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.

Theorizing as Emancipatory Action; Emancipatory Action as Theorizing

Over the past year those of us managing the Nursology.net website have experienced two unintended consequences – growing awareness of the importance of fundamental nursing/ public health knowledge and action, and the imperative to examine the structural and interpersonal dynamics of racism. As the web manager of this Nursology.net site as well as the NurseManifest.com website, the home of “Overdue Reckoning on Racism in Nursing,” I have had a front-row seat from which to witness and participate in these two complimentary processes.

From the NurseManifest sphere, we have addressed (explicitly and implicitly) questions such as: “How does our activism contribute to our discipline?” “What are the fault-lines in nursing created by our failure to address racism in nursing?” “How can we engage in authentic reckoning with racism in nursing?” “How can this reckoning shift nursing to more fully engage in facilitation of humanization for those who have historically been harmed by racism?” “How can nursing knowledge be decolonized to fully embrace the knowledge and wisdom of Black, Indigenous, Latina/x, and other nurses of color?”

From the Nursology.net sphere, we have addressed (explicitly and implicitly) questions such as: “What does decolonization of nursing knowledge mean?” “What dynamics have persisted to bring us to this point in history where the scholarship and theorizing of Black, Indigenous, Latina/x and other nurses of color are strikingly absent from our historical record?” “How can we move away from performative action, to fully abandon white privilege in nursing, and to welcome nurse scholars of color to the center of our discourse?”

I do not have direct answers to any of these questions. In fact I believe there are no specific “action” prescriptions that can provide “answers.” The response to all of these questions is what I believe to be critical emancipatory process — a process that begins with a recognition of the fundamental realities of racism and dedication to the hard work of deepened awareness and action for change. In the first chapter of the text “Philosophies and Practices of Emancipatory Nursing,”(1) Kagan, Smith and Chinn identified the following characteristics of emancipatory knowledge and critical theory that informs emancipatory action, as revealed by the chapter authors who contributed to the text:

What is “critical’ –

  • Unpacking hegemonies
  • Upstream thinking
  • Interrogating historical/social context
  • Framing/anticipating transformative action

What is “emancipatory”

  • Facilitating humanization
  • Disrupting structural inequities
  • Self-reflection
  • Engaging communities

Taken together, these characteristics point to a deep understanding of what it might mean to bring knowledge and action together as one – the process and understanding that emerges from “knowing what we do, and doing what we know.” In my experience growing up and becoming an “elder” as a fully colonized white woman, I know all too well the experience of separation of mind and body, of understanding and experience. But there is a glimmer of recognition when I encounter instances – my own and those revealed to me in stories others recount – when experience and understanding come together as one – when we recognize the importance of personal knowing and doing. And, recognize when that unified experience reveals new knowledge, new understanding. This process of action/reflection is theorizing at its best. African American scholar Anthony James Williams described this process of theorizing that he observed in his mother and grandmother:

Everyday black women theorists are often forgotten, undervalued and rarely considered theorists due to their lack of formal training and scholarly publications. But for my maternal lineage, the social patterns they observed became lessons. Those lessons then became theories about the social world they incorporated into their daily lives. Keen observation on their part lead to mental maps of where it would be safe to walk as black women, raise their children and avoid white violence. As the wife of a man in the military, my grandmother inevitably had her own theory of residential redlining based on her lived experience well before any academics published on the topic. (2)

Now is the time to engage in the critical emancipatory act of centering the voices of nurses of color who have been undervalued and discounted, only rarely recognized as theorists. The privileged white gaze from which nursing scholarship views the world recognizes only that which appears consistent with white experience, white culture. To face the realities surrounding white complicity that perpetuates racism is a possibility that is either far too frightening, or simply not comprehensible. But comprehend we must if we are to ever move to a reality where all experience is celebrated as valid and valuable, where skin color is not a determinant of whether you live or die.

The time has now come for all in our discipline – nursologists, nurses, students, educators, administrators, policy-makers – to make a strong and unequivocal turn away from all words and actions that render advantage for those whose skin is “white” and that disadvantage all of those with dark skin. It is time to abandon performative words and actions that claim to care for all, and turn instead to dismantle dehumanizing forces of racism and restore full humanization for all. For those who have white skin, it is time to reckon with your own complicity, unveiling the fault-lines (rifts, splits) created by the persistence of racism, and engage in the healing that must be done. For those who have dark skin, it is time to gather the courage to speak your truth, calling on your keen capabilities to discern injustice. For all of us together, it is time to form strong bonds of connection and support for this difficult path. It is a difficult path, but it is the path that will lead us to mental maps – to theorizing the healing that must take place. As we have experienced in our “Overdue Reckoning on Racism in Nursing” journey, it is also a path that is lined with moments of pure joy!

Sources:

  1. Kagan, P. N., Smith, M. C., & Chinn, P. L. (2014). Introduction. In P. N. Kagan, M. C. Smith, & P. L. Chinn (Eds.), Philosophies And Practices Of Emancipatory Nursing: Social Justice As Praxis (pp. 1–20). Routledge Taylor & Francis Group.
  2. Williams, A. J. (2018, June 15). Who Teaches Academics to Theorize? Inside Higher Ed. https://www.insidehighered.com/advice/2018/06/15/theorizing-black-scholars-differs-white-western-academic-standards-no-less-valid

Guest Post: Allies and Advocates – Transforming Cultural Competence

Contributors: Jennifer Weitzel, Jeneile Luebke,
Linda Wesp, Maria Del Carmen Graf, Ashley Ruiz,
Anne Dressel, & Lucy Mkandawire-Valhmu

The murder of George Floyd and Breonna Taylor has prompted a wake-up call to reflect on the pervasive issue of structural racism.  As a nation created through histories of colonization and slavery, these murders—among countless others—have acted as a catalyst for American society to recognize and act to disrupt continued legacies of racism embedded into the fabric of American society1.  As nurses, as a part of this society (and thus a reflection of society) it is incumbent upon the nursing profession to take a stark look at the ways in which the legacy of structural racism has continued to inform nursing practice, education, and research.  Doing so speaks towards the nursing professions commitment towards supporting best health outcomes for everyone.  As the most trusted profession, and largest healthcare profession, such allyship not only recognizes this issue, but acts to decolonize discourses, and provides explicit attention to the impact that racism holds on health outcomes.  Such measures call to realize the reality that racism is a health issue, that must no longer remain on the periphery of nursing education, research, and practice in the U.S. (see https://nursology.net/2020/01/14/decolonizing-nursing/ ) .

Source

Nursing as a science, has historically been constructed from a positivist and Eurocentric framework that serves to sustain the domination of “whiteness as a form of disciplinary power.”2(p.196)  Cultural competence is often the primary concept used to guide the nursing profession in addressing the needs of diverse populations locally and globally.3 The principles of cultural competence are heavily influenced by the social and political history of the U.S.4 Practicing with cultural competence is tainted with the effects of racial bias, as this concept fails to recognize how perceived “cultural differences” are code for modern-day racist ideologies dating back to colonialism.6 Therefore, what is often believed to be cultural knowledge is rooted in White, European worldviews and codified into healthcare practices based on faulty interpretations and observations of “Othering”. 

Calls have been put forth for nursing transform these harmful approaches to cultural competency using emancipatory knowledge development and critical theory. Although nursing has been heavily impacted by the hegemonic ideologies of the biomedical model, we have also pioneered ways of knowing that disrupt oppressive knowledge paradigms.   The very institutionalization of competence within the medical field was one way for healthcare providers to establish a standard of expertise. This was key to the professionalization of many disciplines informed by the biomedical model, which focuses primarily on biological factors of health and excludes psychological, environmental, and social influences.Because of the societal value placed on our education and our expertise (cultural competence), nurses enjoy a position of power in Western models of health care. Operating blindly within the hierarchies of power existent in the Western, biomedical model of health leads to running the risk of de-contextualizing the care we provide. For example, Ilowite, Cronin, Kang, and Mack found that parents of children with cancer, regardless of race and ethnicity, wanted detailed information regarding their child’s prognosis.7 However, the researchers also found that physicians provided less information to Black and Hispanic parents than to White parents. This is an example of how healthcare providers exert power by deciding what information to share with patients based on perceived cultural norms and implicit bias.

Most individuals entering the healthcare field espouse a belief that they need to deliver care with impartiality.  However, without a sufficient understanding of the machinations of racism in everyday society, the ways in which racism are perpetuated in the healthcare system will remain a blind spot.6 In attempting to provide care regardless of race or ethnic background, we might overcompensate (“I don’t see color”) and subsequently fail to see how social determinants of health, including racism, affect our patient’s opportunities to achieve and maintain optimal health. 6

Practicing with cultural competence is predicated on the nurse’s ability to learn and understand cultures other than their own  to predict health behaviors and ultimately health outcomes.7 When these predictions drive how care is delivered, the complexities of how individuals, families, and communities make decisions about life, illness, and death become reduced to single narratives and stereotypes.9 By many of our textbooks and NCLEX review materials still provide content based on assumptions and broad categorizations. These assumptions often boil down to ideas such as the belief that because of their race or ethnicity, people share static traits, values, and beliefs, racial categories are legitimized as objective truths, when in reality, these categories are social constructions shaped by history and politics.

It is fundamentally impossible for nurses to provide culturally competent care under the premise that knowledge is based on these singular narratives, beliefs, and stereotypes. We must be open to the use of new frameworks that underpin the delivery of nursing care to meet the needs of diverse populations.  These frameworks derive from epistemologies that challenge Western hegemonic knowledge, how it is produced and who produces it.  For example, cultural safety is a concept originating from indigenous Maori New Zealanders that calls on nurses to engage in ongoing self-reflection about issues of power and privilege. Intersectionality theory, rooted in Black feminist thought, requires an understanding that people identify in a myriad of ways that are fluid and interactive.  These identities, some of which are self-ascribed, and others are socially ascribed, form matrices that confer or deny power. Legal scholars introduced Critical Race Theory (CRT) drawing from critical legal and civil rights scholarship.  CRT is underpinned by the following assumptions:

1.  Race is a social construct with no basis in science.

2. White supremacy does not exist on the fringes of society but is embedded in the everyday order of U.S. life.

3.  The voices of those experiencing racism are essential to knowledge development.

4.  The notion of ‘colorblindness’ is a detour that allows White people to absolve themselves of racial biases and deny the oppressive realities of structural racism.

These are a few of the concepts and frameworks that could inform nursing science and ultimately our practice. Why are we interested in theories from other disciplines? How might we develop nursology discipline specific knowledge that addresses the issues?  In the midst of the world witnessing the murder of George Floyd by police officers, the COVID-19 pandemic continues unabated with its current epicenter in the U.S.  In urban metropolitan areas, we have watched how centuries of disinvestment in Black and Brown communities and systematic oppression has led to health disparities that are also manifesting clearly in this pandemic in disproportionate morbidity and mortality of Black and Brown peoples.  Ethnic minority populations are at greater risk for contracting Covid-19, or experiencing severe COVID related illnesses.10  According to the CDC’s report on COVID-19 in the Racial and Ethnic Minority Groups, cases of COVID-19 are highest among American Indian persons, and hospitalization rates for COVID-19 related illness are highest among Latinos, American Indians, followed by Black persons.10  Since Covid-19 was first reported on the Navajo Nation in mid-March, infection rates per capita have soared to the highest in the country compared with any individual state.11   The COVID-19 pandemic thus only exacerbates the challenges that ethnic minority communities already face, particularly American Indians who already experience disproportionate disparities in health outcomes.

The time for nurses to act is now, not just in the care of people and communities that are most marginalized, but to address the very root of marginalization and oppression through a practice of critical reflection on our own profession: which of our theories need to be contested because they are rooted in colonist and white supremacist ideologies?  How can we embrace of innovative ways of theorizing, through meaningful and intentional care that results from a critical and reflective analysis of the realities going on around us and our role as a profession in fostering lasting change? We leave you with these questions and call upon you as fellow allies and advocates on the path towards health equity and social justice.  When we discuss racism, should we not include all races and ethnicities?

Sources

  1. Paradies Y. Colonisation, racism and indigenous health. J.Popul. Res. 2016; 33(1):83-96.
  2. Puzan E. The unbearable whiteness of being (in nursing). Nurs Inq. 2003; 10(3):193-200.
  3. Rajaram SS. Bockrath S. Cultural competence: New conceptual insights into its limits and potential for addressing health disparities. J Health Dispar Res Prac. 2014; 7(5):82-89.
  4. Kirmayer LJ. Rethinking cultural competence. Transcult Psychiatry. 2012; 49(2). 149-164. doi.org/10.1177/1363461512444673
  5. Wesp, L. M., Scheer, V., Ruiz, A., Walker, K., Weitzel, J., Shaw, L., . . . Mkandawire-Valhmu, L. An Emancipatory Approach to Cultural Competency: The Application of Critical Race, Postcolonial, and Intersectionality Theories. Advances in Nursing Science, ePub Ahead of Print. 2018.  doi:10.1097/ans.0000000000000230
  6. Hester, RJ. The promise and paradox of cultural competence. HEC forum. 2012;24(4):279-291. doi.org/10.1007/s10730-012-9200-2.
  7. Ilowite MF. Cronin AM. Kang TI. & Mack JW. Disparities in prognosis communication among parents of children with cancer: The impact of race and ethnicity. Cancer. 2017; 123(20): 3995-4003.
  8. Brascoupé S. Waters C. Cultural safety: Exploring the applicability of the concept of cultural safety to Aboriginal health and community wellness. Int J Indig Health; 2009; 5(2):6-41.
  9. Carter C. Lapum J. Lavallée L. Schindel ML & Restoule JP (2017). Urban First Nations Men: Narratives of Positive Identity and Implications for Culturally Safe Care. J Transcult Nurs. 2017; 28(5):445-454.
  10. Centers for Disease Control (CDC).  COVID-19 Racial and Ethnic Health Disparities. 10 December 20.  Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/increased-risk-illness.html
  11. Cheetham, J. Navajo Nation: The people battling America’s worst coronavirus outbreak.  BBC News.  15 June 2020.  Retrieved from: https://www.bbc.com/news/world-us-canada-52941984

Note: this post is based on the ANS article published in the spring of 2020 – Weitzel, J., Luebke, J., Wesp, L., Graf, M. D. C., Ruiz, A., Dressel, A., & Mkandawire-Valhmu, L. (2020). The Role of Nurses as Allies Against Racism and Discrimination: An Analysis of Key Resistance Movements of Our Time. ANS. Advances in Nursing Science, 43(2), 102–113. https://doi.org/10.1097/ANS.0000000000000290

L-R: Jennifer Weitzel, Jeneile Luebke, Linda Wesp, Maria Del Carmen Graf, Ashley Ruiz, Anne Dressel, Lucy Mkandawire-Valhmu

Jennifer Weitzel, MS, RN is a doctoral student and public health nurse with Public Health Madison & Dane County. Her research examines the use of cultural safety in the delivery of humanitarian nursing in Haiti

Jeneile Luebke, PhD, RN is a post-doctoral nurse research fellow at University of Wisconsin-Madison. Her area of research and expertise include violence in the lives of American Indian women and girls, and utilization and application of postcolonial and indigenous feminist methodologies.

Linda Wesp, PhD, FNP, APNP, RN is a Clinical Assistant Professor at University of Wisconsin-Milwaukee in the College of Nursing and Zilber School of Public Health, with a focus on health equity, participatory research, and critical theories. She also works as a family nurse practitioner and HIV Specialist at Health Connections, Inc. in Glendale, WI

Maria del Carmen Graf, MSN, RN, CTN-A, is a PhD candidate at UW-Milwaukee. Her research area includes studying the mental health needs within vulnerable populations with an emphasis on the Latina population and women of color in the US using a Postcolonial Feminist approach.

Ashley Ruiz RN, BSN, is a doctoral nursing student and clinical instructor at the University of Wisconsin-Milwaukee, as well as a Sexual Assault Nurse Examiner (SANE). Her current work focuses on advancing feminist theory in nursing science for the purposes of providing a theoretical foundation for addressing the problem of violence against women. Such advances inform Ashley’s research, which seeks to identify and develop nursing interventions that are tailored towards the unique needs of Black women that disclose sexual assault and seek healthcare services

Anne Dressel, PhD, CFPH, MLIS, MA, is an Assistant Professor in the College of Nursing at the University of Wisconsin-Milwaukee, where she also serves as Director of the Center for Global Health Equity

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.

The Environment, Climate Change, and the #Climate Strike: A Nursology Perspective

with contributions by Peggy Chinn
Also see Adeline Falk-Rafael’s “addendum” to this post below

The nursology.net management team agreed to participate in the September 20, 2019 #Climate Strike – Nursology.net went to a  green screen acknowledging the importance of this public action for the entire day on September 20th. By doing so, we joined people “[i]n over 150 countries . . , to support young climate strikers and demand an end to the age of fossil fuels. The climate crisis won’t wait, so neither will we.” (from Global Climate Strike)

Climate can be defined as “characteristic weather conditions of a country or region; the prevalent pattern of weather in a region throughout the year, in respect of variation of temperature, humidity, precipitation, wind, etc., esp. as these affect human, animal, or plant life” (Oxford English Dictionary, 1889/2008)

The lack of sufficient attention to widely documented climate change by so many people, is, of course, the impetus for #Climate Strike. Climate change is defined as “an alteration in the regional or global climate; esp. the change in global climate patterns increasingly apparent from the mid to late 20th cent. onwards and attributed largely to the increased levels of atmospheric carbon dioxide produced by the use of fossil fuels .”(Oxford English Dictionary, 1889/2008).

The nursology.net management team’s concern with climate reflects our heritage of Florence Nightingale’s emphasis on environment and the effects of environment on human beings’ health status. Climate is, of course, a major aspect of environment, although climate is rarely mentioned in nurse theorists’ discussions of environment. An exception is found in the content of Orem’s self-care framework. Orem (2001) referred to two dimensions of what she labeled environmental features–physical, chemical, and biological features; and socioeconomic cultural features. Physical and chemical features include what typically is thought of as at least part of the climate—the atmosphere of the earth, gaseous composition of air, solid and gaseous pollutants, smoke, [and] weather conditions (Orem, 2001). Another exception is found in the content of a new conceptual model—the Conceptual Model of Nursology for Enhancing Equity and Quality—Population Health and Health Policy (Fawcett, in press). Following a suggestion from a PhD nursology student at the University of Massachusetts 2018 Five Campus PhD Forum, climate was explicitly included in this conceptual model in the definition of the physical environment.

Two recent nursing scholars have given primary focus on the environment in their work; their work provides important foundations for nursing action. Patricia Butterfield’s Upstream Model for Population Health (BUMP Health) provides a framework for addressing general issues related to health and the environment at a population level (Butterfield, 2017).  Dorothy Kleffel has been a thought-leader in nursing for more than 2 decades pointing the way toward a nursing focus on the environment and its effect on health (Kleffel, 1996).

A recent search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete), using the search terms, climate AND nursing, yielded 1,875 publications. However, a search using the terms, climate change AND nursing, yielded only 186 publications Two particularly informative publications are scoping reviews of the literature (Hosking & Campbell-Lendrum, 2012; Lilienfeld, Nicholas, Breakey, & Corless, 2018). Another informative publication is a call for action (Travers, Schenk, Rosa, & Nicholas, 2019).

Contemporary interest in environment and climate change has been prompted by two global initiatives–the 2008 World Health Organization (WHO) Member States World Health Assembly resolution (Hosking & Campbell-Lendrum, 2012) and the United Nations (UN) Sustainable Development Goals (Lilienfeld et al., 2018). The WHO resolution supports progress on studies of the effects of climate change on human health, including health vulnerability, health protection and its costs, the impact of migration and adaptation policies, and decision-support and other tools. Other health effects of climate change include an increase in communicable and noncommunicable diseases, weather-related injuries, mental health disorders, and effects of nutritional deficiencies on growth and development (Lilienfeld et al., 2018).

Hosking and Campbell-Lendrum’s (2012) scoping review of literature published between 2008 and June 2010 yielded 40 relevant papers. Of concern is that none of the papers were reports of studies of effective interventions, which clearly was a major gap in our literature of that time. Lilienfeld et al.’s (2018) scoping review placed climate change with the context of nursology. They identified and categorized 48 papers in their search of literature from 1996 to 2018, only a few of which were research reports. The categories are;

  • Background of climate change
  • Health consequences
  • Nursing knowledge and attitudes
  • Reference to UN Millennium Development Goals and/or the UN Sustainable Development Goals
  • Migration and/or adaptation strategies
  • Urgency
  • Plan
  • Climate justice

Once again, a major gap is research, especially the design and testing of interventions.

Travers, Schenk, Rosa, and Nicholas’ (2019) call for action by nurses may be the catalyst needed to advance nursology’s contribution to filling the gap in the literature. They underscored the findings of previous literature reviews revealing the effects of climate change on the environment and, consequently, on human health. Their call for action, which encompasses research, education, advocacy, and practice, exhorts nurse “to step up and see themselves as part of the solution to climate change” (Travers et al., 2019, p. 11).

There is, however, little evidence that nurses have begun to step up, to move beyond “talk about what needs to be done” (Travers et al., 2019, p. 11). As reported in The Washington Post (Tan, 2019), nurses are continuing to talk about climate change. An encouraging development is nurses’ willingness to join climate-oriented organizations as they increase their awareness of and even experiences of recent natural disasters, including hurricanes, wild fires, floods, and tornados (Tan, 2019).

The global action of the #Climate Strike, including worldwide demonstrations led by teenagers on Friday, September 20, 2019, and planned future Friday demonstrations certainly is encouraging. Perhaps these demonstrations will be a catalyst to actions by nursology students, faculty, and practitioners to conduct the research needed to identify effective interventions to mitigate the deleterious effects of climate change on human health. Perhaps, too, these demonstrations will move the UN and federal governments worldwide to fund that research.

Nursology is founded on a holistic conceptual orientation that points the way to recognizing the role of environment on human health, and toward nursing action to respond to this global crisis. It is time for nursologists and nursing as a discipline to step up to the challenge and provide a leading voice for healing the planet, for healing those who are harmed by the climate crisis, and join the many others who are demanding social and political action now to turn this crisis around.

Addendum by Adeline Falk-Rafael: Watson’s early publications of her philosophy and science of caring also explicitly identified the provision for “supportive protective and(or) corrective” environments, including specifically the physical environment as a carative factor. Although her language has changed, I believe the intent has not. That aspect of her theory was one key which led me to develop the mid-range theory of Critical Caring, based on her and Nightingale’s work (although my thinking has also been influenced by Butterfield’s and Kleffel’s work). Note: Adeline  (who is on our management team) was hiking in the Alps when we prepared this post!  Thank you Adeline for adding this important information to this post!)

References

Butterfield, P. G. (2017). Thinking Upstream: A 25-Year Retrospective and Conceptual Model Aimed at Reducing Health Inequities. Advances in Nursing Science, 40, 2–11. http://dx.doi.org/10.1097/ANS.0000000000000161

Fawcett, J. (in press). The conceptual model of nursology for enhancing equity and quality: Population health and health policy. In M. Moss & J. Phillips (Eds.), Health equity and nursing: Achieving equity through population health & public policy. New York, NY: Springer.

Hosking, J. & Campbell-Lendrum, D. (2012). How well does climate change and human health research match the demands of policymakers? A scoping review. Environmental Health Perspectives, 8, 1076-1082.

Kleffel, D. (1996). Environmental Paradigms: Moving Toward an Ecocentric Perspective. Advances in Nursing Science, 18, 1–10. https://doi.org/10.1097/00012272-199606000-00004

Lilienfeld, E., Nicholas, P. K., Breakey, S., & Corless, I. B. (2018). Addressing climate change through a nursing lens within the framework of the United Nations sustainable development goals. Nursing Outlook, 66, 482-494.

Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). St. Louis, MO: Mosby.

Oxford English Dictionary (1889/2008). Definitions of climate and climate change.

Tan, R. (2019, September 20). Why nurses, America’s most trusted professionals, are demanding “climate justice.” The Washington Post. Retrieved from
https://www.washingtonpost.com/local/why-nurses-americas-most-trusted-profession-are-speaking-out-against-climate-change/2019/09/19/1c5314d8-dae2-11e9-a688-303693fb4b0b_story.html

Travers, J. L., Schenk, E. C., Rosa, W. E., & Nicholas, P. K. (2019). Climate change, climate justice, and a call for action. Nursing Economic$, 37, 9–12.

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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