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

Orem’s Self-Care Theory: A Critical Theory to Tanzania Nurses in the Wake of COVID-19

Guest author: Katunzi Mutalemwa
with Rosemary Eustace

see also Practice Exemplar
Self-Care Theory in Tanzania

Self-care is an integral part of nursing care delivery systems. Pioneered by Dr. Dorothea Orem, the self-care theory offers nurses with unique opportunities for health promotion, disease prevention and rehabilitation care worldwide. Self-care supportive-educative strategies through health promotion and prevention initiatives have been instrumental in health care service delivery in Tanzania, especially in primary care clinics. The emerging COVID-19 pandemic has delineated new care demands on self-care requisites that Tanzania populations need to meet in order to stay healthy and free of the illness.  With such a pandemic, nurses are being tasked to find new ways of assisting clients to effectively meet their self-care needs that best fit the cultural context.  So the following question remains to be answered: What kind of nursing system(s) are in demand in Tanzania in this COVID-19 era? 

The Orem’s Self-care theory guided the practice exemplar “Self Care Theory in Tanzania.” This exemplar highlights two common self-care strategies utilized in Tanzania in the wake of COVID-19, that we identify as Non-pharmaceutical (NP) and Alternative pharmaceutical (AP) self-care nursing interventions.  The first example is focused on hand washing as a basic NP self-care strategy.  The second example relates to complimentary alterative medicines (CAM) as an Alternative pharmaceutical (AP) self-care strategy in particular herbal steam therapy (commonly known as kujifukiza in Kiswahili).

As the most trusted health care professionals in the world, we “nurses” have the duty and responsibility to help individuals, families and communities to be able to choose and select the right information for self-care.   In the wake of COVID-19, nursing self-care delivery systems should focus on prevention and health promotion in a safe and cost-effective manner. This approach supports Dr Jacqueline Fawcett assertion that “Nursology has an answer to how to emphasize primary prevention.” [Read her blog The Value of Primary Prevention]. This is the right time to do so.  We have to be part of the solution by being proactive and advocating for effective non-pharmaceutical (NP) and Alternative pharmaceutical (AP) self-care policies through the lens of unique nursing perspectives, in this case, Orem’s Self-Care theory. 

The two exemplars clearly tell the story that upon planning of any successful health-related project, it is important to understand the extent of self-care practices in a community, collaboration, training needs in self-care and development of guidelines/protocols. The “Kujifukiza” (i.e. herbal steam therapy) phenomenon was eye opening. It is not surprising to see that Sub-Saharan nurses are receptive of alternative modalities but lack appropriate knowledge about complementary health therapies (Gyasi, 2018).   For example, I (Katunzi) am one of those nurses who lack appropriate knowledge about CAM. I was not fortunate to have this kind of education in my nursing program beside a one-day CAM observational opportunity during a palliative care rotation. I am now compelled to advocate for nursology-led initiatives to study and promote evidence-based protocols or guidelines. 

There is a lot to be done and a lot to learn from each other about Orem’s self-care theory guided practice related to NP and AP self-care strategies. To continue this dialogue on NP and AP self-care strategies, we would like to invite nurses and nursing students around the world to reflect on the COVID-19 pandemic as it relates to these important self-care issues:

  1. How has hand washing, a non-pharmaceutical (NP) self-care public health strategy been utilized within your cultural context (family, workplace or community)?
  2. How has alternative pharmaceutical (AP) self-care public health strategies been utilized in your cultural context (family, work place or community)?
  3. If Dorothea Orem lived to see the COVID-19 pandemic, what do you think she would say about nurses, nursing and self-care?

Please share your thoughts in the comment chat box. We look forward to hearing from you!

Suggested Readings

Mutalemwa, K. & Eustace, R. (2020). Self-Care Theory in Tanzania. Nursology.net Practice Exemplar https://nursology.net/practice-theory-exemplars/self-care-theory-in-tanzania/

Dorothea Orem: Self-Care Deficit Theory https://nurseslabs.com/dorothea-orems-self-care-theory/  web accessed on 29/05/2020

Gyasi, R. M. (2018). Unmasking the practices of nurses and intercultural health in sub-Saharan Africa: a useful way to improve health care?. Journal of evidence-based integrative medicine, 23 2515690X18791124.

Orem, D. (1991). Nursing: Concepts of practice. (4th ed.). In George, J. (Ed.). Nursing theories: the base for professional nursing practice. Norwalk, Connecticut: Appleton & Lange https://www.who.int/reproductivehealth/self-care-interventions/definitions/en/ web accessed on 08/06/2020

About Katunzi Mutalemwa

Katunzi Mutalemwa, BScN is an evolving young Tanzanian nurse leader who just completed his baccalaureate nursing education in the Fall 2019. He is currently working on a Non-Communicable Diseases (NCDs) project in Tanzania and waiting to start his one year nursing internship at Kilimanjaro Christian Medical Center in November 2020. Mr. Katunzi was honored to write his BScN thesis on ‘Nurses Experiences of Caring LGBTQ Patients with HIV Infections guided by Travelbee’s Human-to-Human Relationship Model’ at Swedish Red Cross University in Sweden. He recently published a book titled “Nurses the Cornerstone of Health Care System” to inspire his fellow nurses in Tanzania. He is the former Chairperson of the University Nursing Students Association of Tanzania (UNSATA). He would like to thank Dr Rosemary Eustace for her mentorship in preparing this information for Nursology.net.

Uncertainty in Life and in the Time of the Covid-19 Pandemic

Uncertainty is, in many ways, a human condition—each of us most likely feel uncertain about something at least some time in our life. However, the current covid-19 pandemic has brought forth a time of what is great uncertainty for many people worldwide. What, though, is the meaning of uncertainty and the outcome of feeling uncertain?

Merle Mishel’s Theory of Uncertainty in Illness tells us that uncertainty is “the inability to determine the meaning of illness-related events” (Mishel as cited in Clayton Dean, & MIshel, 2018, p. 49). More generally, uncertainty is defined as “The state of not being definitely known or perfectly clear; doubtfulness or vagueness. . . . the quality of being indeterminate as to magnitude or value” (Oxford English Dictionary, 1921/1989).

Mishel’s theory also tells us that uncertainty may be regarded as a danger or an opportunity. What are dangers associated with uncertainty during the covid-19 pandemic? Mental health problems, such as anxiety and depression, have been cited as a danger—Chinn wrote of the “Hidden Risks of Physical Distancing and Social Isolation” during the current pandemic. Foli wrote about the psychological trauma experienced by nurses caring for people with covid-19.

What are opportunities associated with uncertainty during the covid-19 pandemic? Media attention to the inequities of health care based on race is an opportunity to highlight what nursologists have known at least since the time of Florence Nightingale. The nursology.net management team has crafted a statement in support of the elimination of health care inequities that is visible in the sidebar of this website. The statement reads in part, “We are dedicated to building praxis in nursing that reflects the tradition of nursing’s dedication to social justice, that addresses injustice, and that welcomes dialogue and action focused on creating needed change within nursing and healthcare.” All nursologists have an opportunity, on which we must now capitalize, to be at the forefront of developing and applying knowledge to overcome finally widely recognized racial-based health care inequities. We must grasp the opportunity given to nursologists by the media and wider society to be recognized as competent and compassionate carers of people critically ill with covid-19. By doing so, we will actualize #neverforget, which Balakrishnan (2020) used to refer to climate change but is perfect for nursology especially at this time.

 Michsel’s Revised Theory of Uncertainty in Illness  tells us that the outcome of feeling uncertain is a new life perspective. What is a preferred new live perspective? Are nursologists and all citizens of our planet willing to a new value system to guide the way we live and interact with others?

Although Mishel’s theories are about uncertainty in illness, many other facets of life involve uncertainty. For example: Will my car start today? Will public transportation be on time? Will the meal I ordered or cooked myself be delicious? Will my family member or friend like the gift I purchased for her or him? Will my partner always love me? Extended to knowledge development, we know that  inferential statistics used to test theoretical hypotheses do not produce results that are “facts” or “laws,” but instead are numbers that represent a certain level of probability – we are, for example,  95% (p = 0.05) or 99% (p = 0.01) certain about some result but %5 or 1% uncertain about the result. Thus, much of what we know empirically is under conditions of uncertainly.

Clearly, if we are to live comfortably with uncertainty, we need to be comfortable with learning that which is not yet certain (if it can ever be certain!). Within the context of theory development, we can learn from rejection of our hypotheses. Indeed, Popper (1963) maintained that rejection of hypotheses is desirable as the next hypothesis will be better–we will have a better theory.  Glanz (2002) added, “There is as much to learn from failure as there is to learn from success” (p. 546).  Knowing “what is not” advances theory development by eliminating a false line of reasoning before much time and effort are invested. Thus, wanting to be certain may be a trap that leads to arrogance or a barrier to accepting at least a certain extent of uncertainty. Paraphrasing Barry (1997), who wrote about truth in science, we can indicate that one can reach certainty “no more than one can reach infinity” (p. 90).   

References

Barry, J. M. (1997). Rising tide: The great Mississippi flood of 1927 and how it changed America. New York, NY: Touchstone/Simon and Schuster.

Balakrishnan, K. (2020, May 28). Aggressive containment, extensive contact tracing. Panel presentation as part of the Coronovirus Seminar: Global perspectives. Boston University School of Public Health webinar/ Retrieved from https://www.bu.edu/sph/news-events/signature-programs/deans-seminars/coronavirus-seminar-series/covid-19-global-perspectives/?utm_medium=email&utm_campaign=DLE%20-%20DSS%20-%20COVID%20-%20Global%20-%2023&utm_content=DLE%20-%20DSS%20-%20COVID%20-%20Global%20-%2023+CID_d2cf1e251bb8e6c937a202dfa97b651b&utm_source=Email%20marketing%20software&utm_term=Join%20us%20online

Clayton, M. F., Dean, M,, & MIshel, M (2018), Theories of uncertainty. In M. J. Smith & P. R. Liehr (Eds.). Middle range theory for nursing (4th ed., pp. 49-81). New York, NY: Springer.

Glanz, K. (2002). Perspectives on using theory. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed., pp. 545-558). San Francisco: Jossey-Bass.

Oxford English Dictionary. (1921/1989). Definition of uncertainty. Retrieved from https://www-oed-com.ezproxy.lib.umb.edu/view/Entry/210212?redirectedFrom=uncertainty#eid

Popper, K. R. (1965). Conjectures and refutations: The growth of scientific knowledge. New York, NY: Harper and Row.

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

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

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

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

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

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

Katie Clark at the Health Commons

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

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

MOODI Outreach

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

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

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

MOODI Outreach

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

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

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

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

References

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

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

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

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

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

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

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

About Kaija Freborg

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

COVID-19 – What would Margaret Newman say?

Dorothy Jones and Jane Flanagan
See also Newman’s Theory of Health
as Expanded Consciousness

Although not the only global challenge we face, COVID-19 has the world’s attention while disrupting so many familiar routines. For those so fortunate, there is the new normal of working from home and countless conference calls that seem to blur one day into the next, almost erasing the confines of time while confining us to a physical space.  When things get back to “normal” what will that look like?

For those in service industries, there is the chaos of being the person in the midst of unsafe places whether the grocery store, a bus or as an employee in a hospital.  Making connections while fearing, am I safe? Do I have what I need to protect myself/ my family? And, sometimes knowing you do not have what you need, and in that moment, your awareness of the disparity of those who have and those who do not is heightened.  What will it be like when things get back to “normal?

 Then there are those who in a whirlwind, may have lost their job.  Now they are struggling to pay bills, perhaps visiting food banks for the first time mixed in with home schooling young children or a full house of grown children now back to the safety of their childhood home.  When and what will be that return to “normal”?  For every scenario, there is opportunity, freedom and new ways of being. There is also potential binding or unraveling.  But no matter the reality, there are the chants to “get back to normal”

Dr. Margaret Newman

This idea of “getting back to normal” raises the question; “What would Margaret say?” We think the answer is …actually, not very much.  She would smile gently and acknowledge each person who spoke and told his or her personal story. She would be present and authentically listen.  Her silence would spur more stories until in the sheer dizziness of it all, the cacophony would stop and everyone would look to her and wonder what she is thinking. Again, silence and this time the room would go quiet.  Finally, she would speak: “I’m just curious about people wanting to go back to normal, what do people think of that?”  Then she would sit and wait for us to react…and we would.  We would discuss how we cannot “go back” and about the opportunity in the chaos. What went well in nursing practice during COVID – 19 that was reflective of nursing and what did not?  She would smile, as we would envision a new future that informed by COVID-19, and the inequities of an illness, linked to an environmental crisis and manifested in our most vulnerable. An illness that has stuck down older adults, minorities and is on a path to literally destroying second and third world countries.  Go back?  No, we would not be going back we would be envisioning a new future, one with boundaryless opportunities.

There is for some, an increased awareness, that the inequities of COVID-19 along with the murder of George Floyd and other racial incidences has heightened the issue of structural racism that has always been simmering under the surface. Go back?  Oh no, we will not go back. Not to complacency, not to a world where nurses today are lauded for their actions during a crisis, but who will return to being a hidden entity, part of the bed charge.  No, we are now in a world that recognizes, yes there were many deaths, but because of nursing care, because of nursing’s commitment to meeting the person where they were at, commitment to delving into knowing other, upward of 85% of those who had COVID and were hospitalized were successfully discharged.  Yes, nursing care! It was the authentic presence of nurses who connected with patients in new ways and journeyed with them on a path of discovery, nurses learning to recognize the pattern of the critically ill when the normal mode of communication was no longer possible, and nurses who transformed the care environment. It was not a cure or a vaccine that made the difference; it was “the difference nursing makes” that made the difference.

The COVID-19 virus made visible a pattern of turbulence and disruption within the global whole.  Lack of awareness to growing social challenges, loss of freedom creation of boundaries and isolation confounded the environment within which the virus emerged. Within this context, the virus took on new meaning and yielded variety of responses. Using the theoretical lens of Health as Expanding Consciousness, Margaret would reflectively and carefully suggest that being exposed to the global and dramatic changes of the day has already begun to reshape/repattern us. She would envision the voice of nurses advocating on behalf of patients, on behalf of the myth of curing rather than healing, on behalf of older adults, racial and ethnic minorities.  Margaret would not support “going back”; instead, she would reflect on the meaning of the unfolding pattern emerging before us …within the context of an illness.

The event COVID-19 has served to make visible the invisible for society as a whole.  Recognition that we are all connected and interrelated. The actions and behaviors of one individual directly affecting the very life of another. Response to the virus has revealed a complex, dynamic human pattern of the whole within a dynamic and changing environment. As the illness experience is unfolding, individual responses shaped by factors including  vulnerability,  gender, age and the older adults, race, ethnicity, compromised health status, poverty, lack of insurance, homelessness, exposure to environmental stressors and population density, and personal responses to life challenges have been made visible. Compromised relationships, sustained loneliness and disconnection challenged human becoming and threatened choices about health and wellness. Rather than creating new problems, COVID-19 has manifested not only a serious disease but made visible longstanding global societal challenges that have gone unnoticed or suppressed.

Margaret would caution that “fixing” the illness (i.e. treating to cure) without addressing the whole person/environment interaction that include people and events surrounding the individual experience, could lead to a reoccurring manifestation of the underlying pattern in new ways (e.g. inequities and disparities in care). She would stress the importance of collaborating with individuals and groups in dialogue, she would identify what is meaningful, to acknowledge the collective increased awareness, and seek to uncover an underlying pattern of the whole. COVID-19 then becomes a stimulus for active discussion, identifying barriers that compromise moving forward as individuals and as a society. The insights gained through information and connecting with another create opportunities for new insights, actions and freedom to participate knowingly in actions that promote transformative change.

The importance of relationship is core to advancing the process of discovery. Partnerships that are open and evolving allow pattern to emerge and potentially increase the realization that we are all interdependent and connected within and across environments. Recognizing that what affects one-person or community can have a reciprocal impact on another. Within the discovery process there is freedom to hold on to what gives new meaning to one’s being and what binds and threatens our freedom  to become and engage in sustainable holistic healing. No, Margaret we are not going back. And she would smile, knowing we are with new heightened awareness and renewed energy, accelerating toward new potentials and  transformation.

Additional References

Newman, M. A. (2008). Transforming presence: The difference that Nursing makes. Philadelphia: F. A. Davis.

Newman, M. A., Smith, M. C., Pharris, M. D., & Jones, D. (2008). The focus of the discipline of nursing revisited. Advances in Nursing Science, 31(1), E16-E27. https://doi.org/10.1097/01.ANS.0000311533.65941.f1

Smith, M. C. (2011). Integrative Review of Research Related to Margaret Newman’s Theory of Health as Expanding Consciousness. In Nursing Science Quarterly (Vol. 24, Issue 3, pp. 256–272). https://doi.org/10.1177/0894318411409421

We ARE the theory-practice connection; COVID-19 tells us so!

Guest Contributors*:
Andra Opalinski and Patricia Liehr

We are responding to Dr. Foli’s request in her blog titled “Say It Ain’t So:  Graduate Students Shade Nursing Theory!” where she stated…What about you?  If you have suggestions for me on how to strengthen the theory-to-primary care advanced practice connection in a master’s level course, please forward them…”

WE BEGIN WITH DEFINITIONS

Throwing Shade: (verb) subtly disrespecting or ridiculing someone or something.

Shade: (noun) a comparative darkness caused by shelter from direct light.

We ARE the theory-practice connection.

As nurse educators who appreciate the theory-practice connection, we had been pondering Foli’s post and then Constantinide’s follow-up about graduate students throwing shade at nursing theory. Not knowing the meaning, we took the “throwing shade” descriptor quite literally and thought how we often prefer to find shade on sunny Florida days!!!  In the midst of our extended pondering and thoughtful conversations came COVID-19; and a virtual class that we co-hosted with NP students to discuss the use of Story theory in practice; and THEN, we serendipitously came across a 2020 calendar page with a haiku by Tomihiro Hoshino entitled “In the Shade.” This haiku accompanies his calendar painting of a redbud tree with hanging red pods amidst green foliage:

In the shade of leaves,
They shyly sway,
Pods like strips of paper
With girlish wishes
Written on them

Moving along to a class with NP students.  

In this class, we were talking about Story theory and the practicality of using it when working with patients. Story Path, a way to pursue story-sharing was the specific lesson (Liehr & Smith, 2020). Clare, an ER nurse, volunteered to share a recent practice story with the class.

“I was caring for an elderly patient in the Emergency Room who had just tested positive for COVID-19. However, this day, the provider I was working with was resistant to putting the patient on a ventilator.” As Clare reflected  on the situation she shared, “I remember asking myself, is the provider just being lazy because the patient is elderly with a poor prognosis? However, I also knew, this doctor reads a lot of research. I still couldn’t help but question the decision. The patient did in fact improve without ventilator assistance,” giving Clare pause….thinking about the juxtaposition of knowledge with practice. As Clare’s recounting of the story concluded, Clare was asked to consider how her COVID-19 experiences may influence the future. The rawness of her sharing was palpable as she elaborated on the pause noted in her story: “I never knew nursing would get to this point. I am becoming suspicious of everyone, even co-workers. I stand away from everyone and wear masks all the time. I am challenged with what feels like lacking compassion. I don’t spend time in the rooms like I always did before, or place a hand on an arm to show comfort because we are thinking, is this the next COVID patient. I do make sure there is a phone in every room and I call often to check on the patients. It just feels less personal. It feels unnatural.”

Hmmm…lacking compassion feels unnatural. There is a theory and/or a philosophical perspective in this sentiment. We could go with Meyeroff’s ideas (1971) about caring as a way of ordering one’s values so that one feels “in place” rather than “out of place” in the world. We could go with Watson’s Transpersonal Caring Moment (Watson, 2018) where people come together in a human-to-human, spirit-to-spirit connection that is meaningful, authentic and intentional. These are just two examples providing context that allows for locating self in the theory-practice connection; many others could be the philosophical/theoretical lens providing context.   

Then the class was asked, “What have you learned from Clare’s story that resonates with your own practice?” Anna was quick to answer, “Everything is fluid and flexible right now, we have protocols, but they change day by day, they are evolving and there is a lot of uncertainty. We have to be able to allow flexibility in new ways. I can’t get into my usual groove.” Then THE question was posed. “Is theory real for you in your everyday practice? If not, it’s ok to say so.” Perhaps the most insightful answer was Brad’s response. “We are taught many theories, but challenged to know how to apply them. I don’t have theory on my mind when I am in front of my patient. It may be subconscious, but I’m not thinking, I’m applying Leininger or Watson right at this moment.”

Brad is right…we don’t expect that nurses live real-time practice checking in with theoretical/philosophical perspectives. However…the perspectives are there and stepping back and reflecting on nursing circumstances may enable forward movement with theory-guided intention and with knowledge-building for the discipline.

Pondering We ARE the theory-practice connection

As the nurse theorist-practitioner team that we are, we have great appreciation for the comments of these practicing nurses who happen to be graduate students. We wondered …Could the shade granted by COVID-19 bring theory out of the shade for students when they don’t even know it? You see, we are educators in a setting where nursing theory is highly valued and caring theory is the organizing spine of our curriculum. Has caring theory become so naturally interwoven in their practice that these NP students know something is amiss but they have difficulty naming it beyond descriptors like “unnatural” or “I can’t get in my groove”? We can only hope….but we can also plan to honor the shade by:  

  • remembering that we are always working from a theoretical perspective – we have only to step back from any nursing situation and consider the principles/concepts that are guiding our actions;
  • creating opportunities to share our practice stories with the knowledge that the implicit theory woven into the practice threads can come alive through scholarly engagement that is open to authentic expression and that gently supports exploration and maturing of an individual nurse’s own thinking;
  • holding the theory-practice connection as a truth that just takes time and professional maturity for appreciation but it is a truth that can be readily described when nurses have a mentor who helps with connecting the practice-theory dots;
  • pairing theorists and nurse practitioners to forge opportunities for growing nursing knowledge grounded in our practice.

Though there is little positive to say about COVID-19 these days, it may be that the pandemic granted some shade for us to reflect on the theory-practice connection in a way that can guide  understanding. After all, We ARE the theory-practice connection. Let’s own it.

Now….what do you think – we would like to hear from you.  How do you see our plan to honor the shade as an integral dimension of developing practice-scholars AND growing the discipline of nursing?  

  1. Liehr, P. & Smith, M.J. (2020). Claiming the narrative wave with story theory. ANS, 43(1), 13-27.
  2. Meyeroff, M. (1971). On caring. Harper & Row: New York.
  3. Watson, J. (2018). Unitary caring science: The philosophy and praxis of nursing. Louisville, CO: University Press of Colorado.

About the contributors

Andra S. Opalinski

Andra Opalinski, PhD, CPNP-PC, NC-BC is a pediatric nurse practitioner and an Associate Professor at the Christine E. Lynn College of Nursing, Florida Atlantic University. She is an advocate for child and adolescent mental health promotion. Her current areas of interest include community-based participatory research with elementary through high school students using mindfulness interventions for self-regulation and stress management skill building. She also uses visual anthropology through photographs to explore perspectives of health of vulnerable populations. Right now, you’ll find her working remotely, doing the best she can to keep her household of 5 under strict physical distancing, and using the visual anthropology approach to document her family’s physical distancing experiences.

Patricia Liehr

Patricia Liehr PhD RN is currently the Associate Dean for Nursing Research and Scholarship at the Christine E. Lynn College of Nursing, Florida Atlantic University (FAU). She is the co-author of story theory and the co-editor of Middle Range Theory for Nursing. Most of her scholarly work has focused on peace, from personal through mindfulness; to global through coming to know both sides (Pearl Harbor; Hiroshima) of surviving the bombings of WWII. Story-gathering has played a major role in her research endeavors and she highly values the place of nursing practice stories for disciplinary knowledge development. Right now, as she moves toward an August retirement from FAU, she is imagining all the things she will do with new-found time.

Critical Caring in the context of COVID-19

A man and a woman were fishing on the river bank when they saw a woman struggling in the current. They rescued her. Soon, they saw a man struggling. They rescued him, too. This continued all afternoon.  Finally, the exhausted pair decided to go upstream to find out where and why so many people were falling in. They discovered a beautiful overlook along the river’s edge without any warning signs or protective barriers. The couple went to community leaders to report the number of victims they had rescued and explained the connection to the unprotected overlook. Community leaders agreed to install a protective guard and post warning signs. Preventing the problem saves resources, energy, and lives.”  (see “The Upstream/Downstream Parable)

Critical Caring is a way of being-in-relation that seeks to protect and enhance human dignity. It is informed by multiple ways of knowing (Chinn & Kramer, 2017) and guided by a caring/social justice ethics in which advocacy for social justice becomes an expression of caring for individuals, groups, communities, or populations. It encompasses both downstream and upstream nursing practice. (Falk-Rafael & Betker, 2012a) The “critical” aspect of the theory reflects both the theory’s roots in contemporary critical social theories and in the work of Nightingale, who I would argue, espoused the tenets of what became known as critical social theory decades before it was formalized by the Frankfurt School in the 1930s.

Adeline Falk-Rafael (on the right) in 2003 with a member of the Older Women’s Network protesting proposed cuts to Long Term Care

Although originally proposed as a middle-range theory of public health nursing (Falk-Rafael,2020), Critical Caring’s seven carative health promoting processes (CCHPs) can readily provide guidance to nurses practicing in the context of the COVID-19 pandemic, regardless of setting. The CHPPs are focused on simultaneously meeting the needs of individuals, groups, and/or communities and building their capacity (CHPP 6) , i.e., helping them to regain/maintain whatever degree of control over their life is possible to maximize their health potential (Falk-Rafael, 2001, Falk-Rafael & Betker, 2012a).

Downstream Caring

 Critical caring begins with the preparation of one’s self (CHPP1) and involves taking measures to monitor, care for, and protect one’s own physical-mental-spiritual health. Examples related to COVID-19 include physical distancing when in public and use of appropriate personal protective equipment. (See series of posts on that topic by Carey Clark). Appropriate PPE provides protection for the nurse and also contributes to the downstream aspect of CHPP 5, relating to the provision and maintenance of a safe and supportive physical environment for the patient/client. Other measures to create a safe environment include such fundamental principles as the separation of infected people from non-infected people, a principle well understood by Nightingale but ignored in some of the long-term care facilities in Ontario, ravaged by COVID-19. 

Central to critical caring is establishing and maintaining a helping-trusting nurse-patient relationship (CHPP 2), a carative process that can be complicated by the use of the necessary PPE.  Transparent face shields and/or mask inserts  may be a great help in that regard when they are available. Touch, even through gloved hands, and verbal communications become even more important in establishing and maintaining a human-to-human connection, and in being able to gain some understanding of  the patient’s lived experience of the situation and providing some measure of comfort. 

Relationship is also essential in the mutuality required in CHPP, 3 the systematic reflexive approach to identifying the health goals of clients and working with them, to the extent possible, in achieving those goals. This process  requires a knowledgeable approach by the nurse whose expertise is available to facilitate patients’ understanding and  decision-making. 

Likewise, relationship, characterized by mutuality, is central to CHPP 4, transpersonal teaching-learning. Whether situated in acute care, focused on treatments or medications, or in the community, focused on issues such as requirements of quarantine or self-isolation, transpersonal teaching-learning is an interactive process in which evidence-informed information and guidance are provided within the context of the patient /client’s understanding, lived experience, hopes and fears. Perhaps in no instance is relationship more important than in the face of death when the nurse can offer a comforting presence and an openness to the patient’s way of finding meaning in the experience (CHPP7). That may involve holding a phone to a patient’s ear or a tablet in front of a patient so that families can virtually be present and connected with their loved one in their final moments.

Although the coronavirus does not discriminate, the pandemic has highlighted societal economic and social inequities that significantly increase the risk of contracting COVID-19, not only in Canada and the U.S., but also globally.  Some of the reasons relate to the need for poorer people to continue to work in jobs away from home, often in the provision of essential services. Moreover,  they are more likely to rely on public transit to get to work; they may be less able to physically distance from family members because of crowded living situations, and/or may lack adequate health care. In situations that might allow work at home, economically disadvantaged people may not be able to afford the necessary electronic equipment; similarly their children may not be able to complete aspects of online education. In even more dire circumstances, homeless people are extremely vulnerable as advice for staying home and frequent hand washing are simply not options for them. Physical distancing is not possible in homeless and respite shelters in which cots are placed closely together.

The COVID-19 pandemic has highlighted societal inequities which, in many aspects, bear a striking resemblance to those Nightingale experienced more than 150 years ago. Her approaches and solutions included downstream nursing by, for example, training nurses to care for those in workhouse infirmaries where paupers were required to come if they were ill because they could not afford care in hospitals. But what is sometimes overlooked, is that she also advocated for solutions at a societal level, far upstream from the workhouses. Nightingale’s approach has been called radical because it advocated for public policy changes to correct the systemic issues at the root of the health problems seen downstream. Her actions led not only to improved nursing care, but also to social change that reduced economic and social inequities. Whereas her workhouse reforms are well known, the principle driving them, equitable access to health care based on need rather than affordability, and her proposal that those reforms should be paid for through progressive taxation, are less well known. Nightingale’s proposed changes included the legislative framework for the Metropolitan Poor Act and culminated, decades later, in the British government taking responsibility for that nation’s health through the National Health Service (Falk-Rafael, 2005). But Nightingale did not stop there; she advocated, for example, for income security, pensions, and education for all because of her conviction that these were measures that promoted the public’s health. Approximately 100 years later, at the primary health conference in Alma Ata, world health leaders came to a similar conclusion, issuing the Declaration of Alma Ata, and raising awareness of what became known as social determinants of health. 

Upstream Caring

It seems to me that homeless shelters may be today’s workhouse equivalents.  Addressing the underlying social and economic (upstream) issues that have contributed to the health inequities exposed by the pandemic challenge us to political advocacy for upstream policy changes. Cathy Crowe, a Canadian nurse activist, has long advocated for policies, such as affordable housing, to allow poorer people to afford housing. And, like Nightingale, she is also concerned with conditions downstream, in respite and homeless shelters. During the pandemic, she, with others, has brought attention to and tirelessly advocated for the City of Toronto to mandate 6’ spacing between cots in homeless shelters. To its shame, the City only agreed to this spacing  many weeks later, after she and other advocates filed a lawsuit claiming that shelter crowding conditions were a violation of the Canadian Charter of Rights and Freedoms. 

A second pandemic focal point in Canada, especially in Quebec and Ontario, are long term care (LTC) facilities. In Canada, long-term care is under provincial jurisdiction, and is not publicly insured under the Canada Health Act. Provinces and territorial jurisdictions may depend on one or more types of funding of LTCs, such as for-profit  or private organizations, municipal and/or provincial funding, In Ontario, all LTC facilities receive some provincial funding.

In Canada,  82% of COVID-19 deaths have occurred in  LTC facilities, although the number of residents in such facilities represents approximately 1% of the population. Canada’s 2 largest provinces, Ontario and Quebec, account for 62% of the country’s population but together account for 94.4% of Canadian COVID-19-related deaths (as of May 25th, 2020). Both provinces have asked for and received military assistance in providing care in the homes most severely affected by the pandemic. In the past few days, military personnel in those homes have issued scathing reports as to the conditions they found in the facilities in which they worked in, 5 in  Ontario and  25 CHSLDs in Quebec.  The reports share some familiar themes: inadequate numbers of trained staff, inadequate separation of infected residents from those not infected, and improper use of PPE. The Ontario report  is particularly scathing, reporting additional issues such as elder abuse and neglect, as well as ant and cockroach infestations in some homes. Those findings, although shocking, should not have come as a complete surprise. Last fall, the National Institute on Aging warned that LTC facilities “were plagued by conditions that increased the risk of spreading infections:  people living in close quarters in residences faced with chronic shortages of staff, with little space or ability to enforce proper physical distancing measures, where poorly paid employees often work on a part-time basis at multiple facilities, increasing the risk”  The COVID-19 pandemic has all-too-tragically shown that to be true. Again, there are similarities with conditions in 19th century British workhouses. Changes to funding of LTC facilities, staffing ratios and qualifications, and frequency and scope of inspections have all been political decisions made within the last 20 years. 

Personal health is inherently political. McDonald asserted that “Nightingale knew that good health required decent social conditions, work, adequate housing, clean air and water.” CHPP 5 refers to providing, creating, and/or maintaining supportive and sustainable environments, including both immediate physical environments but also social, political, and economic environments (Falk-Rafael, 2020). Improving those environments requires public policy change. To reduce health inequities, policy changes are needed that serve to redistribute a nation’s wealth throughout the population, rather than allow it to accumulate in the top 1%. As Nightingale knew, the increased revenue from such taxation has the potential to fund other programs such as universal, publicly funded health care, including elder care, and education. Policies such as those to establish minimum wages or a guaranteed basic income help to reduce economic inequities; policies such as affordable housing and rent control help to reduce homelessness.

 A healthy population depends on healthy public policies. Political action to effect necessary changes can range from informed voting to the comprehensive, systematic approach Nightingale used: taking advantage of powerful connections, providing well-reasoned arguments, and  supporting those arguments with data obtained through reading, consulting with experts, and, if necessary, her own investigations. I believe, like Nightingale, it is nurses who need to take the lead in promoting policy changes to improve the public’s health because it is nurses who work at the intersection of public policy and personal lives.

References

Chinn, P.L. & Kramer, M. K. (2019) Knowledge development in nursing: Theory and process. (10th ed.), New York: Elsevier

Falk-Rafael, A. R. (2005). Speaking truth to power: nursing’s legacy and moral imperative. ANS. Advances in Nursing Science, 28(3), 212–223. https://doi.org/10.1097/00012272-200507000-00004

Falk-Rafael, A. R. (2020). Adeline Falk-Rafael’s Critical Caring Theory. In Nursing Theories and Nursing Practice (5th ed.) M.C. Smith (Ed.), pp. 502-521. Philadelphia: F.A. Daviis.

Falk-Rafael, A. R., & Betker, C. (2012). Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: “The Trombone Slide” of Nursing. ANS. Advances in Nursing Science, 35(2), 98–112. https://doi.org/10.1097/ANS.0b013e31824fe70f

Moving from training to educating

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

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

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

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

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

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

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

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

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

 

References

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

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

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

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

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

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

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

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

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

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