I listened with great interest to the webinar presentation by Shannon Zenk, PhD, MPH, RN, FAAN, Director, National Institute of Nursing Research (NINR), on “The Future of Nursing Research: Innovation, Collaboration and Impact,” to the American Association of Colleges of Nursing on April 28, 2022. Dr. Zenk outlined the priorities of the NINR (2022) as addressing health equities, social determinants of health, population and community health, prevention and health promotion, and systems and models of care. The major thrusts of the new strategic plan appear to support efforts to address systematic and structure inequities (NINR, 2022). What really piqued my interest, however, was at the very end of the session, during the “question and answer” period.
There were questions about whether the NINR would consider a funding line surrounding nurses’ well-being and health, especially given the suffering during COVID-19. Dr. Zenk indicated that the pandemic had raised such awareness, and those at the NINR were conscious of the need to give attention to this area. She reported that at the January Council meeting a “concept” had been proposed to address the idea of burnout, nurse health, and related issues. Dr. Zenk described how such ideas went through a process of “concept clearance,” and may or may not turn into funding opportunities with a subsequent funding announcement. She again emphasized that such concepts were taken into account and encouraged concepts be forwarded.
As a theorist and nurse scientist in the areas of nurse well-being, nurse-specific psychological trauma, and substance use in nurses (Foli, 2022; Foli & Thompson, 2019), this seemed like good news. It’s often difficult to know where to go for funding as a scientist who has applied to the NIHs. Where does this topic best fit? With the National Institute of Mental Health (NIHM), the National Institute for Occupational Safety and Health (NIOSH), or the National Institute on Drug Abuse (NIDA) and so forth. But like so many of the feet in the kingdom, the slipper doesn’t quite fit. And as I consider the issue of nurses’ health and well-being, it’s a bigger issue, conceptually, than which national institute one should seek funding from.
It is the issue – and perhaps discomfort – of seeing nurses in the duality of roles as caregivers/comfort givers and recipients of such care and comfort. Or simply put, both nurse and patient. Fawcett’s (1984) metaparadigm of person, health, environment, and nursing is examined as we pursue this conceptually. Is it a reduction to three: Person-nurse, health, environment? Or five: person/nurse, health, environment, nursing? How does the concept of person change as we insert “nurse” into “person” or does it? For example, how is the nurse, who is subject to a physical injury and psychologically traumatized due to patient violence, transformed into “person/patient”? At what point, if there is one, does that transformation occur? Or is there a point, and if not, isn’t that what we are grappling with? The nurse is still the nurse.
Conti-O’Hare (1998; 2002) seems to be the first nurse theorist who attempts to bridge person and nurse into one conceptual “being.” In her work, Conti-O’Hare is clear that the nurse is wounded, in part, because they are a nurse and that, simultaneously, nurses seek healing through the profession. Conti-O’Hare (2009) writes:
It seems though that some wounded people are drawn consciously or unconsciously toward places, people, or experiences that offer the hope or possibility of greater personal well-being and wholeness (p. 136).Source
These words are prophetic as we look to more current findings in adverse childhood experiences (ACEs) reported by today’s nursing students. As a quick review, research dating back to 1995 (Felitti et al., 1998) has consistently found significant associations between childhood maltreatment and neglect and negative health outcomes such as substance use, risky behaviors, and chronic illnesses. Remember, ACEs are “dose dependent” with higher reported frequencies being more strongly associated with negative outcomes (range 0 to 10). In research conducted by Clark and El-Makarim Aboueissa (2021), over 40% of nursing students reported an ACE score of 4 or more. Keep in mind, the national average of individuals with 4 or more ACEs is 12.5 to 13.3%. The authors conclude that their study results support Conti-O’Hare’s theory. Indeed, nursing students appear to be wounded before coming into our schools.
My own anecdotal experiences would align with this, at least after clinical experiences begin. Asked to attend a post-clinical experience for public health nursing students to present my middle range theory of nurses’ psychological trauma, I was both sadly reminded of and concerned about the amount of trauma the students had been exposed to. One had been punched in the stomach by a patient. One had seen a middle school student choking another. One had seen a high school student throw another into lockers. Some students stared blankly into space, shutting down. Another sobbed, and yet another tried to intellectualize their experiences. Their primary clinical instructor handled this with grace and expertise, following up with students to ensure their well-being.
And more questions arise: Are nursing faculty then nurses who tend to their wounded students/person/patients? At what point do students become nurses and do they still exist as person/patient? What is the intersection between these roles and how does this intersection impact the care given to others (non-nurses)?
Unfortunately, I don’t have clear-cut answers. But as a theorist, the work I do is to raise a glass and have a discussion. It’s to present ideas that we may not have thought about before, theoretical ideas that have implications “in real life,” for big stake issues such as research funding, empirical studies, patient care, nursing education, and the health of nurses.
Clark, C. S., & El-Makarim Aboueissa, A. (2021). Nursing students’ adverse childhood experience scores: A national survey. International Journal of Nursing Education and Scholarship, 18(1), 1-11. https://doi.org/10.1515/ijnes-2021-0013
Conti-O’Hare, M. (2002). Nurse as the wounded healer: From trauma to transcendence. Jones and Bartlett Publishers.
Conti-O’Hare, M. (1998). Examining the wounded healer archetype: A case study in expert addictions nursing practice. Journal of the American Psychiatric Nursing Association, 4, 71-76.
Fawcett, J. (1984). The metaparadigm of nursing: Present status and future refinements. Journal of Nursing Scholarship, 16(3), 84–87. https://doi.org/10.1111/j.1547-5069.1984.tb01393.x
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A, M., Edwards, V.,…Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experience (ACE) Study. American Journal of Preventative Medicine, 14(4), 245–258.
Foli, K. J. (2022). A middle-range theory of nurses’ psychological trauma. Advances in Nursing Science, 45(1), 86-98. doi: 10.1097/ANS.0000000000000388
Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Sigma Theta Tau Publishing.
MacCulloch, T., & Shattell, M. (Eds). (2009). Reflections of a “wounded healer.” Issues in Mental Health Nursing, 30, 135-137. doi: 10.1080/01612840802601390
National Institute of Nursing Research. (2022). National Institute of Nursing Research: 2022-2026 Strategic Plan. https://www.ninr.nih.gov/sites/files/docs/NINR_One-Pager12_508c.pdf