The possession of knowledge is fundamental to the beginning of understanding. On the basis of knowledge, cognitive activity develops from mere recall of facts to critical inquiry. One way of facilitating cognitive development is to utilize models of phenomena. A model evolves from a theoretical base and organizes data in such a way as to aid and further the understanding of that which it describes. Models are graphic representations of phenomena. They are quite flexible in their descriptive power and can be used to illustrate a variety of the aspects possessed by all entities. Models can describe the process or content of a phenomenon. They can be used to illustrate structural or functional properties and can also describe spatial or temporal relationships. Models are "abstracted and reconstructed form(s) of reality" (Riehl & Roy, 1974, p. 2). Therefore, they can serve as efficient tools for teaching a variety of material in an organized and more readily memorable form.
The use of models in nursing is especially helpful due to the variety and complexity of the phenomena with which nurses are confronted. Models facilitate data collection and the cognitive recognition of the course and meaning of events in the environment. The underlying rationale for the use of models in nursing is that models can serve as frameworks for intervention. To intervene is to take purposeful action in anticipation or response to occurrences. However, before a nurse intervenes, she must possess factual information regarding phenomena, grasp the relationship of these facts, recognize the occurrence of phenomena, and be able to label phenomena correctly. To perform these functions requires, at some point, the dissection of phenomena into their constituent elements, hence model building. Intervention can then be directed at any or all of the elements with the intention of increasing the efficiency and efficacy of nursing intervention. Models do not prescribe intervention. On the contrary, they should facilitate creativity in intervention.
Model of Psychosexual Development
The model of psychosexual development presented here (Figure) presents both the process and the content of this developmental process. Psychosexual development was chosen for model building because of the growing acceptance of sexuality as a nursing concern and the lack of psychosexual interventions based on healthy development. The model illustrates the steps which, when taken as a whole, result in a sexually integrated being. The content portion of the model includes t¿he key factors necessary to integrate development as well as the critical events or occurrences which have immediate and long-term consequences for sexual development. The model uses both a chronological and a developmental approach and identifies biological, psychological, and sociological variables which influence psychosexual development.
The model portrays "healthy" sexual development and quantifies the "normal" progress toward sexual integration. Movement in the model is progressive but regression or stagnation is possible if key factors or events are absent or altered or if severe stress, such as illness, occurs. The flow of events in the model is cumulative since future development is dependent on those events and experiences which occurred previously.
Components of the Model
The unbroken line at the base of the model represents the time dimension in psychosexual development and the general developmental stages. In vertical type and above this line are the critical events which are fixed on the time/development line in the order that they occur. Contained within the boxes and connected by uni-directional arrows are the key elements of sexual development placed sequentially in order of initial emergence.
At conception, via the combination of parental genetic material, the genotype of the individual is determined. Gonadal development and the subsequent production of hormones results in differentiation of the embryo's internal and external sexual organs into sex-appropriate forms.
Birth is an especially significant event in psychosexual development in that it is at this time when, based on the external genitalia, the neonate's family and others identify it as either male or female. Much of the subsequent training and life experience of the individual is determined at this time, based on femaleness or maleness.
During the pre-pubescent stage, the foundation for future growth and development in all areas is laid. The individual is being acted upon by a host of interpersonal and extrapersonal variables. Cultural and societal norms, mores, and values set limits on sexuahty and provide a structure for development. The role relationships experienced and observed by the individual also influence ultimate sexual integration. The individual is also engaged in psychological growth. The self-concept and body image are being formed and these elements have a fundamental relationship to development as a sexual being.
Time, the environment, and the individual interact to produce identification - the process of introjection of social, moral, occupational and sexual values and roles (Murray & Zentner, 1975, p. 84). The prepubescent individual is learning to correctly label the self and others as male or female and to identify sex-appropriate behaviors. Thus gender identity and gender role development give rise to the beginnings of sexual identity.
The pubescent stage commences with the onset of pubertal hormone secretion. The adolescent's morphology is undergoing rapid changes, especially as regards physiological sexual development. Behavior is affected by the increasing need for independence as a task of self-identity. The environment simultaneously encourages and discourages the exercise of this independence resulting in intra- and interpersonal conflict.
The young adult continues to work at the task of developing an identity. One portion of this identity concerns sexuality. The individual is engaged in testing sexual attitudes, values, and beliefs, in coming to terms with sexual activity, and, generally, in developing some consistency regarding sexual identity.
Adult sexuality is the product of all that has gone before and is firmly rooted in the identity. It is an integration of previous experience which allows for acceptance and expression of oneself as a sexual being in the present and future. Adult sexuality can be broadly classified as procreative or nonprocreative in nature. Procreative expressions end physiologically with the onset of menopause for women. Although males retain their physiological capacity to procreate beyond that of females, they generally forego procreative expressions at about the same time. Non-procreative expressions are those in which sexual satisfaction is the primary focus. These continue indefinitely and extend to the end of life.
PSYCHOSEXUAL DEVELOPMENT MODEL
The Model as a !teaching Tool
The model presented here has been used at both the undergraduate and Master's level to teach content in relation to healthy and illness-altered sexuality. It provides the necessary cognitive base for timely and effective intervention in that the major elements in psychosexual development are identified and can be described in a chronological fashion. Discussion of each element and its relationship to the elements both before and after build a wholistic and sequential picture of sexual development, and can be used as a starting point for understanding normative and individual variation. In addition, it provides a foundation for each of the four phases of the nursing process - assessment, planning, intervention, and evaluation.
This model is a broad outline for the collection of assessment data through its identification of developmental elements. By fixing the client on the time line, the student is able to focus data gathering on the elements that, at that point, have greatest significance. History-taking is facilitated by the knowledge of prior significant developmental elements. Planning is enhanced by the model's focus on the current client state and the variables impinging on sexuality. The future-directed aspects of the model in terms of the ongoing process of sexual development help to give direction to both short- and long-term goals, Intervention is assisted through the general use of the model which keeps students centered upon implementing the design resulting from assessment and planning. Evaluation is served by the knowledge of normal development contained in the model, hence, deviation can be identified. Evaluation criteria are implied in a general way, and students can be assisted to specify criteria in relation to individual clients and their circumstances.
This model has been used with baccalaureate students to provide an organizing framework for teaching content regarding the alteration of sexual function due to illness or injury. The nature of the physiologic disruption was used as the base from which the ramifications for psychosexual development were discussed. When used this way, the model provided a comfortable melding and integration of physiological, psychological and sociological content. For instance, contrast was used to illustrate the consequences of a C-4 level spinal cord transection between a 50- and a 16-year-old male. In both the physiological alteration was identical. However, the consequences in terms of psychosexual development, while similar in some respects, had very different ramifications as regards issues such as procreation and identity formation. The model served to graphically illustrate these differences.
With Master's level students, the model has been utilized to focus first on healthy sexual development in the primary prevention course, and then to focus on the effect of stressors such as illness in the secondary and tertiary prevention courses. The intervention base consisted of strategies such as anticipatory guidance, validation of normalcy, education regarding effects of disease, alternate forms of sexual expression, and referral. It was stressed that appropriate interventions should be based on consideration of the critical events and interferences occurring in the client's life. For example, appropriate interventions for a 25-year-old woman pre and post hysterectomy should include counseling and education, which explores the personal significance of this event for the client, expectations regarding child-bearing, myths about sexuality post hysterectomy, etc. In the case of a married female, the husband should be included in counseling, both alone and together with his wife, and discussion should center on many of the same issues.
This model is an attempt to meaningfully reduce psychosexual development to its essential elements in order to facilitate learning, and, ultimately, the development of nursing interventions that are evolved from a theoretical base, produced out of a wholistic view of psychosexual development and arise from a conception of sexuality as a healthy, normal phenomenon. It certainly possesses limitations. No model can replace the nurse-client relationship upon which knowledge and insight into the client's unique character and needs are based. However, utilizing a model as a foundation for learning and nursing practice can become the first step in determining successful client service. Using a psychosexual development model in concert with our overall view of human beings serves to strengthen our commitment to treating individuals as integrated wholes. "Human sexuality, that dimension of maleness and femaleness in one's personality, is expressed in every human act; it is inseparable from the maintenance of one's health" (Jacobson, 1974).
- Jacobson, L. (1974). Illness and human sexuality. Nursing Outlook, 22:50-52.
- Murray, R., & Zentner, J. (1975). Nursing assessment and health promotion through the life span. Englewood Cliffs, NJ: Prentice-Hall.
- Riehl, JR, & Roy, C. (1974). Conceptual models for nursing practice. New York: AppletonCentury-Crofts.