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Strengths-Based Nursing A holistic approach to care, grounded in eight core values


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OVERVIEW: 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.
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24 AJN August 2014 Vol. 114, No. 8
I’m looking for the light; those little glimmers
that make me think there’s something there. I
am looking for people’s gifts of what they’ve
got going for them.
—Nurse Heather Hart, as cited in
Strengths-Based Nursing Care: Health
and Healing for Person and Family1
Despite the recent attention paid to prevention,
wellness, and patient-centered care, the medi-
cal model, with its emphasis on a patient’s
deficits rather than strengths, remains the dominant
practice model in health care. Most nurses have been
trained to focus almost exclusively on problems and
things that are not working. They analyze the pa-
tient’s concerns through a “deficit lens,” focusing
on pathology, attending to the abnormal and the
dysfunctional, with the goal of “fixing” problems.
Yet in many situations, there are more things that
are right than are wrong. Strengths-based nursing
(SBN) brings a new balance to deficit-based care.
SBN focuses on understanding deficits and prob-
lems within a broader, holistic context that uncovers
inner and outer strengths.
Diane Bourget, a clinical nurse specialist who at-
tended an SBN 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 hos-
pital’s child psychiatric unit, Dan Pacheco, a Native
American adolescent, was admitted showing signs
of a severe psychotic break, having recently threat-
ened the life of a young woman. Through their ini-
tial interview with Dan, the crisis intervention team
discovered that in his community Dan was believed
to possess special powers because he “heard voices”
OVERVIEW: 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 heal-
ing, 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
A holistic approach to care, grounded in eight core values.
Nursing AJN August 2014 Vol. 114, No. 8 25
By Laurie N. Gottlieb, PhD, RN
(that is, he had auditory hallucinations). The chal-
lenge for the team was to reduce Dan’s potential to
endanger others while allowing him to maintain the
status and power he held within his tribe.
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 discus-
sion with his family and the interdisciplinary team of
psychiatrists, nurses, 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 re-
tained 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 consis-
tent with those of modern medicine. Had they instead
focused exclusively on his deficits, Dan, his family, and
his health care team might not have found a solution
that was agreeable to all.
Undoubtedly, many nurses already practice ele-
ments of SBN without having labeled the approach as
such. But the label we use is important 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 prac-
tice.”1 Although nurses with a deficit-focused perspec-
tive 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, grow-
ing, and in many cases, thriving. Even nurses treating
unconscious patients in an ICU can use the SBN ap-
proach. For example, by closely observing patients’
responses to stimuli, nurses can schedule painful or
intrusive procedures for times when they will be best
Illustration by Janet Hamlin.
26 AJN August 2014 Vol. 114, No. 8
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 lev-
els of health. This article proposes that SBN is an ap-
proach 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.
With the expansion of health care coverage in the
United States mandated by the Affordable Care
Act, many are asking who will provide care for the
flood of new patients expected to enter the health care
system. Similar discussions have taken place in Can-
ada since 1947, when some Canadian provinces be-
gan implementing public health insurance plans that
covered hospital services, continuing beyond 1984
when the Canada Health Act was introduced. As the
largest group of health care providers, nurses were ex-
pected to take on a much greater role to accommodate
the increased demand for care. There was consider-
able debate, however, about the type of role nurses
should play. Some envisioned nurses assuming more
medical functions. Others believed nurses should focus
more on health than on illness and that nursing should
play a complemental role to medicine.2
Providing chronic care. Although there are differ-
ing perspectives on the role of nurses in various con-
texts, the SBN model has consistently proven superior
in treating patients with chronic conditions. Browne
and colleagues recently conducted a meta-analysis
of 27 reviews, 29 quality studies, and nine economic
evaluations of nurse-involved and nurse-led inter-
ventions for patients living in the community with
complex chronic medical conditions and social cir-
cumstances. They found that interventions led by
specialty trained or advanced practice nurses who
“supplemented rather than replaced the physician,”
providing proactive (as opposed to reactive or on-
demand) assessment and monitoring in the context
of comprehensive care (delivered in collaboration
with family members, home nursing and support
personnel, hospital staff, and other caregivers), pro-
duced outcomes (patient functioning, hospitalization
rate, and quality of life) that were better and often
less costly than those provided through physician-led
models or by nurses using a physician-substitution or
physician-replacement model.3
Prenatal and early-childhood care. Similar results
have been reported for other nurse-led initiatives that
emphasize self-efficacy and human ecology (work-
ing with the patient’s family members and support
networks), most notably the Nurse– Family Partner-
ship program (
Research has demonstrated the benefits of these val-
ues in creating partnerships; building capacity and
confidence; and helping patients use their strengths to
achieve their goals, develop coping skills, and broaden
their resources.
Unfortunately, many seem to believe that taking
on such responsibilities as case management requires
nurses to relinquish much of the traditional nursing
role— caring for the whole person, providing direct
body care, and spending the time to get to know
both 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-oriented, depersonalized, fragmented, and of-
ten uncaring system in which people are treated as di-
agnoses rather than respected for their personhood.
Basic needs described by Kitson as “fundamentals of
care”—such as nutrition, elimination, bathing, and
comfort measures that promote the rest required for
healing—have gone unmet.6, 7
Although the issue is complex, with many factors
contributing to the problems inherent in our cur-
rent health care system, we lack a vision for nursing
shaped by well-defined values that could help the
profession determine priorities and guide nurses’ ac-
tions. We also need a better understanding of the fact
that nursing’s—as opposed to medicine’s—unique
contribution to better outcomes in patient and family
health and healing has been empirically established.4, 8
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 of the nurse’s role. She
described nursing’s mandate as health and healing and
the role of the nurse as “put[ting] the patient in the
best condition for nature to act upon him.”9 Night-
ingale understood health as a process of becoming,
while she described healing as an act or process of res-
toration or recovery from disease. She also recognized
that the human body and mind had innate restorative
and reparative capacities, and that nurses could em-
power patients to contribute to their own healing by
creating physical and interpersonal environments that
SBN reaffirms that health and healing are
the central goals of nursing. AJN August 2014 Vol. 114, No. 8 27
allow this to happen.10 For example, such simple ac-
tions as turning down room lights, controlling the
number of visitors, closing doors to control noise lev-
els, moving patients closer to a window, and remind-
ing visitors to wash their hands help create a physical
environment that promotes healing. Likewise, nurses
create interpersonal healing environments by being
fully present in their interactions with patients, lis-
tening attentively, and demonstrating compassion
through nonclinical, appropriate touch.
Nightingale’s vision was bold. She arrived at her
understanding of health and healing through astute
observation, the experience of caring for both the
healthy and the sick, and the study of many disci-
plines. We are beginning to accumulate scientific evi-
dence that validates many of Nightingale’s insights.
For example, she considered physical and emotional
environments key to health and healing. She also un-
derstood that patients need the support of loved ones
to assist them in their 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, and positive emotions.11 Moreover, neu-
robiologic studies have affirmed that reducing stress
enhances telomerase levels, which are involved in cel-
lular health.12
The current health care system has become more fo-
cused on disease and increasingly sophisticated in its
use of technology. As nurses pursue advanced educa-
tion, their sphere of practice has expanded into such
traditionally medical areas as diagnosis, treatment, and
medication prescription.13 Although nurses have largely
relinquished their assistant-to-the-physician role, many
have become even more tethered to medicine by substi-
tuting 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 on health, healing, and the al-
leviation of suffering through actions that draw on in-
ner 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 quantifi-
able, nursing is practiced as a set of technical activi-
ties 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 en-
ables 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 considered a
means of achieving this transformation. Although the
Institute of Medicine’s 2010 report The Future of
Nursing: Leading Change, Advancing Health sug-
gests that nurses can fulfill numerous roles through-
out a transformed health care system, including on
hospital boards and in hospital design, real change
can occur only with a shift—from disease to health
and healing, from doing for to working with patients
and families, from teaching and telling to learning
from. Any transformation must include a rethinking
and restructuring of the nurse’s role and the way
nursing is practiced.
Nurses need to carve out a unique role for them-
selves that complements and parallels medicine. To do
so, they will need to more explicitly connect Nightin-
gale’s teachings about working with innate mecha-
nisms that support health and healing to such values
as holism, compassion, and the importance of the en-
vironment and relational care. SBN fulfills these re-
SBN is based on the belief that relationships are the
key to healthy functioning and healing. In keeping
with Nightingale’s teachings, SBN seeks to create con-
ditions that support the person’s innate health and
healing at all levels: from cells (biological) to citizens
(person and family) to communities (support net-
works). SBN incorporates Nightingale’s teaching to
honor personhood, the right of people to have their
values and beliefs respected. But SBN goes beyond
that, creating environments and experiences that bet-
ter enable patients and their families to take control
over their lives and health care decisions. SBN recog-
nizes that deficits coexist with strengths and that prob-
lems can be understood only within the context of a
person’s life experiences. It attempts to discern a per-
son’s strengths and use them to deal with problems,
compensate for deficits, and overcome limitations.
SBN enables patients to take control over
their lives and health care decisions.
28 AJN August 2014 Vol. 114, No. 8
SBN comprises eight interrelated values (Figure 1).1
These values are illustrated in the nurse–patient inter-
actions described below.
Health and healing. SBN reaffirms that health
and healing are the central goals of nursing. Health
supports the patient’s ability to adapt with flexibility
to life’s challenges, rally from insults, and live with
purpose and meaning. Health coexists with illness
and creates wholeness. Healing restores wholeness
and involves the rediscovery and reestablishment of
equilibrium. In the process of healing, people de-
velop new skills that can sustain and increase their
Nurses promote health by helping people develop
their capacities for attachment, regulation, and cop-
ing.15 They seek to identify and support a person’s
biological, 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 phys-
ical and psychosocial insults.
A few years ago, I cared for Lucille Glover, a
73-year-old woman who was diagnosed with ad-
vanced lung cancer. She feared dying alone and had
trouble being alone while she slept. Aware of the re-
parative powers of sleep and the therapeutic value of
authentic presence and attentive listening, I suggested
that the family consider hiring a compassionate, car-
ing 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. Achieving this type of seren-
ity and, thereby, lowering levels of cortisol (the stress
hormone) tend to improve immunologic function,
thus facilitating healing. The practice of SBN enabled
me to see a way to help the family help Ms. Glover
access her inner strengths.
Uniqueness. SBN recognizes that no two people
are alike; each is genetically different and has a par-
ticular disposition. Moreover, people experience and
respond to their environments in unique ways. Illness,
tragedy, and hardship can reveal a person’s inner
strengths. The uniqueness of individuals is defined by
both their strengths and deficits—by how these affect
their physical, behavioral, and interpersonal responses
and form each person’s identity. Recognizing an in-
dividual’s uniqueness, therefore, requires an under-
standing of both strengths and weaknesses.
Sarah Jones is the two-and-a-half-year-old
daughter of a 20-year-old single mother. She has a se-
vere, debilitating form of juvenile arthritis that was
previously misdiagnosed and has left her unable to
walk. Her nurse, Gillian Taylor, practices the Mc-
Gill model of nursing, which provided the conceptual
underpinning for SBN.16 Here, she describes her first
encounter with this family:
If I drew just a genogram [a visual depiction of
the structure of the family] and wrote some
facts about this mother and daughter on paper,
any person would say, “What a disaster and
what misery”—a nd I would say: “What resil-
ience and what gutsiness!”. . . The first thing
that struck me was Sarah’s drive; her wish to
Health and Healing
Holism and Embodiment
Subjective Reality and
Created Meaning
Person and Environment
Are Integral
Learning, Timing,
and Readiness
Figure 1. The Values of Strengths-Based Nursing AJN August 2014 Vol. 114, No. 8 29
do things on her own was fierce. She scooted
around on her bum, asked for help when she
needed it, and . . . the mom put out her hand
and gave her daughter a little help and then
pulled away, so that her daughter could indeed
say, “I’m doing it myself”; and the mom could
say, “Yes you are! Yes you are!”
—G illian Taylor, as quoted in Strengths-
Based Nursing Care: Health and Healing for
Person and Family1
Gillian’s strengths-based orientation allows her to
appreciate the unique way Sarah expresses agency
and autonomy (an innate strength) as well as the
parenting style of Sarah’s mother, who encourages
and supports Sarah’s development.
Holism and embodiment. Martha Rogers de-
scribes people as unitary beings who respond to
their internal and external environments as integrated
wholes.17 Holism recognizes the interconnectedness of
the parts as they affect each other and the functioning
of the whole person. Symptoms, for example, are the
body’s way of signaling that something is not func-
tioning properly. Enabling the innate healing mecha-
nism to restore a sense of wholeness often requires
both symptom treatment and containment or elimina-
tion of that which causes the dysfunction.
I once cared for Mary Bourne, a 92-year-old
woman who lived in a senior residence home. She de-
veloped a fissure between her esophagus and trachea
that repeatedly resulted in aspiration pneumonia. After
several hospital admissions, the nutritionist suggested
the insertion of a percutaneous endoscopic gastros-
tomy tube, but Ms. Bourne refused. Mealtime was an
important social activity for Ms. Bourne, and food
was a source of pleasure that she considered very im-
portant to her quality of life. From the perspective of
SBN, the nurse’s role is to help patients achieve their
goals in the healthiest possible way. In Ms. Bourne’s
case, the goals would be to enable her to continue en-
joying food and participating in mealtime activities,
while also meeting her nutritional requirements and
preventing another recurrence of aspiration pneumo-
nia. I asked Ms. Bourne to note the foods that had
caused her to choke. She discovered that small food
items, such as peas and corn, were most often at fault.
Ms. Bourne then eliminated these foods from her diet.
I also reviewed with Ms. Bourne the foods she liked
best and suggested new ways to enjoy them in forms
less likely to cause aspiration, such as shakes or pud-
dings. Because I understood Ms. Bourne’s personhood,
I was able to work with her to find solutions, rather
than see her as a diagnosis in need of medical “fixing.”
Subjective reality and created meaning. Experi-
ences shape understanding because they hold specific
meaning. Experiences, perceptions, representations,
emotions, and meanings guide people’s understanding
of events (their “reality”) and affect their responses.
Searching for meaning involves creating narratives
that are woven together from facts, past and current
experiences, perceptions, and beliefs. The construc-
tion of the narrative is an important integrative pro-
cess that creates health and facilitates healing.18, 19
The case of Texas-reared Rabbi Ronnie Cahana il-
lustrates how profoundly our narratives can affect our
outlook. At the age of 57, Rabbi Cahana, a deeply
spiritual man, had a brain-stem stroke that left him
cognitively intact but quadriplegic. Because he main-
tained the ability to move his eyes, the rabbi developed
a blinking system through which to communicate. His
reality is captured in a poem he dictated to his daugh-
ter through this system. The poem provides a glimpse
into his inner world and insight into the strengths that
allowed him to adapt to his quadriplegia:
You have to believe you’re paralyzed to play
the part of a quadriplegic; I don’t. In my mind
and in my dreams every night I Chagall-man
float over the city, twirl and swirl. With my toes
kissing the floor. I know nothing about this
statement of man without motion. Everything
has motion. The heart pumps, the bloods race
course, the lungs culminate, the body heaves,
the mouth moves, the eyes turn inside-out. We
never stagnate. Life triumphs up and down.
—Rabbi Cahana, as quoted in “Joy,
Compassion and Fulfillment: Kitra
Cahana’s Spiritual Transformation,”
SBN encourages nurses to appreciate and facilitate
the communication of patients like Rabbi Cahana.
Through communication, such as the rabbi’s poetry,
nurses come to know their patients and gain insight
into how they experience their reality. Through his
poem, Rabbi Cahana is telling the world that he re-
tains his identity as a person and not as a quadriplegic.
Person and environment are integral. Person and
family are affected by environment, both physical and
social. One environment may bring out a person’s
best while another may bring out the same person’s
vulnerabilities. People grow and thrive when there is
a “goodness of fit” with their environments. Such en-
vironments enable people to draw on their strengths
and provide themselves with opportunities for devel-
opment, healing, and thriving.
John Marsala, a nurse manager at a university
teaching hospital, tells of an experience he had early in
his nursing career when he worked on a busy cardiol-
ogy unit. He was assigned a patient who had been
admitted for angina. John prepared the patient for an-
gioplasty and started the iv fluid and medication line.
When the patient returned from the procedure, bleed-
ing from the catheterization entry wound, John ap-
plied pressure to the wound until the bleeding stopped.
Later in the shift, when John checked on the patient,
30 AJN August 2014 Vol. 114, No. 8
he noticed that the patient had a 5 o’clock shadow
and offered to give him a shave. Of the many actions
John took to care for the patient during his 12-hour
shift, the shave was the one on which both the patient
and his family remarked. John, reflecting on the inci-
dent many years later, says, “The shave made him feel
so good. He went from looking like a sick patient to a
healthier-looking person. It restored his sense of per-
sonhood. It made the family feel good to see their
loved one looking so much better, and they responded
differently to him.”
Nurses with an SBN orientation are acutely aware
that they are an integral part of the environment for
both patients and their families and can profoundly
affect them, even during a brief, one-time encounter.
Nurses frequently see people in times of crisis and are
often remembered for such simple acts of kindness as
a warm smile or a compassionate touch. People re-
member nurses who are knowledgeable, competent,
and compassionate; who engage them in conversa-
tion; and who are interested in their concerns and re-
sponsive to their needs. People also remember acts
of sullenness, unkindness, insensitivity, and rudeness,
which make them feel devalued, ignored, and disre-
spected. SBN emphasizes the importance to healing of
the physical and social environment and encourages
nurses to be mindful of noise levels and ventilation.
Self-determination. SBN respects a person’s self-
knowledge and values choice and self-determination,
even though there are always limits to the choices
available and a person’s ability to act in her or his
own interest is affected by circumstances, knowledge,
and predisposition. The cases of Ms. Glover, Sarah
Jones and her mother, Ms. Bourne, and Rabbi Ca-
hana all illustrate the importance of allowing patients
to exercise self-determination. Almost every act of liv-
ing involves a choice about how to respond to specific
circumstances and limitations, and within the context
of health care, what interventions to undertake. SBN
sees the nurse’s role not as deciding for others but
rather as listening attentively and deeply in order to
clarify, elaborate, explain, provide information, make
suggestions, connect people with resources, and advo-
cate for patients and their families so they may hear
their own voices and make their voices heard.1
Learning, timing, and readiness. Learning, which
is essential to survival, change, growth, and transfor-
mation, involves biological, psychological, and social
processes.21 Without learning, humans cannot navi-
gate their environment. But readiness to engage in a
new activity as a prelude to change is a prerequisite
for learning. Timing, in the context of health care, re-
quires synchronizing the desired outcome with the
body’s capabilities and the mind’s willingness. It re-
quires the nurse to be attuned to the patient and to
know the point at which intervention will be most
successful. Learning, readiness, and timing are all re-
quired for healing, which SBN maintains can occur
even during the act of dying.
Revisiting the case of Ms. Glover. At the end of her
life, Ms. Glover developed delirium and was admitted
to the palliative care unit. In her delirium, she repeat-
edly called out the name “Annie.” When I asked Ms.
Glover’s niece about Annie, she told me that Annie
was her other aunt, Ms. Glover’s older sister, who had
passed away two years earlier, also from lung cancer.
Ms. Glover had not seen her sister for over a decade,
though they had corresponded by e-mail prior to An-
nie’s death. Even when Annie was dying, Ms. Glover
had told her niece that she believed her sister was fak-
ing her illness to get attention. Annie had known that
her sister resented her, but she had expressed no ani-
mosity toward her to other family members. Ms.
Glover’s niece was concerned that her aunt would die
in an agitated, guilt-ridden state, so I encouraged her to
share with her aunt memories of happier times when
the two sisters got along. I also encouraged her to let
Ms. Glover know that Annie had harbored no ill feel-
ings toward her but rather understood and loved her.
A few days later, Ms. Glover was no longer deliri-
ous or agitated. She radiated a sense of calm. She died
peacefully a week later. Through SBN, I understood
the importance of timing and was able to help Ms.
Glover’s niece recognize that her aunt might finally be
ready to let go of the narrative she’d long held of her
sister’s death, so that she might die healed.
SBN actively engages people in their own learning,
seeks indications of readiness, and times interventions
based on knowledge of the person and their situation,
which grows out of curiosity, concern, and openness.
Collaborative partnership. The nature of the
nurse–patient relationship is collaborative. Each
brings her or his own experience, knowledge, and
competencies to the relationship. The nurse has for-
mal and practical knowledge of health and healing,
and the patient and family have knowledge of them-
selves and their circumstances. A collaborative part-
nership requires the nurse to be open, nonjudgmental,
and willing to share power.22 The patient and family
are more likely to want to collaborate when they feel
valued, understood, respected, and secure. Focusing
on them as individuals and recognizing their strengths
is key to successful collaboration.
Collaborative partnerships require the partners to
find common ground, set goals jointly, and determine
a course of action that’s right for the patient. The nurse
provides information that aligns with the patient’s
developing skills so that both nurse and patient can
SBN honors and dignifies people, enabling
them to live as they choose. AJN August 2014 Vol. 114, No. 8 31
participate fully as partners. In the case of Ms. Bourne,
this meant that, with guidance, the patient was able to
discover her own solution to preventing aspiration
pneumonia. When people are unconscious or other-
wise unable to care for themselves, the nurse needs to
assume multiple roles, including caregiver, protector,
advocate, supporter, and nurturer.
As illustrated in the case of Dan, SBN does not ig-
nore deficits or pretend they do not exist. In fact, it
is as important to consider patients’ deficits as it is
to consider their strengths; both are essential aspects
of the whole person. In trying to create a condition of
wholeness for Dan, his nurse needed to consider how
to minimize his deficits and work with his strengths,
thereby allowing him to function at his highest level
(health and healing; holism and embodiment). She
recognized that Dan’s “voices” accorded him great re-
spect within his tribe (uniqueness; subjective reality and
created meaning; person and environment are inte-
gral), although auditory hallucinations are considered
pathological (a deficit) in the context of modern med-
icine. By working with Dan to manage his psychosis
without completely eliminating his “voices,” his care
team honored his tribal beliefs (self-determination),
enabling him to understand that he needed medica-
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 (collab-
orative partnership).
To person and family. SBN is built on principles of
empowerment, self-efficacy, and hope. Such strengths-
based paradigms as the Developmental Model of
Health and Nursing have been found to promote
hope, healthy behaviors, and quality of life in stroke
survivors.23 These principles need to be in play if peo-
ple are to assume greater control over their lives and
take charge of their own health and healing. Feelings
of self-control and of being in charge are essential in
coping with problems and stress.
Empowerment. People empower themselves,
though clinicians may create conditions that enable
them to do so by working with their strengths or help-
ing them develop new strengths. Feelings of empower-
ment enable people to take greater control over their
health through self-management, give them the confi-
dence to be partners in their own care, and help them
discover inner resources and innate capacities for heal-
ing they didn’t realize they had. Empowerment gives
people choices and, thus, enables them to choose
among alternatives.
Self-efficacy is a belief in oneself and in one’s abil-
ity to achieve a desired goal and bring about a desired
outcome. After decades of research into predictors of
successful change, self-efficacy has emerged as one of
the most robust.24, 25 Self-efficacy entails having confi-
dence in one’s competencies and resources, which is
an important prerequisite for taking charge in com-
plex, challenging, and often chronic matters of health
and healing.
Hope is the expectation that something positive
will occur. Stephenson characterized it as having the
following attributes26:
• a process of thoughts, feelings, behaviors, and re-
• directed at an object that is meaningful to the
• anticipatory in nature
• future oriented, but grounded in the present and
linked to the past
When problems are viewed as challenges to be
overcome rather than as sources of fear, uncertainty,
denial, and helplessness, then a person’s energy can
be redirected to such areas as positive coping and
self-healing. The nurse’s role is to open up possibili-
ties for the patient, creating opportunities to enter-
tain different options until a solution is found.27
A transformative shift of attention. SBN shifts at-
tention away from a preoccupation with a diagnosis,
problem, or symptom and toward an appreciation of
living a full life while making necessary accommoda-
tions to deal with an illness. Disease and other cata-
strophic events are viewed as challenges to be engaged
as part of a person’s life’s journey. SBN honors and
dignifies people, enabling them to be who they are
and to live as they choose.
To nursing and nurses. We are gaining a deeper
awareness of our innate capacities for healing and
well-being, and of the influence of environments and
relationships in these areas. The care of another re-
quires input from many disciplines, including nurs-
ing and medicine. It requires the ability to develop
both theoretical and practical knowledge, and a
broad repertoire of analytical and technical skills.28
Nurses who are in touch with and guided by their
values are more likely to feel inspired and empowered.
Whereas medicine contributes to the healing process
through medical and surgical interventions, nursing is
seen in the SBN model as contributing to healing by
creating environments that maximize a person’s innate
healing capacities. There is mounting evidence that
stress reduction can improve healing,29 and recent re-
search suggests that critically ill patients may benefit
from such stress-reducing nursing interventions as
SBN is built on principles of empowerment,
self-efficacy, and hope.
32 AJN August 2014 Vol. 114, No. 8
interpersonal touch.30 When nurses attend to the fun-
damentals of care (such as comfort, hygiene, nutrition,
positioning, and pain management), they reduce stress
and support the body’s capacity for healing. Such evi-
dence provides nurses with an argument for redesign-
ing their roles within the health care system so that it
makes better use of their knowledge and skills and
values time devoted to nursing care.
SBN also enhances interdisciplinary practice by
recognizing nursing’s specific expertise. Interdisci-
plinary practice is best achieved when there is a dif-
ferentiation of roles. Only then can professionals
know how best to integrate their respective knowl-
edge and skills to benefit patients and families. SBN
enables nurses to have greater control over their
practice by having an autonomous role. Nurses re-
port greater satisfaction when allowed to exercise
their nursing functions autonomously.31
To the health care system. Most health care or-
ganizations advertise that they are patient centered
and family focused, yet economic, political, and or-
ganizational interests often take priority over patient
and family needs. SBN is an approach that actually
puts into practice many of the tenets of person- and
family-centered care, making care more responsive
and relevant, less fragmented, and more accountable
to patients and their families.
SBN will inevitably lead to a more cost-effective
and efficient system because it makes better use of
the knowledge and skills of its health care profes-
sionals. If people assume greater control over their
self-care, they are likely to make better use of their
inner capacities for health and healing, enjoy better
health, and make more appropriate use of health
care services.3
Laurie N. Gottlieb is a professor of nursing at McGill University
in Montreal. The author acknowledges Bruce Gottlieb, PhD, for
his advice and support in preparing this manuscript. Contact au-
thor: The author and planners have dis-
closed no potential conflicts of interest, financial or otherwise.
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For 33 additional continuing nursing education
activities on professional development, go to
... Strengths-based education.: Participants receive brief strengths-based HCV education (Gottlieb, 2014). Strengths-based education can improve knowledge and motivation to achieve health-related goals among PLWH (Craw et al., 2008;Gardner et al., 2005;Gottlieb, 2014). ...
... Strengths-based education.: Participants receive brief strengths-based HCV education (Gottlieb, 2014). Strengths-based education can improve knowledge and motivation to achieve health-related goals among PLWH (Craw et al., 2008;Gardner et al., 2005;Gottlieb, 2014). The nurse case manager helps participants identify their strengths within the context of engaging in HCV care, including social support and engagement in HIV primary care (Fusfeld et al., 2013;Grebely et al., 2011). ...
Co-infection with HIV and hepatitis C virus (HCV) results in a threefold increase in relative risk of progression to end stage liver disease and cirrhosis compared to HCV alone. Although curative treatments exist, less than one quarter of people with HCV are linked to care, and even fewer have received treatment. The Care2Cure study is a single-blinded, randomized controlled trial to improve the HCV care continuum among people co-infected with HIV. This ongoing study was designed to test whether a nurse case management intervention can (i) improve linkage to HCV care and (ii) decrease time to HCV treatment initiation among 70 adults co-infected with HIV who are not engaged in HCV care. The intervention is informed by the Andersen Behavioral Model of Health Services Use and consists of nurse-initiated referral, strengths-based education, patient navigation, appointment reminders, and care coordination for drug-drug interactions in the setting of HIV primary care. Validated instruments are used to measure participant characteristics including HCV knowledge, substance use, and depression. The primary outcome is linkage to HCV care (yes/no) within 60 days. In this protocol paper, we describe the first clinical trial to examine the effects of a nurse case management intervention to improve the HCV care continuum among people co-infected with HIV/HCV in the era of all-oral HCV treatment. We describe our work in progress, challenges encountered, and strategies to engage this hard-to-reach population.
... Physiological, behavioral, environmental and teach them to use their resource mobilization skills (focusing on individuals' strengths) are among the roles and responsibilities of the nurse [6,7]. Strengths-Based Nursing Care (SBNC), published by Gottlieb in 2014, was a new philosophy of thinking in nursing and based on positive, the best and best working areas [8]. According to this philosophy, nurses and health professionals are charged with the responsibility of helping individuals find their own strengths to deal with both everyday challenges and adversities that threaten their integrity, that is, their sense of wholeness as well as the intactness of their lives [9]. ...
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Objective: Strengths-based nursing is a new approach and care philosophy and it is still unclear how it affects patients in the surgery period. The aim of this study was to determine the experiences of patients who had undergone coronary artery bypass graft surgery managed with this philosophy. Patients and Methods: This qualitative study consisted of 23 patients who had undergone coronary artery bypass graft surgery in the Cardiovascular Surgery Department of a university hospital in Izmir, Turkey. The data were collected using Individual Identification Form, Semi-structured Interview Forms, SWOT Analysis Form and Classification of Qualitative Strengths Form. Thematic data analysis was used to evaluate patient answers to the research questions. Results: According to the analyses performed, seven main themes consisting of “Perception of Being Strong”, “Perception of Being Weak”, “Care Process”, “Effects of Heart Disease”, “Reason for the Occurrence of the Disease”, “Need for Knowledge” and “Solution Seeking” were determined in the preoperative interviews, and five main themes consisting of “Perception of Being Strong”, “Perception of Being Weak”, “Surgery”, “Care Process” and “Education” were determined in the postoperative interviews. Conclusion: This new philosophy in patient management has positive effects because it increases patients’ hopes for life, healing and facilitating adaptation to the surgical procedure.
... Physiological, behavioral, environmental and teach them to use their resource mobilization skills (focusing on individuals' strengths) are among the roles and responsibilities of the nurse [6,7]. Strengths-Based Nursing Care (SBNC), published by Gottlieb in 2014, was a new philosophy of thinking in nursing and based on positive, the best and best working areas [8]. According to this philosophy, nurses and health professionals are charged with the responsibility of helping individuals find their own strengths to deal with both everyday challenges and adversities that threaten their integrity, that is, their sense of wholeness as well as the intactness of their lives [9]. ...
... Use of strengthsbased nursing[30] can enable nurses to provide an environment of moral support, facilitating patient's generation of self-awareness.This ethical practice of nursing care, using affective awareness and empathy, supports person-centered care which not only gives patients a sense of being cared for physically but also being cared about emotionally, socially and spiritually. is important to nursing because it is a universally experienced phenomenon[16,31] caring human science theory offers a structure to guide nursing practice related to the experience of suffering. Watson's[32][33][34][35][36] caring theory identifies the usefulness of the transpersonal caring relationship between the nurse and patient to protect, enhance, and preserve the patient's wholeness[34]. ...
... One such example is strengths-based nursing, which "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" (Gottlieb, 2014, p. 24). Standing on the shoulders of these nursing giants, we broadly define nursing as promoting health-with health being defined in partnership with clients and families (Gottlieb, 2013(Gottlieb, , 2014. Indeed, this article makes a clarion call for the rethinking of the nursing profession as going beyond physical and mental health. ...
In this article, the nursing health history is revisited with a hermeneutic lens to uncover means by which this tool can better serve nursing practice. It is argued that further distanciation from the developmental and medical model is necessary to accurately uncover health and history in the nurse–client encounter. Based on the works of prominent hermeneutic philosophers, such as Heidegger, Gadamer, Merleau‐Ponty, Ricoeur, and Taylor, four orientations to health history and nursing are explored: orientation to caring, orientation to narrative, orientation to time, and orientation to the body. The nursing health history is used as a vehicle for illuminating the usefulness of a hermeneutic perspective in everyday nursing practice. This article reveals views of health, history, and health history that are already known to nurses and the nursing milieu but are concealed by more dominant outlooks. The hermeneutical perspective presented in this article can help to reveal the important dimensions of everyday nursing practice and foster a richer attunement with the complex health experiences of individuals.
... Particularly if educators are not mindful that the ostensibly benign act of touring potentially exoticizes community members and unintentionally fosters uncritical depictions of people's differences. However, this can be mediated by properly preparing and debriefing students before and after the activity, or partnering with a known and respected community organization whose representatives can share community-based insights, provide counterpoints to dominant stereotypes, and highlight positive characteristics and resources in the community [29]. ...
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Background and objectives: Medical school curricula increasingly seek to promote medical students’ commitment to redressing health disparities, but traditional pedagogical approaches have fallen short of this goal. The objective of this work was to assess the value of using community-based guided tours of disadvantaged neighborhoods to fill this gap. Methods: A total of 50 second-year medical students participated in a guided tour of disadvantaged public housing neighborhoods in Richmond, Virginia. Students completed self-reflexive writing exercises during a post-tour debriefing session. Student writings were analyzed to assess the tour’s effect on their awareness of poverty’s impact on vulnerable populations’ health and wellbeing, and their personal reactions to the tour. Results: Student writings indicated that the activity fostered transformative learning experiences around the issue of poverty and its effects on health and stimulated a personal commitment to working with underserved populations. Themes from qualitative analysis included: increased awareness of the extent of poverty, enhanced self-reflexive attitude towards personal feelings, biases and misperceptions concerning the poor, increased intentional awareness of the effects of poverty on patient health and well-being, and, encouragement to pursue careers of medical service. Conclusions: This pilot demonstrated that incorporating self-reflexive learning exercises into a brief community-based guided tour can enhance the social consciousness of medical students by deepening understandings of health disparities and promoting transformative learning experiences.
... Sobre a sugestão das enfermeiras quanto à necessidade de sensibilização para integrar os serviços, acredita-se que é um processo lento, mas possível por meio do redirecionamento do modelo assistencial que orienta as práticas dos profissionais, colocando o usuário no centro das ações, respeitando sua singularidade, inserindo a família no processo de cuidado (27) e tendo em mente que o alcance de melhores condições de saúde acontece a partir de ações conjuntas de promoção, prevenção e cura. ...
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Objective: to identify the profile of the counter-referred patients by the "nurse liaison" and to describe the experience of the professionals who participated in the project. Method: intervention research, with twelve nursing nurses from a hospital and an Emergency Care Unit, and 26 nurses from Primary Health Care. Data were obtained through questionnaires and counter-referral forms. Results: Out of 43 counter-referred individuals, 62.8% are over sixty years, 53.5% are men with multi-pathologies. Among the positive aspects, the nurses highlighted the dialogue between health care services, agility in the acquisition of inputs for the continuity of care in primary care, benefiting patients after hospital discharge. The greatest challenge was the lack of time and the deficit of nurses to perform the function. Final considerations: the presence of the "nurse liaison" has proved to be an important strategy to improve integration between services and to promote continuity of care.
Behavioral health screening and assessment is an ongoing process of gathering and synthesizing important information across a range of domains including mental health, substance use, interpersonal relationships, and social determinants of health (SDOH) in order to inform treatment planning. This chapter will provide an overview screening and assessment practices vital to integrated behavioral health practice. The assessment process described in this chapter will be rooted in the ecological systems perspective discussed in Chap. 2 and will be person centered, strength based, holistic, and recovery oriented. The purpose of assessment is to inform the development of a robust clinical formulation and treatment plan (described in Chap. 5) designed to address the intersectional issues that clients face from a bio-psycho-social perspective. This chapter will focus on assessment and documentation areas that include: (1) screening for common behavioral health issues such as depression, anxiety, stress, trauma, suicide, and substance use; (2) assessing personal strengths and capacities that lead to health; (3) past and current problems in the functional domains of health, mental health, substance use, interpersonal relationships, employment, and daily living; and (4) assessing social determinants of health. The chapter will conclude with an illustrative case study highlighting important areas and considerations of the assessment process.
Using a phenomenological design, the researcher repeated a previous study of males, this time exploring the question of what is the experience of suffering voiced by female patients 6-12 months after hospitalization for blunt trauma. Eleven female volunteers were interviewed and asked questions about how they suffered, what made their suffering more or less bearable, and how they were transformed through their suffering. Like the males, female participants experienced changes in patterns resulting in perceptions of suffering. Participants reported mostly experiencing physical, emotional, and social forms of suffering, whereas fewer participants experienced economic and spiritual suffering. Experiences of suffering resulted from the threat to their sense of wholeness because of their injuries. Intrinsic and extrinsic factors made participants' suffering more or less bearable as they regained or revised their shattered wholeness. Positive attitude and motivation were significant intrinsic factors, whereas quality supportive care was the most significant extrinsic factor. Feeling cared about emotionally was as important as feeling cared for physically in helping participants better bear their suffering. Poor quality care was a significant negative extrinsic factor resulting in suffering being made more unbearable. Through their experiences of suffering and finding meaning in that suffering, participants were transformed, amending their previous state and resulting in a new state of wholeness. Knowledge gained through this phenomenological study may help nurses understand suffering and guide their care and caring to alleviate it or make it more bearable.
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A topic of long-standing interest for university administrators and faculty is how to help first-year college students succeed aca-demically. On average, only 73.6% of college freshman return for their sophomore year (National Center for Higher Education Management Systems [NCHEMS], 2007). Although academic success in college requires some preexisting capabilities, these abilities do not always differentiate high-achieving students from low-achieving students (Kitsantas, 2002; Zimmerman & Schunk, 2008). By contrast, there is an extensive body of evi-dence with regard to academic performance suggesting that dif-ferences in low-and high-achieving students are closely linked to an individual's level of self-regulation (Zimmerman & Schunk, 2008). Self-regulation refers to the degree to which students are "metacognitively, motivationally, and behaviorally active partici-pants of their own learning process" (Zimmerman, 1989, p. 329). Considering the above evidence, it would be interesting to
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Introduction: Nurses use several forms of touch in patient encounters. Interpersonal touch elicits specific physiological and psychological responses, including neuroendocrine effects and reduction of stress. Critical illness is a state of excessive physiological and psychological stress. Aims: To critically review evidence on the effect of touch on physiological outcomes in critically ill individuals. Results of intervention studies in adult critical care settings were reviewed along with supportive evidence from studies in other populations. Methods: Critical literature review based on studies published in MEDLINE, PubMed, Cinahl, Embase, and Cochrane databases. Results: Eleven studies were reviewed. Significant effects of interpersonal touch included lower systolic and diastolic blood pressure and respiratory rate, improved sleep, and decreased pain. Almost no results were replicated owing to discrepancies among studies. Although the effect of touch on cardiovascular autonomic status appears considerable, several confounders must be considered. In noncritically ill populations, replicable findings included increased urinary dopamine and serotonin, natural killer cytotoxic activity, and salivary chromogranin. Effects on plasma cortisol and immune cells were variable. Effects appear to vary according to amount of pressure, body site, duration, and timing: Moderate pressure touch may elicit a parasympathetic response in contrast to light touch, which may elicit a sympathetic response. Moreover, touch effects may be mediated by the density of autonomic innervation received by the body areas involved and repetition of sessions. Conclusion: The physiological pathway mediating the effects of touch is unclear. Although no concrete conclusions can be drawn, research evidence suggests that touch interventions may benefit critically ill individuals.
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Caring, a core tenet of nursing practice, grew out of a holistic approach. Nurse theorists often note the establishment of a therapeutic relationship as the beginning point of caring, with subsequent nursing interventions reliant upon this relationship for effectiveness. Relational exchange serves as a source of either stress or healing between participants, and rarely is its impact neutral. Relational stress, in fact, has become a primary contributor to many disease processes in terms of promotion and progression and perhaps even initiation. Patient-provider relationships have a long history in medical and nursing literature as critical to providing effective interventions, but our understanding of relational dynamics between patients and providers remains fairly superficial. This theoretical article adapts a previously described biobehavioral model to illustrate the nature and centrality of caring relationships in nursing practice. The dynamic process of face-to-face engagement is deconstructed from a psychobiological standpoint in order to understand the physiological, emotional, cognitive, and behavioral impacts of relational interaction. This understanding is then applied to the patient-provider relationship. Finally, the utility of biomarkers of stress, positive emotion and resonance, and of disease is discussed relative to the patient-provider relationship. Methodological and interpretive challenges inherent in this line of research, along with suggestions to address such challenges, are also presented.
In the context of projections of growing physician shortages in the United States, the author reviews the IOM recommendations regarding a greater role for nurses and discusses controversial proposals to expand the scope of practice of NPs in states with restrictive laws.
Kitson A, Conroy T, Wengstrom Y, Profetto-McGrath J, Robertson-Malt S. International Journal of Nursing Practice 2010; 16: 423–434 Defining the fundamentals of careA three-stage process is being undertaken to investigate the fundamentals of care. Stage One (reported here) involves the use of a met a-narrative review methodology to undertake a thematic analysis, categorization and synthesis of selected contents extracted from seminal texts relating to nursing practice. Stage Two will involve a search for evidence to inform the fundamentals of care and a refinement of the review method. Stage Three will extend the reviews of the elements defined as fundamentals of care. This introductory paper covers the following aspects: the conceptual basis upon which nursing care is delivered; how the fundamentals of care have been defined in the literature and in practice; an argument that physiological aspects of care, self-care elements and aspects of the environment of care are central to the conceptual refinement of the term fundamentals of care; and that efforts to systematize such information will enhance overall care delivery through improvements in patient safety and quality initiatives in health systems.
Background. Critical thinking and reasoning take many forms; however, a problem-orientation remains the favoured approach in health care. Purpose. This paper considers the effects of a problem-orientation and argues that a solution-orientation fits nursing's interests more closely and represents an exciting way forward in both education and practice. Discussion. Whilst a problem-focus is criticized by some, it remains largely unchallenged as the guiding light for nursing practice. A major reason is that the problem focused approach has strong cultural roots. It is deeply embedded in our thinking, and has become taken-for-granted and not often recognized or debated. Whilst problem-solving has an important place in helping to diagnose disorder and overcome difficulties, nursing needs to move beyond its borders because the role also concerns problem-free issues such as health and well-being. Creativity, imagination and focusing on strengths not problems are also important cognitive processes. Conclusion. A problem-orientated approach in nursing has had a constraining rather than enabling influence. By refocusing on a solution-focused approach, we could show how we are different from medicine, and how we aim to do nursing differently through using skills such as engagement, resilience-building, community development, primary health care and health education.
Pre-treatment diet and exercise self-efficacies can predict weight loss success. Changes in diet self-efficacy across treatment appear to be even stronger predictors than baseline levels, but research on changes in exercise self-efficacy is lacking. Using data from a pilot study evaluating tangible reinforcement for weight loss (N=30), we examined the impact of changes in diet and exercise self-efficacy on outcomes. Multiple regression analyses indicated that treatment attendance and changes in exercise self-efficacy during treatment were the strongest predictors of weight loss. Developing weight loss programs that foster the development of exercise self-efficacy may enhance participants' success.
Over the past 30 years investigators have called repeatedly for research on the mechanisms through which social relationships and social support improve physical and psychological well-being, both directly and as stress buffers. I describe seven possible mechanisms: social influence/social comparison, social control, role-based purpose and meaning (mattering), self-esteem, sense of control, belonging and companionship, and perceived support availability. Stress-buffering processes also involve these mechanisms. I argue that there are two broad types of support, emotional sustenance and active coping assistance, and two broad categories of supporters, significant others and experientially similar others, who specialize in supplying different types of support to distressed individuals. Emotionally sustaining behaviors and instrumental aid from significant others and empathy, active coping assistance, and role modeling from similar others should be most efficacious in alleviating the physical and emotional impacts of stressors.