University Health System, San Antonio, Texas

Elma Ileana Fonseca, MSN, RN, CVRN-BC,
Debra Fraley, MSN, RN, CCRN, CCNS,
Charles Reed, PhD, RN, CNRN
November, 2019

Practice/Theory Exemplar (Modeling & Role Modeling)


University Health System (Bexar County Hospital District) San Antonio, Texas is a Level 1 Trauma county hospital with 38 established clinics serving Bexar County, a population of 1,986,049 and 22 adjacent counties.

Description of the settings

With over 30 clinics throughout San Antonio, University Health System provides healthcare for families close to home. University Health System is committed to delivering patient-centered, culturally competent and high-quality healthcare for adults and children

University Health System believes in a patient and family-centered team approach.  Here, teams of physicians, nurses, technologists and other professionals work with individuals and their family to develop and individualized plan of care. See more information here

Key nurses involved in implementation

Debra Fraley, MSN, RN, CCRN, CCNS – currently Debbie is the clinical nurse educator of the emergency department; She has worked in the Surgical Trauma Intensive Care Unit before becoming an advanced practice nurse and educator.

Jennifer Ramos, MSN, RN, CMSRN – Jennifer  has had many roles since becoming an RN on the medical-surgical unit.  Currently she is a nurse educator and works with new hires in clinical nursing orientation.

Joycelyn Desarno, BSN, RN – Joycelyn is currently a bedside nurse in the Neonatal Intensive Care Unit.  She is very active in the nurse practice committee on her unit and currently enrolled in a Master’s degree in nursing program.

Carmen Paccione, MSN, RN, CCRN-K, CCNS:  Carmen has extensive experience at the bedside working initially as an LVN in the medical-surgical population and then as a bedside RN with the surgical trauma ICU patients.

Kate Robertson, MSN, RN:  retired, former director of Surgical Trauma ICU, Operating Room.

Susana Pawkett, BSN, RN: patient care coordinator with the Hem/Onc Unit; magnet champion

Mary Ann Pienaman, MSN, RN:  retired, pediatric nurse educator

Date of Implementation – 2006-present (13 years)
Theoretical Framework

In 2006, we started our journey to achieve Magnet status which required us to choose a nursing theory that best reflected our nursing practice.  The population we serve is diverse and challenging with much individualization to provide the best care.  In our quest to find a nursing theory which reflected the health system values and beliefs and allows us to keep the patient at the center of care we selected the Modeling and Role-Modeling Theory of nursing by Helen Erickson.

The modeling part of the theory assists nurses to focus on, recognize and understand the unique perspectives that each person brings to the nurse-patient relationship; their needs or worldview helps nurses stay focused on the individual and their personal needs.  Role-Modeling uses the patient’s model of the world to plan interventions to meet the perceived needs, grow, develop and heal.  The nurse intervenes to build trust, promote the patient’s strengths, positive orientation, a sense of control and assists in setting of mutual health goals.  Within this theory, we work to provide holistic care, mobilize resources for meeting basic needs and help the patient manage response to stressors. See more information here.


We introduced our new nursing theory to staff using several different strategies.  We had multiple sessions for staff to receive education on the concepts within theory.  After these sessions, we used case studies to demonstrate how this theory is put into practice at the bedside.  We highlighted case studies from many different areas so staff could understand how this theory works for their particular patient population.  During our nursing celebration, we invited Helen Erickson to speak on Modeling and Role Modeling and round on the floors to speak with our nurses and answer questions related to translating this theory into practice.  We reviewed our current professional practice model and felt that an update was needed to help the nurses better understand our theory and how to implement it into our practice.  A mini system-wide conference was held including representatives from the different clinics and units in the hospital.  Our goal was to decide how to develop a professional practice model.  The group generated many different ideas and concepts that might be used.

Members were selected from the conference participants to serve as our leadership group.  As a team, we worked diligently over the next few months trying to decide how to integrate the Modeling and Role-Modeling theory into our Professional Practice Model.  Specific Components of the Professional Practice Model were designed to reflect the theory, provide us with a common understanding and standardize everyday practice for nurses.  We have invited Helen back to our health system, providing case studies for her to review with our nurses on how we continue to demonstrate Modeling and Role Modeling with our patients.  We have also presented at the Society for the Advancement of Modeling and Role-Modeling, presenting our cases in Grand Rounds.

Approach to Evaluation

Achievement of Magnet status in 2006 validated that we were on target with out choice of nursing theory! To evaluate our outcomes, patient satisfaction surveys are reviewed routinely.  Leadership rounding has been put into place in all units where the leaders speak with patient about their care and discuss our requests for feedback.  Our patients are encouraged to use the Get Well Network to take surveys and tell their story about the care they receive and nominate staff for excellence care and service.  Some comments include:

“All nurses and Techs were superior in their care for me.  May God bless them all.  All physicians went beyond their call of duty, very patient and understanding with regards to my needs.”

“During my stay at University myself and my family were able to work with a few nurses that were great to work with.  All of the nurses were great.  These nurses had great bedside manner, listened to my concerns, spoke with my family, and the best was put a smile on our faces.  The smiles are much appreciated and it was a reminder day and night that there is always something positive in the day.  Thank you so much!”

My nurses and team have been amazing!!  They are considerate, nice, always smiling and telling me what is going on and what they are doing with me.  They make me feel better about getting better.  Having open heart surgery is scary.  They made it better.”

“The staff is great.  Love the nurses and doctors work hard”

Practice Recommendations

Nurses should learn to see each person as an individual, learn to ask for an assess each patient’s perspective and recognize their way-of-knowing, i.e., each person’s worldview so that they can understand what is important to the individual.  Working from this perspective helps people heal and recover, gives them hope and some control.  While we have to do the tasks necessary to take care of the patient’s medical problem, it is essential that nurses take care of the person first and from the individual’s perspective.  This will help us better serve our communities and improve health.

Theory development recommendations

To further develop theory, our recommendations are to focus on the development of person centered care where we can seek out ways to concentrate on the needs of the individual as a more well-rounded approach to health care.


2016 Presentation-The Society for the Advancement of  Modeling and Role-Modeling (San Antonio, Texas).  Fraley, Debra.  “Professional Practice Model” (Download PDF of the presentation here)

Related Literature

Erickson, H. (1988). Modeling and Role-Modeling: Erickson Approaches with Physiological Problems. In J. Zeig & S. Lankton (Eds). Ericksonian psychotherapy: The state of the art. New York, NY: Bunner/Mazel, pp. 477-490.

Erickson, H. (2019). Modeling and Role-Modeling Nursing Theory. In M. Smith, (Ed 5).  Nursing theories and nursing practice, (pp. 183-209).

Erickson, H. (ED) (2006). Modeling and Role-Modeling: A View From the Client’s World. Cedar Park, TX: Unicorns Unlimited.

Erickson, H., Tomlin, E., & Swain, M. (1983/2009). Modeling and Role-Modeling: A Theory and Paradigm for Nursing. Prentice Hall: Englewood Clifffs, N.J.  Second-ninth printing,   Unicorns Unlimited: Cedar Park, TX.

Helen Erickson rounding with nurse leadership and nurses from Post Anesthesia Care Unit