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CE: Strengths-Based Nursing

Gottlieb, Laurie N. PhD, RN

AJN, American Journal of Nursing: August 2014 - Volume 114 - Issue 8 - pp 24-32
doi: 10.1097/01.NAJ.0000453039.70629.e2
Feature Articles

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.

A holistic approach to care in which eight core values guide nursing action, thereby promoting empowerment, self-efficacy, and hope.

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 author: The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

“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 Family 1

Despite the recent attention paid to prevention, wellness, and patient-centered care, the medical 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 patient'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 problems within a broader, holistic context that uncovers inner and outer strengths.

Diane Bourget, a clinical nurse specialist who attended 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 hospital's child psychiatric unit, Dan Pacheco, a Native American adolescent, was admitted showing signs of a severe psychotic break, having recently threatened the life of a young woman. Through their initial interview with Dan, the crisis intervention team discovered that in his community Dan was believed to possess special powers because he “heard voices” (that is, he had auditory hallucinations). The challenge for the team was to reduce 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 discussion 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 retained his tribal status. The team's broad focus was consistent with the values of SBN. They viewed Dan as a whole person, a greatly respected member of a community whose values were not completely consistent with those of modern medicine. Had they instead focused exclusively on his deficits, Dan, his family, and his health care team might not have found a solution that was agreeable to all.

Undoubtedly, many nurses already practice elements 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 practice.”1 Although nurses with a deficit-focused perspective may sometimes seize an opportunity to motivate patients and families by concentrating on strengths rather than deficits, this approach is not an essential part of their schooling and its consistent use cannot be relied on in professional practice. Nurses whose practice is strengths based, on the other hand, seek capacities, competencies, and skills that patients and their families might use for recovery, survival, growing, and in many cases, thriving. Even nurses treating unconscious patients in an ICU can use the SBN approach. For example, by closely observing patients’ responses to stimuli, nurses can schedule painful or intrusive procedures for times when they will be best tolerated (capitalizing on inner strengths); by noting the nature of family responses and their effect on the patient, nurses can communicate caring and respect, thereby reducing environmental stress (maximizing outer strengths).

SBN recognizes the importance of focusing on strengths that can empower patients to assume greater control over their own healing and health—it enables nurses to help people help themselves attain higher levels of health. This article proposes that SBN is an approach to care that provides the vision, values, and evidence that can transform and humanize health care by reconnecting it with the concepts of Florence Nightingale and expanding those concepts to meet the realities of 21st-century health care.

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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 Canada since 1947, when some Canadian provinces began 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 expected to take on a much greater role to accommodate the increased demand for care. There was considerable 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 differing perspectives on the role of nurses in various contexts, 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 interventions for patients living in the community with complex chronic medical conditions and social circumstances. 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), produced 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 (working with the patient's family members and support networks), most notably the Nurse–Family Partnership program ( Research has demonstrated the benefits of these values 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 often uncaring system in which people are treated as diagnoses 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 current health care system, we lack a vision for nursing shaped by well-defined values that could help the profession determine priorities and guide nurses’ actions. 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

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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 Nightingale understood health as a process of becoming, while she described healing as an act or process of restoration or recovery from disease. She also recognized that the human body and mind had innate restorative and reparative capacities, and that nurses could empower patients to contribute to their own healing by creating physical and interpersonal environments that allow this to happen.10 For example, such simple actions as turning down room lights, controlling the number of visitors, closing doors to control noise levels, moving patients closer to a window, and reminding visitors to wash their hands help create a physical environment that promotes healing. Likewise, nurses create interpersonal healing environments by being fully present in their interactions with patients, listening attentively, and demonstrating 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 disciplines. We are beginning to accumulate scientific evidence that validates many of Nightingale's insights. For example, she considered physical and emotional environments key to health and healing. She also understood 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, neurobiologic studies have affirmed that reducing stress enhances telomerase levels, which are involved in cellular health.12

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Restructuring the Nurse's Role

The current health care system has become more focused on disease and increasingly sophisticated in its use of technology. As nurses pursue advanced education, their sphere of practice has expanded into such traditionally medical areas as diagnosis, treatment, and medication prescription.13 Although nurses have largely relinquished their assistant-to-the-physician role, many have become even more tethered to medicine by substituting for physicians and taking on more of what were, traditionally, physician's tasks, rather than expanding the nursing role. While diagnosis and treatment may be one aspect of advanced practice nursing, it should not be the nurse's total focus. Nursing should provide care that differs in substantive ways from that seen in the medical model—not simply be a variant of the same disease- and problem-focused care. The nurse's primary focus should be on health, healing, and the alleviation of suffering through actions that draw on inner strengths and outer resources, creating conditions that allow patients to achieve maximum functioning.

Another driver of the current system has been a preoccupation with cost-effectiveness and managed care. When all of health care is seen to be quantifiable, nursing is practiced as a set of technical activities rather than as a set of relational, social, and moral activities with a technical base.14 Many nurses and administrators believe that performing medical tasks is more complex, and thus a better use of nurses’ time, than providing comfort measures or listening to patients’ concerns. But nurses can and often do accomplish both. Medical tasks should not eclipse the importance of ensuring patient comfort and safety within the context of a caring relationship that enables nurses to get to know patients as individuals.

To address unsustainable levels of spending in our health care system, many have called for systematic transformation, and SBN should be considered a means of achieving this transformation. Although the Institute of Medicine's 2010 report The Future of Nursing: Leading Change, Advancing Health suggests that nurses can fulfill numerous roles throughout 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 themselves that complements and parallels medicine. To do so, they will need to more explicitly connect Nightingale's teachings about working with innate mechanisms that support health and healing to such values as holism, compassion, and the importance of the environment and relational care. SBN fulfills these requirements.

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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 conditions that support the person's innate health and healing at all levels: from cells (biological) to citizens (person and family) to communities (support networks). 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 better enable patients and their families to take control over their lives and health care decisions. SBN recognizes that deficits coexist with strengths and that problems can be understood only within the context of a person's life experiences. It attempts to discern a person's strengths and use them to deal with problems, compensate for deficits, and overcome limitations.

SBN comprises eight interrelated values (Figure 1).1 These values are illustrated in the nurse–patient interactions 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 develop new skills that can sustain and increase their health.

Nurses promote health by helping people develop their capacities for attachment, regulation, and coping.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 physical and psychosocial insults.

A few years ago, I cared for Lucille Glover, a 73-year-old woman who was diagnosed with advanced lung cancer. She feared dying alone and had trouble being alone while she slept. Aware of the reparative powers of sleep and the therapeutic value of authentic presence and attentive listening, I suggested that the family consider hiring a compassionate, caring person to spend nights at her bedside. When Ms. Glover was agitated, the caregiver sat beside her bed, stroked her arm, dimmed the lights, and spoke with her quietly. The presence of the caregiver provided Ms. Glover with a sense of security that empowered her to reduce her stress. Achieving this type of serenity and, thereby, lowering levels of cortisol (the stress hormone) tend to improve immunologic function, thus facilitating healing. The practice of 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 particular 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 individual's uniqueness, therefore, requires an understanding 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 severe, debilitating form of juvenile arthritis that was previously misdiagnosed and has left her unable to walk. Her nurse, Gillian Taylor, practices the McGill 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”—and I would say: “What resilience and what gutsiness!”… The first thing that struck me was Sarah's drive; her wish to 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!””

—Gillian Taylor, as quoted in Strengths-Based Nursing Care: Health and Healing for Person and Family 1

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 describes 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 functioning properly. Enabling the innate healing mechanism to restore a sense of wholeness often requires both symptom treatment and containment or elimination 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 developed 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 gastrostomy 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 important 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 enjoying food and participating in mealtime activities, while also meeting her nutritional requirements and preventing another recurrence of aspiration pneumonia. 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 puddings. 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. Experiences 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 construction of the narrative is an important integrative process that creates health and facilitates healing.18, 19

The case of Texas-reared Rabbi Ronnie Cahana illustrates 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 maintained 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 daughter 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,” Time 20

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 retains 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 environments enable people to draw on their strengths and provide themselves with opportunities for development, 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 cardiology unit. He was assigned a patient who had been admitted for angina. John prepared the patient for angioplasty and started the iv fluid and medication line. When the patient returned from the procedure, bleeding from the catheterization entry wound, John applied pressure to the wound until the bleeding stopped. Later in the shift, when John checked on the patient, 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 incident 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 personhood. 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 remember nurses who are knowledgeable, competent, and compassionate; who engage them in conversation; and who are interested in their concerns and responsive to their needs. People also remember acts of sullenness, unkindness, insensitivity, and rudeness, which make them feel devalued, ignored, and disrespected. 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 Cahana all illustrate the importance of allowing patients to exercise self-determination. Almost every act of living 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 advocate 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 transformation, involves biological, psychological, and social processes.21 Without learning, humans cannot navigate 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, requires synchronizing the desired outcome with the body's capabilities and the mind's willingness. It requires 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 required 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 repeatedly 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 Annie's death. Even when Annie was dying, Ms. Glover had told her niece that she believed her sister was faking her illness to get attention. Annie had known that her sister resented her, but she had expressed no animosity 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 feelings toward her but rather understood and loved her.

A few days later, Ms. Glover was no longer delirious 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 formal and practical knowledge of health and healing, and the patient and family have knowledge of themselves and their circumstances. A collaborative partnership 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 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 otherwise unable to care for themselves, the nurse needs to assume multiple roles, including caregiver, protector, advocate, supporter, and nurturer.

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Putting it All Together

As illustrated in the case of Dan, SBN does not ignore deficits or pretend they do not exist. In fact, it is as important to consider patients’ deficits as it is to consider their 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 respect within his tribe (uniqueness; subjective reality and created meaning; person and environment are integral), although auditory hallucinations are considered pathological (a deficit) in the context of modern medicine. 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 medication in order to attain the level of stability required for him to be judged safe to return to the community (learning, timing, and readiness) and allowing him to participate in developing a workable solution (collaborative partnership).

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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 people 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 helping them develop new strengths. Feelings of empowerment enable people to take greater control over their health through self-management, give them the confidence to be partners in their own care, and help them discover inner resources and innate capacities for healing 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 ability 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 confidence in one's competencies and resources, which is an important prerequisite for taking charge in complex, 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 relationships

* 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 possibilities for the patient, creating opportunities to entertain different options until a solution is found.27

A transformative shift of attention. SBN shifts attention away from a preoccupation with a diagnosis, problem, or symptom and toward an appreciation of living a full life while making necessary accommodations to deal with an illness. Disease and other catastrophic 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 requires input from many disciplines, including nursing 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 research suggests that critically ill patients may benefit from such stress-reducing nursing interventions as interpersonal touch.30 When nurses attend to the fundamentals of care (such as comfort, hygiene, nutrition, positioning, and pain management), they reduce stress and support the body's capacity for healing. Such evidence provides nurses with an argument for redesigning 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. Interdisciplinary practice is best achieved when there is a differentiation of roles. Only then can professionals know how best to integrate their respective knowledge and skills to benefit patients and families. SBN enables nurses to have greater control over their practice by having an autonomous role. Nurses report greater satisfaction when allowed to exercise their nursing functions autonomously.31

To the health care system. Most health care organizations advertise that they are patient centered and family focused, yet economic, political, and organizational 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 professionals. 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

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