PATIENT-CENTERED APPROACHES IN NURSING Faye Glenn Abdellah I.
Background of the Theorist
She was born in New York City on Marc h 13, 1919.
1942 – graduated from Fitkin Memorial Hospital School of Nursing in Neptune, New Jersey 1945 – received her B.S. in Nursing 1947 – received her M.A. in Nursing Nursing 1955 – received her Ed.D. (all from Teachers College , Columbia University)
She taught at Yale. The frustrations that arose from this teaching experience led to the beginnings of her pursuit of the scientific basis of nursing practice.
Abdellah served as Deputy Surgeon General and as Chief Nurse Officer for the U.S. Public Health Service, Department of Health and Human Services, Washington, DC.
She retired from the USPHS with the rank of rear admiral.
1993 – she became Dean of the newly formed Graduate School of Nursing, Uniformed Services University of the Health Sciences.
She had been granted 11 honorary doctorates by various institutions.
Abdellah was a research consultant to the W HO.
She had been recognized by Sigma Theta Tau as a Distinguished Research Fellow, and recipient of the Excellence in Nursing Award, and the first Presidential Award.
Abdellah awarded the Allied Signal Award for her groundbreaking research in aging.
The Institute of Medicine presented her with the Gustav O. Lienhard award.
Abdellah realized that for nursing to gain full professional status and autonomy, a strong knowledge base was imperative.
Nursing also needed to move away from the control on medicine and toward a philosophy of comprehensive patient-centered care.
Abdellah and her colleagues conceptualized 21 nursing problems to teach and evaluate students.
The typology of 21 nursing problems first appeared in the 1960 edition of PatientCentered Approaches to Nursing and had a far-reaching impact on the profession and on
the development of nursing theories. II.
Major Assumptions in Abdellah’s Theory
These relate to: 1) Change and anticipated changes that affect nursing 2) Need to appreciate the interconnectedness of social enterprises and social problems 3) Impact of problems such as poverty, racism, pollution and so forth on health and health care delivery 4) Changing nursing education 5) Continuing education for professional nurses
6) Development of nursing leaders from underserved groups III.
Abdellah’s Major Concepts in her Theory
A) Health
Her concept of health may be the dynamic pattern of functioning where there is continued interaction with internal and external forces that results in the optimal use of necessary resources that serve to minimize vulnerabilities. By performing nursing services through a holistic approach to the patient, the nurse helps the patient achieve a state of health. To effectively perform these services, the nurse must accurately identify the lacks and deficits regarding health that the patient is experiencing. These lacks or deficits are the patient’s health needs. B) Nursing Problems
The patient’s health needs can be viewed as: 1) Overt – can be seen 2) Covert – hidden; can be: a) Emotional b) Sociological c) Interpersonal Nursing problem presented by a patient is a condition faced by the patient or patient’s
family that the nurse can assist them to m eet. *Nursing Problems = “Nursing Functions” or “Nursing Goals”
*Nursing Problems ≠ “Patient-centered Problems” *Nursing diagnoses were a determination of the nature and extent of nursing problems presented by individuals receiving nursing care. *Nursing functions were nursing activities that contributed to the solution for the same nursing problem. Within the practice of nursing, it was anticipated that these 21 problems guide care and promote the development of the nurse’s judgmental ability. In each of the broad nursing
problems are numerous specific overt and covert problems. In her typology of 21 nursing problems presented by patients, she includes three columns: a) Basic nursing problem presented by the patient b) Specific problem of patient c) Common conditions C) Problem Solving
Quality professional nursing care requires that nurses can be able to identify and solve overt and covert nursing problems. These requirements can be met by the problem-solving approach. Problem-solving Process:
a) Identification of Problem b) Selection of Pertinent Data
c) Formulation of Hypotheses through Collection of Data d) Test of Hypotheses e) Revision of Hypotheses The problem solving approach was selected because of the assumption that the correct identification of nursing problems influences the nurse’s judgme nt in selecting the next steps in solving the patient’s nursing problems.
IV.
The 21 Nursing Problems Abdellah’s 21 Nursing Problems
Basic Needs
1) To maintain good hygiene and physical comfort. 2) To promote optimal activity; exercise, rest and sleep. 3) To promote safety through the prevention of accident, injury, or other trauma and through the prevention of the spread of infection. 4) To maintain good body mechanics and prevent and correct deformities. Sustenal Care Needs
5) To facilitate maintenance of a supply of oxygen to all body cells. 6) To facilitate the maintenance of nutrition of all body cells. 7) To facilitate the maintenance of elimination. 8) To facilitate the maintenance of fluid and electrolyte balance. 9) To recognize the physiological responses of the body to disease conditions – pathological, physiological, and compensatory. 10) To facilitate the maintenance of regulatory mechanisms and functions. 11) To facilitate the maintenance of regulatory mechanisms and functions. Remedial Care Needs
12) To identify and accept positive and negative expressions, feelings, and reactions. 13) To identify and accept the interrelatedness of emotions and organic illnesses. 14) To facilitate the maintenance of effective verbal and nonverbal communication. 15) To promote the development of productive interpersonal relationships. 16) To facilitate progress toward achievement of personal spiritual goals. 17) To create and/or maintain a therapeutic environment. 18) To facilitate awareness of self as an individual with varying physical, emotional, developmental needs. Restorative Care Needs
19) To accept the optimum possible goals in the light of limitations, physical and emotional. 20) To use community resources as an aid in resolving problems arising from illness. 21) To understand the role of social problems as influencing factors in the cause of illness.
V.
Abdellah’s Theory and Nursing’s Metaparadigm
A) Person
Abdellah describes people as having physical, emotional and sociological needs which may be overt or covert. People are helped by the identification and alleviation of problems they are experiencing. The model implies that by resolving each problem, the person returns to a healthy state or one with which he can cope. In her model, all persons have self-help ability and the capacity to learn, both of which vary from one individual to another. B) Health (or the achieving of health)
It is the purpose of nursing services. Health is a state mutually exclusive of illness. It is defined implicitly as a state when the individual has no unmet needs and no anticipated or actual impairments. Abdellah’s concept of health maybe defined as the dynamic pattern of functioning whereby
there is a continued interaction with internal and external forces that results in the optimal use of necessary resources that serve to minimize vulnerabilities. C) Environment
The environment is the home and community from which the patient comes. The model suggests that patients interact with and respond to their environment and that the nurse is part of the environment. Society is included in “ planning for optimum health on local, state, national, and international levels”.
D) Nursing
Nursing is a helping profession broadly grouped into the 21 problem areas to guide care and promote the use of nursing judgment. She considers nursing to be a comprehensive service that is based on art and science and aims to help people, sick or well, cope with their health needs. Nursing care is doing something to or for the person or providing information with the goal of meeting needs, in increasing or restoring self-ability, or alleviating an impairment. VI.
Patient-centered Approaches to Nursing models 10 steps to identify the client’s problems:
1) Learn to know the patient. 2) Sort out relevant and significant data. 3) Make generalizations about available data in relation to similar nursing problems presented by other patients. 4) Identify the therapeutic plan. 5) Test generalizations with the patient and make additional generalizations. 6) Validate the patient’s conclusions about his nursing problems.
7) Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behaviour. 8) Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan. 9) Identify how the nurse feels about the patient’s nursing problems. 10) Discuss and develop a comprehensive nursing care of plan. 11 nursing skills to be used in developing a treatment typology:
1) Observation of health status 2) Skills of communication 3) Application of knowledge 4) Teaching of patients and families 5) Planning and organizing of work 6) Use of resource materials 7) Use of personal resources 8) Problem-solving 9) Direction of work of others 10) Therapeutic use of the self 11) Nursing procedures VII.
Use of the 21 Problems in the Nursing Process
Nursing Process Assessment
Data collection and analysis Nursing Diagnosis
Summarization of data
Patient-Centered Approaches Identification of Problem & Selection of Pertinent Data The nursing problems provide guidelines for the collection of data. Formulation of Hypotheses through Collection of Data The results of the data collection would determine the patient’s
specific overt and covert problems. These specific problems would be grouped under 1 or more of the broader nursing problems. Planning
Setting of goal
Formulation of Hypotheses through Collection of Data The statements of the nursing problems contain the basis for desired
outcomes and most closely resemble goal statements. Implementation
Action on the problem
Test of Hypotheses Interventions that would be appropriate for the categories or nursing
problems. Evaluation
Evaluate if goal is met/unmet
Revision of Hypotheses It is evaluated in terms of the patient’s progress or lack of progress
toward the achievement of the stated outcomes and goals. The patient’s ability to provide self-help in the identified areas must be
evaluated.
*Criterion – is a value-free name of a measurable variable believed or known to be a relevant
indicator of the quality patient care. – can be used to measure patient care. The measurement of criteria may be related
to the measurement of the achievement of the desired outcomes. VIII.
Critique
A) Simplicity
The typology is very simple and is descriptive of nursing problems thought to be common among patients. The concepts of nursing, nursing problems, and the problem-solving are defined explicitly. The model has a limited number of concepts, and its only st ructure is a list. B) Generality
The 21 nursing problems are general and linked to neither time nor environment. The focus of the model varies in generality. The broadest goal is to positively affect nursing education, while subgoals are to provide a scientific basis on which to practice and to provide a method of qualitative evaluation of educational experiences for students. C) Empirical Precision
The concepts are very specific with empirical references that are easily identifiable. Ready linkage of the concepts and the typology to reality is secondary to an inductive approach to theory development. D) Derivable Consequences
The typology provided a general framework in which to act, but continued neither specific nursing actions nor patient-centered outcomes. The importance of nursing the whole patient, considering today’s idea of holism, is not
apparent in her work. The emphasis on problem-solving is not limited by time or space and therefore provides a means for continued growth and change in provision of nursing care.
