ARTICLE

10.1177/0894318404266327
Preterm
Nursing Infant
ScienceHealth
Quarterly
Promotion
, 17:3, July 2004

A Theory of Health Promotion for Preterm Infants

Based on Levine’s Conservation Model of Nursing
Linda C. Mefford, RN; PhD
Assistant Professor, University of Tennessee College of Nursing, Knoxville, Tennessee

The infant born prior to the completion of term gestation faces many challenges in order to merely survive in the
extrauterine environment. A preterm birth is also a time of extreme crisis for the family. There is a great need for the
refinement of nursing practice models for neonatal intensive care nursing, to assure that the holistic nursing care
needs of the infant and family are met. This article describes a new middle range theory of health promotion for
preterm infants based on Levine’s conservation model of nursing that can be used to guide neonatal nursing
practice.

To survive in the extrauterine environ-
ment, preterm infants confront myriad
unique challenges not faced by infants
born at term. Since many major organ
systems mature during the final trimes-
ter of pregnancy, preterm infants must
complete the essential physiologic ad-
aptations to extrauterine life using im-
mature systems. Neonatal intensive
care nurses must provide nursing care
that is supportive of both the infant and
the family during this transitional pe-
riod of potential crisis, with the goal of
reuniting a healthy infant with a stable
family. There is a great need for the re-
finement of nursing theoretical frame-
works to guide holistic nursing practice
in the neonatal intensive care unit
(NICU). Levine’s conservation model
of nursing provides an ideal conceptual
framework for this setting.
Levine’s Conservation Model
and Neonatal Nursing
In Levine’s conservation model, the
goal of nursing care is the conservation,
or “keeping together” (Levine, 1967, p.
46), of the wholeness of the individual,
who is identified as a patient (Levine,
1996). The environment includes the
Nursing Science Quarterly, Vol. 17 No. 3,
July 2004, 260-266
DOI: 10.1177/0894318404266327
© 2004 Sage Publications
internal environment (involving physi-
ologic and pathophysiologic processes)
and the three components of the exter-
nal environment—perceptual, opera-
tional, and conceptual (Levine, 1973).
Wholeness (integrity or health) is the
state in which the internal environment
and the external environment have the
best fit (Levine 1989, p. 330), or exist in
a smooth interface. A disruption at the
interface between the internal environ-
ment and the external environment
poses an environmental challenge (Le-
vine, 1989, p. 336) and can create a dis-
ruption in health. To restore health, the
nurse implements therapeutic and sup-
portive nursing interventions in accor-
dance with the conservation principles
of nursing (conservation of energy,
structural integrity, personal integrity,
and social integrity), with the goal of
restoring a state of wholeness, or health.
A conceptual diagram of Levine’s
model is shown as Figure 1.
The conservation model has been
applied to the care of infants in a variety
of situations. Newport (1984) explored
the conservation of energy and social
integrity in term newborns in a compar-
ison of the efficacy of providing thermal
care by skin-to-skin contact with the
mother as opposed to caring for the in-
fant in a warming bed. In a related study,
Mellien (2001) cited Levine’s model as
a conceptual influence in a comparison
of thermal stability of preterm infants.
Mefford (1989) used the conservation
model as a framework within which to
examine the influence of position
(flexed side-lying versus supine) on ox-
ygenation, heart rate and blood pressure
stability, and sleep state in mechanically
ventilated preterm infants. Langer
(1990) used the conservation model as a
framework for a minimal handling pro-
tocol (p. 23) to reduce the amount of
stimulation and environmental stress
experienced by preterm infants in the
NICU. Although Levine’s model was
not specifically stated as a conceptual
framework, Tribotti (1990) published a
nursing protocol for the admission of a
preterm infant to the NICU that focused
primarily on energy conservation.
Deiriggi and Miles (1995) used Le-
vine’s model to frame a study examin-
ing the effects of the use of a waterbed
on the heart rate of medically stable
preterm infants. Finally, since preterm
birth is a risk factor for childhood devel-
opmental delay (Volpe, 2001), it is also
of interest to note a case study by Sav-
age and Culbert (1989) demonstrating
the utility of Levine’s model in planning
early intervention services for children
with developmental disabilities.
Keywords: health-promotion, Le-
vine’s conservation model, neonatal in-
tensive care nursing, premature infants

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Threat to
Energy
Internal Balance
Environment
Disruption of
External Wholeness
Environment
Threat to
Personal
Integrity
Figure 1. Conceptual Diagram of Levine’s Conservation Model of Nursing
NOTE: From “The Relationship of Nursing Care to Health Outcomes of Preterm Infants: Testing a Theory of Health Promotion for Preterm Infants Based on Le-
vine’s Conservation Model of Nursing” (p. 24), by L. C. Mefford, 1999, Dissertation Abstracts International, 60(09B), 4522. Copyright 1999 by L. C. Mefford.
Reprinted with permission.
A Theory of Health Promotion
for Preterm Infants Based on
Levine’s Conservation Model
The process of theory synthesis de-
scribed by Walker and Avant (1995)
was used to develop a middle range the-
ory based on Levine’s conservation
model of nursing—a theory of health
p r o m o tio n f o r p r eter m in fan ts
(Mefford, 1999). The theoretical propo-
sitions are stated in Table 1, and a con-
ceptual diagram representing the theory
is shown as Figure 2.
Application of the Theory of Health
Promotion for Preterm Infants
Environmental Challenges
A preterm birth disrupts both the
normal intrauterine developmental tra-
jectory of the fetus and the psychosocial
adaptation of the family (Als, 1986;
Blackman, 1991).The immature infant
is abruptly thrust into an extrauterine
environment that provides a poor fit
(Als, 1986, p. 16) for the developing
physiologic systems (Als, 1982, 1986).
This lack of fit thus creates an environ-
mental challenge, with disruption of the
state of wholeness that existed in utero.
Even the birth of a healthy infant is a
time of developmental crisis for the
family, requiring the parents to transi-
tion into the role of parent and to inte-
grate the child into the family. A
preterm birth complicates this transi-
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Preterm Infant Health Promotion 261
Threat to
Energy Structural
Structural
Integrity
Nursing Balance Integrity
Conservation
Adaptation of Wholeness
Social
Personal
Threat to Integrity Integrity
Social
Integrity
Table 1
A Theory of Health Promotion for Preterm
Infants Based on Levine’s Conservation Model
Theoretical Propositions
If preterm birth disrupts the usual intrauterine path of fetal growth and development, resulting in the
birth of a preterm infant who is fully competent for survival in the intrauterine environment but not yet
fully competent for extrauterine life;
And if an environmental challenge is created by the entry of the preterm infant with intrauterine com-
petencies into the extrauterine environment of the NICU;
And if this environmental challenge results in a disruption of wholeness of the infant and family;
And if this disruption of wholeness is characterized by:
(a) the preterm infant’s lack of physiologic maturity for independent survival in the extrauterine envi-
ronment (threat to the balance of energy);
(b) the potential for reversible and/or irreversible injury during the NICU experience due to the struc-
tural immaturity of the preterm infant (threat to structural integrity);
(c) the preterm infant’s lack of neurologic and sensory maturity for the modulation of external envi-
ronmental stressors (threat to personal integrity); and
(d) the disruption of the family system (threat to social integrity);
And if the infant and family respond to the disruption of wholeness by the process of adaptive change;
And if the NICU nurse plans and implements therapeutic and supportive nursing interventions that
support the adaptive efforts of the infant and family;
And if these nursing interventions foster the goal of promoting wholeness through:
(a) Conservation of energy;
(b) Conservation of structural integrity;
(c) Conservation of personal integrity; and
(d) Conservation of social integrity;
Then, the outcome of nursing care is wholeness, or health, of the infant and family, as reflected by:
(a) Physiologic stability and growth;
(b) Minimal structural injury;
(c) Neurodevelopmental competence; and
(d) Stability of the family system with integration of the infant into the family.
NOTE: From “The Relationship of Nursing Care to Health Outcomes of Preterm Infants: Testing a The-
ory of Health Promotion for Preterm Infants Based on Levine’s Conservation Model of Nursing,” (pp. 23-
26), by L. C. Mefford, 1999 (Doctoral Dissertation, University of Tennessee), Dissertation Abstracts In-
ternational, 60 (09B) 4522. Copyright 1999 by L. C. Mefford. Adapted with permission.
262 Nursing Science Quarterly, 17:3, July 2004
Conception
Extrauterine
Environment
Preterm Birth
Intrauterine
Competencies
Term Birth
Figure 2. Conceptual Diagram of the Theory of Health Promotion for Preterm Infants Based on Levine’s Conservation Model of Nursing
NOTE: From “The Relationship of Nursing Care to Health Outcomes of Preterm Infants: Testing a Theory of Health Promotion for Preterm Infants Based on Le-
vine’s Conservation Model of Nursing” (p. 24), by L. C. Mefford, 1999, Dissertation Abstracts International, 60(09B), 4522. Copyright 1999 by L. C. Mefford.
Adapted with permission.
tion because the parents are now simul-
taneously dealing with two potential
crisis situations: the birth of a child and
the illness of a family member (Kenner,
Lott, & Flandermeyer, 1998). The en-
tire family system is transported to an
altered developmental trajectory and
must form a new interface with the
unexpected external environmental
reality.
The healthy fetus is in a state of rapid
physiologic change, with the develop-
ing organ systems intended for survival
in the intrauterine environment where
the uterus provides not only thermal
control and life support, but also a
unique muted sensory environment and
gentle restriction of movement (Als,
1982, 1986). In describing the nature of
the external environment, Levine
(1969) stated,
The background of environmental in-
formation is incessant, and every
kind of stimulus impinges upon the
individual at once. Sight, sound,
odor, temperature, posture in relation
to gravity and body position—all the
information that is necessary in order
t o o r i e n t t h e i n d iv i d u a l —h e
unceasingly receives. (p. 96)
The infant in the NICU is confronted
with this incessant barrage of informa-
tion, yet does not have the mature sen-
sory systems and fully organized ner-
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Physiologic Structural
Immaturity Immaturity
Preterm Infant
In the NICU
Neurologic Disruption
Immaturity In Family
System
vous system needed to competently
process these new and different stimuli.
The perceptual environment is the
part of the external environment to
which the individual responds using the
senses (Levine, 1973). The uterus is a
dark, relatively quiet, fluid-filled envi-
ronment, and sensory stimuli are pri-
marily vestibular and tactile in nature.
This compliments the developing sen-
sory abilities of the fetus, since the tac-
tile and vestibular sensory systems ma-
ture during early gestation while the
auditory and visual systems mature dur-
ing the last trimester (White-Traut, Nel-
son, Burns, & Cunningham, 1994). In
contrast, the NICU is filled with com-
plex sensory stimuli (lights, noise, peo-
ple, equipment), the combined effect of
which can easily overwhelm the infant’s
immature sensory and neurological
systems.
The operational environment refers
to environmental components to which
the individual responds using mecha-
nisms other than the senses, including
microorganisms, gravity, and radiation
(Levine, 1973). Much of the operational
environment is potentially damaging to
the preterm infant. The uterus and pla-
centa formed a protective barrier
against microorganisms, therefore the
immature integumentary and immune
systems of the preterm infant do not yet
provide competent defenses against
Physiologic Minimal
Stability and Structural
Nursing
Growth Injury
Adaptation Health
Neuro- Stable
Developmental Family
Competence System
extrauterine microorganisms (Kenner
et al., 1998). The fluid-filled intrauterine
environment also protected the fetus
from the potentially detrimental effects
of gravity. During the last trimester of
pregnancy, the muscle mass increases
and the fetus becomes increasingly
cramped within the confines of the
uterus, facilitating the development of a
physiologic flexion (Fay, 1988, p. 24)
which enables the term newborn to
better resist gravity. Over the first few
months of extrauterine life, this exces-
sive flexion diminishes and a balanced
flexor-extensor tone emerges. The
preterm infant has both a reduced mus-
cle mass and a generalized hypotonia,
and therefore responds to gravity by as-
suming a hyperextended posture and
abnormal movement patterns (Fay,
1988).
Finally, the conceptual environment
includes the cognitive, emotional, psy-
chological, and spiritual experiences of
life (Levine, 1973). The ability to per-
form conceptual skills is dependent
upon adequate functioning of the cen-
tral nervous system (CNS). The neuro-
logic system of the fetus undergoes dra-
matic changes in both structure and
function during the final trimester
(Volpe, 2001). As a result, preterm in-
fants have varying levels of neurodevel-
opmental competence for interaction
with the extrauterine environment (Als,

1982, 1986). In the protected environ-
ment of the uterus, the fetus had little
need to perform conceptual skills such
as learning. However, birth and subse-
quent entry into the extrauterine envi-
ronment presents great conceptual chal-
lenges. In order to survive, the newborn
infant must rapidly begin to learn how
to perform oral feedings and how to so-
cially interact with parents and care-
givers. The earlier the gestational age of
the infant at birth, the less competent the
CNS and therefore the more difficult
the learning challenges. The family sys-
tem also faces great conceptual chal-
lenges. If the family is to survive the cri-
sis of a preterm birth, then they must
develop successful coping strategies
and support systems. Families entering
the NICU environment must learn to
understand and speak several new lan-
guages as they endeavor both to com-
prehend the physiologic, structural,
personal, and social challenges
confronting their infants and to
communicate with their infants.
A Disruption of Wholeness:
Physiologic Immaturity as
a Threat to Balance of Energy
The work of sustaining life is per-
formed at the cellular level, with oxy-
gen an essential element necessary for
the cellular release of energy (Levine,
1973). The lungs are one of the final
major organ systems to reach maturity,
but since the placenta performs the
function of gas exchange, pulmonary
immaturity is not a problem in utero.
With a preterm birth, the lungs become
the only route of gas exchange. Preterm
infants often have an inadequate pro-
duction of surfactant, and may also have
a structural inadequacy of lung tissue
with a minimal capacity for gas ex-
change, therefore, preterm infants have
a great threat to the balance of energy.
Energy balance is also greatly depend-
ent upon the adequate intake of nutri-
ents, but the structural immaturity of the
gastrointestinal system leaves the
preterm infant ill-equipped for the di-
gestion and absorption of nutrients. In
addition, the immaturity of the CNS
presents challenges with the coordina-
tion of the reflexes for sucking, swal-
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Preterm Infant Health Promotion
lowing, and breathing, making the
independent oral intake of nutrients by
preterm infants extremely difficult
(Kenner et al., 1998).
A Disruption of Wholeness:
Structural Immaturity as a
Threat to Structural Integrity
The developing physiologic systems
confront multiple threats to structural
integrity. The impaired barrier function
of the skin and immature immune sys-
tem increase the risk for infection. The
im m atu r e lu n g s ar e at r is k f o r
bronchopulmonary dysplasia, a chronic
lung disorder related to the toxic effects
of supplemental oxygen and to
barotrauma from positive pressure ven-
tilation. The retinas of the eyes are
vascularized during the final weeks of
pregnancy, therefore preterm birth cre-
ates the risk for a disruption in retinal
vascularization called retinopathy of
prematurity that can lead to retinal de-
tachment and blindness. The immature
gastrointestinal tract places the infant at
risk for necrotizing enterocolitis, with
risks of intestinal perforation, peritonitis,
and necrotic loss of bowel (Kenner
et al., 1998).
The immature CNS of the preterm
infant is also at great risk for impaired
structural integrity. Many preterm in-
fants still have a developmental struc-
ture called the germinal matrix, the ana-
tomic site of development of neural
cells. This highly vascular and metabol-
ically active structure can be easily
damaged, resulting in periventricular-
intraventricular hemorrhage. Another
concern is periventricular leukomalacia,
a necrotic loss of white matter related to
both ischemic injury of brain tissue and
to subsequent reperfusion injury with
cellular damage by free radicals. Both
periventricular-intraventricular hemor-
rhage and periventricular leukomalacia
can result in serious adverse develop-
mental sequelae, including cerebral
palsy (Volpe, 2001). The threat to struc-
tu r al in teg r ity ex ten d s to th e
musculoskeletal system, as preterm in-
fants confront gravity with a reduced
muscle mass and hypotonia, and there-
fore are at risk for musculoskeletal ab-
ormalities that can interfere with the
263
developmental tasks of infancy and
with learning to walk (Barb & Lemons,
1989; Fay, 1988).
A Disruption of Wholeness:
Neurologic Immaturity as a
Threat to Personal Integrity
Levine’s (1967, 1973) concept of
personal integrity relates to the individ-
ual’s sense of self-identity, self-worth,
and self-esteem. Although the preterm
infant does not yet have the higher cog-
nitive abilities with which to verbally
communicate a sense of self-identity
and uniqueness, the neurologic ground-
work for personal integrity is being es-
tablished and neurologic damage can
interfere with the emergence of per-
sonal integrity. During the final weeks
of gestation, the CNS is completing the
critical phase of organization, charac-
terized by dendritic branching and for-
mation of synaptic connections (Volpe,
2001). The NICU environment itself
has an adverse effect on the process of
CNS organization, creating the poten-
tial for altered patterns of neuronal con-
nections, neurologic damage and long-
term developmental disorders (Kenner
et al., 1998; Volpe, 2001).
A Disruption of Wholeness:
Disruption in Family System
as a Threat to Social Integrity
A preterm birth creates many chal-
lenges for the family system, including
grieving the loss of a healthy infant, dis-
ruption in bonding and attachment, and
parenting a child with special needs. In
many cases, the death of the infant is a
very real threat. The social identity of
the infant is defined primarily by the
family’s social identity and the infant’s
position within the family. The admis-
sion of an infant to the NICU separates
the infant and family, placing great
stress on the family system and creating
a threat to social integrity.
Adaptation
When a challenge is encountered in
the external environment, the individual
must be able to stabilize the internal en-
vironment to remain healthy (Levine,
1991). Levine described adaptation as
“the process by which individuals ‘fit’
264 Nursing Science Quarterly, 17:3, July 2004
the environments in which they live”
(Levine, 1996, p. 38), with the CNS per-
forming the critical integrating function
that allows a unified adaptive response
(Levine, 1966, 1969). The preterm in-
fant attempts to generate an integrated
adaptive response to fit the extrauterine
environment, however the generalized
immaturity of the organ systems, espe-
cially the CNS, makes adaptation quite
difficult (Als, 1986; Barb & Lemons,
1989; White-Traut et al., 1994). The
family system is also simultaneously
calling upon its adaptive resources to
cope with the crisis in the unfamiliar en-
vironment of the NICU, surrounded by
a new, yet temporary, support system
composed of NICU staff, particularly
neonatal nurses.
Nursing Care
The act of nursing occurs at the inter-
face between the patient’s internal envi-
ronment and external environment (Le-
vine, 1973), with the nurse using
nursing skill and knowledge to create an
environment in which the process of ad-
aptation can take place with the greatest
degree of success (Levine, 1966, 1973).
Nursing care of the preterm infant and
family should be both therapeutic and
supportive in nature and directed to-
ward conserving integrity (wholeness
or health) during the crucial adaptation
to extrauterine life by addressing the
four conservation principles of nursing.
D ep en d in g o n th e d eg r ee o f
prematurity, the infant’s transitional pe-
riod of physiologic adaptation to extra-
uterine life may last from a few hours to
several months (as infants born several
months prematurely must continue to
develop their immature organ systems
in a parallel manner to that which oc-
curs in utero). For the family, however,
adaptation often lasts a lifetime, as the
long-term outcome of the preterm in-
fant is significantly influenced by the
degree of nurturing and enrichment in
the social environment (Blackman,
1991).
Nursing Care to
Conserve Energy
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Critical nursing interventions to pro-
mote conservation of energy include
supporting the pulmonary and cardio-
vascular systems during the transition
to extrauterine life, to assure that ade-
quate oxygen is available to perform the
cellular work of life. Nurses must main-
tain airway integrity, assess breathing
and circulation, monitor the adequacy
of oxygenation and ventilation, provide
supplemental oxygen and mechanical
ventilation as indicated, and position
the infant to promote optimal pulmo-
nary function and comfort. It is espe-
cially important to maintain an appro-
priate balance between energy supply
and demand during the phase of acute
illness by implementing nursing mea-
sures to keep the infant calm, promote
rest, manage pain, and promote thermal
stability. Conservation of energy also
includes assuring the appropriate intake
of nutrients. The immaturity of the gas-
trointestinal system often necessitates
the provision of nutrition either
parenterally or through gastric or
transpyloric tubes, requiring careful
monitoring for complications. When
the infant reaches the convalescent
phase, nurses play an integral role in
assisting the infant to learn oral feeding
skills.
Nursing Care to Conserve
Structural Integrity
The preterm infant faces multiple
threats to structural integrity that neces-
sitate meticulous nursing care. Since
bronchopulmonary dysplasia has been
linked to barotrauma and to the toxic ef-
fects of supplemental oxygen (Kenner
et al., 1998), nursing interventions di-
rected at minimizing the infant’s needs
for oxygenation and ventilation should
also help to reduce the likelihood of
lung damage. Since a major risk factor
for retinopathy of prematurity is the ad-
ministration of supplemental oxygen to
preterm infants (Kenner et al., 1998),
and since the brain has little tolerance
for episodes of hypoxia (Volpe, 2001),
then nursing interventions to promote
optimal oxygenation status while also
minimizing the need for supplemental
oxygen may help to reduce the likeli-
hood of both retinal damage and brain
injury. Preterm infants tend to have a
pressure-passive cerebral circulation,
with an impaired ability to autoregulate
cerebral brain flow, and as a result there
appears to be a relationship between
fluctuations in systemic blood pressure
an d th e o ccu r r en ce o f b o th
periventricular-intraventricular hemor-
rhage and periventricular leukomalacia
(Volpe, 2001). Therefore, nursing inter-
ventions to stabilize blood pressure by
maximizing cardiovascular stability,
minimizing noxious environmental
stimulation, and promoting comfort
may also help to minimize the likeli-
hood of these neurologic problems.
Since preterm infants are at increased
risk for infection, careful handwashing,
use of aseptic technique with invasive
lines, and interventions to promote opti-
mal skin integrity should minimize the
likelihood of infection. The risk of
necrotizing enterocolitis may also be
r ed u ced b y clo s ely m o n ito r in g
tolerance of enteral feedings and by
responding rapidly to rest the bowel in
the event of feeding intolerance.
Levine stated, “Structural integrity is
seriously threatened unless daily nurs-
ing care is frankly rehabilitative in its
intent” (Levine, 1967, p. 52). Musculo-
skeletal abnormalities require ongoing
therapeutic intervention to promote a
normal posture and a proper balance of
flexor and extensor tone. Nursing care
of the preterm infant should provide
particular attention to promoting flexed
posture with midline positioning of the
upper extremities in order to help coun-
teract the effects of gravity upon the
weak muscles of the preterm infants and
to facilitate the development of hand-to-
mouth and hand clasping movements
(Barb & Lemons, 1989; Fay, 1988).
Nursing Care to Conserve
Personal Integrity
The hazardous NICU environment
poses great risks for disruptions in the
personal integrity of the preterm infant,
primarily due to the fragile nature of the
developing CNS. An adequately func-

tioning CNS is the cornerstone for the
conservation of personal integrity.
Since nurses have primary control over
the NICU environment and since a pri-
mary role of the professional nurse is to
manipulate the environment to facilitate
healing (Levine, 1966), then nurses
should take a leading role in modifying
the NICU to provide a developmentally
supportive environment for the preterm
infant.
Infant behavior is the primary
method of communication for the in-
fant, and alterations in neurodevelop-
mental competence are reflected in that
behavior (Als, 1982). A useful frame-
work from the adjunctive discipline of
psychology for interpreting the behav-
ior of preterm infants and promoting
neurodevelopmental competence is
Als’ (1982, 1986) synactive theory of
preterm infant behavior. This theoreti-
cal framework conceptualizes a net-
work of five behavioral subsystems: au-
tonomic, motor, state, attention-
interaction, and self-regulation. Each of
these subsystems are simultaneously
interacting both with the environment
and with the other four subsystems, and
the level of subsystem functioning is
observable through infant behavior. Als
(1982, 1986) advocates regular assess-
ments of infant behavior, with subse-
quent individualization of both the envi-
ronment and caregiving procedures in
order to minimize behavioral signs of
stress, or avoidance behaviors, and to
promote behavioral signs of stability, or
approach behaviors. The goal of pro-
viding individualized, developmentally
supportive care is to optimize develop-
mental progress and to support the
emergence of infant individuality (Als,
1982, p. 229). According to Als (1986),
“The level of differentiation and ability
to modulate behavior are the dominant
parameters of an infant’s individuality
and personal uniqueness, recognizable
over time” (p. 17). This conceptualiza-
tion by Als of the meaning of preterm
infant behavior provides support for the
theoretical assertion that a primary role
of the NICU nurse is to provide nursing
interventions to conserve personal
integrity.
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Preterm Infant Health Promotion
To participate with the patient to im-
plement nursing interventions that sup-
port successful adaptation and promote
health (or conserve wholeness), it is es-
sential that the nurse be able to effec-
tively communicate with the patient.
Levine (1973) stated that the nurse must
be able to recognize “the individual’s
holistic response which indicates the
nature of the adaptation taking place.
The nurse must learn to read the mes-
sage” (p. 13). The patient uses various
modes of communication to deliver this
message—not only language but also
nonverbal communication (Levine,
1973). Therefore, in order to plan and
deliver holistic nursing care for preterm
infants, it is essential that neonatal
nurses be able to not only interpret
physiologic cues (such as vital signs,
physical assessment findings, and labo-
ratory results), but also to read the mes-
sage (Levine, 1973, p. 13) embedded in
infant behavior and then to modify the
N I CU env ir o n m en t ( in clu d in g
caregiving processes) to minimize signs
of stress and promote self-regulatory
behaviors.
Nursing Care to Conserve
Social Integrity
A primary goal of nursing care
should be to conserve social integrity by
assisting the family through the crisis
period surrounding a preterm birth. The
nurse should recognize the essential
role of the family in the conservation of
social integrity and the promotion of
optimal infant health, and should there-
fore take the lead in modifying the
NICU so that it is welcoming to the fam-
ily and promotes parental comfort and
competence. Nursing interventions to
promote social integrity initially focus
on assisting the parents to grieve the
loss of a healthy newborn infant and
providing support to cope with the
stressors associated with a preterm
birth and the NICU environment. As
the NICU stay progresses, the focus
of nursing care also includes fostering
parent-infant attachment, providing
parent education, facilitating parental
performance of infant care skills, and
promoting an intact family system. The
265
neonatal nurse is largely responsible for
helping the parents to acquire an under-
standing of the languages spoken in the
NICU, both by teaching the parents to
interpret the behavioral cues of their in-
fant and by helping them to understand
their infant’s physiologic challenges.
The family should be an active partner
with the neonatal nurse and the
multidisciplinary NICU team in the dis-
charge planning process and in assuring
the adequacy of resources for support
following discharge. A primary goal of
nursing care should be to ensure that
when the infant is physiologically and
neurodevelopmentally mature enough
to be discharged from the NICU, the
family is ready to assume total infant
care.
Health: Conservation
of Wholeness
For the preterm infant, wholeness
can be viewed as attaining a state of
health equivalent to that of a newborn
infant born at term gestation, including
the successful integration of the infant
into the family system. A major marker
of wholeness (or health) is for the infant
and family to achieve a level of inde-
pendent functioning that enables the in-
fant to be discharged from the NICU to
the care of the family on or before the
baby’s expected due date for term gesta-
tion. The attainment of health (or con-
servation of wholeness) is marked by
physiologic stability and growth (con-
servation of energy), minimal structural
injury (conservation of structural integ-
rity), neurodevelopmental competence
(conservation of personal integrity),
and a stable family system with integra-
tion of the infant into the family
(conservation of social integrity).
Implications for Nursing
Practice and Research
An initial test of the validity of this
middle range theory has been per-
formed (Mefford, 1999). This was a ret-
rospective study of 235 preterm infants
in a Level 3 NICU, examining the influ-
ence of consistency of nursing care on
the health outcomes at the time of hos-
266 Nursing Science Quarterly, 17:3, July 2004
pital discharge. A structural equation
modeling test of a path diagram drawn
to reflect the theoretical propositions
was performed. The final model was a
complete mediation model, with the in-
fluence of integrity at birth on the age at
which health was attained completely
mediated through the provision of con-
sistency of nursing caregivers. These
findings provide strong support for the
utility of this theory of health promotion
for preterm infants based on Levine’s
conservation model of nursing as a
guide for nursing practice in the NICU.
Additional research to further test the
theory is currently underway.
Translating nursing theory into clini-
cal nursing practice is an essential step
in advancing the scientific base of the
discipline of nursing. Neonatal inten-
sive care nursing is a specialty in which
the nurse must be highly attuned not
only to critical physiologic changes, but
also to subtle messages from the infant
and psychosocial support needs of the
family. The application of holistic nurs-
ing practice based on a sound nursing
theory should help to improve the
health outcomes of these fragile
patients and their families.
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