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

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

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

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

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

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

Minako Kakimoto

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

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

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

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

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

Yayoi Kajiwara

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

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

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

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

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

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

Yoshie Kamiya

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

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

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

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

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

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

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

Guest Post – Nursing’s call to action to address the social determinants of health

Guest contributors:
Kelli DePriest, PhD, RN
Paul Kuehnert, DNP, RN, FAAN 
Teddie Potter, PhD, RN, FAAN

Recently, several Expert Panels of the American Academy of Nursing collaborated to draft a new conceptual framework and consensus statement related to social determinants of health. The year-long endeavor integrated the thoughts and expertise of 15 nursing leaders. The outcome of our work directs nursing actions toward health policies supporting actions at multiple levels (i.e., upstream, midstream, and downstream) to promote equity in planetary health-related quality of life. We propose that planetary health-related quality of life, individual and population factors, and environments are the overarching societal contexts in which population health concerns arise. These population health concerns are articulated by stakeholders who, in turn, are the catalyst for population-focused nursing actions.

These population-focused nursing actions occur at multiple levels, in a variety of settings with a variety of persons and groups, and shape health policies, systems and services. Over time, the actions and interactions depicted by the cycle change the societal contexts and may lead to enhanced planetary health-related quality of life. We underscore the crucial need to eliminate systemic and structural racism if equity in planetary health-related quality of life is to be attained. We presented our findings and implications for action during a policy dialogue at the American Academy of Nursing Policy Conference in October 2020. Collaboration on this project inspired the following call-to-action.

Call to Action

Nurses are consistently ranked the most trusted profession by the American people. This trust is earned by the demonstration of care for people, day in and day out, in a wide variety of settings. It is time for all nurses do something to address the social determinants of health. We propose three concrete approaches.

The first two approaches can be summarized as praxis. According to Paulo Freire in Pedagogy of the Oppressed (1972), praxis is reflection and action on the world  to transform it.  

Reflection, the first approach, is often overlooked in calls for action. Yet we need to take a moment to reflect on what we mean by social determinants of health and what nursing actions in this space will help us achieve health equity. The consensus makes clear that equity cannot be achieved at any level (local, national, or global) until all forms of structural racism are eliminated. Eliminating structural racism should be a shared goal for all nurses.

We have work to do around structural racism in nursing. Nursologists are starting this type of reflection and discussion through nursology.net. (see https://nursology.net/about/nursology-management-team-statement-on-racism/). These conversations need to occur wherever we live and work, in the classroom, in the community, on social media, and with colleagues inside and outside of nursing. The consensus paper can be used to spark reflection and prompt discussions to support action.

Take action on social determinants to create transformative change is the second recommended approach. Action differs depending on our role. The consensus paper draws on the conceptual framework to provide several examples of population-focused nursologists’ actions to address policy issues. The common themes from the examples are that nursologists need to have a seat at the table when all policies are developed, using a Health in All Policies approach, which  includes policymaking across sectors, not only  those policies directly related to health, and nursologists need to advocate for policies that have been shown to effectively advance health equity.

Black, Indigenous, and Hispanic people in this country are experiencing disproportionately high rates of illness and death from the COVID-19 pandemic. To address this syndemic (Poteat, Millett, Nelson, & Beyrer, 2020), we need to address the structural racism at the root cause of these disparities. Who better to forge the path forward, than this group of nursology  leaders? It is time to move to action.

Inspire action on the environment and social determinants of health is the third approach. Another population-focused nursologists’ action from the conceptual framework posits that nursologists must build coalitions to be successful in this work. Others need to be inspired to join the effort. If nursologists are unsure of how to inspire, or lack inspiration themselves, they can read a few blog posts on nursology.net or nursesdrawdown.org for examples. Nursologists can also go to #nursetwitter where there are conversations about nursologists addressing the social determinants of health along with reflection and discussion on how to dismantle structural racism within nursology. Nursologists  can also be inspired by leaders who advocate for nursology by serving on boards, writing op-eds, acting as expert sources for the media, reaching out to legislators, and/or running for office themselves. Inspiration comes in many forms. There is an energy and passion required to do this work and if you have the capacity, please help inspire others to join the movement.

We leave you with the call-to-action to reflect, act, and inspire. We look forward to continuing this conversation.

References

Freire, P. (1972). Pedagogy of the oppressed. Herder and Herder.

Poteat, T., Millett, G. A., Nelson, L. E., & Beyrer, C. (2020). Understanding COVID-19 risks and vulnerabilities among black communities in America: the lethal force of syndemics. Annals of Epidemiology47, 1–3. https://doi.org/10.1016/j.annepidem.2020.05.004

About the contributors;

The authors are writing as nursology colleagues who have worked together through the Environmental and Public Health Expert Panel at the American Academy of Nursing (AAN). Paul and Teddie are the past and current chair of the expert panel and fellows of AAN and Kelli worked with the expert panel through the AAN Jonas Policy Scholars Fellowship program.

Kelli DePriest, PhD, RN

Dr. DePriest is a health policy and research fellow at the Institute for Medicaid Innovation and adjunct faculty at the Johns Hopkins University School of Nursing. Her research mission is to investigate strategies to leverage innovation in the Medicaid program to improve and/or inform the development of interventions and policies designed to achieve health equity for children and families living in poverty. Twitter: @kellidepriest

Paul Kuehnert, DNP, RN, FAAN

Dr. Paul Kuehnert is President and CEO of the Public Health Accreditation Board, the national non-profit organization that sets standards for and accredits governmental public health departments in the United States. Dr. Kuehnert’s career spans nearly 30 years of providing executive leadership to private and governmental organizations to build and improve systems to address complex community health needs. Dr. Kuehnert is a pediatric nurse practitioner and holds the Doctor of Nursing Practice in executive leadership as well as the Master of Science in public health nursing degrees from University of Illinois at Chicago. He was named a Robert Wood Johnson Foundation Executive Nurse Fellow in 2004, a Fellow in the National Academies of Practice in 2010, and a Fellow in the American Academy of Nursing in 2015. Twitter: @PaulKuehnert

Teddie Potter PhD, RN, FAAN

Saintelmophotography.com

Dr. Potter is Clinical Professor, specialty coordinator of the Doctor of Nursing Practice in Health Innovation and Leadership, and Director of Planetary Health for the University of Minnesota School of Nursing.

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

Contributor (with Jacqueline Fawcett): Katherine Richman

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

Primary Nursology

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

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

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

A Reflection on Primary “Nursology”

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

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

The Attending Nursologist

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

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

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

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

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

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

Dr. Dee explained,

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

About contributor Katherine Richman

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

Guest post: “Let’s talk theory”; Perspectives from the Associate Degree Nursing World

Contributors:
Emma Crocker, DNP, RN
Patrick McMurray, BSN, RN
Shelley Mitchell, BA, BSN, MS, RN
Elizabeth Mizerek, MSN, RN, FN-CSA, CEN, CPEN,
CNE, FAEN, PhD Candidate
Timothy Joseph Sowicz, Ph.D., NP-C

Authors’ Disclosure:
The authors would like to note that all members
put in equal amounts of work in this project. 


Nursing theory is the foundation of our practice, the way we differentiate nursing from other professions and disciplines. As readers of the Nursology blog, we assume that we do not need to discuss why nursing theory is essential to our practice. We would instead like to call your attention to a concerning trend – the lack of nursing theory in associate degree nursing programs. Please note that we are making generalizations based on our experience of graduating from and/or working in associate degree programs. There is a paucity of current research surrounding theory in associate degree programs.

According to the National Council of State Boards of Nursing (NCSBN), in 2019 50% licensure applicants were graduates from ADN and diploma schools of nursing; this number has historically been even higher. In other words, half of our newly practicing nurses may not have foundational knowledge of nursing theory to apply to their practice, further widening the theory practice gap. If theory content is not being integrated into the initial nursing education for half of our profession, how can we convince them it is important, let alone essential to their praxis? 

 We suspect that several factors contribute to the lack of theory in some ADN programs. Many nursing education programs are externally accredited by agencies such as the Accreditation Commission on Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE). Previous accreditation standards required nursing education programs to explicitly name the nursing theorists that guide the curriculum. This emphasis has been removed from current standards, allowing nursing education programs to use general educational theorists such as Knowles Adult Learning Theory.

 Another critical point is that ADN programs do not usually require doctoral-level preparation for nurse faculty. According to the 2018-2019 National League of Nursing’s annual survey of nursing schools, 74% of schools replied that it was “somewhat difficult” or “challenging” to hire new faculty. The primary reasons cited were an inability to offer competitive salaries and a lack of qualified candidates. ADN programs usually have fewer financial resources and do not have research missions. Therefore, they have difficulty attracting and retaining faculty with research-focused doctorates and higher educational credentials. This may result in ADN faculty who do not have the knowledge and/or experience with integrating theory into pre-licensure education.

Without the requirements of accreditation and with faculty who are not supported and enabled to the inclusion of nursing theory, it is our anecdotal observation that many ADN programs have dropped the emphasis on nursing theory. We have personally worked in nursing education programs where theory is either given cursory attention or not included in the curriculum at all. This has resulted in removing or deemphasizing nursing theory from a large portion of the nursing professional population.

 Nursing theory is currently situated in a place where it feels like it only belongs to some nurses, those embedded in academia or research, never practice. This has created a culture where most nurses and students cringe at the thought of theory-based content, with some complaining it has very little to do with “real-world” nursing practice. Nursing theory has not been made relevant to the modern nurse.

 Many nurse scholars might use this conversation as yet another reason why the entry level of nursing practice should be raised. Students seeking nursing education in the U.S. encounter many barriers, such as socioeconomic status, geography, structural racism, and more. Many of these students choose to attend ADN programs rather than seek a BSN, especially as their entry to practice. If we want to continue to grow the practice of nursing in the US, we need to support and encourage ADN programs, especially in the integration of nursing theory in practice.

The authors of this blog post greatly value the contributions of ADN programs, ADN graduates, and ADN educators. We would like to challenge all educators, scholars, and researchers to consider how we might restore nursing theory to its rightful place in all levels of nursing education. Nursing theory belongs to all nurses – not just those in higher education. 

Nursologists, what do you think?

About the contributors:

Emma Crocker

Emma Crocker, DNP, RN – CHIPS Health and Wellness Center, St, Louis, Missouri. Emma is a equity driven, population health quality improvement doctorate and advocate, devoted to ensuring the implementation of constituent-centered health policies, enabling communities to thrive located in St. Louis, Missouri. Twitter: @EmmaCrockerDNP.

Patrick McMurray

Patrick McMurray, BSN, RN – Adjunct nursing faculty, Robeson Community College, Lumberton, North Carolina. Patrick is a Adjunct Nursing Faculty at Robeson Community College, in N.C. Patrick is patient about community college nursing education and championing social change via equitable access to nursing education. Twitter: @nursePatMacRN.

Shelley Mitchell

Shelley Mitchell, BA, BSN, MS, RN – Professor of Nursing, Austin Community College, Austin, Texas. Shelley contains multitudes. She teaches full-time in Austin Community College’s Professional Nursing Program, which has been voted as the best in the region for three years in a row, and she is deeply involved in the college’s equity and inclusion work. She has a BA in English from Oberlin College in addition to her nursing education, and she reads comics and writes queer romance in her spare time. Twitter: @ProfShelleyRN

Elizabeth Mizerek

Elizabeth Mizerek, MSN, RN, FN-CSA, CEN, CPEN, CNE, FAEN, PhD Candidate – Director of Nursing Education, Mercer County Community College, West Windsor, New Jersey.  Elizabeth is the Director of Nursing Education at Mercer County Community College in New Jersey. She is currently a PhD candidate at Widener University in Chester, Pennsylvania pursuing a doctoral degree in Nursing Science. Her research interests include nursing education, patient safety, and emergency preparedness.

Tim Sowicz

Timothy Joseph Sowicz, Ph.D., NP-C – Assistant Professor, UNC Greensboro, Greensboro, NC. Tim is an assistant professor at UNC Greensboro. His research is concerned with aspects of living with heroin and opioid use disorders, especially following an overdose.

Guest post: The Role of Nurses and Women’s Health Advocates in Advancing a Social Justice Agenda in the Current Climate: The Case of Wisconsin

Contributors (see bios below)
Lucy Mkandawire-Valhmu, PhD, RN; Jeneile Luebke, PhD, RN;
Carolyn Eichner, PhD; Kaboni Gondwe, PhD, RN;
Diane Schadewald, DNP, RN; Peninnah Kako, PhD, RN;
Jacqueline Callari-Robinson, BSN, RN; Brittany Ochoa-Nordstrum;
Nicole Weiss; Jacqueline Campbell, PhD, RN, FAAN

As nursing professionals and women’s health advocates, we have watched in disbelief events unfolding in Barron County, Wisconsin. Embrace, a shelter serving survivors of sexual assault and domestic violence in Barron County, is facing backlash for displaying a Black Lives Matter (BLM) sign. Reacting to the sign, local officials stripped the organization of funding worth $25,000 and law enforcement are unwilling to continue collaborating with Embrace.

Source

Embrace, located in Northern Wisconsin, serves a predominantly White populace, but also has a significant population of migrant farmworkers and Somali refugees. Migrant farmworker women face difficulties in accessing help following an experience of violence due to transportation and language barriers. Many refugee women also often have a history of sexual violence and trauma. Black women make up less than 2% of the population in Baron County yet constitute 10% of the population accessing help at Embrace’s shelter. Part of the St. Croix Chippewa tribe is also located in Embrace’s service area. Black women and American Indian (AI) women are disproportionately impacted by violence, but do not ordinarily seek help despite the potential for severe negative impacts such as injury or even loss of life.

The National Intimate Partner and Sexual Violence Survey (NISVS) report shows that 84.3% of AI women have experienced lifetime violence (Rosay, 2016). The NISVS shows 41% of Black women have experienced physical IPV in their lifetime with homicide being one of the leading causes of death for women aged 44 and younger. It is in this context that Embrace seeks to serve the most vulnerable populations of women in a four-county area where they are the only available domestic violence shelter.

 We are in unprecedented times with an ongoing COVID-19 pandemic that not only disproportionately affects the lives of Black and Brown women and their communities, but also increases their risk of violence and homicide. A recent US study showed a surge in the incidence of severe intimate partner violence (IPV) during the Covid-19 pandemic compared to the previous 3 years, and a decrease in the number of people seeking hospital care (Gosangi et al., 2020). It is important to be clear that this supports the idea that the stressors of Covid-19 including the economic fallout may exacerbate existing IPV but probably does not start IPV that has not existed before.  Consistent with what has been seen in some other countries, IPV and sexual assault advocates across the state began to report an increase in self and police referrals to their agencies after the pandemic began (Luthern, 2020).

Domestic violence related homicides have been on the increase in Wisconsin even before the pandemic.  According to End Abuse Wisconsin’s Domestic Violence Homicide Report (2020), there were 47 domestic violence related homicide deaths in 2018, and 72 in 2019.  And frighteningly, as of September 29, 2020, domestic violence homicide has taken 69 Wisconsin lives this year.   If that pattern continues, it is estimated that 93 lives will be lost this year. Also concerning is that 22% of the victims, so far in 2020, were age 18 or under. 

Black communities in urban metropolitan areas like Milwaukee are disproportionately impacted by violence in general while also experiencing tensions with law enforcement. Recent acts of police brutality captured on video and circulated widely on social media have implications for community relations with law enforcement. The fear that community members have about police officers potentially using excessive and unjustified force in the policing of Black bodies (Frazer, Mitchell, Nesbitt, et al., 2018) can impact women’s help-seeking following an experience of violence. Black women may want to call the police if they feel like they are in danger from their partner’s abuse but they do not want that partner to be harmed and they usually do not want him to go to jail.  They, like most abused women, just want the violence to stop.  At the same time, there needs to be a non-racist police response available to abused women who are in fear for their and their children’s lives.  There needs to be carefully informed triage (a concept well known to nursing) for 911 calls for IPV so that police are not brought in when not needed but can be brought to homes where there is a high risk for homicide.  

Our state has also been the site of civil unrest in the past few months. In Kenosha, the police shooting of Jacob Blake in August resulted in protests requiring the declaration of a state of emergency. Clashes have also ensued between law enforcement and community members in Wauwatosa in the last few weeks as a result of protests for the February, 2020 shooting and killing of Alvin Cole by a police officer. Apart from these incidents that have created not only unrest but also continued mistrust between Black and Brown communities and law enforcement, there have also been concerns about the prevalence of the trafficking and sexual violation of young Black and Brown women. In Kenosha, Chrystul Kizer, a 19-year-old African American woman, was released this year after being charged for killing a man who sexually abused her as a child in what her defense team argued was self-defense (Fortin, 2020).  Her defense team spoke of how the criminal justice system fails to protect Black and Brown women and girls and yet also holds them disproportionately ‘accountable’ for crimes that would not be charged in cases of White women and girls. This is eloquently detailed by Beth Richie in Arrested Justice

Within the past few months, Wisconsin has had a number of Indigenous women murdered and missing.  Kozee Medicinetop Decorah (Ho-Chunk Nation) was found deceased on May 16, 2020, a victim of domestic violence related homicide (Volpenheln, 2020).  Stephanie Greenspon was found deceased on August 19, 2020. It is suspected that she was also a victim of violence related homicide. Her case is still being investigated by the FBI (Menominee Nation, 2020).  Kaitlyn Kelly has been missing since June 17th (Conklin, 2020). There has been little mention of the missing and murdered Indigenous women in local or national media, particularly taking into account the extent of national and even global media attention drawn to the missing of Jamie Closs;  Closs went missing in the area where Embrace is located, but she was eventually located.

Given all this, dialogue from law enforcement and local officials indicating willingness and commitment to community safety and wellbeing would be helpful. Instead, the response of law enforcement to Embrace’s display of a Black Lives Matter sign intensifies tensions and mistrust between the police and the communities they serve. It also seriously undermines the vital work of the only shelter in a four-county area, further endangering the most vulnerable populations Embrace serves.

 Employing relevant theories to our practice as nurses and liaising with our colleagues across disciplines has now become urgent. Together with colleagues across disciplines, nurses need to support and advocate for survivors of violence. Screening and identification of resources for women is of utmost importance, and shelters like Embrace both ensure the provision of shelter and connect women with urgently needed health and social services. As nurse scholars, we wrote this blog post in collaboration with our colleagues at Women’s and Gender Studies at University of Wisconsin-Milwaukee as part of building coalitions. But we also did so for the purposes of deepening our understanding of the urgent healthcare challenges experienced by the most vulnerable across our state, in the context of the rising tensions and mistrust among various institutions and agencies that exist to enhance the health, wellbeing and safety of all Wisconsin communities.

Violence is central and even essential to the sustaining of social hierarchies that inform the oppression of some groups while enhancing the privilege of others (Collins, 2017). Patricia Hill Collins (2017) points out how without human agency and resistance, institutions can engage in bureaucracies that replicate power dynamics, and even perpetuate normalized violence that maintains dominance and inequities. Law enforcement is one institution, and healthcare, of which nurses are a part, is another.

Robin Walter’s theory of Emancipatory Nursing Praxis comes to mind as one that guides us towards allyship in advancing a social justice agenda in pursuit of health equity, which is central to ensuring the health and wellbeing of the most marginalized in our communities during this time. In order to advance a social justice agenda, there is need for nursing as a profession to partner closely with domestic violence advocates and shelters like Embrace as well as law enforcement officers, who play an important role in enhancing the safety and wellbeing of our communities. We must engage in research and dialogue that would help us reimagine a criminal justice response that acknowledges the context of racism in which Black and Brown women experience violence.

As professionals, we need to respond and to meet their urgent needs for health and safety. It has never been more urgent to engage in the learning processes that Walter outlines, critically reflecting on our social location in relation to those we serve, shifting our worldview and experiencing transformation by expanding our consciousness (Walter, 2017).

References

Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, … & Laughon, K. (2003). Risk factors for femicide in abusive relationships: results from a multisite case control study. American journal of public health, 93(7), 1089–1097. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447915/

Collins, P. H. (2017). On violence, intersectionality and transversal politics. Ethnic and Racial Studies, 40(9), 1460-1473. https://www.fbi.gov/news/stories/operation-cross-country/operation-cross-country

Conklin, M. (July 28, 2020). Searching for Katelyn Kelley: The 22-year-old Menominee woman is part of a crisis of missing Indigenous people that Wisconsin is just beginning to confront. Wisconsin Examiner.  https://wisconsinexaminer.com/2020/07/28/searching-for-katelyn-kelley/

Fortini, J.  (June 23, 2020). Chrystul Kizer, teen charged with killing abuser, is released on bond. The New York Times. https://www.nytimes.com/2020/06/23/us/chrystul-kizer-free-bond.html

Frazer, Eva et al. “The Violence Epidemic in the African American Community: A Call by the National Medical Association for Comprehensive Reform.” Journal of the National Medical Association vol. 110,1 (2018): 4-15. doi:10.1016/j.jnma.2017.08.009 https://pubmed.ncbi.nlm.nih.gov/29510842/

Gosangi B., Park H., Thomas R., Gujrathi R., Bay C. P., Raja A. S., …  Khurana, B. (2020). Exacerbation of Physical Intimate Partner Violence during COVID-19 Lockdown. Radiology, 202866, Epub ahead of print. https://pubs.rsna.org/doi/10.1148/radiol.2020202866

Luthern, A. (May 18, 2020). Milwaukee is seeing a spike in homicides, and nearly half of them are related to domestic or family violence. Milwaukee Journal Sentinel. https://www.jsonline.com/story/news/crime/2020/05/18/milwaukee-homicides-nearly-half-linked-domestic-family-violence/3121220001/

Menominee Nation (October 22, 2020).  Press Release: Vehicle Arson and Discovery of Human Remains on Menominee Indian Reservation. Menominee Indian Tribal Newshttps://www.menominee-nsn.gov/NewsPages/NewsItem.aspx?NewsID=Vehicle%20Arson%20and%20Discovery%20of%20Human%20Remains%20on|10/22/2020

Richie, B. (2012).  Arrested Justice: Black women, violence and the America’s prison nation. NY: NYU Press.

Rosay, A. (2016). Violence Against American Indian and Alaska Native Women and Men. NIJ Journal, 277, 38-45.  Retrieved from:  http://nij.gov/journals/277/pages/violence-against-indians-alaska-natives.aspx

U.S. Department of Health and Human Services, Health Resources and Services Administration, & National Center for Health Workforce Analysis (2017). Sex, Race, and Ethnic Diversity of U.S, Health Occupations (2011-2015), Rockville, Maryland.

Volpenheln, S. (June 29, 2020).  Wisconsin family calls for harsher charges in ‘heinous’ killing of Ho-Chunk woman.  Milwaukee Journal Sentinel. https://www.jsonline.com/story/news/2020/06/29/wisconsin-family-calls-harsher-charges-homicide-ho-chunk-woman/3239543001/

Walter, R. (2017). Emancipatory nursing praxis. A theory of social justice in nursing. Advances in Nursing Science, 40(3), 225-243. Also see Walter’s Theory on Nursology.net

Acknowledgement:

We are grateful for the support and input of the following colleagues from Women’s and Gender Studies: Anna Mansson McGinty, PhD, Xin Huang, PhD, Kristin Pitt, PhD, Gwynne Kennedy, PhD, Melinda Brennan, PhD, & Jeremiah Favarah, PhD

About the contributors

Lucy Mkandawire-Valhmu, PhD, RN is Associate Professor in the College of Nursing at University of Wisconsin-Milwaukee (UWM). Her research focuses on violence in the lives of Black and American Indian women. As a feminist scholar, she seeks to creatively identify interdisciplinary interventions and to inform policy that centers the voices of women in addressing gender-based violence. Dr. Mkandawire-Valhmu also seeks to contribute to the development of feminist theory that would help to advance nursing science.

Jeneile Luebke, PhD, RN is a post-doctoral nurse research associate at University of Wisconsin-Madison. She in an enrolled member of Bad River Band of Lake Superior Chippewa Indians. She received her early nursing degrees (LPN and ADN) in Bemidji, MN, and her BS and MS Nursing from the University of Wisconsin- Madison, and her PhD at UW-Milwaukee. Her area of research and expertise include intimate partner violence in the lives of American Indian women, community health nursing and utilization and application of postcolonial and indigenous feminist methodologies. She is a survivor of intimate partner violence and is passionate about sharing her knowledge and personal experiences to help to support and empower other women to transition to survivorhood.

Carolyn J. Eichner is Associate Professor of History and Women’s & Gender Studies at the University of Wisconsin, Milwaukee. She was a Member at the Institute for Advanced Study in Princeton, New Jersey, in 2015-2016. Eichner is the author of Surmounting the Barricades: Women in the Paris Commune (Indiana University Press); published in French as Franchir les barricades: les femmes dans la Commune de Paris (Editions de la Sorbonne). She has two forthcoming books: Feminism’s Empire, which traces the roots of nineteenth-century French anti-imperialism in the race, gender, and class politics of the era’s first French feminists to engage with empire; and A Brief History of the Paris Commune for the 2021 sesquicentennial of the 1871 revolution (Rutgers University Press). Eichner he is currently writing The Name: Legitimacy, Identity, and Gendered Citizenship. She has published in journals including Feminist Studies, Signs: Journal of Women in Culture & Society, French Historical Studies, and Journal of Women’s History

Kaboni Gondwe, PhD, RN is an assistant professor at University of Wisconsin-Milwaukee College of Nursing. Her research interests are on maternal and child health and she is focused on studying effects on how chronic life stressors moderates the effects of perinatal stress on preterm biomarkers in African American /Black mothers and Malawian Black mothers. She completed her PhD in Nursing from Duke University in 2018 where her research focused on relationship between preterm birth with postpartum stress and mother-infant relationship. She received her undergraduate degree and midwifery training from University of Malawi, Kamuzu College of Nursing and her Master in Nursing Education and Nursing Administration from Ohio University. 

Diane Schadewald, DNP, MSN, RNC, WHNP-BC, FNP-BC joined the faculty of the University of Wisconsin-Milwaukee, College of Nursing in 2013 and is currently a Clinical Professor. I have been certified as a Family Nurse Practitioner and a Women’s Health Nurse Practitioner since 1993. As a board-certified Women’s Health Nurse Practitioner, I have experience providing care for Black women as well as AI women who are at risk for or who have experienced IPV. Since working in academia, I have practiced in primary care and am currently working for an online nurse practitioner service. Prior to working in academia, I practiced in an OB/GYN clinic setting. I’m a co-author of Women’s Health: A Primary Care Clinical Guide which is in its 5th edition. I have also lectured on care of women who have experienced female genital cutting and IPV. I’m currently working on an educational research project about female genital cutting.

Peninnah Kako, PhD, RN, FNP-BC, APNP is an Associate Professor at the University of Wisconsin-Milwaukee (UWM) College of Nursing. Dr. Kako’s research focus includes improving health care access for underserved populations, issues affecting women living with HIV in sub-Saharan Africa. Her research also focuses on violence in the lives of women. Her research aims to contribute to efforts that meet primary and secondary HIV prevention needs in sub-Saharan Africa; and build sustainable, timely, and effective interventions to assist African women and their families in accessing treatment and managing chronic HIV illness. Clinically, Dr, Kako has served in underserved populations including corrections as a family nurse practitioner.

Jacqueline Callari-Robinson, BSN, RN is a Doctoral student at the University of Wisconsin, Milwaukee, School of Nursing, Research Assistant for Tracking our Truth, and an on-call SANE Nurse for United Concierge TELESAFE Program. Previously, Jacqueline was the Director of Sexual Assault Prevention and Statewide SANE Coordinator for the Wisconsin Coalition Against Sexual Assault and the Wisconsin Department of Justice. In that role, she developed the Wisconsin adult, adolescent, and pediatric SANE training courses. Jacqueline was also instrumental in the facilitation and creation of the Wisconsin Attorney General Sexual Assault Response Team (SART). Working collaboratively with SANE programs, law enforcement communities, and the Wisconsin Crime Lab, the AG SART addressed patient access to advocacy driven medical forensic care and the composition, handling, and processing of sexual assault kits. 

Brittany Ochoa-Nordstrum is set to graduate with a Bachelor’s degree in Sociology in the spring of 2021. As a recipient of a SURF (support for undergraduate research fellow) award, Brittany is working under the mentorship of Dr. Lucy Mkandawire-Valhmu on various projects pertaining to advocacy for marginalized communities of color. Brittany’s area of study is medical racism and its impacts on maternal mortality amongst African American women in Milwaukee. She is applying to Ph.D. programs across the country in Sociology and African Diaspora studies. As a third generation Mexican American, her life experiences often inform her passion for these areas of study. When Brittany is not researching, she is often involved in planning and organizing community grassroots demonstrations and fundraisers to benefit marginalized groups around the city of Milwaukee.

Nicole Weiss is a current graduate student at the University of Wisconsin-Milwaukee pursing a Masters of Sustainable Peacebuilding. Nicole is the project coordinator for the Department of Justice funded project: Tracking our Truth, Providing Access to Advocacy Driven Medical Forensic Care. She received her BA in International Studies at the University of Wisconsin-Milwaukee. Her areas of focus include undertaking a holistic, systems approach to complex issues within our community through facilitation and conflict resolution strategies.

Jacqueline Campbell, PhD, RN, FAAN is a national leader in research and advocacy in the field of domestic and intimate partner violence (IPV). She has authored or co-authored more than 230 publications and seven books on violence and health outcomes. Her studies paved the way for a growing body of interdisciplinary investigations by researchers in the disciplines of nursing, medicine, and public health. Her expertise is frequently sought by national and international policy makers in exploring IPV and its health effects on families and communities.

How Evidenced Based Practice Supports Inequality

Guest contributor: Mike Taylor,
Member, Nursology Theory Collective

About six years ago, the Maryland Department of Health sponsored a conference for all state stakeholders with an interest in chronic disease, including nursing and medical groups, hospitals, EMS and diabetes product companies. The latest evidenced based practice models were being presented but I was only half listening because I, like most of those in the room, already knew what we were going to hear. Which is what happened, in session after session we heard that non-white patients had the highest incidence in all chronic disease states, probably related to genes or culture, and the major solutions were primarily public awareness and ethnic specific education without any mention of the role of racism.

So, I decided to shake things up and during the break went to the Department of Health table in the exhibit hall and asked the two representatives there if we were ready to tackle institutional racism or if we were still playing around the edges. Looking unsure what to say, one of them responded “we are still playing around the edges” but offered that there was a new director who may be willing to talk with me and she would send her over to my table. She never came and the chance for a different conversation ended there.

While the department of health representatives didn’t deny the existence of institutional racism, unless evidence of institutional racism and other inequalities are allowed to be presented as part of the discussion nothing will change.

In addressing institutional racism, we tend to spend 80% of our time on awareness which is only 20% of the problem and not on changing institutions which is 80% of the problem. In this first of a series of blogs, I will argue that evidenced based practice (EBP) is a key component of the institutional structures that support racial and economic inequalities. The evidence about any clinical subject is often contradictory even in well-designed studies which is not a problem but simply a feature of the difficulty of doing science. The fact that the evidence found in scientific journals provides a range of possible answers, requires practioners, practice organizations and health systems to make choices about what evidence to include and not to include in their own practice and in practice guidelines. The science of EBP may appear to be objective but the process of choosing the subject and design of studies along with what evidence to use and how to use it is inherently subjective and open to bias that perpetuate economic and racial inequalities.

Institutional selection of what evidence to include in policy and practice is based on the degree of fit with an existing institutional theory. The institutional theories that support inequalities in race and poverty, are unspoken but widely accepted theories of health without theoreticians and based on unquestioned assumptions which can make them hard to challenge.

If we in the Nursing Theory Collective specifically and in nursing in general, are to undertake this fight to change the intertwined histories of these inequalities we must concentrate on changing the institutions and the false assumptions they are based on, and demand alternatives. Follow-up blogs will examine the use of EBP in supporting three areas of institutional inequalities including the maintenance of structural racism, control of nursing practice and control of patient autonomy. Please reach out to me and tell me what assumptions you have found in your work that you feel need to be questioned.

About William (Mike) Taylor

Mike Taylor is an independent nursing theorist specializing in the application of complexity science to health and compassion. His Unified Theory of Meaning Emergence takes a major stride in connecting the mathematics of complexity with self-transcendence and compassion. He has spoken at international, national and regional conferences on complexity in nursing, health, and business. He is a member of the board of the Plexus Institute where he is the lead designer of the Commons Project, a web based platform for rapid social evolution in climate change.

Abstract Thoughts with Aphantasia: Learning Nursing Theory without the Ability to Imagine

Guest contributor: Elizabeth “Ellis” Meiser, MSN, RN-BC, CNE

            When I took a nursing theory course for the first time in my educational experience (at the doctorate level, mind you), I found myself grateful to finally be able to identify what may make learning theory difficult for me. A few years ago I was listening to a podcast in my car from the BBC. It began with a discussion on spatial navigation and transitioned into mental visualization. The topic was on how some people have a limited ability to imagine. The podcast asked listeners to close their eyes (I waited until I got to my destination to complete the exercise, don’t worry!) and picture a beach. Go ahead and do this if you can. Close your eyes and call to mind beautiful white sand, a palm tree, blue waves crashing under a clear blue sky. I settled into my seat and closed my eyes. But when I tried to see a beach, nothing happened. It was then I realized that I had a processing condition called aphantasia.

            Individuals with aphantasia have difficulty imagining visually. For me, it means when I close my eyes all that happens is I stop seeing. Most people are on a spectrum of capability when it comes to visualization. Some can recall only things they have seen before, for some it may appear like something from a cartoon, and for others it is as realistic as if it were before their eyes. Perhaps it seems shocking that I would not be aware of this until my mid-twenties, but how often does it come up in conversation? I suppose I always thought when someone said “mind’s eye” or that they could “picture it” these were expressions but that they couldn’t actually do it. Turns out, most people can actually picture things when my mind is woefully dark. With an impact on my ability to remember things, I just always assumed I had a poor memory.

My lifelong struggle with having to learn about and analyze abstract ideas suddenly made sense! The blog posts from Dr. Foli and Shannon Constantinides about the concerns with teaching theory in nursing education, along with the potential impact of generational differences, jumpstarted my questioning of my own journey through abstract learning. I cannot envision physical things, words, shapes, or even colors. Without those capabilities, I wonder: what could be the main factor impacting my ability to truly grasp abstract concepts? There could even be a combination of many contributing factors. Then I wondered, does it even matter? Why do I even need to understand theories?

As I mentioned, I’ve been through nearly ten years of formal education for nursing and cannot recall a course dedicated to nursing theory. I became faculty armed with a master’s in nursing leadership and management and a handful of education classes from my music education undergrad. I had been exposed to Piaget’s developmental theory and Maslow’s hierarchy of needs. I knew how to write objectives using Blooms, and in my master’s had been introduced to a variety of leadership theories. I had not, however, explored anything on Benner, Henderson, or even anything beyond the fact that Nightingale had something to do with a lamp. I didn’t even know nursing theories existed, and when presented with them in my doctorate program, I struggled understanding them and their purpose. However, in my practice of simulation, I have recognized the impact of Jefferies on how frameworks can guide development of scenarios. I have embraced Benner by recognizing how to consider the learners, where they are within the program, and within their own growth process. Much of this required me to evaluate how to learn abstract concepts.

Ultimately, a huge hurdle on abstract thought for me must involve aphantasia, which presents for me as the inability to daydream and the absence of visual recollection. It can be hard for me to remember what I’ve read or seen. As a learner, and now as a nursing educator, I feel as if it is taken for granted that all learners have the capacity to visualize mental images. Despite this having implications for learning, aphantasia is not currently considered a learning disability. Furthermore, there has been no progress on aiding those with aphantasia in developing the ability to produce mental imagery as it seems to be a neurological deficit. I am unsure of whether identifying students with aphantasia, or to what extent they are capable of visualizing, is important. Instead, what we need to do is create a holistic learning environment that is accessible to a variety of learners and learners need to be equipped with tools that suit their learning style. Using varied education techniques to address learning styles has long since been routine, but how often have we considered the student’s ability for mental imagery? How are we sharing abstract ideas? Is it in a tangible way? Do we encourage students to reflect on how they think, process, and picture things? Perhaps we need to consider adding this to the conversation to help students assess their learning needs before we begin introducing abstract concepts.

When it comes to theory, abstract instruction, or other types of instruction, I have found myself having to use a range of resources. For example, graphs, images, and diagrams may help explain concepts, but they are difficult to recall as I cannot recreate them in my mind. Instead, I found myself using a mixture of media, videos, and having to use my trusty gel pens and notebook paper. As it is in any pool of learners, these will have different effects for different learners but include:

  • Make personal or emotional links to content
    • I find relating theories to stories extremely helpful. This means grounding abstract ideas to something that I can relate to, or experience.
  • Listen to podcasts or a recording of a lecture
    • This may be difficult for some with aphantasia as there is no visual imagery to which to connect the audio.
  • Write notes and draw concept maps on paper to physically forge connections
    • An age-old recommendation that should never have been replaced by typing and is even more effective when summarizing in my own words.
  • Use Flash cards, mnemonics or other rote memory tasks
    • While I can’t bring these to mind at a later date, I can force memorize the basic concepts before scaffolding the more abstract ones.
  • Involve music or rhythm
    • Again, this is helpful for the more basic concepts. However, there has been some evidence of links between those with aphantasia also having difficulty remembering sounds, tones, or music so this is very dependent on ability.
  • Teaching others or simply reading notes out loud
    • Yet another traditional method of evaluating learning and using kinesthetics and physicality to the party. When I get lost in reading about theory, I find that reading it out loud helps me stay on track.

It is crucial to remember that while linking learning to visual memory reportedly leads to better academic outcomes, it does not equate to higher intelligence. It certainly has an impact, but it is not the only variable to consider. Reflecting on how important the mind’s eye is to learning leads me to wonder how different schooling would have been had I known about aphantasia. For myself, I can apply it to what remains of my terminal degree and my continued lifelong learning. For others, I can write about its impact and attempt to add to the discussion on what influences how, when, and to whom we teach nursing theory and knowledge. Ultimately, we need to work with all learners to be advocates for what they need to succeed regardless of the topic at hand.

About Elizabeth “Ellis” Meiser

Ellis is a Clinical Educator of Nursing at Longwood University in Farmville, VA. They have their MSN with a focus on leadership and management, is a Certified Nurse Educator, and is certified in medical-surgical nursing. They are in their first year as a doctoral student in the online EdD Nursing Education program at Teachers College, Columbia University.

Being True to Yourself: A Career as a Nurse Educator Guided by Critical Caring Pedagogy

Guest Contributor: Erin Dolen, MS, RN, CNE*

My career in nursing education has spanned the better part of a decade. For the majority of that time, I taught in an associate’s degree nursing program. At first, I was not sure if nursing education was for me. I was always a preceptor on the nursing units during my time in the hospitals, but that does not necessarily equate to being a good educator. After a semester, I was hooked. I found so much joy in showing my students not just how to do nursing, but how to be nurses. Forget “teaching to the test”! I would teach through experience, stories, relationships, respect, and caring.

Over the years, I thought I was developing into an expert nurse educator. I obtained my MSN, I passed my Certified Nurse Educator (CNE) exam, and I achieved quite a following among the student body. Until one day, it all changed. I was accused of being too personal, too attached to my stories and experiences, too outward in my sharing. I couldn’t understand why this faculty member was attacking me for being who I am, for valuing my relationship with my students, for giving them a part of me so they know I am human too. The lateral violence (let’s face it, that is what it was) became too much and I decided to move on to where I currently am, a baccalaureate nursing program.

My world has changed. I am now valued for giving my students everything that I have. For sharing not just my experiences but who I am as a person, a nurse, a mom, a friend. I care about them, and they know this. I want them to succeed beyond all ways they could imagine. I want them to learn from me; not just how to be a nurse but how to be someone who cares, who is empathetic, moral, ethical, a life-long learner, and is committed to the profession of nursing. Through my own education at Teacher’s College, Columbia University in the Online Nursing Education EdD program, now I know why. My whole nursing education career I have been guided by the Critical Caring Pedagogy (CCP).

CCP provides a framework for nursing education that, all at once, encompasses ontology, epistemology, ethics, and praxis (Chinn & Falk-Rafael, 2018). This framework consists of seven critical caring health-promoting processes: preparing oneself to be in relation, developing and maintaining trusting-helping relationships, using a systematic reflective approach to caring, transpersonal teaching-learning, creating and supporting sustainable environments, meeting needs and building capacity of students, and being open and attending to spiritual-mysterious and existential dimensions (Chinn & Falk-Rafael, 2018).

Isn’t this what I have been doing all along? All seven?! I have just come to the realization that my own practice as a nurse educator for the last decade has consisted of being in a caring and guiding relationship with my students, the foundation of CCP. I have been guided by a theory I had no formal knowledge of until now. And yet, I was faulted for it. Told I was giving too much of myself to my students. Told that I was to teach the material, not cultivate relationships. Told I made the two students out of HUNDREDS uncomfortable (yes, you guessed it, these students were academically unsuccessful and reaching for reasons for their appeal to be upheld). I almost gave up teaching. I knew I could not work in an environment that did not support my own values and approach to the teaching-learning relationship. Until I moved into my current position, where my foundation in CCP is respected, appreciated, and celebrated. To where my colleagues also practice with the guidance of CCP, whether they know it or not.

Now I can put into words what I have felt all along. Thank you, Peggy Chinn and Adeline Falk-Rafael, for providing the framework and empirics to support what I felt was the right way to teach deep down in my core. Critical Caring Pedagogy has given my teaching practice meaning and validity. I will carry this knowledge with me wherever I go, and I will never give up teaching.

Source

Chinn, P.L. & Falk-Rafael, A. (2018). Embracing the focus of the discipline of nursing: Critical caring pedagogy. Journal of Nursing Scholarship, 50(6), 687-694. Doi: 10.1111/jnu.12426

*About Guest Contributor Erin Dolen
E Dolen Picture

Erin is an Assistant Professor of Practice at Russell Sage College in Troy, NY. She is a doctoral student in the EdD Nursing Education Program at Teachers College, Columbia University. She has her MSN with a focus in Nursing Education from Excelsior College. Erin has her national certification as a Certified Nurse Educator. Her nursing background is in emergency medicine. She lives in Delmar, NY with her husband and two children.

A Nurse Practitioner’s Perspectives on Theory in Practice

Guest Post
Welcome  to Guest Contributor Christine Platt, NP-C*,

PhD Student at the University of Arizona College of Nursing

This week I asked, why does nursing theory matter to me? Can I see it directly affect my practice? As a nurse practitioner I see, on average, 26 patients each clinic day. Nursing theory helps define who I am as a nurse and what my goals are as a professional. It also can be evident in the way I give care at the bedside or even the way I influence health policies and practices of my community.

To begin, let’s look at what nursing is not. When discussing primary care, it is easy to think about making a diagnosis and then prescribing medication or a procedure to fix the disease. While these aspects may play a role in nurse practitioner practice, they don’t encompass the professional advanced practice of nursing. Without theory, the focus of our practice could easily become too narrow or lack the direction to influence and promote well-being. For example, let’s take the act of treating acne in a clinic. Without a disciplinary perspective, a nurse practitioner (NP) could easily look at the papules and pustules and determine an antibiotic, retinoid, hormonal control (such as spironolactone or oral birth control) will decrease the papules. If the acne is recalcitrant or scarring, the NP may decide isotretinoin is the best course of action. Without theory, we treat diseases instead of the patient and our communities.

Now, let’s contrast the same situation using our unique disciplinary perspective in our practice. Looking holistically, the NP notes that the patient won’t look them in the eyes very often, they seem withdrawn, which could be due to the embarrassment that the acne is causing. As the NP listens and learns more about the patient, they realize that the patient is depressed, has recently had suicidal ideation, and the patient’s current living conditions are stressful with a poor diet. Moreover, the acne flares significantly during weather inversions that increase pollution and aggregate the patient’s asthma. Nursing is not simply writing a prescription for isotretinoin.

Nursing has helped define our profession as a wholistic one that considers the person, environment, and nursing care to improve health (Fawcett, 1984). Nursing is further assessing the patient’s safety, linking them to the right mental health provider, improving diet, while simultaneously developing a relationship of trust. It does involve treating the acne, but it is so much more than the ability to write a prescription or plan of care. It involves understanding the patient’s culture, their beliefs, and the barriers to improved care. As more and more nurses are prepared at the PhD and DNP levels, they have a great opportunity to conduct research and implement change in practice. They continue to evolve the discipline from the original metaparadigm concepts toward the development and use of middle range theories, which are more specific to the problems they are investigating to guide their work. With their specialized knowledge, they influence change at community, state, national, and even global levels. The broad influence of theory translating into practice is evident when browsing over any national nursing conference program. With the case of the acne patient, NPs may take their experiences and develop studies with PhD and DNP nurses who focus on research and quality improvement projects. They can present their findings to legislators on asthma, acne, pollution, and poor nutrition, as a means of decreasing all of these in the community. They develop algorithms for treating acne combined with depression or other diseases.

Next time you come into contact with a patient, reflect on your nursing perspective in addition to all the specialized knowledge you have. Then think about how more specific theories could facilitate your practice, or maybe they are already embedded in your practice, ready to be articulated more explicitly, tested, and further refined. One of my favorite nursing theorist noted, “Nursing is not only a professional practice, it is a scientific practice as well (Reed, 2019).” Theory-based practice is essential and should be included in how we provide and deliver care on a daily basis. However, it is also time to consider how our professional practice can influence and improve our theories. If you have had an experience similar to mine, please share in the comments. I am excited to take part in this process and look forward to hearing how other nurse practitioners translate theory into practice and their practice into theory.

References

Fawcett, J. (1984). The Metaparadigm of Nursing: Present Status and Future Refinements. Image: the Journal of Nursing Scholarship, 16(3), 84-87. https://doi.org/10.1111/j.1547-5069.1984.tb01393.x

Reed, G. P. (2019). Intermodernism: A Philosophical Perspective for Development of Scientific Nursing Theory. Advances in Nursing Science, 42(1), 17-27. https://doi.org/10.1097/ANS.0000000000000249

About Christine Platt

Christine Platt, MSN, PHN, FNP-C began her career in nursing as a registered public health nurse and hospital staff nurse in St. Paul, MN. She became a critical care RN working in both cardiac and neuro intensive care units and received her CCRN certification after moving to Utah in 2006. She took on the role of house supervisor before returning to graduate school at Brigham Young University, where she received her MSN degree to become a family nurse practitioner. Currently, she sees patients in dermatology and also volunteers in the evenings to serve the community’s under- or un-insured population. Her family is a licensed foster family, caring for medically fragile children over the last decade. As a second-year PhD student at the University of Arizona, she has two areas of research, which span her clinical practice of dermatology and her passion for helping children with disabilities in the U.S. foster care system.

Hope in Nursing

Contributors: Barbara MacDonald
and Jane K. Dickinson

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

JKD: How did you get interested in hope?

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

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

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

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

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

JKD: What connections exist between hope and nursing knowledge?

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

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

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

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

Reference

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

About the contributors

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

 

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