Psychoneuroimmunology in Nursing

Contributor: Christine Hodgson, MSN, RN, CPNP-PC

In the first week of my nursing Ph.D. program, I heard a brief presentation from a professor who taught “psychoneuroimmunology.”  I had never heard that word, but I knew I had to take that class.  I was entering my Ph.D. journey after a long career as a primary care pediatric nurse practitioner. I had started to feel a thirst for knowledge about the mind-body-spirit connection, how it relates to wellness, and how we can implement integrative healthcare across cultures. Fortunately, my first year included a class on nursing theory development and evaluation, so I was prepared to enter this mysterious class with my newly solidified personal worldview, epistemology, ontology, and favorite nursing theories.

“Complexity” by Owen Hodgson (age 17)

Psychoneuroimmunology (PNI) did not strike me as a theory at first. I had just finished refresher classes in endocrinology and immunology, wherein having an old textbook didn’t matter too much because these reductionist sciences were slowly changing. On the other hand, I quickly learned that PNI was a young theory about bi-directional communication among the mind-brain-immune-endocrine systems that was gaining an evidence base and interest across many disciplines. My professor, Dr. Pace, noted that he loved teaching nurses because we “are so good with theories.” I stopped to think about how PNI contrasted with the nursing theories I had learned…as well as how it aligned with nursing theories (more on that later).

What is PNI?

PNI is a re-emergence of ancient beliefs that organisms are integrated systems (Daruna, 2012, p.13). Robert Ader was a psychologist who, along with Nicholas Cohen, originated PNI and advanced the field of mind-body science in 1980 (Daruna, 2012, p.21). Ader’s discovery that rats could be trained to have a particular immune response came at a time when biomedical science was ready for a new holistic theory. PNI has established that the immune system crosses the blood-brain barrier affecting physical, cognitive, psychological, and behavioral functions. Probably the most well-known model within PNI is that of the Stress Response (Pace, 2020, October 26). Acute psychological or physical stress activates pro-inflammatory cytokines such as IL-1 and IL-6. Acute stress also shifts the body’s homeostasis to a sympathetic (fight or flight) response and triggers the hypothalamus-pituitary-adrenal axis (HPA) to release cortisol. These acute immune mechanisms help protect the human organism in the short term. However, chronic or cumulative stress can lead to inflammation and cortisol dysfunction. In addition to physiologic changes, cytokines affect neurotransmitters leading to changes in cognition and behavior. Pace summarized how multiple complex pathways related to stress and inflammation increase the risk for physical and mental illness throughout life.

What are PNI Interventions?

We can measure immune biomarkers through blood or saliva, so scientists have been able to test interventions that prevent or disrupt the stress-immune pathway. Mindfulness, meditation, nutrition, exercise, sleep, and counseling are just a few PNI interventions that have an evidence base for various illnesses (Pace, 2020, November 23). Nursing practice already values these nurturing and accessible tools, so we are all PNI practitioners.

PNI and Nursing Theory

I believe our very first nurse theorist, Florence Nightingale, would have appreciated the tenets of PNI. Not only did Nightingale’s prescient focus on infection control address the immune system’s role in health, but her methodical and statistical approach to nursing also laid the foundation for complex knowledge discovery (Nelson & Rafferty, 2011). Grand nursing theories that followed Nightingale’s work included those in the integrative-interactive paradigm, which views a patient as an interactive whole capable of a multitude of adaptation responses to their environment. Examples of integrative-interactive conceptual models include Sr. Callista Roy’s adaptation model, Betty Neuman’s systems model, and Barbara Dossey’s theory of integral nursing (Smith & Parker, 2015, p. 88). The field of PNI is producing voluminous empiric evidence that the human body is an interconnected whole, which supports these holistic nursing theories.

For a more specific example of how a nursing theory could guide a hypothetical PNI research study about the long-term effects of stress, I will refer to Betty Neuman’s systems model (NSM) (Lowry & Aylward, 2015) and provide a conceptual-theoretical-empirical structure (Gigliotti & Manister, 2012). I hypothesize, based on previous research (Felitti et al., 1998), that adverse childhood events (ACEs) cause inflammation that leads to cardiovascular disease (CVD) later in life, and smoking behaviors mediate the relationship. NSM is a model about a client’s adaptation to internal or external stressors and includes the client concepts of stressor, invasion of the normal line of defense, lines of resistance, and core response (Lowry & Aylward, 2015). The theoretical linkages of PNI in my study are ACEs, cortisol response via the HPA axis; inflammation/cognitive changes/maladaptive behaviors; and cardiovascular disease, respectively. The empirical measures of these links are a self-report ACE questionnaire; salivary cortisol levels; attenuated cortisol response measures/depression and anxiety symptom survey; and blood pressure/cholesterol/smoking behaviors, respectively. Here physiological and psychological variables of the hypothesis are directly measured, allowing us to understand the more abstract concepts of the NSM and their relationships to one another. The NSM also includes a concept of intervention as prevention that aligns with the wellness focus of PNI.

Nursing Knowledge Development and the Future of PNI

Despite congruence with existing nursing theories, incorporating PNI in developing a new middle-range nursing theory could move down the ladder of abstraction to a more concrete explanation of concepts (Smith & Liehr, 2018, chapter 2). For example, a middle-range PNI nursing theory might focus on the prevention and treatment of ACEs with children and their families. PNI emphasizes the natural healing processes of humans, is adaptable to the personalized or the public health level, and even has economic benefits to a healthcare system (Daruna, 2012, p. 280-83). If we adopt a nursing PNI conceptual model for wellness and prevention, we can improve outcomes such as depression, diabetes, cancer, heart disease, autoimmune diseases, and more.

Two years after my introduction to the term psychoneuroimmunology, I am preparing for my comprehensive exams. As I reflect on my Ph.D. curriculum, I realize the degree to which nursing theories and PNI have already informed my nursing research and practice. I hope to contribute to a future where nurses, guided by theory, have more understanding and tools to care for the complex human being…but first, back to studying!

References

Daruna, J. H. (2012). Introduction to psychoneuroimmunology. (2nd ed.) Elsevier, Inc.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8

Gigliotti, E., & Manister, N. N. (2012). A beginner’s guide to writing the nursing conceptual model-based theoretical rationale. Nursing Science Quarterly25(4), 301–306. https://doi.org/10.1177/0894318412457060

Lowry, L. W. & Alyward, P. D. (2015). Betty Neuman’s Systems Model. In M. C. Smith & M. E. Parker (Eds.) Nursing theories & nursing practice. (4th ed., pp. 165-181) F. A. Davis Company.

Nelson, A. M. & Rafferty, S. (Eds). (2011). Notes on Nightingale: the influence and legacy of a nursing icon. (1st ed.) Cornell University.

Pace, T. W. W. (2020, October 26). Stress as a risk factor for illness. [Powerpoint slides]. University of Arizona College of Nursing, Psychoneuroimmunology: Foundations and Clinical Implications. D2L: https://d2l.arizona.edu/d2l/home

Pace, T. W. W. (2020, November 23). PNI mechanisms of wellness I. [Powerpoint slides]. University of Arizona College of Nursing, Psychoneuroimmunology: Foundations and Clinical Implications. D2L: https://d2l.arizona.edu/d2l/home

Smith, M. J.  & Liehr, P. R. (2018). Middle range theory for nursing. (4th ed.). Springer.

Smith, M. C. & Parker, M. E. (Eds.) (2015). Nursing theories & nursing practice. (4th ed.). F. A. Davis Company.

About Christine Hodgson

Christine Hodgson has been a pediatric nurse practitioner for over 20 years. She currently works in school-based health clinics, including one on an Indian reservation. She lives in Montana with her husband who is a pediatrician, three sons, and two golden retrievers. She loves to hike, bike and ski in the mountains, travel and read. She plans to study the resilience of indigenous children around the globe.

Peace and Power Process in Action in Nursing Department Meetings: A Case Study

Jacqueline Fawcett
Lisa Sundean
JoAnn Mulready-Shick

Academic department structures and governance tend to reflect university–wide structures and governance that are typically characterized as hierarchical, competitive, and power-over/power as control. The decision to revise a department of nursing by-laws provided an opportunity to transition to adopt a more egalitarian structure with shared governance between the department faculty and the department and college administrators.

Consequently, during Academic Year (AY) 2017-2018, the faculty of a department of nursing agreed to a new governance structure that involved development of by-laws for the department. Three faculty members then agreed to serve on a committee to revise our department by-laws. The By-Laws Committee members first considered our previous traditional use of Robert’s Rules of Order for department meetings and recognized those rules as a patriarchal power-over/power as control structure. As we questioned assumptions and traditions, we determined that Robert’s Rules no longer served us and did not support our desire for a more progressive, egalitarian structure of group process and shared governance. We therefore suggested using the Peace and Power process .

The purpose of the Peace and Power process is to guide group process “in cooperative and peaceful ways, and in ways that challenge the status quo and lead to social and political change in the direction of equality and justice for all . . . . the process . . . also [is] . . . .a means of creating healthy group interactions and promoting health by reducing stress and distress created by hostile conflict” (Chinn & Falk-Rafael, 2015, p. 62). The theory of Peace and Power “provides a framework for individuals and groups to shape their actions and interactions to promote health and well being for the group and for each individual, using processes based on values of cooperation and inclusion of all points of view in making decisions and in addressing conflicts. Based on the processes . . . individuals and groups can make thoughtful choices about the ways they work together to promote healthy, growthful interactions and avoid harmful, damaging interactions” (Chinn, 2018).

Perhaps most important is that the Peace and Power process is a way to operationalize power-as-freedom, that is, freedom to knowingly participate in change (Barrett, 2010) instead of power-over/power as control. Thus, the emphasis is on the solidarity of our department learners (aka faculty, staff, and students) rather than power held over the group by any one individual or authoritative body.

Following successive drafts and revisions based on faculty feedback, the department by-laws were approved by the department faculty in Spring 2019 and were implemented in Fall 2019. The by-laws included the stipulation that department meetings would be conducted using the Peace and Power process. Faculty also recognized their need to engage in new learning about this innovative method .

The faculty agreed that the Peace and Power process reflects the shared values and commitments formed by the group. Specifically, the faculty agreed that the Peace and Power process is consistent with our department values (Integrity, Inclusion, Diversity, Transparency, Transformation, Resilience, Relationships, Accountability, Collaboration, Equity, and Excellence) and a department goal to implement the department by-laws. Noteworthy is that the department values are consistent with two of the university-wide values–transformation and engagement. The Peace and Power process also supports the initial implementation efforts within the department and the entire university to eliminate structural racism and to promote diversity and inclusion. Incidentally, the transition to Peace and Power process as a means to shared governance and a healthy work environment is supported by the recent release of the Future of Nursing Report 2020-2030: Charting a Path to Achieve Health Equity (National Academy of Medicine, 2021). Specifically, among the 54 sub-recommendations is an emphasis on improved nursologist well-being through healthy work environments that include structural, socio-emotional, justice, and policy foci.

During the first department meeting of Fall 2019, faculty were intentionally reminded of the new by-laws and the Peace and Power process by members of the By-Laws Committee. Implementing the Peace and Power process in the department involves rotating leadership of monthly department meetings. This means that the department chair does not chair each department meeting; instead, after a slow start in AY 19-20, by AY 20-21, a different faculty member volunteers to convene and lead each meeting. Furthermore, the department meetings operate within values-based decision-making and mutual agreement of best options by means of consensus building discussions during department meetings and anonymous online voting as needed, such as elections to committees and final decisions about curriculum and programs. Moving critical voting decisions to the anonymous online format extended over a short period of time, ensures that all voices are included and that votes are not potentially coerced by peer pressure.

During AY 2020-2021, the By-Laws Committee members engaged in a series of micro-learning sessions to raise awareness about the content and meaning of the by-laws, including a more thorough explanation of PEACE powers (Chinn, 2013). A Fall 2020 micro-leaning session focused on differences between discussions that could be characterized as diversity or divisiveness. This session was added to the meeting agenda and presented by the department chair. The Spring 2021 micro-learning sessions focused on familiarizing faculty more thoroughly with the content of and more fully operationalizing the Peace and Power process. One micro-learning session focused on the outcome of the Peace and Power process as “movement that is ever shifting to the direction of peace” (Chinn, 2013, p. 10), along with the meaning of the word, PEACE, which is the acronym for five powers:

  • Praxis—synchronous reflection and action to transform the world
  • Empowerment—growth of personal ability to enact one’s will in the context of love and respect for others
  • Awareness—growing knowledge of self and others
  • Cooperation—commitment to group solidarity and integrity
  • Evolvement–commitment to deliberate growth and change (Chinn 2013, p 10 ).

The PEACE powers are operationalized when values and commitments are formed by the group (i.e., the faculty), when department meeting leadership rotates among the faculty, and when values-based decision making and mutual agreement of best options occurs.

During the Spring 2021 semester, each department meeting concluded with a request for reflections. Examples of reflection prompts, which were meant to prompt reflections about the process of Peace and Power during department meetings, are:

  • Please share an appreciation for someone or something that has happened during this meeting today.
  • What could have been different in today’s meeting and how would future meetings be shaped?

Faculty were asked to place their answers/reflections in the zoom chat box (department meetings throughout the pandemic were held via zoom technology). Examples of responses are:

  • I appreciate the discussions today which were very civil and constructive.
  • I appreciate the discussions [of] awareness of individuals and their feelings.
  • I enjoy listening to others perspectives and thoughts.
  • I appreciate the open communication and problems solving about common challenges (e.g., email overload for everyone!)
  • The meeting today was a very good example of the Peace and Power Process, so thank you to everyone for your contributions to our dialogue.
  • Appreciate the positive communication and openness to hear all voices
  • Thank you to everyone for sharing their thoughts on this topic…a good question for us to ponder further is how do we operationalize self- care and meet our department goals?

The By-Laws Committee members recognize the ongoing nature of implementation of the structural change for the department. Accordingly, future plans are to create a standing agenda item with the intention to further sustain the Peace and Power process at the monthly meetings. Two specific future actions include additional micro-learning sessions and ending each department meeting with a reflective practice.

We gratefully acknowledge the excellent contributions of undergraduate nursology learner Stephen Miller (BS, December 2021) and PhD nursology learner Julianne Mazzawi (PhD, June 2021) to the micro-learning sessions.

References

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

Chinn, P. L. (2013). Peace and power: New direction for building community. Jones & Bartlett

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

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

National Academy of Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. https://nam.edu/publications/the-future-of-nursing-2020-2030/ i

Contributors

Co-contributors with Nursology.net team member Jacqueline Fawcett

Lisa J. Sundean, PhD, MHA, RN is an Assistant Professor at Fairfield University and formerly at the University of Massachusetts Boston. She is Board Chair of the CT Center for Nursing Workforce, Board Member of the CT League for Nursing, a consultant for the Center to Champion Nursing in America, a national leader with the Nurses on Boards Coalition, and a Fellow in the New York Academy of Medicine. Her research and scholarship focus on nurses in board governance roles, health policy, and nursing workforce development. Dr. Sundean is a Daisy Foundation Award recipient for Extraordinary Nurses.

JoAnn Mulready-Shick, EdD, RN, CNE, ANEF, is a Clinical Professor in the Department of Nursing, UMass Boston, and a Nurse Scientist at the Boston VA Healthcare System. Her scholarship centers on nurse educator development, student success, and clinical education innovation.

Structure and Design as an Expression of Nursing’s Ontology

“When I walk in the door of the College of Nursing building I feel different.  There is something deeply peaceful about this place.” “I can’t put my finger on it, but when I’m here I can think, feel, and connect to myself…I’m present ”. “It’s not like any other building on campus. It’s about studying nursing from the inside out”.

Over the 15 years that I’ve been fortunate enough to call Florida Atlantic University’s Christine E. Lynn College of Nursing (CELCON) my home I’ve heard these and many similar comments about being in the College of Nursing’s building. I joined the faculty in 2006 when the building was new, and my direct experience of the building was one of the factors that drew me to this College. The ontology of nursing was vividly re-presented in the building’s architecture and design. The design of the building was an intentional process, meticulously planned and implemented by Anne Boykin, Dean at the CELCON for over 30 years, co-author of the theory of Nursing as Caring, and a transformational leader. The focus of the discipline of nursing: caring, human wholeness, and the interrelationship of wellbeing to the human-environment relationship (Smith, 2019) informed the creation of this “home” that truly reflected the heart and soul of nursing. Dr. Boykin collaborated with architects who understood her vision and captured it in the structure and design of the building. It is an example of creating living spaces that reflect foundational values (Boykin, Touhy & Smith, 2021).

The College of Nursing building was created to be a healing environment that reflected three guiding ideas: 1) the College’s philosophy of caring, including its definition of nursing; 2) a reverence for the environment and its centrality to wellbeing; and 3) the harmonious flow of energy through attention to structure and design, referred to as feng shui in Chinese philosophy. (Smith, 2019, p. 290). “The purpose of the building was to create a living, breathing place that invites, teaches, houses, protects and nurtures” (Boykin & Raines, 2006, p. 45).

Having a home for the College of Nursing was Anne Boykin’s dream, and a generous philanthropist and fellow nurse and friend, Christine E. Lynn, funded the building. The building is 75,000 square feet with three floors, with a circular design to reflect wholeness and connectedness. “The College is dedicated to Caring: advancing the science, practicing the art, studying its meaning, and living caring day-to-day”. Nursing is defined as “nurturing the wholeness of person-environment through caring” (https://nursing.fau.edu/about/college-at-a-glance/vision-and-mission.php). This core dedication to the mission is cast in the terrazzo floor of the atrium of the building as the “dance of caring persons”. It is a visual reminder of the College’s philosophy and model of relating. The dance is grounded in respect and valuing of all persons who are encouraged and supported in a culture that values persons living caring and growing in caring. (https://nursing.fau.edu/about/college-at-a-glance/index.php).

The atrium faces a garden with trees and plants known for their healing properties, rocking chairs and benches, and a labyrinth, an ancient symbol of self-reflection and wholeness. Walking the labyrinth is a journey to our own center and back again out into to the world. (Boykin & Raines, 2006, p. 46). This labyrinth is unique in that it is oval rather than round; its designer felt that the shape represented the face, the place of human connection between nurses and others. The healing garden is an environment for students, staff and faculty enjoy. Palm trees and other plants are around the building. Bamboo is on each side of the entrance of the building is a symbol of blessings within. The color of the exterior and interior of the building is mostly earth tones, a nurturant element that most closely represents nursing.

View from the 2nd floor of the Atrium that looks out at the garden, featuring the “Dance of Caring Persons” image embedded in the floor.

This unitary perspective on person-environment integrality led to creating a “green” building, one that embraces principles of sustainability and stewardship of the earth. The building is designated as a Leadership in Energy and Environmental Design (LEED) gold-certified building. It features minimal destruction of the earth surrounding the building, water savings through low flow toilets and recycled water for garden irrigation, healthy indoor air and natural light throughout the building, construction using materials and appliances that decrease impact on deforestation and the environment, use of products and supplies that are natural and non-chemical, and energy efficiency. (Boykin & Raines, 2006).

The feng shui design principles are based on creating environments in which people feel comfortable and supported. Feng shui masters and experts in healing architecture consulted from the beginning on the design elements. Before the groundbreaking the feng shui master engaged the College community in a ritual blessing ceremony to honor the land and prepare the earth to accept and nurture this new home. (Boykin & Raines, 2006). The front of the building faces north, the most propitious direction. The back of the building borders on a lake. Water is a source of life, and this water source is visually incorporated through river rock in the garden that visually is contiguous to a swath of black tile that flows throughout the building. A bagua or feng shui blueprint guided the placement of different areas in the College. The five elements of earth, water, fire, wood and metal are used in particular areas of the building along with the colors and shapes they represent. For example, “helpful persons” on the first floor is the office of Student Support Services housing advisors and assistant deans, while on the third floor it is the Dean’s Suite. The element of wood using block shapes permeates the design in this area along with the color green. Another example is that the Office of Research and Scholarship is located in the “prosperity” area of the bagua represented by the fire element with angular shapes and the color red.

The three floors of the building have different purposes; the first floor is the welcoming space for the community. The second floor is focused on spaces for students including large and smaller classrooms with connectivity for distance learning, a kitchen with communal eating space, the lab area for simulation and skills practice, and individual and group study areas, a large doctoral student study room and the Center for Nursing Research and Scholarship. The third floor has the suites for the Dean, administrative support staff, eminent scholars, associate deans, faculty offices, several conference rooms and a faculty kitchen and eating space.

Other unique features that reflect nursing’s ontology are open spaces for gatherings and events, a museum and the Archives of Caring (the only archive in the world that houses the work of caring scholars), a large yoga or exercise space with a bamboo floor, a holistic space for classes and a room with a massage table, and a “sacred space”, a room for meditation, reflection or contemplation.

The ontology, or essential nature of nursology, is reflected clearly in the structure and design of the Christine E. Lynn College of Nursing. It is an environment that nurtures the growth of students, faculty and staff in bringing the values to life in all missions of the College: teaching, research, practice and service. “Through intentional design features the concepts of reflection/mindfulness, aesthetic appreciation, healing environments, human-environment integrality, holistic health, and the significance of self-care to the being-becoming of the nurse are prominent”. (Smith, 2019, p. 290).

Sources

Boykin, A. & Raines, D. (2006). Design and structure as an expression of caring. International
Journal for Human Caring, 10(4), 45-49.

Boykin, A., Touhy, T.A. & Smith, M.C. (2021). Evolution of a caring-based college of nursing.
In M. Hills, J. Watson & C. Cara (Eds.), Creating a caring science curriculum: An
emancipatory pedagogy for nursing (pp. 187-200). New York, NY: Springer Publishing.

Smith, M.C. (2019). Advancing caring science through the missions of teaching,
research/scholarship, practice and service. In W. Rosa, S. Horton-Deutsch & J. Watson (Eds.), A Handbook for Caring Science: Expanding the Paradigm. (pp. 285-301) New York, NY: Springer Publishing.

Smith, M.C. (2019) Regenerating the focus of the discipline of Nursing. Advances in Nursing
Science. 42(1), 3-16,

Theory’s Reality in Nursing Practice: Florence Nightingale’s Legacy

Contributor: Isabel Faia

The contemporary imbalance in environmental matters predominantly involve climate change and our supposedly beloved home planet’s ecosystems issues. Human beings are continuously disrespectful of their relationships with the universe ecosystem.

Humankind is responsible to a great extent for this state of “dysbiosis” of our planet, which is similar to the state of each person’s gut microbiome. This lack of balance and harmony in nature, is the root cause of the emerging of new and complex pathological challenges, which, like the Covid-19 pandemic, have become impossible to ignore. Countries the globe over have been forced to take very strict contingency measures, with different levels of freedom and restrictions in order to slow down the devastating effects of sickness and death that the virus has caused.

Healthcare professionals have an important role in managing the many menacing threats to populations of our planet, their well-being and survival. Nursing as a professional discipline, has many theories that can use used to as evidence for safe and competent practice. The concepts of Fawcett’s metaparadigm of nursing provide a way to understand and guide nursing during the pandemic – human beings, environment, health, nursing  However, given the reality of our current world, other key concepts also provide paths that guide our understanding of the reality we face in the pandemic. 

I contend that we are closing a cycle, a full 360° spin, that brings us back to Florence Nightingale’s work. From Nightingale’s framework, the nurse’s primary role is caring and helping people in their healing process. Nightingale told us that the environment is a key influencing factor in this process, which when operationalized, can increase the potential for recovery and survival. Nursing care in this framework emphasizes the optimization of ventilation and natural lighting of spaces, noise reduction, frequent hand washing and disinfection, hygiene of spaces, among other aspects of the environment. Nightingale supported the importance of these environmental aspects, by collecting and statistically analyzing data from everyday practice.

We can use the symbol of the lamp to illuminate the paths of what today’s nursing practice can be, and promote multidisciplinary recognition of nurses profound contributions to population health. We face the fact that 200 years since Nightingale’s ideas were first published, widespread recognition nursing at both the ontological and epistemological levels still remains a challenge to overcome. Therefore, we all have to effectively communicate to our communities worldwide a clear vision of what nursing is.

At a personal level, I have just completed two decades of my career as a nurse, predominantly caring for critically ill patients in the context of urgency/emergency rooms and also in an intensive care unit. This led to an experience marked by a great many interdependent nursing activities, which contribute to the progressive distancing from fundamental nursing theoretical thinking. I perceive myself in a state of profound professional numbness. Not meaning that the quality of my autonomous nursing activities were questionable, but instead were automatically executed and with little awareness of theory. This is similar to an experienced car driver, who over the years enters into a state of relative unconsciousness, an automated practice, when driving. This progressive loss of professional identity became evident in the scope of the Masters in Critical Care Nursing Specialty that I am currently attending at Univesidade Católica Portuguesa (Lisbon). When re-visiting in class the evolution of thought in and the production of knowledge throughout nursing’s history, in a short time and instinctively my practice gained the semantics of nurses’ expression, more specifically in content format and other implicit dimensions, as if it were on standby and with a click it would switch on. What seemed difficult to transfer into practice, proved to be the root of my daily professional practice.

That is why when I read the post The Impossibility of Thinking “Atheoretically” (Fawcett, 2019) in Nursology, suggested by the Master’s Nursing Theories Chairwoman, I cathartically identified with it. In my experience of hibernated nursing and of unconscious semantics, in the past I considered myself to be a nurse distant from theories, which would belong to an exclusively academic context. Now I confess that this process was a boost of vital energy, illuminating and motivating me to an increasingly challenging and exciting life as a nurse.

About Isabel Faia

I’m an ICU nurse since 2014, working for the past 20 years in a public hospital in Madeira Island, Portugal. Presently, I am doing a Masters in critical care nursing, at Health Sciences Institute, UCP Lisbon. This post was made in the nursing theories curricular unit of the Masters in Nursing Course of the Health Sciences Institute of UCP (Lisbon), with the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).

COVID-19 Through the Lens of Nursing Theories

Contributor: Navninder Kaur, MSN, CMSRN


It all started in January of 2020 when the news started circling around about a contagious viral disease spreading in the East. The situation was not much of a concern, with a thought that just like other diseases like SARS, which originated and spread in one region, it will subside soon. However, as essential resources like gloves, masks, and hand sanitizers started disappearing from store shelves around the last week of February, and come March, our hospital had its 1st case of COVID-19. Soon, things got chaotic and out of hand, when we started running out of PPE’s, medical and ICU beds, ventilators, and staff to take care of patients. While hospitals were overwhelmed with the extensive virus outbreak, health care professionals came to the frontlines, fighting the unknown enemy, without any specific treatment.

Every member of the health care industry was directly or indirectly affected by the virus or its consequences, and above all, nurses played a crucial role in this fight. Nurses, comprising more than 50% of the health care and allied professionals, plunged into desperate conditions to care for human lives. What made their role even more paramount was that they spent far more time with patients than any other member of the healthcare team. Even the nurses who were pregnant, breastfeeding, elderly, retired, had co-morbidities or were students put their patients before their own families and health.

Nursing has evolved through wars and pandemics. The Crimean war led Nightingale to shape modern nursing practice. Her environmental theory saved many lives and improved the face of public health. With the ongoing pandemic, all nurses have a bit of Nightingale in them, working under tremendous pressure to address population needs. In the Year of the Nurse and Midwife, nurses raised concerns of public awareness

What set nurses apart from physicians, respiratory therapists, anesthesiologists, and other health care professionals in this time of incredible adversity? While all of these professionals’ focus is on science and empirical knowledge, it is a strong foundation of nursing theories, frameworks, and models that separate nursing from other professions. Knowingly or unknowingly, nurses have implemented nursing theories in their practice during these times of crisis. Whether it is identifying environmental components as outlined by Nightingale or Abdellah’s 21 nursing problems including physical, social, and emotional, or Johnson’s behavioral system model in which constancy is maintained through biological, psychological, and sociological factors or Neuman’s model which emphasizes that a person is a complete system, nurses have not just treated the “illness” but addressed the patient as a “whole”.

When COVID hit our hospital, our administrators outlined policies based on the recommendations of infectious disease specialists, and nurses were asked to limit visits to patients’ rooms to twice per shift to minimize the spread of infection. Nurses could not swallow that; we ended up being in the room 7 to 8 times on an average! Perhaps that contributed to 85% of patients who were successfully discharged from hospitals.

Above all, it was the application of Watson’s 10 carative factors that played a substantial role in the discipline of nursing during these difficult times. Despite the strict visitation policies put in place by hospitals, nurses made sure families were able to connect to their patients via video conferencing. This nursing action cultivated the spirit of love and kindness. They let family members and loved ones know they could contact as many times as possible during the day. Nurses listened to their fears and promoted their expression of feelings. Social media has a plethora of photos and videos of nurses holding patients’ hands, sitting at the bedside of dying patients when no family members could be present. Nurses comforted family members who had psychological stress and negative emotions from not being present with their loved ones during their last moments. Nurses made it possible for my family to wish goodbye to my father-in-law who was 200 miles away from us and passed away after losing his fight against this disease.

By embracing Leininger’s culture care theory, nurses provided care with transcultural understanding, sometimes performing rituals, praying with the patient, while connected with their families on the phone/video, and providing holistic care. During an unrelenting global pandemic, nurses have promoted transformational changes to sustain and preserve human dignity.

About Navninder Kaur

Navninder Kaur is a student in the Online Nursing Education EdD program at Teachers College, Columbia University. She is a clinical instructor at Western Connecticut State University in Danbury, CT. She has 10 years of clinical experience in adult medical-surgical nursing.

Examining the Evolving Role of the BSN-Prepared Nurse outside Acute Care Settings: A Nursing – Shared Theory/Conceptual Model Approach

Co-Contributor: Katunzi Mutalemwa

The purpose of this blog is to describe a baccalaureate (BSN) prepared nursologist’s, Katunzi Mutalemwa personal lived pre-internship clinical learning experience in primary care at a local community-based non-governmental outpatient clinic run by The Tanzania Doctors with African CUAMM  in collaboration with a local District hospital.

Katunzi’s reflections have been interpreted within the context of nursology discipline-specific knowledge of Neuman’s Systems Model (NSM), and the Theory of Self-Care of Chronic Illness (TSCC), as well as the Expanded Chronic Care Model, a model shared with public health.

Inasmuch as the ECCM is a shared model, the starting point for the interpretation is the nursology discipline-specific conceptual model that is NSM (Villarruel et al., 2001). Whereas the NSM guided the overall understanding of the reflections, the concepts of the TSCC guided some of the specific actions described, as did the ECCM. The NSM provides a nursology conceptual foundation that takes into considerations the multiple levels of client/client system influences – the physiological, psychological, socio-cultural, developmental and spiritual interacting factors and environmental stressors. The model has the potential of advancing the future of nursology in the area of expanded nursing scope of practices and services in response to chronic disease management.

Katunzi’s reflections highlight the role of the BSN-prepared nursologists in the management and prevention of chronic diseases beyond the walls of the acute care settings (i.e., community-based primary health care settings)

The main ideas seen in this blog are consistent with the World Health Organization’s (2020) State of World Nursing publication, the nursology.net blog Primary-care-primary-nursology-and-the-attending-nursologist, the AACN White-Paper on the Vision-Academic-Nursing; the Health Resources & Services Administration (HRSA) 2018 call for Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program as well as several journal articles on the role of the primary care nursologist (e.g. Anderson et al., 2012; Bodenheimer, & Mason, 2016; Borgès Da Silva et al., 2018; Epping-Jordan, 2002; Lipstein, et al., 2016; Norful, et al., 2017).  The description of the roles and responsibilities discussed in this blog acknowledge the varied contextual nursing scope of practices across the globe.

Katunzi’s Nursing Context/Situation

The personal reflections demonstrate how a BSN-prepared nursologist practices within the Tanzania Nursing and Midwifery Council (TNMC) (2014) general nurse full scope of practice. The TNMC’s major role definitions of a general nurse prepared at the baccalaureate level are: 1) Accountability, Ethical and Legal Practice; 2) Care Provision, Health Promotion, Leadership and Management and, 3) Professional, Personal and Quality Development. For instance, the care provisions and leadership definition of the TNMC general scope of practice, the BSN-prepared nurse roles includes, but is not limited to developing practice guidelines, representing nursing at the management meetings, preparing and presenting nursing budgets at management team meetings, participating in nursing research and utilizing research results in provision of nursing care, providing comprehensive nursing care and carrying out nursing management independently, formulating relevant policies about patient and client care, and reviewing performance appraisal for nurses. According to the TNMC, if assigned, a BSN-prepared nurse is also allowed to prescribe medications for persons with some acute, emergency conditions and chronic illnesses and to prescribe physical therapy and other rehabilitative treatments in keeping with existing protocols.

Katunzi’s reflections

Community Resources and Policies and, Health Care System (Concepts of the ECCM)

As a BSN-prepared nurse completing a pre-internship clinical learning opportunity in a private community-based clinic (NSM community as the client system), I was mentored into the primary care role by a team of nurses and other healthcare providers. I was involved in the management of clients living with diabetes and heart diseases (adults and adolescents) (NSM developmental variable) trice a week and also participated in conducting monthly supervisions in satellite health centers. I learned to assure patients/clients maintained a maximum level of wellness by keeping stressors and stress responses at a minimum through effective, efficient care at three levels of prevention (NSM prevention as intervention). Utilizing a holistic approach (NSM physiological, psychological, socio-cultural, development, and spiritual variables), I was exposed in health counseling, medication administration, health teaching, case management and care coordination services (NSM prevention as intervention]. I worked closely with nurses in other satellite health centers within the clinic’s catchment area. The collaboration strengthened patient treatments and improved care. I regularly participated in conducting home visits and tracking down patients who were lost to follow-up careI dealt with barriers such as clients’ religious and traditional beliefs that hinder adherence to prescribed regimen (NSM socio-cultural and spiritual variables).

As a part of the learning process, I practiced advocacy and I was able to participate in regular district administrative meetings to negotiate consultation fees and cost of drugs with district authorities (NSM socio-cultural variable). I improved my nursing skills in individual/family and community assessment while fulfilling this role. For instance, I was able to share with the authorities how financial challenges forced clients to take half doses of their prescribed medication and intentionally caused missed follow-up visits. Likewise, I noted that other clients opted to traditional herbal treatments as they were perceived to be cheaper than hospital medications. I was able to see how self-medication practices (Concepts of the TSCC) can harden caring of chronic patients. Some patients opt to buy drugs in stores rather than visit the clinic or hospital. Some of the challenges were attributed to lack of transportation and health illiteracy on disease processes (NSM socio-cultural variable). I called attention to the impact of laxed drug dispensing policies on clients’ lives.  For example, I shared how clients with contraindicated medication can easily procure the drugs from a local drug store, making them at risk of readmissions and possibly death. In addition, as a community health educator, I advised patients and their families to participate in community development projects such as livestock keeping, small scale agricultural that helped them to earn extra money for buying drugs and supporting individual and family their well-being (NSM socio-cultural and spiritual variables ).

Delivery System Design and Self-Management Support(Concepts of the ECCM)

The community clinic was centered at a District Hospital and operated synergically with ten other health centers within our catchment area (NSM community as the client system). I learned to assure the provision of self-care maintenance, self-care monitoring, and self-care management services (Concepts of the TSCC). For instance, I was involved in caring for chronic disease patients especially type 1 diabetic patient by empowering and preparing clients to manage their health through effective and safe self-injection practice. I provided health education on regular testing to control glucose levels as well as insulin-self administration.  Assessing clients’ health literacy levels in the treatment process was a crucial piece of my practice role. I developed peer guided groups with an interpofessional team comprising of a nutritionist and physician. In addition, I conducted monthly supervision at each of the ten assigned health centers. During the supervisory visits, I was involved on assessing the overall patient’s adherence practice to nursing care and follow up (Concepts of the TSCC). I also participated in conducting professional development seminars to nurses on management of patients living with chronic diseases, how to conduct referrals and improve protocols to manage patients with diabetic ketoacidosis and heart failure (NSM variances from wellness). I completed frequent home visits with nurses and other providers to assess the client’s progress, adherence practices and storage of medications (concepts of the TSCC), as well as delivered promotional health messages to patients and families (NSM primary prevention as intervention).

Decision Support and Clinical Information System (Concepts of the ECCM)

I learned how to make clinical decisions in chronic disease management consistent with scientific data and patient preferences. For example, when I saw patients with medical adherence issues, I made sure I educated the clients on possible consequences and let the clients make informed decisions (NSM primary prevention as intervention). I always acknowledged the challenging presence of scientifically unproved treatment plans attributed to the growing number of traditional doctors involved in client’s health care decisions (NSM individual as the client system). I always paid attention to gender-based influences (NSM socio-cultural and spiritual stressors) in medication adherence NMS-. For instance, I was able to determine that men attended treatments when they had severe signs and symptoms of an illness and/or at advanced stage of disease. To address this social determinant among some of the men, I participated in initiating the use of mobile phones to trace patients on monthly basis. This initiative had a positive impact on “no show” clients who had access to mobile phones.

Implications for nursologist scholars

Katunzi’s reflections have implications for advancement of nursology discipline-specific knowledge and future professional transformations. The evolving role of the nursologist  in primary care (Wojnar & Whelan, 2017) calls for a well-rounded RN (Swan, et al, 2006) and, most importantly, a BSN-prepared global nursology  workforce (Wojnar & Whelan, 2017). Use of the ECCM requires ongoing research — or review of existing research – to determine the validity of the model as a shared theory/model (Villarruel et al., 2001) that is useful in new nursing education curricula (Humphrey, 2019),  reimbursement (Funk & Davis, 2015) and regulatory models (Start, 2020) situations that fit BSN-prepared nurses’ full scope of nursologists’ practice and meet clients’ health and social needs in places where people live, learn and play.  

We would like to learn from our nursology.net readers on their perceptions of these questions:

  1. What does the future of nursology hold for the role of the BSN-prepared nursologist in primary care, especially in the United States where primary care is regarded as a major role of advanced practice nursologists holding master’s and/or Doctor of Nursing Practice degrees?
  2. How can nursologists overcome the barriers and maximize contextual opportunities to fulfill their roles? 
  3. What barriers may influence effective adoption of applicable borrowed and shared theories/models in nursology-led chronic disease management interventions?

We welcome nursologists at different levels of practice (i.e., LPN, ADN, BSN, DNP, PhD-prepared) to share their stories of how they provide primary care services (or ambulatory care or community-based care), in private or public health care systems.  Please share your thoughts in comments section below

References

Anderson, D., St. Hilaire, D., Flinter, M., (May, 2012). Primary Care Nursing Role and Care Coordination: An Observational Study of Nursing Work in a Community Health Center OJIN: The Online Journal of Issues in Nursing, 17, 2, http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No2-May-2012/Primary-Care-Nursing-Role-and-Care-Coordination.html

Barr, V, Robinson, S, Marin-Link, B, Underhill, L, Dotts, A, Ravensdale, D, & Salivaras, S. (2003). The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model, Hospital Quarterly, 7(1), 73-82.

Bodenheimer, T., & Mason, D. (June, 2016). Registered nurses: Partners in transforming primary care. In Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June. http://64.62.135.154/docs/macy_pubs/Macy_Monograph_Nurses_2016_webPDF.pdf

Borgès Da Silva, R., Brault, I., Pineault, R., Chouinard, M.-C., Prud’homme, A., & D’Amour, D. (2018). Nursing Practice in Primary Care and Patients’ Experience of Care. Journal of Primary Care & Community Health, 9, 1-7 https://doi.org/10.1177/2150131917747186

Epping-Jordan, J., (Ed.) (2002). Innovative care for chronic conditions: building blocks for action: global report (document no. WHO/NMC/CCH/0201). World Health Organization Global Report. https://www.who.int/diabetes/publications/icccreport/en/

Funk, K. A., & Davis, M. (2015). Enhancing the role of the nurse in primary care: the RN “co-visit” model. Journal of general internal medicine30(12), 1871-1873.

Health resources & Services Administration (2018).  Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program. Retrieved from https://www.hrsa.gov/grants/find-funding/hrsa-18-012

Humphrey, B., L., Mixer, S. J., Thompson, K., Davis, S., Elliott, L., Lakin, B., … & Niederhauser, V. (2019). Transforming RN roles in community-based integrated primary care (TRIP): Background and content. Issues in mental health nursing40(4), 347-353.

Lipstein, S. H, Kellermann, A. L., Berkowitz, B., Phillips, R., Sklar, D., Steele, G. D., & Thibault, G. E. (September, 2016). Workforce for 21st century health and health care: A vital direction for health and health care. National Academies of Medicine. https://nam.edu/wp-content/uploads/2016/09/Workforce-for-21st-Century-Health-andHealth-Care.pdf.

Norful, A., Martsolf, G., de Jacq, K., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic review. International journal of nursing studies74, 15-23.

Start, R., Brown, D. S., May, N., Quinlan, S., Blankson, M., Rodriguez, S. R., & Matlock, A. M. (2020). Strategies for creating a business case that leverages the RN role in care coordination and transition management. Nursing Economics38(4), 203-217.

Swan, B. A., Conway-Phillips, R., & Griffin, K. F. (2006). Demonstrating the value of the RN in ambulatory care. Retrieved from https://jdc.jefferson.edu/cgi/viewcontent.cgi? article=1012&context=nursfp

The Tanzania Nursing and Midwifery Council (2014). Scope of Practice for Nursing and Midwives in Tanzania. United Republic of Tanzania.

Wojnar, D. M., & Whelan, E. M. (2017). Preparing nursing students for enhanced roles in primary care: The current state of pre-licensure and RN-to-BSN education. Nursing Outlook65(2), 222-232.

Villarruel, A.M., Bishop, T.L., Simpson, E.M., Jemmott, L.S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14, 158-163. 

Culture Shock, Grief and Nursing Theories

Contributor: Aisha Chahal, MSN, CMSRN

Culture shock is a state where people experience the stages of honeymoon, frustration, adaptation and acceptance. It is an intense feeling that follows the grief process. I had first-hand experience with all these stages of culture shock when I came to the land of opportunities, the United States of America, in 2012. I started my first job as a bedside Registered Nurse. It felt like I had accomplished the purpose of my life by getting a job at Yale-New Haven Hospital. Yale seemed like a place in heaven. It was beautiful to see that people could order food over the phone and a beautiful tray with fancy food items arrive at the bedside within a few minutes. Nurses only had four to five patients instead of the thirty that I had cared for earlier in my career. Patients had call bells and people responded to those bells. There were computers, scanners, medication dispensing machines and robots to deliver supplies. I was in the honeymoon phase.

But then came frustration as food items were thrown away if patients did not like them. Computers took away my time to be with my patients. The machines, robots, and technology had turned people into objects. I barely had time to know my patients or colleagues on a personal level. But I adapted and accepted by learning to fit into the situation. I learned that all this was crucial for patient safety, evidence-based practice, patient satisfaction scores and reimbursements.

After 8 years, I relived the stages of culture shock while learning in-depth about nursing theories in my doctorate program and educating nursing students on nursing theories at the same time. Nursing theories fascinated me and sparked my interest to learn more about the focus and identity of nursing discipline. Learning new concepts, making connections, discussing with nurse educators and colleagues, listening to some of the theorists themselves send me into the honeymoon phase once again.

I was determined to start my clinical day with the students by discussing a nursing theory. With all enthusiasm, I showed up at 6.45 am to meet my students and talk about nursing theories starting with Florence Nightingales’ framework and Watson’s Caring theory before we see our patients. Then once again, I experienced the frustration phase as students were disinterested, inattentive, unpassionate, and incurious which was exactly the opposite of what I was prepared for. I stopped the talk in the middle and let them start their routine patient assessments. I was deeply saddened by reliving the experience as I knew that I would have to adapt and accept the reality just like I did a few years back.

But this time, instead of accepting, I felt challenged to change the norm. Students viewed the content of nursing theories as dry, complicated to understand, of no practical use, and grade-lowering. The next week, I planned to discuss Neumann’s System Model with the vision that students can feel and experience the essence of the theory and view clients as an open system responding to various stressors in the environment. Instead of theory, I started our discussion with the theorist, Betty Neumann. We discussed how she grew up on a farm and took care of her sick father who died at the age of 36, which created her passion for nursing. Her mother was a devoted self-taught midwife. We talked about her academic, professional, and volunteer work. I shared images and videos depicting her life and vision. Then we discussed her vision of creating the nursing theory and related concepts of the theory.

Students were completely engaged, asked questions, and seemed ready to minimize the theory-practice gap. In the post- clinical conference that day, students were able to identify intra, inter and extra-personal stressors for their clients. They also identified the interventions they performed or planned to perform at primary, secondary and tertiary levels of prevention. They developed a deeper connection to the theorist, theory, clients and themselves. They identified who they are in relation to the focus of nursing discipline. After that week, we continued discussing a theorist and a nursing theory each week before clinical and each student-patient interaction is now guided by the concepts of that theory. Every week, we now look forward to our discussion of nursing theories and viewing people from different perspectives to provide competent and compassionate nursing care

I invite all the nursing students, nurse educators, nurse scholars, and nurse researchers to prevent nursing theories from following the similar pattern of stages of culture shock and grief. Instead of frustration, anger, denial, adaptation, and acceptance, our collaborative efforts can lead to a focused nursing discipline in which every nurse is changing lives by using the strong foundational pillars of nursing theories.

About Aisha Chahal

Aisha Chahal, MSN, CMSRN, is a doctoral nursing student in the Online Nursing Education EdD program at Teachers College, Columbia University. Aisha has completed her Masters of Science in Nursing Education in 2019. She is a clinical instructor at Western Connecticut State University. She has have 10 years of clinical experience in medical-surgical nursing. Her passion is exploring effective teaching-learning strategies to educate nursing students on Transcultural Nursing.

Guest post: Aesthetic Knowing: A Transformative Encounter

Contributor: Bibiane Dimanche Sykes

Knowing is an elusive concept. It is fluid, and it is internal to the knower (Chinn & Kramer, 2018). Carper (1978) identified four fundamental patterns of knowing for an understanding of the conceptual structure of nursing knowledge. The four patterns are classified logically to elucidate aspects of empirics, personal knowledge, ethics and aesthetic knowing in nursing. Here, the pattern of aesthetic knowing is demonstrated through the actions, comportment, thoughts, behaviors and exchanges of the nurse’s relationship with the patient. It is aesthetic knowing that allows us to navigate when faced with nuanced situations.

The Call

It was late on a Tuesday morning. I was pleased to finally have a few days of rest from work and was already planning how I was going to spend my second day off, when I heard the ring tone from my phone. I glimpsed at the phone screen and noticed that it was a number I was unfamiliar with, so I decided to skip the call and told myself that they can always leave me a voice message if it is important. Ten minutes later, I heard the same familiar ringtone of my phone. This time it was coming from work. “Oh my,” I thought, what could it be…. did I forget to enter a note on the computer, or have I failed to sign the medication sheet? When I picked up the phone, the Director of Nursing at the subacute nursing facility I worked for was on the line. She mentioned that Ms. Smith’s situation took a turn for the worse; her condition had weakened overnight. According to Nancy, the Director of Nursing, Ms. Smith had been asking to see me since yesterday, and it was her nephew whose desperate call I had moments earlier ignored.

Nurse-Patient Relationship

Ms. Smith was a 75-year-old widow who moved about 7 months ago to the hospice unit where I worked as a charge nurse. Her overall health and well-being had since deteriorated. Her cancer had metastasized to other adjacent organs of her body, and treatment was no longer a viable option. She had very little family support. Her only living relative was a nephew who visited occasionally. Although she had many other disciplines assigned to her care, she seemed to gravitate more towards me. I also enjoyed her company and spent many hours of my free time listening to her joys and regrets about life. I would play her favorite songs, encourage her to eat, to bathe, and to take her medications, before her pain became unbearable. She looked forward to the days I was at work, and I would always stop by her room for a chat whenever I had the chance. She confided in me and shared many of her life and death expectations, which included the minute details of her imminent death and funeral wishes. She and I developed a bond and maintained a caring nurse-patient relationship that encompassed understanding, trust and compassion.

The Encounter

It was already afternoon when I rushed into Ms. Smith’s room that Tuesday. She seemed agitated; however, she immediately became calm at the sound of my voice, telling her that it was going to be okay. As I was helping her take her prescribed medications, she appeared to be hallucinating. She kept on saying something about not being able to get on the bus. She was becoming restless and continued to repeat this for about an hour. I finally approached her and asked why she was not able to get on the bus. She opened her eyes for the first time since I entered her room and mumbled, “they wouldn’t let me, I don’t have money to pay for it.” I was devastated at the thought of that. I knew this day would come but still I was becoming emotional. I reminded myself that I needed to stay on course to help fulfill her wish of an undisturbed, smoothed transition. I thought for a second, what could I do to alleviate her suffering at this moment? I searched in my pocket and found a quarter. I slipped it into her hand and whispered in her ear, “use this for your bus fare, it’s going to be fine.” I felt her tight squeeze as she received the quarter, and less than five minutes later, Ms. Smith peacefully took her last breath with poise and dignity.

Aesthetic Knowing

Aesthetic knowing is what makes possible knowing what to do and how to be in the moment, instantly, without conscious deliberation (Chinn & Kramer, 2018). I am currently an adjunct professor, teaching nursing fundamental to first year students. Every semester, I share this experience with my students. It serves as the perfect introduction to the conceptual framework of the nursing discipline through the patterns of knowing (Carper, 1978). The patterns of knowing in nursing ultimately presents a tool for developing abstract and theoretical thinking in the classroom. It allows for broader, clearer perspectives and self-integration of the concepts of empirics, personal knowledge, ethics and finally aesthetic in nursing education (Carper, 1978). This transformative encounter that I had experienced with my patient embodies the true essence and elements of aesthetic knowing.

Sources

Carper, B. (1978). Fundamental patterns of knowing in nursing. ANS. Advances in Nursing Science, 1(1), 13–23. https://doi.org/10.1097/00012272-197810000-00004

Chinn, P. L. & Kramer, M. K. (2018). Knowledge Development in Nursing: Theory and Process. 10th Ed. Elsevier. St. Louis, MO.

Aesthetic Knowing. (2021, February 2). https://nursology.net/aesthetic-knowing/

About Bibiane Dimanche Sykes

Bibiane Dimanche Sykes is a student in the Doctorate of Nursing Education (EdD) Program at Teachers College, Columbia University. She earned a Master of Science degree in Nursing Education at Mercy College in Dobbs Ferry, New York. She’s an Adjunct Professor at Mercy College in Dobbs Ferry, New York and also works as a Clinical Nurse Quality Assurance in New York City. Bibiane is a wife and mother of 4 sons. She enjoys reading, traveling and prides herself in giving back to the community. She serves her community through various philanthropic and nursing organizations.

It’s Time We Raise Nursologists!

Report from the 2021 Virtual Nursing Theory Week

Contributors:
Christina Nyirati
Sharon Stout-Shaffer

At the time of the 2021 Virtual Nursing Theory Week, Christina Nyirati and Sharon Stour-Shaffer presented the baccalaureate curriculum they designed and now implement at Heritage University located on the Yakama Reservation in Washington State. This is the only session that was recorded during the conference; it represents the value of nursing knowledge in shaping the present and future of nursing as a discipline. The following is a brief description and a video of their presentation.

The first Heritage University BSN Program Outcome reads “The Graduate of the Heritage University BSN Program explains how nursing’s fundamental patterns of knowing –personal, aesthetic, ethical, empirical and emancipatory –contribute to understanding the complexity of nursing care in the treatment of human response”.

Carper’s (1978) Fundamental Patterns of Knowing in Nursing is the foundation of the BSN Program. Freshmen study discrete courses in each of Carper’s fundamental patterns: personal, aesthetic, ethical, and empirical knowing. The Personal Knowing course is founded on personal knowing as a precondition for nursing care. Students practice various methods of reflection to develop personal knowing in every moment of nursing care. The Aesthetics of Nursing course is grounded in assumptions from Nightingale’s theory of nursing arts and aesthetics as a fundamental pattern of knowing in nursing. An experiential course, based in the principles of performing arts, the focus is on the act of care; Students explore and apply dramatic arts foundational to holistic nursing care competencies. The Ethical Knowing course emphasizes the practice of ethical comportment in nursing care. The Empirical Knowing course students introduces students to fundamental theories, concepts, evidence, and competencies pertaining to generation of nursing knowledge.

Senior year features the community as the unit of nursing care, and is founded on Chinn and Kramer’s (2019) emancipatory knowing in nursing. The Policy, Power & Politics of Nursing course focuses on the professional nurse role in taking responsibility for shaping social policy. The two Community Oriented Nursing Inquiry and Practice and the Community Based Participatory Research courses center on principles of socially just reflective action to overcome health inequities.

Faculty developed rubrics to evaluate how students integrate the fundamental patterns of knowing nursing into clinical practice. Students complete reflective writing assignments during clinical practice each semester from sophomore through senior year.

About the contributors:

Christina Nyirati, RN, PhD

Christina Nyirati is Professor of Nursing at Heritage University on the Yakama Nation Reservation in Washington, where she serves as the founding Director of the BSN Program. Dr. Nyirati came to Heritage from Ohio University and The Ohio State University, where she directed the Family Nurse Practitioner (FNP) Programs. She practiced more than 30 years as an FNP in primary care of vulnerable young families in Appalachian Ohio, and worked to reduce dire neonatal and maternal outcomes. Dr. Nyirati challenges FNP educators to consider nursing knowledge as the essential component of the FNP program as the Doctor of Nursing Practice (DNP) evolves and becomes requisite for entry into advanced practice. Now at Heritage Dr. Nyirati prepares nurses in an innovative undergraduate curriculum faithful to the epistemic foundations of nursing. Two cohorts have graduated from the Heritage BSN Program. They openly proclaim and use their powerful nursing knowledge to correct inequities in their communities.

Sharon Stout-Shaffer, PhD, RN

Sharon Stout-Shaffer, PhD, RN, Professor Emerita, Capital University, Columbus, Ohio; Adjunct Faculty, Heritage University, Toppenish, Washington; Nursing Education Specialist, S4Netquest, Columbus, Ohio. Sharon has over 30 years of experience in educational administration and teaching in both hospital and academic settings. Her career has focused on developing education based on a nursing model that includes concepts of holism and healing.

Her Ph.D. in Nursing from The Ohio State University focused on the psychophysiology of stress and relaxation-based interventions to promote autonomic self-regulation and immune function in people living with HIV. She has attained certification in Psychosynthesis, Guided Imagery, and more recently, the Social Resilience Model; she has presented numerous papers on integrating holism into curricula as well as caregiver wellbeing and resilience including Adelaide, Australia, 2011; Reykjavik, Iceland, 2015; American Holistic Nurses Association Phoenix, 2016 & Niagara Falls, 2018.

During her tenure as Director, Post-Graduate Programs at Capital University, Sharon taught the graduate theory course and co-developed a theoretically grounded holistic healing course as the foundation for graduate study; the graduate program has been endorsed by the American Holistic Nurses Credentialing Center. Since her retirement, she has co-developed and implemented numerous educational interventions designed to develop the Therapeutic Capacity of working nurses and nursing students. This work includes concepts of centering, compassion, managing suffering, the psychophysiology of resilience and essential contemplative practices to develop stress resilience, deal with moral distress and promote long-term wellness. She is currently teaching courses in Personal Knowing and Nursing Ethics for undergraduate nursing students at Heritage University. Her most recent publication is dedicated to holistic self-care and self-development. (Shields, D. & Stout-Shaffer, S. 2020). Self-Development: The foundation of holistic self-care. In Helming, M., Shields, D., Avino, K., & Rosa, W. Holistic nursing: A handbook for Practice (8th). Jones and Bartlett Learning, Burlington MA.)

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

Contributor: Ana Filipa Paramos

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

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

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

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

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

References

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

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

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

About Ana Filipa Paramos

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

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