Wiedenbach's Nursing Theory: Management of Ankylosing Spondylitis with the Helping Art of Clinical Nursing

Abstract

In the presence of a chronic disease that affects the individual with all its aspects, nursing care should be patient-specific and in accordance with current data. This article, it is aimed to explain the nursing care practices given to an individual with AS based on Wiedenbach's nursing theory.

Headnote

Abstract

In the presence of a chronic disease that affects the individual with all its aspects, nursing care should be patient-specific and in accordance with current data. This article, it is aimed to explain the nursing care practices given to an individual with AS based on Wiedenbach's nursing theory.

Keywords: ankylosing spondylitis, the helping art of clinical nursing, Wiedenbach's nursing theory.

Introduction

Ankylosing spondylitis (AS), one of the seronegative spondyloarthropathies, is a systemic, progressive, chronic rheumatic disease characterized by ankylosis and inflammation of the axial skeleton. The etiology AS is not fully explained, although genetic predisposition, especially HLA-B27, and a triggering infection are mentioned in its etiology (Eashwar, Dinesh and Gopalakrishnan,2019; Liang et.al., 2019; Braun and Sieper, 2007). AS keeps the spine and causes radiological changes in the sacroiliac joints and spine. The main clinical features of AS, which is mostly seen in young men, are inflammatory lower back and back pain, tenderness in the sacroiliac joints, pain due to inflammation of the areas where tendons or ligaments attach to the bones (enthesopathy), morning stiffness, limitation in spinal movements and Schober tests, functional disorders and poor quality of life associated with specific organ involvement and large joint involvement, especially hip. In other words, it causes limitation of movement due to joint involvement, serious organ failure due to organ involvement which leads to deterioration in the quality of life of the individual and, accordingly, to negative psychological consequences such as depression and anxiety (Song et.al.,2021; Liang et.al., 2019; Sucuoglu et.al., 2015; Akyol, Alevli and Ucan, 2013). AS usually starts at an early age, mostly occurs in young adults, and affects the patient in their most productive years. Symptoms occur before the age of 30 in 80% of cases (Sari, Ozturk and Akkoc, 2015). The prevalence of AS is believed to be between 0.1% and 1.4% globally (Linda et.al., 2014). Its prevalence in our country has been reported to be 0.49% (Aksu, 2015). Lower back pain and stiffness that increase without activity are the most common initial symptoms. With the progression of the involvement to the cervical region in the future, the posture changes in the direction of forward flexion and the movements of the patient are restricted or even prevented (Bahcivan et.al., 2015; Akyol, Alevli and Ucan, 2013). AS causes a serious decrease in the patient's quality of life so its management should not be limited to the hospital only, but should also be expanded to include the community and family (Linda et.al.,2019; Bahcivan et.al., 2015). Management of the patient with AS should aim to maximize the individual's long-term health-related quality of life by controlling symptoms and inflammation, preventing progressive structural damage, ensuring and maintaining the patient's activities and functions in daily life, and participation in social life (Song et.al., 2021).

Therefore, in AS cases, it is possible to meet the needs that are made difficult or even prevented by the limitation of movement due to the disease with effective and high-quality nursing care. In this direction, for AS management, the nurses should benefit to use nursing theories and models for improving the quality of care. As it is known, the systematic and scientific application of nursing care is possible by integrating theories and models into care. Nursing theories and models are into the individual at the center of care and in nursing care, the effects of variables and the needs of the individual are based on the principles of professionalism (Baykara et.al., 2019; Kaya et.al., 2010). In the light of this information, in the presence of a chronic disease that affects the individual with all its aspects, nursing care should be patient-specific and in accordance with current data.

This article was aimed to explain the nursing care practices given to the patient based on Wiedenbach's nursing theory. Permission was obtained from the patient then the data collection phase was started.

Conceptual Framework for the Theory: Wiedenbach, who put forward the theory of "The Helping Art of Clinical Nursing" in 1964, defined nursing as "the art of helping". Wiedenbach tried to explain the essence of nursing philosophy with three concepts. These are seeing life as a reward and respecting it, respecting each person's worth, autonomy, and individuality, and respecting individuals' beliefs and willingness to act in accordance with those beliefs (Baysan et.al., 2019; Wiedenbach, 1970). Although science and art are seen as opposites in theory, they are creatively combined in nursing care. The main goal is to reach the goal by using art, knowledge and skills (Teksoz and Ocakçı, 2014). Wiedenbach sees nursing as an art based on purposeful care. Art in theory is explained as understanding patients' needs and concerns, developing goals and actions aimed at improving patients' abilities, and guiding activities related to the medical plan to improve the patient's condition (Thapa and Thakur, 2017; Wiedenbach,1970). The nursing art, which focuses on the perception and feelings of the nurse, is activated by the patient's behaviors. The art dimension of nursing is to understand the needs of the patient, to define their anxieties, to develop goals and practices to maintain independence and to create an individual health plan (Baysan et.al., 2019; Teksoz and Ocakci, 2014). Wiedenbach, who defined people as functional beings with internal coping ability, also expressed nursing as a purposeful mixture of thoughts, emotions and explicit actions. In the theory, nursing is defined as the applications made to observe a patient's need for help, the behaviors and symptoms that occur due to his/her illness, to investigate the meaning of these symptoms, to determine the cause of the discomfort and the ability of the patient to solve the discomfort (Petiprin,2020;Hawkins,1987). Wiedenbach states that each person has a unique potential to develop within himself/herself the resources that ensure his/her independence. It also states that people strive for independence and need to be stimulated to realize their self-worth. In Wiedenbach's theory, self-awareness and self-acceptance are crucial to personal integrity and self-worth. Whatever an individual is doing at any given moment is representative of the best judgment available to that person at that moment (Wiedenbach, 1970). Wiedenbach defines the four main elements of clinical nursing as philosophy, purpose, practice and art. Nursing philosophy is concerned with attitudes, beliefs, and how this attitude affects reality. The aim is all activities aimed at the general well-being of the patient. Practice is observable actions that are influenced by the patient's beliefs and feelings about meeting his/her need for help. The art of nursing involves understanding a patient's needs and concerns, developing goals and actions to increase the patient's ability, and managing activities related to the medical plan to improve the patient's condition. The nurse also focuses on the prevention of complications that may arise due to the reoccurrence of the conditions that caused the patient's discomfort or the development of new concerns (Petiprin, 2020; Hawkins,1987; Wiedenbach,1970). Wiedenbach's vision of nursing practice is closely related to the measurement, application and evaluation step of the nursing process. According to Wiedenbach, nursing practice consists of identifying a need for help, providing the help needed, verifying that the need for help is being met, or an evaluation showing that the help has achieved its purpose (Jayamalli and Priya,2020).

Identifying the Need for Help: A patient's need for help is defined as a patient-requested measure that can potentially restore or expand the patient's ability to cope with conditions that affect health. In Wiedenbach's nursing theory, it is very important that a patient's need for help derives from the patient's perception of his or her condition (Petiprin, 2020;Pektekin, 2013; Wiedenbach, 1970). At this stage, the nurse should define the situation of the individual by seeking answers to questions such as "Does the patient have a need?, Is he aware of the need?, What are the factors that prevent him from fulfilling his need?, What is the situation where he needs help?" (Pektekin, 2013).

Providing Needed Help: After the patient's needs are determined, a plan is prepared for the patient and the patient's assistance needs by evaluating the current conditions and possibilities. At this stage, nurse-patient collaboration is very important. The care plan prepared specifically for the individual and how this plan will be implemented are explained to the patient by the nurse. If the patient complies with the recommendations and accepts the need for help, the need for help is met in line with this plan. If he does not accept, the reasons should be investigated, the need for help should be questioned again and a new plan should be made in which the patient will be included in the care (Baysan et.al., 2019).

Evaluation of Help Achievement: At this stage, whether the patient's need for help is met and the effectiveness of the interventions should be evaluated. The fact that the patient's need for help has disappeared indicates that the nursing process is planned and implemented effectively and in accordance with the purpose. After this stage, it is expected that the patient will feel relieved and state that the addiction situation has disappeared. If it is determined that the patient's need for help continues, all stages should be reviewed again (Baysan et.al., 2019; Pektekin, 2013).

Case Report: Mr. H.A. is 49 years old, single and living with his family. H.A states that when he was 30 years old, he was diagnosed with AS as a result of the examinations performed after he applied to a university hospital with the complaint of unbearable lower back pain that increased in the morning and decreased during the day. The patient says that he has been living with this disease for 19 years and expresses his condition and feelings by saying "I can say that life before the disease does not exist for me, it has been so long that I can hardly remember my old state". The patient has been using Salazopyrin regularly for 2 years with the recommendation of the doctor, and in case of severe pain, he takes the drug called Endol. He stated that he could not go to the doctor due to the pandemic and that he postponed meeting with his doctor during this period and did not use his medicine regularly. He states that he used to smoke before he was diagnosed and quit smoking after the disease appeared (Table 1).

Identifying the Need for Help (Data Collection): After the interviews with the patient, it was determined that he had pain, fatigue and sleep problems, especially during the attack periods. In addition, it was determined that he had problems in the treatment compliance phase, and it was determined that the change in posture affected his body image negatively. It has been determined that changes in body image affect the social relations and even marital status of the patient and cause the development of the feeling of isolation/loneliness in the patient. It has been determined that although the individual has a high awareness of his needs, he does not attempt to solve his problems and meet his needs.

At this stage, the data collection phase about the patient has been completed and possible nursing diagnoses were determined as;

* Chronic pain due to progressive inflammation in the joints,

* Fatigue due to chronic back pain

* Disruption in sleep pattern due to chronic pain

* Change in body image due to posture disorder

* Ineffective individual coping (Table 2).

Providing Needed Help (Planning and Implementation): At this stage, the patient's need for help was defined, the needs were determined, and interventions were planned and implemented. In other words, the nurse carries out the planning and implementation steps of the process at this stage.The patient stated that he had low back pain, especially in the mornings, and that he could not go to work because of the pain most of the time. In this direction, the location of the pain, its severity, increasing and decreasing factors were determined by discussing with the individual. The patient states that when he lifts heavy, his pain is relieved, so when his pain is severe, he relaxes by lifting heavy objects. Upon this, it was explained to the patient that such risky methods would cause trauma. Information was given about taking a warm shower and doing relaxation exercises when the pain was intense, especially in the morning hours. In order to provide pain control, the benefit of using pharmacological and nonpharmacological methods in combination has been explained and it has been stated that methods such as massage, stretching and relaxation can be used. A weekly walking calendar was created with the individual by suggesting that exercise is important for the disease and regular walks are recommended. H.A., who has chronic pain due to AS, stated that he feels tired all the time due to the pain and that his sleep pattern is disrupted accordingly. After the interviews with the patient, the nursing process was planned in line with the patient's needs. It is recommended to sleep in the supine position and, if possible, without a pillow. H.A, who stated that he had trouble falling asleep, was suggested that in order to facilitate the transition to sleep, it would be beneficial not to consume beverages such as tea and coffee that could disrupt his sleep pattern. In addition, planning was made considering the characteristics of the patient to ensure sleep hygiene. It was stated that before going to sleep, he should stay away from excessive mental stimulus and apply methods such as reading books and listening to music to facilitate the transition to sleep. The patient stated that the sleep problems he had experienced caused him to feel tired during the day and that he had a very difficult time in his work life. Thereupon, it was recommended to meet with the physiotherapist in order to create an activity plan suitable for the patient's energy level. The patient stated that he initially thought that this meeting would not be beneficial for him and that he did not want to meet. At this stage, the choice is left to the patient, and the relationship between AS and exercise, the contribution of exercise and physiotherapy to symptom management, is explained in a method suitable for the characteristics of the individual. The resources that he can benefit from the disease-specific exercise programs are presented as an alternative, and the positive effects of exercise on the disease are also emphasized. As stated before, H.A. stated that he was diagnosed with AS at the age of 30. He stated that his self-confidence decreased due to a change in posture and the development of kyphosis over time, that he did not want to meet with any of his friends, and that he even avoided marriage because he was afraid that no one would like him. He stated that he did not use his medications in the first years of his diagnosis, and therefore his posture deteriorated rapidly, and this situation affected him psychologically very badly. In this direction, the patient was given the opportunity to express himself and to express his feelings and thoughts. He was encouraged not to perceive his illness negatively and not to hesitate to express himself comfortably and openly to the person with whom he communicated. It was explained that the changes he experienced developed due to the disease, but his progress could be stopped with exercise and rehabilitation. The effect of changes in body image on social life was evaluated. A long-term roadmap was determined by discussing possible causes and actions can be taken with the patient.

H.A. states that he did not use his medicine for a long time at first because he was diagnosed at a young age and could not accept the disease, then he had problems with medication adherence from time to time, and he did not go to the doctor for a year due to the pandemic and could not do the recommended exercises. At this stage, it was suggested that the patient talks to his doctor over the phone, the importance of the arrangement of his medications and exercises were explained, and the exercises and practices that he could do at home were discussed with the patient, and he was encouraged to turn to home exercises. Plans were made to increase the patient's quality of life, the effect of adherence to drug therapy on disease management was explained, and suggestions were presented to increase the adaptation to daily life in line with his needs. Information was given about domestic regulations such as not using pillows while lying down or using pillows suitable for their posture, preferring an inclined table, avoiding sitting on low soft seats for a long time, etc.

Evaluation of Help Achievement: At this stage, it was evaluated whether the patient's need for help was met. As a result of his phone call with his doctor about pain management, a medication change was made. After the phone calls he made with his doctor regarding compliance with the treatment, his medication arrangement was made, and it was observed that he started to use his medications regularly. It was determined that his level of knowledge about non-pharmacological methods was low, and methods that could be applied in line with his individual characteristics were determined and suggested. The patient stated that his sleep quality increased and he woke up better in the morning after the domestic arrangements for fatigue and deterioration in sleep patterns and the stretching movements he made before going to sleep. After the interviews with the individual about the deterioration in body image, he was provided with a physiotherapy specialist to stop the development of kyphosis or prevent it from getting worse.

Conclusion: Nursing care interventions include practices that center on the person/patient. For this reason, the field of duty of nursing can be expressed as "now" or "the moment when it is in communication with the person/patient" (Muslu and Ozsoy, 2017). Wiedenbach defined nursing as "the art of helping". The art of nursing consists of conscious actions driven by the behavior of the patient; however, a nurse is a person who not only acts, but also thinks, feels and evaluates. Knowledge, on the other hand, encompasses everything perceived and grasped by the human mind. It can be real, speculative or practical. A nurse uses her academic/professional knowledge and implicit knowledge from her experiences while planning and implementing interventions (Wiedenbach, 1963). The use of theory in nursing care provides the solution of problems and the increase in the quality of care by using different care models in patient care and disease management (Zuhur and Ozpancar, 2017). Especially chronic diseases have created the need for individual care, as they require long-term care, affect the individual in all aspects, and show individual differences. In this context, the use of nursing theories and models ensures that care is individualized and of a certain standard and quality (Koc et.al.,2017; Inan, Ustun and Bademli, 2013).

When examined in the literature, it is seen that although the interest in nursing models and theories is high in theory, its use is limited in research and data collection stages, mostly in patient care interventions (Zuhur and Ozpancar, 2017; Koc et.al.,2017; Inan, Ustun and Bademli, 2013; Theofanidis & Fountouki, 2008). Wiedenbach's theory allows determining the help needs of patients diagnosed with AS, a chronic disease, to plan individual care in line with these needs, to provide the patient's need for help, and to evaluate the effects of the nursing care provided. Therefore, in the conceptual framework of nursing care to be applied to patients with AS, it is recommended to use the nursing model of Wiedenbach, which advocates individualized care, and it is thought that this model will guide the execution of effective nursing care.

Informed Consent Statement: Necessary consent for the study was obtained from the patient.

Sidebar

Correspondence: N. Hazal Doner, Lecturer, Izmir University of Economics, Vocational School of Health Services. 35330 Balcova, Izmir, Turkey e-mail: [email protected]

References

References

Aksu K, (2015), Certolizumab pegol for ankylosing spondylitis treatment. RAED Journal 7(1):14-S17.

Akyol G., Alevli S. & Ucan ES. (2013) The relationship between pulmonary function and exercise capacity and quality of life in patients with ankylosing spondylitis. Tuberk Toraks 61(3): 227-234.

Bagcivan G, Cinar FI, Cinar M, Oflaz F, Uzun S, Pay S. (2015) Living with pain in ankylosing spondylitis: a qualitative study. Contemp Nurse 51(2-3): 135-47.

Baykara ZG, Calikan N. , Ozturk D., Karadag A. (2019) The Use Of Nursing Theories And Models: A Qualitative Study. Cukurova Med J. 44(1):281289.

Baysan A, Yildirim Y, Fadiloglu ZC, Ayker SF.(2019) Education Based On The Nursing Theory Of Wiedenbach For Individuals With A Stoma. Van Health Sciences Journal 12(1):20-25.

Braun J & Sieper J. (2007) Ankylosing spondylitis. Lancet 369:1379-90.

Dean LE, Jones GT, MacDonald AG, Downham C, Sturrock RD, Macfarlane GJ. (2014) Global prevalence of ankylosing spondylitis. Rheumatology 53:650-657.

Eashwar V.M.A., Dinesh T, Gopalakrishnan S. (2019) Ankylosing spondylitis - A review article. Drug Invention Today 12(11):2759-63.

Hawkins J.(1987) The historical evolution of theories and conceptual models for nursing. Chestnut Hill, MA: Boston College. (ERIC Document Reproduction Service No. ED284969)

Inan FS, Ustun B & Bademli KA. (2013) Review Of Theory/Model-Based Nursing Research In Turkey. Journal of Anatolia Nursing and Health Sciences 16(2): 132-139.

Jayamalli N & Priya J.(2020) Conceptual Framework for the study based on Ernestine wiedenbach helping art of clinical nursing theory - for coping and quality of life among perimenopausal women. Ann Trop Med & Public Health 23(23):232-381.

Kaya N, Babadag K, Kacar GY, Uygur E. (2010) Nurses' Nursing Model / Theory, Nursing Process, and Classification Systems Know and Implication Status. Maltepe University Journal Of Nursing Science And Art 3(3):24-33.

Koc Z, Kiziltepe SK , Tugba Cinarli T, Sener T. (2017) The Use of Theory in Nursing Practice, Research, Management and Education. Journal Of Education And Research In Nursing 14 (1):62-72.

Liang L, Pan Y, Wu D, Pang Y, Xie Y, Fang H. (2019) Effects of Multidisciplinary Team-Based Nurse-led Transitional Care on Clinical Outcomes and Quality of Life in Patients With Ankylosing Spondylitis. Asian Nursing Research 13:107-114

Muslu M & Ozsoy S. (2017) Nursing, Aesthetics and Art. Journal Of Education And Research In Nursıng 14 (4): 287-291.

Pektekin C. (2013) Nursing Philosophy Theories-Care Models and Political Approaches. Istanbul Medical Bookstore, İstanbul.

Petiprin, A (2020) Nursing Theory. Available at https://nursing-theory.org/theories-andmodels/wiedenbach-the-helping-art-of-clinicalnursing.php Accessed:13.02.2021

Sarı I, Ozturk M.A& Akkoc N. (2015), Treatment of ankylosing spondylitis. Turk J Med Sci 45:416-430

Song Y, Xie X, Chen Y, Wang Y, Yang H, Nie A, Chen H. (2021) The effects of WeChat-based educational intervention in patients with ankylosing spondylitis: a randomized controlled trail. Arthritis research & therapy 23(1) :72.

Sucuoglu H, Gun K, Uludag M, Sari H. (2015) Clinical Characteristics, Working, Education and Social Life of Patients with Ankylosing Spondylitis. J PMR Sci 18:79-86.

Teksoz E & Ocakci AF. (2014) Art Practices in Child Nursing, Dokuz Eylul University School of Nursing Electronic Journal 7(2): 119-123.

Thapa T & Thakur P. (2017) Effectiveness of Video Assisted Programme (VAP) On Knowledge and Practice Regarding Endotracheal Suctioning of Mechanically Ventilated Patients. International Journal of Science and Research 6(6): 2208-2212.

Theofanidis D., Fountouki A. (2008) Nursing Theory: a discussion on an ambiguous concept. International Journal of Caring Sciences. 1(1):15-20

Wiedenbach E. (1970), Nurses' Wisdom in Nursing Theory. The American Journal of Nursing 70(5): 1057-1062.

Wiedenbach E. (1963)The helping art of nursing. American Journal of Nursing 63:11 -54 Available at<http://journals.lww.com/ajnonline/Abstract/1963/6 3110/THE_HELPING_ART_OF_NURSING_.7>. a spx Accessed: 13.02.2021

Zuhur S & Ozpancar N. (2017) The use of nursing models in the management of chronic diseases in Turkey: A systematic review. Journal of Research and Development in Nursing 19(2):57-74.