Strengths-Based Nursing
A holistic approach to care, grounded in eight core values
By Laurie N. Gottlieb, PhD, RN
Strengths-based nursing (SBN) is an approach to care in which eight core
values guide nursing action, thereby promoting empowerment, self-efficacy, and
hope. In caring for patients and families, the nurse focuses on their inner and
outer strengths—that is, on what patients and families do that best helps them
deal with problems and minimize deficits. Across all levels of care, from the
primary care of healthy patients to the critical care of patients who are
unconscious, SBN reaffirms nursing’s goals of promoting health, facilitating
healing, and alleviating suffering by creating environments that work with and
bolster patients’ capacities for health and innate mechanisms of healing. In doing
so, SBN complements medical care, provides a language that communicates
nursing’s contribution to patient and family health and healing, and empowers the
patient and family to gain greater control over their health and healing.
Keywords: empowerment, healing, health, nurse–patient relationship,
nursing values, patient-centered care, self-management, strengths-based nursing
the dominant practice model in
I’m looking for the light; those
health care. Most nurses have been
little glimmers that make me
trained to focus almost exclusively
think there’s something there. I
on problems and things that are not
am looking for people’s gifts of
working. They analyze the patient’s
what they’ve got going for
concerns through a ―deficit lens,‖
them.
focusing on pathology, attending to
—Nurse Heather Hart, as cited
the abnormal and the dysfunctional,
in
Nursing
with the goal of ―fixing‖ problems.
Care: Health and Healing for
Yet in many situations, there are
Person and Family1
more things that are right than are
Strengths-Based
Despite the recent attention paid to
wrong.
Strengths-based
nursing
prevention, wellness, and patient-
(SBN) brings a new balance to
centered care, the medical model,
deficit-based care. SBN focuses on
with its emphasis on a patient’s
understanding deficits and problems
deficits rather than strengths, remains
1
within a broader, holistic context that
Dan’s potential to endanger others
uncovers inner and outer strengths.
while allowing him to maintain the
Diane Bourget, a clinical nurse
status and power he held within his
specialist who attended an SBN
tribe.
study group I conducted, recounted a
case that was particularly illustrative
of the SBN approach. (All cases
discussed in this article are real, and
all nurses who are identified in this
article have given me permission to
use their names. To protect patient
privacy, patient names have been
changed and identifying details have
been omitted, except in the case of
Rabbi Cahana, whose story has
already appeared in a number of
publications.)
When
Diane
was
working on a crisis intervention team
on a hospital’s child psychiatric unit,
Dan Pacheco, a Native American
adolescent, was admitted showing
signs of a severe psychotic break,
having recently threatened the life of
a young woman. Through their initial
interview
with
Dan,
the
crisis
intervention team discovered that in
his community Dan was believed to
possess special powers because he
―heard voices‖ (that is, he had
auditory hallucinations). The challenge for the team was to reduce
After Dan had spent several weeks
on the unit, his psychosis was
controlled through medication and
his delusional ideation had subsided.
Able to recognize that he was ill,
Dan was willing to engage in a
discussion with his family and the
interdisciplinary
psychiatrists,
nurses,
team
of
and
social
workers about the best plan to treat
his
disease.
Together,
they
negotiated a way to meet everyone’s
goals by finding a medication dosage
that would reduce Dan’s psychotic
symptoms
without
completely
obliterating his ―voices,‖ so that he
was no longer a danger to himself or
others but retained his tribal status.
The
team’s
broad
focus
was
consistent with the values of SBN.
They viewed Dan as a whole person,
a greatly respected member of a
community whose values were not
completely consistent with those of
modern medicine. Had they instead
focused exclusively on his deficits,
2
Dan, his family, and his health care
treating unconscious patients in an
team might not have found a solution
ICU can use the SBN approach. For
that was agreeable to all.
example,
Undoubtedly, many nurses already
patients’ responses to stimuli, nurses
practice elements of SBN without
can schedule painful or intrusive
having labeled the approach as such.
procedures for times when they will
But the label we use is important
be best
because it can take the approach to a
different level of awareness. As
Patricia Benner has noted, SBN puts
―into words what expert nurses come
to know and experience over time in
their best practice . . . [and gives]
clarity, insight, and rigor to a central
but poorly understood value and
wisdom embedded in the best of
nursing practice.‖1 Although nurses
with a deficit-focused perspective
may sometimes seize an opportunity
to motivate patients and families by
concentrating on strengths rather
than deficits, this approach is not an
essential part of their schooling and
its consistent use cannot be relied on
in
professional
practice.
Nurses
whose practice is strengths based, on
the other hand, seek capacities,
competencies, and skills that patients
and their families might use for
recovery, survival, growing, and in
by
closely
observing
tolerated (capitalizing on inner
strengths); by noting the nature of
family responses and their effect on
the patient, nurses can communicate
caring and respect, thereby reducing
environmental stress (maximizing
outer strengths).
SBN recognizes the importance of
focusing
on
strengths
that
can
empower patients to assume greater
control over their own healing and
health—it enables nurses to help
people help themselves attain higher
levels of health. This article proposes
that SBN is an approach to care that
provides the vision, values, and
evidence that can transform and
humanize
health
care
by
reconnecting it with the concepts of
Florence Nightingale and expanding
those concepts to meet the realities
of 21st-century health care.
many cases, thriving. Even nurses
3
THE CURRENT HEALTH CARE
the role of nurses in various contexts,
CLIMATE
the SBN model has consistently
With the expansion of health care
proven superior in treating patients
coverage
with chronic conditions. Browne and
in
the
United
States
mandated by the Affordable Care
colleagues
Act, many are asking who will
meta-analysis of 27 reviews, 29
provide care for the flood of new
quality studies, and nine economic
patients expected to enter the health
evaluations of nurse-involved and
care system. Similar discussions
nurse-led interventions for patients
have taken place in Canada since
living
1947,
complex chronic medical conditions
when
provinces
some
began
Canadian
implementing
and
in
social
recently conducted
the
community
circumstances.
a
with
They
public health insurance plans that
found that interventions led by
covered hospital services, continuing
specialty
beyond 1984 when the Canada
practice nurses who ―supplemented
Health Act was introduced. As the
rather than replaced the physician,‖
largest
care
providing proactive (as opposed to
providers, nurses were expected to
reactive or on-demand) assessment
take on a much greater role to
and monitoring in the context of
accommodate the increased demand
comprehensive care (delivered in
for care. There was considerable
collaboration with family members,
debate, however, about the type of
home nursing and support personnel,
role nurses
hospital staff, and other caregivers),
group
of
should
health
play. Some
trained
or
envisioned nurses assuming more
produced
medical functions. Others believed
functioning, hospitalization rate, and
nurses should focus more on health
quality of life) that were better and
than on illness and that nursing
often less costly than those provided
should play a complemental role to
through physician-led models or by
medicine.2
nurses using a physician-substitution
Providing chronic care. Although
outcomes
advanced
(patient
or physician-replacement model.3
there are differing perspectives on
4
Prenatal and early-childhood care.
oriented,
Similar results have been reported
fragmented,
for other nurse-led initiatives that
system in which people are treated as
emphasize self-efficacy and human
diagnoses rather than respected for
ecology (working with the patient’s
their
family
described
members
and
support
depersonalized,
and
often
personhood.
uncaring
Basic
by
Kitson
needs
as
networks), most notably the Nurse–
―fundamentals of care‖—such as
Family
nutrition, elimination, bathing, and
Partnership
program
(www.nursefamilypartnership.org).4
comfort measures that promote the
Research
rest required for healing—have gone
has
demonstrated
the
benefits of these values in creating
unmet.6, 7
partnerships; building capacity and
Although the issue is complex, with
confidence; and helping patients use
many factors contributing to the
their strengths to achieve their goals,
problems inherent in our current
develop coping skills, and broaden
health care system, we lack a vision
their resources.
for nursing shaped by well-defined
Unfortunately, many seem to believe
values that could help the profession
that taking on such responsibilities as
determine
case management requires nurses to
nurses’ actions. We also need a
relinquish much of the traditional
better understanding of the fact that
nursing role—caring for the whole
nursing’s—as
person, providing direct body care,
medicine’s—unique contribution to
and spending the time to get to know
better outcomes in patient and family
both
health
the
patient
and
family.5
Relational care has been devalued—
or, in many cases, viewed as a
regrettable casualty of technologic
progress—by
nurses,
nurse
administrators and managers, nursing
school faculty, and physicians. These
developments have created a disease-
and
priorities
and
opposed
healing
has
guide
to
been
empirically established.4, 8
NIGHTINGALE’S VISION
In
1860,
Florence
Nightingale
published her seminal Notes on
Nursing: What It Is and What It Is
Not, in which she laid out her vision
5
of the nurse’s role. She described
compassion
nursing’s mandate as health and
appropriate touch.
through
nonclinical,
healing and the role of the nurse as
Nightingale’s vision was bold. She
―put[ting] the patient in the best
arrived at her understanding of health
condition for nature to act upon
and
him.‖9
understood
observation, the experience of caring
health as a process of becoming,
for both the healthy and the sick, and
while she described healing as an act
the study of many disciplines. We
or process of restoration or recovery
are
from disease. She also recognized
scientific evidence that validates
that the human body and mind had
many of Nightingale’s insights. For
innate restorative and reparative
example, she considered physical
capacities, and that nurses could em-
and emotional environments key to
power patients to contribute to their
health and healing. She also un-
own healing by creating physical and
derstood that patients need the
interpersonal environments that
support of loved ones to assist them
Nightingale
allow this to happen.10 For example,
such simple actions as turning down
room lights, controlling the number
of visitors, closing doors to control
noise levels, moving patients closer
to a window, and reminding visitors
to wash their hands help create a
physical environment that promotes
healing.
Likewise, nurses
create
interpersonal healing environments
by being fully present in their
interactions with patients, listening
attentively,
and
demonstrating
in
healing
beginning
their
through
to
astute
accumulate
recovery—thus,
while
nursing in the Crimean War, she took
the time to help soldiers write letters
to their families back home.
In support of this vision, research
over the past 30 years has repeatedly
linked perceived social support to
better physical and mental health,
with these benefits mediated through
stress-buffering mechanisms, better
self-control,
emotions.11
and
Moreover,
positive
neu-
robiologic studies have affirmed that
reducing stress enhances telomerase
6
levels, which are involved in cellular
on health, healing, and the alleviation
health.12
of suffering through actions that
RESTRUCTURING
THE
NURSE’S ROLE
The current health care system has
become more focused on disease and
increasingly sophisticated in its use
of technology. As nurses pursue
advanced education, their sphere of
practice has expanded into such
traditionally
medical
areas
as
diagnosis, treatment, and medication
prescription.13 Although nurses have
largely relinquished their assistantto-the-physician role, many have
become even more tethered to
medicine
by
substituting
for
physicians and taking on more of
what were, traditionally, physician’s
tasks, rather than expanding the
nursing role. While diagnosis and
treatment may be one aspect of
advanced practice nursing, it should
not be the nurse’s total focus.
Nursing should provide care that
differs in substantive ways from that
seen in the medical model—not
simply be a variant of the same
disease- and problem-focused care.
The nurse’s primary focus should be
draw on inner strengths and outer
resources, creating conditions that
allow patients to achieve maximum
functioning.
Another driver of the current
system has been a preoccupation
with cost-effectiveness and managed
care. When all of health care is seen
to
be
quantifiable,
nursing
is
practiced as a set of technical activities rather than as a set of relational,
social, and moral activities with a
technical base.14 Many nurses and
administrators
believe
that
performing medical tasks is more
complex, and thus a better use of
nurses’ time, than providing comfort
measures or listening to patients’
concerns. But nurses can and often
do accomplish both. Medical tasks
should not eclipse the importance of
ensuring patient comfort and safety
within the context of a caring
relationship that enables nurses to get
to know patients as individuals.
To address unsustainable levels of
spending in our health care system,
many have called for systematic
transformation, and SBN should be
7
considered a means of achieving this
THE
transformation.
OF SBN
Although
the
UNDERLYING
VALUES
Institute of Medicine’s 2010 report
SBN is based on the belief that
The Future of Nursing: Leading
relationships are the key to healthy
Change, Advancing Health suggests
functioning and healing. In keeping
that nurses can fulfill numerous roles
with Nightingale’s teachings, SBN
throughout a transformed health care
seeks
system, including on hospital boards
support the person’s innate health
and in hospital design, real change
and healing at all levels: from cells
can occur only with a shift—from
(biological) to citizens (person and
disease to health and healing, from
family) to communities (support net-
doing for to working with patients
works).
and families, from teaching and
Nightingale’s
telling
personhood, the right of people to
to
learning
transformation
from.
must
Any
include
a
have
to
create
conditions
SBN
incorporates
teaching
their
values
that
to
and
honor
beliefs
rethinking and restructuring of the
respected. But SBN goes beyond
nurse’s role and the way nursing is
that,
practiced.
experiences
Nurses need to carve out a unique
patients and their families to take
role for themselves that complements
control over their lives and health
and parallels medicine. To do so,
care decisions. SBN recognizes that
they will need to more explicitly
deficits coexist with strengths and
teachings
that problems can be understood only
about working with innate mecha-
within the context of a person’s life
nisms that support health and healing
experiences. It attempts to discern a
to
holism,
person’s strengths and use them to
compassion, and the importance of
deal with problems, compensate for
the environment and relational care.
deficits, and overcome limitations
connect
such
Nightingale’s
values
as
creating
environments
that
better
and
enable
SBN fulfills these requirements.
8
psychological, social, and spiritual
healing
abilities
through
such
processes as sleep, nutrition, and
pain control. Nurses create healing
environments
by
supporting
a
person’s efforts to recover from
physical and psychosocial insults.
SBN comprises eight interrelated
values (Figure 1).1 These values are
illustrated in the nurse–patient inter-
and
Lucille Glover, a 73-year-old woman
who was diagnosed with advanced
lung cancer. She feared dying alone
actions described below.
Health
A few years ago, I cared for
healing.
SBN
reaffirms that health and healing are
the central goals of nursing. Health
and had trouble being alone while
she slept. Aware of the reparative
powers of sleep and the therapeutic
supports the patient’s ability to adapt
value of authentic presence and
with flexibility to life’s challenges,
attentive listening, I suggested that
rally from insults, and live with
purpose
and
meaning.
Health
coexists with illness and creates
wholeness.
wholeness
Healing
and
restores
involves
the
rediscovery and reestablishment of
equilibrium.
In
the
process
of
healing, people develop new skills
that can sustain and increase their
family
consider
hiring
a
compassionate, caring person to
spend nights at her bedside. When
Ms.
Glover
was
agitated,
the
caregiver sat beside her bed, stroked
her arm, dimmed the lights, and
spoke with her quietly. The presence
of the caregiver provided Ms. Glover
with
a
sense
of
security
that
empowered her to reduce her stress.
health.
Nurses promote health by helping
people develop their capacities for
attachment, regulation, and coping.15 They seek to identify and
support
the
a
person’s
biological,
Achieving this type of serenity and,
thereby, lowering levels of cortisol
(the stress hormone) tend to improve
immunologic
function,
thus
facilitating healing. The practice of
9
SBN enabled me to see a way to help
describes her first encounter with this
the family help Ms. Glover access
family:
her inner strengths.
If I drew just a genogram [a
Uniqueness. SBN recognizes that no
visual depiction of the structure
two people are alike; each is
of the family] and wrote some
genetically different and has a par-
facts about this mother and
ticular disposition. Moreover, people
daughter on paper, any person
experience and respond to their
would say, ―What a disaster
environments
ways.
and what misery‖—and I would
Illness, tragedy, and hardship can
say: ―What resilience and what
reveal a person’s inner strengths. The
gutsiness!‖. . . The first thing
uniqueness of individuals is defined
that struck me was Sarah’s
by both their strengths and deficits—
drive; her wish to do things on
by how these affect their physical,
her
behavioral,
interpersonal
scooted around on her bum,
responses and form each person’s
asked for help when she needed
identity. Recognizing an individual’s
it, and . . . the mom put out her
uniqueness, therefore, requires an
hand and gave her daughter a
understanding of both strengths and
little help and then pulled away,
weaknesses.
so that her daughter could
Sarah Jones is the two-and-a-half-
indeed say, ―I’m doing it
year-old daughter of a 20-year-old
myself‖; and the mom could
single mother. She has a severe,
say, ―Yes you are! Yes you
debilitating form of juvenile arthritis
are!‖
that was previously misdiagnosed
—Gillian Taylor, as quoted in
and has left her unable to walk. Her
Strengths- Based Nursing Care:
nurse, Gillian Taylor, practices the
Health and Healing for Person
McGill model of nursing, which
and Family1
in
and
unique
own
was
fierce.
She
conceptual
Gillian’s strengths-based orientation
underpinning for SBN.16 Here, she
allows her to appreciate the unique
provided
the
way Sarah expresses agency and
10
autonomy (an innate strength) as
Ms. Bourne refused. Mealtime was
well as the parenting style of Sarah’s
an important social activity for Ms.
mother,
Bourne, and food was a source of
who
encourages
and
supports Sarah’s development.
pleasure that she considered very im-
Holism and embodiment. Martha
portant to her quality of life. From
Rogers describes people as unitary
the perspective of SBN, the nurse’s
beings who respond to their internal
role is to help patients achieve their
and
as
goals in the healthiest possible way.
Holism
In Ms. Bourne’s case, the goals
recognizes the interconnectedness of
would be to enable her to continue
the parts as they affect each other
enjoying food and participating in
and the functioning of the whole
mealtime
person. Symptoms, for example, are
meeting her nutritional requirements
the body’s way of signaling that
and preventing another recurrence of
something
functioning
aspiration pneumonia. I asked Ms.
properly. Enabling the innate healing
Bourne to note the foods that had
mechanism to restore a sense of
caused her to choke. She discovered
wholeness
both
that small food items, such as peas
symptom treatment and containment
and corn, were most often at fault.
or elimination of that which causes
Ms. Bourne then eliminated these
the dysfunction.
foods from her diet. I also reviewed
external
integrated
environments
wholes.17
is
not
often
requires
activities,
while
also
I once cared for Mary Bourne, a
with Ms. Bourne the foods she liked
92-year-old woman who lived in a
best and suggested new ways to
senior residence home. She de-
enjoy them in forms less likely to
veloped
her
cause aspiration, such as shakes or
that
puddings. Because I understood Ms.
aspiration
Bourne’s personhood, I was able to
pneumonia. After several hospital
work with her to find solutions,
admissions, the nutritionist suggested
rather than see her as a diagnosis in
the insertion of a percutaneous
need of medical ―fixing.‖
esophagus
a
fissure
and
between
trachea
repeatedly resulted in
endoscopic gastrostomy tube, but
11
Subjective reality and created
meaning.
Experiences
shape
that allowed him to adapt to his
quadriplegia:
understanding because they hold
You have to believe you’re
specific
Experiences,
paralyzed to play the part of a
representations,
quadriplegic; I don’t. In my
meaning.
perceptions,
emotions,
and
guide
mind and in my dreams every
people’s understanding of events
night I Chagall-man float over
(their ―reality‖) and affect their
the city, twirl and swirl. With
responses. Searching for meaning
my toes kissing the floor. I
involves creating narratives that are
know
woven together from facts, past and
statement
current experiences, perceptions, and
motion. Everything has motion.
beliefs. The construction of the
The heart pumps, the bloods
narrative is an important integrative
race
process that creates health and
culminate, the body heaves, the
facilitates healing.18, 19
mouth moves, the eyes turn
The case of Texas-reared Rabbi
inside-out. We never stagnate.
Ronnie
Life triumphs up and down.
Cahana
meanings
illustrates
how
nothing
of
about
man
course,
this
without
the
lungs
profoundly our narratives can affect
—Rabbi Cahana, as quoted in
our outlook. At the age of 57, Rabbi
―Joy,
Cahana, a deeply spiritual man, had a
Fulfillment:
Kitra
brain-stem stroke that left him
Spiritual
Transformation,‖
cognitively intact but quadriplegic.
Time20
Compassion
and
Cahana’s
Because he maintained the ability to
SBN encourages nurses to appreciate
move his eyes, the rabbi developed a
and facilitate the communication of
blinking system through which to
patients like Rabbi Cahana. Through
communicate. His reality is captured
communication, such as the rabbi’s
in a poem he dictated to his daughter
poetry, nurses come to know their
through this system. The poem
patients and gain insight into how
provides a glimpse into his inner
they
world and insight into the strengths
Through his poem, Rabbi Cahana is
experience
their
reality.
12
telling the world that he retains his
shift, when John checked on the
identity as a person and not as a
patient, he noticed that the patient
quadriplegic.
had a 5 o’clock shadow and offered
are
to give him a shave. Of the many
integral. Person and family are
actions John took to care for the
affected
both
patient during his 12-hour shift, the
One
shave was the one on which both the
Person
and
by
physical
environment
environment,
and
environment
social.
a
patient and his family remarked.
person’s best while another may
John, reflecting on the incident many
bring
person’s
years later, says, ―The shave made
vulnerabilities. People grow and
him feel so good. He went from
thrive when there is a ―goodness of
looking like a sick patient to a
fit‖ with their environments. Such
healthier-looking person. It restored
environments enable people to draw
his sense of personhood. It made the
on
provide
family feel good to see their loved
themselves with opportunities for
one looking so much better, and they
development, healing, and thriving.
responded differently to him.‖
out
their
may
the
bring
same
strengths
and
out
John Marsala, a nurse manager at a
Nurses with an SBN orientation
university teaching hospital, tells of
are acutely aware that they are an
an experience he had early in his
integral part of the environment for
nursing career when he worked on a
both patients and their families and
busy
was
can profoundly affect them, even
assigned a patient who had been
during a brief, one-time encounter.
admitted for angina. John prepared
Nurses frequently see people in times
the patient for angioplasty and
of crisis and are often remembered
started the iv fluid and medication
for such simple acts of kindness as a
line. When the patient returned from
warm smile or a compassionate
the procedure, bleeding from the
touch. People remember nurses who
catheterization entry wound, John
are knowledgeable, competent, and
applied pressure to the wound until
compassionate; who engage them in
the bleeding stopped. Later in the
conversation; and who are interested
cardiology
unit.
He
13
in their concerns and responsive to
clarify, elaborate, explain, provide
their needs. People also remember
information,
acts
unkindness,
connect people with resources, and
insensitivity, and rudeness, which
advocate for patients and their
make them feel devalued, ignored,
families so they may hear their own
and disrespected. SBN emphasizes
voices and make their voices heard.1
the importance to healing of the
Learning, timing, and readiness.
physical and social environment and
Learning, which is essential to
encourages nurses to be mindful of
survival,
noise levels and ventilation.
transformation, involves biological,
of
sullenness,
Self-determination. SBN respects
make
change,
psychological,
suggestions,
growth,
and
and
social
Without
learning,
a person’s self-knowledge and values
processes.21
choice and self-determination, even
humans
though there are always limits to the
environment.
choices available and a person’s
engage in a new activity as a prelude
ability to act in her or his own
to change is a prerequisite for
interest is affected by circumstances,
learning. Timing, in the context of
knowledge, and predisposition. The
health care, requires synchronizing
cases of Ms. Glover, Sarah Jones and
the desired outcome with the body’s
her mother, Ms. Bourne, and Rabbi
capabilities
Cahana all illustrate the importance
willingness. It requires the nurse to
of allowing patients to exercise self-
be attuned to the patient and to know
determination. Almost every act of
the point at which intervention will
living involves a choice about how to
be
respond to specific circumstances
readiness, and timing are all required
and limitations, and within the
for healing, which SBN maintains
context
can occur even during the act of
of
health
care,
what
most
cannot
But
and
navigate
their
readiness
the
successful.
to
mind’s
Learning,
interventions to undertake. SBN sees
dying.
the nurse’s role not as deciding for
Revisiting the case of Ms. Glover. At
others
listening
the end of her life, Ms. Glover
attentively and deeply in order to
developed delirium and was admitted
but
rather
as
14
to the palliative care unit. In her
SBN, I understood the importance of
delirium, she repeatedly called out
timing and was able to help Ms.
the name ―Annie.‖ When I asked Ms.
Glover’s niece recognize that her
Glover’s niece about Annie, she told
aunt might finally be ready to let go
me that Annie was her other aunt,
of the narrative she’d long held of
Ms. Glover’s older sister, who had
her sister’s death, so that she might
passed away two years earlier, also
die healed.
from lung cancer. Ms. Glover had
SBN actively engages people in their
not seen her sister for over a decade,
own learning, seeks indications of
though they had corresponded by e-
readiness, and times interventions
mail prior to Annie’s death. Even
based on knowledge of the person
when Annie was dying, Ms. Glover
and their situation, which grows out
had told her niece that she believed
of curiosity, concern, and openness.
her sister was faking her illness to
Collaborative
partnership.
get attention. Annie had known that
nature
the
her sister resented her, but she had
relationship is collaborative. Each
expressed no animosity toward her to
brings her or his own experience,
other family members. Ms. Glover’s
knowledge, and competencies to the
niece was concerned that her aunt
relationship. The nurse has formal
would die in an agitated, guilt-ridden
and practical knowledge of health
state, so I encouraged her to share
and healing, and the patient and
with her aunt memories of happier
family have knowledge of them-
times when the two sisters got along.
selves and their circumstances. A
I also encouraged her to let Ms.
collaborative partnership requires the
Glover
had
nurse to be open, nonjudgmental, and
harbored no ill feelings toward her
willing to share power.22 The patient
but rather understood and loved her.
and family are more likely to want to
A few days later, Ms. Glover was no
collaborate when they feel valued,
longer delirious or agitated. She
understood, respected, and secure.
radiated a sense of calm. She died
Focusing on them as individuals and
know
that
Annie
of
The
nurse–patient
peacefully a week later. Through
15
recognizing their strengths is key to
Dan, his nurse needed to consider
successful collaboration.
how to minimize his deficits and
Collaborative partnerships require
work with his strengths, thereby
the partners to find common ground,
allowing him to function at his
set goals jointly, and determine a
highest level (health and healing;
course of action that’s right for the
holism
patient.
recognized
The
nurse
provides
and
embodiment).
that
Dan’s
She
―voices‖
information that aligns with the
accorded him great respect within his
patient’s developing skills so that
tribe (uniqueness; subjective reality
both nurse and patient canparticipate
and created meaning; person and
fully as partners. In the case of Ms.
environment are integral), although
Bourne,
auditory
this
meant
that,
with
hallucinations
are
guidance, the patient was able to
considered pathological (a deficit) in
discover
to
the context of modern medicine. By
pneumonia.
working with Dan to manage his
preventing
her
own
solution
aspiration
When people are unconscious or
psychosis
otherwise
for
eliminating his ―voices,‖ his care
themselves, the nurse needs to
team honored his tribal beliefs (self-
assume multiple roles, including
determination),
caregiver,
understand that he needed medica-
unable
to
protector,
care
advocate,
supporter, and nurturer.
PUTTING IT ALL TOGETHER
As illustrated in the case of Dan,
SBN does not ignore deficits or
pretend they do not exist. In fact, it is
as important to consider patients’
deficits as it is to consider their
without
completely
enabling
him
to
tion in order to attain the level of
stability required for him to be
judged
safe
to
return
to
the
community (learning, timing, and
readiness) and allowing him to
participate in developing a workable
solution (collaborative partnership).
strengths; both are essential aspects
BENEFITS OF SBN
of the whole person. In trying to
To person and family. SBN is built
create a condition of wholeness for
on principles of empowerment, self-
16
efficacy, and hope. Such strengths-
desired goal and bring about a
based
the
desired outcome. After decades of
Developmental Model of Health and
research into predictors of successful
Nursing have been found to promote
change, self-efficacy has emerged as
hope, healthy behaviors, and quality
one of the most robust.24, 25 Self-
of life in stroke survivors.23 These
efficacy entails having confidence in
principles need to be in play if peo-
one’s competencies and resources,
ple are to assume greater control
which is an important prerequisite
over their lives and take charge of
for
their
challenging,
paradigms
own
health
as
and
healing.
taking
charge
in
and
often
complex,
Feelings of self-control and of being
matters of health and healing.
in charge are essential in coping with
Hope
problems and stress.
something
Empowerment. People empower
themselves, though clinicians may
is
Stephenson
the
chronic
expectation
positive
will
characterized
that
occur.
it
as
having the following attributes26:
create conditions that enable them to
• a process of thoughts, feelings,
do so by working with their strengths
behaviors, and relationships
or
• directed at an object that is
helping
them
develop
new
strengths. Feelings of empowerment
meaningful to the person
enable people to take greater control
• anticipatory in nature
over
• future oriented, but grounded in
their
health
through
self-
management, give them the confi-
the present and linked to the past
dence to be partners in their own
When problems
are viewed as
care, and help them discover inner
challenges to be overcome rather
resources and innate capacities for
than as sources of fear, uncertainty,
healing they didn’t realize they had.
denial, and helplessness, then a
Empowerment gives people choices
person’s energy can be redirected to
and, thus, enables them to choose
such areas as positive coping and
among alternatives.
self-healing. The nurse’s role is to
Self-efficacy is a belief in oneself
open up possibilities for the patient,
and in one’s ability to achieve a
creating opportunities to entertain
17
different options until a solution is
contributes to the healing process
found.27
through
A transformative shift of attention.
interventions, nursing is seen in the
SBN shifts attention away from a
SBN
preoccupation
diagnosis,
healing by creating environments
problem, or symptom and toward an
that maximize a person’s innate
appreciation of living a full life while
healing capacities. There is mounting
making necessary accommodations
evidence that stress reduction can
to deal with an illness. Disease and
improve healing,29 and recent re-
other catastrophic events are viewed
search suggests that critically ill
as challenges to be engaged as part
patients may benefit from such
of a person’s life’s journey. SBN
stress-reducing nursing interventions
honors and dignifies people, enabling
as
them to be who they are and to live
nurses attend to the fundamentals of
as they choose.
care (such as comfort, hygiene,
To nursing and nurses. We are
nutrition,
gaining a deeper awareness of our
management), they reduce stress and
innate capacities for healing and
support the body’s capacity for
well-being, and of the influence of
healing. Such evidence provides
environments and relationships in
nurses
these areas. The care of another re-
redesigning their roles within the
quires input from many disciplines,
health care system so that it makes
including nursing and medicine. It
better use of their knowledge and
requires the ability to develop both
skills and values time devoted to
theoretical and practical knowledge,
nursing care.
with
a
and a broad repertoire of analytical
medical
model
as
interpersonal
and
contributing
touch.30
positioning,
with
SBN
an
surgical
When
and
argument
also
to
pain
for
enhances
and technical skills.28
interdisciplinary
Nurses who are in touch with and
recognizing
guided by their values are more
expertise. Interdisciplinary practice
likely
and
is best achieved when there is a dif-
medicine
ferentiation of roles. Only then can
to
empowered.
feel
inspired
Whereas
practice
nursing’s
by
specific
18
professionals know how best to
make more appropriate use of health
integrate their respective knowledge
care services.3 ▼
and skills to benefit patients and
families. SBN enables nurses to have
greater control over their practice by
having an autonomous role. Nurses
report
greater
satisfaction
when
allowed to exercise their nursing
functions autonomously.31
health care organizations advertise
that they are patient centered and
focused,
yet
nursing at McGill University in
Montreal. The author acknowledges
Bruce Gottlieb, PhD, for his advice
and
support
in
manuscript.
preparing
Contact
this
author:
[email protected].
To the health care system. Most
family
Laurie N. Gottlieb is a professor of
The
author and planners have disclosed
no potential conflicts of interest,
financial or otherwise.
economic,
political, and organizational interests
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