VISCERAL NURSOLOGY

Contributor: Ellen E. Swanson, MA, RN, BSN, PHN, HNB-BC (Retired)

Recently I had a professional practice story published in the American Holistic Nurses Association journal, “Beginnings”. Several responses to the story motivated me to think about the potential use of professional practice stories in nursing education. I shared with a local nursing professor and the magazine editor the possibility of using professional practice stories to have students identify what nursing theories and ways of knowing they saw in a given story.

This prompted a literature review on the topic of storytelling in nursing. I also recalled that I had a section about storytelling in my graduate position paper of 1998. One of the references for that paper was “To a Dancing God” by Sam Keen (1970; 1990). I reviewed his quote: “A visceral theology majors in the sense of touch rather than the sense of hearing.” (p. 159). I immediately said to myself that if there can be visceral theology, there can be visceral Nursology!

And what would visceral Nursology look like? Definitions of visceral include “proceeding from the instinctive, bodily, or deep abdominal place rather than intellectual motivation.” This brought to mind two concepts: the felt sense and aesthetic knowing.

I first explored the concept of the felt sense in 2007, and continued to read more about it over time. One way I came to understand the felt sense is as an immediate precursor to intuitive insights.

The following statements about ‘felt sense’ are taken from two books which I found quite helpful. The first book is Focusing (1979) by Eugene T. Gendlin. The second book is Waking the Tiger: Healing Trauma (1997) by Peter A. Levine. A more recent book, Your Body Knows the Answer: Using Your Felt Sense to Solve Problems, Effect Change & Liberate Creativity (2014) by David I. Rome teaches how to access the felt sense.

  1. The felt sense is a difficult concept to define with words, as language is a linear process and the felt sense is a non-linear experience. Consequently, dimensions of meaning are lost in the attempt to articulate this experience. (Levine p. 67)
  2. A felt sense is not a mental experience but a physical one. Physical. A bodily awareness of a situation or person or event. An internal aura that encompasses everything you feel and know about the given subject at a given time – encompasses it and communicates it to you all at once rather than detail by detail. (Gendlin p. 32)
  3. Perhaps the best way to describe the felt sense is to say that it is the experience of being in a living body that understands the nuances of its environment by way of its responses to that environment. (Levine p. 69)
  4. In many ways, the felt sense is like a stream moving through an ever-changing landscape…..once the setting has been interpreted and defined by the felt sense, we will blend into whatever conditions we find ourselves. This amazing sense encompasses both the content and climate of our internal and external environments. Like the stream, it shapes itself to fit those environments. (Levine p. 69-70)
  5. The felt sense can be influenced – even changed by our thoughts – yet it’s not a thought, it’s something we feel. (Levine p. 70)
  6. The felt sense is a medium through which we experience the fullness of sensation and knowledge about ourselves. (Levine p. 8)
  7. Nowadays the phrase, “trust your gut” is used commonly. The felt sense is the means through which you can learn to hear this instinctual voice. (Levine p. 72)
  8. The felt sense heightens our enjoyment of sensual experiences and can be a doorway to spiritual states. (Levine p. 72)
  9. One must go to that place where there are not words but only feeling. At first there may be nothing there until a felt sense forms. Then when it forms, it feels pregnant. The felt sense has in it a meaning you can feel, but usually it is not immediately open. Usually you will have to stay with a felt sense for some seconds until it opens. The forming, and then the opening of a felt sense, usually takes about thirty seconds, and it may take you three or four minutes, counting distractions, to give it the thirty seconds of attention it needs. When you look for a felt sense, you look in the place you know without words, in body-sensing. (Gendlin p. 86)

I was so relieved to see how I had practiced nursing for decades put into words. I couldn’t always explain how I knew the effective interventions that seemed to just ‘happen’. I didn’t feel free to explore this in the non-holistic based career roles the first 30 years of my career. My graduate work in the late 1990’s gave me freedom to explore more holistic ways of thinking and practicing, but still doing it all rather privately. Membership in the Minnesota Holistic Nurses Association also gave me colleagues with whom to share more holistically.

The next movement toward being more open about my practice came when I learned about Modeling and Role Modeling Theory in 2012, two years before my retirement! Perhaps if I had been more open to nursing theories earlier, I wouldn’t have felt like I needed to hide how I practiced all those years. Listening, presence, and putting myself in the shoes of the other were always three of my stronger interventions. To see a theory include this latter one was such a relief. And it was in studying Modeling and Role Modeling that I learned there were a variety of ways of knowing, and aesthetic knowing was one of them.

However, I did not understand aesthetic knowing as fully until the more recent Nursology posts. I experience sheer delight with this learning. I can finally acknowledge my way of practicing to my nursing community. Chinn & Kramer (2018 p. 142) define aesthetic knowing as “An intuitive sense that detects all that is going on and calls forth a response, and you act spontaneously to care for the person or family in the moment.” It involves sensations as opposed to intellectuality. Chinn & Kramer (2018) also say “Aesthetic knowing is what makes possible knowing what to do and how to be in the moment, instantly, without conscious deliberation.” In other words, I have to not only let my head get out of the way, but also not let my head talk me out of aesthetic knowing, in both my professional life and personal life.

And so it is for me, that aesthetic knowing is Visceral Nursology. I now have a theory, an organization, and a way of knowing that supports how I practice.

REFERENCES

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

Erickson, H.L. (Ed). (2006). Modeling and Role-Modeling: A View from the Client’s World. Unicorns Unlimited. Cedar Park, TX.

Gendlin, E. T. (1979). Focusing. (2nd ed.) Bantam Books. NY.

Keen, S. (1970, 1990). To a Dancing God: Notes of a Spiritual Traveler. Harper Collins. San Francisco.

Levine, P.A. with Frederick, A. (1997). Waking the Tiger: Healing Trauma. North Atlantic Books. Berkeley, CA.

Rome, D.I. (2014). Your Body Knows the Answer: Using Your Felt Sense to Solve Problems, Effect Change & Liberate Creativity. Shambhala. Boston & London.

About Ellen Swanson

Ellen Swanson

Ellen E. Swanson is retired from a 46 year nursing career that included ortho-rehab, mental health, OR, care management, consulting, and supervision. She also had a private practice in holistic nursing for 15 years, focusing on health and wellness teaching and counseling. She served on the leadership council for the Minnesota Holistic Nurses Association for ten years.
She enjoys writing that incorporates holistic concepts, whether through storytelling or her booklet about Alzheimer’s or her book about healing the hierarchy.

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.

Psychoneuroimmunology in Nursing

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

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

“Complexity” by Owen Hodgson (age 17)

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

What is PNI?

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

What are PNI Interventions?

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

PNI and Nursing Theory

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

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

Nursing Knowledge Development and the Future of PNI

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

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

References

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

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

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

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

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

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

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

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

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

About Christine Hodgson

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

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

Jacqueline Fawcett
Lisa Sundean
JoAnn Mulready-Shick

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

Contributors

Co-contributors with Nursology.net team member Jacqueline Fawcett

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

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

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

Contributor: Isabel Faia

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

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

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

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

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

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

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

About Isabel Faia

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

COVID-19 Through the Lens of Nursing Theories

Contributor: Navninder Kaur, MSN, CMSRN


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

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

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

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

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

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

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

About Navninder Kaur

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

Does Informed Consent Exist for Black Patients?

Contributor: Harriet Omondi MSN, APRN, FNP

Systemic racism and racial inequality are two concepts that are deeply ingrained in American history. These two issues come up in every single presidential election where candidates compete for the minority vote by promising reparations for black people and an end to systemic racism. Research has repeatedly revealed that minorities lag in the majority of health-related outcomes and this is often directly linked to racial inequity. In a recent blog post by Dr. Chinn titled, ‘Nursing and Racism: Are We Part of the Problem, Part of the Solution or Perhaps Both’, she eloquently addressed how we as nurses can be a part of the solution in ending racism. This can be achieved by educating ourselves on race relations, teaching our children by example by respecting people that may look different, and being empathetic to black people under our care. Patients trust nurses and easily share their fears and worries and nurses are often tasked with the burden of explaining procedures or give informed consent. Black people have been used in research studies over the years without consent or at times treated without full disclosure. How did this begin and how can nurses help resolve this problem?.

Source

The idea of informed consent began in the early 20th century and thus laid the foundation for the assertion of patient autonomy (Bazzano et al., 2021). Four landmark cases Mohr v Williams, Pratt v Davis, Rolater v Strain, and Schloendorff v Society of New York Hospital set a precedent for patient autonomy and formed the idea of the need for informed consent in medicine and research (Bazzano et al., 2021). In Mohr vs Williams, the patient had agreed to surgery on the right ear but during surgery, the surgeon decided that the left ear was worse off than the right ear and performed surgery on the left ear instead of the right ear (Bazzano et al., 2021, p. 80). The plaintiffs hearing thereafter worsened and she sued the surgeon for battery and assault for performing surgery on the left ear instead of the right as she had previously agreed (p. 82). Mrs. Mohr won the case as the court agreed that the surgeon was wrong for performing surgery on the left ear without her consent (p. 82). I have chosen to discuss informed consent because as much as research is important for the advancement of medicine and technology it is equally important to allow subjects to comprehend what they are signing up for and the potential risks or benefits of research. Participants need to also be aware that if they need to withdraw from a research study they can do so freely without fear of retaliation.

The issue of informed consent is a touchy subject when it comes to minorities especially the black population. This stems from the notion that historically blacks were seen as property and therefore the master did not need permission to do with them as they please. It is well documented that Dr.Marion Sims who is seen as “the father of gynecology” for pioneering successful gynecological surgeries, performed experiments on powerless black slaves without consent. The Tuskegee experiment is another well-known example of racial injustice where young black men some of whom were infected with syphilis were recruited for a research study on syphilis. Informed consent was not obtained for this study and when Penicillin became available to treat the disease the men were not treated. In addition, the men in the study were initially told the study would last six months but it went on for 40 long years where these men suffered the debilitating effects of syphilis without treatment. Fast forward to the 21st century while advances have been made in terms of how black people are treated more is yet to be done.

Working as a primary care nurse practitioner I have encountered countless black patients who distrust the medical system so much so that they would rather forgo medical treatment and seek alternative therapies. This distrust is deeply rooted in medical apartheid that they have witnessed or experienced over the years and it is up to us as nurses and frontline health care workers to empower these patients and provide culturally competent care to ease their doubt. Due to a lack of trust in the healthcare system rooted in racist practices, the black community continues to lag in nearly all aspects of healthcare. This issue has been at the forefront in the past year where we have seen black communities fair much worse on Covid-19 related outcomes, in addition, the vaccination rate among the black community is far less compared to the other races. When I ask my black patients why the hesitancy, the most common answer is, “can’t trust what they’re putting in my body”. One recent example that comes to mind is one of my black female patients was recently diagnosed with breast cancer and advised by her oncologists that she needed radiation after chemotherapy to eradicate cancer. The patient told the oncology team that she did not want radiation because she had a near-death experience during chemotherapy and did not want any more treatment. The oncologist kept pressing the idea of radiation on the patient and per the patient, a “black nurse was brought in to convince me to get radiation.” Ultimately the patient vehemently declined and radiation was not done. This is a classic example of how black patient`s requests are mostly ignored or dismissed with the assumption that they do not know any better.

Therefore, as nurses, we must take into account the complicated history of black people with medicine while providing care. We have to be empathetic to the needs of our black patients keeping in mind that they may have fear of not only the physical ailment but of the providers and the healthcare system as a whole and may need a safer environment. Jean Watson who is one of my favorite theorists once said. “Maybe this one moment, with this one person, is the very reason we’re here on earth at this time.” If we approach each patient with this in mind you never know if you might be the one person who changes their view on the distrust of the medical establishment.

References

Bazzano, L. A., Durant, J., & Brantley, P. (2021). A modern history of informed consent and the role of key information. Ochsner Journal, 21(1), 81–85. https://doi.org/10.31486/toj.19.0105

About Harriet Omondi

I have been a nurse practitioner for the past seven years, I graduated from Texas Woman`s University in 2014 and immediately started working in a Federally Qualified Health Center (FQHC) where I oversaw a clinic for patients with a dual diagnosis of mental health. When I started at the FQHC the clinic was new and only had five patients and after a year I had a panel of 100 new patients. Currently, I work for UT Health in Houston and care for patients in a primary care clinic. Prior to that, I worked as a nurse for six years with adult medical-surgical patients, pediatrics, and home- health caring for medically fragile children. In the Fall of 2020, I took the bold step of enrolling at Texas Woman`s University to pursue a doctorate in nursing where I have completed two semesters. My primary areas of research interest are obesity, women’s health, and preventative medicine with an emphasis on health promotion.

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Culture Shock, Grief and Nursing Theories

Contributor: Aisha Chahal, MSN, CMSRN

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

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

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

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

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

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

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

About Aisha Chahal

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

Guest Post: Aesthetic Knowing 101

Contributor: Peg Hickey, MSN, RN

For three years, I have been an adjunct clinical instructor. And thanks to a recent course on nursing theory, I have been able to closely examine my own understanding of nursing knowledge and my commitment to the nursing profession. The most extraordinary part about teaching is having the opportunity to impart this knowledge to the future generation of nurses. Students’ primary goal is to focus on the empirical aspects of nursing; however, my unwritten objective for the students is to define nursing by their connection to the human spirit. As an educator, this involves integrating learning experiences related to the patterns of knowing (Chinn & Kramer, 2018).

Day 1

One-by-one, I greeted my six students as they arrived in the lobby on their very first day of their clinical rotation for Fundamentals of Nursing. Their nerves were palpable: they didn’t speak to me or each other and nobody smiled (yes, I have learned to recognize a masked grin by observing the eyes and foreheads). I have never been accused of being a threatening presence in any way, shape, or form, yet the students stood before me with fear in their eyes. (Flashback to my own experiences in nursing school from the early ‘90’s). I was able to discern the truth of this moment and acknowledge the impact of feelings on their very first clinical experience. My aesthetic knowing of being able to recognize a deeper meaning to their human experiences of anxiety and fear laid the foundation for an enriching nursing experience for all of us. I was helping to build the future of nursing (Nursology.net, 2021).

Commitment

First experiences are memorable for students. Some may consider their initial attempts at nursing to be insignificant and only equate success with tasks: starting an IV, changing a wound dressing, or administering medication. Of course, on our first day we didn’t perform any of those tasks, but one student did display an intangible act of commitment: she followed through with a patient’s request for tissues. Keep in mind, this was her first clinical exposure; we were only minutes on the unit in and in the midst of a tour. Yet during those moments, this student spoke to a patient, asked a staff member where the tissues were, located them, and carried them with her until the tour ended, when she brought the tissues to the patient. At face value, simplicity. Yet it was important for her to know that she performed critical acts of nursing in this seemingly simple task: communication, commitment, and caring. Baillie (2007) reminds us of Henderson’s definition of commitment: Nurses who “responded to patients’ needs in a timely manner were perceived as caring; patients were dissatisfied when nurses apparently forgot patients and their needs” (p.6). I complimented my student, and her smile was beaming beneath her mask.

Compassion

The following week, my students were assigned to obtain a patient history, a conventional start to the development of communication and interpersonal skills. During post-conference, one student reported that she was unable to complete the assignment; instead, she had connected with a young woman with a terminal disease who requested a foot rub. She decided to fulfill the wishes of the patient and put off asking about her medical history, demonstrating an appropriate and meaningful prioritization of care. The lesson in post-conference focused not on an incomplete assignment, but on the ability of nurses to recognize significant and meaningful moments and to take action (Chinn & Kramer, 2018). This student completed a patient history the following week and that was OK with me.

Caring

During an attempt at a physical assessment, my student and I encountered a Mandarin-speaking patient who was visibly distressed. While using an audiovisual interpreter, our patient kept repeating a phone number over and over and over. The interpreter told us “she wants to call her husband.” Recognizing that nothing else mattered to this patient at that moment, we stopped our assessment, dialed the number, and the patient spoke to her husband. Following their conversation, she was smiling, grabbing to hold our hands, and visibly relieved that we understood. This encounter allowed us to distinguish between the science and art of nursing and to feel how the experience of being understood is both inspiring for the patient and gratifying for the nurse.

What better way to introduce the aesthetic pattern of knowing by calling it out in the clinical setting and defining what it is: “An intuitive sense that detects all that is going on and calls forth a response, and you act spontaneously to care for the person or family in the moment” (Chinn & Kramer, 2018, p. 142). Another idea for incorporating the meta-paradigms in nursing education is to change the course titles “Fundamentals” and “Foundations” to “Aesthetic Knowing in Nursing” so beginning students feel empowered by authentic nursing actions of communication, commitment, and caring behaviors.

The first introduction to a clinical experience lays a crucial foundation for nursing students. My hope is to impart a meaningful impression about the interpersonal nature of nursing; one they will be reminded of when they miss that first IV or administer a medication late. My students are off to a great start and I hope they know that every week when our clinical day ends, I am smiling beneath my mask.

References

Bailie, L. (2007). An exploration of the 6Cs as a set of values for nursing practice. British Journal of Nursing, 26(10), 558–563. https://doi.org/10.12968/bjon.2017.26.10.558

Chinn, P. L., & Kramer, M. K. (2018). Knowledge development in nursing: Theory and process (10th ed.). Elsevier.

Henderson, A., Van Eps, M. A., Pearson, K., James, C., Henderson, P., & Osborne, Y. (2007). “Caring for” behaviours that indicate to patients that nurses “care about” them. Journal of Advanced Nursing, 60(2), 146–153. https://doi-org.ezproxy.cul.columbia.edu/10.1111/j.1365-2648.2007.04382.x

About Peg Hickey

Peg lives in Queens, NY and has been a nurse since 1993. She is currently a nurse educator at Columbia University Medical Center working on a program designated to incorporate diabetes-related simulation into the curriculum for medical and nursing students. Peg is also an adjunct instructor at Hunter-Bellevue and Pace University Schools of Nursing.

It’s Time We Raise Nursologists!

Report from the 2021 Virtual Nursing Theory Week

Contributors:
Christina Nyirati
Sharon Stout-Shaffer

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

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

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

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

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

About the contributors:

Christina Nyirati, RN, PhD

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

Sharon Stout-Shaffer, PhD, RN

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

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

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