Angeles University Foundation Angeles City

Graduate School

Ernestine Wiedenbachs

The Helping Art of Clinical Nurs-ing

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 nur-turing 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 ones understanding and in-

terpretation 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 profes-

sion 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 Wiedenbachs Theory

Identify and analyze the Helping Art of Clinical Nursing Theory

Identify the strengths, weaknesses and limitations of Wiedenbachs theory

Relate Wiedenbachs theory to the present day nursing practice

II. Theory Analysis

A. Historical Evolution of the Theory/Background of the Theorist

Ernestine Wiedenbach was born to an affluent German family in 1900 but they immi-

grated 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 listen-

ing to stories by her sisters 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 en-

rolled 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 Nurs-

ing 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 set-

ting 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 In-

formation 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 en-

tering 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 en-

rolled 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 College.

In 1952, she joined the faculty at Yale University where she met Ida Jean Orlando Pel-

letier, Patricia James and William Dickoff. Orlando, being a nurse theorist herself, stimu-

lated Wiedenbach to understand the concept of self and the effect a nurses thoughts

and feelings to the outcome of her actions. James and Dickoff meanwhile were profes-

sors of Philosophy and taught at nursing programs in Yale. They persuaded Wiedenbach

to develop her theory.

Wiedenbach retired and moved to Florida in 1966 after an active and successful aca-

demic career. She died at the age of 97 on March 8, 1998.

B. Approach to the Development of the Model

Definition of Four Major Concepts

Person - posessess self-direction and relative independence, makes best use of ca-pabilities, fulfils responsibilities, has resources to maintain self; in other word, is a func-

tioning being (Wiedenbach as cited by Meleis, 2010) - whether nurse or patient endowed with a unique potential to develop

self-sustaining resources. People generally tend toward independence and ful-

filment of responsibilities (Eichelberger and Sitzman, 2011)

Nursing - 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 (Wieden-

bach, 1964) - effective identification of a patients 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 Organizations defini-tion 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 dis-

comfort, 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 nurs-

ing 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 nurses 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 philoso-

phy. - Wiedenbach, 1964

According to Wiedenbach, a nursing philosophy has three essential components:

1. Reverence for the gift of life

2. Respect for the dignity, worth, autonomy and individuality of each human being.

3. A resolution to act on personally and professionally held beliefs

Purpose

Purpose - that which the nurse wants to accomplish through 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 pa-

tient. - Wiedenbach, 1964

The fulfilment of purpose involves essentially three Major units of Nursing Practice:

1. Identification of the individuals ned for help

2. Ministration of help needed

3. Validation that the help given was indeed the help needed.

Practice

Overt action, directed by disciplines, thoughts and feelings toward meeting the pa-

tients need-for-help, constitutes the practice of clinical nursing goal-directed, delib-

erately carried out and patient-centered - Wiedenbach, 1964

Wiedenbach considered that there are three elements necessary for effective prac-

tice, knowledge, judgement and skills, with three additional components of practice

directly related to patient care - identification, ministration and validation with coordi-

nation 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 coor-

dinating 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 and concepts that are put forward to explain phenomena par-ticularly relevant to the subject areas of the natural sciences, the social sciences and

the humanities

Practical - knowing how to apply factual or speculative knowledge to the situation at hand.

Judgement represents the nurses 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. Wieden-

bach, suggested that judgement is very personal and the nurse will exercise this ac-

cording 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 nurses emotions and thoughts have been disciplined. Uncontrollable emo-

tions can blot out both knowledge and purpose. Unfounded assumptions can distort

facts. Hence, the nurse requires as broad a knowledge and experience base as possi-

ble and as great a clarity of purpose as practical, in order to make a sound judge-

ment.

Skills present the nurses 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 them-

selves. These are different from nurses actions which are carried out as means to an

end rather than the means by which they are reached. Wiedenbach identified two

fundamental skills by which the nurse carries out her role. First is procedural, which are considered to be options by which the nurse may identify and meet her patients 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 individualised care of patients taking into account their experi-

ences and their own perception of their condition and needs. Wiedenbach, organised

four elements to identification of the patients need for help.

Observing behaviours consistent or inconsistent with comfort

Exploring the meaning of individual patients behaviour with them

Determining the cause of the discomfort or incapability

Determining if patients can resolve 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 patients need for help has been met as a result of the

help given.

Wiedenbach identified one other element in practice that indirectly affects the nurses

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 individu-alized action. Nursing art, then, is carried out by the nurse in a one-to-one relationship with the patient and constitutes the nurses conscious responses to specifics in the pa-

tients immediate situation. - Wiedenbach, 1964

- the art of clinical nursing consists of:

1. The nurses understanding of the patients condition, situation and need.

2. The nurses internal goals and external actions that are meant to enhance patient

capability through appropriate nursing care.

3. The nurses activities directed toward improvement of the patients condition

through artful utilisation of the medical plan of care

4. The nurses interventions aimed at prevention of recurrence of the current concern

or development of a new concern.

There are three operational processes that influence nursing art - stimulus, preconcep-

tion and interpretation. Nurse act on the basis of these operations and their actions

may be rational, reactionary or deliberative. Stimulus is the patients presenting be-

haviour, preconception is an expectation of what the patient may be like and interpre-

tation is a comparison of perception with expectation or hope, However, preconcep-

tion 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 nurses immediate perception of

patients 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 pa-

tients behaviour and how the nurse had hoped or expected the patients behaviour to

be. Deliberative action is in stark contrast to both rational and reactionary acts. In carry-

ing out deliberative acts nurses apply the principles of helping and thus fulfil their pur-

pose, to gain an understanding of what patients mean by the behaviour they are dis-

playing.

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 patients actions, they use their perseverance

in identifying the need for help and in offering help

Exploration and validation of nurses and patients perceptions, thoughts, and feelings

increase the effectiveness of help offered to patients in need of help

Deliberate nursing action is an overt act consisting of several components: the need

for help, validation and ministration of help

Congruent nurse and patient perceptions of the need for help and evaluation of help

enhance effective care and decrease discomfort

Mutually understood and agreed-on nursing actions will have a positive effect on the

patient

Help given to individuals in need of help is categorised as: identification of variance

from normal (principle of inconsistency/consistency); identification of an individuals

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 Wiedenbachs conceptual framework is yet another theory exists. The prescrip-

tion 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

Wiedenbachs theory is clear, consistent and intelligible in terms of concepts and defini-

tion 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 isnt so complex. Also, al-

though 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 con-

sequence, it was successful in providing a description for the professional nursing prac-

tice.

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 set-

ting; 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 per-

ceive 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. Theory Synthesis

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 ap-

plied in everyday nursing practice in order to provide individualized client care.

Wiedenbachs 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 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 patient's behavior. (Tomey & Alligood, 2005)

However, in Wiedenbach's model, the focus of nursing research is related to the pa-

tient'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 Wiedenbachs theory is provided in the digram be-

low. 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. Theory Derivation

Wiedenbachs Theory can be simplified by a mother who saw her daughter fall down

from a bicycle. The mothers perceives her daughters 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. Bibliography and Appendices Meleis, Afaf Ibrahim. Theoretical Nursing: Development & Progress, 3rd ed. Walnut St, PA:

Lippincott Williams & Wilkins, 2005

Raile-Alligood, Martha, and Anne Marriner Tomey. Nursing Theorist and Their Work. St.

Louis, MO: Mosby Elsevier, 2010

Snowden, Austyn, Allan Donnel, and Tim Duffy. Pioneering Theories in 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. London: Jones and Barlett Publishers, 2011