Theory’s Reality in Nursing Practice: Florence Nightingale’s Legacy

Contributor: Isabel Faia

The contemporary imbalance in environmental matters predominantly involve climate change and our supposedly beloved home planet’s ecosystems issues. Human beings are continuously disrespectful of their relationships with the universe ecosystem.

Humankind is responsible to a great extent for this state of “dysbiosis” of our planet, which is similar to the state of each person’s gut microbiome. This lack of balance and harmony in nature, is the root cause of the emerging of new and complex pathological challenges, which, like the Covid-19 pandemic, have become impossible to ignore. Countries the globe over have been forced to take very strict contingency measures, with different levels of freedom and restrictions in order to slow down the devastating effects of sickness and death that the virus has caused.

Healthcare professionals have an important role in managing the many menacing threats to populations of our planet, their well-being and survival. Nursing as a professional discipline, has many theories that can use used to as evidence for safe and competent practice. The concepts of Fawcett’s metaparadigm of nursing provide a way to understand and guide nursing during the pandemic – human beings, environment, health, nursing  However, given the reality of our current world, other key concepts also provide paths that guide our understanding of the reality we face in the pandemic. 

I contend that we are closing a cycle, a full 360° spin, that brings us back to Florence Nightingale’s work. From Nightingale’s framework, the nurse’s primary role is caring and helping people in their healing process. Nightingale told us that the environment is a key influencing factor in this process, which when operationalized, can increase the potential for recovery and survival. Nursing care in this framework emphasizes the optimization of ventilation and natural lighting of spaces, noise reduction, frequent hand washing and disinfection, hygiene of spaces, among other aspects of the environment. Nightingale supported the importance of these environmental aspects, by collecting and statistically analyzing data from everyday practice.

We can use the symbol of the lamp to illuminate the paths of what today’s nursing practice can be, and promote multidisciplinary recognition of nurses profound contributions to population health. We face the fact that 200 years since Nightingale’s ideas were first published, widespread recognition nursing at both the ontological and epistemological levels still remains a challenge to overcome. Therefore, we all have to effectively communicate to our communities worldwide a clear vision of what nursing is.

At a personal level, I have just completed two decades of my career as a nurse, predominantly caring for critically ill patients in the context of urgency/emergency rooms and also in an intensive care unit. This led to an experience marked by a great many interdependent nursing activities, which contribute to the progressive distancing from fundamental nursing theoretical thinking. I perceive myself in a state of profound professional numbness. Not meaning that the quality of my autonomous nursing activities were questionable, but instead were automatically executed and with little awareness of theory. This is similar to an experienced car driver, who over the years enters into a state of relative unconsciousness, an automated practice, when driving. This progressive loss of professional identity became evident in the scope of the Masters in Critical Care Nursing Specialty that I am currently attending at Univesidade Católica Portuguesa (Lisbon). When re-visiting in class the evolution of thought in and the production of knowledge throughout nursing’s history, in a short time and instinctively my practice gained the semantics of nurses’ expression, more specifically in content format and other implicit dimensions, as if it were on standby and with a click it would switch on. What seemed difficult to transfer into practice, proved to be the root of my daily professional practice.

That is why when I read the post The Impossibility of Thinking “Atheoretically” (Fawcett, 2019) in Nursology, suggested by the Master’s Nursing Theories Chairwoman, I cathartically identified with it. In my experience of hibernated nursing and of unconscious semantics, in the past I considered myself to be a nurse distant from theories, which would belong to an exclusively academic context. Now I confess that this process was a boost of vital energy, illuminating and motivating me to an increasingly challenging and exciting life as a nurse.

About Isabel Faia

I’m an ICU nurse since 2014, working for the past 20 years in a public hospital in Madeira Island, Portugal. Presently, I am doing a Masters in critical care nursing, at Health Sciences Institute, UCP Lisbon. This post was made in the nursing theories curricular unit of the Masters in Nursing Course of the Health Sciences Institute of UCP (Lisbon), with the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).

Sept 23 – Panel Discussion -Decolonizing Nursing: What? Why? How?

A webinar panel presentation sponsored by Nursology.net in association with the Center for Nursing Philosophy 

September 23, 2021, 6 – 7:30  PM Eastern (US & Canada)

ALL ARE INVITED!

Panelists

  • Lisa Bourque Bearskin, RN, PhD, Thompson Rivers University (BC)
  • Lucinda Canty, RN, PhD, University of St. Joseph (CT)
  • Barbara Hatcher, PhD, MPH, RN, FAAN, George Mason University
  • Lucy Mkandawire-Valhmu, PhD, RN, University of Wisconsin-Milwaukee
  • Daniel Suárez-Baquero, PhD, MSN, BSN, University of California San Francisco
  • Bukola Salami, RN, MN, PhD, University of Alberta
  • Jennifer Woo, PhD, CNM, WHNP, FACNM, Texas Woman’s University

Moderator  – Miriam Bender, PhD, RN, University of California Irvine

Register in advance. After registering, you will receive a confirmation email containing information about joining the webinar.

Sept 23 – Panel Discussion -Decolonizing Nursing: What? Why? How?

A webinar panel presentation sponsored by Nursology.net in association with the Center for Nursing Philosophy 

September 23, 2021, 6 – 7:30  PM Eastern (US & Canada)

ALL ARE INVITED!

Panelists

  • Lisa Bourque Bearskin, RN, PhD, Thompson Rivers University (BC)
  • Lucinda Canty, RN, PhD, University of St. Joseph (CT)
  • Barbara Hatcher, PhD, MPH, RN, FAAN, George Mason University
  • Lucy Mkandawire-Valhmu, PhD, RN, University of Wisconsin-Milwaukee
  • Daniel Suárez-Baquero, PhD, MSN, BSN, University of California San Francisco
  • Bukola Salami, RN, MN, PhD, University of Alberta
  • Jennifer Woo, PhD, CNM, WHNP, FACNM, Texas Woman’s University

Moderator  – Miriam Bender, PhD, RN, University of California Irvine

Register in advance. After registering, you will receive a confirmation email containing information about joining the webinar.

COVID-19 Through the Lens of Nursing Theories

Contributor: Navninder Kaur, MSN, CMSRN


It all started in January of 2020 when the news started circling around about a contagious viral disease spreading in the East. The situation was not much of a concern, with a thought that just like other diseases like SARS, which originated and spread in one region, it will subside soon. However, as essential resources like gloves, masks, and hand sanitizers started disappearing from store shelves around the last week of February, and come March, our hospital had its 1st case of COVID-19. Soon, things got chaotic and out of hand, when we started running out of PPE’s, medical and ICU beds, ventilators, and staff to take care of patients. While hospitals were overwhelmed with the extensive virus outbreak, health care professionals came to the frontlines, fighting the unknown enemy, without any specific treatment.

Every member of the health care industry was directly or indirectly affected by the virus or its consequences, and above all, nurses played a crucial role in this fight. Nurses, comprising more than 50% of the health care and allied professionals, plunged into desperate conditions to care for human lives. What made their role even more paramount was that they spent far more time with patients than any other member of the healthcare team. Even the nurses who were pregnant, breastfeeding, elderly, retired, had co-morbidities or were students put their patients before their own families and health.

Nursing has evolved through wars and pandemics. The Crimean war led Nightingale to shape modern nursing practice. Her environmental theory saved many lives and improved the face of public health. With the ongoing pandemic, all nurses have a bit of Nightingale in them, working under tremendous pressure to address population needs. In the Year of the Nurse and Midwife, nurses raised concerns of public awareness

What set nurses apart from physicians, respiratory therapists, anesthesiologists, and other health care professionals in this time of incredible adversity? While all of these professionals’ focus is on science and empirical knowledge, it is a strong foundation of nursing theories, frameworks, and models that separate nursing from other professions. Knowingly or unknowingly, nurses have implemented nursing theories in their practice during these times of crisis. Whether it is identifying environmental components as outlined by Nightingale or Abdellah’s 21 nursing problems including physical, social, and emotional, or Johnson’s behavioral system model in which constancy is maintained through biological, psychological, and sociological factors or Neuman’s model which emphasizes that a person is a complete system, nurses have not just treated the “illness” but addressed the patient as a “whole”.

When COVID hit our hospital, our administrators outlined policies based on the recommendations of infectious disease specialists, and nurses were asked to limit visits to patients’ rooms to twice per shift to minimize the spread of infection. Nurses could not swallow that; we ended up being in the room 7 to 8 times on an average! Perhaps that contributed to 85% of patients who were successfully discharged from hospitals.

Above all, it was the application of Watson’s 10 carative factors that played a substantial role in the discipline of nursing during these difficult times. Despite the strict visitation policies put in place by hospitals, nurses made sure families were able to connect to their patients via video conferencing. This nursing action cultivated the spirit of love and kindness. They let family members and loved ones know they could contact as many times as possible during the day. Nurses listened to their fears and promoted their expression of feelings. Social media has a plethora of photos and videos of nurses holding patients’ hands, sitting at the bedside of dying patients when no family members could be present. Nurses comforted family members who had psychological stress and negative emotions from not being present with their loved ones during their last moments. Nurses made it possible for my family to wish goodbye to my father-in-law who was 200 miles away from us and passed away after losing his fight against this disease.

By embracing Leininger’s culture care theory, nurses provided care with transcultural understanding, sometimes performing rituals, praying with the patient, while connected with their families on the phone/video, and providing holistic care. During an unrelenting global pandemic, nurses have promoted transformational changes to sustain and preserve human dignity.

About Navninder Kaur

Navninder Kaur is a student in the Online Nursing Education EdD program at Teachers College, Columbia University. She is a clinical instructor at Western Connecticut State University in Danbury, CT. She has 10 years of clinical experience in adult medical-surgical nursing.

The Epistemology of Nursology: One Perspective

On May 12, 2021, I was honored to present the keynote address for the 2nd International Videoconference Forum, “The Epistemology of Nursing Knowledge: Its Importance in Times of Pandemic,” sponsored by the Benemérita Universidad Autónoma de Puebla, in Puebla, México. The topic I had been asked to address was the epistemology of our discipline. Although I certainly do not consider myself an epistemologist, I accepted the challenge of articulating my version of the epistemology of nursology.

The complete presentation is available below. A summary of the presentation is given here.

Inasmuch as epistemology refers to a theory of knowledge (Zander, 2007), I described the theory of nursology knowledge as embracing and “epistemological plurality . . . [that reflects] . . . a commitment to recognizing different ways of knowing to support [nursology’s disciplinary] mandate to consider the individual holistically and in context” (Ou et al., 2017, p. 7).
Epistemology is concerned with

  • Beliefs about the knowledge
  • The knowledge
  • The truth of the knowledge
  • Justification for the knowledge

My Beliefs about the Knowledge of Nursology

I and at least some other nursologists believe the epistemology of nursology includes a metaparadigm, philosophies, conceptual models, theories, and methods of scholarly inquiry. I acknowledge multiple versions of the metaparadigm; my version is human beings, environment, health, and nursologists’ activities. I believe that multiple philosophies, conceptual models, theories (grand theories, middle-range theories, situation-specific theories), and methods of scholarly inquiry are recognized as valid knowledge about our discipline. I also believe that the findings of every instance of scholarly inquiry constitute a theory, and that methods of scholarly inquiry encompass historical, philosophical, and empirical methods, all of which can include qualitative (subjective) and quantitative (objective) approaches.

The Knowledge

My understanding of the knowledge of nursology encompasses five ways of knowing – tenacity, authority, a priori, practice/practice wisdom, and theory—as well as eight fundamental patterns of knowing in nursing—empirical, aesthetic, ethical, personal, sociopolitical, emancipatory, spiritual, and unknowing.

The Truth of the Knowledge

My understanding of the truth of nursology knowledge is that “acting in the best interests of the people for whom [nursologists] care requires valuing both subjective and objective ways of knowing” (Zander, 2007, p. 7), and that the nursology scholarly methods of inquiry encompass both the objective (quantitative) and the subjective (qualitative). Both objective and subjective knowledge can be explicit or implicit/tacit.

Justification for the Knowledge

I maintain that methods for obtaining both objective and subjective knowledge are needed for “multidimensional understanding of the client within the context of situation, family and environment” (Ou et al., 2017, p. 7), which is best determined by conduct of scholarly inquiry for the purpose of development of situation-specific theories. In keeping with the conference theme, my presentation also included content about decolonizing nursology knowledge, which may be accomplished by revising or discarding the existing metaparadigm, philosophies, conceptual models, and theories to eliminate the current dominant Euro-centric worldviews of white privilege (Chinn, 2021).

Additional Comments

My presentation also included these suggestions for attaining social justice.

  • Develop new knowledge of how to increase planetary health equity and reduce or eliminate planetary health disparities
  • Develop new knowledge of how to eliminate structural and systematic racism

I agree with Chinn (2021) that much of the work of decolonizing and social justice can be achieved through an emphasis on development of situation-specific theories by inviting people to tell their stories of their health experiences. The stories than can be analyzed within the context of the situation and the people’s culture, with attention to avoiding stereotyping of the story-tellers on the basis of their culture. Decolonizing nursology knowledge and focusing on social justice also can be achieved through developing knowledge that “is an interchange between [culturally and contextually relevant] theory and practice and [is] guided by [culturally and contextually relevant] philosophy is like a kind of pendulum where all three elements [[culturally and contextually relevant] philosophy, theory, practice] are treated as equals” (Hoeck & Delmar, 2018, p. 1).

Conclusion

I believe it is crucial to the survival of nursology that we think and act on the basis of our five ways of knowing and a synthesis of our eight types of theories always and especially at this time of the pandemic, when so much emphasis is on doing tasks without sufficient attention to the why of the tasks beyond the pragmatic.

References

Chinn, P. L. (2021). Equity and social justice in developing theories. In E-O Im & A. I. Meleis (Eds.), Situation specific theories: Development, utilization, and evaluation in nursing (pp. 29-37). Springer Nature Switzerland.

Epistemology (2021, June 13). https://en.wikipedia.org/wiki/Epistemology
Hoeck, B., & Delmar, C. (2018). Theoretical development in the context of nursing—The hidden epistemology of nursing theory. Nursing Philosophy, 19(1), 10 pages. https://doi.org/10.1111/nup.12196

Ou, C. H. K., Hall, W. A., & Thorne, S. E. (2017). Can nursing epistemology embrace p-values? Nursing Philosophy, 18(4), 9 pages. https://doi.or/10.1111/nup12173

Zander, P. E. (2007). Ways of knowing in nursing. The historical evolution of a concept. Journal of Theory Construction and Testing, 11(1), 7-11.

The slides can also be viewed here

Examining the Evolving Role of the BSN-Prepared Nurse outside Acute Care Settings: A Nursing – Shared Theory/Conceptual Model Approach

Co-Contributor: Katunzi Mutalemwa

The purpose of this blog is to describe a baccalaureate (BSN) prepared nursologist’s, Katunzi Mutalemwa personal lived pre-internship clinical learning experience in primary care at a local community-based non-governmental outpatient clinic run by The Tanzania Doctors with African CUAMM  in collaboration with a local District hospital.

Katunzi’s reflections have been interpreted within the context of nursology discipline-specific knowledge of Neuman’s Systems Model (NSM), and the Theory of Self-Care of Chronic Illness (TSCC), as well as the Expanded Chronic Care Model, a model shared with public health.

Inasmuch as the ECCM is a shared model, the starting point for the interpretation is the nursology discipline-specific conceptual model that is NSM (Villarruel et al., 2001). Whereas the NSM guided the overall understanding of the reflections, the concepts of the TSCC guided some of the specific actions described, as did the ECCM. The NSM provides a nursology conceptual foundation that takes into considerations the multiple levels of client/client system influences – the physiological, psychological, socio-cultural, developmental and spiritual interacting factors and environmental stressors. The model has the potential of advancing the future of nursology in the area of expanded nursing scope of practices and services in response to chronic disease management.

Katunzi’s reflections highlight the role of the BSN-prepared nursologists in the management and prevention of chronic diseases beyond the walls of the acute care settings (i.e., community-based primary health care settings)

The main ideas seen in this blog are consistent with the World Health Organization’s (2020) State of World Nursing publication, the nursology.net blog Primary-care-primary-nursology-and-the-attending-nursologist, the AACN White-Paper on the Vision-Academic-Nursing; the Health Resources & Services Administration (HRSA) 2018 call for Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program as well as several journal articles on the role of the primary care nursologist (e.g. Anderson et al., 2012; Bodenheimer, & Mason, 2016; Borgès Da Silva et al., 2018; Epping-Jordan, 2002; Lipstein, et al., 2016; Norful, et al., 2017).  The description of the roles and responsibilities discussed in this blog acknowledge the varied contextual nursing scope of practices across the globe.

Katunzi’s Nursing Context/Situation

The personal reflections demonstrate how a BSN-prepared nursologist practices within the Tanzania Nursing and Midwifery Council (TNMC) (2014) general nurse full scope of practice. The TNMC’s major role definitions of a general nurse prepared at the baccalaureate level are: 1) Accountability, Ethical and Legal Practice; 2) Care Provision, Health Promotion, Leadership and Management and, 3) Professional, Personal and Quality Development. For instance, the care provisions and leadership definition of the TNMC general scope of practice, the BSN-prepared nurse roles includes, but is not limited to developing practice guidelines, representing nursing at the management meetings, preparing and presenting nursing budgets at management team meetings, participating in nursing research and utilizing research results in provision of nursing care, providing comprehensive nursing care and carrying out nursing management independently, formulating relevant policies about patient and client care, and reviewing performance appraisal for nurses. According to the TNMC, if assigned, a BSN-prepared nurse is also allowed to prescribe medications for persons with some acute, emergency conditions and chronic illnesses and to prescribe physical therapy and other rehabilitative treatments in keeping with existing protocols.

Katunzi’s reflections

Community Resources and Policies and, Health Care System (Concepts of the ECCM)

As a BSN-prepared nurse completing a pre-internship clinical learning opportunity in a private community-based clinic (NSM community as the client system), I was mentored into the primary care role by a team of nurses and other healthcare providers. I was involved in the management of clients living with diabetes and heart diseases (adults and adolescents) (NSM developmental variable) trice a week and also participated in conducting monthly supervisions in satellite health centers. I learned to assure patients/clients maintained a maximum level of wellness by keeping stressors and stress responses at a minimum through effective, efficient care at three levels of prevention (NSM prevention as intervention). Utilizing a holistic approach (NSM physiological, psychological, socio-cultural, development, and spiritual variables), I was exposed in health counseling, medication administration, health teaching, case management and care coordination services (NSM prevention as intervention]. I worked closely with nurses in other satellite health centers within the clinic’s catchment area. The collaboration strengthened patient treatments and improved care. I regularly participated in conducting home visits and tracking down patients who were lost to follow-up careI dealt with barriers such as clients’ religious and traditional beliefs that hinder adherence to prescribed regimen (NSM socio-cultural and spiritual variables).

As a part of the learning process, I practiced advocacy and I was able to participate in regular district administrative meetings to negotiate consultation fees and cost of drugs with district authorities (NSM socio-cultural variable). I improved my nursing skills in individual/family and community assessment while fulfilling this role. For instance, I was able to share with the authorities how financial challenges forced clients to take half doses of their prescribed medication and intentionally caused missed follow-up visits. Likewise, I noted that other clients opted to traditional herbal treatments as they were perceived to be cheaper than hospital medications. I was able to see how self-medication practices (Concepts of the TSCC) can harden caring of chronic patients. Some patients opt to buy drugs in stores rather than visit the clinic or hospital. Some of the challenges were attributed to lack of transportation and health illiteracy on disease processes (NSM socio-cultural variable). I called attention to the impact of laxed drug dispensing policies on clients’ lives.  For example, I shared how clients with contraindicated medication can easily procure the drugs from a local drug store, making them at risk of readmissions and possibly death. In addition, as a community health educator, I advised patients and their families to participate in community development projects such as livestock keeping, small scale agricultural that helped them to earn extra money for buying drugs and supporting individual and family their well-being (NSM socio-cultural and spiritual variables ).

Delivery System Design and Self-Management Support(Concepts of the ECCM)

The community clinic was centered at a District Hospital and operated synergically with ten other health centers within our catchment area (NSM community as the client system). I learned to assure the provision of self-care maintenance, self-care monitoring, and self-care management services (Concepts of the TSCC). For instance, I was involved in caring for chronic disease patients especially type 1 diabetic patient by empowering and preparing clients to manage their health through effective and safe self-injection practice. I provided health education on regular testing to control glucose levels as well as insulin-self administration.  Assessing clients’ health literacy levels in the treatment process was a crucial piece of my practice role. I developed peer guided groups with an interpofessional team comprising of a nutritionist and physician. In addition, I conducted monthly supervision at each of the ten assigned health centers. During the supervisory visits, I was involved on assessing the overall patient’s adherence practice to nursing care and follow up (Concepts of the TSCC). I also participated in conducting professional development seminars to nurses on management of patients living with chronic diseases, how to conduct referrals and improve protocols to manage patients with diabetic ketoacidosis and heart failure (NSM variances from wellness). I completed frequent home visits with nurses and other providers to assess the client’s progress, adherence practices and storage of medications (concepts of the TSCC), as well as delivered promotional health messages to patients and families (NSM primary prevention as intervention).

Decision Support and Clinical Information System (Concepts of the ECCM)

I learned how to make clinical decisions in chronic disease management consistent with scientific data and patient preferences. For example, when I saw patients with medical adherence issues, I made sure I educated the clients on possible consequences and let the clients make informed decisions (NSM primary prevention as intervention). I always acknowledged the challenging presence of scientifically unproved treatment plans attributed to the growing number of traditional doctors involved in client’s health care decisions (NSM individual as the client system). I always paid attention to gender-based influences (NSM socio-cultural and spiritual stressors) in medication adherence NMS-. For instance, I was able to determine that men attended treatments when they had severe signs and symptoms of an illness and/or at advanced stage of disease. To address this social determinant among some of the men, I participated in initiating the use of mobile phones to trace patients on monthly basis. This initiative had a positive impact on “no show” clients who had access to mobile phones.

Implications for nursologist scholars

Katunzi’s reflections have implications for advancement of nursology discipline-specific knowledge and future professional transformations. The evolving role of the nursologist  in primary care (Wojnar & Whelan, 2017) calls for a well-rounded RN (Swan, et al, 2006) and, most importantly, a BSN-prepared global nursology  workforce (Wojnar & Whelan, 2017). Use of the ECCM requires ongoing research — or review of existing research – to determine the validity of the model as a shared theory/model (Villarruel et al., 2001) that is useful in new nursing education curricula (Humphrey, 2019),  reimbursement (Funk & Davis, 2015) and regulatory models (Start, 2020) situations that fit BSN-prepared nurses’ full scope of nursologists’ practice and meet clients’ health and social needs in places where people live, learn and play.  

We would like to learn from our nursology.net readers on their perceptions of these questions:

  1. What does the future of nursology hold for the role of the BSN-prepared nursologist in primary care, especially in the United States where primary care is regarded as a major role of advanced practice nursologists holding master’s and/or Doctor of Nursing Practice degrees?
  2. How can nursologists overcome the barriers and maximize contextual opportunities to fulfill their roles? 
  3. What barriers may influence effective adoption of applicable borrowed and shared theories/models in nursology-led chronic disease management interventions?

We welcome nursologists at different levels of practice (i.e., LPN, ADN, BSN, DNP, PhD-prepared) to share their stories of how they provide primary care services (or ambulatory care or community-based care), in private or public health care systems.  Please share your thoughts in comments section below

References

Anderson, D., St. Hilaire, D., Flinter, M., (May, 2012). Primary Care Nursing Role and Care Coordination: An Observational Study of Nursing Work in a Community Health Center OJIN: The Online Journal of Issues in Nursing, 17, 2, http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No2-May-2012/Primary-Care-Nursing-Role-and-Care-Coordination.html

Barr, V, Robinson, S, Marin-Link, B, Underhill, L, Dotts, A, Ravensdale, D, & Salivaras, S. (2003). The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model, Hospital Quarterly, 7(1), 73-82.

Bodenheimer, T., & Mason, D. (June, 2016). Registered nurses: Partners in transforming primary care. In Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June. http://64.62.135.154/docs/macy_pubs/Macy_Monograph_Nurses_2016_webPDF.pdf

Borgès Da Silva, R., Brault, I., Pineault, R., Chouinard, M.-C., Prud’homme, A., & D’Amour, D. (2018). Nursing Practice in Primary Care and Patients’ Experience of Care. Journal of Primary Care & Community Health, 9, 1-7 https://doi.org/10.1177/2150131917747186

Epping-Jordan, J., (Ed.) (2002). Innovative care for chronic conditions: building blocks for action: global report (document no. WHO/NMC/CCH/0201). World Health Organization Global Report. https://www.who.int/diabetes/publications/icccreport/en/

Funk, K. A., & Davis, M. (2015). Enhancing the role of the nurse in primary care: the RN “co-visit” model. Journal of general internal medicine30(12), 1871-1873.

Health resources & Services Administration (2018).  Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program. Retrieved from https://www.hrsa.gov/grants/find-funding/hrsa-18-012

Humphrey, B., L., Mixer, S. J., Thompson, K., Davis, S., Elliott, L., Lakin, B., … & Niederhauser, V. (2019). Transforming RN roles in community-based integrated primary care (TRIP): Background and content. Issues in mental health nursing40(4), 347-353.

Lipstein, S. H, Kellermann, A. L., Berkowitz, B., Phillips, R., Sklar, D., Steele, G. D., & Thibault, G. E. (September, 2016). Workforce for 21st century health and health care: A vital direction for health and health care. National Academies of Medicine. https://nam.edu/wp-content/uploads/2016/09/Workforce-for-21st-Century-Health-andHealth-Care.pdf.

Norful, A., Martsolf, G., de Jacq, K., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic review. International journal of nursing studies74, 15-23.

Start, R., Brown, D. S., May, N., Quinlan, S., Blankson, M., Rodriguez, S. R., & Matlock, A. M. (2020). Strategies for creating a business case that leverages the RN role in care coordination and transition management. Nursing Economics38(4), 203-217.

Swan, B. A., Conway-Phillips, R., & Griffin, K. F. (2006). Demonstrating the value of the RN in ambulatory care. Retrieved from https://jdc.jefferson.edu/cgi/viewcontent.cgi? article=1012&context=nursfp

The Tanzania Nursing and Midwifery Council (2014). Scope of Practice for Nursing and Midwives in Tanzania. United Republic of Tanzania.

Wojnar, D. M., & Whelan, E. M. (2017). Preparing nursing students for enhanced roles in primary care: The current state of pre-licensure and RN-to-BSN education. Nursing Outlook65(2), 222-232.

Villarruel, A.M., Bishop, T.L., Simpson, E.M., Jemmott, L.S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14, 158-163. 

Does Informed Consent Exist for Black Patients?

Contributor: Harriet Omondi MSN, APRN, FNP

Systemic racism and racial inequality are two concepts that are deeply ingrained in American history. These two issues come up in every single presidential election where candidates compete for the minority vote by promising reparations for black people and an end to systemic racism. Research has repeatedly revealed that minorities lag in the majority of health-related outcomes and this is often directly linked to racial inequity. In a recent blog post by Dr. Chinn titled, ‘Nursing and Racism: Are We Part of the Problem, Part of the Solution or Perhaps Both’, she eloquently addressed how we as nurses can be a part of the solution in ending racism. This can be achieved by educating ourselves on race relations, teaching our children by example by respecting people that may look different, and being empathetic to black people under our care. Patients trust nurses and easily share their fears and worries and nurses are often tasked with the burden of explaining procedures or give informed consent. Black people have been used in research studies over the years without consent or at times treated without full disclosure. How did this begin and how can nurses help resolve this problem?.

Source

The idea of informed consent began in the early 20th century and thus laid the foundation for the assertion of patient autonomy (Bazzano et al., 2021). Four landmark cases Mohr v Williams, Pratt v Davis, Rolater v Strain, and Schloendorff v Society of New York Hospital set a precedent for patient autonomy and formed the idea of the need for informed consent in medicine and research (Bazzano et al., 2021). In Mohr vs Williams, the patient had agreed to surgery on the right ear but during surgery, the surgeon decided that the left ear was worse off than the right ear and performed surgery on the left ear instead of the right ear (Bazzano et al., 2021, p. 80). The plaintiffs hearing thereafter worsened and she sued the surgeon for battery and assault for performing surgery on the left ear instead of the right as she had previously agreed (p. 82). Mrs. Mohr won the case as the court agreed that the surgeon was wrong for performing surgery on the left ear without her consent (p. 82). I have chosen to discuss informed consent because as much as research is important for the advancement of medicine and technology it is equally important to allow subjects to comprehend what they are signing up for and the potential risks or benefits of research. Participants need to also be aware that if they need to withdraw from a research study they can do so freely without fear of retaliation.

The issue of informed consent is a touchy subject when it comes to minorities especially the black population. This stems from the notion that historically blacks were seen as property and therefore the master did not need permission to do with them as they please. It is well documented that Dr.Marion Sims who is seen as “the father of gynecology” for pioneering successful gynecological surgeries, performed experiments on powerless black slaves without consent. The Tuskegee experiment is another well-known example of racial injustice where young black men some of whom were infected with syphilis were recruited for a research study on syphilis. Informed consent was not obtained for this study and when Penicillin became available to treat the disease the men were not treated. In addition, the men in the study were initially told the study would last six months but it went on for 40 long years where these men suffered the debilitating effects of syphilis without treatment. Fast forward to the 21st century while advances have been made in terms of how black people are treated more is yet to be done.

Working as a primary care nurse practitioner I have encountered countless black patients who distrust the medical system so much so that they would rather forgo medical treatment and seek alternative therapies. This distrust is deeply rooted in medical apartheid that they have witnessed or experienced over the years and it is up to us as nurses and frontline health care workers to empower these patients and provide culturally competent care to ease their doubt. Due to a lack of trust in the healthcare system rooted in racist practices, the black community continues to lag in nearly all aspects of healthcare. This issue has been at the forefront in the past year where we have seen black communities fair much worse on Covid-19 related outcomes, in addition, the vaccination rate among the black community is far less compared to the other races. When I ask my black patients why the hesitancy, the most common answer is, “can’t trust what they’re putting in my body”. One recent example that comes to mind is one of my black female patients was recently diagnosed with breast cancer and advised by her oncologists that she needed radiation after chemotherapy to eradicate cancer. The patient told the oncology team that she did not want radiation because she had a near-death experience during chemotherapy and did not want any more treatment. The oncologist kept pressing the idea of radiation on the patient and per the patient, a “black nurse was brought in to convince me to get radiation.” Ultimately the patient vehemently declined and radiation was not done. This is a classic example of how black patient`s requests are mostly ignored or dismissed with the assumption that they do not know any better.

Therefore, as nurses, we must take into account the complicated history of black people with medicine while providing care. We have to be empathetic to the needs of our black patients keeping in mind that they may have fear of not only the physical ailment but of the providers and the healthcare system as a whole and may need a safer environment. Jean Watson who is one of my favorite theorists once said. “Maybe this one moment, with this one person, is the very reason we’re here on earth at this time.” If we approach each patient with this in mind you never know if you might be the one person who changes their view on the distrust of the medical establishment.

References

Bazzano, L. A., Durant, J., & Brantley, P. (2021). A modern history of informed consent and the role of key information. Ochsner Journal, 21(1), 81–85. https://doi.org/10.31486/toj.19.0105

About Harriet Omondi

I have been a nurse practitioner for the past seven years, I graduated from Texas Woman`s University in 2014 and immediately started working in a Federally Qualified Health Center (FQHC) where I oversaw a clinic for patients with a dual diagnosis of mental health. When I started at the FQHC the clinic was new and only had five patients and after a year I had a panel of 100 new patients. Currently, I work for UT Health in Houston and care for patients in a primary care clinic. Prior to that, I worked as a nurse for six years with adult medical-surgical patients, pediatrics, and home- health caring for medically fragile children. In the Fall of 2020, I took the bold step of enrolling at Texas Woman`s University to pursue a doctorate in nursing where I have completed two semesters. My primary areas of research interest are obesity, women’s health, and preventative medicine with an emphasis on health promotion.

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Nursology and the Bold Future of Nursing

Recently I was invited to give a presentation for faculty and students at the M. Louise Fitzpatrick College of Nursing at Villanova University, based on my keynote address at the March 2019 conference “Nursing Theory: A Fifty Year Perspective, Past, Present and Future.” Download the text of that speech here.

True to the lifeways of pandemic time, I could only be present with people at Villanova University virtually, and developed a set of slides for the presentation. So in a spirit of sharing, here are the slides – the message of this presentation calls for all to boldly claim the essence and value of nursing/nursology, and to recognize barriers that stand in the way of fully enacting this essence in our practice. (Note: if the slides do not show to the end, view the slides here instead)

Culture Shock, Grief and Nursing Theories

Contributor: Aisha Chahal, MSN, CMSRN

Culture shock is a state where people experience the stages of honeymoon, frustration, adaptation and acceptance. It is an intense feeling that follows the grief process. I had first-hand experience with all these stages of culture shock when I came to the land of opportunities, the United States of America, in 2012. I started my first job as a bedside Registered Nurse. It felt like I had accomplished the purpose of my life by getting a job at Yale-New Haven Hospital. Yale seemed like a place in heaven. It was beautiful to see that people could order food over the phone and a beautiful tray with fancy food items arrive at the bedside within a few minutes. Nurses only had four to five patients instead of the thirty that I had cared for earlier in my career. Patients had call bells and people responded to those bells. There were computers, scanners, medication dispensing machines and robots to deliver supplies. I was in the honeymoon phase.

But then came frustration as food items were thrown away if patients did not like them. Computers took away my time to be with my patients. The machines, robots, and technology had turned people into objects. I barely had time to know my patients or colleagues on a personal level. But I adapted and accepted by learning to fit into the situation. I learned that all this was crucial for patient safety, evidence-based practice, patient satisfaction scores and reimbursements.

After 8 years, I relived the stages of culture shock while learning in-depth about nursing theories in my doctorate program and educating nursing students on nursing theories at the same time. Nursing theories fascinated me and sparked my interest to learn more about the focus and identity of nursing discipline. Learning new concepts, making connections, discussing with nurse educators and colleagues, listening to some of the theorists themselves send me into the honeymoon phase once again.

I was determined to start my clinical day with the students by discussing a nursing theory. With all enthusiasm, I showed up at 6.45 am to meet my students and talk about nursing theories starting with Florence Nightingales’ framework and Watson’s Caring theory before we see our patients. Then once again, I experienced the frustration phase as students were disinterested, inattentive, unpassionate, and incurious which was exactly the opposite of what I was prepared for. I stopped the talk in the middle and let them start their routine patient assessments. I was deeply saddened by reliving the experience as I knew that I would have to adapt and accept the reality just like I did a few years back.

But this time, instead of accepting, I felt challenged to change the norm. Students viewed the content of nursing theories as dry, complicated to understand, of no practical use, and grade-lowering. The next week, I planned to discuss Neumann’s System Model with the vision that students can feel and experience the essence of the theory and view clients as an open system responding to various stressors in the environment. Instead of theory, I started our discussion with the theorist, Betty Neumann. We discussed how she grew up on a farm and took care of her sick father who died at the age of 36, which created her passion for nursing. Her mother was a devoted self-taught midwife. We talked about her academic, professional, and volunteer work. I shared images and videos depicting her life and vision. Then we discussed her vision of creating the nursing theory and related concepts of the theory.

Students were completely engaged, asked questions, and seemed ready to minimize the theory-practice gap. In the post- clinical conference that day, students were able to identify intra, inter and extra-personal stressors for their clients. They also identified the interventions they performed or planned to perform at primary, secondary and tertiary levels of prevention. They developed a deeper connection to the theorist, theory, clients and themselves. They identified who they are in relation to the focus of nursing discipline. After that week, we continued discussing a theorist and a nursing theory each week before clinical and each student-patient interaction is now guided by the concepts of that theory. Every week, we now look forward to our discussion of nursing theories and viewing people from different perspectives to provide competent and compassionate nursing care

I invite all the nursing students, nurse educators, nurse scholars, and nurse researchers to prevent nursing theories from following the similar pattern of stages of culture shock and grief. Instead of frustration, anger, denial, adaptation, and acceptance, our collaborative efforts can lead to a focused nursing discipline in which every nurse is changing lives by using the strong foundational pillars of nursing theories.

About Aisha Chahal

Aisha Chahal, MSN, CMSRN, is a doctoral nursing student in the Online Nursing Education EdD program at Teachers College, Columbia University. Aisha has completed her Masters of Science in Nursing Education in 2019. She is a clinical instructor at Western Connecticut State University. She has have 10 years of clinical experience in medical-surgical nursing. Her passion is exploring effective teaching-learning strategies to educate nursing students on Transcultural Nursing.