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Breaking out of the system and moving to strengths-based care

MacDonald, Barbara J. MS-DEDM, BSN, RN, CDE; Dickinson, Jane K. PhD, RN, CDCES

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doi: 10.1097/01.NURSE.0000757156.83297.d4
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A FEW YEARS AGO, two older adult residents broke out of a rural long-term-care facility by stealing an idling car and taking off across the prairie. It was a bright spring day with snow still on the ground, warmth in the air, and the promise of new things to come. Reporters asked people to be on the lookout for these two older adults. Upon hearing this, the immediate thought was: “You go, guys! Good for you!” Imagine how liberating that would be for them! Such bandits. Rather than thinking about the risks and potential negative outcomes, the listener reaction was one of exhilaration because of the residents' energy, ingenuity, and drive to break free of the system. It was a celebration of their strengths in crafting and executing a successful breakout plan.

Dr. Atul Gawande, a surgeon and public health researcher, emphasizes that what people want is not just to stay safe and live longer, but to live meaningful, autonomous lives and share their stories of a life well-lived, recognizing that “...the chance to shape one's story is essential to sustaining meaning in life.”1 He stresses that “we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone's lives.”1 Should this not be the case for every healthcare encounter—not just at the end of life, but throughout the lifespan? This call to reshape our practices and institutions could be accomplished by taking an approach that centers on the assets and strengths of the person or population. This long-term-care facility breakout can be used as a metaphor for seizing the opportunity to reshape healthcare and include a strengths-based approach at its core.

What is a strengths-based approach?

Strengths-based approaches, which emerged in the mid-1980s in the field of social welfare, focus on the strengths of individuals, families, groups, and organizations to empower them and help in their recovery.2,3 A strengths-based approach emphasizes hope and possibility and, in the simplest terms, focuses on the positive.3 It fosters collaboration between individuals and their healthcare team to find the best path forward.

Strengths-based care has a history in mental health and social work, spanning at least the past 3 decades.4 This approach is also found in some education systems where strengths-based values and attitudes undergird the processes and outcomes of every intervention and provide a philosophy of teaching and of life based on attitudes and values that display respect for others.5

However, empirical evidence to support the use of strengths-based approaches in healthcare is limited because it is difficult to synthesize data based on diverse populations and situations.3 Despite this, there seems to be emerging interest in strengths-based approaches. The United Kingdom even embedded them in legislation in the Care Act 2014.6

On the surface, most clinicians agree with the principles of a strengths-based approach to healthcare. In truth, however, the current problem-based model of healthcare focuses on shortfalls and positions the healthcare professional—not the person living with the disease—as the expert in designing solutions.7 Many healthcare models and systems are designed to identify deficits and problems and focus on fixing them. This model has been criticized because it neglects context, as well as psychological and social components.8 This problem-based model also creates reliance on the healthcare professional as an “expert” to fix the problem, rather than determining strengths and solutions that exist within individuals, who are the experts in their own body and self-care.7

Additionally, the healthcare system is provider-centric with policies, funding models, and resources built for the convenience and efficiency of those providing care rather than those receiving it.9 For example, initial assessment forms and processes are most often designed for the convenience of the healthcare provider within the system. These forms are designed for maximum efficiency, ironically capturing all kinds of information that may or may not be used for this encounter—or ever, for that matter. These types of assessments often ask questions in ways that steer people toward answering “correctly” and may not capture accurate information. Imagine how beneficial it would be to have the initial assessment in a nonurgent care environment begin with “How are things going for you? What is going well, and what brings you hope?”

A strengths-based approach focuses on strengths versus deficits; solutions and competencies, not what needs to be fixed; and what is working versus what is not. It is a collaborative, not hierarchical, approach that builds on resources versus expert opinion.10 This is not to say that within a strengths-based approach problems are ignored, but rather that healthcare professionals make attempts to identify the resources and strengths that will form the basis to address the challenges.7 With a strengths-based approach to clinical care, individuals and families are active participants in decision-making and planning to promote and restore health.10

Strengths-based approaches and the nursing model

There is growing interest in strengths-based approaches within nursing. Such approaches are consistent with the nursing model, which is grounded in nursing theory. This foundation emphasizes holistic care with a focus on the whole person, including the person's social circle and support system.11 Many will claim that a strengths-based approach already exists within person-centered care inherent in the nursing model; however, there are no formal structures in place to ensure strengths-based approaches form the basis of care.12 Swartz recognized that identifying strengths has guided nursing assessments and interactions for some time already and proposes that a strengths-based approach could potentially enhance outcomes in a clinical setting when there is a foundation of empowerment, efficacy, and hope.10 Strengths-based nursing research is underway and has been incorporated into some nursing academic curricula; however, more studies are needed to demonstrate the benefits of this approach.13,14

In the meantime, there is room to consider existing nursing theories, philosophies, and processes incorporated into daily practice that provide opportunities for a strengths-based approach, which calls upon nurses to consider the values and attitudes inherent in our philosophy of nursing practice.15 The philosophy we apply to nursing practice is actualized through our thoughts, words, and actions. To move toward this approach, nurses need to reflect on the future we want to create. Using our collective “voice,” we will be able to move toward a strengths-based nursing model of care. This includes embracing strengths-based, person-centered messages.16 This means not referring to people as their disease; they are not “diabetics,” they are people with diabetes. It is not “the DKA in Room 2, Bed 3.” This type of language is not only disrespectful but dehumanizing.

Empowerment, self-efficacy, and hope

Strengths-based approaches focus on the core values that promote empowerment, self-efficacy, and hope.17 An example of strengths-based care is the role hope plays when considering it as a construct in diabetes self-management. Hope can be considered a pilot light within each of us that continues to burn, even in the darkest times, and nurses can inspire hope in people with diabetes by looking at their strengths. Acknowledging their skills and ability to navigate all aspects of diabetes self-management is a starting point that inspires hope about the healthcare encounter and the possibility of a relationship of trust and collaboration leading toward viable solutions. This begins with genuine acknowledgment about where they are in the moment, whether it is commenting on the work involved in checking glucose levels and self-adjusting insulin, or perhaps even acknowledging their attendance at this appointment. A trusting, collaborative relationship between nurse and person with diabetes involves learning and working alongside one another with an individualized and strengths-based approach to diabetes management.

Strengths-based care emerged in the literature as a practical way for nurses to foster hope and take action to effect empowerment and sustainable change. Gottlieb suggests that the nurse's role is to develop a strengths-based mindset, which entails active listening, being engaged in the encounter, and responding to people and their families.18 Focusing on strengths provides hope and supports people to believe in their power to enact change and have control over their lives.19

People have hopes and dreams; they want the best for themselves and their families. They want to live well and be positive, contributing members of society. When we focus only on the problem and on the healthcare professional, we may be missing the person's hope, determination, resilience, and fortitude, among other things. The person is right there in front of us, alive and functioning at least to some degree, and to the best of their current ability. The strengths-based approach identifies what is right and builds on it. Even though they may be seeking care for a serious and life-threatening situation, such as being informed they have an aortic aneurism, a strengths-based approach acknowledges the stress and uncertainty that the person is experiencing and supports an inventory of strengths and potential actions for the person. What this looks like is being present, saying that you imagine that it must be so hard to take it all in, possibly suggesting that they may want to have someone with them to understand the multitude of conversations and information that is coming at them, to support stress reduction through some calm deep breathing, and focusing on some of the hopeful pieces, such as detecting the aneurysm so treatment or surgery can begin.

Formalizing the strengths-based approach within the nursing process

There is a need for collaboration to determine how to formalize the strengths-based approach into nursing practice in a systematic, practical way. To apply strengths-based care consistently across all care environments, it needs to become part of the nursing process. For example, an effective starting point in working with people with diabetes is to begin by saying, “First, let's focus on what is working.” Follow that with swift action to collaborate and optimize diabetes therapies individualized to the person's interests and needs.

A formal shift to the strengths-based paradigm will require careful attention and commitment to system change processes, evaluation, and appropriate research and best practices.7 Gottlieb proposes a two-phased approach which moves from precommitment to adoption where awareness is raised, understanding is deepened, and ideas are tested before new processes are formed to adopt a strengths-based approach.19 These steps may lead to a shift in practice consistent with a strengths-based philosophy and may address some of the perceptions that the approach may be impractical and take too much time.19 A formal shift to incorporate a strengths-based approach could simply mean designing and using checklists within the nursing process that focus on strengths and ensure standardized process steps that provide an opportunity to measure impact more specifically.20

A shift toward the strengths-based model will require collaboration by nursing leaders followed by a coordinated effort for standardizing and adopting it into all practice settings and nursing curricula. We need to look to the nursing experts—academic, research-based, and at point-of-care—along with strengths-based evidence to create tools to promote its uptake. A strengths-based approach must become instinctive, universal, and embedded in the culture of nursing at every level in academia, research, and all practice settings. Nursing leaders can also use a strengths-based approach when interacting with students, research participants, and employees.

It seems that the examples of strengths-based approaches from disciplines such as social work relate most closely to chronic diseases. Nurses can apply them across all types of nursing care throughout the lifespan. In an emergency scenario, the ABCs of airway, breathing, and circulation are well ingrained and are a very quick example of checking off strengths. In the current COVID-19 pandemic, a strengths-based approach in nursing has emerged as everyone strives to adapt to their circumstances, accessing resources as they are able and as they are available, and in many cases developing resilience and self-reliance in their attempt to cope.

To effect large-scale change, we need to engage nursing leaders from all practice areas, academia, and research, and we also must include both seasoned and novice nurses in our effort to design a pathway for incorporating strengths-based care into the nursing process. Nurses can band together to make this happen in a large and meaningful way. It will also be important to involve the public in discussion and plans for strengths-based nursing care, as they have a vested interest and need to be represented.

Hammond notes that fundamental change needs a set of guiding principles that are based on people's attitudes and values that shape and influence the way they care for others. “A true strengths-based approach is one that governs the way we think about people and the way we go about our work on a daily basis for all actions and interactions.”7

The endgame

After only a few hours, the long-term-care facility breakout bandits were found, perfectly fine with the car stuck in the mud. Imagine them leaning on the hood of the car in the sunshine, legs crossed, all James Dean-like, calmly waiting for someone to arrive. In a strengths-based world, these two would be celebrated for their energy, gumption, ambition, and brilliance. The nursing staff would recognize their strengths and devise a plan with the two adventurers to see how that kind of energy could be put to effective use going forward.

Clearly these two residents were unique. A large-scale change toward a strengths-based approach will take more than a few bandits to lead the charge. We will need strong nursing leadership and collaboration to mobilize and formalize this change. If we embed strengths-based care into every aspect of the well-established nursing process, create tools, and support nurses in making it the norm, we can have a large-scale impact with the person truly at the center.

The long-term-care facility breakout bandits seized the opportunity to break free from the system. In the moment, they squashed the status quo. That is what it will take for nurses to integrate strengths-based care and make this approach instinctive in the critical-thinking process of nursing care. Nurses have a long-standing history of coming together to bring about change. Embracing a strengths-based approach will take significant strength and coordination. The wealth of philosophies, models, research, and experience are the strengths that form the foundation for a collaborative approach to formalize a strengths-based approach in nursing.


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holistic care; nursing care; strengths-based care

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