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