Figure this out. Forty years ago, if you want to be a registered nurse, you have to set up a trolley in preparation for a medical procedure as one of central items in the final examination (Mc Mahon & Pearson, 1998).
Virginia Avenel Henderson, dissatisfied with the blurring definitions of nursing, revolutionized the image of a nurse as a distinct independent practitioner in her pioneering theory, “Definition of Nursing”. In her seminal work, Nature of Nursing (1964), she called for “an occupation or especially a profession whose services affect human life to define its functions.”
The “concept of nursing” as Henderson described it has multidimensional facets. In her paper entitled “Concept of Nursing” which was presented during the Third Battersea Memorial Lecture sponsored by the Association of Integrated and Degree Courses in Nursing (AIDCN) at the historical Nightingale School, St. Thomas’ Hospital London on November 7, 1977, she discussed the different definitions of nursing as affected by forces of socio-political phenomena, the evolving health services, academic preparation of a nurse, how the profession of medicine views nursing, and ultimately, the perceptions of patients as primarily driven by their stature in society (i.e. socioeconomic, educational attainment, cultural health practices and beliefs.)
The different definitions of nursing ad infinitum, coupled with the different functions of a professional nurse across the globe, served as impetus for Henderson to define a universal concept of nursing. She encouraged, however, that every nurse should have her on concept of nursing because nursing per se is a naturally evolving profession.
Henderson’s view on nursing offers pragmatic values on nursing practice, education and research. This article presents feasible instances on how to utilize Henderson’s concept in dealing with patients, ethico-legal implications of nursing practice, nursing curriculum development and academic preparation of a nurse and clinical nursing research within the perspectives of Philippine setting.
Henderson on Nursing Practice
The reason why Henderson is hailed as “Teacher of Nurses” because nurses are indebted to her on the scope of nursing practice. Role disparities among nurses are evident during the time of Henderson. With the birth of her theory, it guided the nurses to remain faithful to his functional roles and professional boundaries. Doing this, the public, being the consumers of care, and the nurse are mutually protected and their best interests are served.This gave way to the aspect of legal jurisprudence of nursing. Henderson believed that nursing must be explicitly defined in Nurse Practice Acts that would provide the legal parameters for the nurse’s functions in caring for consumers and safeguard the public for unprepared and incompetent practitioners. She further advocated for national nursing organizations and geopolitical units to enact legislation to control the preparation, function and licensing of nursing personnel. During her time, Henderson was so alarmed that many states had no provision for nursing licensure to ensure safe and competent care for the consumers (George, 1995).
The practice of regulating nursing practice through licensure is evident today. In the Philippines, the Board of Nursing which is the “ultimate authority in regulating the nursing profession in the country” through the Professional Regulation Commission, has expressed its mission to “lead nursing development to its highest level of excellence for the health and safety of the public.”
The legal definition of nursing, as within the context on the language of constitution, directs the roles of a nurse in a society. This unifying force guides both the nurse and the patient on the activities in the health care setting.
Let me illustrate. We often encounter individuals with cough and colds asking us nurses for prescription of drugs. Being fully aware with our scope of practice as stipulated in the Nursing Law (RA 9173), we are not authorized to prescribe drugs. Instead, we tailor health teachings as our independent and interdependent roles (e.g., increase fluid intake, rest, intake of vitamin C rich foods, consult doctor if symptoms still persist).
In Republic Act No. 9173, otherwise known as the Philippine Nursing Act of 2002, the scope of nursing in the country is defined in functional concepts like how Henderson constructed her theory.
This passage is the barometer on what the society should expect from a Filipino Nars. Do you still know this passage by heart and soul?
Section 28. Scope of Nursing. - A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and old age. As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. A members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary health care, comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral topical and parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration, special training shall be provided according to protocol established;
(b) establish linkages with community resources and coordination with the health team;
(c) Provide health education to individuals, families and communities;
(d) Teach, guide and supervise students in nursing education programs including the administration of nursing services in varied settings such as hospitals and clinics; undertake consultation services; engage in such activities that require the utilization of knowledge and decision-making skills of a registered nurse; and
(e) Undertake nursing and health human resource development training and research, which shall include, but not limited to, the development of advance nursing practice.
Comparing the Philippine legal definition of nursing with Henderson’s theory, we can view distinct commonalities.
“Nursing is primarily assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible (Henderson, 1966 as cited by Anonuevo et al, 2000).”
The theme on the concept of nursing by Henderson is universal. It is encompassing that it was adopted by World Health Organization Expert Committee on Nursing Practice in 1995 (Kim, 2010).
Henderson’s definition of nursing is revolutionary and visionary. Revolutionary, in the sense, that it radically elevated the status of nursing as a profession with its own scientific knowledge and practice base, autonomy, authority and responsibility to its clients. Visionary because it paves the way of nursing to grow and assume various expanded roles nowadays. Advanced practice nursing and post graduate academic degrees of nurses today trace its roots to this theory.
The principles and practices of nursing must be built upon and derived from the definition of the profession. Nurses functional roles are explicitly elaborated in the theory, and can be viewed in three spheres: in relationship with the patient/client, the physician and the health care team.
In relationship with the patient (including the family), the nurse can act as a substitute (doing for), supplement (helping) and complementary (working with) in meeting fundamental basic needs geared towards the ultimate goal of healthy independence. I will peruse the concept of independence in the proceeding text.
Henderson asserted that nurse is distinct from medicine. She clearly pinpointed that nurses do not follow doctor’s orders, but rather they follow in a philosophy which allows physician to give orders to patients (Octaviano and Balita, 2008). However, she underscored that the primary function of a nurse must be performed in such a way that it promotes the physician’s therapeutic plan (George, 1995). I must say, therefore, that nurses are not handmaids of physician and being adjunct to medicine. Nurses have their own identity!
Nurses, according to Henderson (1977), though act interdependently with other health workers must be masters of their unique roles. In situation where other members of the health care team are unavailable, the nurse is the person best prepared to supply the help for such specialists. We can assess symptomatology and create nursing diagnoses, interpret laboratory findings, know therapeutics and diagnostics, understand drug dynamics, tailor heath education and diet planning.
Meeting the 14 Basic human needs as equated to healthy independence
The concept of nurse’s unique function demands that nurses understand the fundamental needs of human. These needs are operationalized into “14 basic human needs” which the nurse should address in the process of providing “basic nursing care to promote human welfare” (Henderson, 1980). (See previous pages on 14 Basic Human Needs)
A recurring theme among nursing theories is the concept of independence. This has been referred to by Henderson as healthy independence, which she stressed out as the goal of nursing.
Self-determination or self-reliance is an indispensable ultimate goal of any health models. The “person” mentioned in theory of the “Mother of Modern Nursing” is both in the disease and wellness state, though wellness isn’t explained explicitly in the theory. Instead, the person is largely seen on the passive, dependent state in the disease continuum.
For example. There are still incidences of tuberculosis in the government hospital where I work amidst the short course chemotherapy campaign of the Department of Health. Rural farmers with history of chronic smoking rushed to hospital presenting dyspnea and hemoptysis . History further revealed failure to complete the therapy. CXR result shows pulmonary tuberculosis, hematology results reveal anemia, leukocytosis with predominance of lymphocytes, decreased serum albumin. Utilizing Henderson’s theory, I will respond by maintaining airway, promoting rest and adequate nutrition, preventing further infection, placing the patient on isolation, initiating peripheral IV and administering antibiotic and antifibrinolytic as ordered.
Nurses nowadays are so astute in meeting the physiologic needs of patients. We assist them to have the physiologic “strength”. We fail to meet the psychological/emotional, learning, spiritual and social/recreation needs of our clients (i.e. these need s constitute the #10-#14th basic needs according to Henderson). Basing from my example, I may explore the reasons why adherence to treatment regimen is low. Doing so may serve as my basis in conducting health education to provide “knowledge” and motivate my clients to have the “will” to be responsible on their own health. This clearly pinpoints how Henderson organized nursing problems rather than medical diagnosis. By having the necessary strength, knowledge and will, independence is attainable, as posited by Henderson.
The assumption on the Activities of Daily Living (ADL), also known as basic needs, still remains true and valid today. Though in Henderson’s theory, almost more than half of the activities focuses on physiologic needs, she advocated “holism” to include the psychosocial and spiritual dimensions of a person.
In delivery of nursing care, the nurse is guided with a scientific problem solving process and with the recognition of nursing process nowadays, it can also be employed. Quality of care rendered by a competent nurse should be evaluated in terms of the “speed” to which the patient regains independence (George, 1995). All nursing care done should be translated into writing, a written nursing care plan. This has valuable implication in terms of legal aspects, outcome evaluation and research.
Henderson further questioned the “nursing process” reminding us all that problem solving is not exclusive to any profession (McBride, nd). The nursing process according to her highlights only the science of nursing, excluding the art of nursing. However, the problem solving approach can be used in her thesis.
In summary, Henderson’s theory:
- Assists nurses, whose primary function is being the direct caregiver to the patient, in finding an immediate reward in patient’s progress from dependence to independence.
- Helps nurses make every effort to understand the patient when he or she lacks will, knowledge, or strength.
- Henderson’s approach to patient care was deliberative and involved decision making.
- Utilizes nursing process (assessment, planning, implementation, & evaluation) as the problem-solving process and is not peculiar to nursing.
Henderson on Nursing Education
In order to promote independence on the patient, the nurse must be competent. Henderson advocated for academic preparation of a nurse in a higher institution of learning which gives her the “broadest possible understanding of humanity and the world which they live” (Henderson, 1977).
Her advocacy, alongside with her proposal on the three phases of curriculum design, dramatically changed the nursing education and is prevalent in the baccalaureate programs in our county today.
She analyzed the curricula of the usual 4 year nursing program in USA and categorized the courses into (1) the humanities, (2) the biological and physical sciences, (3) the social sciences, and (4) the medical and nursing arts and sciences. The growing variation among programs offered by schools of nursing results to different roles of a nurse assumed in health care setting. This is the reason why Henderson (1977) proposed a basic nursing program.
Henderson (1977) gave emphasis on interdisciplinary education and fostering a humanistic concept of health care. The basic nursing curriculum which includes social and bio-physical sciences has three natural stages of learning. The first stage is devoted in assisting patient to meet his activities of daily living, the second stage focuses on symptomatic nursing or common physical and emotional dysfunctions and third stage integrates care to the different developmental stages and whole life span of an individual.
In the Philippine setting, the basic nursing curriculum as proposed by Henderson is evident in the four year nursing programs today. The 1st year is devoted on studying physical, biological and social sciences and effective communication skills. The 2nd year focuses on normal physiologic functioning, primary health care, basic nursing care and fundamental concepts of nursing. The 3rd year and senior year integrate multidimensional care to varied clients (ie. Individual, family, groups, community) across life span with physiologic and psychosocial alterations supported by scientifically-driven research. The product of the program is a nurse generalist.
Student nurses should develop clinical judgments, direct individualized patient care, a habit of inquiry, and be lifelong students.
Henderson’s immortal contributions to nursing education is encapsulated in her definition of nursing, her proposed nursing program and the nursing books she authored like the Textbook of the Principles and Practice of Nursing, Basic Principles of Nursing Care and Nature of Nursing, which served as nursing classics and the guiding light on the practice of nursing.
Henderson developed three phases of curriculum that students should progress through their learning.
- Fundamental needs of the patient, the planning of the nursing care, and the unique function of the nurse helping the patient perform his activities of daily living.
- Helping patients meet their needs during marked body disturbances or pathological states that demand modifications in the nurse’s plan of care.
- Patient and family-centered, wherein students become involved in the complete study of the patient and its needs.
Henderson on Research
Henderson unsurpassed contribution to scientific inquiry is her survey and assessment of nursing research that shifted nursing research away from studying nurses to studying the differences that nurses can make in people's lives and the Nursing Studies Index that captured the intellectual history of the first six decades of this century (McBride, nd).
Her early ideas recognized on the importance of an outcomes orientation, health promotion, continuity of care, patient advocacy, multidisciplinary scholarship, integration of the arts and sciences, and boundary spanning (McBride, nd). She encouraged on the utilization of library for research work and inclusion of research subjects in the baccalaureate level.
As a proof of her dedication to inquiry, she advocated on “clinical research”. Although, her theory is not written in testable terms, her 14 basic needs can be reformulated into research questions (Mc Ewan & Wills, 2007).
In an article written by Nicely, Bruce, DeLario and Ginger (2011), the theory of Virginia Henderson was utilized creatively in the practice and principles of nursing as applied to organ donation after brain death in the clinical practice. This shows how the theory can be feasible in clinical research.
Evelyn Adam, a Canadian nurse, extended the work of Henderson, by developing concepts integrated into a conceptual model (George, 1995). There are six major units in the conceptual model namely goal of the profession, beneficiary, role, source of difficulty, intervention which includes the focus and modes and consequences. This model can be translated into further research as it seeks to operationalize the theory of Henderson into tangible form.
Henderson further includes the following in using her theory on research:
- Guide to evaluate and improve practice.
- Basing their practice on research findings and acquiring the habit of looking for research.
- Utilizing library resources and hoping that nurses would conduct research to improve practice rather than to merely gain academic respectability.
- Believed that nursing would not become a research-based profession until practicing nurses learn to use library resources.
The Nursing Process as Applied to Henderson’s Needs Theory
Henderson’s 14 components and definition of nursing
Assessment focuses on Henderson’s 14 components of health.
Analysis: Compare data to knowledge base of health and disease.
Identify individual’s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge.
Prioritization of needs are done by the nurse together with the patient.
Long term goal: optimal independence
Short term goals: successful activities as directed to the fulfillment of the long term goals.
Document how the nurse can assist the individual, sick or well.
Assist the sick or well individual in to performance of activities in meeting human needs to maintain health, recover from illness, or to aid in peaceful death.
Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities.
Carry out treatment prescribed by the physician.
Henderson’s 14 components and definition of nursing
Use the acceptable definition of nursing and appropriate laws related to the practice of nursing.
The quality of care is drastically affected by the preparation and native ability of the nursing personnel rather that the amount of hours of care.
Successful outcomes of nursing care are based on the speed with which or degree to which the patient performs independently the activities of daily living
Table 1. Needs Theory’s Nursing Process[i]
Henderson’s definition of nursing and 14 components of basic nursing care can be useful in guiding the assessment and care of patients preparing for surgical procedures. For example, in assessing Mr. G’s preoperative vital signs, the nurse noticed he seemed anxious. The nurse encouraged Mr. G. to express his concerns about the surgery. Mr. G. told the nurse that he had a fear of not being able to control his body and that he felt general anesthesia represented the extreme limit of loss of bodily control. The nurse recognized this concern as being directly related to Henderson’s fourth component of basic nursing care: Move and maintain desirable postures. The nurse explained to Mr. G. that her role was to “perform those acts he would do for himself if he was not under the influence of anesthesia” (Gillette, 1996, p. 267) and that she would be responsible for maintaining his body in a comfortable and dignified position. She explained how he would need to be positioned during the surgical procedure, what part of his body would be exposed, and how long the procedure was expected to take. Mr. G. also told the nurse about an experience he had following an earlier surgical procedure in which he experienced pain in his right shoulder. Mr. G. expressed concern that being in one position too long during the surgery would damage his shoulder and result in waking up with shoulder pain again. Together they discussed positions that would be most comfortable for his shoulder during the upcoming procedure, and she assured Mr. G. that she would be assessing his position throughout the procedure.
- Myrene Aseron
-Paul Froilan Garma
-Nadine Cybil Solano
Anonuevo, C. et al. (2000). N207 Theoretical Foundations of Nursing (module). Philippines: UP Open University.
George, J.B. (1995). Nursing Theories: The Base of Professional Nursing Practice (Fourth Edition). Reprinted Manila, Philippines: Educational Publishing House.
Henderson, V. (1964). The Nature of Nursing. American Journal of Nursing, 64 (8), 64. Retrieved June 13, 2011, from http:///www.jstor.org/pss/3419278.
___________. (1980). Preserving the Essence of Nursing in a Technological Age. Journal of Advanced Nursing, 5 (3), 245-260.
Kim, H.S. (2010). The Nature of Theoretical Thinking in Nursing (Third Edition). New York: Springer Publishing Company.
McBride, A.B. (nd). In Celebration of Virginia Avenel Henderson. Retrieved June 12, 2011, from http://healthsci.clayton.edu/eichelberger/in_celebration_of_virginia_avene.htm.
McEwen, M., & Wills, E. (2007). Theoretical Basis for Nursing (Second Edition). Philippine Edition: Lippincott Williams & William.
McMahon, R. , & Pearson, Allan. (1998). Nursing as Therapy (Second Edition). United Kingdom: Nelson Thornes.
Nicely, Bruce, DeLario and Ginger. (2011). Virginia Henderson's principles and practice of nursing applied
to organ donation after brain death. Progress in Transplantation. North American Transplant Coordinators Organization provided by ProQuest & InforLearning Company. Retrieved June 12, 2011, from http://findarticles.com/p/articles/mi_qa4117/is_201103/ai_n57242444/?tag=mantle_skin;content.
Octaviano, E. and Balita, C. (2008). Theoretical Foundations of Nursing: The Philippine Perspective. Manila: Ultimate Learning Series.
Tomey, A.M & Alligood, M.A. (2002). Nursing Theories and their work (5th ed.). Missouri: Elsevier (Singapore) Pte Ltd.
Mission, Vision, Values and Objectives of Board of Nursing. Retrieved June 30, 2011, from http://nursing.philippinedirect.com/index.php?option=com_content&task=view&id=14&Itemid=27
AN ACT PROVIDING FOR A MORE RESPONSIVE NURSING PROFESSION, REPEALING FOR THE PURPOSE REPUBLIC ACT NO. 7164, OTHERWISE KNOWN AS "THE PHILIPPINE NURSING ACT OF 1991" AND FOR OTHER PURPOSES. Retrieved June 30, 2011, from http://www.lawphil.net/statutes/repacts/ra2002/ra_9173_2002.html
Parker, M. and Smith, M. (2010). Nursing theories and Nursing practice. USA: F. A. Davis Company