Running head: THEORETICAL IMPLICATIONS 1

Theoretical Implications: Advocacy and the Helping Art of Nursing

Laura Snyder

SUNY Polytech Institute

NUR-500: Theoretical Foundations for Nursing Practice

November 2018
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Theoretical Implications: Advocacy and the Helping Art of Nursing

“To formulate one’s central purpose in nursing is a soul-searching experience”

(Wiedenbach, as cited in Parker et al., 2001). This simple, yet powerful statement provides

much insight to the perspective mindset of Ernestine Wiedenbach, an inspirational nursing

theorist of the 20th century. In the rapidly evolving health care world that exists today,

understanding, respecting, and deciphering the work of nursing ancestors such as Wiedenbach is

of critical importance. More than ever, nurses must define and uphold their purpose in practice

in order to effectively advocate for excellent patient care. Ernestine Wiedenbach’s established

theory regarding the helping art of clinical nursing is a key component of her professional legacy

and remains influential in the concept of nursing advocacy today.

Theorist

Personal Information

Ernestine Wiedenbach, born on August 18th, 1900, grew up in Hamburg, Germany

with her American mother and German father. When she was nine years old, the family

migrated to America, and Ernestine travelled to many different states as she completed her

education. Her prosperous family strongly supported her desire for learning as she earned her

Bachelor of Arts from Wellesley College in 1922. However, they were averse to her passion for

continued education when Wiedenbach announced her intent to pursue nursing, as this career

was associated with a lower socioeconomic class at that time. Motivated and self-sufficient,

Ernestine overruled her parents’ reluctance to accept her decision and enrolled in nursing school.

Shortly after beginning her studies, Wiedenbach evolved a leader in advocating for improved

education, a position that ultimately resulted in her dismissal from the program. Nonetheless,

certain faculty and friends who immediately recognized her powerful potential helped Ernestine
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in securing a place in a different program, and she graduated from John Hopkins School of

Nursing in 1925 (Peptiprin, 2016).

Within the first nine years of her nursing career, Wiedenbach achieved her Master of

Arts in 1934 and began writing professionally for the American Journal of Nursing (AJN).

Working here, Wiedenbach’s professional network expanded tremendously, as she developed

relationships with many national nursing and health care leaders. Instrumental in student and

military nursing recruitment, Ernestine remained with the AJN until after World War II. After

returning to clinical practice, Wiedenbach invested in her passion for maternal-child nursing,

eventually sharing all her experiences and knowledge through her work as faculty at Yale

University. Even after her retirement in 1966, Ernestine persevered in her passion for nursing

care and development. Through participation in educational conferences and informal seminars,

Wiedenbach worked alongside her fellow friends and nursing theorists in becoming an advocate

for both the local community and national nursing practice. As she developed her professional

nursing theories, she recognized her gift for writing and assisted in the transcription of health

care books for the visually impaired. Maintaining her independent personality, Ernestine sought

to help others even in her older years with limited mobility. Although she was forced to accept

the very nursing care she promoted after an injury from hurricane home destruction, Wiedenbach

spent the remaining years of her life in a retirement village, where she eventually died in 1998

(Parker et al., 2001).

Theory

Major Characteristics

Published in text in 1964, Clinical Nursing: A Helping Art described one of

Wiedenbach’s most influential conceptual nursing models (Peptiprin, 2016). The major
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elements of this profound theory include purpose, mastery in understanding and skill,

relationship development, passion for improvement, and service (“Clinical nursing: a helping

art,” 1964). Wiedenbach focused on the concept of purpose in many of her theories, especially

in the helping art, and discusses in detail the importance of its identification. Parker et al. (2001)

records an interview where Ernestine asked her students to define their purpose in nursing. After

describing the blank look present on their faces, she revealed that they would respond with a

vague, general answer. “‘It’s just to take care of people…of those who need care.’” In reply,

Ernestine stated “that’s not a real purpose in nursing. It is your commitment which specifies

what you want to accomplish through your actions” (as cited in Parker et al., 2001, p.71). Thus,

a critical component of this theory is the specific purpose for that individual nurse. Wiedenbach

defines her personal purpose as “to motivate the individual and/or facilitate his efforts to

overcome the obstacles that may now as well later, interfere with his ability to respond capably

to the demands made of him by the realities in his situation” (as cited in Parker et al., 2001,

p.72).

Wiedenbach established that once purpose is identified, the nurse determines how to

fulfill that individualized purpose through mastering her skills and knowledge. Once the nurse

understands the scenario and the tasks at hand, she must possess the ability to create and

maintain a relationship with both the patient and the health care team. Any tasks that the nurse

may need to perform, no matter how excellent her skill level, will be better achieved when there

are healthy, flourishing relationships with all of those who are involved. The nurse then utilizes

these resources to help advance her knowledge and provide the highest quality care to the

patient. Wiedenbach consistently attempted to lead by example regarding this characteristic of

her theory. By always showing interest in advancing her knowledge, she hoped to inspire others
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to do the same. Of course, this ties in with the last major component of the theory, which

focused on serving others rather than prioritizing the nurse’s personal needs. Implementing these

five concepts of purpose, excellence, teamwork, improvement and modesty in a professional and

consistent manner creates the true art of nursing (Parker et al., 2001) (Peptiprin, 2016).

In order to provide visualization to others of her helping art theory, Ernestine published

an illustration of concentric circles explaining the components of her philosophy. Wiedenbach

describes these circles beginning with the “core” circle, which she defines as the “experiencing

individual” (as cited in Parker, 2001, p.76). The surrounding circles are direct service, the

sequelae of that service (i.e. coordination, consultation and collaboration), nursing activities (i.e.

education, administration, and organization) and finally research (i.e. publication and advanced

study). Ernestine writes that the art of nursing most reveals itself in the second circle, direct

service. Its three elements, according to the theorist, include “identification of the individual’s

experienced need for help, ministration of help needed, and validation that the help provided

fulfilled its purpose” (as cited in Parker, 2001, p.76). Ernestine writes that the patient’s

recognition of his individualized “appearance, manner…behavior…and…the nurse’s expectation

of him” is critical in the art of nursing. The past experiences and perceptions of both the patient

and nurse are implicit in the identification process. Deliberate action of this concept is focused

on determining the following: the presence of a patient’s pain or lack of understanding, the cause

behind this deficiency, the necessity to cure this discomfort or provide knowledge, and a

detection of a “need-for-help.” This “need-for-help” is a determination of whether the patient can

meet his needs without the assistance of nursing intervention (as cited in Parker, 2001).

Ministration, the second unit of direct service, involves the nurse’s provision of help, the

patient’s willingness to accept that assistance and the nurse’s ability to utilize a variety of
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resources (i.e. experience, values, other members of the health care team) in treatment. These

resources are proved effective in the final segment of direct service, validation. Ernestine

describes validation as a process evaluated by the response from the patient himself (verbal and

non-verbal behavior) and the nurse’s assessment of the resolution (as cited in Parker, 2001).

Theory Usefulness

Duran & Cetinkaya-Uslusoy (2015) state the critical need for nurses to understand the

meaning of nursing as an art and follow Wiedenbach’s principles as they treat patients. They

refer to an evolving “climate of evidence-based practice” and reveal the current attitude of

nursing students regarding the implementation of nursing as a clinical art (p. 309). By

examining a study performed in a nursing school in Turkey, the authors discuss influences of

Wiedenbach’s theory and the students’ understandings of nursing as a helping art under the three

main categories of communication, professional standards, and application of expertise. Duran

& Cetinkaya-Uslusoy provide background to their research by quoting Ernestine’s philosophy

that “the nurse is a functioning, human being who acts, thinks, and feels” (p. 309). While most

literature emphasizes the art of nursing in relation to its common aesthetic principles (i.e.

communication, creativity, etc.), this study highlights that nursing students also include the

provision of safe, effective and sincere nursing care as part of nursing’s helping art. The authors

state that these students recognized that the art of nursing mainly centers on defined, artful and

purposeful actions by the nurse. Ernestine’s theory provides the backbone to this ideology, as it

fundamentally affirms the specific and directed actions by the nurse in effort to truly understand

each patient’s needs, work in harmony with both the healthcare team and patient and create a

carefully formulated plan to establish an individualized goal (Nickel, Gesse, & MacLaren, 1992).
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Jenner (1997) also utilizes Wiedenbach’s theory in an analytical examination of the

common acceptation of nursing as both an art and a science. Through a detailed inspection of

the works of several different nursing authors, Jenner focuses on the genuine meaning of the art

of nursing and intertwines Ernestine’s philosophy into her findings. Her research stresses that

many writers emphasize the beauty and representation that nursing provides, particularly in the

form by which nurses advocate for their patients. However, Jenner associates with

Wiedenbach’s ideology, suggesting that this concept involves much more in respect to intent and

operation. She concludes that although current literature provides a myriad of varying

definitions for the art of nursing, it universally refers to “the intentional creative use of oneself,

based upon skill and expertise, to transmit emotion and meaning to another. It is a process that is

subjective and requires interpretation, sensitivity, imagination, and active participation” (pp.10-

11).

Concept

Major Characteristics

The concept of advocacy has long been established as an essential component of nursing.

Vaartio, Leino-Kilpi, Salanterä, & Suominen (2006) define advocacy as an “integral part of the

nurse’s efforts to promote and safeguard the well-being and interests of his/her patients or clients

by ensuring that they are aware of their rights and have access to information for informed

decisions” (p.282). Because of the variety of ways in which nurses can advocate for their

patients, the authors write that it is necessary to understand the exact meaning of advocacy, the

method of its execution, and the effect it has upon the patient and nurse experience. Vaartio et al.

(2006) explain that advocacy extends beyond a process between the nurse and patient but can

also be used as a tool to evaluate the practice of excellent nursing care. Advocacy aids in the
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molding of what health or illness means to both the nurse and the patient. Establishing the nurse

as “a constant observer of the patient’s condition,” advocacy allows the nurse to assess the

patients’ feelings, recognize their needs, and support them in whatever decision or treatment they

determine as a priority (p.283). By acting as the voice for the patient, the nurse not only

validates and supports the patient’s cause but provides protection from the anxiety and distress

that often befalls the patient in medical need. The authors recognize that advocacy implies a

moral and ethical responsibility of the nurse to perform safely and effectively in their practice

(Vaartio et al., 2006).

Hanks (2013) testifies to the importance of advocacy and explains this concept as one

that directly influences the way by which nurses uphold their profession as a respected and

admirable career. In addition to the care provided for individual patients, there is an expanding

focus on family, patient groups, and society in which nursing advocacy plays an immense role.

In his research, Hanks explores the history of nursing advocacy, tracing it back to Florence

Nightingale’s writings. Deciphering the works of numerous other nursing theorists from the 20th

century, Hanks clarifies essential characteristics of advocacy and emphasizes its role in

exceptional nursing care.

Just as each patient requires personalized care, Hanks (2013) affirms that advocacy

mandates an individual understanding of both the patient and the nurse. Curtin (as cited in

Hanks, 2013), states that this concept is “the basis of all other nursing activities,” and that by

providing the patient the necessary knowledge to decide subsequent actions, the nurse creates an

educated, supportive environment, customized to that specific patient’s needs (p.164). Hanks

also stresses the importance of respecting the patient as a human being. The nurse holds a moral

obligation in assisting her patients, particularly the defenseless and ill-informed in gaining an
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independent state. Valuing the patients’ thoughts and desires requires the nurse to remain self-

aware and unbiased as she provides care, comfort, and understanding (Hanks, 2013).

Utility

Kalaitzidis & Jewell (2015) question the necessity of advocacy by exploring the presence

of stated requirements for nurses to act as advocates in different professional nursing

associations. In their research, the authors examine the professional codes established by various

associations including the International Council of Nurses (ICN), American Nurses Association

(ANA), Nursing and Midwifery Council (NMC), National Competency Standards (NCS), Code

of Professional Conduct, Code of Professional Ethics and the nursing associations of both Japan

and Australia. While the presence of advocacy is explicitly stated in three provisions of the

Australian Nursing and Midwifery Council, it is only specified twice by the ANA and NCS, once

by the Codes of Professional Conduct and Ethics, ICN, NMC and not mentioned at all in the

Japanese Code of Ethics. Because of this varying identification, Kalaitzidis & Jewell provide a

critical analysis of whether advocacy is a clearly understood and determined role of the nurse.

In the basic English language, advocacy primarily refers to the idea of one speaking for

another, whether it be for another person or for a certain policy. In the specific field of nursing,

these two differing subjects of advocacy are the patient or a health care policy. Kalaitzidis &

Jewell (2015) refer to this idea as “patient advocacy” verses “policy advocacy” (p.309).

However, Mosby’s Medical, Nursing, and Allied Health Dictionary (as cited in Kalaitzidis &

Jewell, 2015) present a third definition, which specifies a stark contrast to this ideal English

understanding. Rather than advocacy referring to a nurse expressing on behalf, or for the patient,

this medical definition involves the nurse speaking to the patient, providing the knowledge

necessary for the patient to make an informed and educated decision. Consequently, Kalaitzidis
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& Jewell state that “information provision” exists as a third definition of advocacy. The authors

go on to explore a variety of peer-reviewed nursing literature in attempt to find clarity and role of

advocacy in nursing. Although most research associates with one or two of the previously stated

definitions, Kalaitzidis & Jewell conclude that the ambiguity of advocacy as a definite role of the

nurse illuminates the need for clarity.

When analyzing the significance of advocacy, Pine (2014) brings to attention another

essential factor regarding the challenges of health care faced in impoverished countries. In her

research, Pine exposes the harsh realities of the hardships that the people of Honduras regularly

face, as the corporate health care system ultimately prioritizes monetary gain and industrial profit

over patient care. Advocacy proves itself essential in providing safe nursing care, as the nurses

in this Central American community face an entirely different battle in addition to illness and

disaster. Pine writes that soon after employment, the nurses who work at these hospitals realize

that advocating for their patients “meant not just fighting for better hospital conditions; it meant

actively opposing a coup-installed government that was directly and violently harming their

patients” (p.16).

Pine (2014) emphasizes that nurses are responsible to utilize any and every resource in

providing excellent nursing care. Most of the community in Honduras who are seeking medical

attention are unable to purchase even the most basic medications and the nursing staff must offer

other solutions to adequately care for these patients. Because the impoverished possess such a

fear of the corrupt government, the nursing staff must often act as their voice in relaying illness,

discomfort, and needs. In lower socioeconomic areas where resources are limited, nursing

advocacy develops into a life-or-death circumstance for both the patient and the nurse. The
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provision of care is a right worth fighting for, and Pine strongly asserts that understanding this

concept of serving other is critical to the implementation of advocacy.

Relationship

Understanding the philosophies of brilliant nursing theorists such as Ernestine

Wiedenbach is significant in respecting, valuing and implementing the history of nursing. In a

similar manner, the identification of critical core concepts such as advocacy is instrumental in

maintaining and advancing the nursing profession. A comparative analysis of Wiedenbach’s

helping art theory with the concept of advocacy proves advantageous in the identification of

similarities and differences.

Commonalities

Undoubtedly, the concept of advocacy plays an essential role in nursing practice and can

relate to Wiedenbach’s theory of helping art in numerous ways. Ernestine’s theory contains

multiple shared implications with the components of advocacy including responsibility,

professionalism, deliberate action, purpose and the pursuit of excellence.

Responsibility. Wiedenbach’s helping art theory possesses a strong connotation with

nursing responsibility. Repeatedly in her work, Ernestine establishes that the nurse is the driving

force behind every step of the patient recovery. The nurse cannot simply assess a problem or

need in her patient with intervention, but instead remains morally obligated to actively seek out

remedial measures. This ties together with the concept of advocacy. At its core, advocacy

promotes caring for the patient by meeting apparent needs. Vaartio, Leino-Kilpi, Salanterä, &

Suominen (2006) state that the foundation of advocacy stands upon nursing “professional

responsibility for ethical conduct” (p.283).

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Goal orientation. Ernestine was passionate that nursing care not only includes a

decisive action, but possesses a defined pursuit of a specific goal. In her book, she discusses that

a nurse should always keep her goals in mind when treating a patient, then direct her behavior

“to obtain them and accepts accountability not only for what she does but for the outcome of her

act as well” (as cited by Parker et al., 2001). This type of focused nursing care can be achieved

by applying the concept of advocacy. After establishing the end goal of care with the patient, the

nurse focuses all her interventions based on ensuring those goals occur. By advocating for the

patient, the nurse can perform excellent care and pursue the pre-established goals.

Professionalism. Intent on maintaining the reputation of nursing as a profession,

Ernestine’s theory necessitates the nurse to treat her patients with dignity, respect, and expertise.

Upholding the identity as a professional caretaker, the nurse must also interact with coworkers,

patients, families and other members of the health care team with dignity and refinement.

Effectively advocating for patient care is best carried out by the utilization of available resources,

often involving the interdisciplinary team. A nurse who consistently demonstrates

professionalism with her coworkers and team members will achieve better success when

attempting to advocate for her patients.

Deliberate action. Ernestine identified three specific directions that deliberate nursing

action can venture, namely one that is “mutually understood and agreed upon, patient-directed,

[or] nurse-directed” (as cited in Parker, 2001, p.73). It requires a conscious, determined

intervention from the nurse in order to achieve many desired outcomes. For example, the nurse

and patient may differ in their wishes for end-of-life care, but it is not the job of the nurse to

convince the patient to act according to what the nurse believes is best. Rather, after providing

thorough education and applying therapeutic listening, the nurse must act according to what the
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patient chooses for his/her life. By doing so, she has effectively informed the patient of available

options and assessed patient understanding. Thus, she can safely determine a course of action

and effectively advocate for her patient.

Pursuit of excellence. Having led by her own example, Wiedenbach was passionate in

her pursuit of education. Mastery of skill composed a major portion of her helping art theory,

and Ernestine believed that the best patient care revolved around the nurse’s ability to stay

current and provide the safest practice. This correlates strongly in nursing advocacy. Nurses

with a higher understanding will educate their patients thoroughly and demonstrate most

effective, evidence-based practice, and those with mastery of skill in practice will ensure

thorough assessments and effective, safe interventions.

Uniqueness

Despite the numerous similarities between the theory of nursing as an art and the concept

of advocacy, several differences remain. The unique characteristics that present dissimilarly

between these two ideologies include nursing approach, patient dependency, individual strengths

and weakness, patient response, and established outcomes.

Nursing Approach. Although both Wiedenbach’s theory and advocacy maintain an

attitude of professionalism between the nurse and the patient, nursing approach differs in the

level of empathy with the patient. While Ernestine’s model focuses on establishing the patient’s

understanding of their own “need for help,” advocacy often involves a certain assumption about

the patient’s level of understanding. For example, imagine a patient afflicted with frequent

exacerbations of congestive heart failure due to poor diet and lack of compliance. Wiedenbach’s

theory promotes a high amount of patient education and careful assessment of the patient’s self-

recognition and ability. Applying the concept of advocacy, however, the nurse may request for a
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family member to take over medication delivery or remove all the salt packets from the patient’s

dinner tray. Although empathy is heavily intertwined with the concept of advocacy, the nurse

seeks immediate and safe care that is mostly acutely influential on the patient outcome.

Patient dependency. The helping art of nursing heavily depends on effective

communication between the patient and nurse. This proves challenging when interacting with an

infant, non-verbal or aphasic patient, or one that exists in a vegetative state. Although the nurse

can make an educated guess at the patients desires and needs, much of Wiedenbach’s theory (i.e.

establishment of “need-for-help” and ministration) depends on communication from the patient.

In contrast, a major component of advocacy involves the nursing principle of assuming the

patient position. For example, when dealing with an intubated and paralyzed patient, the nurse

relies on non-verbal communication and personal experience in order to effectively advocate for

this patient. By talking with the family, assessing external signs of pain or discomfort, vigilantly

reviewing labs and fluid balance values, etc., the nurse can easily advocate for her patient

independently from the patient’s communication ability.

Individual strengths and weaknesses. In order to effectively advocate in nursing care,

the nurse must be able to connect in some way with the patient. Her facial expressions, body

language, mannerisms, conversations with others, etc. determine the patient’s response and

overall relationship between them. Perhaps personal connection and carefree conversation is an

area where the nurse lacks confidence. This deficiency will strongly impede her ability to speak

for or to the patient regarding any health care decisions, thereby hindering her success in

advocating for the patient’s wants and needs. However, utilizing Ernestine’s principle involves

the patient at the core center. If the nurse perceives a poor relationship or senses mistrust from

the patient, she can attempt to remedy the situation or offer a different health care provider. An
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essential component of the helping art is maintaining professional relationships and developing

excellent rapport with those under her care. If this cannot be achieved, the nurse identifies that

“need-for-help” that is not being met and will arrange a new solution.

Patient response. Patient advocacy involves frequent reassessment of the circumstance

and the patient understanding. If the patient refuses to accept the situation or is dissatisfied with

the outcome, advocacy involves independent interventions in guiding the patient towards

acceptance. In contrast, the helping art involves the utilization of multiple resources to provide

effective education. Depending on the patients response to a situation, Wiedenbach’s theory

promotes reassessment of the patient’s “need for help.”

Established outcomes. The patient’s attitude regarding a negative outcome will also

differ between the application of the advocacy concept and Ernestine’s ideology. Although both

principles are goal-oriented to the patient’s best interest, validation is more of a major

component of Ernestine’s theory. If there is a negative outcome, the helping art of nursing

promotes the nurse adapting to the circumstance and working with the patient to establish a new

goal. Advocacy, in contrast, suggest that the nurse reinforce realistic expectations with the

patient and provide essential information regarding the patient’s options for best quality of care.

Although the nurse may acknowledge and validate the patient’s emotions and support their goals,

the nurse also must promote what is in the patient’s best interest.

Application

Wiedenbach’s theory of nursing as a helping art and the concept of advocacy clearly have

many similarities as well as contrasting features. In addition to their relationship to one another,

these ideologies also relate to practice, education and leadership in several ways. Despite the
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thorough establishment of these features, relevant questions remain that further research can

explore.

Relevance

Although written years ago, the philosophy and principles embedded in Wiedenbach’s theory

remain incredibly relevant in current culture. Advocacy, as evidenced by previously stated

literature, remains a term that continues to evolve and influence the practices of nurses today.

Practice. Wiedenbach focused on the artful form of interweaving the nurse’s and

patient’s goals. Her theory can undoubtedly influence nursing practice in numerous ways,

including nurse-patient relationships, application of resources, direct patient care and evaluation

of therapy. Jenner (1997) describes in detail the artful beauty of a therapeutic relationship

between the nurse and patient. She points out that as the very nature of art is “creative,

interpretative, evocative, communal, subjective, and expressive,” so must the nurse mirror these

principles in the treatment and care of her patients. In a similar manner, Duran & Cetinkaya-

Uslusoy (2015) support this implication to nursing practice by the process of advocacy. The

authors boldly state that certain artistic components of nursing simply cannot be learned through

reading or lecture. Jenner (as cited in Duran & Cetinkaya-Uslusoy, 2015) states that at its core,

the art of nursing “contrasts with skill, artifice, and craft in putting stress upon something more,

in employing a personal, analyzable creative force that transits and raises the art or product

beyond a skill, artifice or craft…” (p.309).

As current resources, procedures, medications, and therapies develop, a nurse must

develop and maintain a certain level of rapport with the patient, applying this artful form of

therapeutic listening and involving the patient’s goals and desires in the plan of care. Utilizing

both the patient’s and nurse’s educated understanding of the situation, the nurse must adequately
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and effectively advocate for her patients’ needs. Just as Vaartio, Leino-Kilpi, Salanterä, &

Suominen (2006), write, a critical component of patient advocacy involves the nurse’s

responsibility “to promote and safeguard the well-being and interests of his/her patients or clients

by ensuring that they are aware of their rights and have access to information for informed

decisions” (p.282).

Education. Parker et al. (2001) reveals that Wiedenbach consistently reminded both her

nursing students and coworkers of the necessity to re-identify one’s purpose in nursing.

Wiedenbach believed that staying focused on self-improvement provided a safe way to recognize

reality, promote change, and challenge self-growth. Her passion for self-improvement and urges

for nurses to accept change indisputably applies to today’s nursing education (Parker et al.,

2001). Jenner (1997) attests to this impact on education, explaining that the very process of

adaption and evolution of nursing practice is part of its artful form.

Similarly, nursing advocacy holds powerful implications to current education in the 21st

century. Duran & Cetinkaya-Uslusoy (2015) testify that now, more than ever before, nurses

possess incredible influence in utilizing advocacy to advance nursing knowledge. The authors

write that the two main concepts of “imagination and improvisation” are critical in nursing care

(p.10). By implementing these skills, nurses can efficiently empathize with the experiences of

the patient. These tools are forceful and effective; there is a call to help train and educate new

nurses in altering care based on best practice (Duran & Cetinkaya-Uslusoy, 2015).

Leadership. Wiedenbach’s theory profoundly influenced the cultural view of nursing,

patient care, and the interprofessional health care team. Nursing leadership is most effectively

demonstrated when nurses recognize the potential their actions have upon these factors. Dewey

(2016) lists some of the ways in which nurses can lead, developing
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definitions of levels of patient independence, rehabilitation strategies, the role of

spirituality in recovery, the importance of family and friends, the different levels of
compassion, the actual process of on-the-spot decision making, the impact of stress, the
definition of different levels of pain, and strategies for how to help patients cope with
difficult news (p.2).

Nurses can also use their role as leaders in the health care team to safely advocate for their

patients, make changes in the patient’s health care plan, and help mentor other members of the

health care team (nurses, resident, respiratory therapist, etc.) in how to better their care. Duran &

Cetinkaya-Uslusoy (2015) state that when nurses rely on their past experiences and adapt their

practice to comply with the patient’s value and needs for care, they set an example of growth and

model the true art of nursing to those around them.

Research Direction

The exploration of the Ernestine’s theory of nursing as a helping art and implications of

the concept of advocacy raises several questions to explore by nursing research. In reference to

education in nursing school, there is a lack of information available regarding pre-graduate

learning of current patient advocacy in relation to the political and social stressors of today.

Hanks (2013) urges nursing schools to begin educating nurses from the beginning of their careers

regarding the exploration of patient advocacy, specifically in reference to social injustices and

advocacy. “In addition to teaching social advocacy to nurses and nursing students, clear

evaluation of the education provided is needed. No longer can it be assumed that the nurse is

somehow magically prepared to effectively perform the social advocate role” (Hanks, 2013,

p.170).

Furthermore, new graduate nurses frequently lack the confidence to share current,

evidence-based practices with their fellow colleagues. Research could be directed to the mental

and social barriers that new nurses face when trying to implement change in nursing care in
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attempt to better advocate for their patients. Hussein, Everett, Ramjan, Hu, & Salamonson (2017)

discuss the increasing level of support required for the graduate nurses of today, especially

considering the increasing complexity of high-acuity cases and heavy workload. The authors

support the need for further research to examine new graduate experiences and their ability to

adapt to change. “Understanding new graduate nurses’ experiences and their unmet needs during

their first year of practice will enable nurse managers, educators and nurses to better support new

graduate nurses and promote confidence and competence to practice within their scope”

(Hussein, Everett, Ramjan, Hu, & Salamonson, 2017, p.9).

Two other questions the nursing research could address involve the implantation of

evidence-based practice (EBP) and nursing approach to patient-defined goals. Effectively

applying the helping art of nursing in promoting adaption, change and growth to best advocate

for excellent patient care is essential to advance nursing practice. Zimmerman (2017) reveals

that the roots of EBP are embedded in quality enhancement, “focusing on accountability,

financial decisions, and an increased knowledge base of medicine…it is necessary for

institutions to collaborate with policy makers, researchers, and clinicians to establish a culture

supportive of EBP” (p.42). In a similar manner, nurses must remain open to the idea of more

patient involvement in their treatment plan and goals. Kalaitzidis & Jewell (2015) attest to this

need, revealing the gap in current literature regarding patient-defined goals as they relate to

nursing advocacy.

Conclusion

The examination and analysis of the work by renowned nursing theorists such as

Ernestine Wiedenbach proves immensely influential in nursing practice. By the identification

and appreciation of critical nursing concepts such as advocacy, one can compare the central
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features of older theories with current nursing principles. Exploring Wiedenbach’s influences

and and identifying key components of her theory of nursing as a helping art provides numerous

theoretical implications for safe, efficient and succesful patient advocacy.

THEORETICAL IMPLICATIONS 21

References

Clinical nursing. A helping art. (1964). Journal of the American Association of Nurse

Anesthetists, 32(6), 401-402. Retrieved from https://sunypoly-illiad-

oclcorg.sunypoly.idm.oclc.org/illiad/illiad.dll?Action=10&Form=75&Value=97216

Dewey, J. (2016). Nursing theory. Salem Press Encyclopedia of Health. Retrieved from

http://sunypoly.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?

direct=true&db=ers&AN=113931268&site=eds-live

Duran, E.T. & Cetinkaya-Uslusoy, E. (2015). Opinions of nursing students on the art of nursing:

A qualitative study. International Journal of Caring Sciences, 8(2), 308-316. Retrieved

from http://www.internationaljournalofcaringsciences.org/docs/8_duran.pdf

Hanks, R. (2013). Social advocacy: A call for nursing action. Pastoral Psychology, 62(2), 163–

173. Retrieved from https://doi-org.sunypoly.idm.oclc.org/10.1007/s11089-011-0404-1

Jenner, C. A. (1997). The art of nursing: A concept analysis. Nursing Forum, 32(4), 5-11.

doi:http://dx.doi.org.sunypoly.idm.oclc.org/10.1111/j.1744-6198.1997.tb00970.x

Kalaitzidis, E., & Jewell, P. (2015). The concept of advocacy in nursing: A critical analysis. The

Health Care Manager, 34(4), 308–315. Retrieved from http://sunypoly.idm.oclc.org

/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2015-

49442-006&site=eds-live

Nickel S, Gesse T, & MacLaren A. (1992). Ernestine Wiedenbach: her professional legacy.

Journal of Nurse-Midwifery, 37(3), 161–167. Retrieved from http://sunypoly.idm.oclc.

org/login?url=http://search.ebscohost.com/login.aspx?

direct=true&db=rzh&AN=107490594&site=eds-live
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Hussein,R., Everett,B., Ramjan,L.M., Hu,W., & Salamonson, Y. (2017). New graduate nurses’

experiences in a clinical specialty: A follow up study of newcomer perceptions of

transitional support. BMC Nursing, 16(1),1-9. doi:10.1186/s12912-017-0236-0.

Parker, M., Aylward, P.D., Dunphy, L.H. Peden, A.R., Gesse T., Dombro, M., Holaday, B.,

Schaefer, K.M., Rittman, M.R., Touhy, T.A., Birnbach, N., Gordon, S.C., Kleiman, S.

Isenberg, M.A., Rogers, M.E., Butcher, H.K., Cody, W.K., Bunkers,S.S., Mitchell, G.J.,

Pharris, M.D., Sieloff, C.L., Frey, M., Killeen, M., Roy, C., Zhan, L., Ruth M. Neil,

R.M., McFarland, M.R., Linden, D., Swanson, K.M., Turkel, M.C., & Purnell, M.J.

(2001). Ernestine Wiedenbach clinical nursing: a helping art. In M. Parker, (Ed.),

Nursing theories and nursing practice (pp.70-84). Philadelphia: F.A. Davis.

Peptiprin, A. (2016). Wiedenbach’s helping art of clinical nursing. Nursing Theory. Retrieved

from http://www.nursing-theory.org/theories-and-models/wiedenbach-the-helping-art-of-

clinical-nursing.php

Pine, A. (2014). Common purpose, common struggle. National Nurse, 110(8), 14. Retrieved

from http://sunypoly.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?

direct=true&db=f5h&AN=100910920&site=eds-live

Vaartio, H., Leino-Kilpi, H., Salanterä, S., & Suominen, T. (2006). Nursing advocacy: how is it

defined by patients and nurses, what does it involve and how is it

experienced? Scandinavian Journal of Caring Sciences, 20(3), 282–292. https://doi-

org.sunypoly.idm.oclc.org/10.1111/j.1471-6712.2006.00406.x

Zimmerman, K. (2017). Essentials of Evidence Based Practice. International Journal of

Childbirth Education, 32(2), 37–43. Retrieved from http://sunypoly.idm.oclc.org/login?

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url=http://search.ebscohost.com/login.aspx?

direct=true&db=awh&AN=123698143&site=eds-live