COVID-19 and Psychological Trauma

I feel guilty as I write this. You see, I’m home with my family, safe and warm. Protected. Others, my comrades and fellow nurses are not. But I can guess, and have read and been informed of what they are facing on the front lines: reassigned to new hospitals and new duties, rendering care, sometimes coerced by employers, without adequate protective equipment. No masks. No gowns. No testing to know who is indeed positive for the virus. One of my students wrote to me, expressing her ethical dilemma of whether to care for patients while she went unprotected, potentially cross-pollinating other patients and her family. They – her employers – had reminded her that she has ethically pledged to do so. Her note brought it to a personal level to me. What could she do, she asked me? I advised her to document, to bring others into the demands of adequate protection, and to consult the CDC guidelines, contact her county health department and so forth. I felt my advice was not nearly enough, a defective response to an impossible riddle.

We are in a pandemic, a global disaster, if you will. The United Nations Office of Disaster Risk Reduction: International Strategy for Disaster Reduction (2017) defines disaster as:

A serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts. Annotations: The effect of the disaster can be immediate and localized, but is often widespread and could last for a long period of time. The effect may test or exceed the capacity of a community or society to cope using its own resources, and therefore may require assistance from external sources, which could include neighbouring jurisdictions, or those at the national or international levels (n.p.).

That about sums it up, doesn’t it? But what of the nurses’ psychological trauma experienced in the disaster?

My student described insufficient resource trauma, the lack of tangible and intangible resources necessary to render safe and quality care. The resources include knowledge, supplies, nursing staff, and other professionals.

My Middle Range Theory of Psychological Trauma includes this type of psychological trauma and the trauma experienced by being a social actor in the midst of an unfolding disaster (see Figure). Nurses will surely face secondary/vicarious trauma as they witness patients’ suffering and offer comfort and caring. They may participate in system or medically-induced trauma as patients are placed on ventilators, relinquishing control of their bodies. For some patients who lived through the Great Depression, memories of austere times may be invoked, causing anxiety and reflective of historical trauma.

Physicians are often tasked with triaging during disasters as the resources become more strained. But I have met with nurses who were involved in the California fires not too long ago. They felt forgotten and overlooked when the post-fire debriefings took place, as if their place in the healthcare hierarchy removed them from sitting at the healing table.

Another graduate nursing student emailed me about her class assignment. She probably won’t be able to finish it because of all the activities she is being called to do in her hospital, an ever changing world filled with chaos and uncertainty. When I weigh the final paper with saving lives, is there any doubt about what priority I should endorse?  But this is territory I’m unfamiliar with.

What I can do is remind myself that my world should be revised, amended, and my teaching should be trauma-informed. I should lace my work with compassion and an understanding of the overwhelming need for people to feel safe, their voices to be heard, and their recovery to be purposeful and inclusive. I can give names to the trauma they are exposed to and by doing so, offer them a path to express this psychological injury now and in the future so that recovery can unfold.

References

Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Indianapolis, IN: Sigma.

United Nations Office of Disaster Risk Reduction. (2017). Terminology. Retrieved from:  https://www.unisdr.org/we/inform/terminology.

 

Hidden Risks of Physical Distancing and Social Isolation

The single most important and essential step being taken worldwide to contain the spread of the COVID19 crisis is what is widely known as “social distancing.” But in fact this is physical distancing that heightens the risk of social isolation, conflict and stress. This necessary physical distancing is only tolerable for the most introverted of introverts, leaving the rest of the population in a state of periodic unrest at best, and deep distress at worst.  We are then faced with not only the possibility of disease/illness caused by the novel corona virus – we are faced with the dis-ease of daily living.  When the environment to which someone is compelled to retreat is a relatively safe haven that provides nurturing and encourages creative solutions to the inevitable frustrations and stress, the outcome will probably be okay at least – perhaps even resulting in some new and healthier patterns of daily living!  But the reality is that for far too many, the environment of “home” is a place of emotional tension, sometimes even emotional and/or physical danger.  For those who are “essential” workers – like many nurses – the workplace where they are now compelled to spend a considerable amount of time is one where their own physical well-being is at risk, and the culture may be also less than nurturing or pleasant – even abusive.  Even the best of circumstances can easily erupt into harmful conflict and emotional tension at a moment’s notice, ignited by the stress and tension of the uncertainties and dangers that we all face in this pandemic.

Now more than ever the world needs nursing – the practice of caring for others informed by the knowledge and the wisdom passed along in the theories and philosophies of nursology.  To me the unifying unique characteristic that is so vital as we face the COVID19 pandemic is the holistic nature of nursing theory and practice.  There are many insights that any of us can tap into in any of our theories – now documented on this website and accessible through the site’s galleries.

My theory and practice of “Peace and Power” is among those that directly address the challenges of social and emotional conflict and distress – distress that also compromises physical well-being.  The theory was developed as an approach to group process that shifts away from the power-over (often damaging) approaches that dominate group interactions, and toward an approach that nurtures all, that respects each person’s humanity, and that deals with conflict in ways that nurture growth and healing – not harm and hurt.  The “group” can  be as small as two people!  Shifting to this approach is not easy and it is especially hard to start learning in a context already stressed by the current pandemic – but it can be done!  The specific theoretical concept and practice is “conflict transformation.”  This abstract concept is possible to translate directly into practice – into the realities of every-day life – starting with awareness of the potential for unrest during this challenging time, and the commitment to  start practicing even with the smallest tension!   Here are a few practical ideas for using this approach where you live and work now.

When you are directly involved in a stressful interaction:
  • If you can, acknowledge the situation as soon as you even suspect that this might escalate.  Do not try to “fix” the conflict, simply acknowledge that it is happening, and ask for others to take time to reflect and find a new direction.  If it is now already escalated, step in to share (briefly) your sense of what is happening, and to ask everyone to take time to breathe and reflect on what is happening. This may be a few minutes, or a few hours – maybe a couple of days.
  • During this time, take deep breaths every few minutes to calm and center your spirit.  Focus on your own body/mind/spirit feelings and your own hopes for how this situation will unfold. Recognize and take into account the stress of the situation around you – in this case the pandemic and the real-life stress everyone is experiencing.
  • Shift to a place of inner calm, where you move away from blame and toward understanding of the situation as a whole.
  • Clarify the underlying values that you believe everyone in the situation shares.
  • Prepare your own “critical reflection” that you will share with the others involved.  This reflection consists of these elements:
    • I feel … focus on your own feelings without blaming others
    • When (or about) … describe factually what happened when your feelings came to the surface.
    • I want, I offer .. describe what you envision happening next to move away from or resolve (transform) the conflict, even if it seems impossible to happen.
    • Because … name the value, goals or ideals that you share with the others who are involved.
  • Take a deep breath, and return to the situation ready share your reflection and invite the others to also move away from conflict toward peaceful and health-promoting interactions. Listen carefully to what everyone shares, and join with them in finding a path forward.  The path might still be rocky along the way, but you will now have a foundation from which you can build.  Keep the process of transforming conflict alive and well as you navigate troubled waters.
When you observe a stressful, potentially harmful interaction:
  • Acknowledge what you are observing, even if it is not immediately clear that something harmful is happening.
  • Offer to serve as a mediator or facilitator, bringing awareness of the situation to light, and encouraging a move away from harm and toward understanding
  • If others are open, share the “Peace and Power” process of conflict transformation as an approach to deal with the situation.

Your Well-Being as a Nurse and the COVID-19 Pandemic

We are in an unprecedented time in history with the coronavirus (COVID-19) pandemic. Nurses and other crucial healthcare providers are at the frontline navigating uncharted and uncertain territory. There are limited supplies, including personal protective equipment, and little is understood regarding the pathway to healing with COVID-19. As such, the management team at Nursology.net has decided to dedicate a series of blog posts to COVID-19 using nursing knowledge as our framework. We hope that with these posts you become more informed about the unknown, and also find some stability during these shaky times. Our first post is dedicated to you, the nurses, and your well-being by PhD candidate Chloe Littzen.

Conceptual Framework for Young Adult Nurse Work-Related Well-Being

As a PhD student, I focused my studies on understanding the well-being of nurses, while specifically emphasizing young adult nurses. Over time, and with the guidance of my trusty advisor and committee, I developed a conceptual framework on the work-related well-being of young adult nurses. This framework and its development are based on my philosophical perspective as an intermodernist (Reed, 1995; 2019), nursing and non-nursing theories (Benner, 1982; Kramer, 1974; Baltes, 1987), salient knowledge on nurse well-being (Paatalo & Kyngas, 2016), relevant nursing knowledge (Fawcett, 1993; Newman, 1992; Parse, 1987; Terry, 2018), and my personal experiences as a young adult nurse. While this is in-process work, this framework has the potential of being a practical tool for nurses’ looking for a resource to help manage their well-being in these uncertain times. 

For a quick refresher, a conceptual framework is a type of theoretical thinking that is abstract, broad in scope, and uses general concepts (Reed, 2018). Within my conceptual framework on young adult nurse work-related well-being there are four main concepts: 1) generational differences in philosophical worldviews; 2) perceived co-worker social support; 3) resilience; and, 4) young adult nurse work-related well-being. The takeaway message is these concepts may all have a significant role in our well-being as nurses. Additionally, there may be things that we can do to sustain and enhance our well-being with these concepts in mind; especially now when our well-being is more vulnerable than ever. So below is a beginning theoretical how-to guide for you to sustain and enhance your well-being at work during this time of unease.

A Theory Guided Approach for Nurse Work-Related Well-Being

  1. We All Don’t See The World The Same Way

This proposition is based upon my concept of generational differences in philosophical worldviews. What this proposition infers is that while we would like to think as nurses we see the world the same way we don’t always.

This is not a bad thing and is quite normal in diverse groups such as the discipline of nursing (there are over 3.8 million nurses in the United States alone!). That being said, it can be stressful when you are faced with a situation where you and colleagues have a disagreement. 

So what can you do to aid these disagreements, especially in crisis times like now?
Try these five easy steps: 
  1. Stop and take a breath. Everything’s better when you breathe, and you have to breathe to do whatever it is you need to do, even critical situations.
  2. Acknowledge your colleagues’ perspective. Whether you agree with it or not, meet them with kindness and respect.
  3. Ask your colleague to explain, when appropriate, why they think about the situation the way they do. If you can’t do this when the event occurs due to the criticality of the situation, ask them to talk afterward even if it is uncomfortable.
  4. Whatever happens, don’t harbor negative thoughts because of disagreements. This can not only be harmful to you but also those around you.
  5. Ask yourself how you have grown from this interaction. What did you learn? Will you do something differently next time you interact during a disagreement?

2. Put Your Oxygen Mask On First

I think this is something we all know intuitively, but because we are nurses (there are some similarities among us I think), we are often more concerned about helping those around us than ourselves. While this is a wonderful character trait, this often leaves us depleted and burned out, ultimately negatively impacting our well-being. So this proposition is focused on building your resilience capacity, where every day you put your oxygen mask on before stepping out the front door.

How do I do that? 

First and foremost identify something that makes you happy.
Not your family member, not your friend, you

Nourish to Flourish

Image by @dlhamptom

You can call this self-care, but whatever it is it has to make you happy and you have to take time out for it. Everyone is different but ask yourself, what works for you? Every day select an amount of time that fits your schedule, whether 5, 20, or 60 minutes, and block it off on your calendar. Treat it like an appointment with your boss, do not break it. Be bigger than your biggest excuse and show up for yourself. If you need to, talk to your family about how you are feeling and see how they can support you during this time. 

So to refresh, here are four steps for you to build your resilience capacity: 
  1. Identify what makes you happy. Alternatively, if you are so depleted that you can’t think of something that makes you happy, try something new!

    For Example:
    Start a daily yoga practice using an online platform (follow the link to a 14-day free trial).
    Try a daily meditation using an app.
    Read a non-work related book, even a page a day counts.
    Go outside (while practicing appropriate physical distancing) for a walk.
  2. Decide upon an amount of time you can dedicate to yourself every day.
  3. Schedule an appointment on your calendar
  4. Show up, every day, even when you don’t want to.  

3. We All Need to Feel Supported

Grow Together

Image from @dommaraju

One of the biggest take-home messages about nurses’ I learned while pouring over the well-being literature is that we need each other, and we need to feel supported. Nurses seem to do better in every organizational outcome if they feel supported by their colleagues and management, which during times of crisis can easily crumble. So what can you do to help yourself feel supported, and simultaneously help your colleagues feel supported?

Find an accountability buddy!

What is an accountability buddy? This is a person that supports you in your well-being, while you simultaneously support their well-being. If you are currently working in the hospital or clinic, this should be a person at your place of work, and optimally each shift you work. If you cannot identify an accountability buddy at work, then identify someone outside of work that you can talk to after your shift. Lastly, if you’re in quarantine or physical distancing (otherwise referred to as social distancing, but more on that at a later time), identify a colleague who you can talk with throughout the day from home over email, texting, or a chat app such as WhatsApp or MarcoPolo. Just because you’re at home doesn’t mean you don’t need support. 

So what do I do with my accountability buddy?

Below are some suggestions to promote support during these uncertain times. But take the time to ask yourself what you need, and also ask your buddy what they need, and then revise as you learn more about each other!

In the Work Environment Physical Distancing or Quarantining After Work
  • Check-in with each other at the beginning, and throughout your shift. Ask each other how you are doing.
  • Advocate for each other to take breaks and lunch, when appropriate.
  • Promote a work environment where you both have someone to talk to if you feel anxious or overwhelmed.
  • Look out for each other to make sure you’re not taking on too much responsibility.
  • Give kudos to each other for positive well-being behaviors (e.g., you did yoga today, that’s so great!).
  • Send each other a daily message and ask each other how you are doing.
  • Advocate for each other to take scheduled breaks and lunch.
  • Promote a space where you both have someone to talk to if you feel anxious or overwhelmed.
  • Share your daily goals with each other, both work and self-care related.
  • Check in to see how you are both progressing through the day.
  • Give kudos to each other for positive well-being behaviors (i.e., you went outside for a walk today, that’s great!) 
  • Check-in with each other after work and share how you are doing over the phone, FaceTime, or Zoom.
  • Reflect on how you took care of yourself today, did you take time for yourself? Did you take a break or lunch?
  • Make a well-being goal for the next day at work. Ask your buddy if this is realistic and achievable, and reform as needed.
  • Check-in daily regarding your well-being goals.
  • Give kudos to each other for positive well-being behaviors (i.e., you asked for help when you needed it, that’s awesome!)

Where to start? 

We are all different, and one of these propositions may have spoken to you more than the others. Start there! Maybe you are already doing one of these suggested, if so, keep it up and try another suggestion to see if it help even more. Above all, just do something! As nurses, our well-being is a critical piece to making it through this difficult time, not just for ourselves, but for everyone on this planet. Change is never easy. We can’t go back and start a new beginning, but we can start today and make a new ending.

Stay safe and please take care of your well-being. 

References

Baltes, P. B. (1987). Theoretical propositions of life-span development psychology: On the dynamics between growth and decline. Developmental Psychology, 23(5), 611-626. https://doi.org/10.1037/0012-1649.23.5.611

Benner, P. (1982) From novice to expert. The American Journal of Nursing, 82(3), 402-407. https://doi.org/

Fawcett, J. (1993). From a plethora of paradigms to parsimony in worldviews. Nursing Science Quarterly, 6(2), 56-58. https://doi.org/10.1177/089431849300600202

Kramer, M. (1974). Reality shock: Why nurses leave nursing. The C.V. Mosby Company.

Newman, M. A. (1992). Prevailing paradigms in nursing. Nursing Outlook, 40(1), 10-13.

Newman, M. A., Smith, M. C., Pharris, M. D., & Jones, D. A. (2008). The focus of the discipline revisited. Advances in Nursing Science, 31(1), e16-e27. https://doi.org/10.1097/01.ANS.0000311533.65941.f1

Parse, R. R. (1987). Nursing science: Major paradigms, theories, and critiques. W. B. Saunders Company.

Paatalo, K., & Kyngas, H. (2016). Measuring hospital nurses’ well-being at work – psychometric testing of the scale. Contemporary Nurse, 52(6), 722-735. https://doi.org/10.1080/10376178.2016.1246072

Reed, P. (1995). A treatise on nursing knowledge development for the 21st century: Beyond postmodernism. Advances in Nursing Science, 17(3), 70-84. https://doi.org/10.1097/00012272-199503000-00008

Reed, P. G. (2018). A philosophy of nursing science and practice: Intermodernism. In P. G. Reed & N. B. C. Shearer (Eds.), Nursing knowledge and theory innovation: Advancing the science of practice. Springer Publishing Company.

Reed, P. G. (2019). Intermodernism: A philosophical perspective for development of scientific nursing theory. Advances in Nursing Science, 42(1), 17-27. https://doi.org/10.1097/ANS.0000000000000249

Terry, H. (2018). Critical inquiry into philosophical perspectives underlying nursing research on acute coronary syndrome [Unpublished doctoral dissertation]. The University of Arizona.

What is Reflected in a Label about Health? Non-Nursology and Nursology Perspectives

Posted the first week of March, which is designated as
National Words Matter Week

A long time ago, I read an editorial in a journal decrying the labels for women’s reproductive health issues. The point was that labels such as incompetent cervical os are pejorative words. At about the same time, I began to think about what we mean when we say that a person (called a patient or a client) does not comply with or adhere to a treatment plan. It seems to me that these words reflect the physician’s or the nursologlist’s prescriptions for the patient, which in turn, reflect the physician’s or the nursologist’s power over and control of the patient.

Indeed, Hess (1996) pointed to “connotations of paternalism, coercion, and acquiescence” (p. 19), and Bissonnette (2008) and Garner (2015) noted the power imbalance and loss of patient autonomy inherent in referring to a patient as non-compliant or non-adherent. I doubt that few if any nursologists would knowingly sanction paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Yet we continue to label patients as compliant or adherent if they do whatever they were supposed to do and as non-compliant or non-adherent if they do not do whatever they were supposed to do.

The issue, of course, is to identify a label that can be used to accurately reflect what happens between a person who is a patient and a person who is a healthcare worker as they interact in matters of health without an overlay of paternalism, coercion, acquiescence, power imbalance, or loss of autonomy.

Most, if not all, nursology conceptual models and theories include consideration of the person’s perspective of the health-related situation and may include a process that addresses how the situation is viewed and resolved. For example, the practice methodology associated with Neuman’s Systems Model includes the perspectives of both the person and the healthcare worker throughout the entire process of diagnosis, goals, and outcomes. The practice methodology associated with King’s Conceptual System is even more explicit, with mutual goal setting, exploration of means to achieve goals, and agreement on means to achieve goal. However, the practice methodologies associated with these nursology conceptual models and theories do not include a label for what happens if the patient does or does not do what had been agreed upon.

I have not yet identified a satisfactory label for what actually happens. However, I suspect that turning to nursology theories of power may provide at least the beginning of an appropriate label. For example, Barrett’s theory of power as knowing participation in change sensitizes us to the distinction between power-as-control and power-as-freedom. Barrett maintained that power-as-freedom involves awareness of what is happening, knowingly participating in choices to be made about what is happening, having the freedom to act intentionally, and being fully involved in creating changes in whatever is happening. Perhaps, then, the label could be knowing participation.

Another example is Chinn’s peace as power theory, which sensitizes us to the distinction between peace-power and power-over. The process of peace as power encompasses cooperation and inclusion of all points of view in making decisions. Accordingly, healthcare decisions are based on thoughtful choices as the person and the healthcare worker work together to promote wellness and growth. Perhaps, then, the label could be thoughtful cooperative choices.

What other label might be even more accurate? How can nursologists actualize our moral goal to do “good for the one for whom the [nursologist]” cares”? (Hess, 1996, p. 19). What label should we use to clearly reflect our ethical knowing? Hess’ (1996) discussion of ethical narrative suggests that cocreated narrative may be the accurate term. She explained, “ethical narrative is crafted by the client and [nursologist] to express the good they are seeking” and that ethical narrative is achieved “through engagement” (p. 20).

Labels, which are words, matter for many, many reasons. Labels may reflect paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Labels also may reflect racism and privilege and other words that perpetuate colonialism (McGibbon, Mulaudzi, Didham, Barton, & Sochan, 2014). We must, therefore, identify and consistently use labels that are consistent with ethical knowing in nursology, with clear understanding of “their meanings and the underlying philosophies or perspectives that they connote” (Lowe, 2018, p. 1).

This blog is adapted from Fawcett, J. (in press). Thoughts about meanings of compliance, adherence, and concordance. Nursing Science Quarterly.

References

Bissonnette, J. M. (2008). Adherence: A concept analysis. Journal of Advanced Nursing, 63, 634-643. Available from: http://dx.doi.org/10.1111/j.1365-2648.2008.04745.x

Gardner, C. L. (2015). Adherence: A concept analysis. International Journal of Nursing Knowledge, 26, 96-101. Available from: http://dx.doi.org/10.1111/2047-3095.12046

Hess, J. D. (1996). The ethics of compliance: A dialectic. Advances in Nursing Science, 19(1), 18-27.

Lowe, N. K. (2018). Words matter. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 47, 1-2.  Available from: http://dx.doi.org/10.1016/j.jogn.2017.11.007

McGibbon, E., Mulaudzi, P. M., Didham, P., Barton, S., & Sochan, A. (2014). Toward decolonizing nursing: The colonization of nursing and strategies for increasing the counter-narrative. Nursing Inquiry, 21. 179-191. Available from: http://dx.doi.org/10.1111/nin.12042 (See also https://nursology.net/2020/01/14/decolonizing-nursing/)

Part 1 – Access to Nursing Knowledge: A Privilege or a Right?

In the practice environment, nurses are guided by evidence-based practice, policy, and procedures specific to their institutions. Comparably, nurses in academia refer to recent and relevant academic literature based upon institutional licenses. In preparation for the Nursing Theory Annual Conference, a gap was revealed among members of the Nursology Theory Collective dependent upon their work environment as it related to access to nursing knowledge. As described by a member of the Nursology Theory Collective who has worked in the practice environment, I attempted to access a nursing research article from fifty years ago and found that I would have to pay $49, when the same article was freely available to my academic colleagues through their organizational access.” This member’s experience was not in isolation, and ended up being more of a norm than a rarity. At the publishers permission the article was able to be shared by academics to those without appropriate access in practice, but this is not a permanent solution and nor should it be a norm.

The question then arose: should access to nursing knowledge be a privilege or a right? Dependent upon our organizational affiliation (or lack thereof) nurses are blocked from relevant and essential nursing knowledge. Practicing nurses then have to consider purchasing academic literature, whether per article or journal subscription, at prices that may be unaffordable for their salary. Nurses in academics face similar issues when they are limited by what specific journal licenses their organizations may have. Ultimately, this may lead to nurses reaching out to colleagues located in other institutions in order to gain access to literature that is needed for their work.

The lack of equity in access to nursing and other disciplinary knowledge further perpetuates issues in nursing, such as the theory-practice gap also, referred to as the academic-practice gap. How can nurses in practice be expected to consider recent and relevant knowledge if they do not have access to it? Some nurses may never realize what they are, and are not able, to access. For example, when nurses’ are on-boarded or oriented into their healthcare institutions, if they are not educated on their resources (such as journal subscriptions or medical libraries – also, why aren’t there nursing or nursology libraries?), how can they be expected to use it for practice, education, or research? Similarly, how can nurses in academia educate or complete research on relevant nursing issues if they are blocked by paywalls (or should we say, selective paywalls – something to consider)? Reaching out to colleagues can result in loss of time/productivity, and coincidentally can place a colleague in an awkward situation. Moreover, this lack of equity in access to knowledge perpetuates a delay in translational research. Remember the old saying that it takes 17 years for research to become practical knowledge? In this day in age where knowledge is produced at such exponential rates, this shouldn’t be the norm.

Solutions for Change: Making Nursing Knowledge a Right

Instead of perseverating on the identified gap at hand, perhaps it’s time to discuss potential solutions and make nursing knowledge a right and not a privilege. Our hope is with this blog you can begin to educate yourself on what is equitable access to nursing knowledge, including potential solutions for change. With this, perhaps you can take some of these solutions back to your institution and colleagues, and keep some in mind for your future work. The following list contains potential identified solutions to creating equity in access to nursing knowledge.

1. Blogs on Nursing and Nursology

Blogging, as well as reading nursing blogs, is a great way to engage with the global nursing community without borders. Through these interactions, you have the capability to learn more about the work of others (whether in-process or complete) be exposed to new ways of thinking, have discussions around important topics, receive feedback on your work, and be referred to relevant and available resources. For example, on Nursology.net you can find blogs on resources for teaching, sociopolitical issues, student perspectives, and exemplars for theories, philosophies, and more. Other notable nursing blogs (such as at the American Journal of Nursing or Advances in Nursing Science) offer an opportunity for nurses to read about and discuss scholarly issues without a fee. Interestingly though, many academic journals do not have an adjacent blog. Perhaps it’s time for editors to consider integrating a blog for their journal, and maybe it is time for you to consider writing a blog about something you are passionate about?

2. Journal Clubs

While journal clubs get a bad reputation for disorganization and/or low participation, they are an effective way to develop community for equitable knowledge access. Whether internal to your institution, or external with colleagues (what about a journal club for practicing nurses AND nurses in academia?!), a journal club can be a great way to help disseminate relevant nursing knowledge to colleagues who otherwise wouldn’t be exposed. Additionally, journal clubs help stimulate discussion on potentially overlooked issues and knowledge gaps, driving our discipline into the future.

3. Nurses On Boards

Often when we think about boards, we picture a dry and unproductive boardroom meeting that could have been summed up in an email (also referred to as CHBAE). This is not to say that this doesn’t occur… but, nurses are hugely underrepresented on boards across the U.S. (and probably the world). The Nurses on Boards Coalition “represents national nursing and other organizations working to build healthier communities in America by increasing nurses’ presence on corporate, health-related, and other boards, panels, and commissions.” How does this relate to knowledge equity in nursing you ask? Well, if nurses are underrepresented on boards, ultimately, what is approved as valid knowledge within an institution (think about hospitals here) will lack a nursing voice. Conversely, if nurses have a voice on boards, they can bring their unique disciplinary perspective to the institution and help drive what IS considered as valid knowledge. Think back to the medical library versus nursing library comment above, or maybe you have another example in mind? That being said, think how your voice could impact your institution on a board, and how that voice could help shape the future of knowledge equity in nursing.

4. Development of Anthology’s on Nursing Knowledge

In 1986, the book titled “Perspectives on Nursing Theory” was published by Dr. Leslie Nicoll which “is an anthology of classic and contemporary peer-reviewed articles that address various theoretical and philosophical perspectives on knowledge development in research and practice” (Reed & Shearer, 2012, p. vii). Since the original publication, there have been six editions of this book, most recently by Dr. Pamela Reed and Dr. Nelma Shearer. This book is an exemplar of what nurses in academia can do to promote access to knowledge for those in the practice environment. Dependent upon the area of expertise (whether theory or perhaps another topic) similar books can be developed that are a collection of the classic and contemporary peer-reviewed articles that address the area of interest. Moreover, as new editions are developed (hopefully faster than 17 years), practicing nurses have an ability to access essential knowledge which helps bridge the theory-practice gap, and simultaneously, translate research into practice. In addition, in light of environmental concerns related to book production, authors, editors, and publishers should consider decreased prices on electronic book versions to decrease their carbon footprint, and also to increase access to nursing knowledge.

5. Open Access Nursing Repositories and Journals

Open access journals and repositories make original research freely available via the internet. While there are concerns around the quality of articles contained within open access repositories and journals, there are acceptable options provided by notable nursing organizations. For example, Sigma Theta Tau International hosts the Virginia Henderson Global Nursing e-Repository (otherwise referred to as the Henderson Repository). The Henderson Repository “is the only repository solely dedicated to sharing works created by nurses around the world. It is an open digital academic and clinical focused service that freely collects, preserves, and disseminates full-text nursing research, educational, and evidence-based practice materials in a variety of formats and item types.” You can even find posters that have been presented at conferences, such as the Nursology Theory Collective’s poster at the King Conference in 2019. Lastly, there is also an underlying community collection that contains theses and dissertations that have been completed and defended, making it easier to access unpublished works (which is also important!). That being said, have you shared your important work with a nursing repository?

6-?. You decide!

Image copyright of Shannon Wheller

While this list is not exhaustive, this is just the beginning. If you have any further solutions to suggest on how to promote equity in access to nursing knowledge, please comment below. Remember, there are no wrong answers! We believe in the incorporation of nursing theory into practice, and practice into nursing theory, and we suggest that to support our discipline we need to close the gap in access to knowledge. Nurses in academia and practice need each other. We are interdependent and better together. We hope that in the process of closing this gap, we can foster collaboration across settings between nurses, ultimately bettering the health and well-being for all. 

Nursing knowledge should be a right and not a privilege, and we all need to work together to enable it to be that way.

Note: The Nursology Theory Collective would like to thank Mike Taylor for bringing up this important issue to discuss with the Nursology community.

References

Reed, P. G., & Shearer, N. B. C. (2012). Perspectives on nursing theory (6th ed.). Lippincott Williams & Wilkins.

The Community as Client: A Critical Caring Exemplar

Dorothea Fox-Jakob

I first heard of Dorothea Fox Jakob when I began public health nursing practice, mid-way through my nursing career.  She was well known in public health nursing circles for her strong advocacy efforts, particularly in relation to influencing public policy changes that would help to address the adverse effects poverty had on human health, and particularly that of children.  That work had earned her a letter of thanks from none other than the nursing theorist, Virginia Henderson!  (See November 20, 2013 post “An Introduction to the Canadian Nursing Theories Perspective“)

Now retired, Dorothea is sorting through her many papers and came upon one she had been invited to give at a local NANDA group meeting in Massachusetts. The request was prompted by her speaking out passionately at a national NANDA meeting on the need for the group to consider nursing diagnoses for communities-as-clients, not only for individuals. The paper, “We Look Like Giants” (click to download), represents a case study of an aspect of the work of a team of 3 public health nurses  with young mothers in a district of Toronto in which she practiced.

The educational background of the PHN team is not specified, except that one was a mental health nurse specialist, one a generalist. I know from dialogue with Dorothea, that she was the 3rd nurse and had attended NYU where she earned a Masters of Public Health Nursing, a degree that prepared her as a public health clinical nurse specialist. NYU, known for its strong emphasis on nursing theory, would also have given her a strong nursing theoretical foundation for her work. The attached paper, however, does not identify a specific nursing theoretical framework that informed the PHN team’s practice.

W hen I read “We look like Giants”, I was struck by how it demonstrated Critical Caring in action.  Although the paper was written 15 years before I articulated the theory, I have previously referred to it as a “descriptive theory”, i.e., it was my effort to articulate the practice of expert public health nurses within a coherent nursing theoretical framework, initially as I observed it in practice (Falk-Rafael, 2005), and then through research (Falk-Rafael & Betker, 2012a; Falk-Rafael & Betker, 2012b) and most recently through further reflection (Falk-Rafael, 2020).

Critical caring is rooted in the writings and example of Nightingale, Watson’s  human caring science, and feminist critical social theories. It is conceptualized  as a way of being (in relation), knowing (embracing multiple ways of knowing), and choosing (ethics). It identifies 7 carative health promoting processes (CHPPs).

In our conversations, Dorothea emphasized that the focus of the 3-public health nurses who undertook this process was in supporting a neighbourhood  drop-in centre by helping it meet the needs of young mothers in the area. And, certainly the “client” in the example may be conceptualized in this way, Client” could also refer to the larger community the drop-in centre served, or the group of Moms who attended the group sessions that the nurses facilitated. Because the paper provides more information about the nurses’ relationship with the group of Moms, I will focus on them as the “community as client” for the purpose of this blog..

CHPP I involves the preparation of self. In addition to Dorothea’s education and nursing experience, she  identifies her own experience as a mother in preparing her for the her work with the group. In addition, she identifies engaging in “soul-searching” and values clarification at the outset.

CHPP II involves developing and maintaining a helping-trusting relationship. Evidence of a respectful, non judgemental, and an authentic way of being present is evident throughout Dorothea’s narrative. Evidence of mutuality in goal-setting and evaluation methods is also described – the mothers identified the issues they wanted to rap (or talk) about and the nurses defined the temporal boundaries (1 ½ hours/week for 10 weeks) and committed to be there. The paper has many examples of inclusiveness and acceptance – sporadic attendees were as welcome as regular attendees, the presence of small children and/or babies was not only accommodated but efforts were made to “spell off” mothers with babies. Self-disclosure and human touch were also identified and contributed to the relationship-building.

Dorothea’s story describes the reflexive approach of the nurse-facilitators in identifying, planning, responding to health goals, as well as in evaluation (CHPP III – using a systematic, reflexive approach). For example, topics were added as new issues were raised. Likewise, some evidence of transpersonal teaching-learning (CHPP IV – engaging in transpersonal teaching-learning) may be seen and/or inferred as group members shared their experiences in managing situations other group members were experiencing. It is clear in the example that the nurse facilitators created a safe environment in which the women could share their experiences comfortably (CHPP V – providing, creating and/or maintaining supportive and sustainable environments).

CHPP VI refers to meeting needs and building capacity. The narrative identifies meeting needs for nourishment and  child-care during the meetings, in addition to attending to the needs for social interaction and improved self-image. As participants were encouraged to call each other between meetings, it is reasonable to assume that their capacity to care for each other may have improved. On another level, the nurses’ efforts also met a need and strengthened the capacity of the drop-in centre to support young mothers in the surrounding community.

CHPP VII refers to being open to various ways of making meaning in which those for whom we care engage. Whereas the narrative does not specifically address this process, group members’ identification of the instillation of hope as one of the outcomes of the group sessions may be an aspect of this carative process.

The focus of Dorothea’s paper was to give an example of public health nursing work with a community- as-client to a group of nurses involved with NANDA at a local level. Although the explicit nursing knowledge that informed the practice of the PHN team is not specified in her paper, retrospectively the congruence of their nursing care for this community  with a nursing theoretical approach is clear. The paper identifies at least one positive outcome, in that the drop-in centre was able to remain viable for at least the next several years . The story’s title, “We Look Like Giants”, an observation of one of the mothers in the group, suggests, perhaps, that  an enhanced self-image of the participating Moms was another.

Sources

Falk-Rafael, A. (2005). Advancing nursing theory through theory-guided practice: the emergence of a critical caring perspective. ANS. Advances in Nursing Science, 28(1), 38–49. DOI 10.1097/00012272-200501000-00005

Falk-Rafael, A. (2020). Adeline Falk-Rafael’s Critical Caring Theory. In M. C. Smith (Ed.), Nursing Theories and Nursing Practice (5th ed) (pp. 509–521). FA Davis.

Falk-Rafael, A., & Betker, C. (2012a). Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: “The Trombone Slide” of Nursing. ANS. Advances in Nursing Science, 35(2), 98. DOI 10.1097/ANS.0b013e31824fe70f.

Falk-Rafael, A., & Betker, C. (2012b). The primacy of relationships: a study of public health nursing practice from a critical caring perspective. Advances in Nursing Science, 35(4), 315–332. DOI 10.1097/ANS.0b013e318271d127.

Throwing Shade at Nursing Theory: a Millennial’s Perspective

Welcome to Shannon Constantinides,
who is joining the Nursology.net blogging team!
Shannon also contributed the content on
Jane Georges’ Theory of Emancipatory Compassion

Dear Colleagues,

Shannon Constantinides

As a current PhD candidate (Yay! I’m making progress) and experienced NP of about a decade (Yikes! Time flies!), I have a few thoughts on Dr. Foli’s well articulated post and associated call for action/ questions regarding nursing theory in academics. It is with a great reverence for the bright minds of this community that I share these ideas with you all. Please consider my comments simply for no more than what they are: some thoughts from a novice scholar (who happens to be a millennial).

First, the humor and humility with which Dr. Foli broached the topic of “nursing students throwing shade at nursing theory” made her post fun to read and so relatable!

Second, and not entirely related to the topic at hand (which I’ll get to), as an NP who often precepts students, I loved the question posed to students, “Are you running from something in your current job, or running toward a goal of being a nurse practitioner?” I think probably too often nurses go to NP (Nurse Practitioner) school without a clear idea of what the role and day-to-day of the job entails. On a number of occasions, I’ve gently refused to write letters of recommendation to NP school for newly graduated BSN students, because I truly believe that the knowledge and experience gained by working as a nurse is beyond measure. First and foremost, NPs are nurses. I can’t underscore enough the importance of building a strong professional foundation. Equally as important is taking the time and opportunities to explore the endless possibilities that come with nursing practice (finding what sets one’s soul on fire, so to speak). I think this goes for new-grad RNs who are fixated on any one speciality, as well. I would not be on the path that has lead me down my professional and academic journey without first practicing in a number of areas (being in the military made this an easy possibility). Having experience in a number of areas has been invaluable to my career as an APN – clinically and in broadening my understanding healthcare systems and the lived experience of health, itself.

Third, I think the struggle to connect theory to practice comes from a few places. Overall, however, I think it may be time we re-envision and modernize how we approach teaching theory, in the first place. We did this for clinical practice, right? How many of our colleagues ever trained in a sim lab, for example? Updating the what, how, and environment in which we teach doesn’t have to be limited to the parameters of the clinical side of practice. I think the sample principles apply to teaching theory, especially if we want students to learn how to integrate the two. So a few thoughts…

Why is there SO MUCH reading!?

I’ve deduced that what has seemed like an ungodly amount of reading over the course of my education has served the following purposes: 1) taught me the practical knowledge needed not kill my patients (literally), 2) exposed me to new ideas, and 3) exercised my brain and made it grow in its ability to comprehend complex and abstract ideas – just like exercising a muscle.

In regard to the amount of reading that goes along with nursing education: I had NO idea! And I say that as a naturally voracious reader who grew up in a home that purposely had no tv! Honestly, I think 99.99% of students have no idea what they’re getting into when they sign up for nursing education – at any place on the educational spectrum. Students need to be reassured, probably on repeat, that the reading has a purpose. As much as the discourse in nursing espouses that we ascribe to the anti-handholding/ law-of-equal-suffering/ eat-our-young narrative, reassuring your students is more than being nice or helpful. On a deeper level, reassuring your students demonstrates the ethics of compassion and caring that is preached in the pedagogy of the discipline.

To that point, your millennial students will also to be curious as to why you’ve selected specific reading material. I’m not saying you need to, or should, justify each reading assignment. However, giving students a general idea of why certain material is important, especially for theory and philosophy, will help create a connection to the content. I say this with love for my generation, but millennials (and post-millennials) are a different animal. We’re a “special” breed, if you will. We have been raised to question everything. Every. Thing. It’s in our DNA. And you’re just in luck, because there’s A LOT of us! By many accounts, we’re the largest generation in history! (That is, millennials – people born between 1981 and 1996, and post-millennials – people born between 1997 and the present day).

Now, to that point, let’s not also forget that the frontal lobe doesn’t fully develop until late adolescence/ early adulthood. So, some of your students who are innately left-brained, “linear” thinkers (who, inherently, may have a harder time wrapping their heads around some of the non-linear concepts in theory and philosophy), will also be young, concrete thinkers. Their brains literally have just only developed to a point of abstract thinking understanding the basic concepts related to the more esoteric ideas we talk about in theory. And this issue is compounded by unique educational, professional, and personal backgrounds and upbringings of each student.

For example, it wasn’t until my masters-level (and more so, PhD) studies, that I really started understanding some of the more abstruse, Delphic concepts in nursing theory. As a BSN and MSN grad of the CU system, I naturally gravitated to Watson’s work – but generally – the more experienced I became professionally, academically, and in life, the more I came to understand the “other” theories I was learning about in school. As an 18-year-old, direct-entry BSN student I could understand (because I saw a way to concretely apply) Orem’s self care theory, Leininger’s cultural care theory, or Carper’s Pattens of Knowing (and, yes, I now know and understand why Carper said in a 2015 interview with Eisenhauer that her work was never meant to be a theory – but try telling that to a young, brand-new, nursing student! There’s no denying a certain level of concreteness to aspects of Carper’s work. This is something I love about Carper’s model – she wanted it to be readily tangible to the user, and it is!)

In reality, it’s taken me nearly two decades to “get the hang of nursing theory” and be able to digest and truly understand the works of such thinkers as Rogers, Patterson and Zderad, or Newman. Or actually appreciate the depth, intricacy, salience, and beauty of Watson’s work. In fact, as a BSN student, I remember sitting in a guest-lecture with Dr. Newman, and being the left-brainer that I am, raised my hand said, “Um, Dr. Newman, I don’t get it…” Looking back, I’m still mortified by this encounter! I was THAT student (insert #facepalm here!).

#facepalm

So, really, it’s taken the better part of my adult life to develop the intellectual ability and emotional maturity needed to sit with and understand complex ideas. There are articles, book chapters, and entire texts I now consider the Holy Grail, which when I first read them specifically remember thinking, “WT_?? Is this even in English???” And to that point: don’t forget that your students are literally learning new languages! They’re not only learning the technical language of healthcare, but also the language the informs the epistemology of nursing. So, again, I think showing your students a little patience, forgiving, and compassionate grace is key.

Likewise, it’s my opinion that once we get to a certain point in our careers (as a clinicians, scholars, educators, administrators, etc.) we take for granted knowledge that has become second-nature. I can say, with complete certainty, that I fall prey to this with my own clinical NP students. What do you mean you don’t have a clear, concise, and evidence-based plan for managing your older adult patient who has insanely complicated medial, psycho-emotional, and social needs?? We have to remember that knowledge for students – whether clinical or related to theory and philosophy – is often entirely new or being presented at a depth they weren’t expected to go to in the past. In addition, with APN students where we’re building off the knowledge and experience that comes from working as an RN and RN education. As far as theory and philosophy are concerned – that knowledge is really complicated, is often brand-new, and often isn’t intuitively grounded in day-to-day nursing work and education. Your students are learning new stuff, a new language, and and learning to think in an entirely different way. Patience is key. Finding a way to foster connection to the content is key. My suggestion would be to keep Benner’s Novice-to-Expert model in the forefront of your minds when you’re working with students – especially when it comes to teaching theory and philosophy.

Middle range theory & the ladder of abstraction.

I think a lot of students aren’t exposed to middle-range theories. This statement is, of course, purely based off anecdote consisting of my own academic and professional experiences, and what sound to be similar experiences shared by my colleagues. It’s my opinion that middle-range theory may an optimal place to bridge the theory-practice gap. Certainly, this bridge will be influenced by the paradigm framing the theory or the paradigm to that which the nurse knowingly or unknowingly ascribes. However, as Smith and Liehr (2014) stated, middle range theories are more straightforward and lie in-between that which is all-inclusive and that which is highly situation-specific. In this regard, a few exemplars that made sense to me and my peers included Story Theory, the Theory of Unpleasant Symptoms, and the Theory of Caregiving Dynamics.

I also think teaching the levels of theory abstraction as described by Smith and Liehr, even at the BSN level, could help make a little more sense of nursing theory in terms of applicability. Do I apply this theory at the bedside? In a specific situation? Does it guide a certain aspect of my practice? Or, is it something that will guide the entirety of how I approach practice, patients, and the general experience of health?

I think it’s so tempting to start off with the classics: the grand nursing theories. But honestly, some (ok, basically all) of those theories are super complicated! For your newer, less experienced learners, maybe initially include something a little more concrete, like a micro theory? Help your students dip their toes in the water, so to speak, rather than throwing them directly into the deep end. I think a lot of harm can be done when faculty knowingly or unknowingly teach at a level that is over the students’ heads. Your students will get there, trust me, but keep it simple in the beginning. Help your students build a strong foundation. You’d do the same with patient care knowledge and skills, right? So, same idea for nursing theory.

Aging-out and aging-into the current sociopolitical & cultural context

I can’t stress this enough: nursing faculty have a critical place not only as clinical and scholarly role models, but in modeling the language and behavior of advocates and voice-givers. When I started my BSN in 2000, and even by the time I graduated with my NP in 2011,  I didn’t really know what social justice was. I couldn’t really answer the question, “What are you doing to be an advocate?” Over the course of my PhD program, however (and thankfully so), I’ve had the amazing fortune to work with and be mentored by some exceptionally stellar minds in my quest to figure out my place as an advocate and voice-giver (especially Dr’s Peggy Chinn, Patricia Liehr, Jane Georges, Debra Hain and Deb D’Avolio… to name a few). And, boy, do I wish I’d had a social justice/ emancipatory focused curriculum as a BSN or MSN student, like our students do at FAU!

So how does this relate to teaching theory? As feminist Holly Whitaker (2019) wrote in her book, “Quit Like a Woman,” we are now, likely more so than ever, aware of our own oppression, the oppression of others, and aware of how our actions or inactions have abetted the oppression and marginalization of others. Whitaker states, and I whole-heartedly agree, that thanks to movements started by the LGBTQIA community, radical feminists, and women of color, our common vernacular now includes words like privilege, misogyny, and patriarchy. (I would also add terms like toxic masculinity and inclusivity). Likewise, I contend that our language reflects a paradigmatic shift that is occurring in society: we are moving toward a more humanistic way in how we view and interact with others. For example, we’re moving away from socially constructed and derogatory descriptors. Rather than calling someone “disabled” we acknowledge that the individual is of other-ability. Rather than being called “elderly” or “geriatric” we honor the experience that comes with older adulthood. We recognize that someone is involved in “sex work” is a “sex worker,” not a “prostitute.” We now see that the term “violence against women” is problematic in that it is passive and alleviates the blame of the perpetrator.

Students, especially millennials, are probably hip to these issues and this type of language, but this is not an assumption to make. It is your responsibility as a faculty member to stay informed and engaged in this regard. Just like you would teach from a place of best evidence regarding clinical practice and patient care, stay up to date on what’s going on in the world, the language being used, and the issues that matter to your students.

The good news is that we now have theories and books that are grounded in a social-justice paradigm! Take, for example, Georges’ (2013) Emancipatory Theory of Compassion (or really, any of Dr. Georges’ work dealing with the nature of human suffering). I adore Georges’ work (and work she’s done collaboratively with Dr. Susan Benedict) for a number of reasons, especially how she takes the concept of suffering head-on, and calls out nursing in regard to the profession’s historical (and generally unspoken) complicit involvement in oppression. Intentionally moving away from the traditional, Western narrative that has a propensity for the patriarchy, Georges’ work focuses instead on alleviating suffering through compassion, empowerment, and deconstruction of power relations. Falk-Rafael’s Critical Caring model, for example, also goes in this direction as it looks at role power relations have in public health outcomes. Likewise, I consider Kagan, Smith, and Chinn’s (2016) Philosophies and Practices of Emancipatory Nursing, and the works there within, a critical must-read for anyone wanting to study or practice nursing theory in context of today’s sociopolitical climate. To that point, a quick search on Amazon revealed a number of nursing textbooks centered around contemporary theory-based approaches for caring for vulnerable populations, approaches to healthcare policy, and approaches for healthcare advocacy.

And, to very briefly touch on the topic of technology in nursing theory: if your students are my age (I’m 37) or younger, we never knew what it was like to live without technology (let alone practice nursing without computers, smart phones, apps, EHRs, or the internet!). My husband, a physician (I know, I married the enemy), is 10 years older than me. We work in the same primary care practice. Even though he is fairly tech savvy, it’s astonishing how much longer it takes him to adapt clinical technology compared to those of us in the clinic who are a decade younger. I’m not saying this is true across the spectrum: I absolutely interact with younger clinicians who have less tech know-how than our colleagues a few decades our senior. What I’m saying is that those of us who were born into and grew up practicing nursing in the information age have a different relationship and understanding of healthcare (and view of the world, in general) than those even a decade ahead of us.

Several years ago, at the suggestion of my fairly tech savvy entrepreneur dad, I read “The World is Flat” by Thomas Friedman. My dad thought this work was incredibly forward-thinking. The concept and manifestation of a globalized humanity secondary to advances in technology was mind-blowing to him. However, I remember thinking, “yeah… so this is not a new thing to me, Dad…” Keep in mind that the world has always looked so different to those of us in the millennial and post-millennial generations. In terms of nursing theory, Watson’s work – I think especially Caring Science as Sacred Science and Unitary Caring Science – both hit the nail on the head in terms of addressing globalization and caring for a global humanity.

Additionally, the exciting thing about nursing theory in the information age is that new theories are emerging to deal with contemporary, tech-related issues! Dr. Rosario Locsin’s Theory of Technological Competency as Caring, for example, is pertinent and relatable for today’s students. A few years ago, I had the opportunity to listen to Dr. Locsin speak about his theory. I was, again, THAT student. I asked Dr. Locsin, “Are your theory and views on artificial intelligence and humanoids questioning how we define existence?” “No. Not necessarily,” he said, “But what if A.I. develops to the point where it can’t be differentiated from naturally living beings? What if a humanoid develops feelings? Can they develop feelings?” These may sound far-fetched, but the future is not that far away and technology is developing at a screaming pace! The philosophic questions, ethical dilemmas, and reality your students will face in the future will undoubtedly look like something out of a sci-fi novel – and for that I applaud Dr. Locsin for boldly going where no nursing theorist has gone before!

This next statement might be considered heresy, but for the sake of discussion, hear me out: I believe some theories are aging-out, or at least need to update their language. This is absolutely not a dig on older theories: let me be very clear about that! Some of the older theories were the embryonic origins of what, over time, have evolved into modern nursing theory and practice. Due to the social and political culture of the time, and in order to be taken seriously, the structure and verbiage of early nursing theories were informed by a patriarchal/ paternalistic, medical narrative that was dictated by an aristocracy of upper class, white, male physicians, scientists, politicians, and power-elite. People were either ill or well. Self-agency was not a thing if you were not a straight, white, cis-male. Social justice was not a thing. Human rights were not a thing. The right to health was not a thing (and arguably is still not a thing). Hearing the critical voices of underserved, under-represented, vulnerable, or marginalized populations was not a thing. Talking about energy (let alone shared energy) was definitely not a thing – or at least not a thing that was spoken of publicly or in circles of “hard science.” The male doctor gave the female nurse orders, and the female nurse would then perform prescribed actions.

I conducted a review of caring theories as a part of my comprehensive exam last summer. Again, let me be very clear: these theories were crafted by minds much more brilliant than I could ever hope mine to be, and there is indescribable wealth, depth, knowledge, and wisdom imbedded in these works. Truly, many will remain as enduring masterpieces of the discipline, and their authors have become beacons of progressive, forward-though. However. …. However, in conducting this review, I found that a few theories that by their nature of being framed by a context that no longer matches the current sociopolitical and cultural climate, have perpetuated the aforementioned narrative informed by the patriarchy and the notion of power imbalance. I believe this is antithetical to the emancipatory movement we are experiencing in nursing – and society, as a whole – where, for example, the out-dated adage of “enabling” the other should be updated to a focus on empowerment.

So, some closing thoughts:

Your students live and will work in a world that that changing at an unfathomable pace. While I believe that a great many works and ideas in nursing theory and philosophy are truly timeless and relevant, some are not. Stay up to date on what is pertinent and what is being published. Teach the classics, but also teach new, relevant theories. Try new articles. Try new textbooks. Talk to your students about what they think is timely and relevant.

And more importantly …. talk to your students. Connect with them. Millennials, in particular, like to be engaged and involved! Finding innovative and creative ways to connect with your students is especially important with the proliferation of online programs, where many students will never set foot campus. Trust me: your effort in this regard will be well worth it! Whether in the classroom or the online environment, I got the most from faculty who taught from a place of compassion and connection – where they openly and earnestly worked to understand the student perspective and got us involved and invested in what we were learning. In fact, I’m still in touch with a few faculty from both my BSN and MSN programs! (Dr’s Lea Gaydos, Lynne Bryant, Amy Silva-Smith…). Dr. Gaydos and Dr. Bryant were my BSN and MSN theory and philosophy professors, respectively, and were two of the first people I called when I had my first theory-related article published in 2019 in NSQ. It’s been nearly 20 years since I took Dr. Gaydos’ class, and I still have my term paper from that course. All I can say is: what an abomination! I was in tears, laughing, when I reread that “gem” last year!

My point is, these professors planted the seed of interest in nursing scholarship at the doctoral level. You will have THAT student. I was THAT student. Who am I kidding… I’m still THAT student! The student who wants to know “why” about everything. The student who will question everything. The student who will argue every last point on an assignment. Trust me when I say this: no matter how much shade your students throw at theory, you ARE making a difference. Because THAT one student … the one who pushed you and nearly drove you crazy … that student may be the one who grows up and wants to continue this dialogue.

Finally, and most importantly: I truly admire and respect Dr. Foli for putting herself out there. The issue she raises (students throwing shade at nursing theory) is very real and very much alive and well in the world of nursing academics. As Dr. Jane Georges once said to me, “violence can be done to students’ ideas,” and I applaud Dr. Foli in her quest to improve the academic experience for her learners.

Sources

Benedict, S. & Georges, JM. Nurses in the Nazi “euthanasia” program. Advances in Nursing Science: 2009; 32(1): 63-74.

Chinn, PL. & Falk-Rafael, A. Embracing the focus of the discipline of nursing: critical caring pedagogy. Journal of Nursing Scholarship: 2018; 50(6): 687-984.

Eisenhauer, ER. An interview with Dr. Barbara Caper. Advances in Nursing Science: 2015; 38(2): 73-81.

Falk-Rafael, A. Nursology: Critical Caring. https://nursology.net/nurse-theorists-and-their-work/critical-caring/. Accessed June 2, 2019.

Falk-Rafael, A. Advancing nursing theory through theory-guided practice: the emergence of a critical caring theory. Advances in Nursing Science: 2005; 28(1): 38-49.

Georges, HM. Biopower, compassion, and nursing. In: Philosophies and practices of emancipatory nursing: social justice as praxis. Kagan, PL., Smith, MC., & Chinn, PL. (eds). New York: Routledge; 2014: 51-63.

Georges, JM. An emancipatory theory of compassion for nursing. Advances in Nursing Science: 2013; 36(1): 2-9.

Georges, JM. Evidence of the unspeakable: biopower, compassion, and nursing. Advances in Nursing Science: 2011; 34(2): 130-135.

Georges, JM. Bio-power, Agamben, and emerging nursing knowledge. Advances in Nursing Science: 2008(A); 31(1): 4-12.

Georges, JM. The politics of suffering: implications for nursing science. Advances in Nursing Science: 2004; 27(4): 250-256.

Kagan, P.N., Smith, M.C. & Chinn, P. (eds.) (2014). Philosophies and practices of emancipatory nursing. Routledge.

Lenz, E.R. & Pugh, L.C. (2014). The theory of unpleasant symptoms. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.

Locsin R. Technological competency as caring in nursing: co-creating moments in nursing occurring within the universal technological domain. The Journal of Theory Construction & Testing: 2016; 20(1): 5-11.

Smith, M.J. & Liehr, P.R. (eds). (2014). Middle range theory for nursing, 3rd ed. Springer.

Smith, M.J. & Liehr, P.R. (2014). Story theory. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.

Watson, J. Unitary caring science: the philosophy and praxis of nursing. Louisville: The University Press of Colorado; 2018.

Watson, J. Caring science as sacred science. Philadelphia: F.A. Davis Company; 2005.

Whitaker, H. (2020). Quit like a woman: the radical choice not to drink in a culture obsessed with alcohol. Random House.

Williams, L. (2014). Theory of caregiving dynamics. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.

Beyond the Boxes: Mandala Introduction and Nursing Organizational Application

Guest contributor: Ellen E. Swanson
This post introduces the new “Practice Exemplar”
describing the application of Mandalas in nursing

See related Education Exemplar

We have constructed so much of our society based on the traditional hierarchical or linear organizational model. This model has dominated and influenced our thinking and behaviors. The linear model has also affected how we organize various types of information in the educational, health care, social, religious, economic, and political arenas. This hierarchical organizational chart looks familiar to all of us.

The energy is linear and we are all in boxes. I want out, don’t you? So, let’s play with this. In place of the hierarchical chart, a new circular model in the form of a mandala template is now available for organizing information. One translation of a Sanskrit root word for mandala means “that which is the essence” (Huyser, 2002 p. 2). In the recent Nursology Education Exemplar highlighting a class at Metropolitan State University in St. Paul, MN, “Nursing Theory Mandala Based on Modeling and Role-Modeling Theory”, we showed the mandala template application to holistic nursing and also to the specific theory of Modeling and Role-Modeling.

© 2011 Ellen E. Swanson, all rights reserved

The template features four rings and a center. Each ring has a suggested definition for application.

  • Ring 1: Outer rainbow ring – seven resources or sources of energy for the chosen application topic.
  • Ring 2: Teaching and learning ring – what each resource or source teaches or contributes.
  • Ring 3: Inner resources ring – resources available from or applied to the body, mind, and spirit either literally or figuratively (ancient cultures included emotions in the mind arena).
  • Ring 4 and center: Manifestation ring — based on the Feng Shui Ba-Gua system and its life aspects.

Visuals are powerful, affecting us consciously and unconsciously. So how then might we use this template visual where energy is circular and therefore synergistically self-enhancing to show the essence of other topics? Let’s start with an organization and look at the application to the MN Holistic Nurses Association. The definitions of the four rings above apply. For an organization, in ring 3, the body segment could be values or purpose, the mind segment could be the mission statement, and the spirit segment could be the vision statement.

© 2011 Ellen E. Swanson, all rights reserved.
The Minnesota Holistic Nurses Association has included their mandala on their website at Minnesota Holistic Nurses Association. This mandala makes visible the holistic nursing theory concepts of trust and collaboration as experienced in the organization.

Download the PDF file of the MinnHNA Mandala here

This mandala makes visible the holistic nursing theory concepts of trust and collaboration as experienced in the organization.

Source:
Huyser, Anneke. (2002). Mandala Workbook for Inner Self-Discovery. Havelte/Holland: Binkey Kok Publications.

About the Author

Ellen E. Swanson, MA, RN, BSN, PHN, HNB-BC (Retired) had a 46 year career that included ortho-rehab, mental health, operating room, management, teaching, care managing, and consulting. For fifteen years she had a private practice in holistic nursing, focusing on health and wellness teaching and counseling. She served on the leadership council for the Minnesota Holistic Nurses Association for ten years.

A Dozen and One Ways to Love Our Discipline!

Later this week February 14th, is Valentine’s Day – the internationally recognized holiday that variously inspires young children to try their hand at making an original card expressing at least admiration for other children, and compels adults to exchange gifts symbolizing their adoration of one another.  Putting aside the commercialization of a day with deep roots in Roman religious festival traditions, I would like to consider ways in which we as nursologists can express, in our actions and deeds, our fundamental respect – and yes, our love, for the discipline to which we have committed our professional lives, and for many, our personal lives as well.

So in the spirit of the best traditions of Valentine’s day – here are a dozen and one ways to love our discipline!

  1. Express appreciation every day to a nurse who has made, or makes a difference in your life.
  2. Form a small support or interest group with a few nurse colleagues to work on a persistent challenge you are facing; include early-career nurses who are so vulnerable to these challenges.
  3. Recognize ways in which racism and other forms of discrimination are expressed in everyday ways in your work environment, acknowledge your part, and explore ways to resist and transform these situations.
  4. Practice the fine art of “active listening” whenever you encounter a nurse colleague whose point of view differs from your own, explore common ground and build bridges of understanding.
  5. Reach out to a nurse who is hurting, discouraged, or fearful for any reason;  listen to their story, and pledge to continue to listen.
  6. Settle on your own clear and succinct explanation of what nursing is all about; express this to at least two other people every day, and notice their responses to refine your message.
  7. Read one article every month, or two books a year, to learn about nursing history and the nurses who made significant contributions to our discipline.
  8. Practice one or more self-nurturing activity every day, such as physical activity (walking, yoga, tai chi), meditation, play and laughter, saying “no” as a complete sentence!
  9. Resolve to speak the truth of nursology to power at every possible opportunity.
  10. Use every avenue possible to communicate with the public – with your local community leaders, the media, and politicians.
  11. Love and care for the earth and its animal creatures as you would your most cherished patient; take at least 3 opportunities each day to teach others to love and care for the earth and for animals.
  12. Join at least one nursing organization and work to create needed changes in our discipline and in healthcare.  AND
  13. Follow Nursology.net, share the site far and wide, and participate in sharing ideas to shape the future of nursing/nursology.
Thank you to the following nursologists who have contributed to this list!
Chloe Olivia Rose Littzen
Jane Hopkins Walsh
Jess Dillard-Wright
Brandon Blaine Brown
Savina Schoenofer
Marlaine Smith
Vanessa Shields-Haas
Christina Nyirati

Transitions in Leadership Positions: Is There a Best Time?

As we know, leaders transition to and from their positions within educational and clinical institutions. Meleis’ transitions theory, which focuses on “the human experiences, the responses, [and] the consequences of transitions on the well-being of people” (Meleis, as cited in Fawcett, 2017, p. 347) tells us that transitions may be anticipated, experienced in the here and now, or have been completed. Transitions may be development, situational, organizational, cultural, or well-illness; each type may occur singularly or with one or more others. (See https://nursology.net/nurse-theorists-and-their-work/transitions-framework-transitions-theory/)

Transitioning to or from a leadership position is a situational transition, which could be combined with a cultural transition as the nursologist moves to or from a new academic or clinical institution or even another country. The situational transition could be combined with a developmental transition as the nursologist enters another lifespan developmental phase. Furthermore, the situational transition could be combined with an organizational transition as an academic institution undergoes a major shift in priorities or a clinical agency merges with another clinical agency.

Alternatively, the transition of a nursologist to or from a leadership position could create an organizational transition as all affected people and structures adjust to the change. Finally, the situational transition, especially transitions from a leadership position, could be combined with a wellness-illness transition if the nursologist experiences a sudden acute illness or can no longer effectively manage a chronic disease.

One question about leadership transitions is: How does a nursologist transition to becoming an effective leader? Another question is: Is there an optimal time for a nursologist to transition to or from a leadership position?

© 2020 Jacqueline Fawcett

HOW DOES A NURSOLOGIST TRANSITION TO BECOMING AN EFFECTIVE LEADER?

Transitioning to becoming an effective leader obviously first requires a desire to be a leader, although at times, a nursologist may find self gently (or not so gently!) pushed into a leadership position by colleagues or senior administrators or by a vacuum left by someone who transitioned from the position suddenly.

Transitioning to becoming an effective leader also requires certain competencies. The American Organization of Nurse Executives (now the American Organization for Nursing Leadership) identified five competencies for effective leadership in practice and education (Waxman, Roussel, Herrin-Griffith, & D’Alfonso, 2017).  Although the competencies focus on those for executive level leadership positions, they are relevant for all levels of leadership. The five competencies are listed here. The specifics of the competencies are available in the Waxman et al. (2017) journal article or at https://www.aonl.org/resources/nurse-leader-competencies:

  1. Communication and relationship-building
  2. Knowledge of the healthcare or academic environment
  3. Leadership
  4. Professionalism
  5. Business skills and principles

The nursologist may already have acquired these competencies or has to acquire them by enrolling in a formal program and/or finding a mentor or leadership coach. Formal programs for nursologists are offered by Sigma Theta Tau International, the American Association of Colleges of Nursing, the American Organization for Nursing Leadership, and the Robert Wood Johnson Foundation. The programs are:

Sigma Theta Tau International
American Association of Colleges of Nursing
American Organization for Nursing Leadership (formerly, American Organization of Nurse Executives)
Robert Wood Johnson Foundation

Mentors and leadership coaches may be included within formal programs or the nursologist may have to approach recognized leaders and ask that they share their wisdom about leadership.

IS THERE AN OPTIMAL TIME FOR A NURSOLOGIST TO TRANSITION TO OR FROM A LEADERSHIP POSITION?

Aspiring or actual leaders may ask: Am I too young or too old to transition to or from a leadership position? Inasmuch as many institutions do not have mandatory age requirements for employees, wisdom is an important element of the transition decision. Although, as Larson (2019) pointed out, wisdom may come with older age, my experience indicates that younger persons also may be wise. Wisdom at any age requires nursologists to use “mindfulness, empathy, and self-reflection to learn from their mistakes, failures, and successes over the years” (Larson, 2019, pp. 789-790). Thus, those people who aspire to be leaders or already are leaders may want to heed Larson’s words and engage in serious self-assessment to determine whether they are ready to transition to or from a leadership position. In addition, aspiring or actual leaders may want to assess their leadership competencies, which can be done using a self-assessment instrument that is available at https://www.aonl.org/resources/online-assessments.

Fang and Mainous (2019) examined factors related to short term deanship, which they regarded as problematic. (A short tenure leadership position is one that ends sooner than the specific term of the position, such as 3 years or 5 or 6 years.) Their study of data from the 2016 American Association of Colleges of Nursing Annual Survey revealed that certain personal and organizational characteristics are associated with short tenure chief nursing academic administrator positions, including the titles of dean, chair, director, or department head. The characteristics are: age (60 or older) at beginning of the leadership position, having a title other than dean, being a dean who subsequently takes another deanship, being a first time dean, being a dean in a school without a tenure system, and being a dean of an associate degree program or a baccalaureate degree program.

As I read Fang and Mainous’s (2019) article, I wondered whether short tenure leadership positions are always problematic. Could it be that the position is not consistent with what the person hopes and dreams it will be? Could it be that the person’s leadership style is not conducive to inspiring a faculty or clinical staff to attain personal, professional, and/or organizational goals? Perhaps, then, transitioning from a short tenure leadership position may be a positive event for the nursologist leader and for the faculty or clinical staff. Perhaps everyone breathes “a sigh of relief” that the leader has transitioned from the position (Larson, 2019, p. 789).

Another situational transition, which may be combined with a developmental transition and which affects almost everyone, is retirement. Those nursologists who are contemplating retirement most likely were or still are leaders in the institutions where they work, even if they are not “official” leaders, such as deans, directors, or chairs. Larson (2019) discussed her decision to retire from her faculty position. She regards retirement as “the next transition in my career development” (p. 789). At age 76, Larson (2019) noted, she “made the scary and difficult decision to retire in less than a year . . . [and] not wait until people breathed a sigh of relief that I was finally gone” (p. 789).

Meleis (2016) wrote about her situational transition of anticipating, experiencing, and completing stepping up from a deanship. She explained that stepping up “connotes climbing to a higher place in our lives, taking with us what we learned in the previous [step]” (p. 187). Meleis identified and described five phases in the transition to and from a deanship. I will presume to be so bold as to generalize Meleis’ (2016) description of the deanship transition to all leaders, add a sixth phase (expressing an initial professional voice), and adapt the phases to both transitioning to and from a leadership position. The six phases are:

  1. Expressing an initial professional voice
  2. Deciding to transition to or from a leadership position
  3. Searching for the leadership position
  4. Being named to the position
  5. Exiting from the position by stepping up
  6. Reclaiming a professional voice

© 2020 Jacqueline Fawcett

I applaud those nursologists who are willing to transition to a leadership position and congratulate those who have transitioned from a leadership position. I send best wishes to all for much happiness, wellbecoming, and exciting and stimulating next ventures in stepping up.

References

Fang, D., & Mainous, R. (2019). Individual and institutional characteristics associated with short tenures of deanships in academic nursing. Nursing Outlook, 67, 578–585. https://doi.org/10.1016/j.outlook.2019.03.002

Fawcett, J. (2017). Applying conceptual models of nursing: Quality improvement, research, and practice. New York, NY: Springer.

Larson E. L. (2019). Musings on retirement. Nursing Outlook, 67, 789-790. https://doi.org/10.1016/j.outlook.2019.04.008

Meleis, A. I. (2016). The undeaning transition: Toward becoming a former dean. Nursing Outlook, 64(2), 186–196. https://doi.org/10.1016/j.outlook.2015.11.013

Waxman, K., Roussel, L., Herrin-Griffith, D., & D’Alfonso, J. (2017). The AONE nurse executive competencies: 12 years later. Nurse Leader, 15, 120–126. https://doi.org/10.1016/j.mnl.2016.11.012