CE Strengths Based Nursing.24

8102019 CE Strengths Based Nursing24

httpslidepdfcomreaderfullce-strengths-based-nursing24 19

HOURSContinuing Education

24 AJN August 2014 Vol 114 No 8 ajnonlinecom

CE

Irsquom looking for the light those little glimmersthat make me think therersquos something there Iam looking for peoplersquos gifts of what theyrsquovegot going for them

mdashNurse Heather Hart as cited inStrengths-Based Nursing Care Health

and Healing for Person and Family1

Despite the recent attention paid to preventionwellness and patient-centered care the medi-cal model with its emphasis on a patientrsquos

deficits rather than strengths remains the dominantpractice model in health care Most nurses have beentrained to focus almost exclusively on problems andthings that are not working They analyze the pa-tientrsquos concerns through a ldquodeficit lensrdquo focusingon pathology attending to the abnormal and thedysfunctional with the goal of ldquofixingrdquo problemsYet in many situations there are more things that

are right than are wrong Strengths-based nursing(SBN) brings a new balance to deficit-based care

SBN focuses on understanding deficits and prob-lems within a broader holistic context that uncoversinner and outer strengths

Diane Bourget a clinical nurse specialist who at-tended an SBN study group I conducted recounteda case that was particularly illustrative of the SBNapproach (All cases discussed in this article are realand all nurses who are identified in this article havegiven me permission to use their names To protectpatient privacy patient names have been changedand identifying details have been omitted except inthe case of Rabbi Cahana whose story has alreadyappeared in a number of publications) When Dianewas working on a crisis intervention team on a hos-pitalrsquos child psychiatric unit Dan Pacheco a NativeAmerican adolescent was admitted showing signsof a severe psychotic break having recently threat-ened the life of a young woman Through their ini-tial interview with Dan the crisis intervention team

discovered that in his community Dan was believedto possess special powers because he ldquoheard voicesrdquo

25

OVERVIEW Strengths-based nursing (SBN) is an approach to care in which eight core values guide nursingaction thereby promoting empowerment self-efficacy and hope In caring for patients and families thenurse focuses on their inner and outer strengthsmdashthat is on what patients and families do that best helpsthem deal with problems and minimize deficits Across all levels of care from the primary care of healthypatients to the critical care of patients who are unconscious SBN reaffirms nursingrsquos goals of promotinghealth facilitating healing and alleviating suffering by creating environments that work with and bolsterpatientsrsquo capacities for health and innate mechanisms of healing In doing so SBN complements medicalcare provides a language that communicates nursingrsquos contribution to patient and family health and heal-ing and empowers the patient and family to gain greater control over their health and healing

Keywords empowerment healing health nursendashpatient relationship nursing values patient-centered careself-management strengths-based nursing

A holistic approach to care grounded in eight core values

Strengths-BasedNursing



ajnwolterskluwercom AJN August 2014 Vol 114 No 8 25

By Laurie N Gottlieb PhD RN

(that is he had auditory hallucinations) The chal-lenge for the team was to reduce Danrsquos potential toendanger others while allowing him to maintain thestatus and power he held within his tribe

After Dan had spent several weeks on the unit hispsychosis was controlled through medication and hisdelusional ideation had subsided Able to recognizethat he was ill Dan was willing to engage in a discus-sion with his family and the interdisciplinary team ofpsychiatrists nurses and social workers about the bestplan to treat his disease Together they negotiated away to meet everyonersquos goals by finding a medicationdosage that would reduce Danrsquos psychotic symptomswithout completely obliterating his ldquovoicesrdquo so thathe was no longer a danger to himself or others but re-tained his tribal status The teamrsquos broad focus wasconsistent with the values of SBN They viewed Danas a whole person a greatly respected member of acommunity whose values were not completely consis-tent with those of modern medicine Had they insteadfocused exclusively on his deficits Dan his family and

his health care team might not have found a solutionthat was agreeable to all

Undoubtedly many nurses already practice ele-ments of SBN without having labeled the approach assuch But the label we use is important because it cantake the approach to a different level of awareness AsPatricia Benner has noted SBN puts ldquointo words whatexpert nurses come to know and experience over timein their best practice [and gives] clarity insightand rigor to a central but poorly understood valueand wisdom embedded in the best of nursing prac-ticerdquo1 Although nurses with a deficit-focused perspec-tive may sometimes seize an opportunity to motivatepatients and families by concentrating on strengthsrather than deficits this approach is not an essentialpart of their schooling and its consistent use cannotbe relied on in professional practice Nurses whosepractice is strengths based on the other hand seekcapacities competencies and skills that patients andtheir families might use for recovery survival grow-ing and in many cases thriving Even nurses treatingunconscious patients in an ICU can use the SBN ap-proach For example by closely observing patientsrsquo

responses to stimuli nurses can schedule painful orintrusive procedures for times when they will be best

I l l u s

t r a t i o n b y J a n e t H a m l i n




tolerated (capitalizing on inner strengths) by notingthe nature of family responses and their effect on thepatient nurses can communicate caring and respectthereby reducing environmental stress (maximizingouter strengths)

SBN recognizes the importance of focusing onstrengths that can empower patients to assume greatercontrol over their own healing and healthmdashit enablesnurses to help people help themselves attain higher lev-els of health This article proposes that SBN is an ap-proach to care that provides the vision values andevidence that can transform and humanize healthcare by reconnecting it with the concepts of FlorenceNightingale and expanding those concepts to meetthe realities of 21st-century health care

THE CURRENT HEALTH CARE CLIMATE

With the expansion of health care coverage in the

United States mandated by the Affordable CareAct many are asking who will provide care for theflood of new patients expected to enter the health caresystem Similar discussions have taken place in Can-ada since 1947 when some Canadian provinces be-gan implementing public health insurance plans thatcovered hospital services continuing beyond 1984when the Canada Health Act was introduced As thelargest group of health care providers nurses were ex-pected to take on a much greater role to accommodatethe increased demand for care There was consider-able debate however about the type of role nursesshould play Some envisioned nurses assuming more

medical functions Others believed nurses should focusmore on health than on illness and that nursing shouldplay a complemental role to medicine2

Providing chronic care Although there are differ-ing perspectives on the role of nurses in various con-texts the SBN model has consistently proven superiorin treating patients with chronic conditions Browneand colleagues recently conducted a meta-analysisof 27 reviews 29 quality studies and nine economicevaluations of nurse-involved and nurse-led inter-ventions for patients living in the community withcomplex chronic medical conditions and social cir-cumstances They found that interventions led byspecialty trained or advanced practice nurses wholdquosupplemented rather than replaced the physicianrdquoproviding proactive (as opposed to reactive or on-demand) assessment and monitoring in the context

of comprehensive care (delivered in collaborationwith family members home nursing and support

personnel hospital staff and other caregivers) pro-duced outcomes (patient functioning hospitalizationrate and quality of life) that were better and oftenless costly than those provided through physician-ledmodels or by nurses using a physician-substitution orphysician-replacement model3

Prenatal and early-childhood care Similar resultshave been reported for other nurse-led initiatives thatemphasize self-efficacy and human ecology (work-ing with the patientrsquos family members and supportnetworks) most notably the NursendashFamily Partner-ship program (wwwnursefamilypartnershiporg)4 Research has demonstrated the benefits of these val-ues in creating partnerships building capacity andconfidence and helping patients use their strengths toachieve their goals develop coping skills and broadentheir resources

Unfortunately many seem to believe that taking

on such responsibilities as case management requiresnurses to relinquish much of the traditional nursingrolemdashcaring for the whole person providing directbody care and spending the time to get to knowboth the patient and family5 Relational care has beendevaluedmdashor in many cases viewed as a regrettablecasualty of technologic progressmdashby nurses nurseadministrators and managers nursing school facultyand physicians These developments have created adisease-oriented depersonalized fragmented and of-ten uncaring system in which people are treated as di-agnoses rather than respected for their personhoodBasic needs described by Kitson as ldquofundamentals of

carerdquomdashsuch as nutrition elimination bathing andcomfort measures that promote the rest required forhealingmdashhave gone unmet6 7

Although the issue is complex with many factorscontributing to the problems inherent in our cur-rent health care system we lack a vision for nursingshaped by well-defined values that could help theprofession determine priorities and guide nursesrsquo ac-tions We also need a better understanding of the factthat nursingrsquosmdashas opposed to medicinersquosmdashuniquecontribution to better outcomes in patient and familyhealth and healing has been empirically established4 8

NIGHTINGALErsquoS VISION

In 1860 Florence Nightingale published her seminalNotes on Nursing What It Is and What It Is Not inwhich she laid out her vision of the nursersquos role Shedescribed nursingrsquos mandate as health and healing andthe role of the nurse as ldquoput[ting] the patient in thebest condition for nature to act upon himrdquo9 Night-ingale understood health as a process of becomingwhile she described healing as an act or process of res-toration or recovery from disease She also recognizedthat the human body and mind had innate restorativeand reparative capacities and that nurses could em-

power patients to contribute to their own healing bycreating physical and interpersonal environments that

SBN reaffirms that health and healing are

the central goals of nursing




allow this to happen10 For example such simple ac-tions as turning down room lights controlling thenumber of visitors closing doors to control noise lev-els moving patients closer to a window and remind-ing visitors to wash their hands help create a physicalenvironment that promotes healing Likewise nursescreate interpersonal healing environments by beingfully present in their interactions with patients lis-tening attentively and demonstrating compassionthrough nonclinical appropriate touch

Nightingalersquos vision was bold She arrived at herunderstanding of health and healing through astuteobservation the experience of caring for both thehealthy and the sick and the study of many disci-plines We are beginning to accumulate scientific evi-dence that validates many of Nightingalersquos insightsFor example she considered physical and emotionalenvironments key to health and healing She also un-

derstood that patients need the support of loved onesto assist them in their recoverymdashthus while nursingin the Crimean War she took the time to help soldierswrite letters to their families back home

In support of this vision research over the past 30years has repeatedly linked perceived social support tobetter physical and mental health with these benefitsmediated through stress-buffering mechanisms betterself-control and positive emotions11Moreover neu-robiologic studies have affirmed that reducing stressenhances telomerase levels which are involved in cel-lular health12

RESTRUCTURING THE NURSErsquoS ROLEThe current health care system has become more fo-cused on disease and increasingly sophisticated in itsuse of technology As nurses pursue advanced educa-tion their sphere of practice has expanded into suchtraditionally medical areas as diagnosis treatment andmedication prescription13 Although nurses have largelyrelinquished their assistant-to-the-physician role manyhave become even more tethered to medicine by substi-tuting for physicians and taking on more of what weretraditionally physicianrsquos tasks rather than expandingthe nursing role While diagnosis and treatment maybe one aspect of advanced practice nursing it shouldnot be the nursersquos total focus Nursing should providecare that differs in substantive ways from that seen inthe medical modelmdashnot simply be a variant of thesame disease- and problem-focused care The nursersquosprimary focus should be on health healing and the al-leviation of suffering through actions that draw on in-ner strengths and outer resources creating conditionsthat allow patients to achieve maximum functioning

Another driver of the current system has been apreoccupation with cost-effectiveness and managedcare When all of health care is seen to be quantifi-able nursing is practiced as a set of technical activi-

ties rather than as a set of relational social and moralactivities with a technical base14 Many nurses and

administrators believe that performing medical tasksis more complex and thus a better use of nursesrsquotime than providing comfort measures or listeningto patientsrsquo concerns But nurses can and often doaccomplish both Medical tasks should not eclipsethe importance of ensuring patient comfort and safetywithin the context of a caring relationship that en-ables nurses to get to know patients as individuals

To address unsustainable levels of spending in ourhealth care system many have called for systematic

transformation and SBN should be considered ameans of achieving this transformation Although theInstitute of Medicinersquos 2010 report The Future ofNursing Leading Change Advancing Health sug-gests that nurses can fulfill numerous roles through-out a transformed health care system including onhospital boards and in hospital design real changecan occur only with a shiftmdashfrom disease to healthand healing from doing for to working with patientsand families from teaching and telling to learningfrom Any transformation must include a rethinkingand restructuring of the nursersquos role and the waynursing is practiced

Nurses need to carve out a unique role for them-selves that complements and parallels medicine To doso they will need to more explicitly connect Nightin-galersquos teachings about working with innate mecha-nisms that support health and healing to such valuesas holism compassion and the importance of the en-vironment and relational care SBN fulfills these re-quirements

THE UNDERLYING VALUES OF SBN

SBN is based on the belief that relationships are thekey to healthy functioning and healing In keepingwith Nightingalersquos teachings SBN seeks to create con-ditions that support the personrsquos innate health andhealing at all levels from cells (biological) to citizens(person and family) to communities (support net-works) SBN incorporates Nightingalersquos teaching tohonor personhood the right of people to have theirvalues and beliefs respected But SBN goes beyondthat creating environments and experiences that bet-ter enable patients and their families to take controlover their lives and health care decisions SBN recog-nizes that deficits coexist with strengths and that prob-lems can be understood only within the context of apersonrsquos life experiences It attempts to discern a per-

sonrsquos strengths and use them to deal with problemscompensate for deficits and overcome limitations

SBN enables patients to take control over

their lives and health care decisions




SBN comprises eight interrelated values (Figure 1)1 These values are illustrated in the nursendashpatient inter-actions described below

Health and healing SBN reaffirms that healthand healing are the central goals of nursing Healthsupports the patientrsquos ability to adapt with flexibility

to lifersquos challenges rally from insults and live withpurpose and meaning Health coexists with illnessand creates wholeness Healing restores wholenessand involves the rediscovery and reestablishment ofequilibrium In the process of healing people de-velop new skills that can sustain and increase theirhealth

Nurses promote health by helping people developtheir capacities for attachment regulation and cop-ing15 They seek to identify and support a personrsquosbiological psychological social and spiritual healingabilities through such processes as sleep nutritionand pain control Nurses create healing environmentsby supporting a personrsquos efforts to recover from phys-ical and psychosocial insults

A few years ago I cared for Lucille Glover a73-year-old woman who was diagnosed with ad-vanced lung cancer She feared dying alone and hadtrouble being alone while she slept Aware of the re-parative powers of sleep and the therapeutic value ofauthentic presence and attentive listening I suggestedthat the family consider hiring a compassionate car-ing person to spend nights at her bedside When MsGlover was agitated the caregiver sat beside her bedstroked her arm dimmed the lights and spoke with

her quietly The presence of the caregiver providedMs Glover with a sense of security that empowered

her to reduce her stress Achieving this type of seren-ity and thereby lowering levels of cortisol (the stresshormone) tend to improve immunologic functionthus facilitating healing The practice of SBN enabledme to see a way to help the family help Ms Gloveraccess her inner strengths

Uniqueness SBN recognizes that no two peopleare alike each is genetically different and has a par-ticular disposition Moreover people experience andrespond to their environments in unique ways Illnesstragedy and hardship can reveal a personrsquos innerstrengths The uniqueness of individuals is defined byboth their strengths and deficitsmdashby how these affecttheir physical behavioral and interpersonal responsesand form each personrsquos identity Recognizing an in-dividualrsquos uniqueness therefore requires an under-standing of both strengths and weaknesses

Sarah Jones is the two-and-a-half-year-olddaughter of a 20-year-old single mother She has a se-vere debilitating form of juvenile arthritis that waspreviously misdiagnosed and has left her unable towalk Her nurse Gillian Taylor practices the Mc-Gill model of nursing which provided the conceptualunderpinning for SBN16 Here she describes her firstencounter with this family

If I drew just a genogram [a visual depiction ofthe structure of the family] and wrote somefacts about this mother and daughter on paperany person would say ldquoWhat a disaster andwhat miseryrdquomdashand I would say ldquoWhat resil-

ience and what gutsinessrdquo The first thingthat struck me was Sarahrsquos drive her wish to

Health and Healing

Uniqueness

Holism and Embodiment

Subjective Reality andCreated Meaning

Person and Environment

Are Integral

Person

FamilyStaff

Learner

Collaborative

Partnership

Learning Timing

and Readiness

Self-Determination

Figure 1 The Values of Strengths-Based Nursing




do things on her own was fierce She scootedaround on her bum asked for help when sheneeded it and the mom put out her handand gave her daughter a little help and thenpulled away so that her daughter could indeedsay ldquoIrsquom doing it myselfrdquo and the mom couldsay ldquoYes you are Yes you arerdquo

mdashGillian Taylor as quoted in Strengths-Based Nursing Care Health and Healing for

Person and Family1

Gillianrsquos strengths-based orientation allows her toappreciate the unique way Sarah expresses agencyand autonomy (an innate strength) as well as theparenting style of Sarahrsquos mother who encouragesand supports Sarahrsquos development

Holism and embodiment Martha Rogers de-scribes people as unitary beings who respond to

their internal and external environments as integratedwholes17 Holism recognizes the interconnectedness ofthe parts as they affect each other and the functioningof the whole person Symptoms for example are thebodyrsquos way of signaling that something is not func-tioning properly Enabling the innate healing mecha-nism to restore a sense of wholeness often requiresboth symptom treatment and containment or elimina-tion of that which causes the dysfunction

I once cared for Mary Bourne a 92-year-oldwoman who lived in a senior residence home She de-veloped a fissure between her esophagus and tracheathat repeatedly resulted in aspiration pneumonia After

several hospital admissions the nutritionist suggestedthe insertion of a percutaneous endoscopic gastros-tomy tube but Ms Bourne refused Mealtime was animportant social activity for Ms Bourne and foodwas a source of pleasure that she considered very im-portant to her quality of life From the perspective ofSBN the nursersquos role is to help patients achieve theirgoals in the healthiest possible way In Ms Bournersquoscase the goals would be to enable her to continue en-joying food and participating in mealtime activitieswhile also meeting her nutritional requirements andpreventing another recurrence of aspiration pneumo-nia I asked Ms Bourne to note the foods that hadcaused her to choke She discovered that small fooditems such as peas and corn were most often at faultMs Bourne then eliminated these foods from her dietI also reviewed with Ms Bourne the foods she likedbest and suggested new ways to enjoy them in formsless likely to cause aspiration such as shakes or pud-dings Because I understood Ms Bournersquos personhoodI was able to work with her to find solutions ratherthan see her as a diagnosis in need of medical ldquofixingrdquo

Subjective reality and created meaning Experi-ences shape understanding because they hold specificmeaning Experiences perceptions representations

emotions and meanings guide peoplersquos understandingof events (their ldquorealityrdquo) and affect their responses

Searching for meaning involves creating narrativesthat are woven together from facts past and currentexperiences perceptions and beliefs The construc-tion of the narrative is an important integrative pro-cess that creates health and facilitates healing18 19

The case of Texas-reared Rabbi Ronnie Cahana il-lustrates how profoundly our narratives can affect ouroutlook At the age of 57 Rabbi Cahana a deeplyspiritual man had a brain-stem stroke that left himcognitively intact but quadriplegic Because he main-tained the ability to move his eyes the rabbi developeda blinking system through which to communicate Hisreality is captured in a poem he dictated to his daugh-ter through this system The poem provides a glimpseinto his inner world and insight into the strengths thatallowed him to adapt to his quadriplegia

You have to believe yoursquore paralyzed to play

the part of a quadriplegic I donrsquot In my mindand in my dreams every night I Chagall-manfloat over the city twirl and swirl With my toeskissing the floor I know nothing about thisstatement of man without motion Everythinghas motion The heart pumps the bloods racecourse the lungs culminate the body heavesthe mouth moves the eyes turn inside-out Wenever stagnate Life triumphs up and down

mdashRabbi Cahana as quoted in ldquoJoyCompassion and Fulfillment Kitra

Cahanarsquos Spiritual Transformationrdquo Time20

SBN encourages nurses to appreciate and facilitatethe communication of patients like Rabbi CahanaThrough communication such as the rabbirsquos poetrynurses come to know their patients and gain insightinto how they experience their reality Through hispoem Rabbi Cahana is telling the world that he re-tains his identity as a person and not as a quadriplegic

Person and environment are integral Person andfamily are affected by environment both physical andsocial One environment may bring out a personrsquosbest while another may bring out the same personrsquosvulnerabilities People grow and thrive when there isa ldquogoodness of fitrdquo with their environments Such en-vironments enable people to draw on their strengthsand provide themselves with opportunities for devel-opment healing and thriving

John Marsala a nurse manager at a universityteaching hospital tells of an experience he had early inhis nursing career when he worked on a busy cardiol-ogy unit He was assigned a patient who had beenadmitted for angina John prepared the patient for an-gioplasty and started the iv fluid and medication lineWhen the patient returned from the procedure bleed-ing from the catheterization entry wound John ap-

plied pressure to the wound until the bleeding stoppedLater in the shift when John checked on the patient




he noticed that the patient had a 5 orsquoclock shadowand offered to give him a shave Of the many actions

John took to care for the patient during his 12-hourshift the shave was the one on which both the patientand his family remarked John reflecting on the inci-dent many years later says ldquoThe shave made him feelso good He went from looking like a sick patient to ahealthier-looking person It restored his sense of per-sonhood It made the family feel good to see theirloved one looking so much better and they respondeddifferently to himrdquo

Nurses with an SBN orientation are acutely awarethat they are an integral part of the environment forboth patients and their families and can profoundlyaffect them even during a brief one-time encounterNurses frequently see people in times of crisis and areoften remembered for such simple acts of kindness asa warm smile or a compassionate touch People re-member nurses who are knowledgeable competentand compassionate who engage them in conversa-tion and who are interested in their concerns and re-sponsive to their needs People also remember actsof sullenness unkindness insensitivity and rudeness

which make them feel devalued ignored and disre-spected SBN emphasizes the importance to healing ofthe physical and social environment and encouragesnurses to be mindful of noise levels and ventilation

Self-determination SBN respects a personrsquos self-knowledge and values choice and self-determinationeven though there are always limits to the choicesavailable and a personrsquos ability to act in her or hisown interest is affected by circumstances knowledgeand predisposition The cases of Ms Glover Sarah

Jones and her mother Ms Bourne and Rabbi Ca-hana all illustrate the importance of allowing patientsto exercise self-determination Almost every act of liv-ing involves a choice about how to respond to specificcircumstances and limitations and within the contextof health care what interventions to undertake SBNsees the nursersquos role not as deciding for others butrather as listening attentively and deeply in order toclarify elaborate explain provide information makesuggestions connect people with resources and advo-cate for patients and their families so they may heartheir own voices and make their voices heard1

Learning timing and readiness Learning whichis essential to survival change growth and transfor-mation involves biological psychological and social

processes21

Without learning humans cannot navi-gate their environment But readiness to engage in a

new activity as a prelude to change is a prerequisitefor learning Timing in the context of health care re-quires synchronizing the desired outcome with thebodyrsquos capabilities and the mindrsquos willingness It re-quires the nurse to be attuned to the patient and toknow the point at which intervention will be mostsuccessful Learning readiness and timing are all re-quired for healing which SBN maintains can occureven during the act of dying

Revisiting the case of Ms Glover At the end of herlife Ms Glover developed delirium and was admittedto the palliative care unit In her delirium she repeat-edly called out the name ldquoAnnierdquo When I asked MsGloverrsquos niece about Annie she told me that Anniewas her other aunt Ms Gloverrsquos older sister who hadpassed away two years earlier also from lung cancerMs Glover had not seen her sister for over a decadethough they had corresponded by e-mail prior to An-

niersquos death Even when Annie was dying Ms Gloverhad told her niece that she believed her sister was fak-ing her illness to get attention Annie had known thather sister resented her but she had expressed no ani-mosity toward her to other family members MsGloverrsquos niece was concerned that her aunt would diein an agitated guilt-ridden state so I encouraged her toshare with her aunt memories of happier times whenthe two sisters got along I also encouraged her to letMs Glover know that Annie had harbored no ill feel-ings toward her but rather understood and loved her

A few days later Ms Glover was no longer deliri-ous or agitated She radiated a sense of calm She died

peacefully a week later Through SBN I understoodthe importance of timing and was able to help MsGloverrsquos niece recognize that her aunt might finally beready to let go of the narrative shersquod long held of hersisterrsquos death so that she might die healed

SBN actively engages people in their own learningseeks indications of readiness and times interventionsbased on knowledge of the person and their situationwhich grows out of curiosity concern and openness

Collaborative partnership The nature of thenursendashpatient relationship is collaborative Eachbrings her or his own experience knowledge andcompetencies to the relationship The nurse has for-mal and practical knowledge of health and healingand the patient and family have knowledge of them-selves and their circumstances A collaborative part-nership requires the nurse to be open nonjudgmentaland willing to share power22 The patient and familyare more likely to want to collaborate when they feelvalued understood respected and secure Focusingon them as individuals and recognizing their strengthsis key to successful collaboration

Collaborative partnerships require the partners tofind common ground set goals jointly and determinea course of action thatrsquos right for the patient The nurse

provides information that aligns with the patientrsquosdeveloping skills so that both nurse and patient can

SBN honors and dignifies people enabling

them to live as they choose




participate fully as partners In the case of Ms Bournethis meant that with guidance the patient was able todiscover her own solution to preventing aspirationpneumonia When people are unconscious or other-wise unable to care for themselves the nurse needs toassume multiple roles including caregiver protectoradvocate supporter and nurturer

PUTTING IT ALL TOGETHER

As illustrated in the case of Dan SBN does not ig-nore deficits or pretend they do not exist In fact itis as important to consider patientsrsquo deficits as it isto consider their strengths both are essential aspectsof the whole person In trying to create a condition ofwholeness for Dan his nurse needed to consider howto minimize his deficits and work with his strengthsthereby allowing him to function at his highest level(health and healing holism and embodiment ) She

recognized that Danrsquos ldquovoicesrdquo accorded him great re-spect within his tribe (uniqueness subjective reality andcreated meaning person and environment are integral ) although auditory hallucinations are consideredpathological (a deficit) in the context of modern med-icine By working with Dan to manage his psychosiswithout completely eliminating his ldquovoicesrdquo his careteam honored his tribal beliefs (self-determination)enabling him to understand that he needed medica-tion in order to attain the level of stability requiredfor him to be judged safe to return to the community(learning timing and readiness) and allowing him toparticipate in developing a workable solution (collab-

orative partnership)

BENEFITS OF SBN

To person and family SBN is built on principles ofempowerment self-efficacy and hope Such strengths-based paradigms as the Developmental Model ofHealth and Nursing have been found to promotehope healthy behaviors and quality of life in strokesurvivors23 These principles need to be in play if peo-ple are to assume greater control over their lives andtake charge of their own health and healing Feelingsof self-control and of being in charge are essential incoping with problems and stress

Empowerment People empower themselvesthough clinicians may create conditions that enablethem to do so by working with their strengths or help-ing them develop new strengths Feelings of empower-ment enable people to take greater control over theirhealth through self-management give them the confi-dence to be partners in their own care and help themdiscover inner resources and innate capacities for heal-ing they didnrsquot realize they had Empowerment givespeople choices and thus enables them to chooseamong alternatives

Self-efficacy is a belief in oneself and in onersquos abil-

ity to achieve a desired goal and bring about a desiredoutcome After decades of research into predictors of

successful change self-efficacy has emerged as one ofthe most robust24 25 Self-efficacy entails having confi-dence in onersquos competencies and resources which isan important prerequisite for taking charge in com-plex challenging and often chronic matters of healthand healing

Hope is the expectation that something positivewill occur Stephenson characterized it as having thefollowing attributes26bull a process of thoughts feelings behaviors and re-

lationshipsbull directed at an object that is meaningful to the

personbull anticipatory in naturebull future oriented but grounded in the present and

linked to the pastWhen problems are viewed as challenges to be

overcome rather than as sources of fear uncertainty

denial and helplessness then a personrsquos energy canbe redirected to such areas as positive coping andself-healing The nursersquos role is to open up possibili-ties for the patient creating opportunities to enter-tain different options until a solution is found27

A transformative shift of attention SBN shifts at-tention away from a preoccupation with a diagnosisproblem or symptom and toward an appreciation ofliving a full life while making necessary accommoda-tions to deal with an illness Disease and other cata-strophic events are viewed as challenges to be engagedas part of a personrsquos lifersquos journey SBN honors anddignifies people enabling them to be who they are

and to live as they chooseTo nursing and nurses We are gaining a deeper

awareness of our innate capacities for healing andwell-being and of the influence of environments andrelationships in these areas The care of another re-quires input from many disciplines including nurs-ing and medicine It requires the ability to developboth theoretical and practical knowledge and abroad repertoire of analytical and technical skills28

Nurses who are in touch with and guided by theirvalues are more likely to feel inspired and empoweredWhereas medicine contributes to the healing processthrough medical and surgical interventions nursing isseen in the SBN model as contributing to healing bycreating environments that maximize a personrsquos innatehealing capacities There is mounting evidence thatstress reduction can improve healing29 and recent re-

search suggests that critically ill patients may benefitfrom such stress-reducing nursing interventions as

SBN is built on principles of empowerment

self-efficacy and hope




interpersonal touch30 When nurses attend to the fun-damentals of care (such as comfort hygiene nutritionpositioning and pain management) they reduce stressand support the bodyrsquos capacity for healing Such evi-dence provides nurses with an argument for redesign-ing their roles within the health care system so that itmakes better use of their knowledge and skills andvalues time devoted to nursing care

SBN also enhances interdisciplinary practice byrecognizing nursingrsquos specific expertise Interdisci-plinary practice is best achieved when there is a dif-ferentiation of roles Only then can professionalsknow how best to integrate their respective knowl-edge and skills to benefit patients and families SBNenables nurses to have greater control over theirpractice by having an autonomous role Nurses re-port greater satisfaction when allowed to exercisetheir nursing functions autonomously31

To the health care system Most health care or-ganizations advertise that they are patient centeredand family focused yet economic political and or-ganizational interests often take priority over patientand family needs SBN is an approach that actuallyputs into practice many of the tenets of person- andfamily-centered care making care more responsiveand relevant less fragmented and more accountableto patients and their families

SBN will inevitably lead to a more cost-effectiveand efficient system because it makes better use ofthe knowledge and skills of its health care profes-sionals If people assume greater control over their

self-care they are likely to make better use of theirinner capacities for health and healing enjoy betterhealth and make more appropriate use of healthcare services3

Laurie N Gottlieb is a professor of nursing at McGill Universityin Montreal The author acknowledges Bruce Gottlieb PhD forhis advice and support in preparing this manuscript Contact au-

thor lauriegottliebmcgillca The author and planners have dis-closed no potential conflicts of interest financial or otherwise

REFERENCES

1 Gottlieb LN Strengths-based nursing care health and heal-ing for person and family New York Springer PublishingCompany 2013

2 Allen M Comparative theories of the expanded role in nurs-ing and implications for nursing practice a working paperNurs Pap 19779(2)38-45

3 Browne G et al Better care an analysis of nursing and health-care system outcomes Ottawa ON Canadian Nurses Associ-ation Canadian Health Services Research Foundation 2012 Jun httpwwwcfhi-fcasscasf-docsdefault-sourcecommis-sioned-research-reportsBrowne-BetterCare-ENpdfsfvrsn=0

4 Olds DL et al Long-term effects of home visitation on ma-

ternal life course and child abuse and neglect Fifteen-yearfollow-up of a randomized trial JAMA 1997278(8)637-43

5 Aranda S Brown R Nurses must be clever to care In Nelson SGordon S eds The complexities of care nursing reconsidered Ithaca NY Cornell University Press 2006 p 122-42

6 Kitson A et al Reclaiming and redefining the fundamentalsof care nursingrsquos response to meeting patientsrsquo basic humanneeds Adelaide SA University of Adelaide School of Nurs-ing Faculty of Health Sciences 2013 httpebooksadelaideeduaudspacebitstream2440758431hdl_75843pdf

7 Kitson A et al Defining the fundamentals of care Int JNurs Pract 201016(4)423-34

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9 Nightingale F Notes on nursing what it is and what it is not London Harrison 1859

10 Zender R Olshansky E The biology of caring researchingthe healing effects of stress response regulation through rela-tional engagement Biol Res Nurs 201214(4)419-30

11 Thoits PA Mechanisms linking social ties and support to physi-cal and mental health J Health Soc Behav 201152(2)145-61

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Guilford Press 201220 Bicker P Joy compassion and fulfillment Kitra Cahanarsquos

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For 33 additional continuing nursing educationactivities on professional development go to wwwnursingcentercomce




By Laurie N Gottlieb PhD RN

(that is he had auditory hallucinations) The chal-lenge for the team was to reduce Danrsquos potential toendanger others while allowing him to maintain thestatus and power he held within his tribe

After Dan had spent several weeks on the unit hispsychosis was controlled through medication and hisdelusional ideation had subsided Able to recognizethat he was ill Dan was willing to engage in a discus-sion with his family and the interdisciplinary team ofpsychiatrists nurses and social workers about the bestplan to treat his disease Together they negotiated away to meet everyonersquos goals by finding a medicationdosage that would reduce Danrsquos psychotic symptomswithout completely obliterating his ldquovoicesrdquo so thathe was no longer a danger to himself or others but re-tained his tribal status The teamrsquos broad focus wasconsistent with the values of SBN They viewed Danas a whole person a greatly respected member of acommunity whose values were not completely consis-tent with those of modern medicine Had they insteadfocused exclusively on his deficits Dan his family and

his health care team might not have found a solutionthat was agreeable to all

Undoubtedly many nurses already practice ele-ments of SBN without having labeled the approach assuch But the label we use is important because it cantake the approach to a different level of awareness AsPatricia Benner has noted SBN puts ldquointo words whatexpert nurses come to know and experience over timein their best practice [and gives] clarity insightand rigor to a central but poorly understood valueand wisdom embedded in the best of nursing prac-ticerdquo1 Although nurses with a deficit-focused perspec-tive may sometimes seize an opportunity to motivatepatients and families by concentrating on strengthsrather than deficits this approach is not an essentialpart of their schooling and its consistent use cannotbe relied on in professional practice Nurses whosepractice is strengths based on the other hand seekcapacities competencies and skills that patients andtheir families might use for recovery survival grow-ing and in many cases thriving Even nurses treatingunconscious patients in an ICU can use the SBN ap-proach For example by closely observing patientsrsquo

responses to stimuli nurses can schedule painful orintrusive procedures for times when they will be best

I l l u s

t r a t i o n b y J a n e t H a m l i n
























































Health and Healing

Uniqueness




Are Integral

Person

FamilyStaff

Learner

Collaborative

Partnership

Learning Timing

and Readiness

Self-Determination







Person and Family1




























processes21





















BENEFITS OF SBN





























REFERENCES




























































































Health and Healing

Uniqueness




Are Integral

Person

FamilyStaff

Learner

Collaborative

Partnership

Learning Timing

and Readiness

Self-Determination







Person and Family1




























processes21





















BENEFITS OF SBN





























REFERENCES






































































Health and Healing

Uniqueness




Are Integral

Person

FamilyStaff

Learner

Collaborative

Partnership

Learning Timing

and Readiness

Self-Determination







Person and Family1




























processes21





















BENEFITS OF SBN





























REFERENCES



















































Health and Healing

Uniqueness




Are Integral

Person

FamilyStaff

Learner

Collaborative

Partnership

Learning Timing

and Readiness

Self-Determination







Person and Family1




























processes21





















BENEFITS OF SBN





























REFERENCES










































Person and Family1




























processes21





















BENEFITS OF SBN





























REFERENCES















































processes21





















BENEFITS OF SBN





























REFERENCES













































BENEFITS OF SBN





























REFERENCES















































REFERENCES





































Documents

CE Strengths Based Nursing.24