A Theory of Parental Post-Adoption Depression: What’s New is New Again

Welcome to guest blogger Karen J. Foli, PhD, RN, FAAN,
Associate Professor,
Director, PhD in Nursing Program
Purdue University School of Nursing
Here she discusses the challenges of interacting with public media
about her theory of parental post-adoption depression (PAD)

Recently, I was contacted by journalists from Denmark and the New York Times. In both cases, they wanted to interview me about my middle range theory of parental terpost-adoption depression (PAD). I was honored to be asked about my work, but what struck me was a feeling of déjà vu. When my book, The Post-Adoption Blues: Overcoming the Unforeseen Challenges of Adoption (2004 and co-authored by John Thompson) was published and then followed by several empirically driven papers published in peer-reviewed journals (see references below), the press was out en masse.

It’s tricky talking to the press. I’ve made my share of mistakes and learned with every interview I’ve given. But back to the content of these interviews – parental post-adoption depression. The first questions I can count on are: “How does this compare with postpartum depression? What about hormonal changes? How common is PAD?” First, I try to explain that we now see postpartum depression as encompassing the perinatal time period. I describe how we really don’t know about hormonal changes with adoptive parents, but there are differences in the experiences of these two parent groups. In terms of prevalence, we’re not sure – my best estimate is 10% to 20% of adoptive parents may experience depressive symptoms.

Adoptive parents reach into society for a license to parent a child born to others. They go through a rigorous, invasive process during which they are waiting, and ultimately matched with an infant or child. Often, parents “sell” themselves as “super parents,” beings that set themselves up with high, often unrealistic expectations. Herein lies the heart of my theory: unmet expectations of themselves as parent, of their child, of family and friends, and of society and others, are associated with depressive symptoms. Based on my research, expectations of themselves are the hardest to meet.

The question becomes: how do nurses and nursology fit into this? Based on my research and writing (see also Nursing Care of Adopted and Kinship Families: A Clinical Guide for Advanced Practice Nurses), the answer is more than you would suppose. Social work is the historical and current default profession that we defer to when children are relinquished and for home studies that evaluate the fitness of adoptive parents. Yet we understand that adoptive children visit healthcare providers more frequently than birth children. Herein lies our opportunity as care providers to support families.

Many adoptive parents experience significant shame when they struggle with PAD. Sometimes, when they share their feelings, they will be met with: “But isn’t this what you’ve wanted?” Nurses in myriad specialty areas can make a positive impact. Pediatric nurses can assess the dynamics between the child and parent and look for cues of impaired or delayed bonding. Nurses providing care to older adults can also assess for PAD – relative placements in foster care and in informal arrangements are surging (also known as kinship caregivers). Primary care providers have multiple opportunities to look for signs of parental depressive symptoms post-adoption and ask about expectations that were or were not met.

To end, when parents experience depression, we know the kids suffer too. Nurses can be savvy caregivers to this special and vulnerable group of parents and their children. While this blog is too brief to relay all that we know about PAD, it’s a welcomed beginning.

References

Foli, K. J., Lim, E., & South, S. C. (2017). Longitudinal analyses of adoptive parents’ expectations and depressive symptoms. Research in Nursing and Health, 40(6), 564-574. doi: 10.1002/nur.21838

Foli, K. J., Hebdon, M., Lim, E., & South, S. C. (2017). Transitions of adoptive parents: A longitudinal mixed methods analysis. Archives of Psychiatric Nursing31(5), 483-492. doi: https://doi.org/10.1016/j.apnu.2017.06.007

Foli, K. J., South, S. C., Lim, E., & Jarnecke, A. (2016). Post-adoption depression: Parental classes of depressive symptoms across time. Journal of Affective Disorders200, 293-302. doi: 10.1016/j.jad.2016.01.049

Foli, K. J., South, S. C., Lim, E., & Hebdon, M. (2016). Longitudinal course of risk for parental post-adoption depression using the Postpartum Depression Predictors Inventory-Revised.  Journal of Obstetric, Gynecologic, and Neonatal Nursing, 45(2), 210-226doi:10.1016/j.jogn.2015.12.011

Foli, K. J., Lim, E., South, S. C., & Sands, L. P. (2014). “Great expectations” of adoptive parents: Theory extension through structural equation modeling. Nursing Research, 63(1), 14-25. doi: 10.1097/NNR.0000000000000006

Foli, K.J., South, S.C., & Lim, E. (2014). Maternal postadoption depression: Theory refinement through qualitative content analysis. Journal of Research in Nursing, 19(4), 303-327. doi: 10.1177/1744987112452183

South, S. C., Foli, K. J., & Lim, E. (2013). Predictors of relationship satisfaction in adoptive mothers. The Journal of Social and Personal Relationships30(5), 545-563. doi: 10.1177/0265407512462681

Foli, K. J., Schweitzer, R., & Wells, C. (2013).  The personal and professional: Nurses’ lived experiences of adoption. The American Journal of
Maternal/Child Nursing, 38
(2), 79-86. doi: 10.1097/NMC.0b013e3182763446

Foli, K. J. South, S. C., Lim, E., & Hebdon, M. (2013). Depression in adoptive fathers: An exploratory mixed methods study. Psychology of Men & Masculinity, 14(4), 411-422. doi: 10.1037/a0030482

Foli, K. J., South, S. C., Lim, E., & Hebdon, M. (2012). Maternal postadoption depression, unmet expectations, and personality traits. Journal of the American
Psychiatric Nurses Association
18(5), 267-277. doi: 10.1177/1078390312457993

Foli, K. J. (2012). Nursing care of the adoption triad. Perspectives in Psychiatric Care, 48(4), 208-217. doi: 10.1111/j.1744-6163.2012.00327.x

Foli, K. J., South, S. C., & Lim, E. (2012). Rates and predictors of depression in adoptive mothers: Moving toward theory. Advances in Nursing Science35(1),
51-63. doi:10.1097/ANS.0b013e318244553e

Foli, K. J., & Gibson, G. C. (2011).  Training ‘adoption smart’ professionals.  Journal of Psychiatric and Mental Health Nursing, 18(5), 463-467. doi:  10.1111/j.1365-2850.2011.01715.x

Foli, K. J. & Gibson, G. C. (2011).  Sad adoptive dads:  Paternal depression in the post-adoption period,International Journal of Men’s Health10(2), 153-162. doi: 10.3149/jmh.1002.153

Foli, K.J. (2010). Depression in adoptive parents: A model of understanding through grounded theory. Western Journal of Nursing Research, 32, 379-400. doi: 10.1177/0193945909351299

Foli, K. J. (2009). Postadoption depression: What nurses should know. American Journal of Nursing, 109, 11. doi: 10.1097/01.NAJ.0000357144.17002.d3

Grayce M. Sills (1926-2016)

Guardian of the Discipline

Thank you to Sharon Tucker, PhD, RN, FAAN
and Christina Nyirati, RN, PhD
for their contributions to this post (see bios below).

Grayce M. Sills, circa 1986 while serving as Acting Dean of the Ohio State University School of Nursing. Photo by Charlene Eldridge Wheeler, featured for month of April, 1987 “Everyday Sheroes” Calendar

Grayce Sills, RN. PhD, FAAN, is widely recognized as a “pioneer . . . and supporter . . . of psychiatric mental health nursing . . . a champion for improving care for the chronically mentally ill . . .  [and] a pioneer in interdisciplinary collaboration among health care professionals” (Parrish, 2016, pp. 155-156).

Grayce Sills was born in Bremen, a small town in southeast Ohio. She was raised by her grandparents and extended family from the age of 2 years, after her mother died. Grayce began her undergraduate education with a liberal arts concentration at Ohio University in Athens, close to her family home. Following her sophomore year, Dr. Sills took a federally funded training job in New York to prepare as a psychiatric aide, hoping to raise enough money to complete her college degree. The psychiatric nurses impressed Grayce with their specialized skill. She was particularly impressed by the head nurse, Betty Oliver, who seemed more able than the physicians to soothe and comfort patients by just being present. Inspired, she began her nursing education at Rockland State Hospital School of Nursing in Orangeburg, New York, where she received her diploma in 1950. Grayce then attended the baccalaureate completion program at Teachers College Columbia University in New York from 1950 to 1951 but did not complete the program.

While at Teachers College, Grayce met Hildegard Peplau, just as Dr. Peplau was completing what many consider the first middle range nursing theory, Interpersonal relations in nursing (Peplau, 1952). Many year later Dr. Sills shared stories about the Peplau seminars with The Ohio State University Ph.D. nursing students who were grappling with theory; Dr. Sills admitted to also being initially confounded by Dr. Peplau’s theoretical inquiries. Timidly curious, yet somewhat intimidated, Grayce left New York to return to her Ohio home. She finally received a baccalaureate nursing degree from the University of Dayton in 1956. Fortunately for our discipline in general and psychiatric nursing in particular, Dr. Peplau was invited to present a nursing workshop at Dayton State Hospital in 1957, where Grayce was working. Explaining how her perspective then shifted profoundly, she stated:

“I owe [a large debt to] Hildegard E. Peplau for bringing me a new perspective, a new approach, a theoretically based foundation for nursing practice, for therapeutic work with patients in those problematic settings. Imagine the excitement of making sense out of a patient’s hallucinatory experience through collaborative work! Imagine the joy that came from discovering that a delusion could be dealt with and satisfactorily eliminated through effective verbal work with patients, a new day had dawned! Theory was used to guide nursing practice. Theory was tested in the real world of practice.” (Sills, 1978, p. 122)

Dr. Sills earned a master’s degree in sociology from The Ohio State University (OSU) in 1964, and began teaching in the OSU School of Nursing that same year. She completed a PhD in sociology, also from OSU, in 1968.  At that time, the PhD in Nursing was not yet offered. Dr. Sills described herself as a “tourist” in the discipline of sociology, grateful for a conceptual perspective complementary to nursing, but convinced that nursing knowledge was necessary for nursing practice. With this conviction, Dr. Sills made major contributions to the nursing programs at OSU, including a graduate clinical nurse specialist program in psychiatric mental health nursing. She also chaired the Department of Family and Community Nursing and served as Director of Graduate Studies.

As the first OSU Nursing Acting Dean, by 1985 Dr. Sills had managed to re-position Nursing in the academic structure of OSU by establishing the College of Nursing with its own budget and self-governance. This, she believed, was the necessary foundation for creating a community of nurse scholars who would advance nursing education and nursing scholarship. Self-governance, she reasoned, would contribute significantly to the power of nursing to develop the scholarly discipline, as well as the practice profession of nursing. Her conviction that borrowed knowledge from established disciplines was useful to nursing – although that knowledge was not  nursing knowledge – influenced her vision for the Ph.D. Program in Nursing at OSU, established in 1985.

Dr. Sills retired from OSU College of Nursing in 1993 as Emeritus Professor. She holds the rare distinction of receiving three awards from OSU: a Distinguished Teaching Award, a Distinguished Service Award, and an honorary doctorate in public service. She also was awarded honorary doctoral degrees from Indiana University and from Fairfield University.

Dr. Sills’ contributions expanded beyond OSU. She chaired the Study Committee on Mental Health Services for Ohio and, in 1986, was chosen as a Woman of Achievement by the Columbus YWCA. As a past chair of the OSU Hospitals Board of Trustees, she was instrumental in gaining board support for magnet hospital status, achieved in 2005. Beyond Ohio, she held visiting professorships at several universities throughout her career and provided international consultation for community based mental health nursing in Italy, Japan, and South Korea. Dr. Sills was a founder of American Psychiatric Nursing Association and the American Nurses’ Association (ANA) Commission on Human Rights. She was elected to the American Academy of Nursing (AAN), and in 1999, was designated as an AAN Living Legend.  She received several other awards, including the ANA Hildegard Peplau Award.

Dr. Sills record of scholarly work includes more than 60 journal articles and book chapters. One of many innovations put forth by Dr. Sills in the idea of nurse corporations. She explained,

“The conceptual key to the corporation proposal is that it changes the fundamental nature of the social contract. The professional nurse would no longer be an employee of the hospital or agency, but rather a member of a professional corporation which provides nursing services to patients and clients on a fee‑for-service basis. . . . Such a change in the nature of the social contract is, it seems to me, fundamentally necessary for the survival of nursing as a profession rather than an occupational group of workers employed by other organizations.” (Sills, 1983, p. 573)

Inasmuch as nurse corporations would operate on a fee-for-service basis, the corporation would determine the costs of nurses’ work, which changes the economics of practice in a profound way. Furthermore, nurse corporations are a solution to the problem of collective bargaining by nurses, such that contracts are between the nurse corporation, which is a professional entity rather than a union, and individuals or organizations (Sills, 1983).

Christina Nyirati recalls that when she was a student at OSU several years ago, Dr. Sills had championed nursology as the name for our discipline.  Peggy Chinn recalls that at an American Nurses’ Conferene of many years ago, Dr. Sills was among the first nurse leaders to propose that the “doctor’s orders” be changed to the “physician’s prescriptions,” to serve as a parallel to the nurse’s prescriptions. ”One wonders what Dr. Sills now would think about the“nursologist’s prescriptions” or the “patient’s self-directed prescriptions”?

Given Dr. Sills’ substantial contributions to our discipline, it is not surprising that she was “affectionately referred to as ‘Amazing Grace’ by everyone who knew her” (Parrish, 2016, p. 166). See this video of an interview of Dr. Sills by Jeanne Clement:

References

Parrish, E., (2016). Remembering a pioneer of psychiatric mental health nursing. Perspectives in Psychiatric Care, 52, 155-156.

Peplau, H.E. (1952). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York, NY: G.P. Putnam’s Sons. [Reprinted 1989. London, UK: Macmillan Education Ltd. Reprinted 1991. New York, NY: Springer.] (Translated into nine languages) .

Sills G. (1978). Hildegard E. Peplau: Leader, practitioner, academician, scholar and theorist. Perspectives in Psychiatric Care, 16, 122–128.

Sills, G. M. (1983). The role and function of the clinical nurse specialist. In N.L. Chaska (Ed.), The nursing profession: A time to speak (pp. 563–579). New York: McGraw‑Hill.

About our guest Contributors

Christina Nyirati, RN; PhD
Photo retrieved from http://www.heritage.edu/faculty-staff/directory/staff-bio/

Christina Nyirati, PhD, RN – 

Professor, Department of Nursing, Chair and BSN Program Director, College of Arts & Sciences, Heritage University, Toppenish, WA.

Grayce Sills became Christina’s mentor when she was admitted to the first OSU PhD nursing cohort in 1985 after several years of experience as a family nurse practitioner (FNP). At their initial meeting Dr. Sills questioned whether, as an FNP, Christina had disavowed her nursing knowledge. Dr. Sills ventured Christina would have to work a little harder than her classmates to question her assumptions about the Discipline of Nursing. Christina recalls Dr. Sills spoke be-musingly about Drs. Paterson and Zderad, Sills’ former OSU faculty colleagues, who had referred to themselves as Nursologists. At a recent American Association of Colleges of Nursing (AACN) Dean’s meeting, Christina reminisced with erstwhile PhD classmate, Dr. Janet Fulton, (now Professor and Associate Dean for Graduate Programs at Indiana University-Purdue University) about their seminars with Dr. Sills, who, with a twinkle in her eye, challenged the doctoral students to ponder nursing as a discipline rather than an applied discipline, and to consider Nursology the organizing concept for our discipline.

Throughout her career Dr. Nyirati has endeavored to fulfill her mentor’s admonition. When she became the founding director of the FNP program at OSU she integrated nursing theory with primary care concepts into the curriculum. Dr. Nyirati challenges FNP educators to consider nursing knowledge as the essential component of the FNP program as the Doctor of Nursing Practice (DNP) evolves and becomes requisite for entry into advanced practice [See article by Nyirati, C. M., Denham, S. H., Raffle, I., & Ware, J. (2012). Journal of Family Nursing, 18, 378-408).

Now as BSN program director at Heritage University on the Yakama Reservation in Washington State, Christina honors Grayce’s legacy as she prepares nurses in a curriculum faithful to the epistemic foundation of nursing. BSN students develop their reflective practices from The Fundamental Patterns of Knowing in Nursing  (See article by Carper, B. A. (1978). Advances in Nursing Science, 1(1), 13-24.) Before her death in 2016, Dr. Sills used to Skype with the first cohort of Heritage BSN students, reminding them to recognize and use their powerful nursing knowledge to correct the inequities in their communities.

Sharon Tucker, PhD, RN, FAAN
Photo retrieved from https://nursing.osu.edu/faculty-and-staff/sharon-tucker

Sharon Tucker, PhD, RN, APRN-CNS, F-NAP, FAAN – 

Grayce Sills Endowed Professor in Psychiatric-Mental Health Nursing, College of Nursing; Translational/Implementation Research Core Director, Helene Fuld Health Trust National Institute for EBP; Nurse Scientist, Wexner Medical Center, The Ohio State University

Faculty and staff at OSU are privileged to continue to advance the work of the amazing Dr. Sills through an endowed professorship established in her name by a generous gift from Dr. Sills and her family. Dr. Tucker was hired in 2017 as the Grayce Sills Endowed Professor of Psychiatric Mental Health Nursing. She has practiced, taught, and conducted research in behavioral and mental health interventions and outcomes for decades. She was recognized in 1997 with an Award for Excellence in Research by the American Psychiatric Nurses Association, at which time Dr. Sills was recognized with the Psychiatric Nurse of the Year Award.

Dr. Tucker seeks to advance Dr. Sills’ work in promoting independent nursing practice (she is a board certified Advanced Practice Psychiatric Clinical Nurse Specialist), teaching interpersonal and health coaching skills, studying mental health assessment strategies and behavior change interventions, and advocating for individuals living with mental illness who are underserved and undertreated.

 

 

 

 

 

 

 

Moving Towards the Next Fifty Years Together

We are delighted to welcome guest bloggers representing the  Nursing Theory Collective
formed March 2019 Case Western Reserve
Nursing Theory Conference:
Chloe Littzen, Jane Hopkins Walsh  and Jessica Dillard Wright

I. Introduction

Chloe Littzen

Jessica Dillard-Wright (L) and Jane Hopkins-Walsh (R)

In March 2019, 130 nurses from all over the world gathered at Case Western Reserve University Frances Payne Bolton School of Nursing in Cleveland, Ohio for Nursing Theory: A 50 Year Perspective, Past, and Future, a landmark conference to celebrate the history of nursing theory and elicit discussion for the future of nursing. The attendees were diverse, comprised of seasoned nursing theorists and doctoral students in equal measure, participating in lively and thoughtful conversation across many domains. The future of nursing theory quickly emerged as a critical issue as nurses working at all levels of expertise expressed their concern over the loss of nursing theory at the institutional level, both academic and clinical. What is at stake in this erosion is discipline-specific nursing knowledge, in particular at this 50-year juncture as the great theorists of nursing like Drs. Peggy Chinn, Joyce Fitzpatrick, Pamela Reed, Callista Roy, Marlaine Smith, and many others approach the end of their illustrious careers. The question resonated, “who will carry the nursing theory torch forward?”

To advance the discipline of nursing, the next wave of nursing theorists and thought leaders must actively engage to advance nursing theory, improve nursing praxis, and articulate nursing’s identity leading our profession into the future. This is the rallying cry that led to the blog post you are reading today. In follow-up to this conference, doctoral student Chloe Littzen engaged other students who attended to embark on a collaborative effort to articulate our vision for the future of nursing theory. What follows is a brief discussion of our course so far, the background, plan, and desired outcomes for convening a nursing theory working group as we envision the next fifty years of nursing theory and beyond.

lI. Background

After the landmark conference concluded, a collaborative effort ensued to form a theory working group focused on promoting nursing theory and advancing nursing’s identity. This group is comprised of both scholars and students and is open to all nurses practicing in all settings. Our first meeting was held online via video-conferencing on May 18th, with a total of six participants from Arizona, Massachusetts, and West Virginia. This first meeting was an experimental think-tank where we considered ideas about the future of nursing and our professional identity. Below, we outline our mission and vision for this nursing theory working group.

III. Plan

The primary mission, as established by our working group, is to promote nursing theory and advance the identity of nursing through knowledge development for all nurses in all settings, including practice, education, research, and policy. As a group, we believe that nursing and nursing theory are dynamic and evolving to meet the needs of an increasingly complex healthcare landscape and global environment. In order to keep nursing theory and nursing relevant and current, thinking about theory must be on-going and iterative, with a continuous cycle of critique, testing, and scholarship. Failure to seriously engage these questions has dire consequences for nursing theory and the profession as nursing as it slowly cedes its identity to the economic pressures of the healthcare environment and the supremacy of biomedicine.

The following bullets summarize our discussion and desired outcomes from the first nursing theory workgroup meeting:

  • Discussion Points:
    1. We need a plan to sustain and evolve nursing theory and nursing’s identity with discipline-specific knowledge.
    2. Nursing theory must be derived from and applicable to the practice environment, not just academia.
    3. The purpose of nursing theory must be clarified for nursing practice, education, research, and policy.
    4. Nurses in clinical practice must have an educational foundation grounded in nursing theory that empowers the application of theory in practice.
    5. Nursing students must be educated and mentored in nursing theory, beginning at the pre-licensure level.
    6. This discussion must include considerations of how nursing theory is taught in the academic environment and how that can be linked to and informed by nursing practice.
    7. The need for nursing theory is global, making this an international, even planetary problem.
  • Desired Outcomes:
    1. To write a manuscript demystifying nursing theory for the nurse in the practice environment.
    2. Write a second manuscript demystifying nursing theory for the nurse educator in academia.
    3. Explore the potential of a future study identifying and describing the barriers and facilitators for using nursing theory in practice, education, research, and policy settings.
    4. Share the discussions, experiences, and findings with the community at Nursology.net.

IV. Invitation – Join us!

While we are a new workgroup, we welcome and encourage all nurses, both advanced scholars and novice theorists alike, to consider joining us in this journey in promoting nursing and nursing theory into the future. We currently meet monthly over Zoom video-conferencing. If you are interested, please contact form below to be placed on the email list for future meetings and content.

If you are planning to go to the 2019 Collaborative K.I.N.G. conference in Washington D.C. from November 14th-15th, we are planning an in-person meeting to take place. We hope to see you there as we drive nursing and nursing theory into the future. Join us!

With optimism and gratitude for the future,
Nursing Theory Collective
(Final group name pending vote at next meeting)

Footnotes:

See more information on the King Conference here.

See more information on the landmark theory conference at Case Western Reserve University Frances Payne School of Nursing here.

Please use this form to contact us if you want to join us, or for more information!

Why Nursology?: The Perspective of an International PhD Student

Guest contributor: Toqa Alanby

Toqa Alanby

Hello, my name is Toqa Alanby MSN, BSN, RN, from Saudi Arabia, a full-time nursing PhD student in Christine E. Lynn College of Nursing at Florida Atlantic University. I have chosen to begin the pursuit of my academic career in Nursing with a sense of determination. Through my B.Sc. in Nursing from Umm Al-Qura University (Mecca, Saudi Arabia), my English program at INTO University of South Florida (Tampa, Florida, US), and my M.Sc. in Nursing from Trinity College Dublin, University of Dublin (Dublin, Ireland), I have dedicated my life to advance my nursing knowledge and skills.

I was introduced to the Nursology website by Dean Marlaine Smith, my advisor, as she said, “websites are vehicles to assist us in coming to know an organization.” The Nursology website is a quantum leap in nursing. Nurse scholars, nurses in clinical settings, and postgraduate students, all of them, can be involved by joining or just by browsing this site. It was designed and maintained by nurse scholars with sufficient experience who can enrich the nursing profession throughout the world. For me as an international PhD student who came from a different background, I found it as a repository for sources about nursing conceptual models, grand theories, middle-range theories, and situation-specific theories, philosophies and related methodologies. It is momentous to nursing practice, education and scientific research because it is a guide to what is already known and what further knowledge and skills are required. Also, I found it as a station that can connect to the pioneers of the nursing profession, a link to enable us to communicate with them easily.

Exploring the website, gave me a better understanding about the history of nursing in the United States. Furthermore, it reminded me of how nursing started in Saudi Arabia. In both cases war had an impact on the development of nursing. For instance, the first mention of nursing in Saudi Arabia was during the time of the Prophet Muhammad in the service of the Muslim armies during periods of war. Women accompanied veterans as companions and caretakers. According to Jan (1996) nursing activities carried over into peacetime when the women served as midwives and continued to nurse the sick and dying.  Subsequently nursing concepts emerged to inform this practice.

Nurses, nursing students and other health professionals understand and view nursing differently. Many definitions have been used to define the concept of nursing. Sapountzi-Krepia (2013) justifies this diversity due to different educational backgrounds, cultures and experiences. Now that nursing is based on the interaction with others, caring appears as one of its central concepts. The concept of care emerged during the decade of the 1950’s; however many factors hampered its progress. It was not until two decades later that not only the first National Caring Research Conference but also the publication of Leininger’s and Watson’s theories stimulated the interest of researchers in the concept (Brilowski & Wendler, 2005). Caring seems to be inherent to nursing practice and originates from respect and concern for the patients, which is a skill that evolves with experience. As for my culture, caring from the Islamic perspective refers to a critical, reflective analysis of what we think we know about our universe and ourselves. Saeed (2006) mentioned that the Islamic philosophy is rooted in the attempt to understand reality rationally. The Qur’an, the Holy book of Muslim faith, and the Sunnah, which documents the life and practices of the prophet, built the Islamic belief system.

Outside of the nursing community, when I talk about nursing science, I always have been asked what distinguishes nursing science from other disciplines? Cowling, Smith & Watson. (2008) answered this question by stating that there are 3 fundamental concepts which are wholeness, consciousness, and caring singled out and positioned in the disciplinary discourse of nursing to distinguish it from other disciplines. In my opinion, nursing implies an intentional activity, attitudes and feelings that shape the professional interaction established between nurses and patients.

Having an understanding of these perspectives will inform health professionals to achieve cultural competence and deliver care that is culturally sensitive (Rassool, 2014). Individualized, holistic care can be achieved by apprehending culture, beliefs and ethnicities, and a display of cultural competence. I saw Dr. Sadat Hoseini’s model on the Nursology website as a model that comes from a Muslim perspective. It is wonderful and informative. However, there is a great diversity of cultural, tribal and linguistic groups among Muslim societies, each of which has its own cultural characteristics and worldview of well-being and sickness. Delivering nursing care to Muslim patients means having an insight of Islamic faith and Islamic beliefs. Thus, what goes on in Saudi Arabia is totally different from what Dr. Hoseini’s model looks for. She is from a different culture, country, and doctrine.

Based on my experience, non-Muslim nurses who work in my country are not able to utilize the existing knowledge and framework of health from Islam to enhance the nursing profession. The inability to shape nursing practice, education, and policy from an Islamic perspective can be attributed to multiple factors such as social status of nursing in the country, professional identity of nurses, and societal approval and recognition (Ismail et al., 2015). Therefore, the professional development of nursing among Muslim nurses is based on utilizing Western practice, education, and ethical models instead of integrating the holistic view of Islam (Gharaibeh & Al-Maaitah, 2012). The curricula of our colleges in Saudi Arabia still follow the theories that come from the United States (F. AlShaibany, personal communication, April 25, 2019). Though, in general, the development of nursing theories and models are almost neglected in Saudi Arabia, whether in education or practice. While nursing students know about nursing theories, they most likely don’t see them as a part of their practice. They also tend more to use theories from other disciplines such as change theories instead of nursing theories.

I was eager to explore nursing from another perspective and the Nursology website was a vehicle to achieve this purpose.  The Western concept is the most visible and distinctive in the site. I believe this site will be a real connection for other nurses around the world to the study of Western nursing. Thus, I hope one day to join the great scholars here to advance Nursology forward and perhaps contribute by sharing my theoretical work from a different cultural point of view. My goal is to embark on an academic career and to conduct research.  In other words, scholars absorb and integrate information coming from the world around them as they create their own work. The role they play calls for the development and maintenance of collective learning and comprehension. A scholar’s work, according to Boyer’s (1990) definition, calls for taking a step backwards from the investigation, searching for connection, and bridging the gap between theory and practice while having one’s knowledge communicated effectively (p.16).

Being able to comprehend and associate with nurses of different cultures is vital for nursing advancement. Understanding cultural differences among nursing perspectives is essential. By educating ourselves about different cultures through communication with diverse nurses in conferences, organized meetings, and engagement with a website like Nursology can prepare us well to broaden our perspectives on nursing knowledge from all over the world in multiple cultures.

References

Boyer, E. L. (1990). Scholarship reconsidered. Princeton, NJ: The Carnegie Foundation for the Advancement of Teaching.

Brilowski, A., & Wendler, C. (2005). An evolutionary concept analysis of caring. J Adv Nurs (50), 641-50.

Cowling, W.R., Smith, M.C. & Watson, J. (2008). The power of wholeness, consciousness, and caring: A dialogue on nursing science, art, and healing. Advances in Nursing Sciences, 31(1), 41-51.

Alshaibany, F. (2019, April 25). Personal Interview.

Gharaibeh, K. & Al-Maaitah, R. (2012). Islam and Nursing, in Religion, Religious Ethics, and Nursing. Spinger New York, NY. p. 229-249.

Ismail, S., Hatthakit, U., & Chinawong, T. (2015). Caring science within islamic contexts: a literature review. Nurse Media Journal of Nursing, 5(1), 34. doi:10.14710/nmjn.v5i1.10189

Jan, R. (1996). Rufaida Al-Asalmiya, the first Muslim nurse. Image: Journal of Nursing Scholarship, 28, 267-268.

Rassool, G. H. (2014). Cultural competence in caring for Muslim patients. Palgrave Macmillan.

Saeed, A. (2006). Islamic Thought: An Introduction. New York, USA: Routledge.

Sapountzi-Krepia, D. (2013). Some thoughts on nursing. Int J Caring Sci (6), 127-133.

Tribute to our Nurse Friends!

We welcome this guest post by Shannon Constantinides, MSN, NP-C, FNP, UCHealth Primary Care,  PhD Student, Florida Atlantic University.  Shannon also contributed the content on Jane Georges’ Theory of Emancipatory Compassion

Shannon Constantinides

In trying to explain to my husband (an osteopathic physician) why Nurses’ Week is an important week, I asked him, “Do you ever notice that I have my “friends” … but that I also have my “nurse friends?” He looked back at me, a bit quizzically, shrugged his shoulders and said, “yeah…? I guess so?” In a conversation a day or so later, he said, “Now that you’ve mentioned it, I guess I have heard you mention your Nurse Friends.” He then gave me a somewhat perplexed look and said, “I have friends who are physicians, but I don’t think I have Physician Friends. At least not in the way you talk about your Nurse Friends.” You’re right, my dear, you don’t.

From the inception of the profession, nurses have been working together, side by side in the figurative and literal “trenches.” Whereas our physician colleagues are trained to be the lone wolves, or as I’ve heard it described, “the captain of the ship,” nurses are from the onset of training, trained to work as part of a team.

This Nurses’ Week, I set an intention to celebrate and honor all my Nurse Friends. To me, Nurses’ Week is a reminder about the joy we find in work – not just the experiences that arise from patient care – but also joy we find from the relationships we’ve built with one another along the way.

In 2018, I had the honor and privilege to interview Dr. Jane Georges, Dean of the Hahn School of Nursing at the University of San Diego and the author of the Emancipatory Theory of Compassion. During the course of our conversation, we got onto the topic of finding joy in work and Nurse Friends. Until Dr. Georges pointed it out, I hadn’t given much thought to the concept of Nurse Friends. My mom, a 30-year NICU RN, had Nurse Friends. Dr. Georges’ mother was also a nurse who had Nurse Friends. “NurseFriends” was simply a word we’d always known, because we both grown up with the knowledge that there are two kinds of friends: your friends, and your NurseFriends.

In discussing ways in which we can recapture joy in work and joy in nursing, Dr. Georges circled back to the concept of NurseFriends and the deep connection nurses share with one another; the connection that allows us to find so much meaning in what we do. “I call it the nurse-nurse bond,” Dr. Georges said, “It’s knowing that we can’t do it alone, which is one of the most beautiful parts of nursing.” In recalling some of the most healing environments in which she’d worked, Dr. Georges commented on the presence of joy, respect, and connection with other nurses.

“We just had this crew,” I mentioned as I reminisced about a group night-shift NurseFriends I worked with during my tenure working in an emergency department. Dr. Georges agreed, “I think the idea of the nurse-nurse bond, or NurseFriends, is worth exploring… how do we build back that community where we’re not adversarial to each other?” I think that the answer lies within ourselves and within the community of our discipline: building up our NurseFriends to strengthen one another, to strengthen the profession, to strengthen ourselves, and ultimately, to strengthen the care we give our patients.

Two years ago, I had to tell a NurseFriend who’d become my primary care patient that I’d found lymphoma on her MRI. That was one of the worst days of my professional career. I remember sitting in my office, sick to my stomach. Delivering bad news to a patient is never easy; delivering bad news to a NurseFriend will break your heart.

This NurseFriend is doing great. Her cancer is in remission. She’s healthy. She’s now the clinical manager of my primary care office. I’m lucky: we caught her cancer early, got her great treatment, and I get to see her smiling face every day.

To all of my NurseFriends, thank you for sharing your light with me. You are my heros not just during Nurses’ Week, but every week!

Nursology’s Philosophical and Practical Knowledge: Unified and Interdependent

Guest Contributor: Martha Raile Alligood, RN, PhD, ANEF

A few months ago, Martha Alligood sent me (Jacquelyn Fawcett) this intriguing article: Rovelli, C. (2018). Physics needs philosophy, philosophy needs physics, Foundations of Physics, 48, 481-491. We decided to write a paper, which has evolved into this blog, about the relationship between philosophy and science in nursology. The specific purpose of this blog is to underscore the importance of the relationship between practical knowing and foundational (philosophical) knowing for advancement of nursology.

Alligood writes:

Rovelli (2018) wrote about the interrelationship of philosophy and science (physics). His discussion of practical and foundational knowing led me to think about nursology and the contemporary disciplinary shift to a practical focus from one that was dominated by general foundational philosophical questions. For example, nursological literature has evolved from a strong foundational philosophical knowledge development focus on nursology’s discipline-specific concepts, models, and theories to an equally strong practical focus on quality of practice and nursing education expansion in relation to practice, specifically, the development of the Doctor of Nursing Practice (DNP) degree programs.

Time has shown the value of such shifts in focus for a discipline. Advancement of a discipline calls for recognition and valuing of the complementary relationship between practical knowing and foundational knowing, as both are essential to the development of a professional discipline, such as nursology.

Practical knowledge is–or should be–based on the results of scientific research. However, if science is essential to move the discipline ahead, then philosophy ensures that we move in the right direction. But, “a broader understanding of the interdependence of practical and philosophical matters in professional nursing is needed” (Bruce, Rietze, & Lim, 2014, p. 65). Drawing from Einstein’s discussions of the influence of philosophies and philosophers on his work, Rovelli (2018) noted, “Scientists do not do anything unless they first get permission from philosophy” (p. 484).

Rovelli’s (2018) claim of an interdependent relationship between physics and philosophy for his discipline also is relevant for nursology. That is, contemporary growth and development of nursology requires an explicit interdependent relationship between foundational knowing and practical knowing. Indeed, the re-emergence of nursology as the name for our discipline after its initial introduction in the 1970s (Fawcett, 2018) is evidence of a contemporary need for terminology at a level of abstraction to incorporate all of the discipline’s knowing–both philosophically foundational and scientifically practical.

Within nursing history there are examples of practical knowing leading to foundational knowing, such as research about the impact of patient positioning that has led to foundational knowledge, but it seems that foundational knowing has the capacity to affect practical knowing in a more powerful manner. An excellent example is the clarification of the disciplinary boundaries of nursological knowledge pertaining to human beings, environment, health, and nursing goals and processes (Fawcett, 1984; Fawcett & DeSanto-Madeya, 2013). This metaparadigmatic clarification led to expansion of nursological knowledge, practice, research, education, administration, and perhaps most importantly, a clearer understanding of the theoretical knowledge that existed at that time.  Explaining the relationship of the various models or theoretical works provided clarity and understanding to move nursological knowledge development to a new level.

Ironically, recognizing the structure within which the various conceptual and theoretical frameworks fit may be seen as both practical and philosophical. Some of the very early National League for Nursing (NLN) faculty-curriculum development work that contributed to that understanding was very practical (O’Leary, 1975; Torres & Yura, 1975). Knowledge and understanding leads to future knowledge and understanding. Thus, foundational knowing and practical knowing collectively is nursological knowing that builds on all previous knowing. That is, there is no dichotomy between philosophical and practical knowing; instead, their complementary unified interrelationship may feature one or the other at periods of growth and change in nursology. Clearly, we want to ”counter those who would discard the discipline’s theoretical traditions as irrelevant or counterproductive, we need to [position] this new generation of critical scholarship to champion the intellectually exciting and complex philosophical challenge within which nursing has been engaged throughout its ideational history” (Thorne, 2014, p. 86).

Fawcett writes:

We know from Kuhn’s (1971) classic treatise on scientific revolutions that disciplinary perspectives change over time, typically as the result of scientists’ inability to continue to find support for a previous version of the disciplinary perspective. Sometimes, the revolution is in methodological shifts and sometimes it is in philosophical paradigm shifts. An example of a methodological shift is our contemporary acceptance of mixed methods research instead of the assertion—lasting into the early 2000s–that qualitative and quantitative methods are philosophically separate and, therefore, cannot ever be combined. An example of a philosophical paradigm shift is the growing recognition and acceptance of conceptual models and theories that reflect the simultaneity world view instead of those conceptual models and theories that reflect the totality world view (Parse, 1987).

The growing interest in nursology as the name for our discipline may be the beginning of major methodological and paradigm shifts from the contemporary emphasis on practical knowledge to a fuller understanding of the vital interrelationship of foundational and practical knowledge. These shifts are evident in that acceptance of nursology as the proper name for our discipline indicate that the foundational knowledge of our discipline guides the way we view our science and our practice—always within the context of an explicit nursological conceptual model and/or theory—rather than leaving the knowledge aspect of our science and our practice to the claim of being “atheoretical” (Fawcett, 2019). As Popper (1965) pointed out, everyone has a “horizon of expectations” (p. 47), such as a conceptual model or theory that guides research and practice, and as McCrae’s (2012) noted, “the legitimacy of any profession is built on its ability to generate and apply theory” (p. 222).

Finally, as Donaldson and Crowley (1978) so wisely told us,

A key point . . . is that the discipline should be governing clinical practice rather than being defined by it. Of necessity, clinical practice focuses on the individual in the here and now who has a problem requiring relevant and appropriate action. The discipline, in contrast, embodies a knowledge base relevant to all realms of professional practice and which links the past, present and future. Its scope goes far beyond that required for current clinical practice. If the discipline were so narrowly defined, professional nursing could be limited to functioning in the realm of disaster relief rather than serving as a force in the promotion of world health. (p. 118)

References

Bruce, A., Rietze, L., & Lim, A. (2014). Understanding philosophy in a nurse’s world: What, where, and why? Nursing and Health, 2(3), 65-71.

Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113–120.

Fawcett, J. (1984). The metaparadigm of nursing: Present status and future refinements. Image: The Journal of Nursing Scholarship, 16, 84 87.

Fawcett, J. (2018, September 24). Our name: Why nursology? Why .net? Retrieved from https://nursology.net/2018/09/24/our-name-why-nursology-why-net/

Fawcett, J. (2019, January 22). The impossibility of thinking “atheoretically.” Retrieved from https://nursology.net/2019/01/22/the-impossibility-of-thinking-atheoretically/

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

Kuhn, T. (1971). The structure of scientific revolutions. Chicago: University of Chicago Press.

McCrae, N. (2012). Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary healthcare. Journal of Advanced Nursing, 68, 222–229. doi: 10.1111/j.1365-2648.2011.05821.x

O’Leary, H. J. (1975). Changes in community nursing service that affect baccalaureate nursing programs. In Faculty-curriculum development, Part V. The changing role of the professional nurse: Implications for nursing education. New York, NY: National League for Nursing, Pub. No. 15-1574.

Parse, R. R. (1987). Nursing science: Major paradigms, theories, and critiques. Philadelphia, PA: Saunders.

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

Rovelli, C. (2018). Physics needs philosophy, philosophy needs physics, Foundations of Physics, 48, 481-491.

Thorne, S. (2014). Nursing as social justice: A case for emancipatory disciplinary theorizing. In P. N, Kagan, M. C. Smith, & P. L. Chinn (Eds.), Philosophies and practices of emancipatory nursing (pp.79-90). New York, NY: Routledge.

Torres, G., & Yura, H. (1975). The conceptual framework as part of the curriculum process. In Faculty-curriculum development Part III: Conceptual framework-Its meaning and function. New York, NY: National League for Nursing, Pub. No. 15-1558.

Moral ecology in nursing

by Darcy Copeland, RN, PhD*

Darcy Copeland

I have the good fortune to have two professional roles that compliment one another beautifully. As a hospital based nurse scientist I have focused my research on workforce issues including workplace violence, professional quality of life, moral distress, and the spiritual/emotional elements of providing care. I am a member of the ethics committee and participate in educational and consultation activities. I am also an associate professor of nursing and teach master’s, PhD and DNP level nursing theory courses. My days are literally sometimes spent filling the “theory-practice” gap on both sides of that gap.

One “gap”, maybe dissonance is more accurate, I notice is how messy ethical decision making is in practice compared to how clean it seems in academia. Nursing students spend time learning about the ANA Code of Ethics, written specifically to be both aspirational and normative. The nine provisions articulate values, duties, and ideals that are foundational to our discipline. Most students probably also learn principles of bioethics and research ethics and at least have a cursory understanding of these when entering clinical practice. Nursologists have debated whether or not we should develop our own ethical framework or adopt an existing framework. Personally, I oppose both of those ideas and would advocate for a pluralistic approach to addressing ethical issues in practice.

There is no debating that nurses are moral agents who must make decisions and be held accountable for their actions. Those decisions, however, occur in complex, dynamic (I’ll say messy) environments involving multiple stakeholders whose perspectives often conflict with one another. In the grand scheme of things nurses receive very little formal education related to ethics. In my experience, it is rare for a practicing nurse to justify an ethical decision by articulating anything from the code of ethics or principles of bioethics. The first thing I hear is most often something like, “it felt like the right thing to do.” This response alone would lead me to believe that the decision was based on the person’s individual moral awareness or personal value system. With more dialogue, however, it becomes clear that the nurse’s own moral compass is the starting point for ethical decision-making, not the end point. Nurses may justify their actions because it is what the patient wanted, because people have the right to make their own decisions, because it was the best way to use available resources, because it is wrong to with-hold information, because that is our policy, etc. Any and all of these are acceptable justifications to act in one way instead of another. Each of these justifications can be traced back to an ethical framework, but not the ethical framework of nursing.

It was from these experiences in teaching and applying ethics that I developed a model of moral ecology in nursing (see below). It is based on the social ecological model in which behavior is contextualized and understood as occurring within a web of complex social systems in which the individual is placed. It was developed from the perspective of American nursing, but could be modified to include the ICN code of ethics and eastern philosophy for example. I plan to use this model in my own teaching as a way to introduce students to the messiness of ethical decision making in practice.

An ecological model of ethics in nursing. © 2019 Darcy Copeland

 

Copeland, D. (in press). Moral ecology in nursing: A pluralistic approach. Sage Open Nursing DOI: 10.1177/2377960819833899

  • Darcy Copeland is an associate professor of nursing at the University of Northern Colorado and a nurse scientist at St Anthony Hospital in Lakewood, CO. She has undergraduate degrees in nursing and psychology from the University of Northern Colorado, a master’s degree in forensic nursing from Fitchburg State College in Massachusetts, a PhD in nursing from UCLA, and is pursuing a master’s degree in health humanities and ethics at the University of Colorado. Her clinical background is in mental health and forensic nursing; her research interests involve the psychosocial work environment including issues of workplace violence, moral distress, professional quality of life, and the spiritual effects of caregiving.