Critical Caring in the context of COVID-19

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.

Adeline Falk-Rafael (on the right) in 2003 with a member of the Older Women’s Network protesting proposed cuts to Long Term Care

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).

Downstream Caring

 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. 

Upstream Caring

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.

References

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

Nightingale’s Vision for Nursing in 2020

It will take 150 years for the world to see the kind of nursing I envision

Painting of Nightingale In the Florence Nightingale Museum

The year 2020 marks the bicentennial of Nightingale’s birth and approximately, at least, the 150th anniversary of her prediction that “It will take 150 years for the world to see the kind of nursing I envision.”  What was that vision, in what ways is it relevant today, and to what extent has it been realized? Although volumes could be written to answer these questions, for the purposes of this blog, it is possible only to highlight a few: her founding of and contribution to documented nursing disciplinary knowledge, i.e., nursology, her contribution to nursing education, and her championing of evidence-based practice and policy.

  • In 1860, Nightingale published the first recorded conceptual framework for nursing, in  “Notes on Nursing.”  in it, she clearly differentiated nursing from medicine; she saw medicine as removing obstructions to nature’s ability to heal  but nursing as creating the best conditions e.g., nutrition, cleanliness, ventilation, etc. for that healing to occur. I think she would be pleased to see the Nursology.net site, dedicated to furthering nursing knowledge.  The site currently hosts 53 nursing theories, from conceptual frameworks to mid-range and situational theories, but each focused on health, as opposed to disease, and on the nurse’s role in promoting healing. And, I think Nightingale would be pleased to see the large numbers of nurses who practice, teach, and.or conduct research guided by nursing

    Turkish lamp from the Florence Nightingale museum

    disciplinary knowledge.  But, I think she would be dismayed at the powerful influence the medical model still has on health care generally and on many nurses, whose practice consciously or unconsciously is strongly influenced by it (Bradley & Falk-Rafael, 2011). It is not possible to practice nursing without an idea of what the scope and nature of that practice is (i.e., a conceptual framework) and if that framework is not solidly rooted in nursing’s disciplinary knowledge, it is vulnerable to dominant influences from other disciplines (Rafael, 1999, 1998).

  • It is no coincidence that also in 1860, Nightingale founded her training school for nursing. Before the introduction of a trained nursing workforce, people who provided patient care (if there were any) might be called nurses  but who, according to McDonald, “were mainly low-paid, disreputable hospital cleaners, notorious for demanding bribes from patients and stealing their gin” (McDonald, 2013, p.36). Some of the important features of the Nightingale program were the requirement that all nurses be trained in a hospital setting, regardless of where they intended to work (e.g., the military, district nursing, midwifery, administrative roles), some of which required additional training. It became a model for many other schools of nursing in Europe, North America, and Australia.  Undoubtedly, some readers of my vintage who initially trained in general hospitals as late as the 1960s, would recognize familiar aspects of her model. (I recall reciting the “Florence Nightingale pledge” on the occasion of my completing the first 6 month’s probationary period of my training)!  Nightingale’s approach  was basically an apprenticeship model in which nursing students provided hands-on nursing care under the supervision of more senior nurses (e.g, clinical co-ordinators/headnurses/ward sisters). The learning that took place on the wards was augmented by classes given by physicians.  McDonald further notes that while Nightingale did not envision university schools of nursing, she advocated for “a professorship of hospital administration, hospital construction, and hospital nursing.”  While admission to universities remained off-limits for women in Nightingale’s time, I believe she would be most pleased to see the  progress that has been made in university education for nurses, both at an entry-to-practice level and in graduate education. In her time,  without regulatory bodies and examinations, graduation from a training school was the only guarantee that a nurse was indeed qualified to practice. My guess is that she would have welcomed regulatory bodies to allow a more diversely qualified nursing workforce.  I would guess that she might even support the use of personal support workers if they were under the supervision of adequately prepared nursing staff.  I fear she would not be in favour of the extensive use of personal support workers seen in some settings, without that supervision.
  • Nightingale’s use of statistics to demonstrate the effects of nursing care in the Crimean War are legend.  What is less known is what McDonald describes as her reputation as the  “the ultimate statistician. Nightingale was deeply influenced by the work of Quetelet, a renowned Belgian mathematician and statistician and author of “Social Physics.” McDonald noted that Nightingale advocated for pilot projects to evaluate the effects of changes to policy and practice. Similarly she stressed evaluation, including cost-benefit analyses, of existing programs and/or policies,  frequently developing the appropriate questionnaires for data collection herself if none were available.  Nightingale used empirical evidence to support approaches to making childbirth safer. Although initially intending to open a lying-in hospital, she decided against it after finding that the mortality data among women giving birth  where they were in contact with medical personnel (e.g. lying-in hospitals) were higher than when they gave birth at home or even in workhouses. Likewise, although her initial rejection of germ theory is well known, her acceptance of it when presented with the evidence by Joseph Lister is less well known. Nightingale’s reputation as a statistician resulted in her  nomination by William Farr, a renowned British statistician, to be the first woman to become a fellow of the Royal Statistical Society in Britain. Her reputation was international; in 1874, she  was elected an honorary member of the American Statistical Association.  I think Nightingale would be pleased to see the growth in the number of nurse researchers, the number of nursing journals that report that research, the existence of hospital libraries and librarians to facilitate access to that research, and the emphasis on evidence-informed practice. Is it enough? I suspect that Nightingale would still see room for improvement!   

Would Nightingale have envisioned a pandemic in which, at the time of writing this blog, more that 3 million people in the world had contracted COVID-19, with approximately 1/3 of those cases being in one of its wealthiest, powerful, and most advanced countries, the United States?  I’m guessing that were she alive today, she might have seen it coming.  Nightingale was a systems thinker; just as she reflected on the cholera outbreaks by noting facetiously “I sometimes wondered why we prayed to be ‘delivered from plague, pestilence and famine’ when all the common sewers of London ran into the Thames”, she might made a similar remark about prevailing economic trends.  Nightingale was a keen advocate for a comprehensive public health system and for government involvement in providing a social safety net, including income security and pensions.

Last evening, I read an article  in the Toronto Star  which spoke to the increased vulnerability to COVID-19 of people with low incomes, who, for a variety of reasons that include the need often  to  work in jobs in which they are more likely to be exposed to the virus. In addition, they tend to be able only to afford housing far from where they work, requiring the use of public transportation, creating further risk. Among the author’s suggestions was one that seemed very familiar:  “It would be far cheaper for society . . .to take a significant portion of . . . public funds and put them into . . . housing that’s affordable for all income cohorts within a reasonable[distance]  . . . of where they have to work, so that there would be more choices throughout any metropolitan region for people than they are given now.”  I was reminded of Nightingale’s famous quote made in 1868: “And if all the money that is spent on hospitals were spent on improving the habitations of those who go to hospitals, and (on prisons) of those who go to prison,  we should want neither prisons nor hospitals.”

Do I believe she would have seen a pandemic coming? Yes, because it seems, unfortunately, society has not learned important lessons from history.

Sources

Bradley, P. & Falk-Rafael, A. (2011). Instrumental care and human-centred caring: Rhetoric and lived reality. Advances in Nursing Science 34(4), 297-314.

McDonald, L. (2013). The timeless wisdom of Florence Nightingale. Canadian Nurse, 109(2), 36.

Rafael, A.R.F. (1999). From rhetoric to reality: The changing face of public health nursing in Southern Ontario. Public Health Nursing, 16(1), 50-59.

Rafael, A.R.F. (1998). Nurses who run with the wolves: The power/caring dialectic revisited. Advances in Nursing Science. 21(1), 29-42.

 

The Community as Client: A Critical Caring Exemplar

Dorothea Fox-Jakob

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

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

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

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

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

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

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

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

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

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

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

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

Sources

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

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

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

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

A Critical Review of 5 Nursing Journal Editorials on the Topic of Nursology

A recent CINAHL search with the keyword “Nursology” revealed 5 editorials in leading nursing journals that focus on acquainting the journal’s readers with the website and the initiative.  Not surprisingly, 3 of those editors were founding members of the Nursology.net website. Each shared a different aspect of the project.

Jacqueline Fawcett is the facilitator of the Nursology website management team.  In her guest editorial in the Journal of Advanced Nursing,1 she briefly reviewed the history of the term and argued for its revival, citing a previous published work.2 “Use of the term, nursology for the discipline,” she and colleagues had noted in 2015,  “avoids the tautology of using the word, nursing, as the label for the discipline and as a concept of our metaparadigm.” In other words, it identifies and distinguishes what nurses know(nursology) from what nurses do(nursing) by using different words.  Fawcett also identified possible disadvantages of a change in terminology, such as causing confusion, or interfering with progress made towards the goal of increasing the number of baccalaureate prepared nurses, although she did not elaborate on how. Fawcett went on to describe the formation of the website and outlined some of its contents: nursological philosophies, theories, and conceptual models with exemplars of the use of nursing theories in practice, education, and research; a history of disciplinary knowledge development; identification of past landmark events and future nursology-focused events, and resources. She concluded by giving examples of the positive feedback about the website that has been received and inviting readers to champion nursology as a disciplinary name or to offer alternative ideas.

Peggy Chinn is the webmaster of Nursology.net.  Her editorial introduces an issue of Advances in Nursing Science3 for which a call had been issued for articles addressing the focus of the discipline.  She noted this was in part to acknowledge that approximately 50 years had passed since a series of conferences had been initiated to explore the nature, focus, and future of disciplinary knowledge. The issue also appeared a few weeks before a similar conference, held at Case Western Reserve to commemorate those 50 years, and within months of the founding of Nursology.net. Chinn emphasized the nurse-led, nurse-developed nature of the site and  described it as providing “the most current and accurate information about nursing discipline-specific knowledge that advances human betterment globally.” She listed the assumptions and principles that guide the project: that nursology is a distinct discipline, vital to human health; is multidimensional bringing together diverse philosophical and theoretic perspectives; is autonomous and makes a unique contribution to health care; and that although nursology interacts with other disciplines cooperatively and collaboratively, it remains distinct and autonomous because it reflects the distinct perspective arising from caring in the human health experience. Chinn concluded by noting that these assumptions both shape the focus of the discipline and suggest issues that deserve serious consideration and discussion “not to achieve consensus but to appreciate the range of possibilities and diversities that inform and shape our discipline.” Whereas Chinn’s editorial highlights the philosophical underpinnings and beliefs that support the neurology.net initiative, it does not elaborate in detail on what ANS readers might expect to find on the site. 

 Jane Flanagan is a member of the Nursology.net management team and editor of the International Journal of Nursing Knowledge. She noted in her editorial4 that  the Nursology.net website is in keeping with the vision of the American Academy of Nursing Theory Guided Practice Expert Panel and described the purpose of the website is “to further the goals of what all of us as nurses are hoping to achieve…to explore the boundaries of nursing science and move that conversation in to a sphere where it reaches many.”  Flanagan noted the initial intent of the website- to be attractive, easy to read, and “overflowing with substance.” She indicated her hope that it will be a significant source of information for all nurses and those interested in nursing and invited feedback and participation of readers in contributing materials, blogs, and comments. She briefly described various sections of the site to provide examples of the resources that might be helpful to readers. Flanagan concluded by highlighting some of the similar reasons that Fawcett gave in her editorial for identifying the name of the discipline as nursology and those who practice, teach, or research disciplinary knowledge as nursologists. She noted, “ the name itself separates us from the stereotype and the reality in some quarters that we are handmaidens to physicians.” Flanagan’s editorial was the first to be published of all 5 editorials, just a month after the launch of the nursology.net website.  While she could have, perhaps, given more details about site contents, she does direct readers to the website for further information.  Her  palpable excitement at being “on the ground floor” of this project will probably encourage them to do so! 

The 3 editorials from members of the nursology.net management team were, as might be expected, exceedingly positive about the site and the initiative.  Two editorials were written by nursing editors who were not part of the Nursology.net management team. While their perspectives vary considerably, they may offer the most substantive perspectives and may prompt further serious and extensive discussion of these issues.

Rosemarie Rizzo Parse’s editorial in Nursing Science Quarterly5 did not share the excitement and optimism evident in the above editorials.  Her understanding of the goal of the website is “to change the name of the discipline of nursing”. She commented favorably on the site’s “décor” but misleadingly reduced its content to a blog, “where contributors continue to add any material they wish without support evidence for the change.”  It is unfortunate that the readers of NSQ are not informed of the stated mission and purpose  of the website, which include developing a repository of nursing knowledge, disseminating that knowledge, and encouraging collaboration among nursing scholars. Currently the website profiles 45 nursing theories, ranging from conceptual frameworks to situation-specific theories, with the Theory of Humanbecoming among them. Parse posited that efforts would be better directed at “making nursing science the hallmark of the discipline” and then asked a number of important questions about what such a change would mean, including how nursing educational programs could base courses on nursing knowledge when there is pressure by accrediting agencies to include more medical-bio-behavioral content. It is not clear how she sees that conundrum being addressed by either term,  nursology or nursing science. Despite having acknowledged that the “proposed change is consistent with O’Toole’s statement  in Mosby’s Medical Dictionary,” the editorial concluded that the change in name ”lacks semantic consistency with disciplinary knowledge and upends logical coherence.”

Sally Thorne’s editorial in Nursing Inquiry,6 begins with her admission of having a long-standing discomfort with the term “Nursing Science”, first because it sounds like a qualifier to science, “as if nurses take part in a skewed, partial, or watered-down version of the scientific enterprise,” and secondly, because the term nursing science has largely been used to describe nursing theorizing, rather than “formal scientific investigation.” Thorne contextualized the introduction of the Nursology.net website as a response from nursing thought leaders arising from their shared awareness and concerns of external pressures that are increasingly shaping nursing and threatening the further advancement of the discipline, and provided readers of Nursing Inquiry with citations of articles exploring the implications of those pressures for the preservation of “core disciplinary knowledge.” Thorne noted the term, Nursology, has been used in nursing literature at least as early as 1971 and, although she confessed to some discomfort with using the term, preferring to use “the study of nursing”, she enthusiastically endorsed the direction  the conversations that have led to the Nursology.net initiative have taken. She concluded that she will be watching the Nursology.net conversation with great excitement, “hoping that it attracts the attention, engagement, and dialogue it deserves, and that it helps bring a new generation of nurses back into an appreciative understanding of why the study of nursing really matters.”

I think I can speak on behalf of the Nursology.net management team in saying, we share that hope! And, I would ask if “ology” refers to “the study of” and is widely used by many other disciplines, e.g, pharmacology, biology, why is there such a hesitancy (I’ve experienced it in talking to other nurses about neurology as well) to use nursology to refer to the unique body of knowledge that is nursing knowledge?  Is it simply prudent caution to make the change for the reasons a number of the editors raised? To what extent does it feel pretentious, i.e., have we internalized a broader societal message that our body of knowledge is not as substantial or valuable as those of other fields? Is this another manifestation of “I’m just a nurse?” And/or, is it simply that it’s new and unfamiliar?

  1. Fawcett J. Nursology revisted and revived. J Adv Nurs. 2019; 1(2):1-2.
  2. Fawcett J, Aronowitz T, AbuFannouneh A, et al. Thoughts about the Name of Our Discipline. Nurs Sci Q.2015;28(4):330-333.
  3. Chinn PL. Introducing Nursology.net. ANS Adv Nurs Sci.2019;42(Jan-Mar):1.
  4. Flanagan J. Nursology – a Site by nurses, for nurses. Int J Nurs Knowl.2018;29(4).
  5. Parse RR. Nursology: What’s in a Name? Nurs Sci Q.2019;32(2):93-94.
  6. Thorne S. The study of nursing. Nurs Inq.2019;26(1):1-2.

 

 

 

 

 

Removing/Refusing the Invisibility Cloak

Invisibility cloaks are magical devices that render the wearers invisible

from Inaugural issue of “Revolution: The Journal of Nurse Empowerment,” 1991

and transparent – they simply become part of the background. Furthermore, the wearer of the cloak can see through it and actually be wearing it without being fully conscious of it. Although invisibility cloaks have existed in mythology for centuries, they have recently been brought to public consciousness through the work J.K. Rowlings in the Harry Potter series. But I think they provide a relevant metaphor for what many nurses often experience – instances in which they and/or their contributions to health and healing remain invisible. And, my question is, can a shift to focusing on the nursing knowledge that underpins our practice and making it visible by naming it Nursology, help nurses in general to remove or refuse the cloak of invisibility?

 In my years of nursing experience, whether in practice, education, or research,  I have experienced and witnessed many instances of nursing and nurses, myself included, being rendered invisible. Nurses may themselves put on the cloak of invisibility by using the phrase, “I’m just a nurse” or by undervaluing their work.  A participant in one of my studies recounted an amazing example of capacity building in a group of adolescent girls but described her role in the transformation that took place as not “ much of anything” 1.

From Revolution: The Journal of Nurse Empowerment

 We can also put on the cloak of invisibility by valuing the knowledge of related disciplines more highly than nursing knowledge, such as happens when nurses dismiss nursing conceptual frameworks as irrelevant while, at the same time, consciously or unconsciously using knowledge from other fields to inform or define their nursing practice, either in scope or content 2,3.

 Sometimes the cloak of invisibility is put on us by others. We may or may not be conscious of the cultural and societal cloaks put on those of us who are women. And those of us who “trained” to be nurses in the 1960s will also be able to relate to the cloaks we acquired as deference to physicians was instilled in us.  We can only remove these cloaks by becoming conscious of them.  Public health nurses in my studies provided evidence that such cloaking continues. For example, one nurse told me about being required by their employer not to refer to themselves as nurses or the work they did as care; instead they were to refer to themselves as public health professionals, in the name of interdisciplinarity. 

 These reflections came about because of a conversation I had with a friend and colleague in which I related the following incident.  I was attending, on behalf of a national nursing association and by invitation, a media release of interest to health and other workers involved in in promoting healthy populations. After the release we were invited to attend a luncheon to discuss implications of the report from each of our perspectives. One gentleman present clearly represented a biomedical approach to health and he and I exchanged perspectives that were rather diametrically opposed to one another. After the luncheon he made his way across the room to me and asked me what my PhD was in (we each had place card tents which included our credentials).  I told him “nursing”.  He thought I misunderstood him and repeated the  question and received the same answer.  He replied, “no, I can’t have a PhD in medicine and you can’t have one in nursing.”  I assured him I did.  Exasperated, he asked what my dissertation topic was.  I answered that it was an oral history of public health nursing in Ontario.  “Ahh”, he replied, “that’s the answer! Your PhD is in history!”  With that he left, satisfied that he had set me straight! 

 In relating that incident to my friend, we contemplated, would that have been the case if my PhD was in Nursology?  I think probably not. It might have raised the question, “What is Nursology” which I would have welcomed!  

 

1.    Falk-Rafael A, Betker C. The primacy of relationships: a study of public health nursing practice from a critical caring perspective. Adv Nurs Sci. 2012;35(4):315-332.

2.    Rafael A. From rhetoric to reality: The changing face of public health nursing in southern Ontario. Public Health Nurs. 1999;16(1):50-59.

3.    Rafael AR. Nurses who run with the wolves: the power and caring dialectic revisited. ANS Adv Nurs Sci. 1998;21(1):29-42.

 

Martha E. Rogers, RN, MSc , EdD (Canada)

Guardian of the Discipline
Downloads (used by permission)
Transformative Learning article
Canadian Nursing in the Year 2020
Enchantment of the Soul
Syllabus: Conceptual Basis of Nursing Practice
Syllabus: The Nature of Nursing Knowledge

Note: we are delighted to introduce a new Nursology.net series – “Guardians of the Discipline” featuring notable nurse leaders who have made significant achievements to assure the integrity and protection of nursology values and ideals.  We begin this series with Canada’s outstanding leader and scholar, Martha E. Rogers.

Martha E. Rogers (York University, Toronto, Ontario, Canada)

Martha E. Rogers is a Canadian nursing scholar and consultant who has made substantial contributions to advancing nursing knowledge. She is currently a Senior Scholar at York University, Toronto, Ontario and was the founder, and remains the director, of Canadian Nursing Consultants. Her contributions in advancing an appreciation of nursing knowledge cross both those roles and fall into 3 major categories that overlap and inform each other:  1). curricular design and pedagogy; 2) consulting work with nursing organizations to promote conscious application of conceptual models practice and in organizational design, and 3) her work on transformative learning in nursing, alternative nursing futures, and development of the concept of enchantment of the nursing soul. 

 Being In a unique position as a nurse who had focused  on future studies during her doctorate, Martha was commissioned by the Canadian Nurses Association in 1995 to develop future scenarios for nursing in Canada in the year 2020.  The book, Canadian Nursing in the Year 2020 was published by the Canadian Nurses Association for a number of years after it was written.  Download this document here (by permission of the author and copyright holder). That work was clearly informed by Martha’s extensive involvement in the previous decade in helping nurses to understand and embrace nursing conceptual frameworks, whether teaching post-RN baccalaureate students or practicing nurses in their workplace.

 In Canadian Nursing in the Year 2020, Martha created 4 scenarios of nursing in 2020 and invited readers to create a 5th.  On the eve of 2020, it is as relevant and sobering to read as it was when it was first published. Elements of each of the scenarios are recognizable in the present time, likely to significantly different degrees in different countries, cultures, and health care systems.  At the end of each scenario, readers  are invited to reflect on their reactions to the scenario and consider what action is necessary to increase or decrease the chances of them happening.

Canadian Nursing in the Year 2020 concludes with a section entitled, “Can one person make a difference.” Believing that to be possible, Martha asserted that maintaining hope and the personal power to take action requires engaging nurses’ minds , hearts, and souls. Critical minds (mind), caring about people (heart), and connecting with the meaning and purpose of nursing  (soul) are among the essentials she identifies as necessary for us to believe that each of us can make a difference. Martha explored in considerably more depth, the concept of the nursing soul in an unpublished article entitled Enchantment of the Soul

 These ideas were informed by Martha’s early nursing practice and education.  In meeting with her recently, I asked her what first sparked her interest in nursing conceptual frameworks and she replied it was the professors in her Post-RN baccalaureate degree. So, it is not surprising that she began to take action in her position as as a Clinical Nurse Specialist at Mount Sinai Hospital in Toronto, where she also served as Conceptual Framework Coordinator. Later, as an academic, Martha taught in a Post-RN BScN program at York.  One course she developed and taught focused on The Nature of Nursing Knowledge, and a second on the Conceptual Basis of Nursing Practice nursing. The transformative learning  approaches she developed in an unpublished manuscript as an approach to “facilitate “nurses’ learning and use of nursing conceptual frameworks” are evident in both course outlines.  As the School of Nursing evolved, Martha’s influence was evident again as the School adopted a caring-human science philosophy as a conceptual framework.1

 As a nursing consultant, Martha conducted many workshops and spoke at numerous conferences in Canada and the U.S. about transformative learning and facilitating nurses’ understanding and use of nursing conceptual frameworks. An example of this approach is seen in one of the videos she produced, “Conceptual Frameworks in Nursing Practice”, which is included below.

 Both through her academic and consulting roles, Martha was involved in research reporting the implementation and/or evaluation of use of nursing conceptual models in practice.  2,3, 4,5, 4 

Martha was passionate about the uniqueness of nursing knowledge and hoped to pass that passion on to others. Her goal was to facilitate nurses’ critical examination of dominant assumptions and values and the practice norms based upon them, and help them instead to value and give voice to their own nursing knowledge and imagine how nursing practice and health care institutions might be different if nursing values and knowledge were  a valued priority. I asked her recently what she thought her greatest contribution was as a “guardian of the discipline.”  This was her reply:  “If there is anything to be said about my work it would be that I held a belief about the beauty and potential power of unique nursing knowledge. It was my quest to explore nursing knowledge and to help others explore it through deep personal reflection and through critical appraisal of and emancipation from dominant paradigms.

References

 1.   Lewis S, Rogers M, Naef R. Caring-Human Science Philosophy in Nursing Education: Beyond the Curriculum Revolution. Int J Hum Caring. 2006;10(4):31-38.

2.   Rogers ME. Creating a Climate for the Implementation of a Nursing Conceptual Framework. JCEN. 1989;20(3):112-116.

3.   Shea H, Rogers M, Ross E, Tucker D, Fitch M, Smith I. Implementation of nursing conceptual models: observations of a multi-site research team. Can J Nurs Adm. 1989;2(1):15-20.

4.   Rogers, M., Jones Paul, L., Clarke, J., MacKay, C. Potter, M. Ward, W. The use of the Roy Adaptation Model in Nursing Administration. Can J Nurs Adm. 1991, June:21-26.

5.       Fitch, M., Rogers, M., Ross, E., Shea, H., Smith I., Tucker, D. Developing a plan to evaluate the use of nursing conceptual frameworks. Can J Nurs Adm. 1991, March/April:22-27.

 

 

An Introduction to the Canadian Nursing Theories Perspective

In a previous blog, I admitted my ignorance of nursing science during both my early diploma nursing education, and at least the first 18 years of my nursing practice.  But in the mid 1980s, I became aware of an increasing trend in Toronto area hospitals to adopt nursing theoretical frameworks.  Long after the fact, I also learned there had been nursing theory conferences held in Toronto around that time and set out to learn about those conferences, the experiences of the nursologists who attended, and with those in other provinces to discover other such events or activities.  What I found far exceeded what could be captured in 1 blog and yet I know I have barely scratched the surface!  My purpose here is first to thank everyone who has been so generous in sharing their time and archival documents (which will eventually be included in the Landmark Events section of the History tab of this website), and second, to invite nursologists from across Canada to add to my limited findings with what I’m sure is a wealth of information.

In pursuing information on the nursing theory conferences, I was reminded also of the other contributions to nursing knowledge made by Canadian nursologists, such as the:

  • Nursing Philosophy conferences organized by the Unit for Philosophical Research in the Faculty of Nursing, University of Alberta, proceedings of which were published;
  • Conceptual nursing frameworks used to guide curriculum development and pedagogy in Canadian University Schools of Nursing. At least one such model-the McGill model, also known as the Allen model or Developmental Health Model-has been explicated by research and used in nursing practice;1,2,3(3 articles of Ford-Gilboe and Margy Warner)
  • The development and or use of nursing conceptual frameworks to guide nursing practice in some hospitals and public health agencies;
  • The critique, comparison, and explication of nursing theories by Canadian nursing scholars.

Each of these areas will be explored in more detail in the weeks and months to come, hopefully by some of the key scholars who have been involved in these efforts. For the remainder of this blog, I will return to the Canadian nursing theory conferences

I have been able to identify 5 Canadian nursing theory conferences. One was held at the University of British Columbia, in 1988, and four in Ontario – two in Toronto in 1986 and 1988, one in Ottawa in 1989, and one at the Hamilton Psychiatric Hospital in 1993, in celebration of 20 years of theory-based nursing practice.4  Indeed HPH may well have been the first hospital in Canada to have adopted a nursing conceptual framework  (first Orlando, and later Peplau) to guide nursing practice.4

Many of the prominent nursing theorists of the time participated in the 1986 conference, including Dickoff and James, Imogene King, Myra Levine, Betty Neuman, Rosemary Parse, Martha Rogers, and Sister Callista Roy.  Some returned for the 1988 Toronto conference and notable additions for this conference included Virginia Henderson and Jean Watson.

Dorothea M. Fox Jakob, a retired public health nurse and nursing activist was a keen

Dorothea Fox-Jakob

participant in both nursing theory and NANDA conferences and, has generously provided proceedings from the 2 Toronto conferences as well as from many of the NANDA conferences.  Those proceedings are in the process of digitization and will be added to this website in the near future. Information about the other 3 conferences would be a great addition, as would information about any other Canadian nursing theory conferences.

Dorothea tells the story of meeting Virginia Henderson at a reception at the 1988 conference and telling her about her work in advocating for poverty reduction. Dorothea had prepared a resolution for the Registered Nurses Association of Ontario (RNAO), arguing that poverty was a health issue and urged RNAO to lobby for poverty reduction at the provincial and federal levels. The resolution was passed and promptly acted upon by RNAO. Dr. Henderson enthusiastically supported Dorothea’s actions and asked her to send her a copy of the resolution, which she did.  In return she received she received a letter in which she says she is encouraged by Dorothea’s efforts in “trying to do something about basic problems in society like poverty. We too often in the States leave this to others thinking that if we do our particular work well that we have fulfilled our role in society.” The handwritten letter, its transcribed content, and a brief statement of context have been framed and hang in the York University School of Nursing.

V Henderson letter-1.jpgReferences

  1. Ford-Gilboe, M. (2002). Developing knowledge about family health promotion by testing the developmental model of health and nursing. Journal of Family Nursing (8)2, 140-156.
  2. Warner, M. (2002). Postscript to “A Developmental Model of Health and Nursing” by F. Moyra Allen. Journal of Family Nursing, (8)2, 136-139.
  3. Ford-Gilboe, M. (1994). A comparison of two nursing models: Allen’s developmental Health Model and Newman’s Theory of Health as Expanding Consciousness. Nursing Science Quarterly (7)2, 113-118.
  4. Forchuk, C. & Tweedell, D. (2001). Celebrating our past: The history of Hamilton Psychiatric Hospital. Journal of Psychosocial Nursing and Mental Health Services (39)10, 16-24.

 

 

 

 

 

Why Not Nursology?

Photo – Adeline Falk-Rafael © 2018

Dr. Jacqui Fawcett  eloquently argued the case for “Why Nursology “a few weeks back. Another question might be asked – why not nursology? The use of “logy” – the study of – is widely used as a convention for identifying the knowledge base of other disciplines, e.g, biology, sociology, psychology, etc. On the other hand, the word “nursing” can be confusing because it has both popular uses, such as sipping a drink slowly or breastfeeding, and professional uses such as nursing (practice) and nursing (knowledge). It is beyond time for distinguishing between those two professional meanings. I believe doing so will go a long way toward making nursing knowledge visible, not only to other health disciplines and the public, but also to nurses and nursing students themselves. Language is powerful – it is the reason, I have previously advocated for replacing the term “student nurse” with nursing student. I look forward to that becoming nursology students!

I am excited about this initiative! Perhaps that is because my first nursing program was a hospital-based diploma program in the Canadian mid-west during the early 1960s in which the only reference to nursing science that I recall was a textbook called “The Art and Science of Nursing.”  The science of nursing was, sadly,  never explicated. I learned nursing basically as an ancillary medical service, i.e., the care required in the context of specific medical diagnoses and/or treatments. Over the next 15 years, I worked in various units in different hospitals in different cities and provinces. I practiced as I had been taught and consistent with how other Registered Nurses practiced. I say with some shame that I wasn’t reading nursing journals during that time and looking back, I think that was the norm for my colleagues, as well. Hospital or unit procedure books provided the necessary instruction for how to perform essential tasks.

It wasn’t until I moved into a leadership position and took a nursing leadership course that I was introduced to and required to engage with nursing (and other) literature. I marveled at how nursing leaders so articulately argued the contributions nurses make to health and healing, contributions that were based on nurses’ assessments and judgments, independent of medical directives. Nursing  process, nursing diagnoses and nursing theories excited me because they named and provided systematic structure for the work that nurses did in promoting health and healing. In other words, they began to make the invisible, visible! I began to read books and papers on my own, but soon realized I needed more knowledge and returned to school.

I don’t think my journey was unusual for that time. What grieves me is seeing still, much too often, nurses who acknowledge the biological, physiological, psychological, sociological and/or medical knowledge that informs their practice but fail to recognize the critical contribution of nursing knowledge. Nursology is a term that by its very nature emphasizes the disciplinary field of study that informs nursing practice. I can’t wait for the first Nursology programs and for nursing researchers and advanced practioners being recognized as nursologists, in keeping with the conventions of so many other disciplines.