A man and a woman were fishing on the river bank when they saw a woman struggling in the current. They rescued her. Soon, they saw a man struggling. They rescued him, too. This continued all afternoon. Finally, the exhausted pair decided to go upstream to find out where and why so many people were falling in. They discovered a beautiful overlook along the river’s edge without any warning signs or protective barriers. The couple went to community leaders to report the number of victims they had rescued and explained the connection to the unprotected overlook. Community leaders agreed to install a protective guard and post warning signs. Preventing the problem saves resources, energy, and lives.” (see “The Upstream/Downstream Parable)
Critical Caring is a way of being-in-relation that seeks to protect and enhance human dignity. It is informed by multiple ways of knowing (Chinn & Kramer, 2017) and guided by a caring/social justice ethics in which advocacy for social justice becomes an expression of caring for individuals, groups, communities, or populations. It encompasses both downstream and upstream nursing practice. (Falk-Rafael & Betker, 2012a) The “critical” aspect of the theory reflects both the theory’s roots in contemporary critical social theories and in the work of Nightingale, who I would argue, espoused the tenets of what became known as critical social theory decades before it was formalized by the Frankfurt School in the 1930s.
Although originally proposed as a middle-range theory of public health nursing (Falk-Rafael,2020), Critical Caring’s seven carative health promoting processes (CCHPs) can readily provide guidance to nurses practicing in the context of the COVID-19 pandemic, regardless of setting. The CHPPs are focused on simultaneously meeting the needs of individuals, groups, and/or communities and building their capacity (CHPP 6) , i.e., helping them to regain/maintain whatever degree of control over their life is possible to maximize their health potential (Falk-Rafael, 2001, Falk-Rafael & Betker, 2012a).
Critical caring begins with the preparation of one’s self (CHPP1) and involves taking measures to monitor, care for, and protect one’s own physical-mental-spiritual health. Examples related to COVID-19 include physical distancing when in public and use of appropriate personal protective equipment. (See series of posts on that topic by Carey Clark). Appropriate PPE provides protection for the nurse and also contributes to the downstream aspect of CHPP 5, relating to the provision and maintenance of a safe and supportive physical environment for the patient/client. Other measures to create a safe environment include such fundamental principles as the separation of infected people from non-infected people, a principle well understood by Nightingale but ignored in some of the long-term care facilities in Ontario, ravaged by COVID-19.
Central to critical caring is establishing and maintaining a helping-trusting nurse-patient relationship (CHPP 2), a carative process that can be complicated by the use of the necessary PPE. Transparent face shields and/or mask inserts may be a great help in that regard when they are available. Touch, even through gloved hands, and verbal communications become even more important in establishing and maintaining a human-to-human connection, and in being able to gain some understanding of the patient’s lived experience of the situation and providing some measure of comfort.
Relationship is also essential in the mutuality required in CHPP, 3 the systematic reflexive approach to identifying the health goals of clients and working with them, to the extent possible, in achieving those goals. This process requires a knowledgeable approach by the nurse whose expertise is available to facilitate patients’ understanding and decision-making.
Likewise, relationship, characterized by mutuality, is central to CHPP 4, transpersonal teaching-learning. Whether situated in acute care, focused on treatments or medications, or in the community, focused on issues such as requirements of quarantine or self-isolation, transpersonal teaching-learning is an interactive process in which evidence-informed information and guidance are provided within the context of the patient /client’s understanding, lived experience, hopes and fears. Perhaps in no instance is relationship more important than in the face of death when the nurse can offer a comforting presence and an openness to the patient’s way of finding meaning in the experience (CHPP7). That may involve holding a phone to a patient’s ear or a tablet in front of a patient so that families can virtually be present and connected with their loved one in their final moments.
Although the coronavirus does not discriminate, the pandemic has highlighted societal economic and social inequities that significantly increase the risk of contracting COVID-19, not only in Canada and the U.S., but also globally. Some of the reasons relate to the need for poorer people to continue to work in jobs away from home, often in the provision of essential services. Moreover, they are more likely to rely on public transit to get to work; they may be less able to physically distance from family members because of crowded living situations, and/or may lack adequate health care. In situations that might allow work at home, economically disadvantaged people may not be able to afford the necessary electronic equipment; similarly their children may not be able to complete aspects of online education. In even more dire circumstances, homeless people are extremely vulnerable as advice for staying home and frequent hand washing are simply not options for them. Physical distancing is not possible in homeless and respite shelters in which cots are placed closely together.
The COVID-19 pandemic has highlighted societal inequities which, in many aspects, bear a striking resemblance to those Nightingale experienced more than 150 years ago. Her approaches and solutions included downstream nursing by, for example, training nurses to care for those in workhouse infirmaries where paupers were required to come if they were ill because they could not afford care in hospitals. But what is sometimes overlooked, is that she also advocated for solutions at a societal level, far upstream from the workhouses. Nightingale’s approach has been called “radical” because it advocated for public policy changes to correct the systemic issues at the root of the health problems seen downstream. Her actions led not only to improved nursing care, but also to social change that reduced economic and social inequities. Whereas her workhouse reforms are well known, the principle driving them, equitable access to health care based on need rather than affordability, and her proposal that those reforms should be paid for through progressive taxation, are less well known. Nightingale’s proposed changes included the legislative framework for the Metropolitan Poor Act and culminated, decades later, in the British government taking responsibility for that nation’s health through the National Health Service (Falk-Rafael, 2005). But Nightingale did not stop there; she advocated, for example, for income security, pensions, and education for all because of her conviction that these were measures that promoted the public’s health. Approximately 100 years later, at the primary health conference in Alma Ata, world health leaders came to a similar conclusion, issuing the Declaration of Alma Ata, and raising awareness of what became known as social determinants of health.
It seems to me that homeless shelters may be today’s workhouse equivalents. Addressing the underlying social and economic (upstream) issues that have contributed to the health inequities exposed by the pandemic challenge us to political advocacy for upstream policy changes. Cathy Crowe, a Canadian nurse activist, has long advocated for policies, such as affordable housing, to allow poorer people to afford housing. And, like Nightingale, she is also concerned with conditions downstream, in respite and homeless shelters. During the pandemic, she, with others, has brought attention to and tirelessly advocated for the City of Toronto to mandate 6’ spacing between cots in homeless shelters. To its shame, the City only agreed to this spacing many weeks later, after she and other advocates filed a lawsuit claiming that shelter crowding conditions were a violation of the Canadian Charter of Rights and Freedoms.
A second pandemic focal point in Canada, especially in Quebec and Ontario, are long term care (LTC) facilities. In Canada, long-term care is under provincial jurisdiction, and is not publicly insured under the Canada Health Act. Provinces and territorial jurisdictions may depend on one or more types of funding of LTCs, such as for-profit or private organizations, municipal and/or provincial funding, In Ontario, all LTC facilities receive some provincial funding.
In Canada, 82% of COVID-19 deaths have occurred in LTC facilities, although the number of residents in such facilities represents approximately 1% of the population. Canada’s 2 largest provinces, Ontario and Quebec, account for 62% of the country’s population but together account for 94.4% of Canadian COVID-19-related deaths (as of May 25th, 2020). Both provinces have asked for and received military assistance in providing care in the homes most severely affected by the pandemic. In the past few days, military personnel in those homes have issued scathing reports as to the conditions they found in the facilities in which they worked in, 5 in Ontario and 25 CHSLDs in Quebec. The reports share some familiar themes: inadequate numbers of trained staff, inadequate separation of infected residents from those not infected, and improper use of PPE. The Ontario report is particularly scathing, reporting additional issues such as elder abuse and neglect, as well as ant and cockroach infestations in some homes. Those findings, although shocking, should not have come as a complete surprise. Last fall, the National Institute on Aging warned that LTC facilities “were plagued by conditions that increased the risk of spreading infections: people living in close quarters in residences faced with chronic shortages of staff, with little space or ability to enforce proper physical distancing measures, where poorly paid employees often work on a part-time basis at multiple facilities, increasing the risk” The COVID-19 pandemic has all-too-tragically shown that to be true. Again, there are similarities with conditions in 19th century British workhouses. Changes to funding of LTC facilities, staffing ratios and qualifications, and frequency and scope of inspections have all been political decisions made within the last 20 years.
Personal health is inherently political. McDonald asserted that “Nightingale knew that good health required decent social conditions, work, adequate housing, clean air and water.” CHPP 5 refers to providing, creating, and/or maintaining supportive and sustainable environments, including both immediate physical environments but also social, political, and economic environments (Falk-Rafael, 2020). Improving those environments requires public policy change. To reduce health inequities, policy changes are needed that serve to redistribute a nation’s wealth throughout the population, rather than allow it to accumulate in the top 1%. As Nightingale knew, the increased revenue from such taxation has the potential to fund other programs such as universal, publicly funded health care, including elder care, and education. Policies such as those to establish minimum wages or a guaranteed basic income help to reduce economic inequities; policies such as affordable housing and rent control help to reduce homelessness.
A healthy population depends on healthy public policies. Political action to effect necessary changes can range from informed voting to the comprehensive, systematic approach Nightingale used: taking advantage of powerful connections, providing well-reasoned arguments, and supporting those arguments with data obtained through reading, consulting with experts, and, if necessary, her own investigations. I believe, like Nightingale, it is nurses who need to take the lead in promoting policy changes to improve the public’s health because it is nurses who work at the intersection of public policy and personal lives.
Chinn, P.L. & Kramer, M. K. (2019) Knowledge development in nursing: Theory and process. (10th ed.), New York: Elsevier
Falk-Rafael, A. R. (2005). Speaking truth to power: nursing’s legacy and moral imperative. ANS. Advances in Nursing Science, 28(3), 212–223. https://doi.org/10.1097/00012272-200507000-00004
Falk-Rafael, A. R. (2020). Adeline Falk-Rafael’s Critical Caring Theory. In Nursing Theories and Nursing Practice (5th ed.) M.C. Smith (Ed.), pp. 502-521. Philadelphia: F.A. Daviis.
Falk-Rafael, A. R., & Betker, C. (2012). Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: “The Trombone Slide” of Nursing. ANS. Advances in Nursing Science, 35(2), 98–112. https://doi.org/10.1097/ANS.0b013e31824fe70f