MODELING AND ROLE MODELING THEORY

E r i c k s o n , T o ml i n & Swa i n
OBJECTIVES:
Upon successful completion of this chapter, students will be able to:
Describe the historical background of the development of Modeling and Role-Modeling
Define the major concepts in Modeling and Role-Modeling
Present the relationship between Modeling and Role-Modeling and concepts in nursings
metaparadigm
Provide an example of use of Modeling and Role-Modeling in clinical practice
Identify strengths and weaknesses of Modeling and Role-Modeling for clinical practice
Discuss the appropriateness of qualitative and quantitative research methods for testing Modeling
and Role-Modeling
Relate Modeling and Role-Modeling to critical thinking, therapeutic nursing interventions,
communication, and outcomes
Cite examples of the contagiousness of Modeling and Role-Modeling
CREDENTIALS AND BACKGROUND OF THE THEORISTS
HELEN C. ERICKSON (1937-present)
Educational Background
1957 - Graduated Saginaw General Hospital
1974 - BSN; University of Michigan
1976 - MSN Psychiatric Nursing; University of Michigan
1984 - Doctorate in Educational Psychology; University of Michigan
Clinical Background
ER and Medical - Surgical Nursing
Director of Health Services; San German, Puerto Rico
Independant Psychiatric Nurse Consultant
Current Activities
Actively researching Modeling and Role-Modeling Theory
Professor Emeritus; University of Texas at Austin
Faculty Consultant for MRM; Various Schools of Nursing & Service Agencies
Board of Directors; American Holistic Nurses Certification Corporation
EVELYN M. TOMLIN (1931- 2011)
Educational Background

Attended Pasadena City College, Los Angeles County General Hospital School of Nursing,
and the University of Southern California, where she received her Bachelor of Science in
Nursing.
1976 MSN Psychiatric Nursing; University of Michigan
Clinical Background
Clinical Instructor at Los Angeles County Hospital School of Nursing in surgical and
maternal and premature infant nursing.
Taught English at Afghan Institute of Technology in Kabul, Afghanistan
Also served as a school nurse and practiced family nursing in the overseas American and
European communities, which included attending more than 46 home deliveries with a
certified nurse-midwife.
Relief staff nurse at the United States Embassy Hospital
Staff nurse in a coronary care unit for 5 years, worked in the respiratory intensive care
unit, and was also the head nurse of the emergency department at St. Josephs mercy
Hospital in Ann Arbor
Also an assistant professor in the RN studies program at the University of Michigan
School of Nursing. For 8 years, she was an assistant professor of nursing in the
fundamentals University of Michigan.
MARY ANN P. SWAIN (1941-present)
Educational Background
Bachelor of Arts in psychology from DePauw University In Greencastle, Indiana
Master of Science and doctoral degrees from the University of Michigan, both in the
field of Psychology
Clinical Background
Faculty Member since 1970, University of Michigan School of Nursing. Swain taught
psychology research methods and statistics as a teaching assistant at DePauw University
and later as a lecturer and an associate professor of psychology in nursing.
Developed with Erickson a model that assesses a patients adaptation to stress, which is
incorporated into the theory of Modeling and Role Modeling
Current Activities
Currently holds the position of provost for the New York State University System and
resides in Appalachia, New York with her husband.

MRM THEORY HISTORY

The Modeling and Role-Modeling paradigm, originally derived by Helen Erickson from a
practice model (later labeled the APAM model), was developed over several years of clinical
practice. Related concepts and their relations were further elaborated, labeled and articulated
during the early 1970's when Erickson began a prolonged collaboration with Mary Ann Swain.
During this period of time, the APAM model was tested, needs and developmental taxonomies
elaborated, and linkages hypothesized.
In the mid 1970's, while enrolled in graduate school at The University of Michigan, Ann Arbor
(UM), Erickson and Tomlin discovered one another. Interested in the promotion of person
centered care, they spent many hours discussing the essence of nursing, the importance of
patient-centered care, and other philosophical assumptions that provide the bases of MRM.
Swain, Principal Investigator of a NIH funded research project, invited Erickson to test the
efficacy of MRM interventions with people who had hypertension. Swain followed her project
with one focused on persons with diabetes; Erickson requested that Tomlin join the research
team. By the early 1980's the original practice model derived from practice, expanded and
tested through research, took on a distinctive life of its own.
Erickson accepted invitations to present the model both instate and out, Tomlin wrote about it,
calling it Erickson's self-care model, and Swain continued to support and encourage further
elaboration and testing. Klienbeck (1977) replicated Erickson's work on the APAM for her
master's thesis and other graduate students used the framework as the bases of their graduate
work. Finally, by the early 1980's it became apparent that sufficient interest existed to take the
work to the next level. The first book, Modeling and Role-Modeling: A Theory and Paradigm
for Nursing., was written.
The Fundamentals Department faculty in the School of Nursing used it as the bases for clinical
practice. Jenny James, Clinical Director of the Medical-Surgical units in the University of
Michigan, Medical Center, observing significant changes in student's attitudes and nursing
actions, contacted Erickson for consultation. Soon after, MRM was adopted as a framework for
the Medical-Surgical units under the direction of James. Debra Finch, then head nurse on one of
the units, adopted the entire model and initiated implementation. Finch concurrently enrolled
in graduate school, developed a clinical tool designed to assess developmental residual and
tested it for her master's thesis.
Simultaneously, courses in MRM offered to graduate students served as a stimulus for
expansion and testing of various concepts; several graduate students adopted the model as the
bases for their theses and dissertations. A cohort of faculty, students, and clinical personnel
met weekly to discuss clinical, research, and educational issues as they related to MRM.
During the fall of 1985, two things occurred that influenced the future of MRM. First, the "MRM
Cohort" decided to offer a conference on the theory and paradigm; and second, Carolyn Kinney
(one of the U of M faculty) decided that the "MRM Cohort" should organize a Society for the
Advancement of MRM. The outcomes of these decisions were the establishment of The Society
for the Advancement of Modeling and Role-Modeling (SAMRM) and the First National
Conference on Modeling and Role-Modeling - sponsored by the SAMRM.
In the fall of 1986, Erickson moved to the University of South Carolina as Associate Dean,
Academic Affairs. Kinney moved to The University of Texas, Austin, as faculty. Tomlin continued
to teach Fundamentals at the U of M for a few years and then retired, moving to Illinois. By the
late 1980's, Swain had moved into Administration at the U of M, and soon after moved on to
New York to assume the position of Provost and Vice President for Academic Affairs for the
New York State University System. In 1986, Erickson moved to Austin, TX, as Professor of
Nursing and Chair of Adult Health.
During the late 1980's MRM continued to grow and spread as Erickson and Kinney worked
together to advance the work of SAMRM; Jenny James implemented the model in various
health care agencies, and other Charter members including Janet Barnfather, Nancy Kline-Leidy,
and Margaret Erickson, continued to test hypotheses and publish findings. Doctoral students at
The University of Texas also adopted MRM. Susan Bowman and colleagues adopted the model
as the bases for their curriculum at Humboldt State University. Their school became the first
School of Nursing to fully implement the model and become nationally accredited with a MRM
based nursing curriculum. Other schools and health care agencies followed.
Today, MRM serves as one of the extant theories for holistic nursing, recognized by ANA as a
specialty in nursing. It has provided the framework for numerous dissertation, several
research studies, and clinical practice
THEORETICAL SOURCES
The theory and paradigm Modeling and Role Modeling was developed using a
retroductive process. The theorists go through four levels of theory development and
then recycle form inductive to deductive to inductive to deductive. The theoretical
sources were used to validate clinical observations. Clinical observations were tested in
light of the theoretical bases. These sources were synthesized with their observations,
which enabled Erickson, Tomlin, and Swain to develop a multidimensional new theory
and paradigm- Modeling and role-Modeling.
The original model was derived inductively from the primary authors clinical and
personal life experiences.
The works of Maslow, Erikson and Piaget, Engel, Selye, and M. Erickson were then
integrated and synthesized into the original model to label, further articulate, and refine
a holistic theory and paradigm for nursing.
Maslows Theory of Human Needs was used to help label and articulate H. Ericksons
observations that unmet basic needs interfere with holistic growth whereas satisfied
needs promote growth.
Piagets theory of Cognitive Development and E. Eriksons theory on the stages of psychological
development gave a framework to explain peoples problems as unfinished developmental
tasks. As tasks are completed, the individual feels stronger in character and health.
Winnicott, Mahler, Bowlby and Kleins work on object attachment was incorporated into the
original model to help develop the concept of affiliated-individuation or, AI. According to the
theorists, when an object repeatedly meets an individuals basic needs, attachment or
connectedness to that object occurs. The authors defined AI as the inherent need to be
connected with significant others at the same time there is a sense of separateness from them
that enhances their uniqueness. AI runs across the life span form birth to death. Research
supports that AI and object attachment is essential to need satisfaction, adaptive coping, and
healthy growth and development.
The authors further state that object loss results in basic need deficits. Loss is real,
threatened, or perceived; it may be a normal part of the developmental process; or it may be
situational. Loss always results in grief; normal grief is resolved approximately in one year. When
only inadequate or inappropriate objects are available to meet needs, morbid grief results.
Morbid grief interferes with the individuals ability to grow and develop to maximum potential.
Engles work explores the psychosocial response to stress and Seyles explores an individuals
biophysical response to stress. This framework supported the authors statement that object
loss results in basic need deficits.
The combination of these theories along with the authors own clinical and personal
background led to the formulation of the Adaptive Potential Assessment Model
(APAM). This model is used to see if individuals can mobilize resources when in a
stressful situation versus adapting.
Erickson credits Milton H. Erickson in the formulation of modeling and role-modeling,
when he told her to model the clients world, understand it as they do, then role-model
the picture the client has drawn, building a healthy world for them. (Erickson, H.C.,
Tomlin, E.M. & Swain, M.A., 1983)
Theory was written over several years.
Culmination of work published in the book, Modeling and Role-Modeling a Theory and
Paradigm for Nursing, in 1983.
USE OF EMPIRICAL EVIDENCE
MAJOR CONCEPTS & DEFINITIONS
A. MODELING
The act of Modeling, is the process the nurse uses as she develops an image and
understanding of the clients world- an image and understanding developed
within the clients framework and form the clients perspective. The art of
Modeling is the scientific aggregation and analysis of data collected about the
clients model.
Modeling occurs as the nurse accepts and understands her client.
B. ROLE-MODELING
The art of role-modeling occurs when the nurse plans and implements
interventions that are unique for the client.
The science of role-modeling occurs as the nurse plans interventions with
respect to her theoretical base for the practice of nursing.
Role-modeling is the essence of nurturance
It requires an unconditional acceptance of the person as the person is while
gently encouraging the facilitating growth and development of the persons own
pace and within the persons own model.
Role-modeling starts the second the nurse moves from the analysis phase of the
nursing process to the planning of nursing interventions.
C. NURSING
Nursing is the holistic helping of persons with their self-care activities in relation
to their health. This is an interactive, interpersonal process that nurtures
strengths to enable development, release, and channeling of resources for
coping with ones circumstances and environment. The goal is to achieve a state
of perceived optimum health and contentment.
D. NURTURANCE
Nurturance fuses and integrates cognitive, physiological and affective
processes, with the aim of assisting a client to move toward holistic health.
Nurturance implies that the nurse seeks to know and understand the clients
model of his or her world and to appreciate its value and significance for that
client from the clients perspective.
E. UNCONDITIONAL ACCEPTANCE
Being accepted as a unique, worthwhile, important individual- with no strings
attached- is imperative if the individual is to be facilitated in developing his or
her own potential. The nurses use of empathy helps the individual learn that the
nurse accepts and respects him or her as is. The acceptance will facilitate the
mobilization of resources needed as this individual strives for adaptive
equilibrium.
F. PERSON
HOW PEOPLE ARE ALIKE:
1. Holism
Human beings are holistic persons who have multiple interacting
subsystems. Permeating all subsystems are the inherent bases. These
include the genetic makeup and spiritual drive. Body, mind, emotion and
spirit are a total unit and they act together. The interaction of the
multiple subsystems and the inherent bases creates holism: holism
implies that the whole is greater than the sum of its parts.
2. Basic Needs
All human beings have basic needs that can be satisfied. Basic needs are
only met when the individual perceives that they are met.
3. Lifetime Development
Lifetime development evolves through psychological and cognitive
stages.
Psychological stages: each stage represents a developmental task or
decisive encounter resulting in a turning point, a moment of decision
between alternative attitudes.
Cognitive stages: Piaget believed that cognitive learning develops in a
sequential manner and he has identified several periods in this process
namely: sensorimotor, preoperational, concrete operations and formal
operations.
4. AFFILIATED-INDIVIDUATION
Individuals have an instinctual need for affiliated-individuation. They
need to be able to be dependent on support systems while
simultaneously maintaining independence from these support systems.
HOW PEOPLE ARE DIFFERENT
1. INHERENT ENDOWMENT
Each individual is born with a set of genes that will some extent predetermine
appearance, growth and development.
2. ADAPTATION
Adaptation occurs as the individual responds to external and internal stressors in
a health-and-growth directed manner. No subsystem is left in jeopardy when
adaptation occurs.
The individuals ability to mobilize resources is depicted by the APAM.
3. MIND-BODY RELATIONS
We are all biophysical, psychosocial beings who want to develop our potential,
this is, to be the best we can be.
4. SELF-CARE
Self-care involves the use of knowledge, resources, and action.
i. Self-care Knowledge: at some level a person knows what has made him
or her sick, lessened his or her effectiveness, or interfered with his or her
growth. The person also knows what will make him or her well, optimize
his or her effectiveness or fulfillment, or promote his or her growth.
ii. Self-care Resources: Internal and additional resources mobilized through
self-care action that will help gain, maintain, and promote an optimum
level of holistic health.
iii. Self-care Action: The development and utilization of self0care knowledge
and self-care resources.
NURSING METAPARADIGMS
NURSING
- The nurse is a facilitator, not an effector. Nurse-client relationship is an interactive,
interpersonal process that aids the individual to identify, mobilize, and develop his or
her own strengths. Rogers has defined this concept as facilitative-affiliation.
Nursing Roles
- Facilitation: Helping client identify, mobilize and develop personal strengths in moving
toward health.
- Nurturance: Gently supporting and encouraging client to integrate all biophysical,
cognitive and affective processes in movement toward health.
- Unconditional Acceptance: Using empathy to fully accept person as worthy with no
strings attached.
Aims of Intervention
- Build Trust: Through nurse-client relationship; keep promises, meet basic physical and
safety needs through being truthful and trustworthy; use touch and boost esteem
needs, through affirming comments about strengths.
- Promote Positive Orientation: In other words, accept client as worthwhile and facilitate
ability to project oneself into a positive future through making comments about events
that might occur next week, etc.
- Promote Control: In other words, perceived control is the key; ask what client needs
and how you can help; offer options in plan of care; recognize small accomplishments
such as breathing evenly, control bleeding.
- Affirm and Promote Strengths: Comment on small strengths, e.g., strong pulse, ability
to void, to walk from bed to chair.
- Set Mutual, Health-Directed Goals: Involve client in developing health directed
interventions that fit within his or her model of the world.

PERSON
- A differentiation is made between patients and clients in this theory. A patient is given
treatment and instruction; a client participates in his or her own care.
- GOAL: for nurses to work with CLIENTS
- A CLIENT is one who is considered to be a legitimate member of the decision-making
team, who always has some control over the planned regimen, and who is incorporated
into the planning and implementation of his or her own care as much as possible.
HEALTH
- Health is a state of physical, mental, and social well-being, not merely the absence of
disease or infirmity. It connotates a state of dynamic equilibrium among the various
subsystems of a holistic person.
THEORETICAL ASSERTIONS
The theoretical assertions of the Modeling and Role Modeling Theory are based on the
linkages between completion of developmental tasks and basic needs satisfaction; among
basic need satisfaction, object attachment and loss, and developmental tasks; and the
ability to mobilize coping resources and need satisfaction.
1. The degree to which developmental tasks are resolved is dependent on the degree to
which human needs are satisfied.
2. The degree to which needs are satisfied by object attachment depends on the
availability of those objects and the degree to which they provide comfort and security
as opposed to threat and anxiety.
3. An individuals potential for mobilizing resources- the persons state of coping according
to the APAM- is directly associated with the persons need satisfaction level.

THEORY EVALUATION:

INTERNAL EVALUATION

Adequacy

The concepts, principles, key ideas and definitions are thoroughly described in relation to
theory's central premise of holism. The theory is broad enough that it can be adapted to a
variety of settings; however, it is not described sufficiently in terms of clinical applications of its
ideas. MRM does identify 13 propositions to predict outcomes, direct the nursing care plan and
evaluate care and five aims of intervention and MRM principles. It seems the theory does not
further indicate how to implement these aims and propositions in order to stay true to the goal
of individualized interventions unique to patients rather than promote a formulaic approach. To
gain a better understanding of how MRM may be applied, one must refer to other work by
those who have attempted to apply the theory piecemeal.

Clarity

MRM is clear and easy to understand, and the language used is simple and straightforward.
Conventional terms, such as nursing and health, are redefined to emphasize holism. MRM also
explains areas where the work of past theorists is relied upon. For example, when discussing
how people are alike, MRM identifies basic needs and lifetime growth, incorporating Maslow's
hierarchy of needs as the framework for understanding basic need satisfaction. MRM also uses
Piaget to understand how people are alike in cognitive development. Using the work of past
theorists helps to lay a clear foundation for MRM.
Consistency

MRM theory defines key concepts and principles early on and continues to use those terms
throughout. The most basic definitions (person, health, etc.) are used later when thinking about
how the concepts relate to individual likenesses and differences. To accept these concepts, one
must understand Erickson and colleagues' view of the individual as holistic, having several
interacting parts and as constantly adjusting to stimuli (Peterson & Bredow, 2009).

Logical Development

For the most part, MRM flows logically, building the theory from the ground up by first defining
key concepts and principles and then showing how they interact. The five aims and 13
propositions unfold from the concepts and principles defined previously. The concepts and
principles support the proposed interventions for clinical practice, even if the interventions
named may arguably be too broad.

However, affiliated-individuation (AI) is a concept that seems somewhat awkwardly included. AI
is defined as an individual's need to be dependent on support systems while at the same time
maintaining some independence from them. Erickson et al. (1983) give the example of the
relationship between child and parent. Of the concepts in the how people are alike section, AI
seems to be more a description of people functioning within support systems and social
networks rather than a mode of personal growth and how people are alike. AI may not need its
own heading and may better be included within another concept such as adaptation.
Level of Theory Development

The classification of MRM has been debated among theorists. Tomey and Alligood (2002)
originally classified MRM as a middle range theory in 1998, yet later changed their thinking to
indicate that MRM is both a guide as well as an abstract theory from which middle-range
theories may be derived. McEwen and Wills (2002) regard MRM as a grand theory - specifically
as an interactive process theory. Peterson and Bredow (2009) include it in their text as a
middle-range theory to illustrate the number of middle range concepts that have developed
from the theory. On The Society For The Advancement of Modeling and Role-Modeling's
website, Judith Hertz (1997) states that MRM is best depicted as a grand theory that
encompasses a number of mid-range theories.

MRM is highly explanatory - instead of focusing on a specific aspect of nursing care and a way
to apply that to patients, MRM promotes a new view. Additionally, it seems that it would not
be enough for a nurse to focus only on meeting goals with the patient, it implies that the nurse
would also need to incorporate a personal change. For nurses who do not have a similar view of
holism, adopting this theory may prove a personal challenge. For these reasons, MRM is more
of a grand theory than a midrange theory.

EXTERNAL EVALUATION

Complexity
MRM is complex theory with interrelated and multi-leveled concepts. It is parsimonious;
though the theory is clear and consistent, a few areas could use greater explanation and
evidence. Specifically, the description of self-care knowledge appears different from the general
use of the term, and could benefit from a more in-depth description of its meaning and
applicability.
Further, the applications of the theory section presents a listing of professionals who have used
MRM for their own studies; however details regarding the results and ways that it was tested
are omitted. It also appears these professionals tested pieces rather than theory as a whole,
adding to the argument that MRM is a grand theory from which middle range theories may be
tested.

Discrimination
MRM is not a discriminating theory; it does not offer specific or exclusive hypotheses for
nursing care. While it presents aims of interventions (i.e., nurses should build trust, promote
client's positive orientation, affirm and promote client's strengths, etc.) and guidelines, it gives
few practical examples of these aims put in to clinical practice. The concepts and principles
presented in this theory could be adapted to many other areas such as social work, psychology
or even teaching. This makes sense, as the theory borrows heavily from people like Erikson and
Piaget, who have enormously impacted psychology and education, respectively.

Reality Convergence

For the most part the assumptions made in MRM converge with reality. Many of the theories
borrowed in MRM are generally accepted and widely used in a variety of fields. MRM does
assume an acceptance of holistic nursing, and while holism has become a more recognized
discipline, some nurses may view it with skepticism.

Pragmatic

While some nurses may welcome MRM and a holistic view of patients, the implementation of
this theory could pose a significant challenge in practice. Build trust, one of the aims of
intervention and likely the first aim that needs to be met, may be difficult to achieve during an
eight or 12 hour shift while a nurse is also caring for other patients. If a patient is impoverished
and coping with several stressors, it seems that a nurse would be only beginning to understand
the patient's situation and needs and get them to open up. The nurse is tasked with uncovering
how to collect intimate information about deeply ingrained behaviors on patients who may
have a difficult time sharing. Even in the case of a couple who has been married for several
years, aggregating and analyzing their partner's world view would be a challenge. The
guidelines offered are merely a starting point, though Erickson et al. (1983) encourage
creativity.
MRM also assumes that patients have a keen understanding of themselves, can readily identify
what is wrong, and know what they need and want. This may be true for a patient who is
admitted for surgery and has a specific action plan in place, yet for many general medicine
patients, the MRM process will take greater understanding on both the part of the patient as
well as the nurse. Patients may be scared, confused or resigned, and they may have many
problems (health and otherwise) that contribute to this. MRM may assume that patients are at
the point where they have a readiness for change and enhanced knowledge, when in fact the
holistic healing process may take more time and resources than a single bedside nurse can
provide.

This is further complicated because MRM is more of a descriptive theory than a prescriptive
one. The implementation of the theory may be approached in very different ways. Lombardo
and Roof (2005) talk about implementing the theory in a case of morbid obesity. Using the
outlined aims and getting a detailed history of the patient, a nursing student attempts to
promote self-care, provide teaching and appeal to the patient's strengths. This application was
based in a home health setting by a student nurse, differing greatly from an inpatient bedside
setting. Baas (2004) wrote a study about self-care resources and activity as predictors of quality
of life after a myocardial infarction. In this study, Baas suggests that MRM is a useful theory
that may guide nurses in increasing internal and external self-care resources. She also suggests
that this is something that can be started during hospitalization and continued as an outpatient
through case management services, though outpatient case management is not mentioned by
Erickson and colleagues (Baas, 2004).
Scope

MRM covers a broad range of phenomena and has a wide range of applicability. It can be
applied to a variety of settings not limited to healthcare. MRM would be of interest to any
helping profession.

Utility

MRM gives a well-grounded framework from which hypotheses can be derived and studied.
The concepts and principles are clearly defined and offer several suggestions to measure
progress. MRM does not present formal hypotheses or a prescriptive mechanisms of action.
How a nurse approaches the implementation of one or several of these concepts, guided by the
theories aims and propositions, is left largely to his or her discretion. This theory is particularly
useful to students, who may wish to practice while learning.

Research on this theory centers around the applicability of one or a few concepts rather than
applying the theory as a whole. For example, instead of tackling each of theory's aims and
propositions, Sappington (2003) wrote about the concept of nurturance and how it can be
applied to assessing and meeting a patient's needs. If MRM is understood as a grand theory
from which more prescriptive mid-range theories may spring, then Sappington's method may
make the most sense for research purposes.
Significance

MRM is central to the role of a nurse and what he or she hopes to accomplish with a patient. By
invoking the overarching theory of holism, MRM appeals to the relationship between the
patient's mind, body, emotion and spirit. It purports that healing goes deeper than the physical.
MRM touches on how we can tap in to a patient's needs and fears, set mutual goals, tailor
teaching and care to suit their needs and reach a new level of health for patients; thus, the
implications of MRM are greatly significant and essential to the field of nursing.