifts (2).

            We have found it preeminently important to enter for a time into our client’s world, to share as empathetically as we can the client’s model of it. As we work from within that model—in a true partnership with our client—we are better able to support adaptive coping and suggest strategies that are acceptable to both nurse and client. Modeling occurs as the nurse accepts and understands her client; role-modeling starts the second the nurse moves from the analysis phase of the nursing process to the planning of nursing interventions.

            Because each one has a personal model of the world, people with nursing needs are not helped in standardized ways. We do not have it within ourselves to know how a unique individual may best be helped; only the individual knows the kind of help he or she needs to mobilize strengths and resources. At some level, people know what has made them sick or distressed, and they know what will make them well or help them feel better. If people do not know this consciously, a skillful nurse can help them learn to know and express themselves, thus identifying the particular assistance they want and need. It is in this context that our concept of self-care has taken shape. For us, self-care is not merely a choice of options within a framework chosen for a patient or designated by the nurse or other professional. We believe self-care for health is broader than that. Our experiences in nursing have convinced us that people have more control and responsibility over their health than they (or their care providers) often realize. They will take that control when they are permitted, invited, and patiently encouraged to do so. In the long run, the one person best equipped to remain in charge and ultimately accountable for goal setting and coordination of his or her own health care is the consumer who contracts for help.

            When we refer to the responsibility people have for their health care, it is not our intention to assign blame for deviations from desired states of comfort and function. Rather, since each person has a unique model—a specific way of getting basic needs met—each person also has the key to what he or she personally needs.

            People also know best their individual timing for change. As they live in families and societies that are inevitably affected by changes in one member, they may move toward change more slowly than we might desire. It frees us from assuming inordinate responsibility to remember that, however great our concern and good will for our clients, making a decision to change is ultimately their prerogative and should be done according to their timeline. Indisputably, they have control over such decisions and we always keep this in mind. We can extend genuine invitations to live and to live well, while standing by without rejecting or abandoning our clients. While waiting and unconditionally accepting them, we continue to facilitate and nurture their growth and development. Nurses interested in providing holistic care will find that modeling and role-modeling will give them freedom to help their clients explore and utilize many alternative means to attaining, promoting, and maintaining health. There are more ways than one to relax, lose weight, reduce pain, fight infection, heal wounds, walk again, “get better,” and so forth.

SUMMARY

Our paradigm for the practice of professional nursing integrates modeling and role-modeling. Modeling is the process by which the nurse seeking to understand her client’s unique model of the world. Role-modeling is the process by which the nurse understands that unique model within the context of scientific theories and, using that same perspective of her client’s unique model, plans interventions that promote health. In Part III we will deal with how these concepts are applied in the nursing process.

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