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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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HOURS
Continuing Education
24 AJN August 2014 Vol. 114, No. 8 ajnonline.com
CE
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”
2.5
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.
Strengths-Based
Nursing
ajn@wolterskluwer.com 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 ajnonline.com
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.
THE CURRENT HEALTH CARE CLIMATE
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 (www.nursefamilypartnership.org).4
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
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 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@wolterskluwer.com 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
RESTRUCTURING THE NURSE’S ROLE
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-
quirements.
THE UNDERLYING VALUES OF SBN
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 ajnonline.com
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
health.
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
Uniqueness
Holism and Embodiment
Subjective Reality and
Created Meaning
Person and Environment
Are Integral
Person
Family
Staff
Learner
Collaborative
Partnership
Learning, Timing,
and Readiness
Self-Determination
Figure 1. The Values of Strengths-Based Nursing
ajn@wolterskluwer.com 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,”
Time20
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 ajnonline.com
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@wolterskluwer.com 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.
PUTTING IT ALL TOGETHER
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).
BENEFITS OF SBN
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-
lationships
• directed at an object that is meaningful to the
person
• 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 ajnonline.com
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: laurie.gottlieb@mcgill.ca. The author and planners have dis-
closed no potential conflicts of interest, financial or otherwise.
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