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

The Definition of Health: Thoughts from Japan

Health is a central concept in most if not all versions of the metaparadigm of nursology (Fawcett, 2019). I have defined health as “human processes of living and dying” (Fawcett & DeSanto-Madeya, 2013, p. 6) and conceptualize health as inclusive of wellness, illness, and disease within that process. I deliberately separated wellness from illness and disease when I realized many years ago that the term, promotion of health, could mean that nursologists’ activities were directed toward promotion of illness and disease as well as wellness, rather than indicating that nursologists’ activities are directed toward promoting wellness and preventing illness and disease.

The St. Mary’s College School of Nursing Library. –A Repository of Nursology Knowledge

However, I recently realized that my conceptualization of health is Euro-centric and reflects my privilege as a white, Anglo-Saxon nursologist (Chinn, 2020). Accordingly, when I had the honor of speaking virtually with faculty and graduate program learners at St. Mary’s College Graduate School of Nursing in Kurume, Japan, in February 2021, I invited the learners to share their thoughts about health by responding to three questions. The questions and their responses constitute most of the remainder of this blog.

• The first question is: What is your definition of health?

• Inasmuch as the nursology curriculum at St. Mary’s College School of Nursing is based on the Roy Adaptation Model (RAM), I then asked this question: To what extent is your definition of health consistent with the Roy Adaptation Model definition of health, which is: “A state and process of being and becoming an integrated and whole human being” (Roy, 2009, p. 48).

• Finally, I asked: How does your definition of health affect what you think and do as a nursologist?

GRADUATE PROGRAM LEARNER TAKAKO TANAKA’S THOUGHTS ARE:

I define health as a feeling of harmony between body, mind, and living in society. Even if people have a disease or disability, they can be considered healthy if they feel that they are able to do what they want to do, while coping with their environment. My definition of health is similar to that of the RAM, in that human health in the RAM is not just a high or low level of health. Instead, it is about growth and development as we interact with our environment. Output behavior, when healthy, is positive adaptive behavior. According to the RAM, if energy is not spent on maladaptive coping, this energy can promote healing and enhance health, even in states of illness. I also believe that if people have a lifestyle disease, for example, and can controls the disease by going to the hospital and taking appropriate medication to stabilize the disease, and are able to live as members of society, then they are healthy. My definition of health has been informed by my work in public health nursing, as I learned to always value the concept of health promotion. Individually and collectively, I want to help people understand their health problems and support them to achieve independence and self-determination on their own, which will likely lead to illness prevention. Furthermore, I believe that it is essential to create an environment that supports health.

GRADUATE PROGRAM LEARNER MIHO YOSHIOKA’S THOUGHTS ARE:

I define health as a state in which subjective well-being and objective health indicators are in marvelous harmony. Subjective well-being differs depending on the culture, customs, and environmental values of each individual; and even if they have a disease or handicap, I think that they are in health if they feel well-being within themselves. However, I ask if there is a possibility of being a detriment to themselves, such as leaving the illness to their own discretion, are they truly healthy? Therefore, I dare to consider that a state in which these conflicting things are in marvelous harmony can be called health. The RAM emphasis on an interaction between the person and the environment is consistent with my idea of subjective well-being. The RAM emphasizes that health behaviors based on individual values are adaptive and can never be measured by the values of others, which helps me to understand that whether people consider themselves healthy is a complete affirmation of their diverse values. However, the RAM contention that health behaviors cannot be measured is not consistent with the inclusion of objective aspects of health in my definition. In recent years, people’s lifestyles and values have changed, and subjective well-being, an aspect of my definition of health, has also diversified. The practice of providing sensitive care for the different needs of each individual requires a holistic understanding of that individual. A nursologist is the professional who is closest to the client. By paying attention to and engaging with the client, I think that we can become aware of the needs of that person and provide individualized nursology that protects human consideration and dignity. I also think that nursology, which requires being close to the client, is important in terms of developing trust and respect for their subjective well-being. Moreover, I think that nursology practice is caring for others, which is essential for curing and healing. Therefore, the attitude of facing each individual, the full use of professional knowledge and experience with dignity to maintain and improve well-being, and cooperation with clients while caring for them, are all affected by my definition of health and by our thinking and acting as a nursologist.

GRADUATE PROGRAM LEARNER MASUMI OKA’S THOUGHTS ARE:

I define health as a state of understanding and accepting of one’s condition, and also a quest for health itself. Although the World Health Organization (1948) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” I regard health as the way of understanding the state of experiencing a disease or disability, accepting one’s response to the disease or disability, and trying to become satisfied and fulfilled despite the disease or disability. My definition also incorporates a holistic perspective that includes the meaning of healing, and I think that it is also a love of one’s existence, including existence with others. There are subjective and objective aspects to health, but factors such as ideals, goals, and prejudices toward health are the driving force behind the quest for health. I believe that human beings are creatures that constantly seek “health” and have the power to control their way of life. In other words, the act of pursuing “health” itself becomes human empowerment, and I think that it also affects one’s quality of life. My definition of health has been greatly influenced by the RAM definition of health. Being and becoming a whole and integrated human being can be interpreted as a quest for health, so that process is health itself. The RAM considers health from the perspective of human goals and the significance of existence, and lack of integration is said to denote inadequate health. The facilitation of the process of integration is seen as care for my idea of a “quest for health” and is consistent with all human care required of nursologists. My definition of health has a great influence on my thinking and behavior as a nursologist. I believe that supporting the acceptance of people with a disease or disability and considering together with them is caring for their “quest for health.” Quality of life changes significantly depending on how disease or disorder is perceived and understood. As a nursologist, I think that by being involved in the process of accepting illness and disability and supporting people’s ability to satisfy themselves, they can accept and love their existence. As a nursologist, I would like to continue to study and learn the potential “investigative power of health” of human beings and contribute to the development of the science of nursology in the future.

GRADUATE PROGRAM LEARNER TATSUNARI HARA’S THOUGHTS ARE:

My definition of health has two aspects: it is the situation in which people think of their condition as being “good” despite any physical malady they might have, and it is also the process they are going through in changing or adapting to their condition to become “better” in terms of their own understanding of the word. My definition of health has been greatly influenced by the RAM, as I learned nursology through the RAM. My definition of health is, however, more abstract than that of the RAM, as my definition emphasizes the largely subjective nature of health. My definition of health has influenced by thoughts and actions. Thus, I understand that nursologists strive to establish a caring connection to patients by ascertaining what kind of state they think is good, their goals and abilities required to attain that state, how they perceive their current situation, and what their values are. Furthermore, as I work in rehabilitation nursology, I see many of the patients leave the hospital with remaining disabilities to go on with their lives. Therefore, we nursologists may be required to change our ideas about health so that we can work together with the patients while thinking about how to establish health in their lives, and encourage any necessary changes they may need to make.

GRADUATE PROGRAM LEARNER MIHO ISHIBASHI’S THOUGHTS ARE:

I think that health is not a concept that opposes illness, but a process in which a person interacts with the environment as a human being and tries to become a person looking positively toward their hopes and wishes. Health in the RAM is an integrated overall condition or process. Nursologists say that by promoting adaptation, they contribute to human health, quality of life, and dignified death. I think that for people to be the people they are, nursologists have to understand the hopes and wishes of what the people want to be and do, as well as understand and support them physically, mentally, and socially. I believe it is necessary to understand the environment surrounding a person, think about the influences that affect their health, and consider how to manage these aspects to make people healthy. I think it is necessary to act as a nursologist to understand people’s hopes and wishes people and to help them attain these hopes and wishes.

GRADUATE PROGRAM LEARNER YUKIE NAKANISHI’S THOUGHTS ARE:

I think of health as being familiar with one’s self, having the ability to deal with problems, and having the ability to make decisions. The notion of health in the RAM as a state of integration is consistent with my thoughts about health. Until I entered graduate school, I was convinced that “health” was not having any illnesses or disability. However, even if one has an illness or a disability, I have now come to think that true health is the ability to face oneself, accept what one has become, and move forward toward the future. While studying the RAM and bioethics, I have learned it is important to learn that “person” equals “life”, and that it is equally important to think about a person’s “purpose of life” and “meaning of life” while practicing nursology. Nursologists are practitioners of caring, so I have realized that it may be inadequate to not understand what health is. In the future, I would like to continue learning so I can augment my humanity and human power, learn more about the attitudes necessary for caring, and put them to practical use.

CONCLUDING NOTE:

As I began to write this blog, I realized that I did not know the Japanese word for health; Google translate provided an answer: Kenkō, which is written in Japanese characters as 健康 (https://translate.google.com/?sl=en&tl=ja&text=health%20&op=translate)

I was remiss in not having invited the St. Mary’s College Graduate School of Nursing faculty and learners to share the word each uses for health. Therefore, I do not know whether their responses reflect a Euro-centric or Japanese meaning for the word.

When I sent a draft of this blog to Eric Fortin, of the St. Mary’s College School of Nursing faculty, he replied with his interpretation of the Japanese characters for health. I am, therefore, indebted to Mr. Fortin (personal communication, April 26, 2021), who wrote “健 means ‘humans build,’ and ‘康’ means “breathing space, . , , probably implying the lack of obstruction or disease. So, ‘humans building breathing space’ implies being healthy.”

REFERENCES

Chinn, P. (2020, January 14). Decolonizing nursing. nursology.net. https://nursology.net/2020/01/14/decolonizing-nursing/

Fawcett, J. (2019, March 21) Questions and Answers about our Discipline: Name and Metaparadigm. Paper presented at the Nursing Theory: A 50 Year Perspective Past and Future Conference. Sponsored by Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. nursology.net. . https://nursologycom.files.wordpress.com/2019/03/cwru-paper-fawcett-3-28-19.pdf

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). F. A. Davis.

Roy, C. (2009). The Roy adaptation model (3rd ed.). Pearson.

World Health Organization. (1948). Preamble to the constitution. World Health Organization. https://www.who.int/about/who-we-are/constitution

Nursing is a Discipline–Donaldson and Crowley Notable Work

Notable Works

The first time that I understood that nursing – what we now call nursology (Fawcett, 2018; Fawcett et al., 2015) – is a discipline was in 1978 when I read the just published Donaldson and Crowley’s now classic journal article, “The discipline of nursing.” My pride in what we are has always been great, so realizing that we are members of a discipline increased my pride from great to greater. I should note that at the time of publication of the Donaldson and Crowley (1978) paper, I did not know about Moore’s 1968 paper, “Nursing: A scientific discipline?” which certainly was due to my admittedly sloppy scholarship!

Sue Donaldson

As I continued to think about nursology as a discipline, I realized I needed to determine the accepted definition of the word. I found that the term, discipline, comes from the Latin disciplina, meaning a branch of instruction or learning (Stein, 1966). Disciplines are distinguished by the subject matter of interest to its members (Schwab, 1962; Walton & Kuethe, 1963). Disciplines are a way of organizing knowledge; they have utility as administrative structures for education.

Donaldson and Crowley’s (1978) article is especially important for their telling us what we are all about. They pointed out, “At least since the time of Nightingale, there has been a remarkable consistency in the recurrent themes that [nursologist] scholars use to explain what they conceive to be the essence of the core of [nursology].” (p. 113). They identified the three general themes listed below. So influential were these themes to me that they became the first version of the relational propositions for my version of our disciplinary metaparadigm (Fawcett, 1984).

*Concern with principles and laws that govern the life processes, well –being, and optimum functions of human beings—sick or well

*Concern with the patterning of human behavior in interaction with the environment in critical life situations

*Concern with the processes by which positive changes in health status are affected. (Donaldson & Crowley, 1978, p 113)

Donaldson and Crowley (1978) identified two types of disciplines– academic and professional. They maintained that nurses (nursologists) are members of a professional discipline and, as such, nursologists have a social mandate to not only develop and disseminate knowledge, but also to use the knowledge in service to human beings. Members of academic disciplines, in contrast, develop and disseminate knowledge but do not have a social mandate to use the knowledge in service to anyone or anything.

Donaldson and Crowley’s (1978) claim that we are members of a professional discipline led me to search for a definition of a profession. I found that the term, profession, refers to a vocation requiring knowledge of some branch of learning (Stein, 1966). Obviously, the emphasis in the definitions of both discipline and profession is knowledge.

As can be seen in the diagram below, which was inspired by Donaldson and Crowley’s (1978) ideas about a professional discipline, I envision the components of the professional discipline of nursology to be science and the profession. For nursology, science encompasses eight types of knowledge—empirical, aesthetic, ethical, personal knowing, sociopolitical, emancipatory, spiritual, and unknowing, too (Carper, 1978; Chinn & Kramer, 2018; Munhall, 1993; White, 1995; Willis & Leone-Sheehan, 2019). Discovery and dissemination of knowledge is accomplished by means of the conduct and publication of the results of scholarly inquiry, including basic, applied, and clinical research (Donaldson & Crowley, 1978), as well as translational research (Wendler et al., 2013). Utilization of knowledge is accomplished by means of implementing the results of translational research into clinical practice activities as well as into educational programs and administration of nursology services.

The double-headed arrows in the diagram indicate that there is a reciprocal relation between science and the profession; between discovery and dissemination of knowledge and utilization of that knowledge; and between scholarly inquiry and practice. Ultimately, the results of utilization of disciplinary knowledge in practice are used to advance the scholarly inquiry that is required for further discovery and dissemination of knowledge.

Moore (1968) and Donaldson and Crowley (1978) indicated that scholarly inquiry guides practice. Thus, the starting point for the reciprocal relation between scholarly inquiry and practice always is scholarly inquiry. Some nursologists may disagree, maintaining that ideas for scholarly inquiry arise from problems encountered in practice. However, Donaldson and Crowley (1978) maintained that “the discipline of [nursology] should be governing clinical practice rather than being defined by it” (p. 118). They went on to explain,

Of necessity, clinical practice focuses on the individual in the here and now who has a problem requiring relevant and appropriate actions. The discipline, in contrast, embodies a knowledge base relevant to all realms of professional practice and which links the past, present and future. Its scope goes far beyond that required for current clinical practice. If the discipline were so narrowly defined, professional [nursology] could be limited to functioning in the realm of disaster relief rather than serving as a force in the promotion of world health. (p 118)

The major impact of Donaldson and Crowley’s (1978) artice is that understanding and recognizing that nursologists are members of a discipline provides the rationale for our place in the academy of higher education among other widely and long-recognized disciplines. Moreover and perhaps most important, are Donaldson and Crowley” (1978) closing words:

For the continued growth, significance, and utility of the discipline of [nursology], researchers must place their research within the context of the discipline. Theories must also be viewed in terms of the basic structural conceptualizations of the discipline [i.e., our nursology conceptual models]. The responsibility for revising and clarifying the structural conceptions, the very framework, of the discipline of [nursology] rests with [nursologist] researchers. This means lessening our preoccupation with the process of [nursology practice] and pedagogy and placing emphasis on content as substance. (p. 120).

Content as substance was, of course, the reason for creation of nursology.net.

References

Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23.

Chinn, P. L., & Kramer, M. K. (2018). Knowledge development in nursing: Theory and process (10th ed.). Elsevier Mosby.

Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26(2), 113-120

Fawcett, J. (1984). The metaparadigm of nursing: Present status and future refinements. Image: The Journal of Nursing Scholarship, 16(3), 84 87.Fawcett, J. (2018, September 24). Our Name: Why Nursology? Why .net? nursology.net.. https://nursology.net/2018/09/24/our-name-why-nursology-why-net/

Fawcett, J., Aronowitz, T., AbuFannouneh, A., Al Usta, M., Fraley, H. E., Howlett, M. S. L, Mtengezo, J. T., Muchira, J. M., Nava, A., Thapa, S., & Zhang, Y. (2015). Thoughts about the name of our discipline. Nursing Science Quarterly, 28(4), 330-333. doi: 10.1177/0894318415599224

Moore, M. A. (1968) Nursing: a scientific discipline? Nursing Forum, 7(4), 340-348. (Reprinted Nursing Forum, 1993, 28(1), 28-31.)

Munhall PL. (1993). “Unknowing”: toward another pattern of knowing in nursing. Nursing Outlook, 41(3), 125–128.
Schwab, J. (1962). The concept of the structure of a discipline. Educational Record, 43(July), 197-204.

Stein, J. (Ed.). (1966). The Random House dictionary of the English language (Unabridged ed.). Random House.

Walton, J., & Kuethe, J. L. (Eds.). (1963). The discipline of education. University of Wisconsin Press.

Wendler, M. C., Kirkbride, G., Wade, K., & Ferrell, L. (2013). Translational research: A concept analysis. Research & Theory for Nursing Practice, 27(3), 214–232. DOI: 10.1891/1541-6577.27.3.214

White, J. (1995). Patterns of knowing: Review, critique, and update. Advances in Nursing Science, 17(4), 73-86.

Willis, D. G., & Leone-Sheehan, D. M. (2019). Spiritual knowing; Another pattern of knowing in the discipline. Advances in Nursing Science, 42(1), 58-68. doi: 10.1097/ANS.0000000000000236

Winning Essay – “Bringing Florence Nightingale to the Bedside of the Critically Ill Patient”

In celebration of the bicentenary of Florence Nightingale’s birth, the Nursing Archives Associates of the Boston University Libraries’ Howard Gotlieb Archival Research Center held an essay contest, open to nursing students enrolled at all levels of study— undergraduate, master’s and doctoral – and focused on Florence Nightingale’s influence on the evolution of nursing, both historical and contemporary. Although all Nightingale 2020 events were postponed due to the COVID-19 pandemic, we are proud to announce the winner of the Muriel A. Poulin Nursing Student Essay Contest.

The winning essay is titled “Bringing Florence Nightingale to the Bedside of the Critically Ill Patient,” written by Laura Beth Kalvas, MS, RN, PCCN, Graduate Fellow, The Ohio State University College of Nursing. Here is the essay:

In her Notes on Nursing (1969), Florence Nightingale argued that nature alone can cure the sick. Cautioning against an over-reliance on medical care, which could do nothing more than remove obstructions to the natural healing process, Nightingale encouraged nurses to put patients in the best possible conditions for nature to act upon them. Her environmental theory highlighted the importance of cleanliness, ventilation, limited noise, uninterrupted sleep, proper nutrition, and sunlight in promoting recovery of the sick (Hegge, 2013; Nightingale, 1969). Within this perspective, the role of the nurse was to provide an environment conducive to healing, support the patient in the healing process, and carefully observe the patient for signs of improvement or decline.

Certainly when Nightingale cautioned against an over-reliance on medical care, she could little have imagined the treatments and technology available today, especially in the care of the critically ill. Yet her careful distinction between the practice of medicine and the practice of nursing remains relevant. In the complex critical care environment, where medical treatments are frequently lifesaving, what unique contribution does the nurse bring to the care of the critically ill patient? I would argue that the role of the critical care nurse remains the same; to put the patient in the best possible condition for nature to act upon them (Nightingale, 1969). Yet “so deep-rooted and universal is the conviction that to give medicine is to be doing something, or rather everything; to give air, warmth, cleanliness . . . is to do nothing” (p. 9), that this important aspect of nursing practice is easily undervalued.

The phenomenon of pediatric delirium offers an interesting case study in the importance of high-quality nursing care in the modern intensive care unit. Delirium is a frequent, significant complication of critical illness consisting of acute changes in mental status that develop over a short period of time and fluctuate throughout the day (American Psychiatric Association, 2013). Up to 65.5% of children in the pediatric intensive care unit (PICU) experience delirium (Meyburg et al., 2017). Affected children exhibit signs of impaired attention, disorientation, agitation, hallucinations, and sleep/wake cycle disturbance (Holly et al., 2018). Children describe their delusional memories of the PICU as highly disturbing, including visual hallucinations of injured
parents, monsters trying to eat them, and insects crawling on the walls (Colville et al., 2008). Furthermore, pediatric delirium is associated with poor clinical outcomes, including increased length of stay (Smith et al., 2017), cost of care (Traube et al., 2016), and mortality (Traube et al., 2017).

Although delirium has only recently caught the attention of the pediatric critical care community (Kudchadkar, Yaster, et al., 2014), it is not a new phenomenon. Through her observations, Nightingale (1969) noted that lack of sunlight, excessive noise, and fragmented sleep were associated with delirium. Today’s pediatric critical care environment is characterized by excessive light and sound exposure and frequent nighttime caregiving (Al-Samsam & Cullen, 2005; Cureton-Lane & Fontaine, 1997). This environment likely contributes to the altered sleep patterns experienced by critically ill children (Kudchadkar, Aljohani, et al., 2014). Providing support for Nightingale’s (1969) early observations, we now know that these environmental exposures and resulting sleep disruption can impair cognitive function (e.g., attention, working memory, emotional regulation; Durmer & Dinges, 2005; Kahn et al., 2013) and disrupt the circadian rhythm of melatonin release, which has neuroprotective properties (Claustrat et al., 2005). Environmentally-induced circadian rhythm dysregulation is one hypothesized pathway to the cognitive changes observed in delirium (Maldonado, 2017), and sleep/wake cycle disturbances are often observed in children with delirium (Holly et al., 2018).

Nurses are uniquely positioned at the bedside to prevent delirium through environmental modification and regulation of the circadian rhythm; interventions which place the patient in the best possible conditions for recovery (Nightingale, 1969). Sleep promotion interventions in the adult ICU are associated with a decreased incidence and duration of delirium (Kamdar et al., 2013; Patel et al., 2014). However, few researchers have considered the role of sleep in the development of pediatric delirium (Calandriello et al., 2018), and few pediatric critical care clinicians implement sleep-promoting interventions to prevent or manage delirium (Kudchadkar, Yaster, et al., 2014; Staveski et al., 2018). Nurse scientists are needed in the medically-dominated field of pediatric delirium research to highlight the important role of the critical care nurse in preventing and managing delirium (Balas et al., 2012).

As a doctoral nursing student, my interest in pediatric delirium is driven both by Nightingale’s (1969) mandate to the nursing profession and the Human Response Model, a conceptual model for nursing that depicts the complex interplay between the patient, their environment, and their health (Heitkemper & Shaver, 1989; Shaver, 1985). My dissertation work focuses on the relationship between exposures in the pediatric critical care environment (i.e., light and sound exposure, caregiving patterns), sleep disruption, and delirium in young, critically ill children. I chose to focus on PICU environmental exposures and sleep patterns because they are inherently nurse-driven; as the primary bedside caregiver, the nurse determines the type of environment in which children receive treatment. This dissertation study will inform future large-scale stu dies of sleep disruption and pediatric delirium, as well as the design and implementation of sleep promotion interventions for the PICU. The validation of sleep promotion as an effective, nurse-driven, non-pharmacological delirium prevention method has the potential to improve the neurocognitive symptom management and clinical outcomes of survivors of pediatric critical illness.

In my future work as a nurse scientist, I will continue to root my research in the ideals espoused by Nightingale in her Notes on Nursing (1969). My long-term career goal is to become a leader in improving the neurocognitive symptom management, clinical outcomes, and long-term health of critically ill children by optimizing the pediatric critical care environment. In today’s complex critical care setting, full of advanced treatments and lifesaving technology, let us never forget the unique role of the nurse: To place critically ill patients in the best possible intensive care environment to receive life saving treatment, heal, and promote long-term health.

References

Al-Samsam, R. H., & Cullen, P. (2005). Sleep and adverse environmental factors in sedated mechanically ventilated pediatric intensive care patients. Pediatric Critical Care Medicine, 6(5), 562–7.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.

Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., Peitz, G. J., & Ely, E. W. (2012). Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Critical Care Nurse, 32(2), 35–8, 40–7; quiz 48. https://doi.org/10.4037/ccn2012229

Calandriello, A., Tylka, J., & Patwari, P. (2018). Sleep and delirium in pediatric critical illness: What is the relationship? Medical Sciences, 6(4), 90. https://doi.org/10.3390/medsci6040090

Claustrat, B., Brun, J., & Chazot, G. (2005). The basic physiology and pathophysiology of melatonin. Sleep Medicine Reviews, 9(1), 11–24. https://doi.org/10.1016/J.SMRV.2004.08.001

Colville, G., Kerry, S., & Pierce, C. (2008). Children’s factual and delusional memories of
intensive care. American Journal of Respiratory and Critical Care Medicine, 177(9), 976–982. https://doi.org/10.1164/rccm.200706-857OC

Cureton-Lane, R. A., & Fontaine, D. K. (1997). Sleep in the pediatric ICU: an empirical investigation. American Journal of Critical Care, 6(1), 56–63.

Durmer, J. S., & Dinges, D. F. (2005). Neurocognitive consequences of sleep deprivation. Seminars in Neurology, 25(1), 117–129. https://doi.org/10.1055/s2005-867080

Hegge, M. (2013). Nightingale’s Environmental Theory. Nursing Science Quarterly, 26(3), 211–219. https://doi.org/10.1177/0894318413489255

Heitkemper, M. M., & Shaver, J. F. (1989). Nursing research opportunities in enteral nutrition. The Nursing Clinics of North America, 24(2), 415–26.

Holly, C., Porter, S., Echevarria, M., Dreker, M., & Ruzehaji, S. (2018). Recognizing delirium in hospitalized children: A systematic review of the evidence on risk factors and characteristics. American Journal of Nursing, 118(4), 24–36. https://doi.org/10.1097/01.NAJ.0000532069.55339.f9

Kahn, M., Sheppes, G., & Sadeh, A. (2013). Sleep and emotions: Bidirectional links and
underlying mechanisms. International Journal of Psychophysiology, 89(2), 218–228. https://doi.org/10.1016/j.ijpsycho.2013.05.010

Kamdar, B. B., King, L. M., Collop, N. A., Sakamuri, S., Colantuoni, E., Neufeld, K. J., Bienvenu, O. J., Rowden, A. M., Touradji, P., Brower, R. G., & Needham, D. M. (2013). The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Critical Care Medicine, 41(3), 800–9. https://doi.org/10.1097/CCM.0b013e3182746442

Kudchadkar, S. R., Aljohani, O. A., & Punjabi, N. M. (2014). Sleep of critically ill children in the pediatric intensive care unit: A systematic review. Sleep Medicine Reviews, 18(2), 103–110. https://doi.org/10.1016/j.smrv.2013.02.002

Kudchadkar, S. R., Yaster, M., & Punjabi, N. M. (2014). Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: A wake-up call for the pediatric critical care community. Critical Care Medicine, 42(7), 1592–1600. https://doi.org/10.1097/CCM.0000000000000326

Maldonado, J. R. (2017). Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. International Journal of Geriatric Psychiatry, 1-30 https://doi.org/10.1002/gps.4823

Meyburg, J., Dill, M. L., Traube, C., Silver, G., & von Haken, R. (2017). Patterns of postoperative delirium in children. Pediatric Critical Care Medicine, 18(2), 128–133. https://doi.org/10.1097/PCC.0000000000000993

Nightingale, F. (1969). Notes on nursing: What it is and what it is not. Dover Publications, Inc.

Patel, J., Baldwin, J., Bunting, P., & Laha, S. (2014). The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia, 69(6), 540–549. https://doi.org/10.1111/anae.12638

Shaver, J. F. (1985). A biopsychosocial view of human health. Nursing Outlook, 33(4), 186–91.

Smith, H. A. B., Gangopadhyay, M., Goben, C. M., Jacobowski, N. L., Chestnut, M. H., Thompson, J. L., Chandrasekhar, R., Williams, S. R., Griffith, K., Ely, E. W., Fuchs, D. C., & Pandharipande, P. P. (2017). Delirium and benzodiazepines associated with prolonged ICU stay in critically ill infants and young children. Critical Care Medicine, 45(9), 1427–1435.
https://doi.org/10.1097/CCM.0000000000002515

Staveski, S. L., Pickler, R. H., Lin, L., Shaw, R. J., Meinzen-Derr, J., Redington, A., & Curley, M. A. Q. (2018). Management of pediatric delirium in pediatric cardiac intensive care patients: An international survey of current practices. Pediatric Critical Care Medicine, 19(6), 538–543.
https://doi.org/10.1097/PCC.0000000000001558

Traube, C., Mauer, E. A., Gerber, L. M., Kaur, S., Joyce, C., Kerson, A., Carlo, C., Notterman, D., Worgall, S., Silver, G., & Greenwald, B. M. (2016). Cost associated with pediatric delirium in the ICU. Critical Care Medicine, 44(12), e1175–e1179. https://doi.org/10.1097/CCM.0000000000002004

Traube, C., Silver, G., Gerber, L. M., Kaur, S., Mauer, E. A., Kerson, A., Joyce, C., & Greenwald, B. M. (2017). Delirium and mortality in critically ill children: Epidemiology and outcomes of pediatric delirium. Critical Care Medicine, 45(5), 891–898. https://doi.org/10.1097/CCM.0000000000002324

Practice and Research Speak: The Words We Use to Describe Ourselves and Others

In March 2020, I posted a blog about the meaning of words used to describe the extent to wish a person’s (patient or client) behavior does not comply with, adhere to, or is concordant with what has been prescribed by nursologists or physicians. In December 2020, I posted a blog about the meaning of words researchers use in their research reports, such as allow, respondents, and informants. In these blogs, I pointed to the power differential that is implied in the use of these words. In the first blog, I asked why do we use compliance, adherence, and even concordance instead of a term that more accurately reflects relationship-based care; and in the second blog, why do we use allow rather than invite, and why do we use respondent or informant rather than people.

The purpose of this blog is to discuss the words we use to describe ourselves and others in the context of healthcare. Collectively, we tend to refer to ourselves (nursologists) as healthcare providers, using the same term for physicians, physical therapists, occupational therapists, social workers, and others who “provide” healthcare “services.” We refer to others (patients, clients, people) as recipients of these services.

Copyright 2021 Jacqueline Fawcett

I have used these terms in my publications for many years. Now, as I become more sensitive to the connotative meaning of words, I must question how my use of these words – provider, recipient – conveys a huge power differential, a clear instance of power-over (Chinn & Falk-Rafael, 2015; https://nursology.net/nurse-theorists-and-their-work/peace-power/), and power-as-control (Barrett, 2010; https://nursology.net/nurse-theorists-and-their-work/theory-of-power-as-knowing-participation-in-change/

In the compliance etc. blog, I referred to co-created narrative, and a comment from a reader of that blog replied that a co-created narrative is one “in which the healthcare consultant and the person consulting with him/her engage in dialogue around the recommendations offered, within an environment of mutual respect and honesty, arriving at a mutually agreed upon plan led by the person seeking input” (https://nursology.net/2020/03/17/what-is-reflected-in-a-label-about-health-non-nursology-and-nursology-perspectives/).

I thank that reader very much for her comment. Healthcare consultant instead of healthcare provider is a better term, as it at least implies peace as power (Chinn & Falk-Rafael, 2015) and power-as-freedom (Barrett 2010) perspectives, as does person who is consulting instead of recipient. I shall do my best to use these words in all future publications until the potential awkwardness or unfamiliarity with these words evolves to the familiar, conveying the dignity and mutual respect of the encounter. (Note that I wrote “do my best” rather than “try,” as I am committed to removing “try” from my vocabulary, for as Yoda tells us: DO OR DO NOT; THERE IS NO TRY.) .

Yoda Says: Do or do not. There is no try.
Yoda in Fawcett’s Art, Antiques, and Toy Museum in Waldoboro. Maine
Photo by Jacqueline Fawcett

I very much look forward to comments from readers of this blog–what are your thoughts about words that convey different types of power? Do you have suggestions for other words to convey who we are and who others are?

References

Barrett, E. (2010). Power as knowing participation in change: What’s new and what’s next. Nursing Science Quarterly, 23(1), 47-54.doi: 10.1177/089431840935379

Chinn, P. L., & Falk-Rafael, A. R. (2015). Peace and power: a theory of emancipatory group process. Journal of Nursing Scholarship, 47(1), 62–69. https://doi.org/10.1111/jnu.12101

Is Medicine a Trade or a Discipline or Profession?

Nursology is regarded as a discipline and a profession, which means that nursology constitutes distinctive knowledge encompassing nursological philosophies, conceptual models, grand theories, middle-range theories, and situation-specific theories (see all content on https://nursology.net and also https://nursology.net/2018/09/24/our-name-why-nursology-why-net/).Medicine, in contrast, is a trade. This assertion is based on my search of literature for several years and pondering the difference between a discipline or a profession and a trade at least since the publication of Donaldson and Crowley’s now classic 1978 article, The Discipline of Nursing. .

I asserted that medicine is a trade in two 2014 publications (Fawcett, 2014a, 2014b) and in 2017, I wrote, under the heading, Medicine is a Trade:

I have never been able to locate any obvious or explicit knowledge that is distinctly medical. A September 18, 2016 search of the Cumulative Index of Nursing and Allied Health (CINAHL Complete) using the search term “medical model” yielded 816 publications. An admittedly quick review of a random sample of the retrieved publications revealed that the term medical model was not defined but rather used in a way suggesting that any reader would know what the term means. (Fawcett, 2017, p. 77)

I have continued to ponder whether medicine should be considered a trade and have wondered why no one has challenged my assertion, at least in any publications or blogs I have seen. Therefore, on January 4, 2021, I expanded my search to other sources–Taber’s Cyclopedic Dictionary, the Oxford English Dictionary, and Wikepedia.

The 22nd edition of Taber’s (Venes, 2013) includes no entry for medical model. Medicine is defined as “the act of maintenance of health, and prevention and treatment of disease and illness” (Venes, 2013, p. 1474). No reference to the knowledge needed to perform the act of medicine is evident. The Oxford English Dictionary also includes no entry for medical model, with only a mention of the term in quotations pertaining to two words, technologizing and miasmatist.

However, two definitions of medicine imply a knowledge base (although not necessarily distinctive knowledge). One definition is: “The science or practice of the diagnosis, treatment, and prevention of disease (in technical use often taken to exclude surgery).” The other definition is: “The medical establishment or profession; professional medical practitioners collectively.”

A search of Wikipedia yielded this statement: “Medical model is the term coined by psychiatrist R. D. Laing in his The Politics of the Family and Other Essays (1971), for the “set of procedures in which all doctors are trained.” It includes complaint, history, physical examination, ancillary tests if needed, diagnosis, treatment, and prognosis with and without treatment.” (https:// en.wikipedia.org/wiki/Talk:Medical model – Wikipedia). Noteworthy is that Laing did not mention the philosophic, conceptual, or theoretical knowledge that would guide the “set of procedures in which all doctors are trained.”

The content in Wikipedia also included an important negative consequence of adherence to the medical model. This consequence is “In the medical model, the physician was traditionally seen as the expert, and patients were expected to comply with the advice. The physician assumes an authoritarian position in relation to the patient. Because of the specific expertise of the physician, according to the medical model, it is necessary and to be expected. In the medical model, the physician may be viewed as the dominant health care professional, who is the professional trained in diagnosis and treatment.” (https:// en.wikipedia.org/wiki/Talk:Medical model – Wikipedia)

My concern with the very idea of “adherence to the medical model” (or adherence to or compliance with anything put forth by a nursologist or a physician) led me to ask “what [do] we mean when we say that a person (called a patient or a client) does not comply with or adhere to a treatment plan. It seems to me that these words reflect the physician’s or the nursologlist’s prescriptions for the patient, which in turn, reflect the physician’s or the nursologist’s power over and control of the patient.” (Fawcett, 2020)

My concern regarding the physician as a professional person is grounded in my inability to identify any distinctive knowledge of medicine that is necessary for the designation of professional in both the OEDO definition of medicine and in the mention in Wikipedia of the professional being “trained,” a word associated with training for a trade.

Of course, I understand that physicians possess a great deal of scientific knowledge. However, that knowledge is of various disciplines, such as anatomy, physiology, histology, and chemistry, not of medicine per se (as there is no distinctive medical knowledge that I have been able to identify),

I have concluded that the so-called “medical model” is a fiction put forth at least since Laing’s (1971) publication by members of the healthcare team (including nursologists) and the general public to ascribe a particular status to a trade. .

Please note that I acknowledge the importance of trades in society. I certainly cannot survive without many tradespersons in my life. However, I maintain that it is important to be very clear about the words we bestow on the members of healthcare teams, words that clearly reflect whether those members belong to a discipline/profession or trade. If members of a discipline/profession, it is necessary to identify the distinctive knowledge that guides practice, and research and education, too..

What do you, a reader of this blog, think? Have you been able to identify distinctive philosophic, conceptual, and theoretical knowledge that would constitute the discipline of medicine? Please add your thoughts to the comments section of this blog. Thank you very much.

References

Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113-120.

Fawcett, J. (2014a). Thoughts about collaboration—or is it capitulation? Nursing Science Quarterly, 27, 260-261.

Fawcett, J. (2014b). Thoughts about interprofessional education.Nursing Science Quarterly, 27, 178-179.

Fawcett, J. (2017). Thoughts about nursing conceptual models and the “medical model.” Nursing Science Quarterly, 30, 77-80. (Permission to provide a link to the PDF of this article was granted by the journal editor)
Fawcett, J. (2020, March 17). What is Reflected in a Label about Health? Non-Nursology and Nursology Perspectives. Blog.

Laing, R. D. (1971). The politics of the family and other essays. Routledge

Venes, D. (Ed.). (2013). Taber’s cyclopedic medical dictionary (22nd ed.). F. A. Davis.

Foundations of Nursology Syllabus: Another New Resource on Nursology.net

Coauthor: Rosemary William Eustace, PhD, RN, PHNA-BC

We, along with all members of the nursology.net management team, are very pleased to offer another resource for nursology – the Foundations of Nursology syllabus. The syllabus is offered in conjunction with our teaching strategies resources (Fawcett, 2019) as well as other nursology website resources about nursing conceptual models, grand theories, middle-range theories, situation-specific theories, and philosophies.

The syllabus is offered to all interested nurse educators in academic and practice settings. Our intent in developing the syllabus was to provide a starting point for the teaching of nursology discipline-specific knowledge, with emphasis on nursology philosophies, conceptual models, and theories. We envision the syllabus as a key foundational tool for teaching and learning the essence of the philosophic, conceptual, theoretical, and application knowledge of our discipline as a foundation for transforming health care and health care delivery.

The syllabus has been designed to address the Future of Nursing documents and various nursology organizations initiatives as well as accreditation criteria for nursology programs (such as the National League for Nursing accreditation criteria for all programs and the American Association of Colleges of Nursing criteria for undergraduate and for graduate programs).

A sample 15 week outline is provided to introduce nursology students to the history and contemporary status of the discipline of nursology and the value and approaches to nursology theory-guided practice, quality improvement projects, and research. Depending on program level, students will use, translate, and/or develop new knowledge in coming to know and engage individuals, families, and communities in the praxis of nursology and wellbecoming, as well as coming to know healthcare systems. The syllabus provides course objectives, suggested methods of instruction, course delivery methods, examples of recommended readings and resources, examples of learning activities, and a sample topical/content outline and course schedule.

We invite readers to post any questions or comments they may have about the syllabus and to recommend development of resources for any other nursology theory-related teaching needs that need to be addressed.

Reference

Fawcett, J. (2019, August 20). How to teach nursology: A new resource on nursology.net. Blog. https://nursology.net/2019/08/20/how-to-teach-nursology-a-new-resource-on-nursology-net/

Connotations of Research Speak: The Meaning of Words Used in Research Reports

Do we allow or invite people to participate in research? Do we refer to people who volunteer to be in a study as subjects or respondents or informants or participants or people?

This blog is about the language we use when we present or publish our research. The impetus for this blog was a colleague’s recent declaration that people were “allowed” to share their experiences of a health related condition for a study. The blog is a follow up to a previous blog that addressed the implication of power when using words such as compliance and adherence and, perhaps, even concordance (Fawcett, 2020), as well as another previous blog focused on diverse meanings of power (Fawcett et al., 2020).

Upon hearing my colleague state that people were “allowed,” I immediately thought: What is meant by indicating that a researcher “allows” people who volunteer to be in a study so to provide answers to the researcher’s questions in an interview format or via a numeric survey? Does stating that the researcher “allows” the people who volunteer for the study to do whatever the researcher wants them to do mean that the researcher holds power over them? Is a “power over” relationship appropriate for what many nursologists claim as a core value and approach to people, that is, “relationship-centered care?” (See Wyer, Alves Silva, Post, & Quinlan, 2014). Does “allowing” people to share experiences for the purposes of research connote “paternalism, coercion, and acquiescence” (Hess, 1996, p. 19), Should we instead “invite” people to share their experiences or answer our survey questions or accept our experimental interventions?

Although most, if not all, nursologists who conduct research no longer refer to the people who volunteer to be in their studies as “subjects,” these people continue to be referred to as “respondents,” the term frequently used when people respond to a numeric survey, or they continue to be referred to as “informants,” when they answer open-ended interview questions. Perhaps most frequently, the people are referred to as a sample or population of “participants.” Until very recently, I was content with referring to people who volunteered for research projects as “participants.” However, I have begun to think that if we nursologists truly value and support relationship-centered care, we should personalize those who volunteer for our research projects. For example, many of the people who have volunteered for my Roy Adaptation Model-guided program of research (Clarke & Fawcett, 2014; Tulman & Fawcett, 2003).) are women during the childbearing phase of life. Should I refer to these people as women rather than participants?

I invite readers to offer their ideas for words that are most compatible with nursologists’ values about our relationships with people who volunteer for our research projects.

References

Clarke, P.N., & Fawcett, J. (2014). Life as a nurse researcher. Nursing Science Quarterly, 27, 37-41.

Fawcett, J. (2020, March 17). What is Reflected in a Label about Health? Non-Nursology and Nursology Perspectives. Blog. https://nursology.net/2020/03/17/what-is-reflected-in-a-label-about-health-non-nursology-and-nursology-perspectives/

Fawcett, J., Shitaki, Y., Tanaka, K., Hashimoto, Y., Fujimoto, R., & Higashi, S. (2020, September 1). Meanings of power. Blog. https://nursology.net/2020/09/01/power-in-nursing/

Hess, J. D. (1996). The ethics of compliance: A dialectic. Advances in Nursing Science, 19(1), 18-27.

Tulman, L., & Fawcett, J. (2003). Women’s health during and after pregnancy: A theory-guided study of adaptation to change. Springer.

Wyer, P. C., Alves Silva, S., Post, S. G., & Quinlan, P. (2014). Relationship-centred care: antidote, guidepost or blind alley? The epistemology of 21st century health care. Journal of Evaluation in Clinical Practice, 20(6), 881–889. https://doi-org/10.1111/jep.12224

Primary Care, Primary Nursology, and the Attending Nursologist: Connections to Nursology Conceptual Models and Theories

Contributor (with Jacqueline Fawcett): Katherine Richman

This blog is meant as a follow up to Christine Platt’s (2020) blog, “A Nurse Practitioner’s Perspectives on Theory in Practice.” Ms. Platt’s mention of primary care led us to recall primary nursing. Primary care refers to the type of care offered by nursologists, typically nursologists who hold graduate degrees and who are considered nursologist practitioners (NPs), such as adult and gerontological NPs, family NPs, and psychiatric-mental health NPs.

Primary Nursology

Primary nursing, which we call primary nursology, refers to the way in which nursologists offer care. It is a care delivery model that was introduced in the 1960s, and is characterized by “accountability, advocacy, assertiveness, authority, autonomy, collaboration, continuity, communication, commitment, and coordination” (Watts & O’Leary, 1980, p. 90). In particular, the primary nursologist is responsible for one or more patients for the entire duration of hospitalization or other clinical setting. Tiedeman and Lookinland (2004) explained:

Each patient is assigned a specific primary [nursologist] based on patient needs and the [nursologist’s] abilities. The primary [nursologist] assumes 24-hour responsibility and accountability for assigned patients for the duration of their hospital [or other clinical setting] stay and has the responsibility and authority to assess, plan, organize, implement, coordinate, and evaluate care in collaboration with the patients and their families. The primary [nursologist] decides how care should be administered and personally administers it whenever possible. When the primary [nursologist] is not available to provide care, responsibility is delegated to an associate [nursologist] who cares for the patients following the care plans developed by the primary [nursologist] (p. 295).

A mid-October 2020 search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete) revealed that discussions of primary nursing (the search term used) rarely mention any conceptual or theoretical basis. An exception is Webb and Pontin’s (1997) report, in which they described their use of the Roper-Logan-Tierney Model of Nursing Based on Activities of Living as the conceptual model on which they based development of a primary nursology care plan audit tool. The audit revealed that “although [nursologists] claim to use a [nursology] framework to structure their care, this is not evident in the documentation” (Webb & Poutin, 1997, p. 399). Another exception is at the Dana-Farber Cancer Institute in Boston, Massachusetts, where the Synergy Model is used as the conceptual basis for practice, coupled with primary nursing for delivery of nursing care (A. Gross, personal communication, October 30, 2020).

A Reflection on Primary “Nursology”

I (KR) was fortunate to begin my professional career, in the mid-1980s, as a primary nurse on a closed adult psychiatric unit. We were a group of hospital diploma and community college graduates, primarily, mentored by a trio of ultra-competent, assertive, and kind nursing leaders. Our practice was not modeled on any specific conceptual framework. Instead, it was modeled on a commitment to strong interdisciplinary leadership and excellent, compassionate care. Like the attending nurses described by Niemela and colleagues (1992) at the UCLA Neuropsychiatric Institute and Hospital, we coordinated and oversaw the care of our primary patients from admission to discharge. We were, in effect, their case managers; in an era when stays were measured in weeks and even months, we convened cross-disciplinary staff conferences and followed up with multidisciplinary treatment plans. We carved out time in every shift to sit and talk with our patients. Each patient was assigned both a primary nurse and an associate nurse. Both roles were filled by the full-time staff nurses.

Our practice model was, to echo Niemela et al. (1992), a “cost-effective, clinically productive, and professionally attractive role,” in our case for clinicians with entry-level nursing credentials (p. 5). The clinical specialist who headed our team eventually pursued her doctorate, though tragically she did not live to complete her degree. Inspired by her memory and by her enduring example, I’m now pursuing my own nursing doctorate.

The Attending Nursologist

After recalling primary nursology, we recalled the attending nurse, to whom we refer as the attending nursologist. The attending nursologist is a variant of primary nursology. A very special feature of the attending nursologist is the explicit link to Johnson’s Behavioral System Model.

The idea of the attending nursologist is a care delivery model developed and implemented at the University of California-Los Angeles (UCLA) Neuropsychiatric Institute and Hospital in the early 1990s (Dee & Poster, 1995; Moreau, Poster, & Niemela, 1993; Niemela, Poster, & Moreau, 1992; V. Dee, personal communication, October 17, 2020). Fawcett and DeSando-Medaya (2013) explained:

The major focus of [the attending nursologist’s] role is clinical case management. Role responsibilities include direct patient care; delegation and monitoring of selected aspects of [nursology] care; provision of leadership, consultation, and guidance to [nursologists]; and collaboration with [multiple discipline] team members. Moreau and colleagues (1993) reported that the [attending nursologist initiative] was well received by the [nursologists] and members of the [multidisciplinary] team. Moreover, attending [nursologists] reported an increase in job satisfaction and retention and a decrease in role conflict [Moreau et al. 1993]. Neimela and colleagues (1992) reported that the attending [nursologist initiative] increased general satisfaction and role clarity and decreased role tension for the [nursologists], and increased their communication with patients’ family members (p. 71).

Dr. Vivien Dee graciously replied to my (JF) query about her experiences with development and implementation of the attending nurse (nursologist) model of care delivery. She explained that the Dee and Poster (1995)

article was written to show the process taken by a chief nurse to bring about change in the workplace, moving from the Primary Nursing Model to the Attending Nurse Model for the delivery of nursing care. The attending nurse would be responsible for the nursing care of designated patients (from admission to discharge) 24/7, in contrast to the primary nurse (shift-based). The Attending Nurse must be a Clinical Nurse Specialist (Masters- prepared), responsible for self-scheduling, and has the authority to prescribe care based on the scope of practice for independent functions based on the California Nurse Practice Act. [The Dee and Poster] article addresses the phases of change using the Kanter’s Theory of Innovative Change, and the role of the executive nurse leader in creating the change. (V. Dee, personal communication, October 17, 2020)

Referring to the authors of the Niemela et al. (1992) and the Moreau et al. (1993) articles, Dr. Dee noted that Niemela “was the clinical nurse specialist – who assumed the role of the Attending Nurse, [and] Moreau was the nurse manager on the unit where the innovation took place. Poster was the Director of Education and Research”. (V. Dee, personal communication, October 17, 2020). Dee was the chief nurse (and the first PhD prepared nurse executive within the UC Hospital system of five hospitals) who implemented the attending nurse practice delivery model (V. Dee, personal communication, November 5, 2020).

Dr. Dee explained,

“The Attending [Nurse] Model was in place throughout my tenure at UCLA-Neuropsychiatric Institute and Hospital (NPI&H). I retired from UCLA-NPI&H [in] 2005. I have never looked back and have not kept up to date if the system is still in place. I think that the DNP today could very well serve as the Attending Nurse (similar to the Attending Physician role). But we need an executive nurse (CNE) with a DNP/PhD to fearlessly lead and create structures that allow for the full scope of practice for nurses with better patient outcomes.” (V. Dee, personal communication, October 17, 2020)

Ditomassi (2012) explained that the attending nurse practice delivery model also has been used by staff at the Massachusetts General Hospital (MGH) in Boston. “[A]ttending nurses function as clinical leaders, managing the care of patients on a single unit from admission to discharge. The attending nurse interacts with the inter-disciplinary team, the patient, and the family to foster continuity, responsiveness, quality, safety, effectiveness, and efficiency . . . And attending nurses make a commitment to work five eight-hour days to promote continuity and relationship-based care” (Ditomassi, 2012, p. 8). Specifically,

“The attending nurse:
• facilitates care with the entire healthcare team. Is a consistent contact for patients, families, and the healthcare team throughout the patient’s care
• identifies and resolves barriers to promote seamless hand-overs, inter-disciplinary collaboration, and efficient patient throughput
• coordinates meetings for timely, clinical decision making and optimal hand-overs across the continuum of care
• ensures that the team and process of care sustain continuous, caring relationships with patients and families that may begin before admission and continue after discharge
• develops a comprehensive patient-care assessment and plan using the principles
of relationship-based care
• communicates with patients and families around the plan of care, answers questions, teaches and coaches
• develops and revises patient-care goals with the clinical team daily
• organizes team huddles that include the attending nurse and physician, staff nurses, house staff, and other disciplines
• serves as a role model for inter-disciplinary problem-solving
• meets with families on a continuous basis regarding the plan of care, disposition, goals of treatment, palliative care, and end-of-life issues” (Ditomassi, 2012, p. 8).

The conceptual and theoretical perspectives used in conjunction with the attending nurse practice delivery model at MGH include, as Ditomassi (2012) and D. Jones (personal communication, October 31, 2020), who is a faculty member at Boston College William F. Connell School of Nursing and director of the Yvonne L Munn Center for Nursing Research at MGH (Ives Erickson, Jones, & Ditomassi, 2013), indicated, relationship-based care, as well as Newman’s Theory of Health as Expanding Consciousness and Watson’s Human Caring Theory, as well as an instrument used to measure Barrett’s Theory of Power as Knowing Participation in Change (D. Jones, personal communication, October 31, 2020).

Ditomassi (2012) mentioned that the attending nurse practice delivery model also was being used at New York University and Baptist Hospital of Miami, Florida. An early November 2020 search of the CINAHL Complete database, however, yielded no relevant literature.

We welcome readers to add what they know about and/or have experienced within primary nursing and/or attending nurse practice delivery models and to refer us to other published and anecdotal accounts of these contemporary approaches to the delivery of nursologists’ practice delivery activities.

References

Dee, V., & Poster, E.C. (1995). Applying Kanter’s theory of innovative change: The transition from a primary to attending model of nursing care delivery. Journal of the American Psychiatric Nurses Association, 1(4), 112–119. http://doi.org/ 10.1177/107839039500100403

Ditomassi, M. (2012, November 1). The attending nurse role. Caring Headlines [Patient Care Services newsletter], 8-9. Massachusetts General Hospital. https://www.mghpcs.org/caring/Assets/documents/issues/2012/November_1_2012.pdf

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of conceptual models and theories (3rd ed.). F. A. Davis.

Ives Erickson, J., Jones, D., A., & Ditomassi, M. (2013). Fostering care at the bedside. Sigma Theta Tau.

Moreau, D., Poster, E.C., & Niemela, K. (1993). Implementing and evaluating an attending nurse model. Nursing Management, 24(6); 56–58, 60, 64.

Niemela, K., Poster, E.C., & Moreau, D. (1992). The attending nurse: A new role for the advanced clinician—Adolescent inpatient unit. Journal of Child and Adolescent Psychiatric and Mental Health Nursing, 5(3), 5–12. http://doi.org/ /10.1111/j.1744-6171.1992.tb00123.x

Tiedeman, M. E., & Lookinland, S. (2004). Traditional models of care delivery: What have be learned? Journal of Nursing Administration, 14(6), 291-297. https://doi.org/10.1097/00005110-200406000-00008

Watts, V., & O’Leary, J. (1980). The 10 components of primary nursing. Nursing Dimensions, 7(4), 90-95.

Webb, C., & Pontin, D. (1997). Evaluating the introduction of primary nursing: The use of a care plan audit. Journal of Clinical Nursing, 6(5), 395–401. https://doi.org/10.1111/j.1365-2702.1997.tb00333.x

About contributor Katherine Richman

Katherine is a first-year nursing PhD student at the University of Massachusetts Boston, focusing on health policy. She holds a BSN from the University of Illinois at Chicago and a PhD in theology from Boston College.

Power in Nursing

Power has been a concern to all living beings – humans and animals – since the beginning of time. Nursologists have been sensitive to power issues at least since Florence Nightingale’s time. It is likely, however, that power has different meanings for different people, including those who hold positions associated with power and those who regard themselves as subjected to power and may think they are powerless.

Very specific meanings of power are evident in a nursology theory developed by Elizabeth Barrett and a nursology theory developed by Peggy Chinn. Elizabeth Barrett developed the theory of power as knowing participation in change. This theory focuses on power-as-freedom, which contrasts with power-as-control. Barrett (2010) explained that power-as-freedom comes from and is associated with participating knowingly in life changes.

Peggy Chinn developed the theory of peace and power. This theory focuses on peace-power, which contrasts with power-over. Chinn (2018) explained, “This theory provides a framework for individuals and groups to shape their actions and interactions to promote health and well being for the group and for each individual, using processes based on values of cooperation and inclusion of all points of view in making decisions and in addressing conflicts.

My interpretation of these theories is that both emphasize power as a beneficial attribute that enables the individual or group to thrive and evolve, as opposed to power as a detrimental attribute that often prevents others from thriving and evolving. But what, I wondered, are meanings of power held by other nursologists?

St. Mary’s College Campus (from http://www.st-mary.ac.jp/about/)

Therefore, I invited graduate students at St. Mary’s College School of Nursing in Kurume, Japan, where I am a visiting professor, to share their meanings of power. I asked the students to respond to two questions:

  • How do you define power?
  • How does power affect what you think and do as a nursologist

The students’ responses are given here. I am indebted to Eric Fortin, who is a faculty member at St. Mary’s College School of Nursing, for translating the students’ responses from Japanese to English. (See notes below for more information about St. Mary’s College School of Nursing)

How do you define power?

Yukari Shitaki wrote: Power is generally defined as authority, motive power, energy, and so on. In nursing, I think that there are many things that are demonstrated through relationships among people, such as manpower, empowerment, and power augmentation, which improve technical skills and abilities. In addition, I think that the way people, whether individuals, groups, or society at large, perceive that power changes according to the situation at any particular time. Therefore, for me, power is defined as the force in the fellowship among people that produces synergistic effects and is further demonstrated through the interactions among them.

Kiyoko Tanaka wrote: We as nursologists work to maintain and promote human health, prevent health problems, create an environment that promotes health, and share and resolve issues related to the destruction of the natural environment and the deterioration of the social environment. In contrast, nursology is caring and has the power to realize and maintain a peaceful human society by fulfilling its role

Yoko Hashimoto wrote: In Japan, some nurses work in the government as licensed nurses and are involved in devising national policies. Many other nurses are involved with patients and local residents in hospitals and communities. Nurses see problems and other issues in their daily practice. Therefore, as nurses, we are working to improve the quality of nursing to solve these issues. I believe that nurses consider motivation and the ability to improve the quality of nursing to be power

Risa Fujimoto wrote: I think that nursologists’ power can be defined as action. As nursologists, everything should be done for the patient. It is very important to possess the ability to do something useful for people and to act on and realize what we want to do, including even little things. I also think that studying at graduate school may be the first step that will lead to having the power of a nursologist.

Saki Higashi wrote: The power of a nursologist for me is defined as the ability to constantly grow from the soul and to spread that around to others. I categorize power into three aspects. The first is the core, the second is influences absorbed from one’s surroundings, and the third is action. The core is latent and spiritual and includes one’s thoughts on nursing. The aspect of power that is absorbed from one’s surroundings is the power that can exert influence and that can be taken in from all external stimuli such as patients and other staff through one’s experiences of being a nursologist. Action is the aspect of power that derives from what has been cultivated up to now, including from the first and second aspects, and it works by giving back what has been absorbed from others through one’s practice and by diffusing one’s own power to those around us. Power is not always constant, but fluctuates; and power, although being influenced by others, also gives of itself and continues to grow.

How does power affect what you think and do as a nursologist?

Yukari Shitaki wrote: The reason I wanted to raise the level of my expertise was that I strongly believe in the importance of education. In my work environment as a perinatal nursologist, I encounter situations in which induced abortions are easily requested due to undesired, unexpected, or young pregnancies. One of the reasons for this involves the issue of sex education. I have thought about what I could do to change the consciousness of the women in these cases by inculcating in them the value of life and the desire to protect its dignity. It is difficult to face such a problem through one individual’s power alone, so it is necessary to first acquire the ability to judge the essence of one’s role as a professional and to think about what kind of method is possible to implement an action from an educational perspective. I also think it is possible to augment an individual’s power by utilizing the power of a larger group through fellowship with its members, and thereby be better able to put necessary actions into practice.

Kiyoko Tanaka wrote: As a pediatric nurse, I realize that the family is very important in child development. If families cannot fully understand children with developmental disabilities and cannot understand the characteristics of their own children, it will not be possible to support those children, and it will be difficult to expand their possibilities with adequate developmental support. It will also be difficult to improve their future health in connection with possible secondary disabilities. The risk of ruining a healthy life can also develop. Conversely, with regard to the mental health of parents, especially mothers, of children with developmental disabilities, feelings of difficulty in raising these c)hildren have led to depression and reduced self-esteem. Based on this situation, we, as nursologists have the power of specialized knowledge to offer counseling, guidance, and a positive nursing environment for children with developmental disabilities and their families in cooperation with related organizations such as prefectures, municipalities, hospitals, and schools. We can also provide information about services available for children with developmental disabilities and their families so that they can maintain, promote, recover from, and prevent illness. In addition, we believe that such support will promote the health of caregivers, promote a better understanding of children with developmental disabilities, and lead to their healthy development.

Yoko Hashimoto wrote: Japan has had a background of advanced medical care catering to the needs of an aging society having an increasingly long lifespan, and medical care is moving from the hospital to the home. However, there are few nurses who are practicing in the field of home nursing, so evidence in this field is weak and, therefore, has failed to lead to policies. In the future, it will be necessary to conduct research and establish evidence for issues arising from daily practice to provide high-quality nursing in response to social changes. It is difficult to act alone, so it is necessary to become involved with others and to work together. Through the power of nurses, nursing practice will be better visualized, which will hopefully allow it to occupy a more important position among government circles, thus leading to improved nursing and medical care.

Risa Fujimoto wrote: For nursologists, power is the ability to help people by being useful to them. In my clinical experience, I often wondered whether I could really help others or if there was something more I could do for them. Therefore, I decided to undertake graduate study with the goal of improving my knowledge level and nursologists’ practice skills. As a rehabilitation nurse, I want to become a nursologist with a wide range of knowledge and be involved in primary through tertiary stroke prevention. We can only become useful to people by taking action and practicing what we know. However, to take action, we cannot act entirely alone; we need the knowledge and skills of other nursologists. Personally, if I obtain enough knowledge in graduate school, I am confident that I will have to play a role in creating an opportunity for many nursologists to understand the value of nursology. So, I think that that would be one of my responsibilities as a nursologist. As a practitioner, I will keep in my heart and mind what I believe to be useful for people and will work to obtain knowledge and skills so that I can better perform the actions of a nursologist.

Saki Higashi wrote: Power influences my activities as a nursologist. In the future, by incorporating my experiences and various influences from the external environment and applying them to my nursology activities, I am confident that I will not only grow as a nursologist, but also expand my influence to people, regions, countries, and the world at large.

References

Barrett, E. (2010). Power as knowing participation in change: What’s new and what’s next. Nursing Science Quarterly, 23(1), 47-54. doi:10.1177/0894318409353797 

Chinn, P. L. (2018, August 23). Peace & Power. Retrieved from https://nursology.net/nurse-theorists-and-their-work/peace-power/

Chinn, P. L., & Falk-Rafael, A. R. (2015). Peace and power: A theory of emancipatory group process. Journal of Nursing Scholarship, 47, 62–69.

More about St. Mary”s College School of Nursing on Nursology.net

Who IS the First?

What is Real Nursing and Who Are Real Nurses? Perspectives from Japan