Angeles University Foundation Angeles City Graduate School
Ernestine Wiedenbach’s
The Helping Art of Clinical Nursing In partial fulfilment of the requirements in Theoretical Foundations in Nursing
Submitted by:
Mary Anne M. Yalung RN
Submitted to:
Dr. Mary Grace D. Brackett
I.
Introduction
People may differ in their concept of nursing but few would disagree that nursing is nurturing or caring for someone in a motherly fashion. - Wiedenbach as cited by Tomey & Alligood, 2006
Our world is seen through different lenses that shape how one’s understanding and interpretation of it. These lenses provides a perspective through which one understand situations and events of life. This same thing applies with the nursing profession. A profession is a discipline characterized by perspectives shared by the members and these perspectives shape the way the members of a discipline tend to view a phenomenon within as well as outside the discipline (Meleis, 2005).
Hence, this report aims to deepen the knowledge and understanding of the different views and theories that shape up the nursing practice.
At the end of the study, the reader/student will be able to: • Determine the evolution of Ernestine Wiedenbach’s Theory • Identify and analyze analyze the Helping Art of Clinical Nursing Theory • Identify the strengths, weaknesses weaknesses and limitations of Wiedenbach’s theory • Relate Wiedenbach’s theory theory to the present day nursing nursing practice
II. II. Theo Theory ry Anal Analys ysis is
A. Historical Evolution of the Theory/Background of the Theorist
Ernestine Wiedenbach was born to an affluent German family in 1900 but they immigrated to the United States during her childhood years. Her interest in Nursing started during her younger years while watching the care of her sickly grandmother and listening to stories by her sister’s friend who was a medical intern by that time. She graduated from Wellesley College in 1922 with a degree in Liberal Arts. Upon graduation she enrolled in Nursing much to the dismay of her parents. On an account by Nickel, Gesse and MacLaren in 1992, Ernestine first entered the Post Graduate Hospital School of Nursing but after a conflict with the school administration she was expelled. A John Hopkins alumna in the person of Adelaide Nutting intervened on her behalf and contacted Elsie Lawler, the Director of the John Hopkins School of Nursing. She was admitted given the condition that she will never organise or encourage dissent among students in John
Hopkins. She compiled and graduated in 1925. Because of her bachelors degree, she was offered a supervisory position upon graduation at John Hopkins Hospital. Later on she transferred to Bellevue in New York and continued her studies obtaining an M. A. from Teachers College, Columbia University in 1934. She then moved out of hospital setting and worked as a public health nurse for the Association for Improving Conditions of the Poor at the Henry Street Settlement. She later on left clinical nursing altogether to work as a professional writer for the American Journal of Nursing under the Nursing Information Bureau. During her stint as a write, she was able to fully developed her writing skills and was also able to gain many important professional contacts. During World War II, while still working with the Nursing Information Bureau, she helped prepare nurses entering the war. A minor heart condition prevented her from helping overseas.
At the end of World War II, Ernestine was persuaded by Hazel Corbin, director of the Maternity Centre Association of New York, to go back to direct patient care. She enrolled as a student midwife at the School for Midwives at 45 years old. She practiced as a nurse-midwife at the Maternity Center Association and taught evening classes at Teachers Teachers College.
In 1952, she joined the faculty at Yale University where she met Ida Jean Orlando Pelletier, letier, Patricia James and William Dickoff. Orlando, being a nurse theorist herself, stimulated Wiedenbach to understand the concept of self and the effect a nurse’s thoughts and feelings to the outcome of her actions. James and Dickoff meanwhile were professors of Philosophy and taught at nursing programs in Yale. They persuaded Wiedenbach to develop her theory.
Wiedenbach retired and moved to to Florida in 1966 after an active and successful successful academic career. career. She died at the age of 97 on March 8, 1998.
B. Approach to the Development of t he Model
Definition of Four Major Concepts
• Person - posessess self-direction and relative independence, makes best use of capabilities, fulfils responsibilities, has resources to maintain self; in other word, is a functioning being (Wiedenbach as cited by Meleis, 2010) self-sustaining
whether nurse or patient endowed with a unique potential to develop develop resources. People generally tend toward independence and ful-
filment of responsibilities (Eichelberger and Sitzman, 2011)
• Nursing - a - a helping art with knowledge and theories. A goal-directed and deliberate blending of thoughts, feelings, perceptions and actions to understand the patient and his condition, situation and needs, to enhance his capability, improve his care, prevent recurrence of problem and real with anxiety, disability or distress (Wiedenbach, 1964) - effective identification of a patient’s need for help through observation of presenting behaviours and symptoms, exploration of the meaning of those symptoms with the patient and codetermining the cause(s) of discomfort
• Health - Not defined. However, she supports the World Health Organization’s definition of health as a state of complete physical, mental and social well being and not merely the absence of disease and infirmity (George, 2008)
• Environment - Conglomerate of objects, policies, setting, atmosphere, time, human beings, happenings past, current or anticipated that are dynamic, unpredictable, exhilarating, baffling and disruptive (Wiedenbach, 1970)
C. Content
Wiedenbach conceptualizes nursing as the practice of identification of a patient's need for help through observation of presenting behaviors and symptoms, exploration of the meaning of those symptoms with the patient, determining the cause(s) of discomfort, and determining the patient's ability to resolve the discomfort or if the patient has a need for help from the nurse or other healthcare professionals. Nursing primarily consists of identifying a patient's need for help. If the need for help requires intervention, the nurse facilitates the medical plan of care and also creates and implements a nursing plan of care based on needs and desires of the patient. In providing care, a nurse exercises sound judgment through deliberative, practiced, and educated recognition of symptoms. The patient's perception of the situation is an important consideration to the nurse when providing competent care (Sitzman & Eichelberger 2003)
Wiedenbach asserted that there are four elements to clinical nursing:
Philosophy
Philosophy, an attitude toward life and reality that evolves from each nurse’s beliefs and code of conduct, motivates motivates the nurse to act, guides her thinking about what to do and influences decisions.It stems from both her culture and subculture, and is an integral part of her. It is personal in character, unique to each nurse and expressed in her way of nursing. Philosophy underlines purpose and her purpose reflects philosophy. - Wiedenbach, 1964
According to Wiedenbach, a nursing philosophy has three essential components: 1. Revere Reverence nce for the gif giftt of life life 2. Respect Respect for the dignit dignity, y, worth, worth, autonomy autonomy and individua individuality lity of each each human being. being. 3. A resolution resolution to act act on on persona personally lly and and profes professiona sionally lly held beliefs beliefs
Purpose
Purpose - that which the nurse wants wants to accomplish through what what she does - is the overall goal toward which she is striving and so is constant. It is her reasons for being and doing; it is the why of clinical nursing and trancends the immediate intent of her assignment or task by specifically directing her activities towards the ‘good’ of her patient. tient. - Wiedenbach, 1964
The fulfilment of purpose involves essentially three Major units of Nursing Practice: 1. Identifica Identification tion of the the individu individual’s al’s ned for help help 2. Minist Ministrat ration ion of help help need needed ed 3. Validation alidation that that the help help given given was indeed indeed the the help needed needed..
Practice
Overt action, directed by disciplines, thoughts and feelings toward meeting the patient’s need-for-help, constitutes the practice of clinical nursing… goal-directed, deliberately carried out and patient-centered - Wiedenbach, 1964
Wiedenbach considered that there are three elements necessary for effective practice, knowledge, judgement and skills, with three additional components of practice directly related to patient care - identification, ministration and validation with coordination indirectly related to it.
Knowledge encompasses all that has been perceived and grasped by the human mind. Knowledge has infinite scope and range. Knowledge may be required by the nurse in the academic arena and be useful for directing, teaching, planning and coordinating the care of the patient but is not sufficient to meet his need for help. This knowledge comes through interaction with patients in the real world environment. Knowledge may be factual, speculative or practical.
Factual - accepted knowledge that are known to be true Speculative - theories - theories and concepts that are put forward to explain phenomena particularly relevant to the subject areas of the natural sciences, the social sciences and the humanities Practical - knowing - knowing how to apply factual or speculative knowledge to the situation at hand.
Judgement represents the nurse’s potential for making sound decisions after weighing the facts. Judgement is derived from a cognitive process of present knowledge against the personal values achieved through ideals, principles and convictions. Judgement also differentiates facts from assumptions, relating them to cause and effect. Wiedenbach, suggested that judgement is very personal and the nurse will exercise this according to the purpose to be served, the available knowledge and her reaction to the prevailing environment at the time, in terms of the time, setting and individuals involved. Decisions that are made this way may not be sound depending on the degree to
which the nurse’s emotions and thoughts have been disciplined. Uncontrollable emotions can blot out both knowledge and purpose. Unfounded assumptions can distort facts. Hence, the nurse requires as broad a knowledge and experience base as possible and as great great a clarity of purpose as practical, practical, in order to make a sound judgejudgement.
Skills present the nurse’s potential for achieving the required results. Skill covers various and numerous acts which are characterized by ‘harmony and movement, expression and intent, by precision and by adroit use of self’(Wiedenbach, 1962).
These acts are carried out with a deliberate purpose in mind and are not goals in themselves. These are different from nurse’s actions which are carried out as means to an end rather than the means by which they are reached. Wiedenbach identified two fundamental skills skills by which the nurse carries carries out her role. First is procedural, which are considered to be options by which the nurse may identify and meet her patient’s need for help. Second is communication. Communication skills are fundamental to identifying to the patient and others the thoughts and feelings the nurse desires to convey whilst caring for her patients.
Identification includes includes individualised care care of patients patients taking into account their experiences and their own perception of their condition and needs. Wiedenbach, organised four elements to identification of the patient’s need for help.
• Observing behaviours consistent consistent or inconsistent inconsistent with comfort • Exploring the meaning of individual patients’ patients’ behaviour with them • Determining the cause of the discomfort or incapability incapability • Determining if patients can resolve their their problems or have a need for help
Ministration is providing the needed help, It requires the identification of the need for help, the selection of an appropriate skill and acceptance of that skill by the patient. Validation is evidence that the patient’s need for help has been met as a result of the help given.
Wiedenbach identified one other element in practice that indirectly affects the nurse’s role. This coordination, in which the nurse coordinates all the services to the patient to prevent fragmentation of care by consulting and conferring with others to plan future care and reporting this information both orally and in writing to ensure teamwork.
Art
…the application of knowledge and skill to bring about desired results… Art is individualized action. Nursing art, then, is carried out by the nurse in a one-to-one relationship with the patient and constitutes the nurse’s conscious responses to specifics in the patient’s immediate situation. - Wiedenbach, 1964
- the art of clinical nursing consists of: 1. The nurse’s nurse’s understan understanding ding of the the patient’s patient’s condit condition, ion, situation situation and and need. 2. The nurse’s nurse’s internal internal goals and and external external actions actions that that are meant meant to enhance enhance patient patient capability through appropriate nursing care. 3. The nurse’s nurse’s activities activities directe directed d toward improveme improvement nt of the patient’s patient’s conditi condition on through artful utilisation of the medical plan of care 4. The nurse’s nurse’s intervent interventions ions aimed aimed at preventio prevention n of recurrence recurrence of the current current concern concern or development of a new concern.
There are three operational processes that influence nursing art - stimulus, preconception and interpretation. Nurse act on the basis of these operations and their actions may be rational, reactionary or deliberative. Stimulus is the patient’s presenting behaviour, haviour, preconception is an expectation of what the patient may be like and interpretation is a comparison of perception with expectation or hope, However, preconception is based on interpretation of the stimulus and may be misinterpreted by the nurse.
A rational act by the nurse is a response guided by the nurse’s immediate perception of patient’s behaviour, what they say and do and how they appear. A reactionary act
however adds the dimension of emotional feelings of the nurse in response to the patient’s behaviour and how the nurse had hoped or expected the patient’s behaviour to be. Deliberative action is in stark contrast to both rational and reactionary acts. In carrying out deliberative acts nurses apply the principles of helping and thus fulfil their purpose, to gain an understanding of what patients mean by the behaviour they are displaying.
The deliberative act is a fundamental part of the Helping Art of Clinical Nursing. Wiedenbach proposed in this theory that this is what constitutes good nursing practice. Also, another purpose of this theory is for the nurse to determine their role as a nurse by identifying their own philosophy to decision making.
Propositions
• When nurses observe inconsistencies in patient’s actions, actions, they use their perseverance in identifying the need for help and in offering help • Exploration and validation of nurses’ and patients’ perceptions, perceptions, thoughts, and feelings increase the effectiveness of help offered to patients in need of help • Deliberate nursing action is an overt act act consisting of several components: components: the need for help, validation and ministration of help • Congruent nurse and patient perceptions perceptions of the need for help and and evaluation of help enhance effective care and decrease discomfort • Mutually understood and agreed-on nursing nursing actions will have a positive effect effect on the patient • Help given to individuals in need of help is categorised categorised as: identification of variance variance from normal (principle of inconsistency/consistency); inconsistency/consistency); identification of an individual’s need for help (principle of purposeful perseverance); utilising self or others for help, advice, information, referral or comfort (principle of self-extension)
The purpose of the theory is to facilitate the efforts of the individual to overcome the obstacles which currently interfere with his ability to respond capably to demands made of him by his condition, environment, situation and time.
Prescriptive Theory
Within Wiedenbach’s conceptual framework is yet another theory exists. The prescription is the action that the nurse deems appropriate to fulfil the main purpose. The nurse will have thought the kind of results she would like to see and will take action to obtain these results, accepting accountability for what she does and for the outcomes of her actions.
Examination of Content
Wiedenbach’s theory is clear, clear, consistent and intelligible in ter ms of concepts and definition though it may not be described as simple because of the too many relational statements. It is quite complex due to its philosophical background though the concept of this theory, that is client entered care is a concept that is isn’t so complex. Also, although the concept for need-for-help may not be applicable to all patients it can be still categorised as general since it can be applied to other health professionals and the theory can be applied to everyday nursing practice. The major concepts of this theory are concrete because they still mean the same in time and circumstance. As for the
empirical applicability, the theory may be difficult to test. Lastly, for the derivable consequence, it was successful in providing a description for the professional nursing practice.
D. Source of Concern
Concepts such as patient-centerer care, perceptions, validation and exploration of thoughts, feelings, and actions are used in many practice setting. The theory gives guidelines for implementing the nursing process and has stimulated many attempts at conceptualising the interaction process, but is limited in its power for prescription. The scope of the theory remains limited to individuals who are conscious in a hospital setting; who are basically motivated to participate in their own care; who are in a state of disharmony with their surroundings, situation or expectations; and who are able to perceive their need for help. Patients who do not deviate from normalcy; who are non compliant and who do not perceive a need for help are not nursing clients. Therefore, its use in practice is limited.
III. III. Theory Theory Synthe Synthesis sis
Although nurses may not articulate the concepts and linkages emanating from Wiedenbach, the central ideas of her theory are used widely. Her theory can be applied in everyday nursing practice in order to provide individualized client care.
Wiedenbach’s theory was also accepted when it came to terms with education by serving the nursing practice in four major ways •
Its is responsible for the preparation of future Practitioners of nursing
•
It arranges arranges for nursing student to gain experience in clinical areas of the hospital or in the homes of patients.
•
Its representatives may function in the clinical area and work closely with the staff
•
It offers educational opportunities to the nurse for special or advance study. (Tomey & Alligood, 2005)
The application of Wiedenbach model to clinical practice requires the nurse to have knowledge of the understanding of human psychology, competence in clinical skills, and the ability to maintain communication with the patient and family. In addition, the nurse must make clinical judgment and use that in making decision about patient care and be able to understand u nderstand patient's behavior. behavior. (Tomey & Alligood, 2005)
However, in Wiedenbach's model, the focus of nursing research is related to the patient's response to the healthcare experience. Her model promotes family relationships, control factors that disable conditions, and use healthcare practices. For instance, Wiedenbach's concept of need-for-help was used as a focus for doctoral research that was completed in 1988.
An example of the application of Wiedenbach’s theory is provided in the digram below. A nurse is caring for a patient who is experiencing fever. The theory helps the nurse and the patient to come up with a mutually agreed intervention.
IV. IV.
Theory Derivation
Wiedenbach’s Theory can be simplified by a mother who saw her daughter fall down from a bicycle. The mothers perceives her daughter’s need to learn how to ride a bike so she will plan and offer to teach. The daughter on the other hand, knowing that she has a need will accept the help. The mother will then teach the child how to ride a bike until the girl can already ride on her own.
V. Biblio Bibliogra graphy phy and and Appendi Appendices ces Meleis, Afaf Ibrahim. Theoretical Nursing: Development & Progress, Progress , 3rd ed. Walnut St, PA: Lippincott Williams & Wilkins, 2005 Raile-Alligood, Martha, and Anne Marriner Tomey. Nursing Theorist and Their Work. Work. St. Louis, MO: Mosby Elsevier, Elsevier, 2010 Snowden, Austyn, Allan Donnel, and Tim Duffy. Pioneering Theories in Nursing. London, Nursing. London, UK: MA Healthcare Limited, 2010 Wright-Eichelberger, Liza, and Kathleen Stzman. Understanding the Work of Nurse Theo rists: A Creative Beginning, 2nd ed. ed. London: Jones and Barlett Publishers, 2011