Faye Abdellah: 21 Nursing Problems Theory

Abdellah's model answers a question you work through at the bedside every shift: what is actually wrong with this patient, and what does the nurse do about it. She built a typology of 21 nursing problems and a problem-solving method around it, and she did it at a time when nurses were taught that diagnosing was not their job.

Biography of Faye Glenn Abdellah

Faye Glenn Abdellah (March 13, 1919 – present) is a nursing research pioneer who developed the Twenty-One Nursing Problems. Her model was ahead of its era because it pointed at a nursing diagnosis, language nurses were then told had no place in their practice. She was the first nurse officer to rank a two-star rear admiral, and the first nurse and first woman to serve as a Deputy Surgeon General.

Early Life

Abdellah was born March 13, 1919, in New York to a father of Algerian heritage and a Scottish mother. The family later moved to New Jersey, where she attended high school.

On May 6, 1937, the German hydrogen-fueled airship Hindenburg exploded over Lakehurst. Abdellah and her brother witnessed the fire and the deaths. That was the turning point. She decided she would never again be powerless when people needed help, and she vowed to become a professional nurse.

Education

Abdellah earned a nursing diploma from Fitkin Memorial Hospital's School of Nursing, now the Ann May School of Nursing. A diploma was enough to practice in the 1940s, but she argued nursing care should rest on research, not hours of care.

She went on to earn three degrees from Columbia University: a bachelor of science in nursing in 1945, a master of arts in physiology in 1947, and a doctor of education in 1955. With that training she could have become a physician. She chose not to. As she explained, she could do everything she wanted within nursing, a caring profession.

Career and Appointments

As an Educator

In her early twenties, Abdellah worked as a health nurse at a private school. Her first administrative post was on the faculty of Yale University from 1945 to 1949, where she was assigned to teach "120 Principles of Nursing Practice" from a National League for Nursing textbook. The book's guidelines had no scientific basis, and she could not defend them to her students. After a year of frustration she gathered colleagues in the Yale courtyard and burned the textbooks. The dean made her pay for them, a debt that took a year to settle, but she never regretted it. It set her on the road to building a scientific basis for practice.

As a Researcher

In 1949 she met Lucile Petry Leone, the first Nurse Officer, and joined the Public Health Service, assigned to the division of nursing focused on research. Abdellah pushed for degree programs over diploma programs, which she believed were never meant to prepare nurses at a professional level. Her early studies were qualitative descriptions; as her career progressed her work pulled in physiology, chemistry, and behavioral sciences.

In 1957 she led a research team in Manchester, Connecticut, that laid the groundwork for progressive patient care: critical patients in an intensive care unit, then immediate care, then home care. The first two phases caught on fast. Abdellah is also credited with developing the first nationally tested coronary care unit out of that work.

Home care, the third phase, met resistance in the mid-twentieth century. People assumed it meant a maid or private nurse in every home, and missed that nurses teaching self-care help patients regain independent function. Forty years later, home care was central to long-term health care.

Established Nursing Standards

Abdellah developed the Patient Assessment of Care Evaluation (PACE), a standards system for measuring the quality of individual health-care facilities, still in use into the 21st century. She was among the first to build a classification system for patient care and patient-oriented records. That work was foundational to Diagnostic Related Groups (DRGs), the coding system Medicare adopted to categorize patients by primary and secondary diagnoses. Each DRG code caps what Medicare pays for a diagnosis or procedure, factoring in patient age and length of stay, which gives providers an incentive to keep costs below the category amount.

Military Nursing Service

During her 40-year career as a Commissioned Officer in the U.S. Public Health Service from 1949 to 1989, Abdellah worked with the Korean people during the Korean War. As a senior officer she was assigned to Japan, China, Russia, Australia, and the Scandinavian countries to define the Public Health Service's role in addressing various health problems, initiating studies in an advisory role.

She served as Chief Nurse Officer from 1970 to 1987 and was the first nurse to reach two-star Flag Officer, named by U.S. Surgeon General C. Everett Koop as the first woman and nurse Deputy Surgeon General from 1982 to 1989. After retirement she founded and served as first dean of the Graduate School of Nursing (GSN) at the Uniformed Services University of the Health Sciences (USUHS).

Works

As a consultant and educator, Abdellah carried her theories worldwide, leading seminars in France, Portugal, Israel, Japan, China, New Zealand, Australia, and the former Soviet Union, and serving as a research consultant to the World Health Organization. That global view taught her to take nontraditional and complementary treatments seriously and to argue they deserved scientific study.

She is a prolific author with more than 150 publications, including Better Nursing Care Through Nursing Research and Patient-Centered Approaches to Nursing, and she developed public-health materials on AIDS, hospice care, and drug addiction. She counts her greatest accomplishment as helping establish a foundation for nursing research as a science. Her problem-solving method serves as a vehicle for naming nursing (patient) problems as the patient moves toward a healthy outcome.

Additional works include Preparing Nursing Research for the 21st Century: Evolution, Methodologies, Challenges; New Directions in Patient-Centered Nursing: Guidelines for Systems of Service, Education, and Research; Effect of Nurse Staffing on Satisfactions with Nursing Care; Patients and Personnel Speak; A Method of Studying Patient Care in Hospitals; Appraising the Clinical Resources in Small Hospitals; Nursing's Role in the Future: The Case for Health Policy Decision Making; Overview of Nursing Research, 1955-1968; the Surgeon General's Workshop, Health Promotion, and Aging proceedings (March 20-23, 1988); and Words of Wisdom from Pivotal Nurse Leaders.

Awards and Honors

Abdellah is recognized as a leader in nursing research within the Public Health Service and as an international expert on health problems. The American Academy of Nursing named her a "living legend" in 1994, the National Women's Hall of Fame inducted her in 2000, and the American Nurses Association inducted her into its Hall of Fame in 2012. Her contributions have earned almost 90 professional and academic honors, including the Allied Signal Achievement Award for pioneering research in aging and Sigma Theta Tau's Lifetime Achievement Award. Her legacy spans more than 60 years.

Her 21 Nursing Problems Theory shifted nursing's focus from disease-centered to patient-centered and brought the care of families and the elderly into the frame. PACE remains the standard used in the United States.

Abdellah's 21 Nursing Problems Theory

In Abdellah's words, nursing "is based on an art and science that molds 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."

This is a human needs theory built from her practice. She designed it as an instrument for nursing education, where it fits best, but it guides care in hospitals and applies to community health nursing as well.

Assumptions

Abdellah's assumptions center on change and anticipated change affecting nursing: the interconnectedness of social enterprises and social problems; the impact of poverty, racism, pollution, and education on health and health-care delivery; the need to change nursing education and to continue educating professional nurses; and the development of nursing leaders from underserved groups.

Major Concepts of 21 Nursing Problems Theory

The model interrelates health, nursing problems, and problem-solving, an approach that is logical by nature.

Individual

Abdellah describes the recipients of nursing as individuals (and families), though she does not spell out her assumptions about the nature of human beings.

Health

Health is the purpose of nursing service. Abdellah does not define it directly but speaks of "total health needs" and "a healthy state of mind and body." Health can be read as a dynamic pattern of functioning, a continued interaction with internal and external forces that produces the optimal use of resources to minimize vulnerabilities.

Society

Society enters through "planning for optimum health on local, state, and international levels," but the clear focus of nursing service stays on the individual.

Nursing Problems

A client's health needs can be viewed as problems, either overt (an apparent condition) or covert (hidden or concealed). Covert problems are often emotional, sociological, or interpersonal, so they get missed or misread. Solving the covert problem often resolves the overt one too.

Problem Solving

Quality professional nursing requires the nurse to identify and solve both overt and covert problems: identify the problem, select pertinent data, formulate hypotheses, test them by collecting data, and revise them when the data demand it.

Subconcepts

Abdellah's Typology of 21 Nursing Problems

The 21 nursing problems fall into three categories: the physical, sociological, and emotional needs of patients; the types of interpersonal relationship between patient and nurse; and the common elements of patient care. Abdellah used Henderson's 14 basic human needs and nursing research to build the classification. The 21 problems are:

1. To maintain good hygiene and physical comfort.
2. To promote optimal activity: exercise, rest, sleep.
3. To promote safety by preventing accidents, injuries, or other trauma and preventing the spread of infection.
4. To maintain good body mechanics and prevent and correct deformity.
5. To facilitate the maintenance of a supply of oxygen to all body cells.
6. To facilitate the maintenance of nutrition for all body cells.
7. To facilitate the maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolyte balance.
9. To recognize the physiologic responses of the body to disease conditions, pathologic, physiologic, and compensatory.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory function.
12. To identify and accept positive and negative expressions, feelings, and reactions.
13. To identify and accept interrelatedness of emotions and organic illness.
14. To facilitate the maintenance of effective verbal and nonverbal communication.
15. To promote the development of productive interpersonal relationships.
16. To facilitate progress toward achievement and personal spiritual goals.
17. To create or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.
19. To accept the optimum possible goals in the light of limitations, physical and emotional.
20. To use community resources as an aid in resolving problems that arise from an illness.
21. To understand the role of social problems as influencing factors in the cause of illness.

Patient needs divide further into four categories: basic to all patients, sustenal care needs, remedial care needs, and restorative care needs.

Basic Needs

Maintain good hygiene and physical comfort; promote optimal health through exercise, rest, and sleep; promote safety by preventing accidents, injury, trauma, and the spread of infection; and maintain good body mechanics and prevent or correct deformity.

Sustenal Care Needs

Maintain the supply of oxygen to all body cells; maintain nutrition and elimination; maintain fluid and electrolyte balance; recognize the body's physiologic responses to disease; and maintain regulatory mechanisms, functions, and sensory function.

Remedial Care Needs

Identify and accept positive and negative expressions, feelings, and reactions; accept the interrelatedness of emotions and organic illness; maintain effective verbal and nonverbal communication; develop productive interpersonal relationships; advance personal spiritual goals; create and maintain a therapeutic environment; and build awareness of the self as an individual with varying physical, emotional, and developmental needs.

Restorative Care Needs

Accept the optimum possible goals within physical and emotional limitations; use community resources to resolve problems arising from illness; and understand the role of social problems as factors in illness.

Abdellah's problem-solving method names 10 steps to identify the patient's problem and 11 nursing skills to develop a treatment typology.

The 10 steps:

1. Learn to know the patient.
2. Sort out relevant and significant data.
3. Make generalizations about available data concerning similar nursing problems presented by other patients.
4. Identify the therapeutic plan.
5. Test generalizations with the patient and make additional generalizations.
6. Validate the patient's conclusions about his nursing problems.
7. Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his or her behavior.
8. Explore the patient and their family's reactions to the therapeutic plan and involve them in the plan.
9. Identify how the nurses feel about the patient's nursing problems.
10. Discuss and develop a comprehensive nursing care plan.

The 11 nursing skills:

1. Observation of health status
2. Skills of communication
3. Application of knowledge
4. Teaching of patients and families
5. Planning and organization of work
6. Use of resource materials
7. Use of personnel resources
8. Problem-solving
9. Direction of work of others
10. Therapeutic uses of the self
11. Nursing procedure

Abdellah also framed nursing as a comprehensive service, which includes:

1. Recognizing the patient's nursing problems.
2. Deciding the appropriate course of action in terms of relevant nursing principles.
3. Providing continuous care of the individual's total needs.
4. Providing continuous care to relieve pain and discomfort and provide immediate security.
5. Adjusting the total nursing care plan to meet the patient's individual needs.
6. Helping the individual become more self-directing in attaining or maintaining a healthy state of body and mind.
7. Instructing nursing personnel and family to help the individual do for himself what he can within his limitations.
8. Helping the individual adjust to his limitations and emotional problems.
9. Working with allied health professions in planning for optimum health on local, state, national, and international levels.
10. Carrying out continuous evaluation and research to improve nursing techniques and develop new ones.

Patient-Centered Approaches to Nursing

Abdellah's set of problems is framed in terms of nursing-centered services used to determine the patient's needs. That orientation sits in tension with the client-centered approach she professes. In moving away from a disease-centered orientation, she swings the pendulum to a nursing orientation, leaving the client somewhere in the middle.

21 Nursing Problems and the Nursing Process

The nursing process in Abdellah's theory runs assessment, nursing diagnosis, planning, implementation, and evaluation.

In assessment, the nursing problems set a standard procedure for data collection: for each identified problem, gather pertinent data, using a direct approach for overt problems and an indirect one for covert problems. The collected data points to the patient's possible problems, grouped under one or more broader nursing problems, which leads to the nursing diagnosis.

After the diagnosis, build a nursing care plan and determine the appropriate interventions. Putting those interventions into action completes implementation. Evaluation follows, measured most readily by the patient's progress, or lack of it, toward the goals set in planning.

Analysis

Abdellah set out to build a clear categorization of patient problems as health needs, but she ended up conceptualizing the nurse's actions instead, defining the nurse's role as alleviating the assessed problems. The problem-solving approach has a real advantage: it sharpens the nurse's critical and analytical thinking, because care rests on sound assessment and validated findings.

The framework applies strongly to individuals as the focus of care. Including aggregates such as the community or society would make it more generalizable, which matters as community-level care gains importance over curative effort in the hospital.

Strengths

The problem-solving approach generalizes readily to clients with specific health needs and specific nursing problems. Practitioners can use it to guide activities across the clinical setting. The language is simple and easy to follow, and the theory centers on problem-solving, an activity that is logical by nature.

Weaknesses

The main limitation is the strong nurse-centered orientation: Abdellah conceptualized the nurse's actions rather than what the client is to achieve, which she had set out to do. The heavy focus on nursing practice and individuals limits generalizability. The framework is also inconsistent with holism. Because the patient can be diagnosed with numerous problems, care can fracture, and potential problems may be overlooked when the client is not seen as being in a particular illness stage.

Conclusion

Abdellah's typology of 21 nursing problems is a conceptual model concerned with patient needs and the nurse's role in identifying problems through problem analysis. Patients are described as having physical, emotional, and sociological needs, and people are the only justification for nursing's existence.

Health is described as a state mutually exclusive of illness; Abdellah does not define it but speaks to "total health needs" and "a healthy state of mind and body." Her framework conceptualizes the nurse's actions more than the categorization of patient problems she aimed for. The theory guides care in the hospital and in community nursing alike. The 21 nursing problems later advanced into a second generation framed as patient problems and patient outcomes, and Abdellah went on to educate the public on AIDS, drug addiction, violence, smoking, and alcoholism.