Say It Ain’t So:  Graduate Students Shade Nursing Theory!

Karen J. Foli, PhD, RN, FAAN

I’d finished grading the last of the master’s-level students’ theory in nursing papers. I’d turned in final grades and then, the message came through: anonymous student course evaluations were ready for my review. I took a long sip of water and put my organic, no preservative, granola bar aside.

Steady, old girl, I said to myself. You have tenure. How bad could they be? I’d done my very best in this hybrid-structured course. The graduate students met on campus about five times throughout the semester and the rest of the “class meetings” were virtual. I liked the hybrid structure as it offered the students a sense of community; yet the online component allowed them to be self-directed as adult learners. I tried to impart a rudimentary foundation of the philosophy of science, and used discourse that included logical positivism, epistemology and ontology. The course content included a deep dive into concept analysis, nursing theorists and the major health behavior theories and – I thought – many applications of nursing theory to practice decisions and interventions. Assignments were student-personalized, asking for them to express their own philosophies of nursing care, present on nursing theorists’ work, and take a stab at concept analysis or critique a published analysis.

Yet, here I sat, wanting to avoid the dreaded student evaluations. No delaying it any longer.  I logged into the student evaluation portal and winced as I read the polarized comments. Many were very complimentary: “Course well organized. Grading was clear with helpful comments given on papers.” A continuation of gratifying comments: “Didn’t think I’d like theory, but I did. Liked the examples. Related it to real life. Dr. Foli’s passion really came through and helped make the class enjoyable.”

Then, one student’s comments made me stop. “Too many readings. I didn’t read most of them. I had to take time away from studying for patho and that’s what a nurse practitioner needs to know.”

Flinging the granola bar into the trash (it tasted like sawdust anyway), I reached for the Little Debbie Valentine cake.

What??? I had practically done summersaults trying to get the practice-to-theory connection in this class. And then I paused to reflect on my audience: students enrolled to become primary care nurse practitioners. Many continued to work at the bedside in highly stressful jobs. They all had personal responsibilities, some of which overwhelmed them (an ill child, a sick mother).

When I spoke to the class at the beginning of the semester, I asked them a question that I didn’t need a public response to: “Are you running from something in your current job or running toward a goal of being a nurse practitioner?” Upon hearing this question, I always looked for the nonverbal responses: heads slightly turned down, eyes glancing sideways. Mouths in grimaces. The ones that seemed to embrace the new career path continued to look directly at me.

So I knew from the beginning of the semester this was a tough audience. These folks were frontline, point-of-service providers who had witnessed and experienced nurse-specific trauma on an ongoing basis. Sadly, for the majority of them, nursing theory meant little.

They were here in this first semester graduate class to learn the facts, just the facts. Or as Chinn and Kramer (2015) describe it: empirical knowledge. As advanced practice nurses, they would be tasked to diagnose, prescribe, recommend a treatment plan, and manage illnesses. They’d also engage with the patients to promote wellness and encourage disease prevention. What did theory have to do with all that?

Well, as I read the students’ comments, I wondered what more I could do to ensure they saw the connection between all the ways of knowing (Chinn & Kramer, 2015), how to apply middle-range theories to their practices, and use theory as an organizing framework to track efforts. I wanted them to see patients as dynamic individuals, not merely as objects that may or may not adhere to a treatment plan.

As I put the Little Debbie wrapper in the trashcan, I felt invigorated (it could have been the sugar rush). They may have thrown some shade at theory, but I pulled out the course syllabus, reviewed it, and made note of how I could continue to refine the course so that every student would see the value of theory in primary care. I did this because it’s so important for our profession. Nursing theory gives us identity, ways to increase nursing science/nursology and patient care practices. As the Year of the Nurse and Midwife, the timing couldn’t be better!

What about you?  If you have suggestions for me on how to strengthen the theory-to-primary care advanced practice connection in a master’s level course, please forward them in the comments below.

Or, better yet, go to Nursology’s Teaching/Learning Strategies (https://nursology.net/resources/teaching-strategies/) and complete the form to submit a strategy to strengthen the link between advanced practitioners’ theory-guided knowledge and nursing practice.

Thanks in advance for your help!

Nurse-Specific Trauma: Let’s Give It a Name

Welcome to Karen J. Foli, PhD, RN, FAAN who is joining the
Nursology.net blogging team! Karen is the author of the
Middle Range Theory of Nurses’-Psychological Trauma, the
Middle Range Theory of Parental Postadoption Depression
and co-author of the recently published book
The Influence of Psychological Trauma in Nursing

Karen J. Foli

When I was earning my PhD, my cognitive world opened up. I learned about how discourse not only reflects reality, it creates reality. In my estimation, The Influence of Psychological Trauma in Nursing allows us to see a reality that eluded us before. Decades later, I find my work in nurse-specific trauma reflecting truth and creating a reality that nurses experience, but couldn’t name. Therefore, their reality of it didn’t exist.

We often hear about compassion fatigue. Its etiology is linked with secondary or vicarious trauma, created by seeing others suffer and experience traumatic events. Conversations abound about how nurses need to be resilient and use resiliency as a buffer to mitigate secondary trauma and secondary traumatic stress. The issue of individual versus organizational culpability in nurse-specific trauma is one that is needed, and for another time…

In addition to secondary trauma, there are six additional nurse-specific and nurse-patient-specific traumas that I have named, described, and provided context for (Foli & Thompson, 2019): historical or intergenerational trauma; workplace violence, system-induced or medically induced trauma, second-victim trauma related to medical errors, trauma from disaster work, and insufficient resource trauma. This final type of trauma is one that I have recently coined based on a current study, the findings of which I will present at the upcoming American Academy of Nursing conference as an e-poster (Foli, 2019).

Insufficient resource trauma. Now that’s a new reality. Every single nurse I have spoken to quickly nods their head in affirming its existence. It’s the trauma that occurs when nurses do not have the knowledge/expertise, personnel, accessibility to other professionals, supplies, and tangible and intangible resources to fulfill their ethical, professional, and organizational responsibilities.

As a nurse… think of being placed in an unfamiliar patient situation with no one to call for help. Think of the shift you are working with an overload patient assignment and two of your patients “go bad.” Think of the phone incessantly ringing on your day off to come in because of short staffing and the guilt experienced because there is no way you can work another shift and be safe. Think of the medication that will be late because pharmacy made an error and the physician on call hasn’t answered the page and you need an answer stat. Think of going into a supply room for the dressing kit and the shelf is empty. But most of all, think of the patients’ call lights that go unanswered because there aren’t enough nurses to render care.

It’s not just a shortage of resources that cause insufficient resource trauma. It’s the push to do more in the time we have, including tackling the electronic health record and as we’ve known for years, sicker patients. In a recently published letter to the editor, “Decline of the American Nursing Profession,” Vignato (2019) describes the decreasing time spent with patients: “.. changes in our health care system are transitioning nurses away from a therapeutic relationship…With these time constraints, nurses are left to complete scripted tasks” (p. 255).

As a result, patients don’t obtain the care they need and deserve. The tendency to see them as tasks to do increases. Nurses leave the units at the end of their shifts feeling guilty, anxious, and isolated. It’s the stuff that kills our spirits.

A common metaphor used in understanding trauma, the iceberg, symbolizes the large mass of “stuff” that’s underneath what is visible. The proportion is such that what is above the water is a fraction of the frozen ice beneath the water’s surface. In the hidden, murky depths lies our processing of trauma, our feelings, needs, desires. Above the surface, for all to see are our behaviors that are born from trauma.

While I believe this metaphor is useful, I also assert that nurse-specific trauma, as events and habitual occurrences, are readily visible to others (Foli & Thompson, 2019). We have an audience watching most of our traumas day in and day out. But are we, our peers, our leaders paying attention?  Let’s give these traumas a name, let’s build reality, and then, let’s get to work on preventing what we can prevent and fixing what we can fix.

References

Foli, K. J. (Accepted; 2019). Nurses’ trauma: “They leave me lying awake at night.” E-poster. American Academy of Nurses 2019: Transforming Health, Driving Policy Conference, Washington, DC, October 24-26, 2019.

Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Indianapolis, Indiana: Sigma.

Vignato, J. (2019). Letter to the editor: Decline of the American nursing profession. Journal of the American Psychiatric Nurses Association, 25(4), 255-256. doi: 10.1177/1078390319826702