We have always lived in interesting and challenging times, filled with reports of numbers indicating what is happening – life expectancy, births, deaths, and most likely millions of other numbers representing important and probably not so important events. Currently, we are living in what many people regard as an especially interesting and challenging time, with numbers about the coronavirus pandemic dominating news reported in the print, radio, television, and internet media. Most recently, numbers about climate change have taken almost center stage as the “hurricane season” occurs. .
I confess to checking the coronavirus pandemic numbers every day, especially for the state of Maine, where I live and now also work during this time of remote teaching and scholarly work. I also keep track of what is happening with hurricanes, which occasionally do make landfall along the coast of Maine and can create many tree downings and power outages, beach erosion, and flooding.
Numbers are perhaps especially important to researchers who conduct quantitative research to test hypotheses. Thinking of numbers within the context of hypothesis testing requires theoretical thinking. Thus, even if implicit, theory is paramount to the interpretation of numbers. Of course, it would be more significant if the numbers were interpreted using explicit theory.
It is, unfortunately, not unusual to read reports of hypothesis testing research conducted by nurses with no mention of any theory that might have guided the research and articulation of the hypothesis. Should we then assume that the researchers are not thinking theoretically? Or, are they unable or unwilling to tell readers what theory was used? As I wrote in a 2019 blog, it is impossible to think atheoretically. Why, then, are so many reports of numbers devoid of any theoretical perspective?
How are we to understand the meaning of numbers about the coronavirus pandemic or climate change without some theoretical perspective? I maintain that it is all nursologists’ responsibility to place all numbers in some theoretical context. For example, nursological conceptual models and theories about primary prevention provide understanding of the extent to which numbers for the coronavirus pandemic are or are not responding to primary prevention interventions (see https://nursology.net/2020/04/21/the-value-of-primary-prevention/). In addition, all nursological conceptual models include attention to the environment, which could easily be extended to encompass the issues surrounding climate change (see my September 24, 2019 post). Furthermore, Nightingale’s theory provides an important nursological perspective for interpreting both pandemic and climate change numbers (see https://nursology.net/2020/05/12/wwfd-what-would-florence-do-in-the-covid-19-pandemic/).
Nightingales’ theoretical perspective of the importance of numbers and the environment is evident in that she “recognized the need to provide an environment conducive to recovery, [and] that data [i.e., numbers] can prompt innovation” (Hundt, 2020, p. 26), and that the effectiveness of theoretically-based innovations is supported by numbers. In particular, for all nursologists “advocating for public policy and conducting research, [theoretically-based numbers] help frame two questions: “How can we improve the health of our communities? Are our interventions making a difference?” (Hundt, 2020, p. 28).
Aula’s (2020) caution about “misplaced trust in numbers” underscores the importance of not only using theory to interpret numbers but also to be wiling to allow the numbers to support rejection of the current version of the theory. Willingness to reject the theory – or at least a hypothesis derived from the theory – is consistent with Popper’s (1965) philosophy of science, which indicates that rejection of the theory leads to a better theory.
“May you live in interesting times” (Wikipedia, 2020) is a widely used saying that may or may not be a positive wish—perhaps it is better to wish to live in uninteresting times that are characterized by tranquility and harmony. I would like to paraphrase a positive interpretation of the saying and offer the wish that all of us may always live in nursological theoretical times and always interpret numbers within the context of nursological theory.
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.
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.
Uncertainty is, in many ways, a human condition—each of us most likely feel uncertain about something at least some time in our life. However, the current covid-19 pandemic has brought forth a time of what is great uncertainty for many people worldwide. What, though, is the meaning of uncertainty and the outcome of feeling uncertain?
Merle Mishel’s Theory of Uncertainty in Illness tells us that uncertainty is “the inability to determine the meaning of illness-related events” (Mishel as cited in Clayton Dean, & MIshel, 2018, p. 49). More generally, uncertainty is defined as “The state of not being definitely known or perfectly clear; doubtfulness or vagueness. . . . the quality of being indeterminate as to magnitude or value” (Oxford English Dictionary, 1921/1989).
Mishel’s theory also tells us that uncertainty may be regarded as a danger or an opportunity. What are dangers associated with uncertainty during the covid-19 pandemic? Mental health problems, such as anxiety and depression, have been cited as a danger—Chinn wrote of the “Hidden Risks of Physical Distancing and Social Isolation” during the current pandemic. Foli wrote about the psychological trauma experienced by nurses caring for people with covid-19.
What are opportunities associated with uncertainty during the covid-19 pandemic? Media attention to the inequities of health care based on race is an opportunity to highlight what nursologists have known at least since the time of Florence Nightingale. The nursology.net management team has crafted a statement in support of the elimination of health care inequities that is visible in the sidebar of this website. The statement reads in part, “We are dedicated to building praxis in nursing that reflects the tradition of nursing’s dedication to social justice, that addresses injustice, and that welcomes dialogue and action focused on creating needed change within nursing and healthcare.” All nursologists have an opportunity, on which we must now capitalize, to be at the forefront of developing and applying knowledge to overcome finally widely recognized racial-based health care inequities. We must grasp the opportunity given to nursologists by the media and wider society to be recognized as competent and compassionate carers of people critically ill with covid-19. By doing so, we will actualize #neverforget, which Balakrishnan (2020) used to refer to climate change but is perfect for nursology especially at this time.
Michsel’s Revised Theory of Uncertainty in Illness tells us that the outcome of feeling uncertain is a new life perspective. What is a preferred new live perspective? Are nursologists and all citizens of our planet willing to a new value system to guide the way we live and interact with others?
Although Mishel’s theories are about uncertainty in illness, many other facets of life involve uncertainty. For example: Will my car start today? Will public transportation be on time? Will the meal I ordered or cooked myself be delicious? Will my family member or friend like the gift I purchased for her or him? Will my partner always love me? Extended to knowledge development, we know that inferential statistics used to test theoretical hypotheses do not produce results that are “facts” or “laws,” but instead are numbers that represent a certain level of probability – we are, for example, 95% (p = 0.05) or 99% (p = 0.01) certain about some result but %5 or 1% uncertain about the result. Thus, much of what we know empirically is under conditions of uncertainly.
Clearly, if we are to live comfortably with uncertainty, we need to be comfortable with learning that which is not yet certain (if it can ever be certain!). Within the context of theory development, we can learn from rejection of our hypotheses. Indeed, Popper (1963) maintained that rejection of hypotheses is desirable as the next hypothesis will be better–we will have a better theory. Glanz (2002) added, “There is as much to learn from failure as there is to learn from success” (p. 546). Knowing “what is not” advances theory development by eliminating a false line of reasoning before much time and effort are invested. Thus, wanting to be certain may be a trap that leads to arrogance or a barrier to accepting at least a certain extent of uncertainty. Paraphrasing Barry (1997), who wrote about truth in science, we can indicate that one can reach certainty “no more than one can reach infinity” (p. 90).
Barry, J. M. (1997). Rising tide: The great Mississippi flood of 1927 and how it changed America. New York, NY: Touchstone/Simon and Schuster.
Clayton, M. F., Dean, M,, & MIshel, M (2018), Theories of uncertainty. In M. J. Smith & P. R. Liehr (Eds.). Middle range theory for nursing (4th ed., pp. 49-81). New York, NY: Springer.
Glanz, K. (2002). Perspectives on using theory. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed., pp. 545-558). San Francisco: Jossey-Bass.
Although not the only global challenge we face, COVID-19 has the world’s attention while disrupting so many familiar routines. For those so fortunate, there is the new normal of working from home and countless conference calls that seem to blur one day into the next, almost erasing the confines of time while confining us to a physical space. When things get back to “normal” what will that look like?
For those in service industries, there is the chaos of being the person in the midst of unsafe places whether the grocery store, a bus or as an employee in a hospital. Making connections while fearing, am I safe? Do I have what I need to protect myself/ my family? And, sometimes knowing you do not have what you need, and in that moment, your awareness of the disparity of those who have and those who do not is heightened. What will it be like when things get back to “normal?
Then there are those who in a whirlwind, may have lost their job. Now they are struggling to pay bills, perhaps visiting food banks for the first time mixed in with home schooling young children or a full house of grown children now back to the safety of their childhood home. When and what will be that return to “normal”? For every scenario, there is opportunity, freedom and new ways of being. There is also potential binding or unraveling. But no matter the reality, there are the chants to “get back to normal”
This idea of “getting back to normal” raises the question; “What would Margaret say?” We think the answer is …actually, not very much. She would smile gently and acknowledge each person who spoke and told his or her personal story. She would be present and authentically listen. Her silence would spur more stories until in the sheer dizziness of it all, the cacophony would stop and everyone would look to her and wonder what she is thinking. Again, silence and this time the room would go quiet. Finally, she would speak: “I’m just curious about people wanting to go back to normal, what do people think of that?” Then she would sit and wait for us to react…and we would. We would discuss how we cannot “go back” and about the opportunity in the chaos. What went well in nursing practice during COVID – 19 that was reflective of nursing and what did not? She would smile, as we would envision a new future that informed by COVID-19, and the inequities of an illness, linked to an environmental crisis and manifested in our most vulnerable. An illness that has stuck down older adults, minorities and is on a path to literally destroying second and third world countries. Go back? No, we would not be going back we would be envisioning a new future, one with boundaryless opportunities.
There is for some, an increased awareness, that the inequities of COVID-19 along with the murder of George Floyd and other racial incidences has heightened the issue of structural racism that has always been simmering under the surface. Go back? Oh no, we will not go back. Not to complacency, not to a world where nurses today are lauded for their actions during a crisis, but who will return to being a hidden entity, part of the bed charge. No, we are now in a world that recognizes, yes there were many deaths, but because of nursing care, because of nursing’s commitment to meeting the person where they were at, commitment to delving into knowing other, upward of 85% of those who had COVID and were hospitalized were successfully discharged. Yes, nursing care! It was the authentic presence of nurses who connected with patients in new ways and journeyed with them on a path of discovery, nurses learning to recognize the pattern of the critically ill when the normal mode of communication was no longer possible, and nurses who transformed the care environment. It was not a cure or a vaccine that made the difference; it was “the difference nursing makes” that made the difference.
The COVID-19 virus made visible a pattern of turbulence and disruption within the global whole. Lack of awareness to growing social challenges, loss of freedom creation of boundaries and isolation confounded the environment within which the virus emerged. Within this context, the virus took on new meaning and yielded variety of responses. Using the theoretical lens of Health as Expanding Consciousness, Margaret would reflectively and carefully suggest that being exposed to the global and dramatic changes of the day has already begun to reshape/repattern us. She would envision the voice of nurses advocating on behalf of patients, on behalf of the myth of curing rather than healing, on behalf of older adults, racial and ethnic minorities. Margaret would not support “going back”; instead, she would reflect on the meaning of the unfolding pattern emerging before us …within the context of an illness.
The event COVID-19 has served to make visible the invisible for society as a whole. Recognition that we are all connected and interrelated. The actions and behaviors of one individual directly affecting the very life of another. Response to the virus has revealed a complex, dynamic human pattern of the whole within a dynamic and changing environment. As the illness experience is unfolding, individual responses shaped by factors including vulnerability, gender, age and the older adults, race, ethnicity, compromised health status, poverty, lack of insurance, homelessness, exposure to environmental stressors and population density, and personal responses to life challenges have been made visible. Compromised relationships, sustained loneliness and disconnection challenged human becoming and threatened choices about health and wellness. Rather than creating new problems, COVID-19 has manifested not only a serious disease but made visible longstanding global societal challenges that have gone unnoticed or suppressed.
Margaret would caution that “fixing” the illness (i.e. treating to cure) without addressing the whole person/environment interaction that include people and events surrounding the individual experience, could lead to a reoccurring manifestation of the underlying pattern in new ways (e.g. inequities and disparities in care). She would stress the importance of collaborating with individuals and groups in dialogue, she would identify what is meaningful, to acknowledge the collective increased awareness, and seek to uncover an underlying pattern of the whole. COVID-19 then becomes a stimulus for active discussion, identifying barriers that compromise moving forward as individuals and as a society. The insights gained through information and connecting with another create opportunities for new insights, actions and freedom to participate knowingly in actions that promote transformative change.
The importance of relationship is core to advancing the process of discovery. Partnerships that are open and evolving allow pattern to emerge and potentially increase the realization that we are all interdependent and connected within and across environments. Recognizing that what affects one-person or community can have a reciprocal impact on another. Within the discovery process there is freedom to hold on to what gives new meaning to one’s being and what binds and threatens our freedom to become and engage in sustainable holistic healing. No, Margaret we are not going back. And she would smile, knowing we are with new heightened awareness and renewed energy, accelerating toward new potentials and transformation.
Newman, M. A. (2008). Transforming presence: The difference that Nursing makes. Philadelphia: F. A. Davis.
Smith, M. C. (2011). Integrative Review of Research Related to Margaret Newman’s Theory of Health as Expanding Consciousness. In Nursing Science Quarterly (Vol. 24, Issue 3, pp. 256–272). https://doi.org/10.1177/0894318411409421
Guest Contributors*: Andra Opalinski and Patricia Liehr
We are responding to Dr. Foli’s request in her blog titled “Say It Ain’t So: Graduate Students Shade Nursing Theory!” where she stated…”What about you? If you have suggestions for me on how to strengthen the theory-to-primary care advanced practice connection in a master’s level course, please forward them…”
WE BEGIN WITH DEFINITIONS
Throwing Shade: (verb) subtly disrespecting or ridiculing someone or something.
Shade: (noun) a comparative darkness caused by shelter from direct light.
We ARE the theory-practice connection.
As nurse educators who appreciate the theory-practice connection, we had been pondering Foli’s post and then Constantinide’s follow-up about graduate students throwing shade at nursing theory. Not knowing the meaning, we took the “throwing shade” descriptor quite literally and thought how we often prefer to find shade on sunny Florida days!!! In the midst of our extended pondering and thoughtful conversations came COVID-19; and a virtual class that we co-hosted with NP students to discuss the use of Story theory in practice; and THEN, we serendipitously came across a 2020 calendar page with a haiku by Tomihiro Hoshino entitled “In the Shade.” This haiku accompanies his calendar painting of a redbud tree with hanging red pods amidst green foliage:
In the shade of leaves, They shyly sway, Pods like strips of paper With girlish wishes Written on them
Moving along to a class with NP students.
In this class, we were talking about Story theory and the practicality of using it when working with patients. Story Path, a way to pursue story-sharing was the specific lesson (Liehr & Smith, 2020). Clare, an ER nurse, volunteered to share a recent practice story with the class.
“I was caring for an elderly patient in the Emergency Room who had just tested positive for COVID-19. However, this day, the provider I was working with was resistant to putting the patient on a ventilator.” As Clare reflected on the situation she shared, “I remember asking myself, is the provider just being lazy because the patient is elderly with a poor prognosis? However, I also knew, this doctor reads a lot of research. I still couldn’t help but question the decision. The patient did in fact improve without ventilator assistance,” giving Clare pause….thinking about the juxtaposition of knowledge with practice. As Clare’s recounting of the story concluded, Clare was asked to consider how her COVID-19 experiences may influence the future. The rawness of her sharing was palpable as she elaborated on the pause noted in her story: “I never knew nursing would get to this point. I am becoming suspicious of everyone, even co-workers. I stand away from everyone and wear masks all the time. I am challenged with what feels like lacking compassion. I don’t spend time in the rooms like I always did before, or place a hand on an arm to show comfort because we are thinking, is this the next COVID patient. I do make sure there is a phone in every room and I call often to check on the patients. It just feels less personal. It feels unnatural.”
Hmmm…lacking compassion feels unnatural. There is a theory and/or a philosophical perspective in this sentiment. We could go with Meyeroff’s ideas (1971) about caring as a way of ordering one’s values so that one feels “in place” rather than “out of place” in the world. We could go with Watson’s Transpersonal Caring Moment (Watson, 2018) where people come together in a human-to-human, spirit-to-spirit connection that is meaningful, authentic and intentional. These are just two examples providing context that allows for locating self in the theory-practice connection; many others could be the philosophical/theoretical lens providing context.
Then the class was asked, “What have you learned from Clare’s story that resonates with your own practice?” Anna was quick to answer, “Everything is fluid and flexible right now, we have protocols, but they change day by day, they are evolving and there is a lot of uncertainty. We have to be able to allow flexibility in new ways. I can’t get into my usual groove.” Then THE question was posed. “Is theory real for you in your everyday practice? If not, it’s ok to say so.” Perhaps the most insightful answer was Brad’s response. “We are taught many theories, but challenged to know how to apply them. I don’t have theory on my mind when I am in front of my patient. It may be subconscious, but I’m not thinking, I’m applying Leininger or Watson right at this moment.”
Brad is right…we don’t expect that nurses live real-time practice checking in with theoretical/philosophical perspectives. However…the perspectives are there and stepping back and reflecting on nursing circumstances may enable forward movement with theory-guided intention and with knowledge-building for the discipline.
Pondering We ARE the theory-practice connection
As the nurse theorist-practitioner team that we are, we have great appreciation for the comments of these practicing nurses who happen to be graduate students. We wondered …Could the shade granted by COVID-19 bring theory out of the shade for students when they don’t even know it? You see, we are educators in a setting where nursing theory is highly valued and caring theory is the organizing spine of our curriculum. Has caring theory become so naturally interwoven in their practice that these NP students know something is amiss but they have difficulty naming it beyond descriptors like “unnatural” or “I can’t get in my groove”? We can only hope….but we can also plan to honor the shade by:
remembering that we are always working from a theoretical perspective – we have only to step back from any nursing situation and consider the principles/concepts that are guiding our actions;
creating opportunities to share our practice stories with the knowledge that the implicit theory woven into the practice threads can come alive through scholarly engagement that is open to authentic expression and that gently supports exploration and maturing of an individual nurse’s own thinking;
holding the theory-practice connection as a truth that just takes time and professional maturity for appreciation but it is a truth that can be readily described when nurses have a mentor who helps with connecting the practice-theory dots;
pairing theorists and nurse practitioners to forge opportunities for growing nursing knowledge grounded in our practice.
Though there is little positive to say about COVID-19 these days, it may be that the pandemic granted some shade for us to reflect on the theory-practice connection in a way that can guide understanding. After all, We ARE the theory-practice connection. Let’s own it.
Now….what do you think – we would like to hear from you. How do you see our plan to honor the shade as an integral dimension of developing practice-scholars AND growing the discipline of nursing?
Liehr, P. & Smith, M.J. (2020). Claiming the narrative wave with story theory. ANS, 43(1), 13-27.
Meyeroff, M. (1971). On caring. Harper & Row: New York.
Watson, J. (2018). Unitary caring science: The philosophy and praxis of nursing. Louisville, CO: University Press of Colorado.
About the contributors
Andra Opalinski, PhD, CPNP-PC, NC-BC is a pediatric nurse practitioner and an Associate Professor at the Christine E. Lynn College of Nursing, Florida Atlantic University. She is an advocate for child and adolescent mental health promotion. Her current areas of interest include community-based participatory research with elementary through high school students using mindfulness interventions for self-regulation and stress management skill building. She also uses visual anthropology through photographs to explore perspectives of health of vulnerable populations. Right now, you’ll find her working remotely, doing the best she can to keep her household of 5 under strict physical distancing, and using the visual anthropology approach to document her family’s physical distancing experiences.
Patricia Liehr PhD RN is currently the Associate Dean for Nursing Research and Scholarship at the Christine E. Lynn College of Nursing, Florida Atlantic University (FAU). She is the co-author of story theory and the co-editor of Middle Range Theory for Nursing. Most of her scholarly work has focused on peace, from personal through mindfulness; to global through coming to know both sides (Pearl Harbor; Hiroshima) of surviving the bombings of WWII. Story-gathering has played a major role in her research endeavors and she highly values the place of nursing practice stories for disciplinary knowledge development. Right now, as she moves toward an August retirement from FAU, she is imagining all the things she will do with new-found time.
A man and a woman were fishing on the river bank when they saw a woman struggling in the current. They rescued her. Soon, they saw a man struggling. They rescued him, too. This continued all afternoon. Finally, the exhausted pair decided to go upstream to find out where and why so many people were falling in. They discovered a beautiful overlook along the river’s edge without any warning signs or protective barriers. The couple went to community leaders to report the number of victims they had rescued and explained the connection to the unprotected overlook. Community leaders agreed to install a protective guard and post warning signs. Preventing the problem saves resources, energy, and lives.” (see “The Upstream/Downstream Parable)
Critical Caring is a way of being-in-relation that seeks to protect and enhance human dignity. It is informed by multiple ways of knowing (Chinn & Kramer, 2017) and guided by a caring/social justice ethics in which advocacy for social justice becomes an expression of caring for individuals, groups, communities, or populations. It encompasses both downstream and upstream nursing practice. (Falk-Rafael & Betker, 2012a) The “critical” aspect of the theory reflects both the theory’s roots in contemporary critical social theories and in the work of Nightingale, who I would argue, espoused the tenets of what became known as critical social theory decades before it was formalized by the Frankfurt School in the 1930s.
Although originally proposed as a middle-range theory of public health nursing (Falk-Rafael,2020), Critical Caring’s seven carative health promoting processes (CCHPs) can readily provide guidance to nurses practicing in the context of the COVID-19 pandemic, regardless of setting. The CHPPs are focused on simultaneously meeting the needs of individuals, groups, and/or communities and building their capacity (CHPP 6) , i.e., helping them to regain/maintain whatever degree of control over their life is possible to maximize their health potential (Falk-Rafael, 2001, Falk-Rafael & Betker, 2012a).
Critical caring begins with the preparation of one’s self (CHPP1) and involves taking measures to monitor, care for, and protect one’s own physical-mental-spiritual health. Examples related to COVID-19 include physical distancing when in public and use of appropriate personal protective equipment. (See series of posts on that topic by Carey Clark). Appropriate PPE provides protection for the nurse and also contributes to the downstream aspect of CHPP 5, relating to the provision and maintenance of a safe and supportive physical environment for the patient/client. Other measures to create a safe environment include such fundamental principles as the separation of infected people from non-infected people, a principle well understood by Nightingale but ignored in some of the long-term care facilities in Ontario, ravaged by COVID-19.
Central to critical caring is establishing and maintaining a helping-trusting nurse-patient relationship (CHPP 2), a carative process that can be complicated by the use of the necessary PPE. Transparent face shields and/or mask inserts may be a great help in that regard when they are available. Touch, even through gloved hands, and verbal communications become even more important in establishing and maintaining a human-to-human connection, and in being able to gain some understanding of the patient’s lived experience of the situation and providing some measure of comfort.
Relationship is also essential in the mutuality required in CHPP, 3 the systematic reflexive approach to identifying the health goals of clients and working with them, to the extent possible, in achieving those goals. This process requires a knowledgeable approach by the nurse whose expertise is available to facilitate patients’ understanding and decision-making.
Likewise, relationship, characterized by mutuality, is central to CHPP 4, transpersonal teaching-learning. Whether situated in acute care, focused on treatments or medications, or in the community, focused on issues such as requirements of quarantine or self-isolation, transpersonal teaching-learning is an interactive process in which evidence-informed information and guidance are provided within the context of the patient /client’s understanding, lived experience, hopes and fears. Perhaps in no instance is relationship more important than in the face of death when the nurse can offer a comforting presence and an openness to the patient’s way of finding meaning in the experience (CHPP7). That may involve holding a phone to a patient’s ear or a tablet in front of a patient so that families can virtually be present and connected with their loved one in their final moments.
Although the coronavirus does not discriminate, the pandemic has highlighted societal economic and social inequities that significantly increase the risk of contracting COVID-19, not only in Canada and the U.S., but also globally. Some of the reasons relate to the need for poorer people to continue to work in jobs away from home, often in the provision of essential services. Moreover, they are more likely to rely on public transit to get to work; they may be less able to physically distance from family members because of crowded living situations, and/or may lack adequate health care. In situations that might allow work at home, economically disadvantaged people may not be able to afford the necessary electronic equipment; similarly their children may not be able to complete aspects of online education. In even more dire circumstances, homeless people are extremely vulnerable as advice for staying home and frequent hand washing are simply not options for them. Physical distancing is not possible in homeless and respite shelters in which cots are placed closely together.
The COVID-19 pandemic has highlighted societal inequities which, in many aspects, bear a striking resemblance to those Nightingale experienced more than 150 years ago. Her approaches and solutions included downstream nursing by, for example, training nurses to care for those in workhouse infirmaries where paupers were required to come if they were ill because they could not afford care in hospitals. But what is sometimes overlooked, is that she also advocated for solutions at a societal level, far upstream from the workhouses. Nightingale’s approach has been called “radical” because it advocated for public policy changes to correct the systemic issues at the root of the health problems seen downstream. Her actions led not only to improved nursing care, but also to social change that reduced economic and social inequities. Whereas her workhouse reforms are well known, the principle driving them, equitable access to health care based on need rather than affordability, and her proposal that those reforms should be paid for through progressive taxation, are less well known. Nightingale’s proposed changes included the legislative framework for the Metropolitan Poor Act and culminated, decades later, in the British government taking responsibility for that nation’s health through the National Health Service (Falk-Rafael, 2005). But Nightingale did not stop there; she advocated, for example, for income security, pensions, and education for all because of her conviction that these were measures that promoted the public’s health. Approximately 100 years later, at the primary health conference in Alma Ata, world health leaders came to a similar conclusion, issuing the Declaration of Alma Ata, and raising awareness of what became known as social determinants of health.
It seems to me that homeless shelters may be today’s workhouse equivalents. Addressing the underlying social and economic (upstream) issues that have contributed to the health inequities exposed by the pandemic challenge us to political advocacy for upstream policy changes. Cathy Crowe, a Canadian nurse activist, has long advocated for policies, such as affordable housing, to allow poorer people to afford housing. And, like Nightingale, she is also concerned with conditions downstream, in respite and homeless shelters. During the pandemic, she, with others, has brought attention to and tirelessly advocated for the City of Toronto to mandate 6’ spacing between cots in homeless shelters. To its shame, the City only agreed to this spacing many weeks later, after she and other advocates filed a lawsuit claiming that shelter crowding conditions were a violation of the Canadian Charter of Rights and Freedoms.
A second pandemic focal point in Canada, especially in Quebec and Ontario, are long term care (LTC) facilities. In Canada, long-term care is under provincial jurisdiction, and is not publicly insured under the Canada Health Act. Provinces and territorial jurisdictions may depend on one or more types of funding of LTCs, such as for-profit or private organizations, municipal and/or provincial funding, In Ontario, all LTC facilities receive some provincial funding.
Personal health is inherently political. McDonald asserted that “Nightingale knew that good health required decent social conditions, work, adequate housing, clean air and water.” CHPP 5 refers to providing, creating, and/or maintaining supportive and sustainable environments, including both immediate physical environments but also social, political, and economic environments (Falk-Rafael, 2020). Improving those environments requires public policy change. To reduce health inequities, policy changes are needed that serve to redistribute a nation’s wealth throughout the population, rather than allow it to accumulate in the top 1%. As Nightingale knew, the increased revenue from such taxation has the potential to fund other programs such as universal, publicly funded health care, including elder care, and education. Policies such as those to establish minimum wages or a guaranteed basic income help to reduce economic inequities; policies such as affordable housing and rent control help to reduce homelessness.
A healthy population depends on healthy public policies. Political action to effect necessary changes can range from informed voting to the comprehensive, systematic approach Nightingale used: taking advantage of powerful connections, providing well-reasoned arguments, and supporting those arguments with data obtained through reading, consulting with experts, and, if necessary, her own investigations. I believe, like Nightingale, it is nurses who need to take the lead in promoting policy changes to improve the public’s health because it is nurses who work at the intersection of public policy and personal lives.
Chinn, P.L. & Kramer, M. K. (2019) Knowledge development in nursing: Theory and process. (10th ed.), New York: Elsevier
Falk-Rafael, A. R. (2020). Adeline Falk-Rafael’s Critical Caring Theory. In Nursing Theories and Nursing Practice (5th ed.) M.C. Smith (Ed.), pp. 502-521. Philadelphia: F.A. Daviis.
Falk-Rafael, A. R., & Betker, C. (2012). Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: “The Trombone Slide” of Nursing. ANS. Advances in Nursing Science, 35(2), 98–112. https://doi.org/10.1097/ANS.0b013e31824fe70f
The single most important and essential step being taken worldwide to contain the spread of the COVID19 crisis is what is widely known as “social distancing.” But in fact this is physical distancing that heightens the risk of social isolation, conflict and stress. This necessary physical distancing is only tolerable for the most introverted of introverts, leaving the rest of the population in a state of periodic unrest at best, and deep distress at worst. We are then faced with not only the possibility of disease/illness caused by the novel corona virus – we are faced with the dis-ease of daily living. When the environment to which someone is compelled to retreat is a relatively safe haven that provides nurturing and encourages creative solutions to the inevitable frustrations and stress, the outcome will probably be okay at least – perhaps even resulting in some new and healthier patterns of daily living! But the reality is that for far too many, the environment of “home” is a place of emotional tension, sometimes even emotional and/or physical danger. For those who are “essential” workers – like many nurses – the workplace where they are now compelled to spend a considerable amount of time is one where their own physical well-being is at risk, and the culture may be also less than nurturing or pleasant – even abusive. Even the best of circumstances can easily erupt into harmful conflict and emotional tension at a moment’s notice, ignited by the stress and tension of the uncertainties and dangers that we all face in this pandemic.
Now more than ever the world needs nursing – the practice of caring for others informed by the knowledge and the wisdom passed along in the theories and philosophies of nursology. To me the unifying unique characteristic that is so vital as we face the COVID19 pandemic is the holistic nature of nursing theory and practice. There are many insights that any of us can tap into in any of our theories – now documented on this website and accessible through the site’s galleries.
My theory and practice of “Peace and Power” is among those that directly address the challenges of social and emotional conflict and distress – distress that also compromises physical well-being. The theory was developed as an approach to group process that shifts away from the power-over (often damaging) approaches that dominate group interactions, and toward an approach that nurtures all, that respects each person’s humanity, and that deals with conflict in ways that nurture growth and healing – not harm and hurt. The “group” can be as small as two people! Shifting to this approach is not easy and it is especially hard to start learning in a context already stressed by the current pandemic – but it can be done! The specific theoretical concept and practice is “conflict transformation.” This abstract concept is possible to translate directly into practice – into the realities of every-day life – starting with awareness of the potential for unrest during this challenging time, and the commitment to start practicing even with the smallest tension! Here are a few practical ideas for using this approach where you live and work now.
When you are directly involved in a stressful interaction:
If you can, acknowledge the situation as soon as you even suspect that this might escalate. Do not try to “fix” the conflict, simply acknowledge that it is happening, and ask for others to take time to reflect and find a new direction. If it is now already escalated, step in to share (briefly) your sense of what is happening, and to ask everyone to take time to breathe and reflect on what is happening. This may be a few minutes, or a few hours – maybe a couple of days.
During this time, take deep breaths every few minutes to calm and center your spirit. Focus on your own body/mind/spirit feelings and your own hopes for how this situation will unfold. Recognize and take into account the stress of the situation around you – in this case the pandemic and the real-life stress everyone is experiencing.
Shift to a place of inner calm, where you move away from blame and toward understanding of the situation as a whole.
Clarify the underlying values that you believe everyone in the situation shares.
Prepare your own “critical reflection” that you will share with the others involved. This reflection consists of these elements:
When (or about) … describe factually what happened when your feelings came to the surface.
I want, I offer .. describe what you envision happening next to move away from or resolve (transform) the conflict, even if it seems impossible to happen.
Because … name the value, goals or ideals that you share with the others who are involved.
Take a deep breath, and return to the situation ready share your reflection and invite the others to also move away from conflict toward peaceful and health-promoting interactions. Listen carefully to what everyone shares, and join with them in finding a path forward. The path might still be rocky along the way, but you will now have a foundation from which you can build. Keep the process of transforming conflict alive and well as you navigate troubled waters.
When you observe a stressful, potentially harmful interaction:
Acknowledge what you are observing, even if it is not immediately clear that something harmful is happening.
Offer to serve as a mediator or facilitator, bringing awareness of the situation to light, and encouraging a move away from harm and toward understanding
If others are open, share the “Peace and Power” process of conflict transformation as an approach to deal with the situation.
As we know, leaders transition to and from their positions within educational and clinical institutions. Meleis’ transitions theory, which focuses on “the human experiences, the responses, [and] the consequences of transitions on the well-being of people” (Meleis, as cited in Fawcett, 2017, p. 347) tells us that transitions may be anticipated, experienced in the here and now, or have been completed. Transitions may be development, situational, organizational, cultural, or well-illness; each type may occur singularly or with one or more others. (See https://nursology.net/nurse-theorists-and-their-work/transitions-framework-transitions-theory/)
Transitioning to or from a leadership position is a situational transition, which could be combined with a cultural transition as the nursologist moves to or from a new academic or clinical institution or even another country. The situational transition could be combined with a developmental transition as the nursologist enters another lifespan developmental phase. Furthermore, the situational transition could be combined with an organizational transition as an academic institution undergoes a major shift in priorities or a clinical agency merges with another clinical agency.
Alternatively, the transition of a nursologist to or from a leadership position could create an organizational transition as all affected people and structures adjust to the change. Finally, the situational transition, especially transitions from a leadership position, could be combined with a wellness-illness transition if the nursologist experiences a sudden acute illness or can no longer effectively manage a chronic disease.
One question about leadership transitions is: How does a nursologist transition to becoming an effective leader? Another question is: Is there an optimal time for a nursologist to transition to or from a leadership position?
HOW DOES A NURSOLOGIST TRANSITION TO BECOMING AN EFFECTIVE LEADER?
Transitioning to becoming an effective leader obviously first requires a desire to be a leader, although at times, a nursologist may find self gently (or not so gently!) pushed into a leadership position by colleagues or senior administrators or by a vacuum left by someone who transitioned from the position suddenly.
Transitioning to becoming an effective leader also requires certain competencies. The American Organization of Nurse Executives (now the American Organization for Nursing Leadership) identified five competencies for effective leadership in practice and education (Waxman, Roussel, Herrin-Griffith, & D’Alfonso, 2017). Although the competencies focus on those for executive level leadership positions, they are relevant for all levels of leadership. The five competencies are listed here. The specifics of the competencies are available in the Waxman et al. (2017) journal article or at https://www.aonl.org/resources/nurse-leader-competencies:
Communication and relationship-building
Knowledge of the healthcare or academic environment
Business skills and principles
The nursologist may already have acquired these competencies or has to acquire them by enrolling in a formal program and/or finding a mentor or leadership coach. Formal programs for nursologists are offered by Sigma Theta Tau International, the American Association of Colleges of Nursing, the American Organization for Nursing Leadership, and the Robert Wood Johnson Foundation. The programs are:
Mentors and leadership coaches may be included within formal programs or the nursologist may have to approach recognized leaders and ask that they share their wisdom about leadership.
IS THERE AN OPTIMAL TIME FOR A NURSOLOGIST TO TRANSITION TO OR FROM A LEADERSHIP POSITION?
Aspiring or actual leaders may ask: Am I too young or too old to transition to or from a leadership position? Inasmuch as many institutions do not have mandatory age requirements for employees, wisdom is an important element of the transition decision. Although, as Larson (2019) pointed out, wisdom may come with older age, my experience indicates that younger persons also may be wise. Wisdom at any age requires nursologists to use “mindfulness, empathy, and self-reflection to learn from their mistakes, failures, and successes over the years” (Larson, 2019, pp. 789-790). Thus, those people who aspire to be leaders or already are leaders may want to heed Larson’s words and engage in serious self-assessment to determine whether they are ready to transition to or from a leadership position. In addition, aspiring or actual leaders may want to assess their leadership competencies, which can be done using a self-assessment instrument that is available at https://www.aonl.org/resources/online-assessments.
Fang and Mainous (2019) examined factors related to short term deanship, which they regarded as problematic. (A short tenure leadership position is one that ends sooner than the specific term of the position, such as 3 years or 5 or 6 years.) Their study of data from the 2016 American Association of Colleges of Nursing Annual Survey revealed that certain personal and organizational characteristics are associated with short tenure chief nursing academic administrator positions, including the titles of dean, chair, director, or department head. The characteristics are: age (60 or older) at beginning of the leadership position, having a title other than dean, being a dean who subsequently takes another deanship, being a first time dean, being a dean in a school without a tenure system, and being a dean of an associate degree program or a baccalaureate degree program.
As I read Fang and Mainous’s (2019) article, I wondered whether short tenure leadership positions are always problematic. Could it be that the position is not consistent with what the person hopes and dreams it will be? Could it be that the person’s leadership style is not conducive to inspiring a faculty or clinical staff to attain personal, professional, and/or organizational goals? Perhaps, then, transitioning from a short tenure leadership position may be a positive event for the nursologist leader and for the faculty or clinical staff. Perhaps everyone breathes “a sigh of relief” that the leader has transitioned from the position (Larson, 2019, p. 789).
Another situational transition, which may be combined with a developmental transition and which affects almost everyone, is retirement. Those nursologists who are contemplating retirement most likely were or still are leaders in the institutions where they work, even if they are not “official” leaders, such as deans, directors, or chairs. Larson (2019) discussed her decision to retire from her faculty position. She regards retirement as “the next transition in my career development” (p. 789). At age 76, Larson (2019) noted, she “made the scary and difficult decision to retire in less than a year . . . [and] not wait until people breathed a sigh of relief that I was finally gone” (p. 789).
Meleis (2016) wrote about her situational transition of anticipating, experiencing, and completing stepping up from a deanship. She explained that stepping up “connotes climbing to a higher place in our lives, taking with us what we learned in the previous [step]” (p. 187). Meleis identified and described five phases in the transition to and from a deanship. I will presume to be so bold as to generalize Meleis’ (2016) description of the deanship transition to all leaders, add a sixth phase (expressing an initial professional voice), and adapt the phases to both transitioning to and from a leadership position. The six phases are:
Expressing an initial professional voice
Deciding to transition to or from a leadership position
I applaud those nursologists who are willing to transition to a leadership position and congratulate those who have transitioned from a leadership position. I send best wishes to all for much happiness, wellbecoming, and exciting and stimulating next ventures in stepping up.