Thelma Schorr is among the greatest of nursing journal editors, serving at the American Journal of Nursing (AJN) company for forty years from 1950-1990. She progressed from editorial assistant to editor-in-chief, and then ten years as president and publisher. When she assumed the editorship of AJN, Thelma assured that the journal provided news for & about nursing, often unavailable otherwise, because this content covered labor issues that hospitals would rather suppress.
Thelma was the de-facto “founder” of the International Academy of Nursing Editors (INANE), gathering together a small group of editors in 1982 to form a new kind of network dedicated solely to the improvement of nursing literature (see inaugural photo below). She was instrumental in creating INANE as an independent “non-organization” functioning as an international collaborative – a collective of nursing editors and publishers focused on meeting the practice, research and education needs of the nursing profession, maintaining a tradition of “non-organization” (meaning that there are no formal officers, no elections, no dues!). (see https://nursingeditors.com/about/). Thelma was honored with INANE’s Margaret Comerford Freda Editorial Leadership Award in 2020, recognizing her enduring influence on nursing journal publishing.
Early in her career prior to joining the AJN company, Thelma launched her illustrious career in journalism by engaging the press to address a health crisis of the time. As a staff nursse at Bellevue Hospital in New York City, she was alarmed that the hospital was keeping active TB patients on an open ward. She fought to have them isolated on a separate unit and no one would listen. So she contacted NY CBS reporter Gabe Pressman and he broke the story, forcing NY Health & Hospitals to provide isolation units for active TB patients.
From that early start, Thelma became a life-long mover and a shaker. She led the way to establish the role of the journal editor as an independent, autonomous function not to be driven or manipulated by organizational or commercial interests. With the rise of feminism in the 70s, Thelma’s editorials emphasized that nursing was not to be subsumed under “medicine,” that “healthcare” was the proper umbrella term. Gradually public media followed this lead. She envisioned possibilities for nursing as a significant discipline in its own right (not as assistants to physicians) and shaped all of her actions to reflect and promote nursing’s professional identity.
During her tenure at the AJN company, she directed the publication of multiple nursing journals and pioneered the inclusion of continuing education articles in nursing journals. Along with Anne Zimmerman, she co-edited Making Choices, Taking Chances: Nurse Leaders Tell Their Stories in 1988, and in 1999, co-wrote with Shawn Kennedy, 100 Years of American Nursing.
Thelma is widely known for her dedication to first-time, inexperienced authors to learn to write for publication. She welcomed creative ideas and encouraged nurses to value their own experience and knowledge. She pioneered the practice of making continuing education available in print journals, making it possible for all nurses to pursue life-long learning to improve patient care. For this, AJN received magazine publishing’s highest award – the Ellie (elephant statue) from the American Society of Magazine Editors. She also pioneered programmed instruction, which was a forerunner of computer instruction. These were offered in the 1970s, long before personal computers & Internet.
Thelma’s editorial leadership has left an unmatched mark on nursing, one that all nursing editors seek to emulate.
Seated, L to R: Unidentified, Elinor S. Schrader (Editor AORN), Thelma M. Schorr (editor, AJN), Rozella Schlotfeld, Dean Case Western University & guest speaker), Sue Hegyvary (Associate dean and Assistant V.P., RPSLMC, Chicago & introduced symposium).Standing, L to R: unidentified, Julie Stillman (Little Brown and Co.), Patricia (Tucker) Nornhold, Peggy Chinn (Editor ANS), Leah Curtin (Editor, Supervisor Nurse), Alison Miller (C.V. Mosby Co), Richard H. Lampert (Appleton-Century-Croft), Shirley H. Fondiller (assistant to the dean for special programs and projects, RPSLMC, and Program Coordinator for the first National Journalism Symposium, April 1981)
After registering, you will receive a confirmation email containing information about joining the meeting.
Dr. Smith is co-author of the book MIddle Range Theory for Nursing, now in its 4th Edition. She was also one of the podium presenters at the 2019 Case Western Reserve Nursing theory conference, shown with other presenters, shown below! We hope you can join us!
Contributor: Ellen E. Swanson, MA, RN, BSN, PHN, HNB-BC (Retired)
Recently I had a professional practice story published in the American Holistic Nurses Association journal, “Beginnings”. Several responses to the story motivated me to think about the potential use of professional practice stories in nursing education. I shared with a local nursing professor and the magazine editor the possibility of using professional practice stories to have students identify what nursing theories and ways of knowing they saw in a given story.
This prompted a literature review on the topic of storytelling in nursing. I also recalled that I had a section about storytelling in my graduate position paper of 1998. One of the references for that paper was “To a Dancing God” by Sam Keen (1970; 1990). I reviewed his quote: “A visceral theology majors in the sense of touch rather than the sense of hearing.” (p. 159). I immediately said to myself that if there can be visceral theology, there can be visceral Nursology!
And what would visceral Nursology look like? Definitions of visceral include “proceeding from the instinctive, bodily, or deep abdominal place rather than intellectual motivation.” This brought to mind two concepts: the felt sense and aesthetic knowing.
I first explored the concept of the felt sense in 2007, and continued to read more about it over time. One way I came to understand the felt sense is as an immediate precursor to intuitive insights.
The following statements about ‘felt sense’ are taken from two books which I found quite helpful. The first book is Focusing (1979) by Eugene T. Gendlin. The second book is Waking the Tiger: Healing Trauma (1997) by Peter A. Levine. A more recent book, Your Body Knows the Answer: Using Your Felt Sense to Solve Problems, Effect Change & Liberate Creativity (2014) by David I. Rome teaches how to access the felt sense.
The felt sense is a difficult concept to define with words, as language is a linear process and the felt sense is a non-linear experience. Consequently, dimensions of meaning are lost in the attempt to articulate this experience. (Levine p. 67)
A felt sense is not a mental experience but a physical one. Physical. A bodily awareness of a situation or person or event. An internal aura that encompasses everything you feel and know about the given subject at a given time – encompasses it and communicates it to you all at once rather than detail by detail. (Gendlin p. 32)
Perhaps the best way to describe the felt sense is to say that it is the experience of being in a living body that understands the nuances of its environment by way of its responses to that environment. (Levine p. 69)
In many ways, the felt sense is like a stream moving through an ever-changing landscape…..once the setting has been interpreted and defined by the felt sense, we will blend into whatever conditions we find ourselves. This amazing sense encompasses both the content and climate of our internal and external environments. Like the stream, it shapes itself to fit those environments. (Levine p. 69-70)
The felt sense can be influenced – even changed by our thoughts – yet it’s not a thought, it’s something we feel. (Levine p. 70)
The felt sense is a medium through which we experience the fullness of sensation and knowledge about ourselves. (Levine p. 8)
Nowadays the phrase, “trust your gut” is used commonly. The felt sense is the means through which you can learn to hear this instinctual voice. (Levine p. 72)
The felt sense heightens our enjoyment of sensual experiences and can be a doorway to spiritual states. (Levine p. 72)
One must go to that place where there are not words but only feeling. At first there may be nothing there until a felt sense forms. Then when it forms, it feels pregnant. The felt sense has in it a meaning you can feel, but usually it is not immediately open. Usually you will have to stay with a felt sense for some seconds until it opens. The forming, and then the opening of a felt sense, usually takes about thirty seconds, and it may take you three or four minutes, counting distractions, to give it the thirty seconds of attention it needs. When you look for a felt sense, you look in the place you know without words, in body-sensing. (Gendlin p. 86)
I was so relieved to see how I had practiced nursing for decades put into words. I couldn’t always explain how I knew the effective interventions that seemed to just ‘happen’. I didn’t feel free to explore this in the non-holistic based career roles the first 30 years of my career. My graduate work in the late 1990’s gave me freedom to explore more holistic ways of thinking and practicing, but still doing it all rather privately. Membership in the Minnesota Holistic Nurses Association also gave me colleagues with whom to share more holistically.
The next movement toward being more open about my practice came when I learned about Modeling and Role Modeling Theory in 2012, two years before my retirement! Perhaps if I had been more open to nursing theories earlier, I wouldn’t have felt like I needed to hide how I practiced all those years. Listening, presence, and putting myself in the shoes of the other were always three of my stronger interventions. To see a theory include this latter one was such a relief. And it was in studying Modeling and Role Modeling that I learned there were a variety of ways of knowing, and aesthetic knowing was one of them.
However, I did not understand aesthetic knowing as fully until the more recent Nursology posts. I experience sheer delight with this learning. I can finally acknowledge my way of practicing to my nursing community. Chinn & Kramer (2018 p. 142) define aesthetic knowing as “An intuitive sense that detects all that is going on and calls forth a response, and you act spontaneously to care for the person or family in the moment.” It involves sensations as opposed to intellectuality. Chinn & Kramer (2018) also say “Aesthetic knowing is what makes possible knowing what to do and how to be in the moment, instantly, without conscious deliberation.” In other words, I have to not only let my head get out of the way, but also not let my head talk me out of aesthetic knowing, in both my professional life and personal life.
And so it is for me, that aesthetic knowing is Visceral Nursology. I now have a theory, an organization, and a way of knowing that supports how I practice.
Chinn, P.L. & Kramer, M.K. (2018). Knowledge Development in Nursing: Theory and Process. (10th Ed.). Elsevier. St. Louis, MO.
Erickson, H.L. (Ed). (2006). Modeling and Role-Modeling: A View from the Client’s World. Unicorns Unlimited. Cedar Park, TX.
Gendlin, E. T. (1979). Focusing. (2nd ed.) Bantam Books. NY.
Keen, S. (1970, 1990). To a Dancing God: Notes of a Spiritual Traveler. Harper Collins. San Francisco.
Levine, P.A. with Frederick, A. (1997). Waking the Tiger: Healing Trauma. North Atlantic Books. Berkeley, CA.
Rome, D.I. (2014). Your Body Knows the Answer: Using Your Felt Sense to Solve Problems, Effect Change & Liberate Creativity. Shambhala. Boston & London.
About Ellen Swanson
Ellen E. Swanson is retired from a 46 year nursing career that included ortho-rehab, mental health, OR, care management, consulting, and supervision. She also had a private practice in holistic nursing for 15 years, focusing on health and wellness teaching and counseling. She served on the leadership council for the Minnesota Holistic Nurses Association for ten years. She enjoys writing that incorporates holistic concepts, whether through storytelling or her booklet about Alzheimer’s or her book about healing the hierarchy.
Join us to learn more about our voices reckoning with racism in nursing. Share your voice in a dialogue, discussion, and future direction inspired by first person interviews and shown through the compelling stories of Black, Indigenous, Latinx, and other nurses of color.
Featuring Nurses from the “Overdue Reckoning on Racism in Nursing” project: Lucinda Canty, Sue Hagedorn, Raeann LeBlanc, Frankie Manning, Melissa Mokel, Gayle Robinson and StoryCenter guides and media production team: Jonny Chang, Joe Lambert, Sharon Mosley, and Daniel Weinshenker.
A Seedworks Foundation Supported Event in Collaboration with StoryCenter
Dr. Elizabeth Ann Manhart Barrett, nurse theorist and researcher, Rogerian scholar, and passionate advocate for nursing science, transitioned peacefully on August 24, 2021 surrounded by her family. She was best known for her theory of Power as Knowing Participation in Change derived from Rogers’ Science of Unitary Human Beings (SUHB) More than 100 studies have been conducted using the theory and/or measurement instrument (PKPCT); the PKPCT has been translated into 7 languages.
Elizabeth developed the first practice methodology for Rogerian nursing practice called Health Patterning, and she had an independent nursing theory-guided practice for many years in New York City based on this method. Elizabeth was a member of the American Academy of Nursing’s Nursing Theory-Guided Practice Expert Panel (NTGP-EP), serving as the organizer and first leader of NTGP-EP along with Dr. Rosemarie Parse. In addition, she was a founding member and first president of the Society of Rogerian Scholars. Elizabeth was a passionate champion of nursing science grounded in nursing theory. Her articles “What is Nursing Science?”(2002) and “Again, What is Nursing Science?”(2017) are classics. She edited four books including Rogers Science-based Nursing that received the ANA Book of the Year Award.
Elizabeth was born in Newburgh, Indiana and was blessed with five children, 14 grandchildren and 15 great grandchildren. After 12 years of working in her home and caring for her children she decided to go to college. She credits her mother, a “feminist”, with inspiring her to pursue her dreams and to help people who were suffering, especially those who were less privileged. She graduated with a Bachelor of Science in Nursing summa cum laude from the University of Evansville (UE) and continued as a part-time student at UE while working full-time and eventually earning a Master of Arts in education with a major in psychology and a Master of Science in Nursing. After this she taught psychiatric/mental health (PMH) nursing at UE and continue to work as a PMH nurse.
In 1976 she moved to Greenwich Village in New York City to begin doctoral study at New York University (NYU). It was a different world from her roots, and she loved New York City. It was there that she began working with Martha Rogers studying and advancing the SUHB. While in the PhD program at NYU she worked as a float charge nurse at Bellevue Hospital Center, fulfilling another dream; she considered Bellevue Psychiatry as the greatest challenge and reward in PMH nursing practice. It was her favorite position. While studying Nursing Science with a major in Theory Development and Research at NYU she taught research at Adelphi University and PMH clinical practicums at City University of New York (CUNY). After graduation she was an Assistant Director of Nursing at Mount Sinai Hospital for 5 years and then joined the faculty at Hunter-Bellevue School of Nursing (CUNY) where she held positions of Director of the Graduate Program and Coordinator of the Center for Nursing Research. She retired as Professor Emerita in 2001 and expanded her private practice to full-time. She was a licensed therapist in the state of New York practicing Health Patterning, a nursing theory guided practice with private clients. For 40 years she was active in mentoring many researchers and scholars in the SUHB and Power Theory and conducting her own research testing and advancing the theory.
Those who knew Elizabeth can attest to her kind, loving and supportive nature and playful sense of humor. We will miss her on this Earth, but we will continue to experience her presence in many ways. May she soar in peace and power!
The SRS Fall 2021 conference planning committee met together this past week to plan a conference tribute to Dr. Elizabeth Ann Manhart Barrett. We invite you to join with us in organizing a Celebration of Light and Life that will be shared on Saturday October 2, 2021 in the afternoon as special part of the conference program. We are compiling photos and memories that will be organized and shared in a powerpoint presentation.
We invite you to please send digital versions of any photos that you may have of Dr. Barrett to firstname.lastname@example.org and email@example.com. The photos may be scanned or you can take a photo of the photo and send in email.
We invite you to share any personal memories that you may have of Dr. Barrett or stories of how her work impacted your work or life. The SRS website has an open text box where the memories can be shared publicly or you can email firstname.lastname@example.org and email@example.com with content to be shared in the conference tribute.
We may also pull content form the website so if you write something there we may also include it. Depending on the volume of content we receive we will have to make choices or edit the stories for use.
There will also be time for open sharing of stories in real time at the conference during the celebration for those who would be comfortable doing so.
The SRS website link to write a memory is here and you can also follow the link to Dr. Barrett’s obituary shared by her family.
Please feel free to reach out with any questions or concerns. As a reminder please register for the conference here and share the conference information widely in your circles.
Now open for submissions – until 11:45 pm EST on November 15, 2021!
The abstracts can be for either a 30-minute “Knowledge Session” or for a virtual poster presentation!
Visit the Nursing Theory Conference website for more details about submitting your abstract! Access to the abstract submission page is also posted in “Due Dates” to the right of each Nursology.net page!
We are delighted to announce the addition of an Education Exemplar describing the St. Mary’s College School of Nursing program designed using the Roy Adaptation Model! You can access the new Exemplar any time from the Nursology.net “Education Exemplars” main page. Or go directly to the St. Mary’s Exemplar here
Guest Contributor: Lydia D. Rotondo, DNP, RN, CNS, FNAP
The practice doctorate in nursing developed in response to an increasingly complex healthcare landscape that requires additional competencies for 21st century advanced nursing practice. Complementing traditional graduate (MS) specialty curricula, the Doctor of Nursing Practice (DNP) program of study incorporates additional curricular content in the areas originally detailed in the 2006 DNP Essential domains (now integrated into AACN’s 2021 Essentials). DNP students complete a summative scholarly practice inquiry project that is theoretically-guided and evidence-based, demonstrating synthesis and application of the tools of clinical scholarship learned throughout the DNP program.
Particularly relevant to the design of DNP projects is the critical importance of context and the application (or adaptation) of best evidence (when available) to specific practice settings or specific populations. As context experts DNPs utilize systems thinking to design, implement, and evaluate interventions within complex adaptive systems revealing new understandings about health care delivery, the healthcare experience, and the role of DNPs as change agents and clinical scholars.
Fifteen years after the release of the DNP Essentials, appropriate focus is now on evaluating the impact of DNP practice on healthcare systems and health outcomes. As a practice discipline, however, there remains little attention by nursing academe regarding the potential impact of the practice doctorate on the discipline of nursing. In other words, how will the growing cadre of DNP-prepared nurses be leveraged to advance the discipline? In today’s interdependent, knowledge–based, digital world, how will advancing the discipline be defined and measured in the coming decades? What additional scholarly tools and curricular content will DNP students need to begin to answer these questions?
As doctoral-prepared nurses, DNPs share stewardship with other doctoral-prepared nursing colleagues to generate disciplinary knowledge. Yet, discussion about DNPs as knowledge producers and theory innovators remains largely unexplored. Scholarly treatment of knowledge generation in nursing practice is not a new phenomenon and has, in fact, been posited and published by several nursing theorists for decades. However, the introduction of the latest iteration of the practice doctorate in nursing, now in its second decade, with more than 36,000 enrolled in DNP programs and close to 8,000 graduates, has not sparked interest among leaders in DNP education to approach practice epistemology from the DNP lens.
Moreover, with a de-emphasis on philosophy of science and theory and stronger attention to evidence-base practice in DNP curricula, DNP programs as currently designed may lack sufficient educational grounding to engage in practice theory development. This further impedes the opportunity for scholarly discourse on practice knowledge production specifically and doctoral roles in nursing knowledge generation more broadly. While the promotion of evidence-based practice among all health professionals is useful to reduce clinical variation in care, there remains nascent opportunity for DNPs to consider how their scholarly work can produce practice-based evidence- knowledge that both improves care outcomes for individuals and populations and illuminates the contributions of nurses to healthcare.
In 2019, we developed a theory and conceptual foundations for clinical scholarship course at the University of Rochester School of Nursing in which students explore the historical and philosophical roots of the practice doctorate in nursing and nursing as a practice discipline. Our early efforts were inspired by Dr. Pamela Reed, Professor at the University of Arizona College of Nursing, whose considerable contributions in the area of practice epistemology provided a framework for course development. In an early course assignment, students are asked to create a concept map using the four nursing metaparadigm concepts to describe their philosophy of nursing. Students present their maps in class which encourages rich discussion about the nature of nursing knowledge related to their role in health care and health/wellness promotion. What is particularly striking is that for many students, this course is their first exposure to nursing’s theoretical grounding and opportunity to reflect on their professional practice from a disciplinary perspective. Several DNP student exemplars from the spring 2021 semester are included below with permission.
Exemplar 1 – Sarah Dunstan, University of Rochester School of Nursing DNP student
Circumnavigating and persevering through life’s most challenging roadblocks, the nurse dutifully guides the most weary and vulnerable of travelers towards safety and solace, both physically and emotionally. Committing to the vision of “Ever Better” and the pursuit of optimal patient wellness, nurse leaders are tasked with the responsibility of advancing the field and creating the new standards of care for the future.
As depicted above, my philosophy of nursing is best explained in the context of a journey. The person, or patient, is represented as a vehicle. Similar to vehicles, each patient is a unique make and model, some with more miles or more baggage than others. The nurse navigating the vehicle must carefully consider these differences and individual patient needs when mapping out the patients’ journey to health. The map, or environment, is laden with roadblocks or barriers to optimal wellness. The barriers may be geographical, financial, cultural, psychological, or physical. Whether few or many, these roadblocks may delay or completely inhibit the patient from reaching their health care goals. The metaparadigm concept of nursing describes the individual caregiver at the bedside that assists the patient around and through these various states of illness in order to reach the ultimate destination of optimal wellness. The destination “Health” is malleable and ever evolving, as depicted with multiple possible end points marked on the map. Health is defined by and dependent on the individual patient and their own informed healthcare goals, as optimal wellness is not always defined as the absence of disease.
The map is in the hands of the DNP-prepared nursing scholar. As a leader and nursing expert in the field, the DNP is the visionary change agent tasked with closing the practice-theory gap at the bedside in the clinical setting. DNPs are the cartographers for the future of nursing, responsible for defining clinical scholarship in nursing, creating, upholding, and disseminating the proposed standards of the discipline.
Exemplar 2 – Christine Boerman, University of Rochester School of Nursing DNP student
My nursing theory and paradigm is composed of many moving parts that work interchangeably and without each of these elements working together, the discipline of nursing would not be complete. My nursing theory is illustrated via the gears that work together in order to create the full working “maChinne” of nursing discipline.
Exemplar 3 – Christina D’Agostino, University of Rochester School of Nursing DNP Student
The figures included within the map are all intended to mirror constellations within that sky, represent the person, the environment and one’s health. Centered at the bottom of the map, shining its beacon of light on the sky is nursing, represented by two hands which provide the foundation. Nursing is a global role. As people around the globe all look up to the same night sky, all people share the benefits of the nursing domain.
My personal philosophy of nursing is a holistic approach of providing culturally-sensitive care for individuals, regardless of locality or ethnicity while being mindful of the interconnectedness that involves the person, environment, and one’s health as the recipient of that care.
Exemplar 4 – Victoria Mesko, University of Rochester School of Nursing DNP Student
My personal philosophy of nursing is: Caring for individuals with a holistic approach, striving for wellness within the community and the world. Along with all of the skills that nurses develop, what sets nurses apart is their caring nature. Nurses have an all-encompassing view of our patients’ mind, body, and spirit. Nurses see patients in the context of their environment and are able to propose treatments that will consider all of the influences on patient’s lives. Nurses take into account all of the meanings that “health” can have to a person, not just the absence of disease, but a sense of wellness even if they have disease. In my map, there is no one nursing domain that is more important than another, as they all have an influence on patient care. The interlocking circle of different hands represents nurses working to form relationships and connections between patients, the community and the environment across cultural lines.
Exemplar 5 – Kalin Warshof, University of Rochester School of Nursing DNP Student
My philosophy of the nursing discipline is the utilization of the art and science of nursing care, compassion, and practice interventions to enhance the health and well-bring of the person, within their individual environmental context, including social determinants, culture, and beliefs. The metaparadigm map depicts the person at the center of the diagram, with nursing as a discipline, nursing interventions and compassionate care contributing to the improvement of health and well-being of the person. This is evident by the upward arrow, with health and well-being above the person, portraying the upmost importance to the person and nursing. The background in light blue, labeled the environment, indicates that the person, nursing discipline, health, and well-being interpretation and improvement occurs within the context of the personal environment. My philosophy of the nursing discipline is consistent with the Doctor of Nursing Practice Essentials I objective focusing on the whole person and their interaction with the environment to improve health and well-being (American Association of Colleges of Nursing [AACN], 2006).
Exemplar 6 – Kara Mestnik, University of Rochester School of Nursing DNP Student
Individual nursing philosophy is shaped overtime by individual practice, and life experience. My philosophy has shifted over the past twenty years, I have gained vast clinical experience and growth in intrapersonal interaction and relationships. The term balance is often sought for and emphasized as an indicator of health and wellness, comparable to the concept of homeostasis. My personal philosophy of Nursing is the ability to navigate all facets of human life despite the magnitude of directional force that may attempt to imbalance ones mental, physical, and spiritual well-being. Refer to (figure 1) for metaparadigm map. Consider the patient the pivot at the center of the compass, with a multidirectional view of their own life and well-being, while the nurse is the hand that holds the compass. The hand holding the compass helps both align and balance the direction the patient is aiming to travel. The nurse becomes both the navigational guide and the stable hand that allows for balance to be achieved at any given period or direction in time. The hands holding the compass indicate a personal connection with the patient as well as an oversight into the larger picture in which patients may travel. The acquired achievement of balance despite a directional force is guided by the hands that allow for health and wellness optimization.
About Lydia Rotondo
Lydia Rotondo, DNP, RN, CNS, FNAP is the associate dean for education and student affairs and director of the doctor of nursing practice program at the University of Rochester School of Nursing. She received her DNP from Vanderbilt University, MSN from the University of Pennsylvania, and BSN from Georgetown University. Lydia is a 2018 AACN Leadership in Academic Nursing Fellow and has actively contributed to the national dialogue on DNP scholarship and curriculum development through presentations at AACN’s doctoral education conference and publications.
In the first week of my nursing Ph.D. program, I heard a brief presentation from a professor who taught “psychoneuroimmunology.” I had never heard that word, but I knew I had to take that class. I was entering my Ph.D. journey after a long career as a primary care pediatric nurse practitioner. I had started to feel a thirst for knowledge about the mind-body-spirit connection, how it relates to wellness, and how we can implement integrative healthcare across cultures. Fortunately, my first year included a class on nursing theory development and evaluation, so I was prepared to enter this mysterious class with my newly solidified personal worldview, epistemology, ontology, and favorite nursing theories.
Psychoneuroimmunology (PNI) did not strike me as a theory at first. I had just finished refresher classes in endocrinology and immunology, wherein having an old textbook didn’t matter too much because these reductionist sciences were slowly changing. On the other hand, I quickly learned that PNI was a young theory about bi-directional communication among the mind-brain-immune-endocrine systems that was gaining an evidence base and interest across many disciplines. My professor, Dr. Pace, noted that he loved teaching nurses because we “are so good with theories.” I stopped to think about how PNI contrasted with the nursing theories I had learned…as well as how it aligned with nursing theories (more on that later).
What is PNI?
PNI is a re-emergence of ancient beliefs that organisms are integrated systems (Daruna, 2012, p.13). Robert Ader was a psychologist who, along with Nicholas Cohen, originated PNI and advanced the field of mind-body science in 1980 (Daruna, 2012, p.21). Ader’s discovery that rats could be trained to have a particular immune response came at a time when biomedical science was ready for a new holistic theory. PNI has established that the immune system crosses the blood-brain barrier affecting physical, cognitive, psychological, and behavioral functions. Probably the most well-known model within PNI is that of the Stress Response (Pace, 2020, October 26). Acute psychological or physical stress activates pro-inflammatory cytokines such as IL-1 and IL-6. Acute stress also shifts the body’s homeostasis to a sympathetic (fight or flight) response and triggers the hypothalamus-pituitary-adrenal axis (HPA) to release cortisol. These acute immune mechanisms help protect the human organism in the short term. However, chronic or cumulative stress can lead to inflammation and cortisol dysfunction. In addition to physiologic changes, cytokines affect neurotransmitters leading to changes in cognition and behavior. Pace summarized how multiple complex pathways related to stress and inflammation increase the risk for physical and mental illness throughout life.
What are PNI Interventions?
We can measure immune biomarkers through blood or saliva, so scientists have been able to test interventions that prevent or disrupt the stress-immune pathway. Mindfulness, meditation, nutrition, exercise, sleep, and counseling are just a few PNI interventions that have an evidence base for various illnesses (Pace, 2020, November 23). Nursing practice already values these nurturing and accessible tools, so we are all PNI practitioners.
PNI and Nursing Theory
I believe our very first nurse theorist, Florence Nightingale, would have appreciated the tenets of PNI. Not only did Nightingale’s prescient focus on infection control address the immune system’s role in health, but her methodical and statistical approach to nursing also laid the foundation for complex knowledge discovery (Nelson & Rafferty, 2011). Grand nursing theories that followed Nightingale’s work included those in the integrative-interactive paradigm, which views a patient as an interactive whole capable of a multitude of adaptation responses to their environment. Examples of integrative-interactive conceptual models include Sr. Callista Roy’s adaptation model, Betty Neuman’s systems model, and Barbara Dossey’s theory of integral nursing (Smith & Parker, 2015, p. 88). The field of PNI is producing voluminous empiric evidence that the human body is an interconnected whole, which supports these holistic nursing theories.
For a more specific example of how a nursing theory could guide a hypothetical PNI research study about the long-term effects of stress, I will refer to Betty Neuman’s systems model (NSM) (Lowry & Aylward, 2015) and provide a conceptual-theoretical-empirical structure (Gigliotti & Manister, 2012). I hypothesize, based on previous research (Felitti et al., 1998), that adverse childhood events (ACEs) cause inflammation that leads to cardiovascular disease (CVD) later in life, and smoking behaviors mediate the relationship. NSM is a model about a client’s adaptation to internal or external stressors and includes the client concepts of stressor, invasion of the normal line of defense, lines of resistance, and core response (Lowry & Aylward, 2015). The theoretical linkages of PNI in my study are ACEs, cortisol response via the HPA axis; inflammation/cognitive changes/maladaptive behaviors; and cardiovascular disease, respectively. The empirical measures of these links are a self-report ACE questionnaire; salivary cortisol levels; attenuated cortisol response measures/depression and anxiety symptom survey; and blood pressure/cholesterol/smoking behaviors, respectively. Here physiological and psychological variables of the hypothesis are directly measured, allowing us to understand the more abstract concepts of the NSM and their relationships to one another. The NSM also includes a concept of intervention as prevention that aligns with the wellness focus of PNI.
Nursing Knowledge Development and the Future of PNI
Despite congruence with existing nursing theories, incorporating PNI in developing a new middle-range nursing theory could move down the ladder of abstraction to a more concrete explanation of concepts (Smith & Liehr, 2018, chapter 2). For example, a middle-range PNI nursing theory might focus on the prevention and treatment of ACEs with children and their families. PNI emphasizes the natural healing processes of humans, is adaptable to the personalized or the public health level, and even has economic benefits to a healthcare system (Daruna, 2012, p. 280-83). If we adopt a nursing PNI conceptual model for wellness and prevention, we can improve outcomes such as depression, diabetes, cancer, heart disease, autoimmune diseases, and more.
Two years after my introduction to the term psychoneuroimmunology, I am preparing for my comprehensive exams. As I reflect on my Ph.D. curriculum, I realize the degree to which nursing theories and PNI have already informed my nursing research and practice. I hope to contribute to a future where nurses, guided by theory, have more understanding and tools to care for the complex human being…but first, back to studying!
Daruna, J. H. (2012). Introduction to psychoneuroimmunology. (2nd ed.) Elsevier, Inc.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8
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About Christine Hodgson
Christine Hodgson has been a pediatric nurse practitioner for over 20 years. She currently works in school-based health clinics, including one on an Indian reservation. She lives in Montana with her husband who is a pediatrician, three sons, and two golden retrievers. She loves to hike, bike and ski in the mountains, travel and read. She plans to study the resilience of indigenous children around the globe.