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Wound management: Using Levine's

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Article in Ostomy/wound management September 2006
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Woun d Management: Using Levine's Conservation Model to Guide Practice

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16/03/2007

Wound Management: Using

Conservation Mod&
Gifide Practice
Matthew J. Leach; BN(Hons), ND, PhD

Effective wound management is needed not only to generate positive patient outcomes, but also to reduce healthcare expenditure and
demand on healthcare services. Implementing Levine's four-principled conservation model which addresses conservation of energy,
structural integrity, personal integrity, and social integrity can provide clinical and financial benefits, as illustrated in the care of venous

leg ulceration. Using Levine's model as a theoretical framework for wound management also can contribute to good nursing practices,
enhancing a care approach that embraces wholeness and health along with cost effective care. Understanding how Levine's model can
improve patient care is further elucidated by discussing each of the principles in relation to wound management.
KEYWORDS: wounds, nursing care, nursing theory

Ostomy/ Wound Management 2006;52(8):74-80

conservation model, initially constructed as a teaching framework for medical-surgical

evine's

nursing,2 is based on the belief that nursing

interventions should be aimed at conserving function.3'4 Roberts and Taylor5 and Fawcett4 state that
nurses currently use Levine's model in practice by acting to preserve Elient energy and integrity encour-

aging bed rest, maintaining pressure area care, and

preserving privacy. To clarify the relationship between

Levine's conservation model and wound management, each of the four principles of Levine's model
will be examined. To enhance understanding of the
context in which Levine's conservation principles are
presented, the underlying assumptions, definitions,
and limitations of the model are discussed.

Levine's

conservation model' consists of four major

principles. The principles are defined as follows:

balancing energy output

conservation of energy
and input to avoid excessive fatigue4

conservation of structural integrity maintaining

or restoring the body structure by preventing physical breakdown and promoting healing5
maintaining
conservation of personal integrity

or restoring the patient's sense of identity and selfworth5 and. acknowledging uniqueness4
conservation of social integrity fostering aware
ness that the patient. . is a social being who interacts with others5 in their social environment.
Each of these principles the reduction in energy
. .

expenditure, the improvement in structural, personal

Dr. Leach is Program. Director, University of South Australia, and a Registered Nurse, Royal District Nursing Service South
Australia. Please address correspondence to: Matthew J. Leach, BN(Hons), ND, PhD, School of Health Sciences, University of
South Australia, North Terrace Adelaide SA 5000; email: Matthew.Leach@unisa.edu.au.

74

OstomyWound Management

and social integrity, and the reclaiming of individual

wholeness and health
is compatible with wound
management.' Levine's principles are also specific and
testable; hence, they already have been utilized as a
framework for many
Many nursing
researchers and practitioners adopt Levine's model
because the conservation principles provide a scientific and research-oriented approach to the majority of
nursing interventions.3 Furthermore, as a theoretical
framework, the rules of conservation and integrity are
applicable to all aspects of nursing, from clinical prac-

interventions under Levine's theory have a present

and short-term focus and do not support health promotion principles, even though health promotion is
an essential component of current nursing practice.'3
Thus, Levine's model does not add support to the use

of interventions that prevent ulcer occurrence and

reoccurrence in susceptible individuals.

Assumptions
An underlying assumption of Levine's model is that

tice to administration.'1 As such, the conservation principles help anticipate and predict all fields of nursing

the nurse creates an environment in which healing can

occur and adaptation is promoted.'4 Individuals are constantly interacting with an external environment; conse-

practice by placing independent information into an

quently, they adapt and preserve their energy and

organized framework.'2
Each of Levine's principles addresses the concept of
conservation, defined by the author' as preserving indi-

integrity in accordance with that environment. However,

when an individual can no longer maintain that energy
and integrity, health is adversely affected.5 This environmerit pertains not only to the external milieu, but also to

vidual wholeness. The purpose of conservation is to

defend, sustain, maintain, and define the integrity of
the system for which it functions." Conservation can be
compared to the process of homeostasis in that it maintains the stability of the organism through ". .multiple,
interacting, and synchronized negative feedback systems. .
The universal concept of conservation also
"describes the way complex systems are able to function
even when severely challenged."2 Therefore, conserva-

".

. .

tion aims to maintain an equilibrium conducive to

health; accordingly, many nursing interventions use
conservation principles to maintain patient wholeness.'3
Meleis'4 claims that all individuals strive for conservation
it is only when the individual can no longer
adapt to adverse stimuli that the nurse becomes the individual's conservator. To illustrate, when an individual
can no longer maintain adequate venous tone and function, venous leg ulceration (VLU) potentially will develop. As a conservator, the nurse can help the client resolve

the disequilibrium by applying external compression

therapy to improve venous function and skin integrity.

the individual's internal environment. For instance,

treating VLU externally with topical dressings, as well as
internalmodifying the physiology of the venous
ly with external compression or venotonic agents, allows

the nurse to create an environment conducive to VLU

healing. Although Levine does not explicitly relate the
four conservation principles to the environment,'5 it
may be through effective wound care that nursing can
conserve energy and skin integrity'4 and as such lend
support to Levine's conservation model.

Conservation of Energy
Energy conservation is based on the belief that
patient activity is dependent on energy balance, that
illness increases energy demand, and that increased

Wound Management

KEY POINTS
Theoretical frameworks help explain relationships
between concepts, observations, facts, and theories.

Limitations
Despite the comprehensiveness and wide application of Levine's theory, the model is not without lim-

itation. For example, Levine's conservation model

focuses on illness as opposed to health; thus, nursing
interventions are limited to addressing only the presenting condition of an individual.3 Hence, nursing

The author uses a conservation model to illustrate

potential relationships between venous ulcer care outcomes and optimal patient well being.

This model may provide a basis for making wound

management choices and facilitate research to help
strengthen the evidence base of wound care practice.

August 2006 Vol. 52 Issue &

75

conserving energy, the integrity of the individual ulti-

energy demand can be measured by the level of

fatigue.4 Even the most basic nursing procedures,
including rest and adequate nutrition,4 utilize the

mately can be defended.'7

principle of conserving energy.2

Nurses need to understand energy conservation as a
universal law applicable to all animate and inanimate
entities.'2 To maintain life activities, energy levels need to
be balanced and constantly renewed.2 Nurses often are
the people in contact with individuals in whom healing
and ageing challenge the ability to conserve energy.2
Therefore, nurses not only help conserve energy through

a reduction in activity, but they also ensure energy

expenditure remains within the ".. individual's capabil.

ity, safety, and comfort."4

In a normal healthy state, the body intentionally

utilizes a minimum level of energy to conserve energy. When the body's system is disturbed, however,
energy is utilized and negative feedback systems are
activated until a normal state is obtained.3 For exam-

ple, the inflammatory and immune systems utilize

energy in order to restore homeostasis and promote
healing.3 In sick persons, energy expenditure often
becomes evident as the process of healing unfolds.
The unwell individual frequently manifests lethargy
and weakness, which subsequently reduces activity
and unnecessary energy expenditure; thus, energy can

be conserved and focused on healing.3 This energy

conservation also preserves functional integrity.'2

Nurses are in a position to conserve patient energy by
reducing the duration of leg ulceration. For instance,
nurses may select wound treatments that restore skin
integrity and minimize energy expenditure, ultimately
resulting in earlier discharge, reduced healthcare expenHowever, in order to
diture, and less emotional
assess the energy-conserving effect of wound treatments, energy needs to be measurable.
Levine3 claims that energy is measured in everyday

nursing practice via body temperature, blood gases,

pulse, and blood pressure; fluctuations determine

either energy expenditure or conservation. However,
it is unclear whether these aforementioned measurements are valid and reliable indicators of changes in
energy levels. Wound healing, on the other hand, may

be an effective measure of energy conservation

because the conservation of structural integrity can-

not be maintained without conserving energy.

76

OstomyWo,,ud Management

By

Conservation of Structural Integrity

Conserving structural integrity is based on the
rationale that changes in structure ultimately affect
function, that structural integrity may be compromised

by pathophysiological processes, and that healing

restores structural integrity.4 Therefore, to regain structure and function, the body needs to restore structural
integrity through repair and healing.'

Healing restores continuity and form through cell

replication; hence, conserving structural integrity.'2
Early detection and management of disease by nurses
reduces tissue destruction, which also conserves structural integrity.2 Specific nursing interventions that conserve structural integrity include anatomic positioning
and range-of-motion exercises to prevent musculoskeletal deformities,'4 pressure area care to prevent pressure
ulcers, and early mobilization and chest physiotherapy
to prevent complications of bed rest.3 In the example of
VLU; compression therapy may restore skin and venous

integrity. Through this conservation of structural

integrity, an individual can feel intact and whole and
subsequently manifest improvements in self-identity.'7

conservation of Personai Integrity

Conserving personal integrity is based on the belief
that individuals require privacy, are responsible for their
own decisions, and illness and hospitalization compromise personal integrity, self-identity, and self-respect.4
Nursing interventions aimed at conserving personal
integrity include protecting and respecting patient privacy, possessions, and defense mechanisms4 and supporting personal choice.2 The conservation of personal
integrity, therefore, aims to protect personal identity.1
Levine'2 argues that the fundamental goal of the nurse

is to provide knowledge and support so the individual

can resume a private independent life. Personal integrity, including self-identity and pride, is compromised
when an individual becomes dependent. Therefore,
interventions aimed at regaining individual independence ultimately conserve personal integrity. The principle of conserving personal integrity is interdependent
with the principles of conserving energy and structural
integrity Without sufficient energy and, in the case of

.1

(
C

Venous leg ulceration

Compression bandaging

Primary dressing

wound environment

(venous) environment

Ulcer healing

Conservation of structural integrity

eased physical and

energy expenditure

Conservation of

energy

Figure 1. Conceptual map outlining the relationship

Conservation Model.

and financial

Conservation of
integrity

Conservation of

social integrity

effective wound management and positive patient outcomes through Levine's

/that conserve energy and restore structural integrity

will arguably re-establish independence. Thus, dressings and interventions that hasten ulcer healing and
ultimately shorten ulcer duration may reduce client
dependency on others. Given that individuals with
VLU also experience depression, helplessness, anxiety,
and negative self-image,'82 effective wound manage-

ment also may restore patient self-worth and personal integrity.

Conservation of Social Integrity

Conserving social integrity is based on the premise

that individual life has meaning only in the context of

social life, individual behavior is influenced by the

ability to relate to various social groups, families often

OstomyWound Management

isolation,

depression,

and negative

wound care, intact skin integrity, dependence on other

individuals is almost certain. Therefore, interventions

78

are affected by an individual's illness, and hospitalization results in social isolation.4

Social factors such as family, friends, culture, religion, education, and socio-economic status all determine how an individual defines him/herself.3"7 Thus, a
loss of these factors (eg, work, income, or family) may

arguably weaken an individual's social integrity.

Therefore, nursing strategies aimed at conserving
social integrity may include providing family support

and education, promoting family participation

in

care, and fostering patient interaction with others.3

A change from an independent role to dependency
on the healthcare system creates conflict for the individual.3 For instance, patients with VLU often become
immobile,2 embarrassed, and socially, isolated and
experience financial difficulty.'8 By facilitating wound
healing, the nurse can indirectly restore the patient's

ability to be mobile, productive, and social.

Furthermore, by decreasing VLU duration and recurrence, effective wound management may inadvertent-

Every activity is a product of the dynamic social systems

to which the individual belongs.'

ly reduce healthcare expenditure and demand on

References

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1.

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