M7-Assignment
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ReadingAssignmentforM7.docxChapter12
Introducing the Theorist
My life journey, filled with challenges and opportunities, helped me discover the essence of my Self, understand my Reason for Being, and uncover my Life Purpose (H. Erickson, 2006a). My Self is reflected in my values and beliefs; my Reason for Being is to learn that unconditional love is the key to human relationships; and my Life Purpose is to facilitate growth in others. The following snippets of my journey offer an occasional glimpse into my Self and the underlying philosophy of modeling and role-modeling (MRM).
Born and raised in north-central Michigan with one older brother and two younger sisters, I learned that our early experiences affect who we become. My father worked for the highway department; our mother cared for the family and worked part-time as a retail clerk. I learned that family connections, caring about others, positive attitudes, respect for the environment, and hard work are essential.
I was 5 years old when World War II was declared. Although too young to understand the implications of the war, I learned that it was important to stand up for our beliefs and life principles.
I learned that anything is possible if we are persistent, our goals have integrity, and we are honest with others and ourselves. I started working when I was about 10 years old. My jobs included babysitting, keeping house for a family in need, waitressing, and clerking. Each was an opportunity to learn about myself, and each was a step toward nursing school.
I enrolled in a diploma program for nurses, and in my junior year, I met my future husband and his family. His father, Milton Erickson, well known for his work with mind–body healing, taught me that people know more about themselves than health-care providers do, that their inner-knowing is essential to healing, and that we can help them by attending to their worldview. I committed to married life, moved to Texas, and accepted the position of head nurse in the emergency room of the Midland Memorial Hospital.
Between 1959 and 1967, I worked in a variety of settings in Texas, Michigan, and Puerto Rico and welcomed four children into our family. I learned valuable lessons about blind prejudice, discrimination, and staying true to self; about how personal stories provide insight into client needs; and about the uniqueness of people and how limiting labels did not capture their wholeness. I had opportunities to develop a professional practice model.
In 1974, I completed my RN-BSN program at the University of Michigan and was recruited as a faculty member and consultant at the University Hospital.
I enrolled in the master’s program in medical–surgical and psychiatric nursing and graduated in 1976. During this time, Evelyn Tomlin and I talked freely about the nursing model I had derived from practice. I labeled and developed the adaptive potential assessment model and worked with Mary Ann Swain to test some of my hypotheses (H. Erickson & Swain, 1982). I continued in my faculty position and advanced to chairman of the undergraduate program and assistant dean.
Over the next 10 years, my model of nursing acquired a life of its own. By the early 1980s, I had speaking invitations but little had been written (H. Erickson, 1976; H. Erickson & Swain, 1982). Together Evelyn, Mary Ann, and I further elaborated some of the concepts. The term modeling and role-modeling (MRM), first coined by Milton Erickson, was selected as the best descriptor of this work. The original edition was printed in November 1982 (H. Erickson, Tomlin, & Swain, 2009), has had eight reprints, and is now considered a classic by the Society for the Advancement of Modeling and Role-Modeling (SAMRM). I completed my PhD in 1984, left Michigan in 1986, spent 2 years at the University of South Carolina School of Nursing as associate dean of academic affairs and then moved to the University of Texas, where I assumed the role of professor and chair of adult health nursing. When I retired in 1997, the Helen L. Erickson Endowed Lectureship on Holistic Nursing was established at the University of Texas in Austin.
I have authored or coauthored chapters on MRM and/or holistic nursing (Clayton, Erickson, & Rogers, 2006; H. Erickson, 1996, 2002, 2006b, 2006c, 2006d, 2006e, 2007, 2008; M. Erickson, Erickson, & Jensen, 2006; Walker & Erickson, 2006), some of which are included in the second book on MRM, and more recently, a book on the relationship between the philosophy and discipline of holistic nursing. I know now that advancing holistic health care is my mission, my life work; MRM is a vehicle for that purpose.1
Overview of Modeling and Role-Modeling Theory
MRM is based in several nursing principles that guide the assessment, intervention, and evaluation aspects of practice. These principles, reflected in the data collection categories (H. Erickson et al., 2009, pp. 148–168), are linked to intervention aims and goals (H. Erickson et al., 2009, pp. 168–201). Although both intervention aims and goals involve nursing actions, they differ in their purpose. Nursing interventions should have intent; nurses should aim to make something happen that facilitates health and healing when they interact with clients. There should also be markers that help us evaluate the efficacy of our activities—intervention goals. Table 12-1 shows the relations among MRM principles of nursing, data needed to practice this model, the aims of nursing actions, and specific goals.
Modeling
The modeling process involves assessment of a client’s situation. It starts when we initiate an interaction with an individual and concludes with an understanding of that person’s perspective of their circumstances. We aim to learn how that individual describes the situation, what he or she expects will happen, and his or her perceived resources and life goals. As we listen and observe, we interpret the information using the constructs embedded in the theory. Stated simplistically, modeling is the process we use to build a mirror image of an individual’s worldview. This worldview helps us understand what that person perceives to be important, what has caused his or her problems, what will help, and how he or she wants to relate to others.
Table 12 • 1 Relations Among Principles, Data Categories, Intervention Goals, and Aims
Principles Categories of Data Goals Aims
The nursing process requires that a trusting and functional relationship exist between nurse and client. Description of the situation Develop a trusting and functional relationship between self and your client. Build trust.
Affiliated-individuation is contingent on the individual’s perceiving that he or she is an acceptable, respectable, and worthwhile human being. Expectation Facilitate a self-projection that is futuristic and positive. Promote client’s positive orientation.
Human development is dependent on the individual’s perceiving that he or she has some control over life while concurrently sensing a state of affiliation. (External) Resource potential Promote affiliated-individuation with the minimum degree of ambivalence possible. Promote client’s control.
There is an innate drive toward holistic health that is facilitated by consistent and systematic nurturance. (Internal) Resource potential Promote a dynamic, adaptive, and holistic state of health. Affirm and promote client’s strengths.
Human growth is dependent on satisfaction of basic needs and is facilitated by growth-need satisfaction. (Internal) Resource potential Promote (and nurture) coping mechanisms that satisfy basic needs and permit growth-need satisfaction. Set mutual goals that are health directed.
Goal and life tasks Facilitate congruent actual and chronological development stages.
Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling: A theory and paradigm for nursing (p. 171). Cedar Park, TX: EST.
Table 12-2 shows the categories of data and the type of information needed in the modeling process.
Table 12-3 shows the priority given to the information we collect. Primary data are acquired from the client; secondary data include the nurse’s observations and information from the family. Tertiary data include information from medical records and other sources. Primary and secondary data are essential for professional practice, whereas tertiary data are added as needed.
Role-Modeling
The role-modeling process requires both objective and artistic actions. First, we analyze the data using theoretical propositions in the MRM model (Table 12-4; H. Erickson et al., 2009, pp. 148–167). We interpret the meaning of what has been provided and search for linkages among the data that will help us understand the client’s worldview. As we analyze the data, implications for nursing actions emerge (H. Erickson et al., 2009, pp. 168–220). Nursing actions are then artistically designed with intent (i.e., the aims of interventions) and specific outcomes (i.e., intervention goals). Our overall objectives are to help people grow and heal and to find meaning in their experiences. The following sections elaborate each of these objectives. The first section addresses the philosophical assumptions that underlie this model; theoretical underpinnings follow with implications for practice. Finally, the global applications of MRM are presented.
Table 12 • 2 Categories of Data and Purpose for Obtaining Data
Categories of Data Collection Purpose of Data Is to Obtain
Description of the Situation
1. An overview of client’s perception of the problem
2. The etiology of the problem including stressors and distressors
3. Client’s perceived therapeutic needs
Expectations
1. Immediate expectations
2. Long-term expectations
Resource Potential
1. External: Social network, support system, and health-care system
2. Internal: Self-strengths, adaptive potential, feeling states, physiological states
Goal and Life Tasks
1. Current goals
2. Plans for future
Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling: A theory and paradigm for nursing (p. 119). Cedar Park, TX: EST.
Table 12 • 3 Sources of Information
Primary Source Client’s self-care knowledge
Secondary Source Tertiary Source Information from family and nurses’ observations Medical records and other information related to client’s case
Table 12 • 4 Selected Theoretical Propositions in MRM Theory
1. Developmental task resolution is related to basic need status.
2. Growth depends on basic need status and is facilitated by growth need satisfaction.
3. Basic need satisfaction leads to object attachment.
4. Object loss leads to basic need deficits.
5. Affiliated-individuation is dependent on one’s perception of acceptance and worth.
6. Feelings of worth result in a sense of futurity.
7. Development of self-care resources is related to basic need satisfaction.
8. Ability to mobilize coping resources is related to need satisfaction.
9. Responses to stressors are mediated by internal and external resources.
10. Ability to mobilize appropriate and adequate resources determines resultant health status.
Philosophical Assumptions
Nursing has a metaparadigm that includes four extant constructs: person, environment, health, and nursing; sometimes social justice is added as a fifth construct (Schim, Benkert, Bell, Walker, & Danford, 2007). The operational definitions of these constructs provide the context necessary to clarify how an individual’s actions are unique to nursing as opposed to the actions of another profession. Although all nursing theories are developed and articulated within this context, our personal philosophy affects how we define and operationalize the constructs of nursing and therefore how we articulate our models (H. Erickson, 2010). For this reason, it is important to be clear about our own philosophical beliefs and how they affect our conceptual definitions and our theoretical models. Nurses can use clear philosophical statements to determine whether the underpinnings of a theoretical model are consistent with their own belief systems (H. Erickson, 2010). When they are not, discrepancies among nursing’s philosophical beliefs, the nurse’s personal belief system, and the theoretical propositions often create dissonance that impedes the nurses’ ability to use the model (H. Erickson et al., 2009). The philosophical assumptions underlying the MRM theory and paradigm are described in the text that follows. The first section presents MRM’s orientation toward two of nursing’s metaparadigm constructs: person and environment. Health, nursing, and social justice are described in the following sections.
Person and Environment
Humans are inherently holistic. This means that all aspects of the human are interconnected and dynamically interactive; what affects one part affects another. This is different from the wholistic person, wherein the parts are associated but not necessarily interconnected or interactive (Fig. 12-1). When we approach people from a wholistic perspective, we can break them down into systems, organs, and other parts. When we view them as holistic, we understand that all the dimensions of the human being are interconnected; what affects one part has the potential to affect other parts. Our holistic nature is manifested through our innate instincts and drives: instincts and drives necessary for humans to maneuver through the pathways of their life journey. Table 12-5 provides examples of each of these. Although some might argue that all animals have an innate instinct to cope and some have an innate ability to receive and interpret stimuli, most would agree that not all animals have an innate drive to receive stimuli in a cognitive form, to acquire skills necessary to perceive and understand stimuli, to give and receive feedback, the freedom to speak, or the freedom to choose. These latter characteristics are unique to the human species, are innate, and often motivate our behavior (Maslow, 1968, 1982). I have added one instinct—an inherent instinct for holistic well-being—and two human drives: the drive for healthy affiliated-individuation and the drive for self-actualization. These instincts and drives affect how we function as holistic beings. The holistic person is one in whom the whole is greater than the sum of the parts, whereas a wholistic person is one in whom the whole is equal to the sum of the parts (H. Erickson et al., 2009, pp. 45–46).
Selected List of Human Instincts and Drives
Instincts Inherent in Human Nature To receive and interpret stimuli
To cope and adapt to stressors
To experience mind–body–spirit intraconnectedness, or holistic well-being
Drives That Motivate Our Behavior To cognitively interpret stimuli
To acquire skills necessary to perceive and interpret stimuli
To give and receive feedback
To communicate freely
To choose and act freely
To experience balanced affiliated-individuation
To be self-actualized
As holistic beings, our mind, body, and spirit are inextricably interrelated with continuous feedback loops. Cells in each dimension can produce stimuli affecting responses in cells of other dimensions. Cellular responses have the potential to become new stimuli, moving the chain reaction around and among the dimensions of the human being. These interactions are dynamic and ongoing. Because we have an internal environment (i.e., within the confines of our physical being) and an external environment (i.e., outside the confines of the biopsychosocial being), external stimuli have the potential to create multiple internal responses, and vice versa. To agree that we are holistic is to believe that we are human beings, living in a context that includes all that is within us and within our external environment—holistic beings, constantly in process both internally and externally. These dynamically interactive dimensions cannot be separated without a loss of information about the person, a loss that diminishes our ability to fully understand the person’s situation.
Humans are inherently intuitive. We know (at some level) what we need. We know what has made us sick and what will help us get well, grow, develop, and heal. We have instinctual information about our own personhood and our mind–body–spirit linkages. This information is called self-care knowledge. Our perceptions of what we have available to help us are called self-care resources. Self-care resources are both internal and external. We have resources within ourselves as well as resources within our external environment. Our actions, thoughts, biophysical responses, and behavior that help us get our needs met are our self-care actions. We are inherently social beings with an innate drive to grow and develop, to become the most that we can be, find meaning in our lives, fulfill our potential, and self-actualize. However, we are vulnerable. Our ability to grow and develop is dependent on repeated satisfaction of our needs. We want and need to be connected or affiliated to others in some way. Simultaneously, we also need to perceive ourselves as unique and individuated from these same people. We call this affiliated-individuation (Acton, 1992; H. Erickson et al., 2009, p. 47; M. Erickson et al., 2006, pp. 182–207). Our drive to be both affiliated and individuated at the same time mandates a balance between being connected while perceiving a sense of one’s self as a unique human being, separate from others. We achieve our drive for a balanced affiliated-individuation through our interactions with others. How well we achieve this balance at any point in our life will determine how we relate to others in the following years.
Although we are social beings with a drive for affiliated-individuation with others, we are also spiritual beings with an inherent drive to be connected with our soul (H. Erickson et al., 2009, 2006). More specifically, our drive for individuation is to fulfill our psychosocial needs while doing soul-work unique to our life journey.
Health
Health is a matter of perception. It is a state of well-being in the whole person, not just a part of the person. It is not the presence, absence, or control of disease; one’s ability to adapt; or one’s ability to perform social roles. Instead, it is a eudemonistic health that incorporates all of these and more. It is a sense of well-being in the holistic, social being. It includes one’s perceptions of her life quality, her ability to find meaning in her existence, and a capacity to enjoy a positive orientation toward the future. As a result, personal perceptions of health may differ from those of others. It is possible for persons with no obvious physical problem to perceive a low level of health, while at the same time others, taking their last mortal breath, may perceive themselves as very healthy. The perception of health status is always related to perceived balance of affiliated-individuation.
Nursing
Nursing is the unconditional acceptance of the inherent worth of another human being. When we have unconditional acceptance for another person, we recognize that all humans have an innate need to be loved, to belong, to be respected, and to feel worthy. Unconditional acceptance of a person as a worthwhile being is not the same as accepting all behaviors without conditions. It does mean, however, that we recognize that behaviors are motivated by unmet needs. Our work, then, is to help people find ways to get their needs met without harming themselves or others.
We do this through nurturance and facilitation of the holistic person. Our goal is to help people grow, develop, and, when necessary, to heal. We use all of our skills acquired through formal education as well as our own innate ability to connect with others to help them recover from illnesses and to live meaningful lives. We do this from the beginning of physical life to the end, even as people are taking their last breath. Within this context, our intent, or what we aim to facilitate when we interact with another human being, is important.
Social Justice
As professional nurses, we are committed to live by the ethics of our profession, serve as advocates for our clients, and serve the public as defined by our professional standards. For nurses who use the MRM theory, this means that we are committed to recognize the individual’s worldview as valid information, to act on that information with the intent of nurturing and facilitating growth and well-being in our clients, and to practice within the context of the Standards of Holistic Nursing as defined by the American Holistic Nurses Association (AHNA, 2013) and recognized by the American Nurses Association (ANA, 2008).
Theoretical Constructs
People have an innate instinct to cope and adapt to stressors and related stress responses that confront us constantly. We adapt as much as we are able to, given our life situation. We need oxygen, glucose, and protein to maintain our physical systems; we also need to feel safe and to be loved. When these needs are perceived to be unmet, they create stressors; stressors produce the stress response. Stress responses can become new stressors mandating still more responses, and so on (Benson, 2006, pp. 240–266; H. Erickson, 1976; H. Erickson et al., 2009). Many of our stress responses are instinctual, a part of our human makeup; however, some have to be learned and developed. As our needs are met, the stressors decrease; and we are able to work through the stress response.
Adaptive Potential
Our ability to mobilize resources at any moment in time can be identified as our Adaptive Potential. The adaptive potential assessment model (APAM; Fig. 12-2), first labeled in 1976 (H. Erickson, 1976; H. Erickson & Swain, 1982; H. Erickson et al., 2009), was derived by synthesizing Selye’s (1974, 1976, 1980, 1985) work with that of George Engel (1964). Our adaptive potential has three states: equilibrium, arousal, and impoverishment. Equilibrium, a state of nonstress or eustress, represents maximum ability to mobilize resources. The individual in equilibrium is in a healthy balance between need demands and need resources.
Arousal and impoverishment are both stress states; needs are unmet, creating stressors and the related stress responses. However, people in arousal are temporarily able to mobilize their resources, whereas those in impoverishment are not. Persons in the first group (arousal) need help solving their problem, finding alternatives. They tend to be tense and anxious but do not demonstrate depleted resources through the expression of fatigue and sadness. On the other hand, impoverished people show the wear and tear of prolonged stress. They have diminished physical resources and are fatigued and sad. People in arousal are at risk for becoming impoverished, and impoverished people are at risk for depleting their resources, getting sick, developing complications, and even dying (Barnfather, 1987; Barnfather & Ronis, 2000; Benson, 2006, pp. 242–254; H. Erickson, 1976; H. Erickson et al., 2009, pp. 75–83; H. Erickson & Swain, 1982). As indicated, a person’s ability to cope is related to how well his or her needs are met at any given point in time.
Human Needs
Human needs, classified as basic, social, and growth needs, drive our behavior. They provide motivation for our self-care actions and emerge in a quasi-hierarchical order. Physiological needs must be met to some degree before social needs emerge. Growth or higher-level needs emerge after the basic and social needs have been met to some degree (for a more detailed taxonomy of human needs, see H. Erickson, 2006a, pp. 484–485). Basic needs are related to survival of the species. When they are unmet, tension rises, motivating behavioral response(s) necessary to decrease the tension. When self-care actions decrease the tension, the need dissipates. When the need is completely satisfied, the tension disappears. When needs are met repeatedly, need assets are built. Conversely, when the need is not met, the tension rises, and need deficits emerge. When the tension continues, need deprivation exists. Need status can be classified on a 0 to 5 scale ranging from deprivation to asset status (Fig. 12-3). Growth needs are different. Because people have an innate drive for self-actualization, growth needs emerge when basic needs are met (to some degree). Unmet growth needs do not create tension unless they are related to a basic need. Instead, satisfaction of growth needs creates tension. The need increases in intensity. Until one feels satiated, the need to continue to behave in ways that will meet growth needs continues.
Need Satisfaction and the Object Attachment Process
Objects that repeatedly meet humans needs become attachment objects. These objects take on significance unique to the individual, are both human and nonhuman, have a physical form (so they stimulate one of the five senses) or are abstract (such as an idea), and are necessary throughout life. When a person perceives that the object is or will be lost, a grieving response occurs. Loss is a subjective experience known by the individual; it can be real, threatened, or perceived. Any loss produces a grieving process. One’s difficulty in resolving the loss depends on the significance of the lost object. The grieving response is normal, occurs in a predetermined sequence, and is self-limited. Normal grieving processes take about 1 year (Fig. 12-4). Grief resolution occurs as the individual finds new ways to view the lost object or finds alternative objects that meet their needs. Commonly accepted processes of grief include sequential phases of shock/disbelief, anger, bargaining, sadness, and acceptance (Kübler-Ross, 1969). Other models (Engel, 1964; Bowlby, 1973) indicate slightly different phases (M. Erickson, 2006, p. 229). Table 12-6 compares three of these models. I believe that their differences are based in the nature of the lost object, its meaning to the individual, and the resources accrued before the experienced loss. Resources are based on one’s ability to work through the normal developmental tasks encountered during the human journey. This issue is discussed further in the text that follows.
Attachment to new objects is necessary for continued growth and grief resolution. The new object can be the same object, perceived in a new way, or a completely new object. Sometimes transitional objects are used to facilitate this process. Transitional objects are those that symbolize the lost object and are never human, but are almost always concrete. For example, mothers attached to their children as preschoolers often experience a loss when their children start school and become increasingly independent. It is common to see these mothers attach to their child’s baby shoes, pictures, or some other symbol of who they were in their previous life stage.
Fig 12 • 4 The need–attachment–development–loss–reattachment model.
Table 12 • 6 Stages of Grief According to Contributing Authors
Engel Kübler-Ross Bowlby
Shock/disbelief Denial/shock
Awareness Anger/hostility Protest
Resolution Bargaining
Loss resolution Depression Despair
Idealization Acceptance Detachment
Italicized stages indicate unresolved loss with movement toward morbid grief.
Reprinted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world (p. 229). Cedar Park, TX: Unicorns Unlimited.
Morbid grief emerges when the individual is unable to find alternative objects that will repeatedly meet their needs. Because we are holistic beings, morbid grief has the potential to result in physical symptoms, illness, and over the long period, disease. What happens in one part of the holistic person has the potential of creating disease in another part, disease that becomes distressful, mandates mobilization of resources often not available, and therefore producing alternative biophysical responses, depleting psychoneuroimmunological resources (Walker & Erickson, 2006
Behaviors that indicate emergence of morbid grief include an inability to move on and let go of the lost object, combined with vacillation between anger and sadness (M. Erickson, 2006, pp. 209–239; Lindeman, 1944, pp. 141–148). Initially individuals are able to focus their anger and sadness, but with time, anger grows into hostility and sadness into depression. When this happens, people are less able to articulate the focus of their feelings or recognize the loss that produced the grieving response in the beginning. They often use language that describes giving up rather than letting go, and sometimes express nostalgia for the lost object. In contrast, those who have let go of the lost object, worked through the normal grief response, and reattached to a new object can usually describe the importance of moving on.
Need Satisfaction and Life Orientation
The degree to which a person’s needs are met repeatedly determines how he or she relates to others; it affects his or her life orientation. When needs are met repeatedly, people are able to grow and develop, to integrate mind–body–spirit, to perceive themselves as worthy human beings, and to experience a healthy balance of affiliated-individuation. When this happens, they are interested in others as individuals who are unique and worthwhile. They enjoy both a sense of connectedness and a sense of individuation. Their life orientation is called a being orientation because they are interested in becoming all they can be and in participating in the same way with others.
However, when needs are repeatedly unmet, growth is limited, and people have difficulty with their developmental processes. Their relationships with others exist within a context of what can be obtained from the other. They are not interested in the well-being of the other, might be threatened by growth in significant others, and are intolerant of the uniqueness of others. More interested in what they can get from someone than what they can give, these people often view others as a source of getting their basic needs met. As a result, often unable to meet the needs of significant others, they are perceived as “needy people.” Their life orientation is called a deficit orientation. Being and deficit orientations exist on a scale; most people have some of both. The balance between the two is what determines one’s overriding traits or personal attributes, one’s values and virtues, and one’s ways of interacting with others.
Developmental Processes
People have an inherent drive for self-actualization. This requires that they pass through predetermined chronological developmental stages—stages with tasks that mandate attention as they emerge. Our ability to work on these developmental tasks depends on our ability to mobilize resources. Resources are derived by getting our needs met at any given time as well as our past experiences. Because our experiences are always contextual, how we resolve our developmental tasks will determine the resources we have to work on current tasks. As we work through a stage-related task, a developmental residual is produced. This residual includes positive and negative attributes, strengths, and virtues. In our original work, we followed Erik Erikson’s (1994) work to define eight stages, their tasks, and the associated residual. Our more recent work has expanded the stages to include one prebirth and another at the time of death because the work of the soul affects the developmental processes during one’s physical life (M. Erickson, 2006, pp. 121–181; Table 12-7).
Sequential Development
Development occurs as a series of predetermined stages with specific tasks in each stage. It is also chronological: unique, sequential stages, and their related tasks emerge during a specific time frame in our lives. During that time, the task becomes predominate in our life journey, drawing resources, focusing attention, and motivating behaviors.
Epigenesis
Development is also epigenetic. Although we have specific tasks that focus our attention at specific times in life, we also rework earlier life tasks and set the framework for later tasks at the same time. This later work is done within the context of the appointed life task. Simply stated, we repeatedly work on all of the developmental tasks at every stage of life, although we have a key task that dominates at any given time. Our ability to manage multiple tasks is dependent on the residual we have produced throughout the process and our current ability to have our needs met.
Linkages
Three key theoretical linkages exist in the MRM model. Relations exist between or among (1) adaptive potential and need status; (2) need status, object attachment, loss, and new attachment status; and (3) developmental task resolution and need satisfaction. Selected theoretical propositions, derived from these linkages, are shown in Table 12-4. Others exist, limited only by an understanding of MRM.
Table 12 • 7 Developmental Stages, Residual, Virtues, and Strengths
Stages/Age Residual Virtue Strength(s)
Integration of Spirit (pre–post birth) Unity vs. duality Groundedness Awareness
Building Trust (birth–15 months) Trust vs. mistrust Hope Drive toward future
Acquiring Autonomy (12–36 months) Autonomy vs. introspection Willpower Self-control
Taking Initiative (2–7 years) Initiative vs. responsibility Purpose Drive
Developing Industry (5–13 years) Competency vs. inferiority Competence Methodological problem-solving
Developing Identity (11–30 years) Self-identity vs. role confusion Fidelity Devotion
Building Intimacy (20–50 years) Intimacy vs. isolation Love Affiliation with individuation
Developing Generativity (midlife to 60s) Generativity vs. stagnation Caring Production
Ego Integrity (60s to transformation) Ego integrity vs. despair Wisdom Renunciation
Transformation (end of physical life) Reconnecting vs. disconnecting Oneness Peace, cosmic under-standing, compassion
Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world (Table 5.1, pp. 128–129). Cedar Park TX: Unicorns Unlimited.
MRM Practice Strategies
Initiating the Relationship
Three sequential strategies are important for those using the MRM model: (1) establishing a mindset, (2) creating a nurturing space, and (3) facilitating the story (H. Erickson, 2006b, pp. 309–317; Table 12-8). Each can be done in seconds once the essence of the strategy is understood. However, before you can start, it is necessary to reflect on your own beliefs about human nature and nursing and to consider how these affect your practice. This helps you clarify how to get your needs met—a prerequisite to meeting the needs of others. Unless we know how to initiate our own self-care, we have difficulty mobilizing the energy necessary to focus on the needs of our clients. Finally, we have to open ourselves to the worth of each individual, to unconditionally accept that each human has an inherent need to be valued, to be treated with respect, and to live with dignity.
Establishing a Mindset
Establishing a mindset involves three strategies: centering, focusing, and opening. Centering helps to organize our resources so that we can connect energetically with our client. It requires that we temporarily put aside other thoughts, worries, or concerns and believe that at some level we can discover what we need to know to help our clients; it requires us to focus on the other with the intent of nurturing their growth and facilitating their healing. When we focus on our client’s needs, we initiate an energetic connection, necessary for a caring–healing environment.
Creating a Nurturing Space
Creating a nurturing space follows naturally when we have established a mind-set. Our goal is to create a caring–healing environment. Although one cannot force growth in others, we can create environments that nurture growth. We do this by decreasing adverse stimuli while increasing positive ones. It is important to remember that you are entering the client’s space and to respect it. Even though you may think it is important to close the door, turn on the radio, or fluff pillows, you will want to assess whether your actions serve to comfort the client. Each of these processes helps you connect with your client in such a way that you will initiate a trusting relationship and create a caring–healing environment. Any stimuli that affects the five senses has the possibility of being comforting, uncomfortable, or discomforting. We can influence these by our actions in the milieu and by our interactions with our client. For example, a noisy hallway or bright lights shining in our eyes are stimuli that seem to drain energy from us, and no doubt our clients experience the same thing. Or consider a beautiful picture, the glimpse of a fully leafed tree swaying in a gentle breeze, soft music of our choice, clean sheets against our skin, or the gentle touch of a loving person. In thinking about how you respond to these stimuli, you will understand that these have the possibility of comforting another human being. You will also understand that how you touch, look, or speak to someone conveys a message about your intent to comfort or not to comfort. Of course, it is extremely important that we consider the individual’s cultural perspectives and values as we consider how to create a nurturing space; what works for one person does not for another. The only way we can know is to ask our clients or, when they are unable to speak for themselves, to ask their significant others.
Table 12 • 8 Three Strategies That Facilitate a Trusting-Functional Relationship
Establish a Mindset Self-care preliminaries Moving forward Enhance sense-of-self.
Center self.
Focus intent.
Open self to the essence of other.
Create a Nurturing Space Reduce distracting stimuli.
Respect client’s space. Attend to sounds, lights, smells, and other stimuli that are distracting and discomforting.
Recognize and respect client’s physical/energetic space.
Connect spirit to spirit. Use eye contact, soft tones, and gentle touch to connect with client.
Facilitate the Client’s Story Tap self-care knowledge. Address stimuli, encourage focus on nurse-client linkage.
Relate to beliefs about client’s self-care knowledge as primary.
Encourage client’s perceptions of the situation.
Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world (pp. 307–317). Cedar Park, TX: Unicorns Unlimited.
Facilitating the Story
Facilitating the story is the third strategy that MRM nurses use. Disclosure of our clients’ self-care knowledge provides basic information needed before we can decide what nursing actions are required—information that provides insight into their worldview. We learn about their perceptions and beliefs, what they believe about their current situation, what they expect will happen, what resources they believe they have, and what they would like to do to alter the situation. It also allows them to “contextualize life experiences and present them in a way that softens associated feelings” (H. Erickson, 2006b, p. 315).
Our clients’ self-care knowledge is best obtained by allowing them to tell their story in their own way. We use active listening to facilitate our clients to tell their stories. This can be done very quickly by initiating the discussion with statements such as, “Tell me about your situation” followed by “Why do you think this has happened?” or “What do you think has caused it?” and “How do you feel about that?” and so forth (H. Erickson et al., 2009, pp. 153–167). The data are then organized into four distinct but interrelated categories: description of the situation, expectations, resource potential, and goals (see Table 12-2). Information provided by our clients has to be interpreted, aggregated, and analyzed before we can use it to plan interventions (H. Erickson et al., 2009, pp. 153–168).
Phases of Understanding the Data
There are three phases in understanding the information gained in MRM practice model. In data interpretation, we use the philosophical and theoretical underpinnings discussed earlier as we attend to words, affects, and nonverbal cues, searching for evidence of coping potential (i.e., adaptive potential), needs status, and developmental residual. Sometimes it is necessary to clarify what we observe to avoid superimposing our own interpretations on these data. For example, clients might have a spouse or significant other but not perceive this individual as supportive. When this happens, they often describe them as “draining” rather than invigorating. We cannot always make these distinctions without asking the client how they perceive their relationship with their significant other (H. Erickson et al., 2009, pp. 160–163). A person’s story usually includes information about interactions among the dimensions of the holistic person, but nurses often have trouble understanding the significance of what they have heard. For example, when people say they are sick because they are too stressed, our first response might be to think about the cause and effect of disease—for example, bacteria (not stress) cause infections. However, the MRM model supports a holistic perspective; we know that mind and body are inextricably interactive. Therefore, we recognize that psychosocial stress stimulates the hypothalamic–pituitary–adrenal axis interactions, compromising the immune system. When this happens, we have more difficulty fighting bacterial invasions. As a result, we know that psychosocial stress has the potential of causing signs and symptoms of physical illness and/or disease.
The second phase, data aggregation, sometimes occurs as we interpret data derived from the primary source (i.e., the client), but not always. To aggregate data accurately, we need to consider data derived from the secondary and tertiary sources as well as the data derived from the client. Although data can be aggregated with only the client’s story and the nurse’s clinical knowledge, it is also helpful to hear the family’s perspective. Sometimes it is important to include the information collected from tertiary sources as well.
When aggregating data, we consider all the information and look for consistencies as well as inconsistencies across the sources of information. Additional information may be necessary to clarify perspectives. Usually, this phase helps determine what needs to be done when moving into the intervention phase of the nursing process.
Data analysis is the next phase. Again, you may be doing all three—interpreting, aggregating, and analyzing—simultaneously. During the analysis phase, you look for theoretical linkages among the data and make diagnoses.
Proactive Nursing Care
Often the process of assessing our clients’ worldview serves as a therapeutic intervention. People in arousal commonly state that they feel much better after talking. Some will ask for minimal help, but some require more sophisticated help. In any case, based on our diagnoses, nursing care is planned within the context of the MRM principles of care, aimed at facilitating well-being in our clients, and designed specifically to meet intervention goals. We do this as we manage technical care such as wound management, intravenous insertion, and so forth. We use nonjudgmental language, caring tones, and direct statements that relay information needed to feel safe and cared about. We also use Ericksonian hypnotherapeutic techniques to promote growth and facilitate healing (H. Erickson et al., 2009, pp. 84–85, 145–147; H. Erickson, 2006b, pp. 315–317; 372–374; Zeig, 1982).
We can also do this without ever touching the person because we use ourselves as conduits of healing energy. Sometimes knowing that someone cares about us will help us grow and heal. We project these messages through our actions when we unconditionally accept the worth of another human being and set intent to facilitate health and healing. Watzlawick (1967) stated that “we cannot not communicate.” Our attitudes, nonverbal behaviors, and touch are often more important than what we say when we convey our intent to help others heal and grow; words are not always necessary. Our demeanor, the way we look at the person, what we focus on first, and how we touch our clients relays our intent. When we enter a relationship with the intent to comfort and nurture the other person, our energy field connects with his; we convey presence and initiate a caring–healing environment (H. Erickson, 2006b, pp. 300–324).
Practice Applications
MRM, recognized by AHNA as one of the extant holistic nursing theories, is used in a variety of settings including educational institutions as a framework for entire programs or specific courses, hospitals to guide practice, and for independent practice (Table 12-9).
The Society for the Advancement of Modeling and Role-Modeling (SAMRM; www.mrmnursingtheory.org), established in 1985, meets biennially with retreats in alternate years. Selected publications (Table 12-10) demonstrate how MRM has been applied across populations and settings from pediatrics to the elderly, chronically ill to the well, and intensive care to home care. Others (such as publications by Baas, Barnfather, Duke, Frisch, Hertz, Kelly, and Perese; see Table 12-10) describe MRM with those who have heart failure, undereducated adult learners, and/or employed mothers with preschool children. For example, Baas (2004) has tested relations between self-care resources and activities and quality of life and developed protocol for nursing practice. Baas, Past President of the American Association of Heart Failure (AAFH) Nurses and Director of Nursing Research at the University of Cincinnati Medical Center (2009–2012), continues to be actively involved in setting practice protocol for nurses working with people experiencing congestive heart failure. Duke, Professor of Nursing and Associate Dean for Research, University of Texas at Tyler, previously interested in the experiences of single mothers (published in Weber, 1999), is currently studying attitudes about and preferences for end-of-life care in persons of Jewish, Hindu, Muslim, Buddhist, and Bhai’I faiths and living in Texas. Both Frisch & Frisch (2010) and Perese (2012) have published textbooks for mental health practitioners; Frisch & Frisch’s book is used as a foundational book, whereas Perese’s was written specifically for advanced practice nurses. Hertz has developed and tested a midrange theory derived from MRM that measures perceived enactment of autonomy in the elderly. Hertz, Professor and Director of Graduate Studies, Northern Illinois University, is currently involved with mentoring graduate students interested in advancing holistic care for the elderly. Case studies are reported by practitioners in each of the SAMRM newsletters; these and additional publications (Hertz, 2013; Hertz, Irving, & Bowman, 2010; Hertz, Koren, Rossetti, & Robertson, 2008; Jablonski & Duke, 2012; Mitty, Resnick, Allen, Bakerjian, Hertz, Gardner et al., 2010) can be found on the SAMRM website (www.mrmnursingtheory.org).
Table 12 • 9 Agencies Using or Teaching Modeling and Role-Modeling
Harding University, School of Nursing, Searcy, Arkansas Theoretical foundation for pediatric clinical course
Metro State University, School of Nursing, St. Paul, Minnesota Theoretical foundation, and student advising
The College of St. Catherine’s, School of Nursing, St. Paul, Minnesota Theoretical foundation, ADN Program
The University of Texas at Austin, School of Nursing Theoretical foundation, the Alternate Entry Program
Contemporary Health Care, Austin, Texas Independent Nurse Practice Agency
Table 12 • 10 Practice/Intervention Studies Related to Modeling and Role-Modeling (MRM) Theory and Paradigm
Author Tested Source
Erickson, H. (1976) Identification of states of coping Unpublished master’s thesis, University of Michigan, Ann Arbor
Erickson, H., & Swain, M. 1982) MRM and well-being Research in Nursing & Health, 5, 93–101
Erickson, H. (1984) Exploration of self-care knowledge Dissertation Abstracts International, 45, 171. University Microfilms No. AAD84–12136
Darling-Fisher, C., & Kline-Leidy, N. (1988) Measuring Eriksonian developmental residual in the adult Psychological Reports, 62, 747–754
Walsh, K., Vanden Bosch, T., & Boehm, S. (1989) MRM applied to two clinical cases Journal of Advanced Nursing, 14(9), 755–761
Barnfather, J., Swain, M. A. P., & Erickson, H. (1989). Construct validity the APAM Issues in Mental Health Nursing, 10, 23–40
Erickson, H., & Swain, M. (1990) MRM and hypertension reduction Issues in Mental Health Nursing, 11(3), 217–235
Finch, D. (1990) MRM nursing assessment model Modeling and Role-Modeling: Theory, Practice and Research, 1(1), 203–213
Kline-Leidy, N. (1990) Relations among stress, resources, and symptoms of chronic illness Nursing Research, 39, 230–236
Erickson, H. (1990) MRM with mind-body problems In J.K. Zeig & Gilligan, S. (Eds.) Brief Therapy: Myths, Methods, and Metaphors. New York: Brunner/Mazel, 473–491.
Acton, G., Irvin, B., & Hopkins, B. (1991) Theory testing research: Building the science Advances in Nursing Science, 14(1), 52–61.
Barnfather, J. (1993) Testing a theoretical proposition of MRM Issues in Mental Health Nursing, 14, 1–18.
Holl, R. (1993) MRM vs. restricted visiting Critical Care Nursing Quarterly, 16(2), 70–82
Baas, L., Deges-Curl, E., Hertz, J., & Robinson, K. (1994) Innovative approaches to theory based measurement: MRM research Advances in Nursing Science Series: Advances in Methods of Inquiry, 5, 147–159.
Webster, D., Vaughn, K., Webb, M., & Player, A. (1995) MRM and brief solution-focused therapy Issues in Mental Health Nursing, 16(6), 505–518
Kline-Leidy, N., & Travis, G. (1995) Relations between psychophysiological factors and physical functioning Research in Nursing & Health, 18, 535–546
Hertz, J. (1996) Perceived enactment of autonomy (PEA) Issues in Mental Health Nursing, 17, 261–273
Baldwin, C. (1996) Perceptions of hope The Journal of Multicultural Nursing & Health, 2(3), 41–45
Erickson, M. (1996) EMBAT and maternal well-being Issues in Mental Health Nursing, 17, 185–200
Sappington, J., & Kelly, J. (1996) A case study Journal of Holistic Nursing, 14(2), 130–141
Baas, L., Fontana, J., & Bhat, G. (1997) Self-care resources and the quality of life Progress in Cardiovascular Nursing, 12(1), 25–38
Raudonis, B., & Acton, G. (1997) Theory-based nursing practice Journal of Advanced Nursing, 26(1), 138–145
Acton, G., Mayhew, P., Hopkins, B., & Yauk, S. (1999) Communicating with persons with dementia Journal of Gerontological Nursing, 25(2), 6–13
Acton, G. (1997) The mediating effect of affiliated-individuation Journal of Holistic Nursing, 15(4), 336–357
Irvin, B., & Acton, G. (1997) Stress, hope and well-being Holistic Nursing Practice, 11(2), 69–79
Jensen, B. (1997) Caring for the caregiver Home Care Provider, 2(6), 34–36
Baas, L., Berry, T., Fontana, J., & Wagoner, L. (1999) Developmental growth in adults with heart failure Journal of Holistic Nursing, 17(2), 117–138
Jensen, B. (1999) Caregiver responses to MRM Dissertation Abstracts International, B 56/06, 3127
Scheela, R. (1999) Remodeling sex offenders Journal of Psychosocial Nursing and Mental Health Services, 37(9), 25–31
Weber, G. (1999) The meaning of well-being (self-care knowledge) Western Journal of Nursing Research, 21(6), 785–795
Barnfather, J., & Ronis, D. (2000) Psychosocial resources, stress, and health Research in nursing & health, 23, 55–66.
Timmerman, G., & Acton, G. (2001) Relations between needs and emotional eating Issues in Mental Health Nursing, 22(7), 691–701
Mayhew, P., Acton, G., Yauk, S., & Communication, dementia, and well-being Gerontological Nursing, 22, 106–110
Hopkins, B. (2001) Berry, T., Baas, L., Fowler, C., & Allen, G. (2002) Spirituality in persons with heart failure Journal of Holistic Nursing, 20(1), pp. 5–30
Perese, E. (2002) Integrating psychiatric nursing into educational models Journal of American Association of Psychiatric Nurses, 8(5), 152–158
Hertz, J., Anschutz, C. (2002) Relationships among PEA, self-care, and holistic health Journal of Holistic Nursing, 20, 166–186
Baas, L. (2004) Self-care resources, activities as predictors of quality of life Dimensions of Critical Care Nursing, 23(3), 131–138
Baas, L., Berry, T., Allen, G., Wizer, M., Awareness in persons with heart failure or transplant Journal of Cardiovascular Nursing, 19(1), 32–40
&Wagoner, L. (2004) Lombardo, S. L., & Roof, M. (2005) Application MRM to person with morbid obesity Home Healthcare Nurse, 23(7), 425–428.
Berry, T., Baas, L., & Henthorn, C. (2007) Self-reported adjustment to implanted cardiac devices Journal of Cardiovascular Nursing, 22(6), 516–524
We cannot cure people, but we can help them heal and grow, even as they are taking their first or last breath. When people heal, they become more fully connected with the multiple dimensions of their mind, body, and spirit, and as a result, they become more fully actualized. A caring–healing environment, created by the nurses’ intent, fosters growth and well-being in their clients. Because people have inherent instincts and drives to grow, develop, and heal, all nursing actions focus on facilitation and nurturance of these innate abilities. We use ourselves to connect with our clients in such a way that we can create trusting functional relationships with them, relationships that have a purpose or are aimed at some outcome. In the MRM model, these relationships aim to affirm clients’ worth; to help them mobilize and build resources needed to cope with their stressors/stress; foster hope for the future; and promote a sense of affiliated-individuation. When people have these experiences, a sense of well-being follows. Although we use every professional skill we have acquired, these are secondary to using ourselves as healing agents. As nurses, we nurture and facilitate people to become the most that they can be. We help them actualize their life roles and find meaning in their existence. When this happens, it affects not only our clients but also those who are significant in their lives.
As nurses, every interaction with our clients and their loved ones provides us with opportunities to affect the future; I call this the “longarm affect” (H. Erickson, 2006b, p. 390). How we perceive our roles as nurses will determine our intent. This in turn affects what we do, how we interact, the focus of our work, and the outcomes of our relationships. We cannot always change what will happen in our lives or those of others, but we can set the intent to help people grow, heal, and move on. J. M.’s letter (see Practice Exemplar 1) suggests that I not only helped his family deal with a life tragedy but also helped them discover ways to find meaning in the experience. I helped them grow, heal, and move on.
Practice Exemplar 1
A man who was the strong, dominant member of his family was lying in bed, incontinent, riddled with cancer, and feeling hopeless. When I learned that he no longer allowed his family to visit, I gently took his hand and told him I was happy to be his nurse that evening. He “looked at me with very sad eyes … [and said] that he didn’t want his family to see him in this condition…. [H]e had always taken care of his family, and now … he couldn’t take care of himself” (H. Erickson, 2006a, p. 325). I rephrased his words and then told him that although he had been the breadwinner in the past and his family members had enjoyed and appreciated that, all they wanted now was to be with him, to share his life, to show him that he was important because he loved them and they loved him. He agreed, and for the next few days his family members took turns just being with him. On the third day when he quietly passed, he and his family were able to grieve with dignity and peace.
Eight years later, I received a letter from his son (only 16 at the time of his father’s death), notifying me that his mother had died. He knew I would want to know that because of what they had learned from me, she was able to pass at home with her family at her side, singing her favorite songs and strumming on the guitar. He went on to state:
In the year my Dad was with you people in Ann Arbor, you were of incalculable aid and comfort to both my parents—you gave them confidence in you and your staff, and the dignity and respect which makes life worth living; no one else could, or did, more genuinely have their gratitude and respect. When I would come down and all seemed to be lost, the one bright spot was that Mrs. Erickson would be coming on, and we could breathe a little more easily as Dad’s anxiety visibly receded. Your kindness and humanity made the world a better place at that time and without you the experience would have been more difficult than you probably believe. Thank you, J. M.
Practice Exemplar 2
Most data are easy to understand although there are some that are symbolic of earlier losses. A middle-aged man I worked with a number of years ago had just been admitted to the hospital for a “workup.” Mr. S. had complained of chronic fatigue for the past 6 months. An hour or so before I saw him, he had learned that he had acute leukemia. When I asked him to tell me about his situation, he told me about his leukemia and then launched into a story about his childhood. He described a time when he was about 16 years old, had been told to watch his younger sister and had let her ride a horse without supervision. She fell off and was killed. He remembered his father telling him that he had not been responsible and that he needed to grow-up and be a man.
Mr. S. looked surprised and said he didn’t know what had made him think of that event and hadn’t thought about it for years. When I asked him what he expected to happen to him, he said he guessed that he was going to die. He went on to say that he thought he had developed leukemia because he hadn’t been responsible, and when he wasn’t responsible; people died. As we explored his resources, he explained that he had been promoted about 9 months earlier and that his new job required skills he didn’t think he had. His conclusions were that he was sick because he had “worried himself to death.” He also stated that he didn’t want his wife to come see him, that he needed to decide what he wanted to do first, and how he could take care of her now that he was sick? When I asked if she or someone else could help him consider options, he said no, that it was his responsibility to take care of himself. To understand these data, I needed to recognize the following:
• People who link new stressful experiences to past experiences are usually dealing with a loss related to the past experience. In his case, it was not only the loss of his sister but also the meaning of the loss. As a 16-year-old boy, he was learning about his ability to make sound decisions, to be independent, to determine who he was as a unique human being in society. He had learned that “when he wasn’t responsible, people died.”
• Although he identified his wife as his significant other, he was overindividuated. He needed to decide how to “tell” his wife about his problem—his problem of not being responsible, not being a “man.” He did not perceive that it was appropriate to seek comfort from her or others.
• Mr. S. is in arousal with unmet safety and belonging needs, unresolved loss with morbid grief, and both positive and negative residual from adolescence on. Strong positive residual from early childhood provides some resources that could be mobilized with assistance.
• Although Mr. S. is chronologically in the stage of Intimacy versus Isolation, his stressors are related to residuals from the stage of Competency versus Limitations.
• Mr. S’s healthy affiliated–individuation has been threatened due to overindividuation.
• Mr. S. wished to be “responsible” to “take care of his wife.”
Specific interventions used in this case are as follows:
• I centered myself and set intent to be energetically connected, using myself as a conduit of healing energy from the universe. Setting an intent to connect and serve as a healing instrument is a prerequisite to facilitating a client’s storytelling. It is also an important strategy for helping people mobilize resources needed to help themselves heal. Centering, setting intent to connect, and to serve as an energetic conduit were strategies used throughout our time together, purposefully initiated with each visit.
• When I asked him to tell me about his situation, I also stated that he could talk about anything that popped into his mind, even if it didn’t seem to be related to his current situation. This strategy is used because people have state-dependent memory, their current experiences are often related to losses incurred in the past. Although they are unaware of these relations, it may be important to help them “uncover” these experiences in their own time and their own way so that they can begin to heal—a prerequisite for mobilizing resources needed to contend with the current situation.
• I used active listening skills as he told his story, using nonverbal communications to encourage him to open up, staying energetically connected, and remaining quiet when he paused, allowing him an opportunity to express his self-care knowledge.
• My question: What do you expect will happen? was used to assess self-care resources and to allow him to identify associated factors and express his worse fears. His response indicated that he was depleted of resources (i.e., impoverished), his definition of being responsible no longer worked for him, and he needed help reframing his behaviors and identifying new resources. I further explored his resources with the follow-up questions.
• Considering that the loss had occurred during the age of adolescence and the task of developing Identity and that healthy resolution of Identify is important for the development of healthy intimacy in the next stage of life, follow-up interventions included exploring alternative ways to think about “being responsible”—the role he had chosen for himself. Using open-ended questions, I helped him consider his relationship with his family by thinking about how he was like the 16-year-old boy and how he was different; how he wanted to be like that boy and how he wanted to be different; and how he wanted to relate to his wife in the future and how he might start. Rhetorical questions, stated as curiosities rather than a demand for a response, were used to stimulate growth. Examples include statements such as I wonder how you are like that 16-year-old boy now, and how you are different? It might even be interesting to think about how you want to be like that boy—or different.
• Biophysical care was also offered and provided with consideration for his developmental resources. Adolescents with healthy developmental resources often vacillate in their need to be independent in their activities of daily life and their needs to have care consistent with earlier stages provided. The only way to know is to offer care and follow the client’s responses. Thus, when asked to help with foot care, it was provided; when told that he could manage making his own outpatient appointments, he was given the information needed to make his appointments and asked if he needed any other information after the appointments were confirmed.
• As he prepared for discharge to the outpatient clinic for chemotherapy, I explored his perceptions of the effects of chemotherapy. He stated that chemotherapy was a poison and would make him sick, that he didn’t look forward to that. I agreed that chemotherapy was a poison, but that there were several things he could do to help himself. Aiming to reframe the perception of chemotherapy outcomes, I suggested that chemotherapy was designed to fight with the bad cells, but he didn’t need to have the chemotherapy fight with his good cells, that he could protect them if he wanted. When he expressed curiosity about protecting his good cells, I helped him learn how to use guided imagery so that the chemotherapy would seek out bad cells and attach them, but leave the others alone. We then talked about ensuring that the chemotherapy had a good chance of doing its work by proactively getting sufficient sleep, drinking fluids, seeking nurturing relations, participating in activities that help him laugh, and other activities that made him feel loved, happy, and at peace.
• Upon discharge, I offered him a business card as a transitional object. I explained that it contained my name and contact information in the event that he wanted to talk with me at any time. I also stated that many people find they are able remember our time together—what they felt, heard, smelled, and saw—by holding the card and/or even just by thinking about it.
I followed this gentleman for several weeks, visiting him occasionally in the outpatient clinic. He always had my business card with him and often commented that it was magic and that it helped him get through the bad days. Two years later I received a letter thanking me for helping him and stating that he was in remission. He and his wife were planning a trip to celebrate their anniversary.
■ Summary
Nurses who use modeling and role-modeling believe the human is holistic with ongoing, dynamic mind–body–spirit interactions; clients are the primary source of information; and nurses are instruments of healing. Modeling is the process used to gain an understanding of their clients’ perceptions and understandings of their conditions, health needs, and possible therapeutic interventions. During the modeling process, nurses gain an understanding of their clients perceptions of what has caused their health problem, what impedes their healing, and what will facilitate healing and growth. Modeling the client’s worldview also helps nurses to understand their clients’ relationships and related roles, identify those that impede health and wellness and those that are meaningful and facilitate healing and growth.
