MAJOR ASSUMPTIONS, CONCEPTS & RELATIONSHIPS

• The language of Abdellah’s framework is readable and clear.

• Consistent with the decade in which she was writing, she uses the term ‘she’ for
nurses, ‘he’ for doctors and patients, and refers to the object of nursing as
‘patient’ rather than client or consumer.
• She referred to Nursing diagnosis during a time when nurses were taught that
diagnosis was not a nurses’ prerogative.

Assumptions were related to

• change and anticipated changes that affect nursing;

• The need to appreciate the interconnectedness of social enterprises and social
problems;
• the impact of problems such as poverty, racism, pollution, education, and so forth
on health care delivery;
• changing nursing education
• continuing education for professional nurses
• development of nursing leaders from under reserved groups

Abdellah and colleagues developed a list of 21 nursing problems.They also identified 10

steps to identify the client’s problems. 11 nursing skills to be used in developing a
treatment typology

10 steps to identify the client’s problems

• Learn to know the patient

• Sort out relevant and significant data
• Make generalizations about available data in relation to similar nursing problems
presented by other patients
• Identify the therapeutic plan
• Test generalizations with the patient and make additional generalizations
• Validate the patient’s conclusions about his nursing problems
• Continue to observe and evaluate the patient over a period of time to identify any
attitudes and clues affecting his behavior
• Explore the patient’s and family’s reaction to the therapeutic plan and involve
them in the plan
• Identify how the nurses feels about the patient’s nursing problems
• Discuss and develop a comprehensive nursing care plan

11 nursing skills

• Observation of health status

• Skills of communication
• Application of knowledge
• Teaching of patients and families
• Planning and organization of work
• Use of resource materials
• Use of personnel resources
• Problem-solving
 • Direction of work of others
• Therapeutic use of the self
• Nursing procedure

The twenty-one Nursing Problems

Three major categories

• Physical, sociological, and emotional needs of clients

• Types of interpersonal relationships between the nurse and patient
• Common elements of client care

21 NURSING PROBLEMS

BASIC TO ALL PATIENTS

• To maintain good hygiene and physical comfort

• To promote optimal activity: exercise, rest and sleep
• To promote safety through the prevention of accidents, injury, or other trauma
and through the prevention of the spread of infection
• To maintain good body mechanics and prevent and correct deformitiy

SUSTENAL CARE NEEDS

• To facilitate the maintenance of a supply of oxygen to all body cells

• To facilitate the maintenance of nutrition of all body cells
• To facilitate the maintenance of elimination
• To facilitate the maintenance of fluid and electrolyte balance
• To recognize the physiological responses of the body to disease conditions
• To facilitate the maintenance of regulatory mechanisms and functions
• To facilitate the maintenance of sensory function.

REMEDIAL CARE NEEDS

• To identify and accept positive and negative expressions, feelings, and reactions
• To identify and accept the interrelatedness of emotions and organic illness
• To facilitate the maintenance of effective verbal and non verbal communication
• To promote the development of productive interpersonal relationships
• To facilitate progress toward achievement of personal spiritual goals
• To create and / or maintain a therapeutic environment
• To facilitate awareness of self as an individual with varying physical , emotional,
and developmental needs

RESTORATIVE CARE NEEDS

• To accept the optimum possible goals in the light of limitations, physical and
emotional
• To use community resources as an aid in resolving problems arising from illness
 • To understand the role of social problems as influencing factors in the case of
illness

Abdellah's 21 problems are actually a model describing the "arenas" or concerns of

nursing, rather than a theory describing relationships among phenomena. In this
way, the theory distinguished the practice of nursing, with a focus on the 21 nursing
problems, from the practice of medicine, with a focus on disease and cure.

ABDELLAH’S THEORY AND NURSING

Although Abdellah’s writings are not specific as to a theoretical statement, such a

statement can be derived by using her three major concepts of health, nursing problems,
and problem solving. Abdellah’s theory would state that nursing is the use of the problem
solving approach with key nursing problems related to health needs of people. Such a
statement maintains problem solving as the vehicle for the nursing problems as the
client is moved toward health – the outcome

NURSING

Acc to her, nursing is based on an art and science that mould the attitudes, intellectual
competencies, and technical skills of the individual nurse into the desire and ability to
help people, sick or well, cope with their health needs.

HEALTH

Health is a dynamic pattern of functioning whereby there is a continued interaction with

internal and external forces that results in the optimum use of necessary resources that
serve to minimize vulnerabilities

NURSING PROBLEMS

• Nursing problem presented by a client is a condition faced by the client or client’s

family that the nurse through the performance of professional functions can
assist them to meet . The problem can be either an overt or covert nursing
problem.
• An overt nursing problem is an apparent condition faced by the patient or family,
which the nurse can assist him or them to meet through the performance of her
professional functions.
• The covert nursing problem is a concealed or hidden condition faced, by the
patient or family, which the nurse can assist him or them to meet through the
performance of her professional functions
• In her attempt to bring nursing practice into its proper relationship with restorative
and preventive measures for meeting total client needs, she seems to swing the
pendulum to the opposite pole, from the disease orientation to nursing
orientation, while leaving the client somewhere in the middle.

PROBLEM SOLVING
The problem solving process involves identifying the problem, selecting pertinent data,
formulating hypothesis, testing hypothesis through the collection of data, and revising
hypothesis where necessary on the basis of conclusions obtained from the data.

ABDELLAH’S THEORY AND THE FOUR MAJOR CONCEPTS

NURSING

• Nursing is a helping profession. In Abdellah’s model, nursing care is doing

something to or for the person or providing information to the person with the
goals of meeting needs, increasing or restoring self-help ability, or alleviating
impairment.
• Nursing is broadly grouped into the 21 problem areas to guide care and promote
use of nursing judgment.
• She considers nursing to be comprehensive service that is based on art and
science and aims to help people, sick or well, cope with their health needs.

PERSON

• Abdellah describes people as having physical, emotional, and sociological

needs. These needs may overt, consisting of largely physical needs, or covert,
such as emotional and social needs.
• Patient is described as the only justification for the existence of nursing.
• Individuals (and families) are the recipients of nursing
• Health, or achieving of it, is the purpose of nursing services.

HEALTH

• In Patient –Centered Approaches to Nursing, Abdellah describes health as a

state mutually exclusive of illness.
• Although Abdellah does not give a definition of health, she speaks to “total health
needs” and “a healthy state of mind and body” in her description of nursing as a
comprehensive service.

SOCIETY AND ENVIRONMENT

• Society is included in “planning for optimum health on local, state, national, and
international levels”. However, as she further delineated her ideas, the focus of
nursing service is clearly the individual.
• The environment is the home or community from which patient comes.

ABDELLAH’S WORK AND CHARACTERISTICS OF A THEORY

Characteristic 1
 • Abdellah’s theory has interrelated the concepts of health, nursing problems, and
problem solving as she attempts to create a different way of viewing nursing
phenomenon
• The result was the statement that nursing is the use of problem solving approach
with key nursing problems related to health needs of people.

Characteristic 2

• Problem solving is an activity that is inherently logical in nature

Characteristic 3

• Framework seems to focus quite heavily on nursing practice and individuals. This
somewhat limit the ability to generalize although the problem solving approach is
readily generalizable to clients with specific health needs and specific nursing
problems

Characteristic 4

• One of the most important questions that arise when considering her work is the
role of client within the framework. This question could generate hypothesis for
testing and thus demonstrates the ability of Abdellah’s work to generate
hypothesis for testing

Characteristic 5

• The results of testing such hypothesis would contribute to the general body of
nursing knowledge

Characteristic 6

• Abdellah’s problem solving approach can easily be used by practitioners to guide

various activities within their practice. This is true when considering nursing
practice that deals with clients who have specific needs and specific nursing
problems

Characteristic 7

• Although consistency with other theories exist, many questions remain

unanswered

USE OF 21 PROBLEMS IN THE NURSING PROCESS

ASSESSMENT PHASE
 • Nursing problems provide guidelines for the collection of data.
• A principle underlying the problem solving approach is that for each identified
problem, pertinent data are collected.
• The overt or covert nature of the problems necessitates a direct or indirect
approach, respectively.

NURSING DIAGNOSIS

• The results of data collection would determine the client’s specific overt or covert
problems.
• These specific problems would be grouped under one or more of the broader
nursing problems.
• This step is consistent with that involved in nursing diagnosis

PLANNING PHASE

• The statements of nursing problems most closely resemble goal statements.

Therefore, once the problem has been diagnosed, the goals have been
established.
• Given that these problems are called nursing problems, then it becomes
reasonable to conclude that these goals are basically nursing goals.

IMPLEMENTATION

• Using the goals as the framework, a plan is developed and appropriate nursing
interventions are determined.

EVALUATION

• According to the American Nurses’ Association Standards of Nursing Practice,

the plan is evaluated in terms of the client’s progress or lack of progress toward
the achievement of the stated goals.
• This would be extremely difficult if not impossible to do for Abdellah’s nursing
problem approach since it has been determined that the goals are nursing goals,
not the client goals.
• Thus, the most appropriate evaluation would be the nurse progress or lack of
progress toward the achievement of the stated goals

AN illustration of the implementation of Abdellah’s framework in Ryan’s care

 • Consider a case of Ryan who experienced severe crushing chest pain ‘shortness
of breath, tachycardia and profuse diaphoresis
• Stage of illness is basic to care
• Selected Abdellah nursing problem
• To maintain good hygiene and personal comfort
• Classification and approach
• Overt problem of pain; Direct and indirect method

Selected Nursing Interventions

• administer oxygen
• elevate headrest
• reposition client
• administer prescribed analgesic
• remain with client
• Criterion measure- Amount of pain

CONCEPT OF PROGRESSIVE PATIENT CARE

• PPC is defined as better patient care through the organization of hospital

facilities, services and staff around the changing medical and nursing needs of
the patient
• PPC is tailoring of hospital services to meet patients needs
• PPC is caring for the right patient in the right bed with the right services at the
right time
• PPC is systematic classification of patients based on their medical needs

ELEMENTS OF PPC

INTENSIVE CARE

• Critically and seriously ill patients requiring highly skilled nursing care, close and
frequent if not constant, nursing observation are assigned to the ICU. One patient
in an ICU requires at least three nurses to observe him in 24 hrs
 • Intermediate care Patients assigned to this unit are both the moderately ill and
those for whom the treatment can only be palliative
• Self care Ambulatory patients who are convalescencing or require diagnosis or
therapy may be cared for in this unit
• Long term care unit This unit will provide services to certain patients now cared
for in the general hospital, in nursing homes, or in their own homes and who
would benefit by care in a hospital environment to achieve its maximum potential
• Home care This programme makes it possible to extend needed services to the
patient after he leaves the hospital and returns to his home in the community

BENEFITS OF PPC
PATIENT

• better attention
• better adjustment
• minimized problems
• life saving care
• constant medical and nursing care

PHYSICIAN

• assuring best nursing care

• drugs and equipments at hand
• orders carried out effectively
• better clinical an team service

HOSPITAL

• effective and efficient use of staff

• improved public image

NURSING PERSONNEL

• individual skills can be used

• more time with patient
 • helping pt. and family to solve problems
• job satisfaction
• in-service education

COMMUNITY

• continuity with hospital services

• minimize the need of hospitalization

IMPLICATIONS OF PPC FOR NURSING EDUCATION

• Many nurse educators feel that the PPC hospital where all five phases of care
are available can provide clinical experience in which the nurse can learn to
solve basic nursing problems in meeting patients’ needs.
• The three month assignment of professional nurses may no longer be realistic in
such a setting.
• Organization of hospital and community services based on patients needs
• In the intensive care unit, the critically ill patients are concentrated regardless of
diagnosis.
• These patients are under the constant audio-visual observation of the nurse, with
life saving techniques and equipment immediately available
• In the intermediate care unit are concentrated patients requiring a moderate
amount of nursing care, not of an emergency nature, who are ambulatory for
short periods, and who are beginning to participate in he planning of their own
care
• The self-care unit provides for patients who are physically self-sufficient and
require diagnostic and convalescent care in hotel-type accommodations. This
unit serves as a link between the hospital and the home.
• In the long-term care unit are concentrated patients requiring prolonged care.
The grouping of such patients will permit staffing patterns that are less costly
• Home care, the fifth element of progressive patient care, extends hospital
services into the home to assist the physician in the care of his patients

USEFULNESS
 • The patient centered approach was constructed to be useful to nursing practice,
with impetus for it being nursing education.
• Abdellah’s publications on nursing education began with her dissertation; her
interest in education for nurses continues into the present.
• Abdellah has also published on nursing, nursing research, and public policy
related to nursing in several international publications. She has been a strong
advocate for improving nursing practice through nursing research

VALUE IN EXTENDING NURSING SCIENCE

• It helped to bring structure and organization to what was often a disorganized

collection of lectures and experiences.
• She categorized nursing problems based on the individual’s needs and
developed developed a typology of nursing treatment and nursing skills..

NURSING RESEARCH

• She has been a leader in nursing research and has over one hundred
publications related to nursing care, education for advanced practice in nursing
and nursing research.

LIMITATIONS

• Very strong nursing centered orientation

• Little emphasis on what the client is to achieve
• Her framework is inconsistent with the concept of holism
Potential problems might be overlooked

SUMMARY

• Using Abdellah’s concepts of health, nursing problems, and problem solving, the
theoretical statement of nursing that can be derived is the use of the problem
solving approach with key nursing problems related to health needs of people.
• From this framework, 21 nursing problems were developed

CONCLUSIONS
 • Abdellah’s theory provides a basis for determining and organizing nursing care.
The problems also provide a basis for organizing appropriate nursing strategies.
• It is anticipated that by solving the nursing problems, the client would be moved
toward health. The nurse’s philosophical frame of reference would determine
whether this theory and the 21 nursing problems could be implemented in
practice.

REFERENCES

1. George Julia B. Nursing theories: The base of professional nursing practice 3rd
edition. Norwalk, CN: Appleton and Lange; 1990.
2. Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987,
35(5),224-225.
Abdellah, F.G. Public policy impacting on nursing care of older adults .In E.M.
Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage
publications. 1991.
3. Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century.
New York: Springer. 1994.
4. Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered
approaches to nursing (2nd ed.). New York: Mac Millan. 1968.
5. Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower
development. International Nursing Review, 1972); 19, 3..
6. Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives
on nursing theory. Boston: Little, Brown, 1986.