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

Diversity, Equity, Inclusion, Justice, and the Future of Nursing Theory: A Webinar of Disciplinary Reflection

To learn more about the Nursology Theory Collective,
or join us in future work, please click here.
See video and full report here

On Friday, June 12th, the Nursology Theory Collective hosted a live webinar titled, “Diversity, Equity, Inclusion, Justice, and the Future of Nursing Theory.” In this webinar, Dr. Lucinda Canty and Patrick McMurray addressed the interrelated concepts of diversity, equity, inclusion, and justice in nursing. They discussed nursing’s homogeneity and how the absence of diversity in our discipline contributes to and reinforces inequity, injustice, and exclusion, even as our professional organizations purportedly value social justice and strive to reduce health inequities.

It is long past time for nurses and nursologists alike to take a stand and actively work towards an antiracist future for nursing. This is nonnegotiable and the time for action is now. We challenge you as readers of Nursology to watch this insightful webinar, reflect on your role in advancing equity and justice, and comment how YOU are going to contribute to transforming nursing into a more diverse, equitable, inclusive, and just discipline.

We understand that this topic may be uncomfortable – and if so, we encourage you to reflect and unpack that discomfort. Maybe you feel defensive as if you have done nothing personally to warrant interrogating your own positionality. Maybe this resonates with you because you see and know this truth as congruent with your own experience.In the words of Monica McLemore, “this can all be different,” if we choose to make it so. The starting place for this is critical self-reflection which paves the way for antiracist growth which creates the possibility for community-building and envisioning new futures for nursing. Embracing the discomfort we can become a more diverse, equitable, inclusive, and just discipline. As Patrick McMurray stated, “nursing is an act of justice,” and it can be if we do the work.

In Solidarity,
The Nursology Theory Collective

For more background on this webinar as well as the presenters, please click here.

Black Lives Matter: Building an Antiracist Nursing Future

Register for June 12th Webinar

“Our lives begin to end the day we become silent about things that matter.” Martin Luther King, Jr.

We, the Nursology Theory Collective, in light of the current events surrounding the murders of George Floyd, Breonna Taylor, and Tony McDade, cannot be silent.

Image created by NTC member Jessica Dillard-Wright

In partial answer to this, we have included our anti-racism position statement below, and invite you, as nurses and nursologists, to join us this Friday, June 12th from 4:00 – 5:00 PM EST to discuss the future of nursing theory and its interrelationship with diversity, equity, inclusion, and justice. We understand that many of us don’t know where to start, but it is in times like these that as the most trusted profession in the United States we must use our privilege to create a more equitable and just world and do something. It’s time we actively listen, learn, unlearn, discuss, and take a stand for those who have been oppressed for hundreds of years, raise their voices, and be better together.

To join this event, please register here in advance to save your seat. 

  • We support the protests in the names of George Floyd, Breonna Taylor, and Tony McDeade, recognizing that their murders are some of the innumerable instances of anti-Black violence that corrode our collective consciousness 
  • We condemn police brutality, a state-sanctioned violence, and recognize its deleterious and disproportionate impact on the lives of Black people
  • We recognize the collusion of white supremacy, capitalism, and patriarchy as the root cause of the ongoing violence that is experienced by Black people
  • Structural racism and white supremacy are public health crises, socially-constructed, legally-entrenched systems of power that benefit and privilege white people
  • We will act to dismantle the structural racism that has characterized the status quo in the United States for over 400 years as a critical, urgent, and essential nursing intervention
  • We recognize our disciplinary complicity with white supremacy, capitalism, and patriarchy, which has shaped modern nursing from its beginnings
  • We collectively commit to do the work: to continue reading and promoting anti-racist work, donate to funds and support initiatives that advance antiracist work, divest from groups that promote hate, promote Black leadership and cite Black scholars, speak out against racism in all its forms, hold space to support and center this essential work while acknowledging this as a forever initiative
  • We commit to uphold anti-racism and anti-oppression, and acknowledge that this commitment must be an ongoing and eternal process

The statement above is a collaborative project, commenced on June 1, 2020. We invite you to join us in this initiative, continue the dialogue, create a better world, amplify Black voices, and show that #BlackLivesMatter.

To join us and sign your name to acknowledge support for the NTC formal position statement, please follow this link: https://forms.gle/NpYWRHtsKe7WZmrD9

In solidarity,
The Nursology Theory Collective

The Nursology Theory Collective is a group of scholars and students that formed after the landmark conference, “Nursing Theory: A 50 Year Perspective Past and Future”, on March 21-22, 2019 at Case Western Reserve University. The mission of the Nursology Theory Collective is to advance the discipline of nursing/nursology through equitable and rigorous knowledge development using innovative nursing theory in all settings of practice, education, research, and policy.

To join the Nursology Theory Collective, and be added to our email list, please send us an email at nursingtheorycollective@gmail.com.

Moving from training to educating

More and more discussion is happening about the words we use in nursing. There are many words we need to move away from or change, and it will likely not happen in my lifetime. We are, however, making progress, and that’s what truly matters. Nursing faculty who teach their students more effective, helpful, and empowering messages are making a difference. Articles that focus on (and use!) strengths-based, person-centered language are moving the needle, as they say.

In addition to compliance and adherence, which Jacqueline Fawcett wrote about recently, training is a word that is prevalent in nursing. It’s time to change that. I often say, “we train animals; we educate people.”

Right now, nursing’s world is being rocked by COVID-19. We’re hearing many stories about PPE, which fit in with the training vs. educating question. Nurses are trained in the use of PPE, likely from their very first day. They are told how to put them on, take them off, perform tasks while wearing PPE, and so on. While they may get a little background on stopping the spread of infection through using these precautions, I’m guessing it really is training. When it comes to caring for patients who are sick and isolated; however, nurses call on their education. They use all five patterns of knowing (empiric, aesthetic, ethical, personal, and emancipatory) (Carper, 1978; Chinn & Kramer, 2018) to provide the best and most comprehensive care possible despite the horrific conditions surrounding them. Nurses are comforting those who are dying alone, and administering medications and ventilation to those who are struggling to breathe. Those skills are not the result of training. They come from being taught, supported, and guided, both in the classroom and in the clinical setting.

My work is in diabetes care and education. Training is a word that is prevalent in the diabetes arena. In fact, while diabetes professionals prefer and typically say, diabetes self-management education, the Center for Medicare and Medicaid Services (CMS) insists on calling it diabetes self-management training. I’ve noticed that as a professional group, we seem to have given up on trying to change that.

The reason it matters in diabetes is that we are working with human beings. Training means basically telling someone to do something a certain way. Like I mentioned earlier, we train animals. Animals don’t understand the rationale behind performing a trick or coming when they are called. Teaching means to explain, support, and educate. It is much broader than training, and it leads to autonomy, understanding, and engagement, rather than compliance or nonadherence. Humans not only have the capacity to understand, they deserve to know the why, what, and how.

The reason it matters in nursing, is that it’s the subtle difference between a profession and a trade. Nurse scholars have been asking whether or not nursing is an applied science, a basic science (Barrett, 2017) or a science at all (Whall, 1993). We’ve been asking what sets us apart from other health professionals. We’ve wondered why other professions don’t use or reference our knowledge base.

Peggy Chinn, in her keynote address at last year’s Nursing Theory: A 50 Year Perspective, Past and Future conference, stated that it’s time to examine our own assumptions and actions (Chinn, 2019). When we refer to being trained as a nurse, or having been trained at a particular school, what are the underlying assumptions? Do we really see nursing as a trade, with trained workers? Or do we see ourselves as professionals who are educated and have a distinct body of knowledge that prepares us to work autonomously?

If we ever hope to change the messages in nursing and health, we have to start with ourselves. We have an opportunity to lead by example, and state proudly that we are educated, informed, and engaged in a valuable profession. We teach future nurses to also engage in the discipline, and we teach patients to engage in their health and well-being – at whatever level that is possible.

Transitioning from training to educating is consistent with caring (Chinn & Falk-Rafael, 2018; Newman, Sime, & Corcoran-Perry, 1991; Watson, 1997), humanism (Paterson & Zderad, 1976), empowerment (Funnell, 1991) and many other nursing concepts. Please join me in removing the word and the mentality of training from our messaging in nursing. Let’s educate instead.

 

References

Barrett, E.A.M. (2017). Again, what is nursing science? Nursing Science Quarterly, 30(2), 129-133.

Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-24.

Chinn, P.L. (2019, March). Keynote Address: The Discipline of Nursing: Moving Forward Boldly. Presented at “Nursing Theory: A 50 Year Perspective, Past and Future,” Case Western Reserve University Frances Payne Bolton School of Nursing. Retrieved from https://nursology.net/2019-03-21-case-keynote/

Chinn, P.L. & Falk-Rafael, A. (2018). Embracing the focus of the discipline of nursing: Critical Caring Pedagogy. Journal of Nursing Scholarship, 50(6), 687-694.

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

Funnell M.M. , Anderson, R.M. , Arnold, M.S. , Barr, P.A., Donnelly, M., Johnson, P.D., Taylor-Moon, D., & White, N.H. (1991). Empowerment: An idea whose time has come in diabetes education. The Diabetes Educator, 17, 37-41.

Newman, M.A., Sime, A.M., & Corcoran-Perry, S.A. (1991). The focus of the discipline of nursing. Advances in Nursing Science, 14(1), 1-6.

Paterson, J. G., & Zderad, L. T. (1976). Humanistic nursing. Wiley.

Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10(1), 49-52.

Whall, A.L. (1993). Let’s get rid of all nursing theory. Nursing Science Quarterly, 6(4), 164-165.

What is Reflected in a Label about Health? Non-Nursology and Nursology Perspectives

Posted the first week of March, which is designated as
National Words Matter Week

A long time ago, I read an editorial in a journal decrying the labels for women’s reproductive health issues. The point was that labels such as incompetent cervical os are pejorative words. At about the same time, I began to think about what 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.

Indeed, Hess (1996) pointed to “connotations of paternalism, coercion, and acquiescence” (p. 19), and Bissonnette (2008) and Garner (2015) noted the power imbalance and loss of patient autonomy inherent in referring to a patient as non-compliant or non-adherent. I doubt that few if any nursologists would knowingly sanction paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Yet we continue to label patients as compliant or adherent if they do whatever they were supposed to do and as non-compliant or non-adherent if they do not do whatever they were supposed to do.

The issue, of course, is to identify a label that can be used to accurately reflect what happens between a person who is a patient and a person who is a healthcare worker as they interact in matters of health without an overlay of paternalism, coercion, acquiescence, power imbalance, or loss of autonomy.

Most, if not all, nursology conceptual models and theories include consideration of the person’s perspective of the health-related situation and may include a process that addresses how the situation is viewed and resolved. For example, the practice methodology associated with Neuman’s Systems Model includes the perspectives of both the person and the healthcare worker throughout the entire process of diagnosis, goals, and outcomes. The practice methodology associated with King’s Conceptual System is even more explicit, with mutual goal setting, exploration of means to achieve goals, and agreement on means to achieve goal. However, the practice methodologies associated with these nursology conceptual models and theories do not include a label for what happens if the patient does or does not do what had been agreed upon.

I have not yet identified a satisfactory label for what actually happens. However, I suspect that turning to nursology theories of power may provide at least the beginning of an appropriate label. For example, Barrett’s theory of power as knowing participation in change sensitizes us to the distinction between power-as-control and power-as-freedom. Barrett maintained that power-as-freedom involves awareness of what is happening, knowingly participating in choices to be made about what is happening, having the freedom to act intentionally, and being fully involved in creating changes in whatever is happening. Perhaps, then, the label could be knowing participation.

Another example is Chinn’s peace as power theory, which sensitizes us to the distinction between peace-power and power-over. The process of peace as power encompasses cooperation and inclusion of all points of view in making decisions. Accordingly, healthcare decisions are based on thoughtful choices as the person and the healthcare worker work together to promote wellness and growth. Perhaps, then, the label could be thoughtful cooperative choices.

What other label might be even more accurate? How can nursologists actualize our moral goal to do “good for the one for whom the [nursologist]” cares”? (Hess, 1996, p. 19). What label should we use to clearly reflect our ethical knowing? Hess’ (1996) discussion of ethical narrative suggests that cocreated narrative may be the accurate term. She explained, “ethical narrative is crafted by the client and [nursologist] to express the good they are seeking” and that ethical narrative is achieved “through engagement” (p. 20).

Labels, which are words, matter for many, many reasons. Labels may reflect paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Labels also may reflect racism and privilege and other words that perpetuate colonialism (McGibbon, Mulaudzi, Didham, Barton, & Sochan, 2014). We must, therefore, identify and consistently use labels that are consistent with ethical knowing in nursology, with clear understanding of “their meanings and the underlying philosophies or perspectives that they connote” (Lowe, 2018, p. 1).

This blog is adapted from Fawcett, J. (in press). Thoughts about meanings of compliance, adherence, and concordance. Nursing Science Quarterly.

References

Bissonnette, J. M. (2008). Adherence: A concept analysis. Journal of Advanced Nursing, 63, 634-643. Available from: http://dx.doi.org/10.1111/j.1365-2648.2008.04745.x

Gardner, C. L. (2015). Adherence: A concept analysis. International Journal of Nursing Knowledge, 26, 96-101. Available from: http://dx.doi.org/10.1111/2047-3095.12046

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

Lowe, N. K. (2018). Words matter. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 47, 1-2.  Available from: http://dx.doi.org/10.1016/j.jogn.2017.11.007

McGibbon, E., Mulaudzi, P. M., Didham, P., Barton, S., & Sochan, A. (2014). Toward decolonizing nursing: The colonization of nursing and strategies for increasing the counter-narrative. Nursing Inquiry, 21. 179-191. Available from: http://dx.doi.org/10.1111/nin.12042 (See also https://nursology.net/2020/01/14/decolonizing-nursing/)

The Community as Client: A Critical Caring Exemplar

Dorothea Fox-Jakob

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

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

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

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

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

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

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

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

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

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

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

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

Sources

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

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

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

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

A Dozen and One Ways to Love Our Discipline!

Later this week February 14th, is Valentine’s Day – the internationally recognized holiday that variously inspires young children to try their hand at making an original card expressing at least admiration for other children, and compels adults to exchange gifts symbolizing their adoration of one another.  Putting aside the commercialization of a day with deep roots in Roman religious festival traditions, I would like to consider ways in which we as nursologists can express, in our actions and deeds, our fundamental respect – and yes, our love, for the discipline to which we have committed our professional lives, and for many, our personal lives as well.

So in the spirit of the best traditions of Valentine’s day – here are a dozen and one ways to love our discipline!

  1. Express appreciation every day to a nurse who has made, or makes a difference in your life.
  2. Form a small support or interest group with a few nurse colleagues to work on a persistent challenge you are facing; include early-career nurses who are so vulnerable to these challenges.
  3. Recognize ways in which racism and other forms of discrimination are expressed in everyday ways in your work environment, acknowledge your part, and explore ways to resist and transform these situations.
  4. Practice the fine art of “active listening” whenever you encounter a nurse colleague whose point of view differs from your own, explore common ground and build bridges of understanding.
  5. Reach out to a nurse who is hurting, discouraged, or fearful for any reason;  listen to their story, and pledge to continue to listen.
  6. Settle on your own clear and succinct explanation of what nursing is all about; express this to at least two other people every day, and notice their responses to refine your message.
  7. Read one article every month, or two books a year, to learn about nursing history and the nurses who made significant contributions to our discipline.
  8. Practice one or more self-nurturing activity every day, such as physical activity (walking, yoga, tai chi), meditation, play and laughter, saying “no” as a complete sentence!
  9. Resolve to speak the truth of nursology to power at every possible opportunity.
  10. Use every avenue possible to communicate with the public – with your local community leaders, the media, and politicians.
  11. Love and care for the earth and its animal creatures as you would your most cherished patient; take at least 3 opportunities each day to teach others to love and care for the earth and for animals.
  12. Join at least one nursing organization and work to create needed changes in our discipline and in healthcare.  AND
  13. Follow Nursology.net, share the site far and wide, and participate in sharing ideas to shape the future of nursing/nursology.
Thank you to the following nursologists who have contributed to this list!
Chloe Olivia Rose Littzen
Jane Hopkins Walsh
Jess Dillard-Wright
Brandon Blaine Brown
Savina Schoenofer
Marlaine Smith
Vanessa Shields-Haas
Christina Nyirati