1. Fulton, Janet S. PhD, RN, ACNS-BC, ANEF, FAAN

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Nursing care procedures can be unpleasant, painful, and embarrassing for patients. Nurses, although proficient in procedural tasks, are generally unenthusiastic about performing unpleasant procedures. In an emergent or critical situation, there is no hesitation. In the day-to-day work of caring for patients, nurses have mixed feelings about invasive procedures. An experienced nurse recently noted feeling bad about inserting a nasogastric tube because of a personal attachment to a favorite patient. Not surprisingly, the greater the emotional-social attachment between nurse and patient, the more challenging it can be for the nurse to perform procedures that cause patient discomfort. Many situations demand that nurses do things "to" patients. Doing to implies care is centered on the provider's goals and external to the patient, whereas doing with shifts the perspective to one of mutuality, the nurse and patient in partnership.


Patient-centered care came into the healthcare lexicon in the last 2 decades as an important initiative for reframing clinical care delivery. In 2001, the Institute of Medicine emphasized the need for providing care that is respectful and responsive to patient preferences, values, and needs.1 Nursing responded with the Quality and Safety Education for Nurses initiative, which called for making patients full partners in care.2 The Quality and Safety Education for Nurses initiative generated a framework for clinical practice based on knowledge, skills, and attitudes as the necessary elements for delivery of competent person-centered care. Schools of nursing and clinical care settings have adopted the framework, and there appears to be general acceptance of person-centered care in nursing and healthcare delivery.


One challenge to actually achieving person-centered care in the clinical setting is the dominance of care systems organized to deliver disease care in a biomedical model where patients are identified as broken body parts-renal failure, pulmonary insufficiency, cognitive impairment. The emphasis is on deficits, and the focus is on abnormal, dysfunctional, or pathological findings. Deficit thinking fosters depersonalized care. In deficit care, patients and families are faced with a series of choices aimed at fixing the broken body parts-medications, treatments, surgeries. Where deficit thinking dominates, personhood becomes background and is easily ignored. Individual and family strengths are overlooked.


In an important new work, Gottlieb3 introduces strengths-based nursing care. Strengths-based care is an orientation to practice that places patients at the center of their own care, consistent with person-centered care, but goes further to include empowering persons to achieve their health goals. Empowered patients take responsibility for their health, recovery, and healing. Empowering patients means establishing meaningful nurse-patient relationships that are able to deal with challenges by building on biological, intrapersonal and interpersonal, and social strength. A strengths-based nursing approach focuses on personhood and aims to assist patients in finding new meaning in their lives. Nurses assist individuals to function as a whole integrated person. Strengths-based nursing is a commitment to supporting a person's continued development by emphasizing positive qualities involved in happiness, well-being, quality of life, and personal growth. A person's unique strengths exist in the presence of disease, and at a time of health challenges, it matters that nurses know and work within the context of strengths to assist each person to achieve their highest level of wellness.


Wellness has no universal definition in nursing practice. It has been presented as 1 of 2 choices in a dichotomous view of health-a person is well or not well, and not well implies the presence of disease. Wellness has also been considered an ideal state and used as an anchor when viewing health as a continuum involving progressively declining states culminating in death. For purposes of codifying provider services, wellness is a label for type of service-a wellness visit-where the purpose of the visit is to validate normal growth and development and to provide preventive care such as screenings or immunizations. What these notions of wellness all have in common is that they distinguish between nondisease and disease.


In contrast, wellness in the context of personhood can be viewed as being the meaning a person brings to his/her life experience, and yes, that life experience may include living with and managing disease. The presence of disease is not the same as not experiencing wellness. Nurses practicing from a strengths-based frame support patients in finding and redefining meaning regardless of disease. Through this lens, a critically ill hospitalized patient has wellness the same as any other person, diseased or not.


How might a strengths-based wellness approach have helped the nurse with inserting a nasogastric in a favorite patient? The patient, recovering from multiple setbacks related to a transplant, had a goal of returning home to continue mothering her 2 adolescent children. Mothering her children gave her life meaning and defined her as well. She had endured much pain and discomfort, and using a strengths-based approach, the nurse helped the patient reflect on her great strengths in endurance for the purpose of achieving her goal. With the patient in agreement, the nurse became a partner in a mutually agreed-upon unpleasant procedure. The procedure was not something the nurse did to the patient; it was done with the patient in partnership. By engaging the patient's strengths and honoring her personhood, the nurse became a collaborator in achieving the patient's goal. Instead of causing pain and suffering, the nurse viewed the procedure as supportive and patient driven.


With the increased calls for all advanced practice nurses to be prepared to deliver care "from wellness through illness," it is timely to reflect on our definition of wellness. Wellness is not the absence of disease, a clinical setting, or a type of service. Wellness is defined by an individual[horizontal ellipsis] it resides in his/her personhood.




1. Institute of Medicine. Crossing the Quality Chasm: A New Health Care System for the 21st Century. Washington, DC: National Academies Press; 2001. [Context Link]


2. Cronenwett L, Sherwood G, Pohl J, et al. Quality and safety education for advanced nursing practice. Nurs Outlook. 2009; 57: 338-348. [Context Link]


3. Gottlieb LN. Strengths-Based Nursing Care. New York, NY: Springer Publishing Company; 2013. [Context Link]