Fostering dialogue about practice knowledge development in a DNP Curriculum; Opportunity for theory innovation?

Guest Contributor: Lydia D. Rotondo, DNP, RN, CNS, FNAP

The practice doctorate in nursing developed in response to an increasingly complex healthcare landscape that requires additional competencies for 21st century advanced nursing practice. Complementing traditional graduate (MS) specialty curricula, the Doctor of Nursing Practice (DNP) program of study incorporates additional curricular content in the areas originally detailed in the 2006 DNP Essential domains (now integrated into AACN’s 2021 Essentials). DNP students complete a summative scholarly practice inquiry project that is theoretically-guided and evidence-based, demonstrating synthesis and application of the tools of clinical scholarship learned throughout the DNP program.

Particularly relevant to the design of DNP projects is the critical importance of context and the application (or adaptation) of best evidence (when available) to specific practice settings or specific populations. As context experts DNPs utilize systems thinking to design, implement, and evaluate interventions within complex adaptive systems revealing new understandings about health care delivery, the healthcare experience, and the role of DNPs as change agents and clinical scholars.

Fifteen years after the release of the DNP Essentials, appropriate focus is now on evaluating the impact of DNP practice on healthcare systems and health outcomes. As a practice discipline, however, there remains little attention by nursing academe regarding the potential impact of the practice doctorate on the discipline of nursing. In other words, how will the growing cadre of DNP-prepared nurses be leveraged to advance the discipline? In today’s interdependent, knowledge–based, digital world, how will advancing the discipline be defined and measured in the coming decades? What additional scholarly tools and curricular content will DNP students need to begin to answer these questions?

As doctoral-prepared nurses, DNPs share stewardship with other doctoral-prepared nursing colleagues to generate disciplinary knowledge. Yet, discussion about DNPs as knowledge producers and theory innovators remains largely unexplored. Scholarly treatment of knowledge generation in nursing practice is not a new phenomenon and has, in fact, been posited and published by several nursing theorists for decades. However, the introduction of the latest iteration of the practice doctorate in nursing, now in its second decade, with more than 36,000 enrolled in DNP programs and close to 8,000 graduates, has not sparked interest among leaders in DNP education to approach practice epistemology from the DNP lens.

Moreover, with a de-emphasis on philosophy of science and theory and stronger attention to evidence-base practice in DNP curricula, DNP programs as currently designed may lack sufficient educational grounding to engage in practice theory development. This further impedes the opportunity for scholarly discourse on practice knowledge production specifically and doctoral roles in nursing knowledge generation more broadly. While the promotion of evidence-based practice among all health professionals is useful to reduce clinical variation in care, there remains nascent opportunity for DNPs to consider how their scholarly work can produce practice-based evidence- knowledge that both improves care outcomes for individuals and populations and illuminates the contributions of nurses to healthcare.

In 2019, we developed a theory and conceptual foundations for clinical scholarship course at the University of Rochester School of Nursing in which students explore the historical and philosophical roots of the practice doctorate in nursing and nursing as a practice discipline. Our early efforts were inspired by Dr. Pamela Reed, Professor at the University of Arizona College of Nursing, whose considerable contributions in the area of practice epistemology provided a framework for course development. In an early course assignment, students are asked to create a concept map using the four nursing metaparadigm concepts to describe their philosophy of nursing. Students present their maps in class which encourages rich discussion about the nature of nursing knowledge related to their role in health care and health/wellness promotion. What is particularly striking is that for many students, this course is their first exposure to nursing’s theoretical grounding and opportunity to reflect on their professional practice from a disciplinary perspective. Several DNP student exemplars from the spring 2021 semester are included below with permission.

Exemplar 1 – Sarah Dunstan, University of Rochester School of Nursing DNP student

Circumnavigating and persevering through life’s most challenging roadblocks, the nurse dutifully guides the most weary and vulnerable of travelers towards safety and solace, both physically and emotionally. Committing to the vision of “Ever Better” and the pursuit of optimal patient wellness, nurse leaders are tasked with the responsibility of advancing the field and creating the new standards of care for the future.

As depicted above, my philosophy of nursing is best explained in the context of a journey. The person, or patient, is represented as a vehicle. Similar to vehicles, each patient is a unique make and model, some with more miles or more baggage than others. The nurse navigating the vehicle must carefully consider these differences and individual patient needs when mapping out the patients’ journey to health. The map, or environment, is laden with roadblocks or barriers to optimal wellness. The barriers may be geographical, financial, cultural, psychological, or physical. Whether few or many, these roadblocks may delay or completely inhibit the patient from reaching their health care goals. The metaparadigm concept of nursing describes the individual caregiver at the bedside that assists the patient around and through these various states of illness in order to reach the ultimate destination of optimal wellness. The destination “Health” is malleable and ever evolving, as depicted with multiple possible end points marked on the map. Health is defined by and dependent on the individual patient and their own informed healthcare goals, as optimal wellness is not always defined as the absence of disease.

The map is in the hands of the DNP-prepared nursing scholar. As a leader and nursing expert in the field, the DNP is the visionary change agent tasked with closing the practice-theory gap at the bedside in the clinical setting. DNPs are the cartographers for the future of nursing, responsible for defining clinical scholarship in nursing, creating, upholding, and disseminating the proposed standards of the discipline.

Exemplar 2 – Christine Boerman, University of Rochester School of Nursing DNP student

My nursing theory and paradigm is composed of many moving parts that work interchangeably and without each of these elements working together, the discipline of nursing would not be complete. My nursing theory is illustrated via the gears that work together in order to create the full working “maChinne” of nursing discipline.

Exemplar 3 – Christina D’Agostino, University of Rochester School of Nursing DNP Student

The figures included within the map are all intended to mirror constellations within that sky, represent the person, the environment and one’s health. Centered at the bottom of the map, shining its beacon of light on the sky is nursing, represented by two hands which provide the foundation. Nursing is a global role. As people around the globe all look up to the same night sky, all people share the benefits of the nursing domain.

My personal philosophy of nursing is a holistic approach of providing culturally-sensitive care for individuals, regardless of locality or ethnicity while being mindful of the interconnectedness that involves the person, environment, and one’s health as the recipient of that care.

Exemplar 4 – Victoria Mesko, University of Rochester School of Nursing DNP Student

My personal philosophy of nursing is: Caring for individuals with a holistic approach, striving for wellness within the community and the world. Along with all of the skills that nurses develop, what sets nurses apart is their caring nature. Nurses have an all-encompassing view of our patients’ mind, body, and spirit. Nurses see patients in the context of their environment and are able to propose treatments that will consider all of the influences on patient’s lives. Nurses take into account all of the meanings that “health” can have to a person, not just the absence of disease, but a sense of wellness even if they have disease. In my map, there is no one nursing domain that is more important than another, as they all have an influence on patient care. The interlocking circle of different hands represents nurses working to form relationships and connections between patients, the community and the environment across cultural lines.  

Exemplar 5 – Kalin Warshof, University of Rochester School of Nursing DNP Student

My philosophy of the nursing discipline is the utilization of the art and science of nursing care, compassion, and practice interventions to enhance the health and well-bring of the person, within their individual environmental context, including social determinants, culture, and beliefs. The metaparadigm map depicts the person at the center of the diagram, with nursing as a discipline, nursing interventions and compassionate care contributing to the improvement of health and well-being of the person. This is evident by the upward arrow, with health and well-being above the person, portraying the upmost importance to the person and nursing. The background in light blue, labeled the environment, indicates that the person, nursing discipline, health, and well-being interpretation and improvement occurs within the context of the personal environment. My philosophy of the nursing discipline is consistent with the Doctor of Nursing Practice Essentials I objective focusing on the whole person and their interaction with the environment to improve health and well-being (American Association of Colleges of Nursing [AACN], 2006).

Exemplar 6 – Kara Mestnik, University of Rochester School of Nursing DNP Student

Individual nursing philosophy is shaped overtime by individual practice, and life experience. My philosophy has shifted over the past twenty years, I have gained vast clinical experience and growth in intrapersonal interaction and relationships. The term balance is often sought for and emphasized as an indicator of health and wellness, comparable to the concept of homeostasis. My personal philosophy of Nursing is the ability to navigate all facets of human life despite the magnitude of directional force that may attempt to imbalance ones mental, physical, and spiritual well-being. Refer to (figure 1) for metaparadigm map. Consider the patient the pivot at the center of the compass, with a multidirectional view of their own life and well-being, while the nurse is the hand that holds the compass. The hand holding the compass helps both align and balance the direction the patient is aiming to travel. The nurse becomes both the navigational guide and the stable hand that allows for balance to be achieved at any given period or direction in time. The hands holding the compass indicate a personal connection with the patient as well as an oversight into the larger picture in which patients may travel. The acquired achievement of balance despite a directional force is guided by the hands that allow for health and wellness optimization.

About Lydia Rotondo

Lydia Rotondo

Lydia Rotondo, DNP, RN, CNS, FNAP is the associate dean for education and student affairs and director of the doctor of nursing practice program at the University of Rochester School of Nursing. She received her DNP from Vanderbilt University, MSN from the University of Pennsylvania, and BSN from Georgetown University. Lydia is a 2018 AACN Leadership in Academic Nursing Fellow and has actively contributed to the national dialogue on DNP scholarship and curriculum development through presentations at AACN’s doctoral education conference and publications.

Nursology and the Bold Future of Nursing

Recently I was invited to give a presentation for faculty and students at the M. Louise Fitzpatrick College of Nursing at Villanova University, based on my keynote address at the March 2019 conference “Nursing Theory: A Fifty Year Perspective, Past, Present and Future.” Download the text of that speech here.

True to the lifeways of pandemic time, I could only be present with people at Villanova University virtually, and developed a set of slides for the presentation. So in a spirit of sharing, here are the slides – the message of this presentation calls for all to boldly claim the essence and value of nursing/nursology, and to recognize barriers that stand in the way of fully enacting this essence in our practice. (Note: if the slides do not show to the end, view the slides here instead)

Be careful what you wish for…

2020 was the year that… “Be careful what you wish for,” once again became imprinted in my brain as truth.

In early 2019, the World Health Organization (WHO) announced that 2020 would be the “International Year of the Nurse and Nurse Midwife.” Among colleagues, there was lots of excitement about this. What would we do to recognize and celebrate this recognition? I heard many ideas—editorials, articles, museum displays, seminars, webinars—maybe we’d even get a stamp! The last time we had a commemorative nurse stamp in the US was 1961, almost 60 years ago. Seems like we were overdue for one.

And then, two months into our memorable year, COVID-19 hit. The world started locking down before the US, but for me, my unforgettable day was March 13 (a Friday, of course) when a symptomatic friend tested positive for the virus. Suddenly, everything changed. We all went into lockdown and remote work became the norm. I tried to figure out how to run a free clinic by phone and email (believe me, it’s not easy). I experienced two weeks of panic, followed by three months of bewilderment, and then settled in for the long haul, which is still ongoing.

Meanwhile, nurses were everywhere. The evening news was flooded with images of nurses in ICUs, EDs, nursing homes, and more. There were interviews with nurses crying, their faces bruised from their PPE googles, mourning their dying and dead patients, wondering if they could have done more. They worried about having enough PPE, their families, and their own health. At the same time, we were celebrated with impromptu parades, celebrations, signs on the street: “Heroes Work Here!”. I was offered a 50% discount at the car wash, but I declined. I figured that as a small business, they needed the money more than I needed a modest saving on washing my car.

We even got a TV show, creatively named NURSES with this tantalizing description: “The series follows five young nurses working on the frontlines of St. Mary’s hospital dedicating their lives to helping others, while figuring out how to help themselves.” Will those nurses be nursologists? Time will tell.

On the other side of the coin, the virus was taking its toll in multiple ways. As of the end of October 2020, the WHO presented an analysis that 1500 nurses worldwide had died of COVID-19, although they admitted that this figure was probably grossly underestimated. The White House put together a coronavirus task force in January that included (according to the New York Times) “internationally known AIDS experts; a former drug executive; infectious disease doctors; and the former attorney general of Virginia” but no nurses. President-elect Biden also put together a task force that seemed more diverse but once again, nurses are conspicuously absent from the membership. At a meeting of nurses in the Oval Office to commemorate National Nurses Day in May, Sophia Thomas, President of the American Association of Nurse Practitioners was rebuked by Donald Trump when she stated that there was sporadic access to PPE throughout the US. “Sporadic for you, but not sporadic for a lot of people,” Trump said. “Because I’ve heard the opposite. I have heard that they are loaded up with PPE now.” Thomas was bullied into politely agreeing and backing down from her original statement. This is not the first time I’ve seen this happen, and it makes me angry every time.

Where is the correct middle ground? Do we want to be “angels,” “heroes,” and members of the “most trusted profession” (according to Gallup, 15 years and running)? Or do we want to be nurses at the table, nurses setting policy, nurses seen as leaders, decision makers, and agents of transformation through research, practice, and education? In other words, nursologists? 2020, our “year” gave us lots of the former, not so much of the latter. And thus I say, “Be careful what you wish for.” I worry that our year of recognition will ultimately reinforce stereotypes and not result in meaningful change. To those in our ranks who have sacrificed their lives, and to others who are dealing with ongoing health issues from COVID-19, both direct and indirect, I hope that is not the case. Maybe with the spotlight off, we can get back to business and work to make incremental, but lasting change, which seems to be what nurses do best. That is my wish for 2021—but I’ll be honest—I would still like a stamp!

Primary Care, Primary Nursology, and the Attending Nursologist: Connections to Nursology Conceptual Models and Theories

Contributor (with Jacqueline Fawcett): Katherine Richman

This blog is meant as a follow up to Christine Platt’s (2020) blog, “A Nurse Practitioner’s Perspectives on Theory in Practice.” Ms. Platt’s mention of primary care led us to recall primary nursing. Primary care refers to the type of care offered by nursologists, typically nursologists who hold graduate degrees and who are considered nursologist practitioners (NPs), such as adult and gerontological NPs, family NPs, and psychiatric-mental health NPs.

Primary Nursology

Primary nursing, which we call primary nursology, refers to the way in which nursologists offer care. It is a care delivery model that was introduced in the 1960s, and is characterized by “accountability, advocacy, assertiveness, authority, autonomy, collaboration, continuity, communication, commitment, and coordination” (Watts & O’Leary, 1980, p. 90). In particular, the primary nursologist is responsible for one or more patients for the entire duration of hospitalization or other clinical setting. Tiedeman and Lookinland (2004) explained:

Each patient is assigned a specific primary [nursologist] based on patient needs and the [nursologist’s] abilities. The primary [nursologist] assumes 24-hour responsibility and accountability for assigned patients for the duration of their hospital [or other clinical setting] stay and has the responsibility and authority to assess, plan, organize, implement, coordinate, and evaluate care in collaboration with the patients and their families. The primary [nursologist] decides how care should be administered and personally administers it whenever possible. When the primary [nursologist] is not available to provide care, responsibility is delegated to an associate [nursologist] who cares for the patients following the care plans developed by the primary [nursologist] (p. 295).

A mid-October 2020 search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete) revealed that discussions of primary nursing (the search term used) rarely mention any conceptual or theoretical basis. An exception is Webb and Pontin’s (1997) report, in which they described their use of the Roper-Logan-Tierney Model of Nursing Based on Activities of Living as the conceptual model on which they based development of a primary nursology care plan audit tool. The audit revealed that “although [nursologists] claim to use a [nursology] framework to structure their care, this is not evident in the documentation” (Webb & Poutin, 1997, p. 399). Another exception is at the Dana-Farber Cancer Institute in Boston, Massachusetts, where the Synergy Model is used as the conceptual basis for practice, coupled with primary nursing for delivery of nursing care (A. Gross, personal communication, October 30, 2020).

A Reflection on Primary “Nursology”

I (KR) was fortunate to begin my professional career, in the mid-1980s, as a primary nurse on a closed adult psychiatric unit. We were a group of hospital diploma and community college graduates, primarily, mentored by a trio of ultra-competent, assertive, and kind nursing leaders. Our practice was not modeled on any specific conceptual framework. Instead, it was modeled on a commitment to strong interdisciplinary leadership and excellent, compassionate care. Like the attending nurses described by Niemela and colleagues (1992) at the UCLA Neuropsychiatric Institute and Hospital, we coordinated and oversaw the care of our primary patients from admission to discharge. We were, in effect, their case managers; in an era when stays were measured in weeks and even months, we convened cross-disciplinary staff conferences and followed up with multidisciplinary treatment plans. We carved out time in every shift to sit and talk with our patients. Each patient was assigned both a primary nurse and an associate nurse. Both roles were filled by the full-time staff nurses.

Our practice model was, to echo Niemela et al. (1992), a “cost-effective, clinically productive, and professionally attractive role,” in our case for clinicians with entry-level nursing credentials (p. 5). The clinical specialist who headed our team eventually pursued her doctorate, though tragically she did not live to complete her degree. Inspired by her memory and by her enduring example, I’m now pursuing my own nursing doctorate.

The Attending Nursologist

After recalling primary nursology, we recalled the attending nurse, to whom we refer as the attending nursologist. The attending nursologist is a variant of primary nursology. A very special feature of the attending nursologist is the explicit link to Johnson’s Behavioral System Model.

The idea of the attending nursologist is a care delivery model developed and implemented at the University of California-Los Angeles (UCLA) Neuropsychiatric Institute and Hospital in the early 1990s (Dee & Poster, 1995; Moreau, Poster, & Niemela, 1993; Niemela, Poster, & Moreau, 1992; V. Dee, personal communication, October 17, 2020). Fawcett and DeSando-Medaya (2013) explained:

The major focus of [the attending nursologist’s] role is clinical case management. Role responsibilities include direct patient care; delegation and monitoring of selected aspects of [nursology] care; provision of leadership, consultation, and guidance to [nursologists]; and collaboration with [multiple discipline] team members. Moreau and colleagues (1993) reported that the [attending nursologist initiative] was well received by the [nursologists] and members of the [multidisciplinary] team. Moreover, attending [nursologists] reported an increase in job satisfaction and retention and a decrease in role conflict [Moreau et al. 1993]. Neimela and colleagues (1992) reported that the attending [nursologist initiative] increased general satisfaction and role clarity and decreased role tension for the [nursologists], and increased their communication with patients’ family members (p. 71).

Dr. Vivien Dee graciously replied to my (JF) query about her experiences with development and implementation of the attending nurse (nursologist) model of care delivery. She explained that the Dee and Poster (1995)

article was written to show the process taken by a chief nurse to bring about change in the workplace, moving from the Primary Nursing Model to the Attending Nurse Model for the delivery of nursing care. The attending nurse would be responsible for the nursing care of designated patients (from admission to discharge) 24/7, in contrast to the primary nurse (shift-based). The Attending Nurse must be a Clinical Nurse Specialist (Masters- prepared), responsible for self-scheduling, and has the authority to prescribe care based on the scope of practice for independent functions based on the California Nurse Practice Act. [The Dee and Poster] article addresses the phases of change using the Kanter’s Theory of Innovative Change, and the role of the executive nurse leader in creating the change. (V. Dee, personal communication, October 17, 2020)

Referring to the authors of the Niemela et al. (1992) and the Moreau et al. (1993) articles, Dr. Dee noted that Niemela “was the clinical nurse specialist – who assumed the role of the Attending Nurse, [and] Moreau was the nurse manager on the unit where the innovation took place. Poster was the Director of Education and Research”. (V. Dee, personal communication, October 17, 2020). Dee was the chief nurse (and the first PhD prepared nurse executive within the UC Hospital system of five hospitals) who implemented the attending nurse practice delivery model (V. Dee, personal communication, November 5, 2020).

Dr. Dee explained,

“The Attending [Nurse] Model was in place throughout my tenure at UCLA-Neuropsychiatric Institute and Hospital (NPI&H). I retired from UCLA-NPI&H [in] 2005. I have never looked back and have not kept up to date if the system is still in place. I think that the DNP today could very well serve as the Attending Nurse (similar to the Attending Physician role). But we need an executive nurse (CNE) with a DNP/PhD to fearlessly lead and create structures that allow for the full scope of practice for nurses with better patient outcomes.” (V. Dee, personal communication, October 17, 2020)

Ditomassi (2012) explained that the attending nurse practice delivery model also has been used by staff at the Massachusetts General Hospital (MGH) in Boston. “[A]ttending nurses function as clinical leaders, managing the care of patients on a single unit from admission to discharge. The attending nurse interacts with the inter-disciplinary team, the patient, and the family to foster continuity, responsiveness, quality, safety, effectiveness, and efficiency . . . And attending nurses make a commitment to work five eight-hour days to promote continuity and relationship-based care” (Ditomassi, 2012, p. 8). Specifically,

“The attending nurse:
• facilitates care with the entire healthcare team. Is a consistent contact for patients, families, and the healthcare team throughout the patient’s care
• identifies and resolves barriers to promote seamless hand-overs, inter-disciplinary collaboration, and efficient patient throughput
• coordinates meetings for timely, clinical decision making and optimal hand-overs across the continuum of care
• ensures that the team and process of care sustain continuous, caring relationships with patients and families that may begin before admission and continue after discharge
• develops a comprehensive patient-care assessment and plan using the principles
of relationship-based care
• communicates with patients and families around the plan of care, answers questions, teaches and coaches
• develops and revises patient-care goals with the clinical team daily
• organizes team huddles that include the attending nurse and physician, staff nurses, house staff, and other disciplines
• serves as a role model for inter-disciplinary problem-solving
• meets with families on a continuous basis regarding the plan of care, disposition, goals of treatment, palliative care, and end-of-life issues” (Ditomassi, 2012, p. 8).

The conceptual and theoretical perspectives used in conjunction with the attending nurse practice delivery model at MGH include, as Ditomassi (2012) and D. Jones (personal communication, October 31, 2020), who is a faculty member at Boston College William F. Connell School of Nursing and director of the Yvonne L Munn Center for Nursing Research at MGH (Ives Erickson, Jones, & Ditomassi, 2013), indicated, relationship-based care, as well as Newman’s Theory of Health as Expanding Consciousness and Watson’s Human Caring Theory, as well as an instrument used to measure Barrett’s Theory of Power as Knowing Participation in Change (D. Jones, personal communication, October 31, 2020).

Ditomassi (2012) mentioned that the attending nurse practice delivery model also was being used at New York University and Baptist Hospital of Miami, Florida. An early November 2020 search of the CINAHL Complete database, however, yielded no relevant literature.

We welcome readers to add what they know about and/or have experienced within primary nursing and/or attending nurse practice delivery models and to refer us to other published and anecdotal accounts of these contemporary approaches to the delivery of nursologists’ practice delivery activities.

References

Dee, V., & Poster, E.C. (1995). Applying Kanter’s theory of innovative change: The transition from a primary to attending model of nursing care delivery. Journal of the American Psychiatric Nurses Association, 1(4), 112–119. http://doi.org/ 10.1177/107839039500100403

Ditomassi, M. (2012, November 1). The attending nurse role. Caring Headlines [Patient Care Services newsletter], 8-9. Massachusetts General Hospital. https://www.mghpcs.org/caring/Assets/documents/issues/2012/November_1_2012.pdf

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of conceptual models and theories (3rd ed.). F. A. Davis.

Ives Erickson, J., Jones, D., A., & Ditomassi, M. (2013). Fostering care at the bedside. Sigma Theta Tau.

Moreau, D., Poster, E.C., & Niemela, K. (1993). Implementing and evaluating an attending nurse model. Nursing Management, 24(6); 56–58, 60, 64.

Niemela, K., Poster, E.C., & Moreau, D. (1992). The attending nurse: A new role for the advanced clinician—Adolescent inpatient unit. Journal of Child and Adolescent Psychiatric and Mental Health Nursing, 5(3), 5–12. http://doi.org/ /10.1111/j.1744-6171.1992.tb00123.x

Tiedeman, M. E., & Lookinland, S. (2004). Traditional models of care delivery: What have be learned? Journal of Nursing Administration, 14(6), 291-297. https://doi.org/10.1097/00005110-200406000-00008

Watts, V., & O’Leary, J. (1980). The 10 components of primary nursing. Nursing Dimensions, 7(4), 90-95.

Webb, C., & Pontin, D. (1997). Evaluating the introduction of primary nursing: The use of a care plan audit. Journal of Clinical Nursing, 6(5), 395–401. https://doi.org/10.1111/j.1365-2702.1997.tb00333.x

About contributor Katherine Richman

Katherine is a first-year nursing PhD student at the University of Massachusetts Boston, focusing on health policy. She holds a BSN from the University of Illinois at Chicago and a PhD in theology from Boston College.

Hope in Nursing

Contributors: Barbara MacDonald
and Jane K. Dickinson

Barbara and Jane worked together as student/faculty in the online MS in Diabetes Education and Management program at Teachers College, Columbia University. Hope was a common thread throughout Barbara’s work in the program, and the conversation continues:

JKD: How did you get interested in hope?

BJM: My introduction to the concept of hope in health care was through a book recommendation: The Anatomy of Hope: How People Prevail in the Face of Illness by Jerome Groopman. In the context of nursing, I have always believed in health equity and striving for the best possible care for all people. To achieve this, hope is the underlying and fundamental driver. To keep keeping on, to advocate, to fight for the best possibilities, one must believe in and have hope for a better future. As nurses, and fellow humans on a journey together, we have the ability and responsibility to identify and foster hope in ourselves and others in need, in our care and as we are able.

JKD: Where do you see hope in nursing? Where is it lacking?

BJM: Hope is everywhere in nursing. Nurses work with the fundamental belief that we will and can make things better. We continue to get up and go to make things better everywhere at all times. We use a process of critical thinking and decision-making to create that better future for people. Hope is the foundation of this process. We are continually thinking about and creating ways to make things better for the people we are fortunate enough to encounter and for whom we provide care. Hope is woven into the fabric of nursing, and yet, ironically, it is not necessarily identifiable, quantifiable, or systematically measured or fostered as an essential component of care. Hope is fostered through strengths-based, rather than deficit-based, models and systems in health care, and we have work to do to achieve that. What if we began with identifying what is going well and what is working, particularly in non-acute care? What if we had an assessment where we asked how hopeful someone is about their health, and what gives them the greatest hope?

JKD: How does hope have an impact on health outcomes?

BJM: I believe that hope is a pilot light in each of us that is always there, even in the darkest times. If hope is identified and fostered, there is the potential for people to rise up and have the will and energy to move toward a desired future. This is true for both the person receiving care and the nurse. Hope is sustained through incremental progression toward the goal and desired future. When people experience success associated with their efforts, they are inspired, empowered and more hopeful about their future. Success and movement toward results, such as blood glucose levels in the goal range, create energy for continuing the momentum toward the desired future. When hope is fostered, health outcomes are positively influenced and people tend to feel more empowered in their self-management and self-advocacy.

JKD: What connections exist between hope and nursing knowledge?

BJM: It is likely that there is an element of hope in all nursing theories, whether named as such or otherwise. Gottlieb’s philosophy of strengths-based nursing is an approach that embodies hope along with empowerment and self-efficacy and their relationships with achieving desired outcomes (Gottlieb, 2014). As inherent as hope is in all aspects of nursing, it is both surprising and disappointing that there is not a formalized mechanism for identifying and fostering hope to systematically advance health outcomes. While hope is specifically mentioned in the works of Weidenbach, Travelbee, and Kolcaba, almost every nursing theory and theoretical/conceptual model appears to be addressing hope in some way.

JKD: What else would you like to tell us about hope and nursing?

BJM: When I asked a leading mental health specialist about scales to measure hope in diabetes self-management, much like the tools used for assessment of depression and diabetes distress, he replied that to his knowledge there are none. Pausing to think about why that is, I wonder if the effort has been placed on what hope is rather than assuming that it is, and strategizing to identify and foster hope. What if we assume that hope exists within everyone, and find ways to foster it in conjunction with evidence-informed best practice to ensure movement toward the desired future? One thing that stuck in my head in the conversation with the mental health specialist was what he said about assessments in general, such as a depression instrument: “whatever you are looking for, you will find.” If we are looking for depression through use of a depression scale, we will find it. So let’s create a measure to find hope and then foster it.

Even in our current reality, I believe that hope is abundant. We pin our hopes on our everyday approaches, and in the potential of the future. There is hope in science for understanding the coronavirus and immunity to it. There is hope in understanding more about how we need to become informed and examine our thoughts and actions about addressing inadequacies and achieving health equity for all. There is hope for humanity to come together to make a better future, and in this nurses and nursing leadership play a fundamental role. By being hopeful we can find a way to optimize nursing practice in the interest of the public. There is hope as we strive for this optimization in this International Year of the Nurse and Midwife. Could there be a more significant challenge and call to action for nurses than what we are currently facing in 2020? I am hopeful that nurses can come together, rise to the challenge, and be the change we are looking for. Let’s be hopeful and lead a path which inspires hope in others as we create a great movement toward health equity.

Reference

Gottlieb, L.N. (2014). Strengths-Based Nursing. American Journal of Nursing,  114(8), 24-32. doi: 10.1097/01.NAJ.0000453039.70629.e2

About the contributors

Barbara J. MacDonald, RN, BSN, MS-DEDM CDE is a diabetes consultant and co-founder of IDEA | Inspiring Diabetes Empowerment Associates, as well as practice advisor for Saskatchewan’s nursing regulatory body. She is a 2017 graduate of the Master of Science, Diabetes Education and Management, Teachers College Columbia University and is completely hopeful about our collective power to shift the health care experience and outcomes for all, particularly those who are most overlooked.

 

Jane K. Dickinson, RN, PhD, CDCES is a Nursology.net blogger and is the Program Director and Faculty for the solely online and asynchronous Master of Science in Diabetes Education and Management at Teachers College Columbia University. Jane’s research, publications, and speaking focus on the language in diabetes and the need to impart hope through our messages to and about people living with diabetes.

Black Lives Matter: Building an Antiracist Nursing Future

Register for June 12th Webinar

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

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

Image created by NTC member Jessica Dillard-Wright

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

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

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

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

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

In solidarity,
The Nursology Theory Collective

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

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

Throwing Shade at Nursing Theory: a Millennial’s Perspective

Welcome to Shannon Constantinides,
who is joining the Nursology.net blogging team!
Shannon also contributed the content on
Jane Georges’ Theory of Emancipatory Compassion

Dear Colleagues,

Shannon Constantinides

As a current PhD candidate (Yay! I’m making progress) and experienced NP of about a decade (Yikes! Time flies!), I have a few thoughts on Dr. Foli’s well articulated post and associated call for action/ questions regarding nursing theory in academics. It is with a great reverence for the bright minds of this community that I share these ideas with you all. Please consider my comments simply for no more than what they are: some thoughts from a novice scholar (who happens to be a millennial).

First, the humor and humility with which Dr. Foli broached the topic of “nursing students throwing shade at nursing theory” made her post fun to read and so relatable!

Second, and not entirely related to the topic at hand (which I’ll get to), as an NP who often precepts students, I loved the question posed to students, “Are you running from something in your current job, or running toward a goal of being a nurse practitioner?” I think probably too often nurses go to NP (Nurse Practitioner) school without a clear idea of what the role and day-to-day of the job entails. On a number of occasions, I’ve gently refused to write letters of recommendation to NP school for newly graduated BSN students, because I truly believe that the knowledge and experience gained by working as a nurse is beyond measure. First and foremost, NPs are nurses. I can’t underscore enough the importance of building a strong professional foundation. Equally as important is taking the time and opportunities to explore the endless possibilities that come with nursing practice (finding what sets one’s soul on fire, so to speak). I think this goes for new-grad RNs who are fixated on any one speciality, as well. I would not be on the path that has lead me down my professional and academic journey without first practicing in a number of areas (being in the military made this an easy possibility). Having experience in a number of areas has been invaluable to my career as an APN – clinically and in broadening my understanding healthcare systems and the lived experience of health, itself.

Third, I think the struggle to connect theory to practice comes from a few places. Overall, however, I think it may be time we re-envision and modernize how we approach teaching theory, in the first place. We did this for clinical practice, right? How many of our colleagues ever trained in a sim lab, for example? Updating the what, how, and environment in which we teach doesn’t have to be limited to the parameters of the clinical side of practice. I think the sample principles apply to teaching theory, especially if we want students to learn how to integrate the two. So a few thoughts…

Why is there SO MUCH reading!?

I’ve deduced that what has seemed like an ungodly amount of reading over the course of my education has served the following purposes: 1) taught me the practical knowledge needed not kill my patients (literally), 2) exposed me to new ideas, and 3) exercised my brain and made it grow in its ability to comprehend complex and abstract ideas – just like exercising a muscle.

In regard to the amount of reading that goes along with nursing education: I had NO idea! And I say that as a naturally voracious reader who grew up in a home that purposely had no tv! Honestly, I think 99.99% of students have no idea what they’re getting into when they sign up for nursing education – at any place on the educational spectrum. Students need to be reassured, probably on repeat, that the reading has a purpose. As much as the discourse in nursing espouses that we ascribe to the anti-handholding/ law-of-equal-suffering/ eat-our-young narrative, reassuring your students is more than being nice or helpful. On a deeper level, reassuring your students demonstrates the ethics of compassion and caring that is preached in the pedagogy of the discipline.

To that point, your millennial students will also to be curious as to why you’ve selected specific reading material. I’m not saying you need to, or should, justify each reading assignment. However, giving students a general idea of why certain material is important, especially for theory and philosophy, will help create a connection to the content. I say this with love for my generation, but millennials (and post-millennials) are a different animal. We’re a “special” breed, if you will. We have been raised to question everything. Every. Thing. It’s in our DNA. And you’re just in luck, because there’s A LOT of us! By many accounts, we’re the largest generation in history! (That is, millennials – people born between 1981 and 1996, and post-millennials – people born between 1997 and the present day).

Now, to that point, let’s not also forget that the frontal lobe doesn’t fully develop until late adolescence/ early adulthood. So, some of your students who are innately left-brained, “linear” thinkers (who, inherently, may have a harder time wrapping their heads around some of the non-linear concepts in theory and philosophy), will also be young, concrete thinkers. Their brains literally have just only developed to a point of abstract thinking understanding the basic concepts related to the more esoteric ideas we talk about in theory. And this issue is compounded by unique educational, professional, and personal backgrounds and upbringings of each student.

For example, it wasn’t until my masters-level (and more so, PhD) studies, that I really started understanding some of the more abstruse, Delphic concepts in nursing theory. As a BSN and MSN grad of the CU system, I naturally gravitated to Watson’s work – but generally – the more experienced I became professionally, academically, and in life, the more I came to understand the “other” theories I was learning about in school. As an 18-year-old, direct-entry BSN student I could understand (because I saw a way to concretely apply) Orem’s self care theory, Leininger’s cultural care theory, or Carper’s Pattens of Knowing (and, yes, I now know and understand why Carper said in a 2015 interview with Eisenhauer that her work was never meant to be a theory – but try telling that to a young, brand-new, nursing student! There’s no denying a certain level of concreteness to aspects of Carper’s work. This is something I love about Carper’s model – she wanted it to be readily tangible to the user, and it is!)

In reality, it’s taken me nearly two decades to “get the hang of nursing theory” and be able to digest and truly understand the works of such thinkers as Rogers, Patterson and Zderad, or Newman. Or actually appreciate the depth, intricacy, salience, and beauty of Watson’s work. In fact, as a BSN student, I remember sitting in a guest-lecture with Dr. Newman, and being the left-brainer that I am, raised my hand said, “Um, Dr. Newman, I don’t get it…” Looking back, I’m still mortified by this encounter! I was THAT student (insert #facepalm here!).

#facepalm

So, really, it’s taken the better part of my adult life to develop the intellectual ability and emotional maturity needed to sit with and understand complex ideas. There are articles, book chapters, and entire texts I now consider the Holy Grail, which when I first read them specifically remember thinking, “WT_?? Is this even in English???” And to that point: don’t forget that your students are literally learning new languages! They’re not only learning the technical language of healthcare, but also the language the informs the epistemology of nursing. So, again, I think showing your students a little patience, forgiving, and compassionate grace is key.

Likewise, it’s my opinion that once we get to a certain point in our careers (as a clinicians, scholars, educators, administrators, etc.) we take for granted knowledge that has become second-nature. I can say, with complete certainty, that I fall prey to this with my own clinical NP students. What do you mean you don’t have a clear, concise, and evidence-based plan for managing your older adult patient who has insanely complicated medial, psycho-emotional, and social needs?? We have to remember that knowledge for students – whether clinical or related to theory and philosophy – is often entirely new or being presented at a depth they weren’t expected to go to in the past. In addition, with APN students where we’re building off the knowledge and experience that comes from working as an RN and RN education. As far as theory and philosophy are concerned – that knowledge is really complicated, is often brand-new, and often isn’t intuitively grounded in day-to-day nursing work and education. Your students are learning new stuff, a new language, and and learning to think in an entirely different way. Patience is key. Finding a way to foster connection to the content is key. My suggestion would be to keep Benner’s Novice-to-Expert model in the forefront of your minds when you’re working with students – especially when it comes to teaching theory and philosophy.

Middle range theory & the ladder of abstraction.

I think a lot of students aren’t exposed to middle-range theories. This statement is, of course, purely based off anecdote consisting of my own academic and professional experiences, and what sound to be similar experiences shared by my colleagues. It’s my opinion that middle-range theory may an optimal place to bridge the theory-practice gap. Certainly, this bridge will be influenced by the paradigm framing the theory or the paradigm to that which the nurse knowingly or unknowingly ascribes. However, as Smith and Liehr (2014) stated, middle range theories are more straightforward and lie in-between that which is all-inclusive and that which is highly situation-specific. In this regard, a few exemplars that made sense to me and my peers included Story Theory, the Theory of Unpleasant Symptoms, and the Theory of Caregiving Dynamics.

I also think teaching the levels of theory abstraction as described by Smith and Liehr, even at the BSN level, could help make a little more sense of nursing theory in terms of applicability. Do I apply this theory at the bedside? In a specific situation? Does it guide a certain aspect of my practice? Or, is it something that will guide the entirety of how I approach practice, patients, and the general experience of health?

I think it’s so tempting to start off with the classics: the grand nursing theories. But honestly, some (ok, basically all) of those theories are super complicated! For your newer, less experienced learners, maybe initially include something a little more concrete, like a micro theory? Help your students dip their toes in the water, so to speak, rather than throwing them directly into the deep end. I think a lot of harm can be done when faculty knowingly or unknowingly teach at a level that is over the students’ heads. Your students will get there, trust me, but keep it simple in the beginning. Help your students build a strong foundation. You’d do the same with patient care knowledge and skills, right? So, same idea for nursing theory.

Aging-out and aging-into the current sociopolitical & cultural context

I can’t stress this enough: nursing faculty have a critical place not only as clinical and scholarly role models, but in modeling the language and behavior of advocates and voice-givers. When I started my BSN in 2000, and even by the time I graduated with my NP in 2011,  I didn’t really know what social justice was. I couldn’t really answer the question, “What are you doing to be an advocate?” Over the course of my PhD program, however (and thankfully so), I’ve had the amazing fortune to work with and be mentored by some exceptionally stellar minds in my quest to figure out my place as an advocate and voice-giver (especially Dr’s Peggy Chinn, Patricia Liehr, Jane Georges, Debra Hain and Deb D’Avolio… to name a few). And, boy, do I wish I’d had a social justice/ emancipatory focused curriculum as a BSN or MSN student, like our students do at FAU!

So how does this relate to teaching theory? As feminist Holly Whitaker (2019) wrote in her book, “Quit Like a Woman,” we are now, likely more so than ever, aware of our own oppression, the oppression of others, and aware of how our actions or inactions have abetted the oppression and marginalization of others. Whitaker states, and I whole-heartedly agree, that thanks to movements started by the LGBTQIA community, radical feminists, and women of color, our common vernacular now includes words like privilege, misogyny, and patriarchy. (I would also add terms like toxic masculinity and inclusivity). Likewise, I contend that our language reflects a paradigmatic shift that is occurring in society: we are moving toward a more humanistic way in how we view and interact with others. For example, we’re moving away from socially constructed and derogatory descriptors. Rather than calling someone “disabled” we acknowledge that the individual is of other-ability. Rather than being called “elderly” or “geriatric” we honor the experience that comes with older adulthood. We recognize that someone is involved in “sex work” is a “sex worker,” not a “prostitute.” We now see that the term “violence against women” is problematic in that it is passive and alleviates the blame of the perpetrator.

Students, especially millennials, are probably hip to these issues and this type of language, but this is not an assumption to make. It is your responsibility as a faculty member to stay informed and engaged in this regard. Just like you would teach from a place of best evidence regarding clinical practice and patient care, stay up to date on what’s going on in the world, the language being used, and the issues that matter to your students.

The good news is that we now have theories and books that are grounded in a social-justice paradigm! Take, for example, Georges’ (2013) Emancipatory Theory of Compassion (or really, any of Dr. Georges’ work dealing with the nature of human suffering). I adore Georges’ work (and work she’s done collaboratively with Dr. Susan Benedict) for a number of reasons, especially how she takes the concept of suffering head-on, and calls out nursing in regard to the profession’s historical (and generally unspoken) complicit involvement in oppression. Intentionally moving away from the traditional, Western narrative that has a propensity for the patriarchy, Georges’ work focuses instead on alleviating suffering through compassion, empowerment, and deconstruction of power relations. Falk-Rafael’s Critical Caring model, for example, also goes in this direction as it looks at role power relations have in public health outcomes. Likewise, I consider Kagan, Smith, and Chinn’s (2016) Philosophies and Practices of Emancipatory Nursing, and the works there within, a critical must-read for anyone wanting to study or practice nursing theory in context of today’s sociopolitical climate. To that point, a quick search on Amazon revealed a number of nursing textbooks centered around contemporary theory-based approaches for caring for vulnerable populations, approaches to healthcare policy, and approaches for healthcare advocacy.

And, to very briefly touch on the topic of technology in nursing theory: if your students are my age (I’m 37) or younger, we never knew what it was like to live without technology (let alone practice nursing without computers, smart phones, apps, EHRs, or the internet!). My husband, a physician (I know, I married the enemy), is 10 years older than me. We work in the same primary care practice. Even though he is fairly tech savvy, it’s astonishing how much longer it takes him to adapt clinical technology compared to those of us in the clinic who are a decade younger. I’m not saying this is true across the spectrum: I absolutely interact with younger clinicians who have less tech know-how than our colleagues a few decades our senior. What I’m saying is that those of us who were born into and grew up practicing nursing in the information age have a different relationship and understanding of healthcare (and view of the world, in general) than those even a decade ahead of us.

Several years ago, at the suggestion of my fairly tech savvy entrepreneur dad, I read “The World is Flat” by Thomas Friedman. My dad thought this work was incredibly forward-thinking. The concept and manifestation of a globalized humanity secondary to advances in technology was mind-blowing to him. However, I remember thinking, “yeah… so this is not a new thing to me, Dad…” Keep in mind that the world has always looked so different to those of us in the millennial and post-millennial generations. In terms of nursing theory, Watson’s work – I think especially Caring Science as Sacred Science and Unitary Caring Science – both hit the nail on the head in terms of addressing globalization and caring for a global humanity.

Additionally, the exciting thing about nursing theory in the information age is that new theories are emerging to deal with contemporary, tech-related issues! Dr. Rosario Locsin’s Theory of Technological Competency as Caring, for example, is pertinent and relatable for today’s students. A few years ago, I had the opportunity to listen to Dr. Locsin speak about his theory. I was, again, THAT student. I asked Dr. Locsin, “Are your theory and views on artificial intelligence and humanoids questioning how we define existence?” “No. Not necessarily,” he said, “But what if A.I. develops to the point where it can’t be differentiated from naturally living beings? What if a humanoid develops feelings? Can they develop feelings?” These may sound far-fetched, but the future is not that far away and technology is developing at a screaming pace! The philosophic questions, ethical dilemmas, and reality your students will face in the future will undoubtedly look like something out of a sci-fi novel – and for that I applaud Dr. Locsin for boldly going where no nursing theorist has gone before!

This next statement might be considered heresy, but for the sake of discussion, hear me out: I believe some theories are aging-out, or at least need to update their language. This is absolutely not a dig on older theories: let me be very clear about that! Some of the older theories were the embryonic origins of what, over time, have evolved into modern nursing theory and practice. Due to the social and political culture of the time, and in order to be taken seriously, the structure and verbiage of early nursing theories were informed by a patriarchal/ paternalistic, medical narrative that was dictated by an aristocracy of upper class, white, male physicians, scientists, politicians, and power-elite. People were either ill or well. Self-agency was not a thing if you were not a straight, white, cis-male. Social justice was not a thing. Human rights were not a thing. The right to health was not a thing (and arguably is still not a thing). Hearing the critical voices of underserved, under-represented, vulnerable, or marginalized populations was not a thing. Talking about energy (let alone shared energy) was definitely not a thing – or at least not a thing that was spoken of publicly or in circles of “hard science.” The male doctor gave the female nurse orders, and the female nurse would then perform prescribed actions.

I conducted a review of caring theories as a part of my comprehensive exam last summer. Again, let me be very clear: these theories were crafted by minds much more brilliant than I could ever hope mine to be, and there is indescribable wealth, depth, knowledge, and wisdom imbedded in these works. Truly, many will remain as enduring masterpieces of the discipline, and their authors have become beacons of progressive, forward-though. However. …. However, in conducting this review, I found that a few theories that by their nature of being framed by a context that no longer matches the current sociopolitical and cultural climate, have perpetuated the aforementioned narrative informed by the patriarchy and the notion of power imbalance. I believe this is antithetical to the emancipatory movement we are experiencing in nursing – and society, as a whole – where, for example, the out-dated adage of “enabling” the other should be updated to a focus on empowerment.

So, some closing thoughts:

Your students live and will work in a world that that changing at an unfathomable pace. While I believe that a great many works and ideas in nursing theory and philosophy are truly timeless and relevant, some are not. Stay up to date on what is pertinent and what is being published. Teach the classics, but also teach new, relevant theories. Try new articles. Try new textbooks. Talk to your students about what they think is timely and relevant.

And more importantly …. talk to your students. Connect with them. Millennials, in particular, like to be engaged and involved! Finding innovative and creative ways to connect with your students is especially important with the proliferation of online programs, where many students will never set foot campus. Trust me: your effort in this regard will be well worth it! Whether in the classroom or the online environment, I got the most from faculty who taught from a place of compassion and connection – where they openly and earnestly worked to understand the student perspective and got us involved and invested in what we were learning. In fact, I’m still in touch with a few faculty from both my BSN and MSN programs! (Dr’s Lea Gaydos, Lynne Bryant, Amy Silva-Smith…). Dr. Gaydos and Dr. Bryant were my BSN and MSN theory and philosophy professors, respectively, and were two of the first people I called when I had my first theory-related article published in 2019 in NSQ. It’s been nearly 20 years since I took Dr. Gaydos’ class, and I still have my term paper from that course. All I can say is: what an abomination! I was in tears, laughing, when I reread that “gem” last year!

My point is, these professors planted the seed of interest in nursing scholarship at the doctoral level. You will have THAT student. I was THAT student. Who am I kidding… I’m still THAT student! The student who wants to know “why” about everything. The student who will question everything. The student who will argue every last point on an assignment. Trust me when I say this: no matter how much shade your students throw at theory, you ARE making a difference. Because THAT one student … the one who pushed you and nearly drove you crazy … that student may be the one who grows up and wants to continue this dialogue.

Finally, and most importantly: I truly admire and respect Dr. Foli for putting herself out there. The issue she raises (students throwing shade at nursing theory) is very real and very much alive and well in the world of nursing academics. As Dr. Jane Georges once said to me, “violence can be done to students’ ideas,” and I applaud Dr. Foli in her quest to improve the academic experience for her learners.

Sources

Benedict, S. & Georges, JM. Nurses in the Nazi “euthanasia” program. Advances in Nursing Science: 2009; 32(1): 63-74.

Chinn, PL. & Falk-Rafael, A. Embracing the focus of the discipline of nursing: critical caring pedagogy. Journal of Nursing Scholarship: 2018; 50(6): 687-984.

Eisenhauer, ER. An interview with Dr. Barbara Caper. Advances in Nursing Science: 2015; 38(2): 73-81.

Falk-Rafael, A. Nursology: Critical Caring. https://nursology.net/nurse-theorists-and-their-work/critical-caring/. Accessed June 2, 2019.

Falk-Rafael, A. Advancing nursing theory through theory-guided practice: the emergence of a critical caring theory. Advances in Nursing Science: 2005; 28(1): 38-49.

Georges, HM. Biopower, compassion, and nursing. In: Philosophies and practices of emancipatory nursing: social justice as praxis. Kagan, PL., Smith, MC., & Chinn, PL. (eds). New York: Routledge; 2014: 51-63.

Georges, JM. An emancipatory theory of compassion for nursing. Advances in Nursing Science: 2013; 36(1): 2-9.

Georges, JM. Evidence of the unspeakable: biopower, compassion, and nursing. Advances in Nursing Science: 2011; 34(2): 130-135.

Georges, JM. Bio-power, Agamben, and emerging nursing knowledge. Advances in Nursing Science: 2008(A); 31(1): 4-12.

Georges, JM. The politics of suffering: implications for nursing science. Advances in Nursing Science: 2004; 27(4): 250-256.

Kagan, P.N., Smith, M.C. & Chinn, P. (eds.) (2014). Philosophies and practices of emancipatory nursing. Routledge.

Lenz, E.R. & Pugh, L.C. (2014). The theory of unpleasant symptoms. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.

Locsin R. Technological competency as caring in nursing: co-creating moments in nursing occurring within the universal technological domain. The Journal of Theory Construction & Testing: 2016; 20(1): 5-11.

Smith, M.J. & Liehr, P.R. (eds). (2014). Middle range theory for nursing, 3rd ed. Springer.

Smith, M.J. & Liehr, P.R. (2014). Story theory. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.

Watson, J. Unitary caring science: the philosophy and praxis of nursing. Louisville: The University Press of Colorado; 2018.

Watson, J. Caring science as sacred science. Philadelphia: F.A. Davis Company; 2005.

Whitaker, H. (2020). Quit like a woman: the radical choice not to drink in a culture obsessed with alcohol. Random House.

Williams, L. (2014). Theory of caregiving dynamics. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.

A Dozen and One Ways to Love Our Discipline!

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

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

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

Transitions in Leadership Positions: Is There a Best Time?

As we know, leaders transition to and from their positions within educational and clinical institutions. Meleis’ transitions theory, which focuses on “the human experiences, the responses, [and] the consequences of transitions on the well-being of people” (Meleis, as cited in Fawcett, 2017, p. 347) tells us that transitions may be anticipated, experienced in the here and now, or have been completed. Transitions may be development, situational, organizational, cultural, or well-illness; each type may occur singularly or with one or more others. (See https://nursology.net/nurse-theorists-and-their-work/transitions-framework-transitions-theory/)

Transitioning to or from a leadership position is a situational transition, which could be combined with a cultural transition as the nursologist moves to or from a new academic or clinical institution or even another country. The situational transition could be combined with a developmental transition as the nursologist enters another lifespan developmental phase. Furthermore, the situational transition could be combined with an organizational transition as an academic institution undergoes a major shift in priorities or a clinical agency merges with another clinical agency.

Alternatively, the transition of a nursologist to or from a leadership position could create an organizational transition as all affected people and structures adjust to the change. Finally, the situational transition, especially transitions from a leadership position, could be combined with a wellness-illness transition if the nursologist experiences a sudden acute illness or can no longer effectively manage a chronic disease.

One question about leadership transitions is: How does a nursologist transition to becoming an effective leader? Another question is: Is there an optimal time for a nursologist to transition to or from a leadership position?

© 2020 Jacqueline Fawcett

HOW DOES A NURSOLOGIST TRANSITION TO BECOMING AN EFFECTIVE LEADER?

Transitioning to becoming an effective leader obviously first requires a desire to be a leader, although at times, a nursologist may find self gently (or not so gently!) pushed into a leadership position by colleagues or senior administrators or by a vacuum left by someone who transitioned from the position suddenly.

Transitioning to becoming an effective leader also requires certain competencies. The American Organization of Nurse Executives (now the American Organization for Nursing Leadership) identified five competencies for effective leadership in practice and education (Waxman, Roussel, Herrin-Griffith, & D’Alfonso, 2017).  Although the competencies focus on those for executive level leadership positions, they are relevant for all levels of leadership. The five competencies are listed here. The specifics of the competencies are available in the Waxman et al. (2017) journal article or at https://www.aonl.org/resources/nurse-leader-competencies:

  1. Communication and relationship-building
  2. Knowledge of the healthcare or academic environment
  3. Leadership
  4. Professionalism
  5. Business skills and principles

The nursologist may already have acquired these competencies or has to acquire them by enrolling in a formal program and/or finding a mentor or leadership coach. Formal programs for nursologists are offered by Sigma Theta Tau International, the American Association of Colleges of Nursing, the American Organization for Nursing Leadership, and the Robert Wood Johnson Foundation. The programs are:

Sigma Theta Tau International
American Association of Colleges of Nursing
American Organization for Nursing Leadership (formerly, American Organization of Nurse Executives)
Robert Wood Johnson Foundation

Mentors and leadership coaches may be included within formal programs or the nursologist may have to approach recognized leaders and ask that they share their wisdom about leadership.

IS THERE AN OPTIMAL TIME FOR A NURSOLOGIST TO TRANSITION TO OR FROM A LEADERSHIP POSITION?

Aspiring or actual leaders may ask: Am I too young or too old to transition to or from a leadership position? Inasmuch as many institutions do not have mandatory age requirements for employees, wisdom is an important element of the transition decision. Although, as Larson (2019) pointed out, wisdom may come with older age, my experience indicates that younger persons also may be wise. Wisdom at any age requires nursologists to use “mindfulness, empathy, and self-reflection to learn from their mistakes, failures, and successes over the years” (Larson, 2019, pp. 789-790). Thus, those people who aspire to be leaders or already are leaders may want to heed Larson’s words and engage in serious self-assessment to determine whether they are ready to transition to or from a leadership position. In addition, aspiring or actual leaders may want to assess their leadership competencies, which can be done using a self-assessment instrument that is available at https://www.aonl.org/resources/online-assessments.

Fang and Mainous (2019) examined factors related to short term deanship, which they regarded as problematic. (A short tenure leadership position is one that ends sooner than the specific term of the position, such as 3 years or 5 or 6 years.) Their study of data from the 2016 American Association of Colleges of Nursing Annual Survey revealed that certain personal and organizational characteristics are associated with short tenure chief nursing academic administrator positions, including the titles of dean, chair, director, or department head. The characteristics are: age (60 or older) at beginning of the leadership position, having a title other than dean, being a dean who subsequently takes another deanship, being a first time dean, being a dean in a school without a tenure system, and being a dean of an associate degree program or a baccalaureate degree program.

As I read Fang and Mainous’s (2019) article, I wondered whether short tenure leadership positions are always problematic. Could it be that the position is not consistent with what the person hopes and dreams it will be? Could it be that the person’s leadership style is not conducive to inspiring a faculty or clinical staff to attain personal, professional, and/or organizational goals? Perhaps, then, transitioning from a short tenure leadership position may be a positive event for the nursologist leader and for the faculty or clinical staff. Perhaps everyone breathes “a sigh of relief” that the leader has transitioned from the position (Larson, 2019, p. 789).

Another situational transition, which may be combined with a developmental transition and which affects almost everyone, is retirement. Those nursologists who are contemplating retirement most likely were or still are leaders in the institutions where they work, even if they are not “official” leaders, such as deans, directors, or chairs. Larson (2019) discussed her decision to retire from her faculty position. She regards retirement as “the next transition in my career development” (p. 789). At age 76, Larson (2019) noted, she “made the scary and difficult decision to retire in less than a year . . . [and] not wait until people breathed a sigh of relief that I was finally gone” (p. 789).

Meleis (2016) wrote about her situational transition of anticipating, experiencing, and completing stepping up from a deanship. She explained that stepping up “connotes climbing to a higher place in our lives, taking with us what we learned in the previous [step]” (p. 187). Meleis identified and described five phases in the transition to and from a deanship. I will presume to be so bold as to generalize Meleis’ (2016) description of the deanship transition to all leaders, add a sixth phase (expressing an initial professional voice), and adapt the phases to both transitioning to and from a leadership position. The six phases are:

  1. Expressing an initial professional voice
  2. Deciding to transition to or from a leadership position
  3. Searching for the leadership position
  4. Being named to the position
  5. Exiting from the position by stepping up
  6. Reclaiming a professional voice

© 2020 Jacqueline Fawcett

I applaud those nursologists who are willing to transition to a leadership position and congratulate those who have transitioned from a leadership position. I send best wishes to all for much happiness, wellbecoming, and exciting and stimulating next ventures in stepping up.

References

Fang, D., & Mainous, R. (2019). Individual and institutional characteristics associated with short tenures of deanships in academic nursing. Nursing Outlook, 67, 578–585. https://doi.org/10.1016/j.outlook.2019.03.002

Fawcett, J. (2017). Applying conceptual models of nursing: Quality improvement, research, and practice. New York, NY: Springer.

Larson E. L. (2019). Musings on retirement. Nursing Outlook, 67, 789-790. https://doi.org/10.1016/j.outlook.2019.04.008

Meleis, A. I. (2016). The undeaning transition: Toward becoming a former dean. Nursing Outlook, 64(2), 186–196. https://doi.org/10.1016/j.outlook.2015.11.013

Waxman, K., Roussel, L., Herrin-Griffith, D., & D’Alfonso, J. (2017). The AONE nurse executive competencies: 12 years later. Nurse Leader, 15, 120–126. https://doi.org/10.1016/j.mnl.2016.11.012

Visions for 2020 – the Year of the Nurse

To all Nursology.net visitors – welcome to the Year 2020!  As we enter this year, we members of the site management and blogging teams join in celebrating the “Year of the Nurse and Midwife” and offer our visions for the coming year and beyond!

The year 2020 was designated In January 2019 by the World Health Organization (WHO) as the “Year of the Nurse and Midwife”  in honor of the 200th birth anniversary of Florence Nightingale.  Far from being a mere sentimental expression recognizing the importance of nursing and midwifery worldwide, this designation is part of a worldwide effort to improve health globally by raising the status of nursing and midwifery.  Here is the statement issued in establishing this designation:

The year 2020 is significant for WHO in the context of nursing and midwifery strengthening for Universal Health Coverage. WHO is leading the development of the first-ever State of the World’s Nursing report which will be launched in 2020, prior to the 73rd World Health Assembly. The report will describe the nursing workforce in WHO Member States, providing an assessment of “fitness for purpose” relative to GPW13 targets. WHO is also a partner on The State of the World’s Midwifery 2020 report, which will also be launched around the same time. The NursingNow! Campaign, a three-year effort (2018-2020) to improve health globally by raising the status of nursing will culminate in 2020 by supporting country-level dissemination and policy dialogue around the State of the World’s Nursing report.

Nurses and midwives are essential to the achievement for universal heath coverage. The campaign and the two technical reports are particularly important given that nurses and midwives constitute more than 50% of the health workforce in many countries, and also more than 50% of the shortfall in the global health workforce to 2030. Strengthening nursing will have the additional benefits of promoting gender equity (SDG5), contributing to economic development (SDG8) and supporting other Sustainable Development Goals. (from https://www.who.int/hrh/news/2019/2020year-of-nurses/en/)

As members of the Nursology.net management team, we are welcoming the 2020 “Year of the Nurse and Midwife” with our visions for this coming year and beyond.  We hope our ideas will inspire you to join in making these values and visions a reality!

Maggie Dexheimer Pharris –

2020 vision. During an eye exam, there is a moment when just the right corrective lens falls into place and suddenly we appreciate 20/20 clarity of vision. Remarkable!  So too it is with theory. In this new decade may nurses around the world find just the right nursology theory to clearly see the path to creating a meaningful practice and equitable, accessible, and healing systems of care!

Karen Foli – 

Unity among nurses based on the care we offer and the universal experiences we share. kindness directed toward patients and fellow nurses, even when they may be unable to reciprocate in that moment. Wisdom to understand how nursing power can be harnessed to forward a sustainable, balanced work life and advocate for improvements in patient and family care. And for nurses’ truth to be spoken freely, a reality to be heard and honored.

Peggy Chinn – 

A renewal of deep respect and tireless dedication for the core values of our discipline – protection of the dignity of each individual, advocacy for the needs of those we serve, and belief in the healing potential of our caring relationships.

Marlaine Smith – 

An accelerating appreciation for the distinctive knowledge of the discipline and the unique contribution that this knowledge can make to the health, well-becoming and quality of life of those we serve. With this appreciation will come the growth of research that is focused on the theories of nursology and practice models that are theory-guided.  Our focus on human wholeness, health as well-being/becoming, the human-environment-health interrelationship and caring is what is missing and most needed in healthcare.

Jane K. Dickinson  –

My vision is that all nurses will know, value, and be guided by nursing knowledge and take caring to the next level in education, practice, and research.

Jessica Dillard-Wright – 

Because 2020 has been declared the Year of the Nurse by the World Health Organisation, my vision for the year is that nursing will embrace the emancipatory potential of our discipline, recognizing the interface between nursing knowledge, nursing praxis, and wellbeing on a global scale. In so doing, we can dismantle injustice and mobilize our profession to nurse the world.

Jacqueline Fawcett

 Now is the perfect time to accept NURSOLOGY as the proper name for our discipline and profession. Now is the perfect time to realize that all individuals licensed as Registered Nurses or equivalent designation worldwide are NURSOLOGISTS. Now is the perfect time for all nursologists to realize they are “knowledge workers” who engage in development, application, and dissemination of nursology discipline-specific knowledge so that we know and everyone else knows the what, why, how, where, and when of our work with those individuals and groups who  seek our services.

Chloe Littzen – 

My vision for nursing in 2020 is that we find unity among our diversity, despite settings, education levels, or beliefs, and work collaboratively to advance the discipline, enabling all nurses epistemic authority and well-being.

Rosemary Eustace – 

The year 2020 is a great reminder of the “200” unique contributions nurses and midwives make each day to improve health, health care, health policy and nursing across diverse settings.  As we celebrate this milestone, let us light our lamps in unity to advance nursing knowledge that is congruent with contemporary health care demands. Let us keep the Power of Nursology alive!

Marian Turkel – 

Vision for 2020: Nursing theory will guide nursing education, nursing practice and nursing research. RN-BSN, BSN and MSN programs will have at least one nursing theory course in the curriculum.  DNP and PhD curriculum will have 2 nursing theory courses.  Nursing faculty and Registered Nurses in the practice setting doing research will use a nursing theory to guide their practice and research.  The Nursology leaders will collaborate with the American Academy of Nursing to organize a conference similar to the Wingspread Conference. The American Nurses Credentialing Center will collaborate with the Magnet Recognition Program©® to require hospitals to have a nursing theory as the foundation for achieving Magnet©® Status Recognition.