Angeles University Foundation

Angeles City
Graduate School

Ernestine Wiedenbach’s

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
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 one’s 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 Wiedenbach’s Theory
• Identify and analyze the Helping Art of Clinical Nursing Theory
• Identify the strengths, weaknesses and limitations of Wiedenbach’s theory
• Relate Wiedenbach’s theory to the present day nursing practice
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 sister’s 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
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 nurse’s 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.
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 patient’s 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 Organization’s 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)
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) 
Wiedenbach asserted that there are four elements to clinical nursing:

Philosophy

Philosophy, an attitude toward life and reality that evolves from each nurse’s 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 individual’s ned for help
2. Ministration of help needed
3. Validation that the help given was indeed the help needed.
Practice

Overt action, directed by disciplines, thoughts and feelings toward meeting the pa-
tient’s 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 nurse’s 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
which the nurse’s 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 nurse’s 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 nurse’s 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 patient’s 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 patient’s 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 patient’s need for help has been met as a result of the
help given.
Wiedenbach identified one other element in practice that indirectly affects the nurse’s
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 nurse’s conscious responses to specifics in the pa-
tient’s immediate situation.
- Wiedenbach, 1964

- the art of clinical nursing consists of:

1. The nurse’s understanding of the patient’s condition, situation and need.
2. The nurse’s internal goals and external actions that are meant to enhance patient
capability through appropriate nursing care.
3. The nurse’s activities directed toward improvement of the patient’s condition
through artful utilisation of the medical plan of care
4. The nurse’s 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 patient’s 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 nurse’s immediate perception of
patient’s behaviour, what they say and do and how they appear. A reactionary act
however adds the dimension of emotional feelings of the nurse in response to the pa-
tient’s behaviour and how the nurse had hoped or expected the patient’s 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 patient’s 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 individual’s
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.
Prescriptive Theory

Within Wiedenbach’s 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

Wiedenbach’s 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 isn’t 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
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.

Wiedenbach’s 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)
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 Wiedenbach’s 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.
IV. Theory Derivation

Wiedenbach’s Theory can be simplified by a mother who saw her daughter fall down
from a bicycle. The mothers perceives her daughter’s 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