Guest Post: Restriction of Visits to Hospitalized Child? An Emerging Need for Theory-Informed Nursing Intervention during Pandemic

Contributor: Ana Filipa Paramos

In Portugal during the pandemic crisis, we have made it impossible for the family to be present during the child’s hospitalization, resulting in increased levels of separation anxiety and stress, with potential negative consequences for the child’s recovery process. Let’s talk about a specific case of a child with a prolonged hospital stay in the middle of a pandemic and unable to have his father visit during the hospitalization. The little boy was accompanied by his mother, but the family nucleus of this child includes his mother and father. Did they speak by cell phone? Yes, they did, but the physical presence and eye contact are not replaceable by a phone call. One afternoon of that long hospitalization, I found the child angry, crying and looking away from our approach, as if he almost blames us for the impossibility of the father being present during the hospitalization. I wondered how we could make this situation less stressful and anxious for the child.

The adoption of a humanistic approach through the use of the Humanistic Theory of Nursing proposed by Josephine Paterson and Loretta Zderad was needed. According to Paterson and Zderad (2007), nursing is seen as an experience lived among human beings that responds to a human need. This theory requires the recognition of the human being as a unique being, endowed with his singularity and, simultaneously, that there is an understanding of the individual characteristics, experiences and needs of each patient (Paterson & Zderad, 2007). Through the dialogue established between me and the child, I understood that his father’s visit was extremely important for the child, since he had a very strong connection with the father.

During our dialogue, there were tears, uncontrollable tears in the child’s eyes. Unable to allow the father’s entry, I asked myself, “How will I be able to respond to this child’s needs?” It was at that precise moment that we decided to place the child’s bed next to the window, allowing the child to establish eye contact with his father, that long awaited and desired eye contact. Immediately after the father’s visualization, a smile and happiness emerged in the child. This contact allowed the immediate decrease in the levels of separation anxiety experienced by the child.

© 2021 Ana Filipa Paramos
Child’s bed next to the window, allowing the child to establish eye contact with his father

in Humanistic Nursing Theory, the concept of nursing does not only address patients’ wellbeing but also patients’ better being, helping them to make the health/disease situation experience as human as possible (Paterson & Zderad, 2007). We must remember that each patient is a person with needs, anxieties, fears and desires that have to be met, regardless of whether we are in the middle of a pandemic or not. We have to try to make the hospitalization experience as less stressful and as comfortable as possible for the patient and, in this case, the father’s visit was an emerging need of this child. Not being a normal visit, the establishment of eye contact through the window was the closest it could be, and it brought immediate happiness to the child. I heard the word “thank you” associated with a look of tenderness and tranquility. Unable to show my smile behind the mask, my eyes shone, and a tear appeared in the corner of my eye, such was the happiness I also experienced at the moment. My experience with the child was an enriching moment for both of us and allowed us both to develop, becoming more and better, of that I have no doubt. We cannot forget that times are difficult and challenging for everyone, but the experiences lived with the patients cannot be put aside in our daily nursing practice.

References

Kleiman, S. (2010). Josephine Paterson and Loretta Zderad’s Humanistic Nursing Theory. In M.E. Parker & M. C. Smith (Eds.), Nursing Theories and Nursing Practice (3rd ed, pp. 337–350). Philadelphia: F.A. Davis Company.

Paterson, J., & Zderad, L. (2007). Humanistic Nursing. http://www.gutenberg.org/ebooks/25020

Wolf, Z. R., & Bailey, D. N. (2013). Paterson and Zderad’s Humanistic Nursing Theory: Concepts and Applications. International Journal of Human Caring, 17(4), 60–73. https://doi.org/10.20467/1091-5710.17.4.60

About Ana Filipa Paramos

I have finished my Nursing Degree in 2016, at Escola Superior de Enfermagem de Lisboa (ESEL). In 2016, I started working as a general nurse at Centro Hospitalar Lisboa Central, more specifically at Hospital Dona Estefânia. From 2016 to 2019 I worked at the pediatric surgery/ pediatric burn unit and in the beginning of the pandemic, I have integrated the pediatric respiratory unit/ COVID, where I currently am.

In 2020 I entered the Master Nursing Course of the Health Sciences Institute of Universidade Católica Portuguesa (Lisbon). This post was made in the nursing theories curricular unit, with the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).

Guest post: The privilege of agency: The political shortcomings of nursing theory

Contributor: Mike Taylor

The four metaparadigm concepts of nursing knowledge have been human beings, environment, health and nursing process; with the state of the person at the center of the definition and achievement of health goals. The idea that an individual has the wherewithal, not only in name but also but also in action, to determine what health means for them as an individual and is able to work to accomplish those same goals is the concept of agency. Among nursing’s most referenced conceptual models and theories — Orem, Parse, Newman and Roy — keep the focus of nursing’s work on the individual before us, and much less of a consideration is on the environment the person inhabits. Newman (1979) for example states that the goal of nursing “is to assist people to utilize the power that is within them as they evolve toward higher levels of consciousness” (p. 67)  The concept of individual agency is central even in theories about the praxis of nursing such as Watson’s theory of human caring where the nurse/patient dyad “is influenced by the caring consciousness and intentionality of the nurse as she or he enters into the life space … of another person. It implies a focus on the uniqueness of self and other…” (https://www.watsoncaringscience.org/jean-bio/caring-science-theory/)

Sourcehttps://www.coe.int/en/web/interculturalcities/systemic-discrimination

Agency is not something that is naturally given to a person but emerges from the process of human development. That process is frequently affected  by poor schools, environmental pollution, and the other mediators of institutional racism and poverty. The chances of an individual reaching full agency, meaning the ability to identify and actualize individual health goals,  in adulthood are much more likely when those limiting factors are not present due to privilege. Even when an individual is able to overcome early life challenges, the social environment where agency can be exercised, there are limits on who can participate based on class, race, and gender. These limitations on the exercise of agency extend to persons who either want to or are actively practicing the profession of nursing. Even when a person can overcome the intersecting influence of race, poverty and gender to become a nurse; the same barriers remain in the practice environment often limiting choice of practice arena and opportunities for advancement to leadership roles.

Nursing theory is right to place individual agency at the center of the health improvement process, but it does not address the uneven distribution of that agency and the effect that has on health. Agency is only possible where it is allowed and when individuals in disadvantaged communities  do not have the inability to develop or exercise agency, the disparities in health outcomes we see today are the result. For nursing theory to meet these health challenges it must develop beyond a focus on individual agency to an emphasis on the social and environmental conditions that limit health improvement which means challenging institutional racism and poverty among others.

To develop the concept of agency in nursing and challenge existing social barriers, I believe that it would be instructive to align the development and exercise of agency with concepts of intersectionality. An important question might be can any correlation be found between the intersectionality and the degree of effective agency as reflected in an individual’s agency and the available social environments where that agency can be exercised. My anticipation is that it would be an inverse correlation with effective agency decreasing as the number of overlapping disadvantages increase. 

Sources

Newman, M., (1979). Theory development in nursing. F.A. Davis. https://openlibrary.org/books/OL4409082M/Theory_development_in_nursing 

Caring Science & Human Caring Theory, Transpersonal Caring and the Caring Moment Defined https://www.watsoncaringscience.org/jean-bio/caring-science-theory/

About William (Mike) Taylor

Mike Taylor is an independent nursing theorist specializing in the application of complexity science to health and compassion. His Unified Theory of Meaning Emergence takes a major stride in connecting the mathematics of complexity with self-transcendence and compassion. He has spoken at international, national and regional conferences on complexity in nursing, health, and business. He is a member of the board of the Plexus Institute where he is the lead designer of the Commons Project, a web based platform for rapid social evolution in climate change.

Launch of BILNOC Leaders Database

We are delighted to launch a database that provides information about Black, Indigenous, Latina/x and other Nurses of Color (BILNOCs) who are (or have been) leaders and scholars who have contributed to the development of the discipline. This will be a significant resource for scholars and students who seek to recognize and honor BILNOC leaders. This database will fill a huge gap that contributes to the underrecognition of the contributions of nurses of color to the discipline.

View the BILNOC Submission Form to review the information we are seeking. You can find a link to the this form from the website “Resources” menu anytime later.

Guest Post: Allies and Advocates – Transforming Cultural Competence

Contributors: Jennifer Weitzel, Jeneile Luebke,
Linda Wesp, Maria Del Carmen Graf, Ashley Ruiz,
Anne Dressel, & Lucy Mkandawire-Valhmu

The murder of George Floyd and Breonna Taylor has prompted a wake-up call to reflect on the pervasive issue of structural racism.  As a nation created through histories of colonization and slavery, these murders—among countless others—have acted as a catalyst for American society to recognize and act to disrupt continued legacies of racism embedded into the fabric of American society1.  As nurses, as a part of this society (and thus a reflection of society) it is incumbent upon the nursing profession to take a stark look at the ways in which the legacy of structural racism has continued to inform nursing practice, education, and research.  Doing so speaks towards the nursing professions commitment towards supporting best health outcomes for everyone.  As the most trusted profession, and largest healthcare profession, such allyship not only recognizes this issue, but acts to decolonize discourses, and provides explicit attention to the impact that racism holds on health outcomes.  Such measures call to realize the reality that racism is a health issue, that must no longer remain on the periphery of nursing education, research, and practice in the U.S. (see https://nursology.net/2020/01/14/decolonizing-nursing/ ) .

Source

Nursing as a science, has historically been constructed from a positivist and Eurocentric framework that serves to sustain the domination of “whiteness as a form of disciplinary power.”2(p.196)  Cultural competence is often the primary concept used to guide the nursing profession in addressing the needs of diverse populations locally and globally.3 The principles of cultural competence are heavily influenced by the social and political history of the U.S.4 Practicing with cultural competence is tainted with the effects of racial bias, as this concept fails to recognize how perceived “cultural differences” are code for modern-day racist ideologies dating back to colonialism.6 Therefore, what is often believed to be cultural knowledge is rooted in White, European worldviews and codified into healthcare practices based on faulty interpretations and observations of “Othering”. 

Calls have been put forth for nursing transform these harmful approaches to cultural competency using emancipatory knowledge development and critical theory. Although nursing has been heavily impacted by the hegemonic ideologies of the biomedical model, we have also pioneered ways of knowing that disrupt oppressive knowledge paradigms.   The very institutionalization of competence within the medical field was one way for healthcare providers to establish a standard of expertise. This was key to the professionalization of many disciplines informed by the biomedical model, which focuses primarily on biological factors of health and excludes psychological, environmental, and social influences.Because of the societal value placed on our education and our expertise (cultural competence), nurses enjoy a position of power in Western models of health care. Operating blindly within the hierarchies of power existent in the Western, biomedical model of health leads to running the risk of de-contextualizing the care we provide. For example, Ilowite, Cronin, Kang, and Mack found that parents of children with cancer, regardless of race and ethnicity, wanted detailed information regarding their child’s prognosis.7 However, the researchers also found that physicians provided less information to Black and Hispanic parents than to White parents. This is an example of how healthcare providers exert power by deciding what information to share with patients based on perceived cultural norms and implicit bias.

Most individuals entering the healthcare field espouse a belief that they need to deliver care with impartiality.  However, without a sufficient understanding of the machinations of racism in everyday society, the ways in which racism are perpetuated in the healthcare system will remain a blind spot.6 In attempting to provide care regardless of race or ethnic background, we might overcompensate (“I don’t see color”) and subsequently fail to see how social determinants of health, including racism, affect our patient’s opportunities to achieve and maintain optimal health. 6

Practicing with cultural competence is predicated on the nurse’s ability to learn and understand cultures other than their own  to predict health behaviors and ultimately health outcomes.7 When these predictions drive how care is delivered, the complexities of how individuals, families, and communities make decisions about life, illness, and death become reduced to single narratives and stereotypes.9 By many of our textbooks and NCLEX review materials still provide content based on assumptions and broad categorizations. These assumptions often boil down to ideas such as the belief that because of their race or ethnicity, people share static traits, values, and beliefs, racial categories are legitimized as objective truths, when in reality, these categories are social constructions shaped by history and politics.

It is fundamentally impossible for nurses to provide culturally competent care under the premise that knowledge is based on these singular narratives, beliefs, and stereotypes. We must be open to the use of new frameworks that underpin the delivery of nursing care to meet the needs of diverse populations.  These frameworks derive from epistemologies that challenge Western hegemonic knowledge, how it is produced and who produces it.  For example, cultural safety is a concept originating from indigenous Maori New Zealanders that calls on nurses to engage in ongoing self-reflection about issues of power and privilege. Intersectionality theory, rooted in Black feminist thought, requires an understanding that people identify in a myriad of ways that are fluid and interactive.  These identities, some of which are self-ascribed, and others are socially ascribed, form matrices that confer or deny power. Legal scholars introduced Critical Race Theory (CRT) drawing from critical legal and civil rights scholarship.  CRT is underpinned by the following assumptions:

1.  Race is a social construct with no basis in science.

2. White supremacy does not exist on the fringes of society but is embedded in the everyday order of U.S. life.

3.  The voices of those experiencing racism are essential to knowledge development.

4.  The notion of ‘colorblindness’ is a detour that allows White people to absolve themselves of racial biases and deny the oppressive realities of structural racism.

These are a few of the concepts and frameworks that could inform nursing science and ultimately our practice. Why are we interested in theories from other disciplines? How might we develop nursology discipline specific knowledge that addresses the issues?  In the midst of the world witnessing the murder of George Floyd by police officers, the COVID-19 pandemic continues unabated with its current epicenter in the U.S.  In urban metropolitan areas, we have watched how centuries of disinvestment in Black and Brown communities and systematic oppression has led to health disparities that are also manifesting clearly in this pandemic in disproportionate morbidity and mortality of Black and Brown peoples.  Ethnic minority populations are at greater risk for contracting Covid-19, or experiencing severe COVID related illnesses.10  According to the CDC’s report on COVID-19 in the Racial and Ethnic Minority Groups, cases of COVID-19 are highest among American Indian persons, and hospitalization rates for COVID-19 related illness are highest among Latinos, American Indians, followed by Black persons.10  Since Covid-19 was first reported on the Navajo Nation in mid-March, infection rates per capita have soared to the highest in the country compared with any individual state.11   The COVID-19 pandemic thus only exacerbates the challenges that ethnic minority communities already face, particularly American Indians who already experience disproportionate disparities in health outcomes.

The time for nurses to act is now, not just in the care of people and communities that are most marginalized, but to address the very root of marginalization and oppression through a practice of critical reflection on our own profession: which of our theories need to be contested because they are rooted in colonist and white supremacist ideologies?  How can we embrace of innovative ways of theorizing, through meaningful and intentional care that results from a critical and reflective analysis of the realities going on around us and our role as a profession in fostering lasting change? We leave you with these questions and call upon you as fellow allies and advocates on the path towards health equity and social justice.  When we discuss racism, should we not include all races and ethnicities?

Sources

  1. Paradies Y. Colonisation, racism and indigenous health. J.Popul. Res. 2016; 33(1):83-96.
  2. Puzan E. The unbearable whiteness of being (in nursing). Nurs Inq. 2003; 10(3):193-200.
  3. Rajaram SS. Bockrath S. Cultural competence: New conceptual insights into its limits and potential for addressing health disparities. J Health Dispar Res Prac. 2014; 7(5):82-89.
  4. Kirmayer LJ. Rethinking cultural competence. Transcult Psychiatry. 2012; 49(2). 149-164. doi.org/10.1177/1363461512444673
  5. Wesp, L. M., Scheer, V., Ruiz, A., Walker, K., Weitzel, J., Shaw, L., . . . Mkandawire-Valhmu, L. An Emancipatory Approach to Cultural Competency: The Application of Critical Race, Postcolonial, and Intersectionality Theories. Advances in Nursing Science, ePub Ahead of Print. 2018.  doi:10.1097/ans.0000000000000230
  6. Hester, RJ. The promise and paradox of cultural competence. HEC forum. 2012;24(4):279-291. doi.org/10.1007/s10730-012-9200-2.
  7. Ilowite MF. Cronin AM. Kang TI. & Mack JW. Disparities in prognosis communication among parents of children with cancer: The impact of race and ethnicity. Cancer. 2017; 123(20): 3995-4003.
  8. Brascoupé S. Waters C. Cultural safety: Exploring the applicability of the concept of cultural safety to Aboriginal health and community wellness. Int J Indig Health; 2009; 5(2):6-41.
  9. Carter C. Lapum J. Lavallée L. Schindel ML & Restoule JP (2017). Urban First Nations Men: Narratives of Positive Identity and Implications for Culturally Safe Care. J Transcult Nurs. 2017; 28(5):445-454.
  10. Centers for Disease Control (CDC).  COVID-19 Racial and Ethnic Health Disparities. 10 December 20.  Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/increased-risk-illness.html
  11. Cheetham, J. Navajo Nation: The people battling America’s worst coronavirus outbreak.  BBC News.  15 June 2020.  Retrieved from: https://www.bbc.com/news/world-us-canada-52941984

Note: this post is based on the ANS article published in the spring of 2020 – Weitzel, J., Luebke, J., Wesp, L., Graf, M. D. C., Ruiz, A., Dressel, A., & Mkandawire-Valhmu, L. (2020). The Role of Nurses as Allies Against Racism and Discrimination: An Analysis of Key Resistance Movements of Our Time. ANS. Advances in Nursing Science, 43(2), 102–113. https://doi.org/10.1097/ANS.0000000000000290

L-R: Jennifer Weitzel, Jeneile Luebke, Linda Wesp, Maria Del Carmen Graf, Ashley Ruiz, Anne Dressel, Lucy Mkandawire-Valhmu

Jennifer Weitzel, MS, RN is a doctoral student and public health nurse with Public Health Madison & Dane County. Her research examines the use of cultural safety in the delivery of humanitarian nursing in Haiti

Jeneile Luebke, PhD, RN is a post-doctoral nurse research fellow at University of Wisconsin-Madison. Her area of research and expertise include violence in the lives of American Indian women and girls, and utilization and application of postcolonial and indigenous feminist methodologies.

Linda Wesp, PhD, FNP, APNP, RN is a Clinical Assistant Professor at University of Wisconsin-Milwaukee in the College of Nursing and Zilber School of Public Health, with a focus on health equity, participatory research, and critical theories. She also works as a family nurse practitioner and HIV Specialist at Health Connections, Inc. in Glendale, WI

Maria del Carmen Graf, MSN, RN, CTN-A, is a PhD candidate at UW-Milwaukee. Her research area includes studying the mental health needs within vulnerable populations with an emphasis on the Latina population and women of color in the US using a Postcolonial Feminist approach.

Ashley Ruiz RN, BSN, is a doctoral nursing student and clinical instructor at the University of Wisconsin-Milwaukee, as well as a Sexual Assault Nurse Examiner (SANE). Her current work focuses on advancing feminist theory in nursing science for the purposes of providing a theoretical foundation for addressing the problem of violence against women. Such advances inform Ashley’s research, which seeks to identify and develop nursing interventions that are tailored towards the unique needs of Black women that disclose sexual assault and seek healthcare services

Anne Dressel, PhD, CFPH, MLIS, MA, is an Assistant Professor in the College of Nursing at the University of Wisconsin-Milwaukee, where she also serves as Director of the Center for Global Health Equity

Lucy Mkandawire-Valhmu, PhD, RN is Associate Professor in the College of Nursing at University of Wisconsin-Milwaukee (UWM). Her research focuses on violence in the lives of Black and American Indian women. As a feminist scholar, she seeks to creatively identify interdisciplinary interventions and to inform policy that centers the voices of women in addressing gender-based violence. Dr. Mkandawire-Valhmu also seeks to contribute to the development of feminist theory that would help to advance nursing science.

Guest Post – Nursing’s call to action to address the social determinants of health

Guest contributors:
Kelli DePriest, PhD, RN
Paul Kuehnert, DNP, RN, FAAN 
Teddie Potter, PhD, RN, FAAN

Recently, several Expert Panels of the American Academy of Nursing collaborated to draft a new conceptual framework and consensus statement related to social determinants of health. The year-long endeavor integrated the thoughts and expertise of 15 nursing leaders. The outcome of our work directs nursing actions toward health policies supporting actions at multiple levels (i.e., upstream, midstream, and downstream) to promote equity in planetary health-related quality of life. We propose that planetary health-related quality of life, individual and population factors, and environments are the overarching societal contexts in which population health concerns arise. These population health concerns are articulated by stakeholders who, in turn, are the catalyst for population-focused nursing actions.

These population-focused nursing actions occur at multiple levels, in a variety of settings with a variety of persons and groups, and shape health policies, systems and services. Over time, the actions and interactions depicted by the cycle change the societal contexts and may lead to enhanced planetary health-related quality of life. We underscore the crucial need to eliminate systemic and structural racism if equity in planetary health-related quality of life is to be attained. We presented our findings and implications for action during a policy dialogue at the American Academy of Nursing Policy Conference in October 2020. Collaboration on this project inspired the following call-to-action.

Call to Action

Nurses are consistently ranked the most trusted profession by the American people. This trust is earned by the demonstration of care for people, day in and day out, in a wide variety of settings. It is time for all nurses do something to address the social determinants of health. We propose three concrete approaches.

The first two approaches can be summarized as praxis. According to Paulo Freire in Pedagogy of the Oppressed (1972), praxis is reflection and action on the world  to transform it.  

Reflection, the first approach, is often overlooked in calls for action. Yet we need to take a moment to reflect on what we mean by social determinants of health and what nursing actions in this space will help us achieve health equity. The consensus makes clear that equity cannot be achieved at any level (local, national, or global) until all forms of structural racism are eliminated. Eliminating structural racism should be a shared goal for all nurses.

We have work to do around structural racism in nursing. Nursologists are starting this type of reflection and discussion through nursology.net. (see https://nursology.net/about/nursology-management-team-statement-on-racism/). These conversations need to occur wherever we live and work, in the classroom, in the community, on social media, and with colleagues inside and outside of nursing. The consensus paper can be used to spark reflection and prompt discussions to support action.

Take action on social determinants to create transformative change is the second recommended approach. Action differs depending on our role. The consensus paper draws on the conceptual framework to provide several examples of population-focused nursologists’ actions to address policy issues. The common themes from the examples are that nursologists need to have a seat at the table when all policies are developed, using a Health in All Policies approach, which  includes policymaking across sectors, not only  those policies directly related to health, and nursologists need to advocate for policies that have been shown to effectively advance health equity.

Black, Indigenous, and Hispanic people in this country are experiencing disproportionately high rates of illness and death from the COVID-19 pandemic. To address this syndemic (Poteat, Millett, Nelson, & Beyrer, 2020), we need to address the structural racism at the root cause of these disparities. Who better to forge the path forward, than this group of nursology  leaders? It is time to move to action.

Inspire action on the environment and social determinants of health is the third approach. Another population-focused nursologists’ action from the conceptual framework posits that nursologists must build coalitions to be successful in this work. Others need to be inspired to join the effort. If nursologists are unsure of how to inspire, or lack inspiration themselves, they can read a few blog posts on nursology.net or nursesdrawdown.org for examples. Nursologists can also go to #nursetwitter where there are conversations about nursologists addressing the social determinants of health along with reflection and discussion on how to dismantle structural racism within nursology. Nursologists  can also be inspired by leaders who advocate for nursology by serving on boards, writing op-eds, acting as expert sources for the media, reaching out to legislators, and/or running for office themselves. Inspiration comes in many forms. There is an energy and passion required to do this work and if you have the capacity, please help inspire others to join the movement.

We leave you with the call-to-action to reflect, act, and inspire. We look forward to continuing this conversation.

References

Freire, P. (1972). Pedagogy of the oppressed. Herder and Herder.

Poteat, T., Millett, G. A., Nelson, L. E., & Beyrer, C. (2020). Understanding COVID-19 risks and vulnerabilities among black communities in America: the lethal force of syndemics. Annals of Epidemiology47, 1–3. https://doi.org/10.1016/j.annepidem.2020.05.004

About the contributors;

The authors are writing as nursology colleagues who have worked together through the Environmental and Public Health Expert Panel at the American Academy of Nursing (AAN). Paul and Teddie are the past and current chair of the expert panel and fellows of AAN and Kelli worked with the expert panel through the AAN Jonas Policy Scholars Fellowship program.

Kelli DePriest, PhD, RN

Dr. DePriest is a health policy and research fellow at the Institute for Medicaid Innovation and adjunct faculty at the Johns Hopkins University School of Nursing. Her research mission is to investigate strategies to leverage innovation in the Medicaid program to improve and/or inform the development of interventions and policies designed to achieve health equity for children and families living in poverty. Twitter: @kellidepriest

Paul Kuehnert, DNP, RN, FAAN

Dr. Paul Kuehnert is President and CEO of the Public Health Accreditation Board, the national non-profit organization that sets standards for and accredits governmental public health departments in the United States. Dr. Kuehnert’s career spans nearly 30 years of providing executive leadership to private and governmental organizations to build and improve systems to address complex community health needs. Dr. Kuehnert is a pediatric nurse practitioner and holds the Doctor of Nursing Practice in executive leadership as well as the Master of Science in public health nursing degrees from University of Illinois at Chicago. He was named a Robert Wood Johnson Foundation Executive Nurse Fellow in 2004, a Fellow in the National Academies of Practice in 2010, and a Fellow in the American Academy of Nursing in 2015. Twitter: @PaulKuehnert

Teddie Potter PhD, RN, FAAN

Saintelmophotography.com

Dr. Potter is Clinical Professor, specialty coordinator of the Doctor of Nursing Practice in Health Innovation and Leadership, and Director of Planetary Health for the University of Minnesota School of Nursing.

Be careful what you wish for…

2020 was the year that… “Be careful what you wish for,” once again became imprinted in my brain as truth.

In early 2019, the World Health Organization (WHO) announced that 2020 would be the “International Year of the Nurse and Nurse Midwife.” Among colleagues, there was lots of excitement about this. What would we do to recognize and celebrate this recognition? I heard many ideas—editorials, articles, museum displays, seminars, webinars—maybe we’d even get a stamp! The last time we had a commemorative nurse stamp in the US was 1961, almost 60 years ago. Seems like we were overdue for one.

And then, two months into our memorable year, COVID-19 hit. The world started locking down before the US, but for me, my unforgettable day was March 13 (a Friday, of course) when a symptomatic friend tested positive for the virus. Suddenly, everything changed. We all went into lockdown and remote work became the norm. I tried to figure out how to run a free clinic by phone and email (believe me, it’s not easy). I experienced two weeks of panic, followed by three months of bewilderment, and then settled in for the long haul, which is still ongoing.

Meanwhile, nurses were everywhere. The evening news was flooded with images of nurses in ICUs, EDs, nursing homes, and more. There were interviews with nurses crying, their faces bruised from their PPE googles, mourning their dying and dead patients, wondering if they could have done more. They worried about having enough PPE, their families, and their own health. At the same time, we were celebrated with impromptu parades, celebrations, signs on the street: “Heroes Work Here!”. I was offered a 50% discount at the car wash, but I declined. I figured that as a small business, they needed the money more than I needed a modest saving on washing my car.

We even got a TV show, creatively named NURSES with this tantalizing description: “The series follows five young nurses working on the frontlines of St. Mary’s hospital dedicating their lives to helping others, while figuring out how to help themselves.” Will those nurses be nursologists? Time will tell.

On the other side of the coin, the virus was taking its toll in multiple ways. As of the end of October 2020, the WHO presented an analysis that 1500 nurses worldwide had died of COVID-19, although they admitted that this figure was probably grossly underestimated. The White House put together a coronavirus task force in January that included (according to the New York Times) “internationally known AIDS experts; a former drug executive; infectious disease doctors; and the former attorney general of Virginia” but no nurses. President-elect Biden also put together a task force that seemed more diverse but once again, nurses are conspicuously absent from the membership. At a meeting of nurses in the Oval Office to commemorate National Nurses Day in May, Sophia Thomas, President of the American Association of Nurse Practitioners was rebuked by Donald Trump when she stated that there was sporadic access to PPE throughout the US. “Sporadic for you, but not sporadic for a lot of people,” Trump said. “Because I’ve heard the opposite. I have heard that they are loaded up with PPE now.” Thomas was bullied into politely agreeing and backing down from her original statement. This is not the first time I’ve seen this happen, and it makes me angry every time.

Where is the correct middle ground? Do we want to be “angels,” “heroes,” and members of the “most trusted profession” (according to Gallup, 15 years and running)? Or do we want to be nurses at the table, nurses setting policy, nurses seen as leaders, decision makers, and agents of transformation through research, practice, and education? In other words, nursologists? 2020, our “year” gave us lots of the former, not so much of the latter. And thus I say, “Be careful what you wish for.” I worry that our year of recognition will ultimately reinforce stereotypes and not result in meaningful change. To those in our ranks who have sacrificed their lives, and to others who are dealing with ongoing health issues from COVID-19, both direct and indirect, I hope that is not the case. Maybe with the spotlight off, we can get back to business and work to make incremental, but lasting change, which seems to be what nurses do best. That is my wish for 2021—but I’ll be honest—I would still like a stamp!

Letter to the ANA

On September 26, 2020, the Nursology.net management team sent the following letter to the American Nursses Association, urging the organization to take a stand on the U.S. Presidential election candidates. We believe that given the dual pandemic of COVID-19 and racism, nursing’s strong voice of advocacy for the health of the nation must be heard. Here is the letter in its entirety:

September 26, 2020
Dr. Loressa Cole, ANA Enterprise CEO
Dr. Ernest J. Grant, President, ANA President
Dr. Debbie Hatmaker, Chief Nursing Officer, ANA Enterprise
American Nurses Association

Dear Drs. Cole, Grant and Hatmaker:


The Management Team of Nursology.net is writing to urge the American Nurses Association (ANA) to reverse its position against endorsing any candidate for President/Vice President in the 2020 election. We understand that the ANA reversed its previous policy to endorse presidential candidates based on the desire to “engage nurses in the voting process through providing accurate information and data and promoting nursing’s political advocacy role without alienating an entire contingency…acknowledging the reality of political polarization in this country” (ANA 2019 Membership Assembly Consideration of ANA’s Presidential Endorsement Process).

The recent draft of the document, Nursing’s Scope and Standards (2020), specifies nursing’s social contract with the public. The document includes nursing’s commitment to reject racism and promote equity and social justice for all. In addition, the document points to nursing’s accountability and responsibility to promote the health of all populations and to advocate for social and environmental justice, and access to high quality and equitable health care.

The proposed ANA Scope and Standards contradicts the ANA position against endorsing a presidential candidate if a particular candidate is a threat to equity, social justice, equitable healthcare and health for the population. While we respect that the Board made their decision thoughtfully, the current situation calls for a reconsideration based on the positions of the current administration that threaten public health. Scientific American, a journal who has never endorsed a candidate for president, has broken with their policy because of the dangerous anti-science views of the President

Today, the country needs to hear nursing’s voice related to this election from the ANA. We find ourselves in the midst of a perfect storm fueled by the mismanagement of a global pandemic, a health and environmental crisis from rampant fires, storms and floods attributed by scientists to climate change, and the public health crisis of systemic racism.

Many have referred to this election as the most consequential in recent history, certainly in our lifetimes. This is not the time for the nursing profession to sit out and fail to exercise our unified voice and moral authority. As the discipline focused on caring for the health and well-being of the people with an understanding of how the physical, social, political and economic environment influences health and well-being, and as the most trusted profession, the ANA must speak out against the policies of the current administration and endorse Joe Biden and Kamala Harris for President and Vice President. Please reconsider your position based on the actions taken by President Trump after your vote in 2019.

Here are a few reasons why we urge the ANA to reconsider and endorse the presidential ticket that is aligned with nursing values and actions and protects the public health:

  • The current administration’s lack of leadership to enact policies to stem the rising incidence of COVID-19 infections, including the President’s lack of providing timely information to the public that could have prevented thousands of infections and death
  • The current administration’s policies that have threatened accessibility to healthcare for millions of Americans by working to overturn the advances made through the ACA
  • The current administration’s position that denies human contributions to climate change and fails to support policies to abate its dangers.
  • The current administration’s lack of acknowledgement of the racial injustices experienced by people of color, especially Black people, at the hands of law enforcement.
  • The current administration’s policies of family separation at the border resulting in hundreds of children being placed in inhumane and dangerous conditions to their health and well-being.
  • The current administration’s lack of meaningful responsiveness to address the public health crisis of gun violence.

While the recommendations of the ANA’s Presidential Endorsement Process (2019) advocate for individual nurses to participate in election activities at the local, state and national levels and take advantage of educational opportunities to learn about the candidates that will inform their voting, nurses will look to the ANA for leadership, especially now. The ANA is the voice of the profession, and this is not the time for that voice to be silent. Without a unified position, the nursing profession is invisible, and the public trust in nursing’s commitment to protecting public health is compromised. Individual nurses can always vote their choice, but the unified voice of our profession is critical at this time in our history.

Please reverse your position and endorse the candidates that will advance policies that protect the health of the public. We cannot be silent. To be silent is to be complicit.

Thank you for your serious consideration of this request.

Respectfully,

Peggy L. Chinn, RN, PhD, DSc(Hon), FAAN peggychinn@gmail.com

Jessica Dillard-Wright, MA, MSN, CNM, RN jdillardwright@gmail.com

Rosemary William Eustace, PhD, RN, PHNA-BC

Jacqueline Fawcett, RN, PhD, ScD(hon), FAAN, ANEF

Jane Flanagan, PhD, RN, ANP-BC, AHN-BC, FNAP, FNI, FAAN

Dorothy Jones, RN, PhD, FAAN

Deborah Lindell, DNP, MSN, RN, CNE, ANEF, FAAN, Deborah.Lindell@gmail.com

Chloe Olivia Rose Littzen, MSN, RN, AE-C

Leslie H. Nicoll, PhD, RN, FAAN leslie@medesk.com

Adeline Falk-Rafael, PhD, RN, FAAN afalk-rafael@rogers.com

Marlaine C. Smith, RN, PhD, AHN-BC, HWNC-BC, FAAN

Marian Turkel, RN, PhD, NEA-BC, FAAN

Danny Willis, DNS, RN, PMHCNS-BC, FAAN

Overdue Reckoning on Racism in Nursing

Our Nursology.net community is committed to addressing the burning issue of racism, how this systemic condition has influenced the development of nursing knowledge, and how this situation can be changed (see our statement on racism in the sidebar for more information). The NurseManifest project has just announced a series of web discussions “Overdue Reckoning on Racism in Nursing” that will interest many nursologists! Starting on September 12th, and every week through October 10th! This initiative is in part an outgrowth of the 2018 Nursing Activism Think Tank and inspired by recent spotlights on the killing of Black Americans by police, and the inequitable devastation for people of color caused by the COVID-19 pandemic.

Racism in nursing has persisted far too long, sustained in large part by our collective failure to acknowledge the contributions and experiences of nurses of color. The intention of each session is to bring the voices of BILNOC (Black, Indigenous, Latinx and other Nurses Of Color) to the center, to explore from that center the persistence of racism in nursing, and to inspire/form actions to finally reckon with racism in nursing.

Lucinda Canty, Christina Nyirati and Peggy Chinn have teamed up to create the plan – you can see the details here; it is also easily accessed from the NurseManifest main menu!

Hope in Nursing

Contributors: Barbara MacDonald
and Jane K. Dickinson

Barbara and Jane worked together as student/faculty in the online MS in Diabetes Education and Management program at Teachers College, Columbia University. Hope was a common thread throughout Barbara’s work in the program, and the conversation continues:

JKD: How did you get interested in hope?

BJM: My introduction to the concept of hope in health care was through a book recommendation: The Anatomy of Hope: How People Prevail in the Face of Illness by Jerome Groopman. In the context of nursing, I have always believed in health equity and striving for the best possible care for all people. To achieve this, hope is the underlying and fundamental driver. To keep keeping on, to advocate, to fight for the best possibilities, one must believe in and have hope for a better future. As nurses, and fellow humans on a journey together, we have the ability and responsibility to identify and foster hope in ourselves and others in need, in our care and as we are able.

JKD: Where do you see hope in nursing? Where is it lacking?

BJM: Hope is everywhere in nursing. Nurses work with the fundamental belief that we will and can make things better. We continue to get up and go to make things better everywhere at all times. We use a process of critical thinking and decision-making to create that better future for people. Hope is the foundation of this process. We are continually thinking about and creating ways to make things better for the people we are fortunate enough to encounter and for whom we provide care. Hope is woven into the fabric of nursing, and yet, ironically, it is not necessarily identifiable, quantifiable, or systematically measured or fostered as an essential component of care. Hope is fostered through strengths-based, rather than deficit-based, models and systems in health care, and we have work to do to achieve that. What if we began with identifying what is going well and what is working, particularly in non-acute care? What if we had an assessment where we asked how hopeful someone is about their health, and what gives them the greatest hope?

JKD: How does hope have an impact on health outcomes?

BJM: I believe that hope is a pilot light in each of us that is always there, even in the darkest times. If hope is identified and fostered, there is the potential for people to rise up and have the will and energy to move toward a desired future. This is true for both the person receiving care and the nurse. Hope is sustained through incremental progression toward the goal and desired future. When people experience success associated with their efforts, they are inspired, empowered and more hopeful about their future. Success and movement toward results, such as blood glucose levels in the goal range, create energy for continuing the momentum toward the desired future. When hope is fostered, health outcomes are positively influenced and people tend to feel more empowered in their self-management and self-advocacy.

JKD: What connections exist between hope and nursing knowledge?

BJM: It is likely that there is an element of hope in all nursing theories, whether named as such or otherwise. Gottlieb’s philosophy of strengths-based nursing is an approach that embodies hope along with empowerment and self-efficacy and their relationships with achieving desired outcomes (Gottlieb, 2014). As inherent as hope is in all aspects of nursing, it is both surprising and disappointing that there is not a formalized mechanism for identifying and fostering hope to systematically advance health outcomes. While hope is specifically mentioned in the works of Weidenbach, Travelbee, and Kolcaba, almost every nursing theory and theoretical/conceptual model appears to be addressing hope in some way.

JKD: What else would you like to tell us about hope and nursing?

BJM: When I asked a leading mental health specialist about scales to measure hope in diabetes self-management, much like the tools used for assessment of depression and diabetes distress, he replied that to his knowledge there are none. Pausing to think about why that is, I wonder if the effort has been placed on what hope is rather than assuming that it is, and strategizing to identify and foster hope. What if we assume that hope exists within everyone, and find ways to foster it in conjunction with evidence-informed best practice to ensure movement toward the desired future? One thing that stuck in my head in the conversation with the mental health specialist was what he said about assessments in general, such as a depression instrument: “whatever you are looking for, you will find.” If we are looking for depression through use of a depression scale, we will find it. So let’s create a measure to find hope and then foster it.

Even in our current reality, I believe that hope is abundant. We pin our hopes on our everyday approaches, and in the potential of the future. There is hope in science for understanding the coronavirus and immunity to it. There is hope in understanding more about how we need to become informed and examine our thoughts and actions about addressing inadequacies and achieving health equity for all. There is hope for humanity to come together to make a better future, and in this nurses and nursing leadership play a fundamental role. By being hopeful we can find a way to optimize nursing practice in the interest of the public. There is hope as we strive for this optimization in this International Year of the Nurse and Midwife. Could there be a more significant challenge and call to action for nurses than what we are currently facing in 2020? I am hopeful that nurses can come together, rise to the challenge, and be the change we are looking for. Let’s be hopeful and lead a path which inspires hope in others as we create a great movement toward health equity.

Reference

Gottlieb, L.N. (2014). Strengths-Based Nursing. American Journal of Nursing,  114(8), 24-32. doi: 10.1097/01.NAJ.0000453039.70629.e2

About the contributors

Barbara J. MacDonald, RN, BSN, MS-DEDM CDE is a diabetes consultant and co-founder of IDEA | Inspiring Diabetes Empowerment Associates, as well as practice advisor for Saskatchewan’s nursing regulatory body. She is a 2017 graduate of the Master of Science, Diabetes Education and Management, Teachers College Columbia University and is completely hopeful about our collective power to shift the health care experience and outcomes for all, particularly those who are most overlooked.

 

Jane K. Dickinson, RN, PhD, CDCES is a Nursology.net blogger and is the Program Director and Faculty for the solely online and asynchronous Master of Science in Diabetes Education and Management at Teachers College Columbia University. Jane’s research, publications, and speaking focus on the language in diabetes and the need to impart hope through our messages to and about people living with diabetes.

Struggling to Find Air: Emancipatory Nursing Response to COVID-19

Guest Contributor: Kathleen ‘Katie’ Clark, DNP
Edited by Kaija Freborg, DNP

“I can’t breathe.”  If these words were uttered in any healthcare setting in the country, an influx of healthcare providers would rapidly respond, attempting to save the person’s life by providing immediate care.  These words not only represent the recent murder of George Floyd, but mirror the racial inequities that exist for those who are struggling to breathe most in the worst pandemic in modern history. 

As a nurse bearing witness to these atrocities in the city of Minneapolis, I have observed nurses organizing themselves to respond as a collective to these unthinkable problems in real-time by taking immediate action to both maintain safety and fight for justice. These nurses are engaging in emancipatory nursing, a form of nursing that has the potential to dismantle power systems that privilege some over others due to economic means, social status, or hierarchies that create health inequity.1 Nurses must struggle to find the freedom to uncover the dominant health practices that foster Western ideals of health and minimizes nurse’s role to that of a ‘helper’ or a ‘do-gooder.’2 

The words, “I can’t breathe,” should call all nurses to action, first to look inward at our role in perpetuating systemic issues related to race and injustice, and then to respond as a collective to undo generations of harm that have traumatized communities and individuals for far too long.  Witnessing a man struggle to find oxygen to survive, at the knee of someone who has sworn to protect and serve — undoubtedly warrants a public health crisis be declared and calls for immediate nursing action.

Many nurses voiced, in their stories, frustrations of the constantly changing guidelines from the CDC or the Minnesota Department of Health (MDH) that have often created fear and conspiracy theories amongst some mostly well intended people.  Unfortunately, while engaging in self-reflection, many of the nurses reported they lacked the energy to continue to participate in social media platforms as the push back from others on these sites felt frustrating and belittling with little change observed.  Some nurses felt compelled to take a break from social media sites altogether because of the backlash experienced while trying to dismantle misinformation, such as information regarding wearing a mask in public spaces.  Others have taken on this opportunity to do more and respond to needs in innovative ways outside of traditional systems.

Katie Clark at the Health Commons

Kagan, Smith, and Chinn have provided a framework of action to inspire us to break these shackles in place — known as ‘emancipatory action’ — which require four vital characteristics to be deemed such work.  These elements include: “facilitating humanization, disrupting structural inequities, self-reflection, and engaging in communities.”1(p6) While strategically these four elements of emancipatory action have not been used together to tackle the racism that has existed in our care settings for the last 100 hundred years to my knowledge, I have witnessed them being practiced independently by nurses responding to the endless crises that have resulted from the COVID-19 virus and the recent racial justice unrest.  While collecting stories from nursing students and nurses in my role as the director of the Health Commons and an assistant professor of nursing at Augsburg University, it is clear that during this pandemic we have taken on the burden of not only caring for patients in practice settings, but also have felt a moral obligation to provide health education to people in social circles, families, and communities. 

Take for example Sarah Jane Keaveny, RN, public health nurse, activist, and Augsburg University nursing alum.  While buildings closed in response to guidelines set by government bodies due to COVID-19, those who were experiencing homelessness were left with limited options.  Typically those in the homeless community access the skyway system, light rail, public library, and other public spaces for shelter, toileting, and rest.  But, as the social quarantine measures continued to heighten, more buildings closed, leaving them with limited options to get their basic needs met.  One individual experiencing homelessness said to me while at the Health Commons , “It’s like no one cares that we are still out here.  I haven’t met anyone with this disease, but I will know people who will die from it because of all these rules.” 

MOODI Outreach

Sarah Jane connected with the existing resources of outreach workers and community members engaged in mutual aid to respond to those displaced by social structural inequities in the pandemic through establishing Mobile Outdoor Outreach Drop-in (MOODI) where meals are offered and connections to resources are made everyday of the week at a local park. In addition, while many of the shelters began moving individuals experiencing homelessness into nearby hotels, many of those left on the streets formed or joined existing encampments.  Because of the increased numbers in the unsheltered community, disproportionately representative of people of color or indigenous peoples, outreach workers were forced to secure food and water for this marginalized group rather than address long term housing or health issues. Sarah Jane has demonstrated emancipatory action through nursing practice and community engagement; while uplifting human dignity, she engages in communities to respond as a collective, outside of institutions or systems that have limited capacity to respond in the urgent manner required in this pandemic.1

 As the infection rates of the pandemic heightened, where black and indigenous populations are dying at alarming rates in comparison to their white counterparts, came the news of George Floyd’s murder by Minneapolis police officers when he was arrested for allegedly using a counterfeit 20 dollar bill at a local grocery store.3 Nurses in our state are coming to know all too well the appalling racial health inequities that exist due to systemic racism; systems of oppression including slavery, Jim Crow laws, redlining, and mass incarceration all tie directly to both wealth and health.While emancipatory knowing asks nurses to analyze root causes, such as inquiring why inequities of income related to race exist in the first place, it also requires us to take action in response to undoing these injustices. 

The unrest, riots, and violence in response to George Floyd’s death resulted in further displacement of those who were living on the streets of Minneapolis; homeless encampments were destroyed due to false accusations of riot participation, curfews were enforced, and members of the National Guard were deployed.  One nurse practitioner, Rosemary Fister, demonstrated disruption of racial policies in this moment when she fought for change in real-time.  As people living on the streets sought to find protection from the rubber bullets and tear gas released, she organized herself and others to respond to those left without protection due to structural inequities, or “a host of offenses against human dignity including…poverty, social inequalities….war, genocide, and terrorism.” 5(p8)  She was able to negotiate shelter at a local hotel for the unhoused to seek temporary protection. 

MOODI Outreach

As those who sought refuge in this space continued their stay past the days of the unrest, later named The Sanctuary Hotel, Rosemary envisioned a way to mobilize and change the policies and procedures relied upon in current systems.  She helped organize volunteers to operate the hotel in solidarity founded on the principles of mutual aid, where everyone had membership and human connections were made.  Knowing that the complexities of previous traumas and suffering wouldn’t simply end by having shelter, and as more barriers presented themselves, she knew the hotel stay for those unsheltered had to come to an end. 

However, this story has inspired a movement in Minneapolis to care for those displaced, to tackle issues of poverty through various means, to approach change using all forms of knowledge while forging a plan ahead with the very people experiencing the targeted oppression as means of disrupting structural inequities. Rosemary has engaged in social justice work in ways that will shape the discipline for the future to come.

These stories of nurses engaging in elements of emancipatory action while caring for marginalized communities in innovative ways during a pandemic and during social unrest, has shed light on what nursing practice can embody.  Many nurses fail to recognize, and most have yet to understand, the root source and impact of racial health disparities, which offers an opportunity to challenge our beliefs in what nursing practice should or shouldn’t entail as we are called to respond to unjust situations through collaborative action.1

Whether providing care in our acute care settings or shaping our communities, nurses can no longer ignore the words, “I can’t breathe” as we collectively gasp for air.

References

1Kagan PN, Smith MC, Chinn PL. Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis.  New York, NY: Routledge; 2014. 

2Chinn PL, Kramer MK. Integrated Theory and Knowledge Development in Nursing. 8th ed. St. Louis, MO: Mosby, Inc; 2011.

3Rosalsky G. National Public Radio. How The Crisis Is Making Racial Inequality Worse. May 26, 2020.

4Alexander,M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York: The New Press; 2010.

5Farmer, P. Pathologies of power: Human rights, and the new war on the poor. Berkeley, CA: University of California Press; 2004.

About Kathleen (Katie) Clark (pronouns she/her):

Katie is an Assistant Professor of Nursing at Augsburg University and is the Director of the Health Commons. She has taught at Augsburg University since 2009 where her primary responsibilities are in the graduate program in courses focused on transcultural nursing, social justice, and civic agency. She also practiced for over eight years in an in-patient hospital in both oncology-hematology and medical intensive care. She has a Masters of Arts in Nursing degree focused on transcultural care and a Doctor of Nursing Practice in transcultural leadership, both from Augsburg University.   Katie has been involved in the homeless community of Minneapolis for over 15 years and has traveled to over twenty countries.  She lives with her husband and three children in Stillwater, Minnesota.

About Kaija Freborg

Kaija Freborg is the Director of the BSN program at Augsburg University and has been teaching as an assistant professor in the undergraduate and the graduate nursing programs since 2011. Her focus in teaching includes transcultural nursing practice as well as addressing social and racial justice issues in healthcare. She obtained a Doctor of Nursing Practice degree in Transcultural Nursing Leadership in 2011 at Augsburg before teaching at her alma mater. Currently her scholarly interest in whiteness studies has her engaging in anti-racist activism work both in nursing education and locally; her aspirations include disrupting and dismantling white supremacy within white nursing education spaces. Previously Kaija had worked at Children’s Hospitals and Clinics in Minneapolis, in both pediatrics and neonatal care, for over 15 years