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.

Guest post: The Overlooked Impact of Case Management during the COVID-19 Pandemic

Contributor:
Christy McDonald, BSN, RNC, Case Manager

I have witnessed an amazing workforce in our hospitals during this pandemic. While physicians and nurses are clearly lifesavers at the bedside, hospital rooms are scarce. These frontline workers need the partnership of nurse case managers to arrange safe discharges and free up beds for those waiting in the ER. But this partnership provides much more than just discharges.

Nurses have a unique perspective that is vital in every area. This idea was explained well in 1952 by Hildegard Peplau, “mother of psychiatric nursing,” who understood the strength of nurses that could create a personal connection with their patients. She created a Theory of Interpersonal Relations, where she named 6 main roles for nurses which could be applied individually according to the needs of the patient. This differentiation of roles including counselor, surrogate, teacher, stranger, resource person, and leader can help nurses today in many different areas of care beyond psychiatric nursing. I believe it has been very beneficial for RN case managers working alongside bedside nurses to fulfill these roles for patients during this pandemic.

These behind the scenes case managers efficiently arrange placement while taking the time to comfort patients and family members, filling the role of counselor, which allows the patient to express their feelings to the case manager. In a time of urgency, these nurses can be a listening ear for family members to process their worries and discuss medical conditions. Often information has been relayed, but family members don’t want to take time away from the bedside staff with clarifying questions. The loved ones value the time and sacrifice given so highly that they are willing to forgo understanding. I personally filled the role of surrogate, which allowed me to fill in for family, when I had a patient who never told his bedside nurse he was a vegetarian because he didn’t want to bother her. He was only eating the bread of his sandwiches. I was able to speak with his spouse who informed me of his diet, and quickly messaged the nurse who changed his meal that very day. The teacher role is something nurses are excellent at providing in normal circumstances, however this pandemic has created a unique need for patients to be educated on a novel virus.

As with all nurses, case managers connect with their patients and loved ones, and want the best outcome for all involved. This in it’s simplest form if fulfilling the stranger role by offering the decency that should be given to any human. However we know that we often connect deeper with the emotions of a patient. For example, a fellow case manager cried with a family member about no visitation policies, because we all mourn the necessary changes needed to slow this pandemic. While continuing these much needed conversations, case managers arrange for home health or skilled nursing admissions. If we can find placement for recovered patients, those who are sick and waiting in holding areas of the ER can receive care from our skilled floor nurses. I worked tirelessly to find an open bed in another state for a pt while discussing end of life decisions with another family, fulfilling both the resource role providing information and the leader role offering direction with the patient’s wishes. It takes so many people working together to provide care in these unprecedented circumstances we find ourselves fighting.

Nurse case managers truly maintain the flow of care so we can provide the maximum benefit to as many patients as possible. Without nurse case managers there would be nowhere for our loved ones to go. And with them we can fulfill the necessary roles as described by Peplau needed to care for our patients.

About Christy McDonald

Christy is a hospital case manager in a large metro healthcare system. She had the privilege of being a bedside NICU nurse for 17 years before moving into Case Management. She has cared for those in public schools, remote Haiti, and the hospital setting. She serves on the Board of Directors for a Haitian NICU and children’s home.

Lessons from the COVID-19 pandemic: Changes to the meaning of our experiences based on Newman’s theory of health as expanding consciousness (HEC)

Report from the Newman Theory/Research/Practice Society (a Japanese Nonprofit Organization)

Contributors: Emiko Endo,
Satoko Imaizumi, Minako Kakimoto,
Yayoi Kajiwara, Yoshie Kamiya

We are pleased to write our blog about the 2020 work of the Newman Theory/Research/Practice Society in Japan. We submitted a brief about our Society on January 10, 2019 (scroll down here to see this brief) followed by more detail from Dr. Margaret Pharris, who introduced our society and work on December 17, 2019.

We had the last pre-praxis research course of HEC for 2019 virtually on August 2, 2020, because the COVID-19 pandemic. We read the last chapter, “A transforming arc”, and Appendix A, “HEC Praxis: The process of pattern recognition” in Newman’s “Transforming presence: The difference that nursing makes.” After that, Emiko Endo, as a leader of this course, introduced the blog by Drs. Jones and Flanagan, “COVID-19 – What would Margaret Newman say?”(June 30, 2020) In listening to it, our comprehension expanded, and we feel enlightened, and awakened in new ways.

There is an increased awareness within selves, our nursing care, and our society. No, we will never get back to normal. We will certainly move on in “Satori.” On an annual event of the Study meeting held by zooming on November 22, 2020, three practicing nurses presented their experiences of turbulence and disruption, and then recognition of the changes to the meaning of their experiences in the COVID-19 pandemic. The following are the summaries of each presentation.

Minako Kakimoto

In February, the spread of COVID-19 started in Asian areas, but I was looking at that situation as no concern of ours, and I thought it would disappear sooner or later like SARS and MARS. However, soon after being informed of the cases with COVID-19 in Japan, daily necessities, masks, alcohol, etc. disappeared from every store and the situations in hospital settings dramatically changed. The nurses, including me in a cancer hospital, had very hard time making temporal rules without any exact knowledge.

Soon after, we were informed that some positive cases were found at my hospital. I was on the list of medical staff exposed deeply to the COVID-19. “It finally came to us. We cannot overlook their distress as no concern of ours.” I felt strong fear. I had a test, and was afraid of the result. “If I am positive, what will happen to my family? If I and my husband are positive, how my child should be?” I imagined a dead body in a special bag and a crying child there. But, fortunately my test was negative.

After that, I was in charge of an outpatient clinic for the clients with fever. There were many difficulties because of a pickup setting. There were many inquiries and complaints from clients. The relationship among the staff became so bad because of a sense of unfairness, stress, overwork, etc. “How long does this chaotic situation last?

One day I spoke to my colleague about how to organize this disorder. Astonishingly, she said, “You told me some time ago that a transformation would occur after a chaos!” Her words made me come to my senses. “It is true. After the chaos, there is our growth.” I felt as if I had the scales fall from my eyes. I certainly grasped the meaning of “We will never get to back to normal” as Dr. Newman said.

I looked at the chaotic staff relationship from a different angle. “We do not need to get back to the normal. The confusion is not really bad, but it will bring forth. We do not need to endure the current difficult situation with many complaints until the typhoon has passed. Let’s find a new way to move on.” I approached my colleagues to exchange ideas about how to stand up. Of course, my change of actions prevailed into my family.

Yayoi Kajiwara

In the midst of the pandemic of COVID-19, my father, who had had a so-called incurable disease for a long time, died. As I learned a lot from my sad but meaningful experience, I would talk about it.

I, as a hospital nurse, had asked patients’ families to put restrictions on visiting their loved ones to prevent bringing COVID-19 virus into the hospital. However, the situation has reversed. I was not allowed to visit my father. I was so afraid of not being able to meet his death. When I had been a nurse at the palliative care unit, I valued a patient’s death surrounded with his or her family members before everything else. But, I thought it might be impossible for me to be present with my father.

I wondered why my father was on the brink of death in the midst of the pandemic of COVID-19 ? “If I cannot be present at my father’s death, what does it mean? My father may be telling me something important to get a new meaning in my experience. He may be telling me that the length of the time is not so important. The importance is to be present with the patient.”

When my father ran into a critical condition, I was finally allowed to see him. I could be present with him for a while with all my heart. My father did die after several days from good-bye with my aching heart. However, in spite of his death, the relationship between him and me has changed through the process of our hard experience in the pandemic. Our relationship came closer than ever, and we became deeply united in spirit.

From this experience, I realized that I had been captured by the “good dying moments” which nurses think. I surely comprehended the meaning of “Transforming presence” in terms of HEC. That is, being present together brings the transformation to both. I realized the true meaning of “Vulnerability, suffering, disease, death do not diminish us” which Dr. Newman emphasized.

I am very thankful to my father, and the lesson on the COVID-19 pandemic will help me better care for clients in our community.

Yoshie Kamiya

I am a nurse in charge of an outpatient clinic at a university hospital. The COVID-19 pandemic brought me so many difficulties and at the same time many lessons.

We, nurses, were distributed one mask for several days and one raincoat bought at a $1.00 shop. At an information desk, I received a lot of phone calls, claims, and complaints from clients because of the lack of information and fear. The staff’s fear and offensive attitudes were also increasing, and some co-workers could not show up because of their children’s care at home. I was full of fear and exhaustion as I could not know how things would turn out.

In those days, I participated in the last class of the pre-praxis study course and we read the blog by Drs. Jones and Flanagan. I vividly remember the shock I felt after reading the blog. “I feel very relieved.” I thought, “What we need to do is not to go back, but to move on even in the process of confusion.” I thought, “Now is a pinch point, but it is not, really. Now is a chance.” Then, I looked back the past experiences and tried to get a new meaning from them. I will tell you about my change.

As the charge nurse at an out-patient clinic, I was always thinking, “I should take a determined attitude,” “I should not make mistakes,” “I should not be afraid of COVID-19,” “I should meet patients with fever by myself.” One day, when I was working the information desk, I spoke with a patient who turned out to be COVID-19 positive. When I was informed of this fact, I was afraid. Moreover, I felt so sorry for my family. However, I did not tell anyone, not even my family, though I was so worried about my contagion.

Finally, COVID-19 had invaded into our hospital. Some nurses were on a watch list for the virus. One day, one nurse came to me and told me, “I feel very afraid, and I feel very sorry for my family.” She told her feeling openly. At this time, I was startled and recognized my pattern. I realized that I was not honest. I piled up “should do” every day.

The pattern recognition, which is the most important concept in HEC, helped me realize my situation. Since then, I tried to be open and to tell what I am thinking and feeling to people. Especially, I tried to be honest and open with the staff. I realize now that our relationship is changing and expanding. This is one of the great lessons to me during the COVID-19 pandemic. There is another one. At the out-patient clinic, we started to receive clients’ words of appreciation. I can accept their thanks honestly and my relationship with clients became more genuine. This is the other lesson from the pandemic. Thank you for listening to me.

All participants were deeply touched by their presentations. “Yes, we will move on!!!” We will continue to search for ‘caring in the human health experience’ during the COVID-19 pandemic.

Trauma-informed teaching in the era of COVID-19

See Dr. Foli’s “Middle Range Theory of Nurses’ Psychological Trauma

2020 was the year I applied trauma-informed approaches to my teaching. This was the year I learned being kind and compassionate were also good pedagogical practices. In previous years, I have been recognized as an “award-winning” teacher. I did all the things a good teacher in a research-intensive university was supposed to do: Incorporated students into research studies that also met course learning objectives, developed innovative teaching/learning methods, integrated solid student accountability into my syllabi, and so forth. And I wasn’t an uncaring teacher before 2020, but perhaps I wasn’t quite so compassionate. Perhaps I was fearful that by showing compassion, I would be less likely to hold students to a high standard of performance.

2020 was different. Many of my master’s students enrolled in the theory course became ill with COVID, or their family members did, or they endured significant traumas or confronted and processed past traumas. Several of the students were frontline workers, faced with COVID on a daily basis. This year, I used the resources on nursology.net by asking them to read two blogs and critique them in their discussion forum – many selected the blogs on issues the nation confronted this year, especially racism and racial disparities. This exercise brought theory to them in a way that no textbook ever could. These blog-writing nursologists were living narratives of those actively advocating for nursing knowledge and theory. As the students prepared their final papers, I saw this year’s learning was at a higher level than previous years and in the context of a virtual platform. Students, preparing for an advanced practice role, stated, “I think differently now.” Nursing knowledge and the distinction between nursing and medicine at the nurse practitioner level has never been more important for us as a discipline.

As a teacher, I learned that I didn’t have to diminish student accountability. But in order for them to take responsibility, I had to gain their trust by authentically showing compassion. Each week, I crafted an email to the class with reminders and updates, and this year, a bit more. I offered hope by reminding them the pandemic would be over at some point. I offered validation that what they were accomplishing wasn’t easy. And I offered them purposeful access to me through technology if they got “stuck.” When I would meet with students, they would thank me for these emails, describing how they would revisit them if they felt “down.” Several wrote me messages of gratitude and described how they looked forward to them every week. In a trauma-informed way, I created a transparent, safe space and established a connection as their teacher. I know now that listening, recognizing trauma, taking time to meet one-on-one, reaching out to “missing in action” students to inquire if they’re okay, giving grace on assignments, and still holding students to a high level can be compatible, and more than that, best practices in trauma-informed education.

2020 was the year . . .

Anyone alive today (except the yet unborn!) will forever relate a memorable end to this sentence . “2020 was the year . . . “! For a handful of humans all over the globe, there will be those who end this sentence with “2020 was the year I was born, and I survived the great pandemic.” Some will also add that someone in their family did not survive , or someone was permanently affected by the ravages of the virus – a fact that will follow them in all the years to come. Of course how we each end that sentence (and the paragraphs that follow that sentence) will change with time, but our nursology.net team members pitched in to share how we are remembering this unprecedented year as it comes to a close in this and in the first few posts of 2021.

Peggy Chinn

Dylan in his home “classroom”

2020 was the year that my 5-year old Cuban/Chinese/Hawaiian/Haole grandson Dylan started kindergarten in daily zoom “classes” with his 24 classmates and fortunately with a very talented kindergarten teacher! His parents and I reflect mournfully on what he is missing by not going to his physical school – a school they selected because it is a public dual-language (Spanish/English) immersion school. The school is located in a zip code with one of the highest rates of COVID-19 cases and deaths in the city Oakland CA, and where racial tensions between police and the community have escalated. But they are both public school teachers, deeply committed to social equity and to ending social disparities, and are seeking to be part of the solutions to the many challenges faced in disadvantaged communities. So here we are at the end of 2020, in the midst of so much suffering that could have been prevented if the situation had been managed differently – suffering that is tragically amplified in disadvantaged communities. Like public school teachers and so many other public servants, as nursologists, we know so many ways in which the knowledge of our discipline could re-direct and re-shape the experience of the COVID-19 pandemic, and how our perspectives – our values and priorities as nursologists – could be mobilized to end health disparities. The growing response to Nursology.net over the course of the year suggests that 2020 may have been the year when widespread recognition and respect for the discipline took hold, when nurses all over the world began to see the significance of our disciplinary knowledge. Just as 5-year-old Dylan has learned the basics of reading and writing (in both Spanish and English) in the face of unprecedented circumstances, so too may it come to be recognized that nurses, in 2020, have learned anew the “reading and writing” fundamentals of our discipline.

Chloe Littzen-Brown

2020 was originally destined to be the year of the nurse and midwife, but it really turned out to be a year of uprising. A year of change and adaptation. A year of learning and unlearning. It was a year of putting action behind our thoughts and words, questioning what we know, and standing up for what’s right — even in the most difficult and darkest of times. We protested, marched, wrote letters, and voted. We began to question our role as nurses in the oppression and marginalization of patients and each other. In 2020, I am proud to call myself a nurse but I know that I, and we, still have a lot of work to do. I hope that we never lose the awareness that 2020 has given us and that we can carry it on to the future to better ourselves, better each other, and better the world. 

Chloe Littzen-Brown and Dr. Robert Brown with their two dogs Liberty and Timmy on their Wedding Day

On a personal note, 2020 has catapulted my private and professional life in many directions. In July, my partner graduated from his emergency medicine residency program after spending the previous 4 months straight caring for COVID-19 patients on the frontline during Ohio’s first wave. I won’t lie that I was (and still am) worried about his health and well-being on the frontlines. Simultaneously, he was (and is!) worried about bringing home COVID-19, as I have underlying health conditions that place me at heightened risk. It is not phased on me that many nurses, physicians, and other healthcare providers have lost their lives during the pandemic working on the frontlines. I am grateful that so far we have both maintained our health, and I hope that with a vaccine around the corner that soon we will be able to provide better protection to our frontline workers and the patients they care for.

Since he graduated my partner accepted a job in Washington state as a physician in the emergency room. Because of this, we ended up moving from Ohio to Washington in July. Prior to us moving, I submitted my IRB application for my dissertation, and to my surprise as we crossed the state line into Washington my application was approved! Since then, we got married (outdoor Zoom wedding!), I have completed my data collection, and currently I am diligently working on my data analysis. I hope to defend my dissertation, (probably over Zoom, note the theme here) in the Spring of 2021. But with all of this, I think what I have taken to heart is the only constant is change… and while that change may not have been what you wanted it to be, if you are willing, open, and present, change can have a positive impact in your life – greater than you ever imagined. I can honestly say if you had asked me where I would be five years ago, I would have given you a completely different answer. I am grateful for where I have ended up, but I am excited to see where 2021 takes me (and us).

Jacqui Fawcett

The year 2020 was my year of sustained close encounters o f the healthcare system kind. Although these encounters were not of the third kind, these were potential for encounters with those who could have been aliens to me. These encounters began on February 10th, when my husband, John, fell on ice outside our house in Maine.  I was at UMass Boston at a lunchtime seminar when I received a phone call from a stranger – a woman who was driving by our house and saw John on the ground. She stopped, called 911, and then called me. The local ambulance crew took John to the local hospital about 15 miles away.  An x-ray revealed he had a fracture of the proximal end of his left humerus. The orthopedic surgeon on call discussed options, and he and John decided on a closed reduction. So far, a seemingly reasonable decision, so to avoid surgery. 

I changed my flight reservation (I typically fly on Cape Air between Maine and Boston) to that evening and saw John at the hospital at about 9 PM. He was in some pain controlled by opioids. He was discharged home the next day with referral for home PT and OT, which were helpful.  I arranged for some grab bars to be installed in the house to ease John’s walking between our living quarters  (we have a  large house that also contains our toy museum) and the bathroom –excellent help from the across the road (we live on US Route !) hardware store staff.  PT and OT continued until February 20th when John’s pain became intense.  So, another call to 911, another trip to the local hospital, this time seen by a different orthopedic surgeon.  X-ray revealed that the closed reduction had failed.  Mutual decision to have surgery, especially when the MD told us that he “loves shoulders!”  Surgery on February 24th followed by OT and PT while still in hospital, until March 1, when John woke up at about 2 AM with intense pain, soon discovered to be a massive hematoma. Off to surgery that day (even though it was a Sunday). Finally to a skilled nursing facility at a very nice life care community for rehab on March 3rd until John finally came home on April 9th with referrals to home nursing (John experienced a 3 cm dehiscence of the surgical site, so dressing changes were needed) and PT.  I am very pleased to let you know that John has recovered almost completely now. The surgical site closed eventually, PT and home RN were not needed by about early May (the home health RN continued longer than I thought  necessary, as I can change surgical dressings!), and his arm has almost full mobility. He was finally discharged from orthopedic follow-up visits in September, so no more trips to his office. John now walks very hesitantly so as not to fall, which is a good thing, although difficult for me to witness. 

 My close encounters with the healthcare team members were much more positive than I would have expected. I did not even have to advocate for John, as his medical and nursing care were efficient, effective, and caring. The second orthopedic surgeon (I had not met the first one) included me in all discussions about John’s condition without my asking for this information, even calling me once when I was at work at UMass Boston. The PT and OT persons included me in their plans of care for John. The hospital and skilled nursing facility staff nurses were caring, expressed their concerns about John, and were receptive to my talking with them about nursology – I gave each one of them our nursology.net card, of course!

The most difficult aspect of the healthcare system encounters came on March 12th, when Covid-19 came to Maine, and I was no longer allowed to visit John at the skilled nursing facility. We tearfully said good night that evening, and I promised to call him every day at 5 PM.  John does not enjoy talking on the telephone, so I was surprised that he agreed to my calling him. Obviously, he needed contact with me. Indeed, when I occasionally called a few minutes after 5 PM, he expressed concern that I had had an accident. So, here we are in November 2020, with me at home in Maine all the time—UMass Boston has been doing remote teaching/learning since March 23rd (end of our spring break).  Although occupied by teaching and lots and lots of zoom meetings with colleagues – I think we may have invented extra meetings to maintain contact while not on campus together—and my usual writing projects,  the second half of spring semester and all of fall semester has seemed like a sabbatical – no commuting to work, more time for self-care,  less worry about the possibility of John falling when I am not at home. 2020 is not a year I would like to repeat but it has not been too challenging for me, for which I am forever grateful.  

Jane K. Dickinson

2020 was the year with no break.

I work in diabetes, and we often discuss how there is no break from diabetes. Even then, we find little ways to take “breaks” – have a family member help out; cut down on the number of daily fingersticks for a few days; carb out on a holiday; etc. I recently got an email from an organization that was announcing they are taking a break from December 19th to January 3rd. They are giving their entire staff this time to “rest and rejuvenate.” Reading this message really made me stop and think about how we all need a break. And how many nurses don’t get a break – from working on the front line exposed to health and human trauma, to literally not having time to eat a meal or go to the bathroom.

2020 was the year with no break from uncertainty. Often nurses work with people who are dealing with uncertainty and this year nurses had to deal with uncertainty in so many ways themselves – all the while helping their patients, students, staff, and family members handle the chaos that everyday life dealt us.

2020 was the year with no break from upheaval. Things were constantly changing – messages, scientific reports, numbers, job security – and yet we just kept going.

2020 was the year with no break from distraction and loss. The kids who are supposed to be at college came home. The kids who are supposed to be in elementary, middle, and high school, began homeschooling. Parents became teachers. Teachers became online instructors. People lost jobs and businesses and loved ones.

2020 was also the year with no break from accomplishment and innovation. Nonprofits and churches and schools got creative. Boards met virtually and made important decisions for their organizations. National and international conferences went online and delivered valuable content. Families and friends met through video conferencing – sometimes groups who hadn’t seen each other in a very long time! More and more nurses have become familiar with Nursology.net. They are accessing its abundant resources to further nursing knowledge to improve nursing education, research, and practice and ultimately the human health experience.

My wish for 2021 is that all nurses get some sort of break to rest and renew, and know that our work is vital to humankind. Happy New Year!

The Marathon of Crisis: “We Want to Live Also”

None of us expected the pandemic to last this long. In March, we rallied against the growing and terrible virus, the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). At that time, we hunkered down, businesses temporarily closed to stem off the rising numbers of infection, and we all kind of figured it would end in about six months. It has not. Crises aren’t supposed to last this long. The nature of this beast is that its danger is unseen; its end is unseen; and its messaging couldn’t be more confusing.

So I didn’t think last April, when my research team and I received a small seed grant from our university called a “COVID Rapid Response Grant,” that the pandemic would be surging in the way it is now, seven months later. In my naivety, I quickly put together an online survey with the major inclusion criterion of having respondents be frontline, critical care nurses. Data collection lasted from mid-June through beginning of September.

My research assistant and I are swimming in the data, tackling a subset of the items, the open-ended responses. This is the qualitative stuff that as Cheryl Beck states (I paraphrase here), puts muscle on the skeleton bones of understanding. It’s rough going. The nurses had a lot to say.

On one hand, it validates so many nurse-specific and nurse-patient specific traumas that I articulate in my theory. Insufficient resource trauma (i.e., not enough personal protective equipment, not enough trained critical care nurses), vicarious trauma (i.e., patients passing alone; families in distress at not being with loved ones); workplace violence (i.e., families frustrated and taking it out on nurses); disaster trauma (i.e., fearful of endangering self and others); and system/medically-induced trauma (i.e., patients being coded and ventilated). These all seem so sterile when I list them but come alive in the narratives that reflect fear for self and fear for their family’s safety if exposed to the virus from them, agony, anxiety, intrusive thoughts, nightmares, isolation, abandonment, suffering, exhaustion. One nurse added: We… will be forever changed.”

They report feeling intense guilt over the limited care they can offer to the patients. I read the texts and re-read them. Then, my eyes see unassuming words buried in the single spaced narratives; a seemingly quiet voice stood out: “We want to live also.”

As I consumed this sentence, I was reminded of the period in my life when I was a full-time writer. I believe in the power of words and of the writer, the truths they can convey. At a visceral level, the writer decides the order of placement, the punctuation for emphasis, the parsimony over emotive phrases, even the phonemic sounds, soft versus hard, such as “puppy” and “paw” versus “dog” and “god.” In this moment, I saw this quote and envisioned an exhausted individual who just wanted to be done with it all and alive to move forward with life. But I think there is more.

This tiny, five-word, soft-sentence encompassed a primary reality: a nurse wanting to exist after this pandemic. The nurse used peripheral words surrounding the statement: the “hospital” viewed nurses as “bodies” to take care of patients, an objectification of the nurse. Beyond the words, the owner of this voice asks, “What about us?” As if to inquire gently, “Have you forgotten about us? Are we an afterthought?” A sentence sends a reminder when there should be none needed, but sends it nonetheless to those who see nurses as “bodies” to care of the sick patients: “We want to live also.”

And perhaps a second message is conveyed by the voice wanting to live – right now – without the trauma, without the fear. The existential plea to the “hospital” to affirm nurses’ right to exist and recognize their right to particular, individual, lived experiences amid a global pandemic. And the system responsibilities to acknowledge that they have provided services and supplies for some individuals to live, but perhaps not all. The “also” after this humble statement is noteworthy: “We want to live also.”

Based on my middle-range theory of nurses’ psychological trauma, one antidote is to use trauma-informed care of self and peers. Demonstrating trauma-informed care principles for self and fellow nurses is a critical piece, especially offering a sense of safety. This is a space occupied only when safety can be authentically assured. Unless organizations step up, safety is scarce. My theory is clear: the solutions to such psychological trauma must be shared between the individual and organization. Resiliency can grow when the environment allows. Fertile soil includes sufficient resources, supportive management, a safe work environment, and mental health services. Importantly, management has to de-objectify nurses and view us as sovereign professionals, individuals who have choices. Second, there will be a time when the pandemic is under control, perhaps when a healing space opens for posttraumatic growth. A few nurses also shared narratives where resiliency and posttraumatic growth existed now. One nurse, who had lived through the “HIV, Toxic Shock, Legionaires, H1N1 and so many other diseases,” seemed able to cope with the current pandemic: “I’ve learned that I can rise above it.” One of the few narratives that contrasted sharply from the majority.

My research assistant, Anna, and I meet virtually to discuss these voices (I can’t call them data right now as they seem so intimate). We discuss our reactions, our general thoughts because I want to authentically make sense of them. I feel responsible to the nurses who offered them to us. Anna is about 30 years younger than me. Yet she and I agree on what we see and feel from the voices, and perhaps within ourselves. There is truth: “We want to live also.”

References

Beck, C. T. (2015). Developing a program of research in nursing. Springer.

Foli, K. J. & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Sigma Theta Tau International Publishing.

Foli, K. J., Reddick, B., Zhang, L., & Krcelich, K. (2020). Nurses’ Psychological Trauma: “They leave me lying awake at night.” Archives of Psychiatric Nursing, 34(3), 86-95. http://doi.org/10.1016/j.apnu.2020.04.011

Everyone is a “novice” when encountering a new challenge or situation: A perspective from Benner’s theory

Although many experienced nurses consider themselves as experts in their fields of practice, it is important to keep in mind that they, too, become novices when they encounter a new clinical challenge or situation such as the Covid-19 pandemic. Benner’s (1984) theory, From Novice to Expert, is an excellent nursology theory that can guide clinical practice in the context of current health care challenges related to Covid-19. The theory includes five stages–novice, advanced beginner, competence, proficiency, and expertise. As nurses pass through these various levels of proficiency, they develop holistic clinical knowledge influenced by nursology education, experience, and intuition (Benner, 1984).

The purpose of this blog is to summarize an exemplar of a  “novice to expert” nursology educational strategy developed in response to the Covid-pandemic Global Nursing Education exemplar.  The exemplar is about a non-profit 501c3 organization, Dr. Gabone QHSC (Quality Healthcare Solutions and Consulting) Inc., which  served global novice nurses experiencing a surge in Covid-19 cases in their clinical practice. These novice nurses, especially those assigned to “Covid-19” units experienced common challenges reported in the literature such as exposure and anxiety related to the lack of personal protective equipment and fear of the unknown (Chen, Lai, & Tsay, 2020) . As a result, they relied heavily on emerging knowledge from public health experts as well as clinical expertise from frontline workers who had already experienced the impact and management of the disease in their practice settings.  Hence, to better serve the novice nurses, the organization assembled teams of interprofessional Covid-19 frontline healthcare workers from various Covid-19 affected areas to share knowledge about how they utilized their highly skilled analytical problem solving abilities, experience, and education to grasp the emerging situation, events, and behaviors via Zoom meetings.

Six educational sessions were offered as resources to heighten the opportunities for novice nurses around the world, in particular targeting Tanzanian nursologists. The topics covered included:

  • Challenges of Covid-19 in nursing practice across various practice settings
  • Typical nursing care shifts for Covid-19 patients
  • Medication administration and medical protocols
  • Infectious disease management
  • Effective use of PPE to prevent spread of COVID-19
  • Effective coping strategies to promote nurses’ individual and family well-being
  • Creating a culture of safety
  • Challenges faced by prospective health care workers.

As the frontline workers described their expert practice, they widened the novice nursologists’ perspectives and acceptance of actual and potential challenges and situations they might encounter in their practice settings. For example, the meetings provided demonstrations of how nursologists are interconnected and how they face similar challenges such as lack of PPE and fear of becoming infected. In addition, some nursologists shared ways they reused supplies while ensuring safety and efficiency for patient care.

Overall, the feedback from the participants was positive. The online mode of delivery included interactive elements such as chats, polling, and emails to facilitate discussions to move beyond the content elements and also facilitate experiential learning to develop expertise. Future recommendations for effective online global education delivery and programming include consideration of delivery time for synchronous presentations, as well as access to technology and internet service in resource poor countries and communities.

As we move forward, I call upon nursology scholars worldwide to utilize Benner’s (1984) Novice to Expert theory to examine how the lived experiences of frontline nurses during the Covid-19 pandemic facilitate knowledge development among novice nurses in clinical practice. Questions to ponder are: 1) How and what did frontline nursolgists learn during the Covid-19 pandemic? 2) What new nursing knowledge was generated by the frontline nursologists as they became the experts? 3) How can we utilize the new knowledge in nursology education and practice to manage future outbreaks/pandemics?

Please feel free to share your comments to this blog.  

References

Benner, P. (1984). From novice to expert. Addison‐Wesley .  

Chen, S-C., Lai, Y-H., & Tasay, S-L.  (2020). Nursing perspectives on the impacts of COVID-19. Journal of Nursing Research28(3), 5 pages.  http://doi.org./10.1097/NRJ.0000000000000389 

By and For Numbers: Meaningless Without Theory

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.

References

Aula, V. (2020, May 15). The public debate around COVID-19 demonstrates our ongoing and misplaced trust in numbers. https://blogs.lse.ac.uk/impactofsocialsciences/2020/05/15/the-public-debate-around-covid-19-demonstrates-our-ongoing-and-misplaced-trust-in-numbers/

Hundt, B, (2020), Reflections on Nightingale in the year of the nurse. American Nurse Journal, 15(5), 26-29.

May you live in interesting times (2020, June 3), In Wikipedia. https://en.wikipedia.org/wiki/May_you_live_in_interesting_times

Popper, K. R. (1965). Conjectures and refutation: The growth of scientific knowledge. Harper Torchbooks.

Never a Guardian: Remembering Breonna Taylor

Want to learn more about Nursing and Racism? Read the following Nursology blogs: Nursing and Racism and Decolonizing Nursing.

Artwork used with permission of the artist Ariel Sinha

The Guardians of the Discipline is a series featured on Nursology.net as a way to commemorate the giants whose shoulders we stand on as we forge our nursing paths. Today, we – the Nursology Theory Collective – would like to memorialize someone who never had the chance to join the discipline, though we understand that she intended to be a nurse (Oppel & Taylor, 2020). Her name is Breonna Taylor. Murdered by the police executing a “no-knock” warrant, Breonna Taylor, a Black woman, was murdered as she slept in her home. Startled by the unannounced and forced entry of Louisville law enforcement, Breonna Taylor’s boyfriend – a licensed gun owner – began firing his gun, assuming their home was being invaded. The police returned fire, striking Breonna who died six excruciating minutes later, no aid ever rendered (Simko-Bednarski et al., 2020). Final analyses showed the police had invaded the wrong home and that she remained alive for minutes without critical aid being offered. Lack of further investigations suggests that  Breonna Taylor’s life has seemingly been brushed aside. To date, no one has been held accountable for her murder. The no-knock policy remains uninterrogated (Oppel & Taylor, 2020).

We wish to honor Breonna Taylor, recognizing the structural missingness her death signifies in our profession (Hopkins Walsh & Dillard-Wright, 2020). NTC members Jane Hopkins Walsh and Jessica Dillard-Wright (2020) “synthesized the concept of structural missingness to capture the state of exclusion from healthcare due to inequalities within a system, a country or globally” (p.1). The concept was imagined to capture the injustices and inadequacies of talking about healthcare as a structurally-sound starting place for any kind of analysis, recognizing the people and groups who are all too often missing in colonized and capitalism driven spaces. In this blog post, we wish to extend this concept, recognizing the implications that the murder of Breonna Taylor has for nursing, acknowledging that nursing will never have the opportunity to learn from her knowledge and experience. 

Breonna Taylor’s murder is a structural missingness double-jeopardy. Her murder points to violent systemic racism, inequities and injustice. As a discipline, nursing is part of the racist system, and carries this internalized and systematized racial prejudice (Barbee, 1993; Barbee & Gibson, 2001). Nursing bears the hallmarks of normative whiteness, part of the hidden curriculum of nursing enacted through practices rooted in the received values around respectability; what are accepted dress codes, hairstyles, body art, leading to gatekeeping, professionalism codes, and civility policing that narrowly define what a nurse looks like (Allen, 2006; Puzan, 2003).  Scholar Ibraham Kendi refers to this implicit racist system as the “White judge” (Kendi, 2017 p. 4). Nursing professor @UMassWalker recently spoke to this idea in their critique of the vague and subjectively worded term “good moral character” bound within their university’s prelicensure nursing syllabus (see Twitter post from July 22, 2020). Dr. Walker’s blog post the next day further expanded upon the issues of institutional racism in the system of nursing education. These enshrined messages and images of how nurses ought to look, speak and act connect back to our received historical narratives- the stories that tell stories (Haraway, 2016). 

The Nightingale chronicles are an example of how this image of normative whiteness in nursing continues to be the dominant legend for all who enter the profession. The reified Nightingale history embeds systemic values that intersect race narratives alongside received norms for behavior, gender, sexuality, and class. Mary Seacole who self identified in her writings as a Creole person, was a Jamaican nurse and peer of Nightingale’s who was awarded international medals for her service in the Crimean war. She was a published author, commented on political issues of slavery and racism, made scientific observations around cholera and diarrhea, but historical letters suggest she was deemed unsuitable for service by Nightingale and other British authorities. Her contributions to nursing are underreported, diminished and debated to this day (McDonald, 2014; Staring‐Derks et al., 2015).

Breonna Taylor will never graduate from nursing school. Murdered in her sleep, she has been rendered structurally missing by virtue of her death by brutal aggressive police actions, a victim of the very institution that purports to serve and protect. Breonna is forever erased from our discipline. We recognize this injustice and by honoring her memory, we refuse to ignore the political ideologies that fail to interrogate aggressive policing systems that neglect to bring her killers, who are still free, before the court. Her death speaks to the complex and structurally violent structures that silently continue to collude, reifying nursing’s hegemony through systematic exclusions and injustices surrounding Black people who are systematically oppressed and erased. We, the discipline of nursing, are not immune from the effects of police brutality, and as a result a future nurse and colleague is missing. Furthermore, nursing is not immune from perpetuating racist systems. We must actively work towards a more just, equitable, and inclusive discipline, recognizing that the minimum bar of humanness demands actively protesting and opposing police brutality and the unacceptable murders of Black people, including Breonna Taylor.

What can you do to support Breonna Taylor, who never got to be a guardian of our discipline?

  1. Learn more about Breonna Taylor and her murder.
  2. Sign a petition demanding justice for Breonna Taylor’s murder.
  3. Read the Nursology Theory Collective anti-racism statement and commit to be actively anti-racist. 
  4. Use the platforms you have to name, address, and dismantle racism and white supremacy in the systems in which you work and live.
  5. Contact your local, state and federal elected officials weekly to inquire about legislation they are enacting to combat violent police practices against Black people and other Non Black People of Color.
  6. Consider running for elected office to embody the change we want to see.
  7. Constructively critique existing nursing theories and philosophies to deconstruct the effects of colonization of our formal knowledge base and to understand the ways that racialized systems and structures influence the development of our discipline.
  8. Use these insights to develop anti-racist research, theory, education, practice and policy that is aimed to decolonize nursing.

References

Allen, D. G. (2006). Whiteness and difference in nursing. Nursing Philosophy, 7(2), 65–78. https://doi.org/10.1111/j.1466-769X.2006.00255.x

Barbee, E. L. (1993). Racism in US nursing. Medical Anthropology Quarterly, 7(4), 346-362. https://doi.org/10.1525/maq.1993.7.4.02a00040

Barbee, E. L., & Gibson, S. E. (2001). Our dismal progress: The recruitment of non-whites into nursing. Journal of Nursing Education, 40(6), 243-244. https://doi.org/10.3928/0148-4834-20010901-03

Haraway, D. J. (2016). Staying with the Trouble: Making Kin in the Chthulucene. Duke University Press.

Hopkins Walsh, J., & Dillard-Wright, J. (2020). The case for “structural missingness:” A critical discourse of missed care. Nursing Philosophy, 21(1), 1–12. https://doi.org/10.1111/nup.12279

Kendi, I. X. (2019). How to be an antiracist. One world.

McDonald, L. (2014). Florence Nightingale and Mary Seacole on nursing and health care. Journal of Advanced Nursing, 70(6), 1436–1444. https://doi.org/10.1111/jan.12291

Oppel, R. A., & Taylor, D. B. (2020, July 9). Here’s What You Need to Know About Breonna Taylor’s Death. The New York Times. https://www.nytimes.com/article/breonna-taylor-police.html

Puzan, E. (2003). The unbearable whiteness of being (in nursing). Nursing Inquiry, 10(3), 193–200. https://doi.org/10.1046/j.1440-1800.2003.00180.x

Simko-Bednarski, E., Snyder, A., & Ly, L. (2020, July 18). Lawsuit claims Breonna Taylor lived for “5 to 6 minutes” after being shot. CNN. https://www.cnn.com/2020/07/18/us/breonna-taylor-lawsuit/index.html

Staring‐Derks, C., Staring, J., & Anionwu, E. N. (2015). Mary Seacole: Global nurse extraordinaire. Journal of Advanced Nursing, 71(3), 514–525. https://doi.org/10.1111/jan.12559