VISCERAL NURSOLOGY

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

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

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

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

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

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

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

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

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

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

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

REFERENCES

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

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

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

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

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

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

About Ellen Swanson

Ellen Swanson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

About Lydia Rotondo

Lydia Rotondo

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

Psychoneuroimmunology in Nursing

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

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

“Complexity” by Owen Hodgson (age 17)

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

What is PNI?

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

What are PNI Interventions?

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

PNI and Nursing Theory

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

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

Nursing Knowledge Development and the Future of PNI

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

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

References

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

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

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

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

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

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

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

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

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

About Christine Hodgson

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

The Nursology Initiative in the Philippines

Contributor: Rudolf Cymorr Kirby P. Martinez, Ph.D.

Philippine Children’s Medical Center (PCMC) is the largest and the national referral center for pediatric cases in the Philippines. I started my professional journey here as a staff nurse after I finished my MA in nursing, and soon after, I completed my Ph.D. I transitioned to academia. After eight years from the time I resigned as a staff nurse, I was appointed as the consultant nursologist of the hospital. This is the first time a nurse assumes a consultancy role in PCMC and the first time that the official designation is that of consultant nursologist. How it came about was serendipitous, to say the least. It all started during the pandemic when the inherent weakness of health care institutions, especially in a developing country like the Philippines, was exposed because of the pandemic’s burden. During this time, the value of nurses received the much-needed attention they deserve. Also, around this time, I realized the fragility of life and the uncertainty of things because of the pandemic. As I was looking for a way to help nurses working in the service sector, one of my mentees in graduate school mentioned that their hospital is currently creating initiatives for their nurses. This hospital was my former employer, PCMC.

I took the initiative to write a letter offering my expertise as a nursologist to the institution’s executive director, Dr. Julius Lecciones, whose office is taking the lead on creating this initiative for nurses. I wrote in the letter how a nursologist could benefit not only the nurses in the hospital but ultimately the children whose lives they are caring for. As a response to the letter, I was given an audience with the department managers, physicians, and some nurse supervisors. During the presentation, I focused on explaining what nursology is all about and proposed a framework for how the expertise of a nursologist could benefit the hospital and its community.

Why “Nursology”?

In the Philippine context, all people educated in nurses are called “nars” (nurse) regardless of where they practice. But most people would associate nurses with those who are working in the service sector as practitioners. (We do not have advanced practice in the Philippines at the moment) so all nurses working in the service sector are “the nurses” in the eyes of the general population. There is a prevailing belief that the penultimate role and function of a nurse in the hospital setting, not academe or research, that to work in the hospital is their reason for being. This is the reason why I deliberately choose “nursologist” to somehow bring into the consciousness of people that nursing is a professional discipline and its practice is not only confined within the four walls of the hospital. From there, I hope that the label we use for nurses will evolve into nursology and its different expressions. I have the same appreciation of nursology similar to some of the contributors from nursology.net, that is it “A name for discipline of nursing, a body of knowledge, a research methodology, and a practice methodology about and for phenomena of concern to nurses” (see “An Invitation to Dialogue about Disciplinary Terms. I am also heavily influenced by Rogerian Science of Unitary Human Beings and the Theory of Nursing as Caring by Boykin & Schoenhoffer: A caring practice means that the knowledge of nursing is expressed by the nurse with the intent to be caring, and their expressions are appreciated by the other person as caring actions.  In addition, I believe that nursology is grounded in the fundamental patterns of knowing in nursing, first identified by Barbara Carper in 1978.

Launching the Nursology Initiative

During the initial talk on the establishment of the Nursology Initiative, I gave a presentation and emphasized in it the unique perspective that a nursologist could bring to the table in terms of nursing research, practice innovation, and creating a center for caring practice. After the presentation, they accepted the framework and further suggested that as part of the consultancy, I will also be a part of the institution’s multi-sector governance council (MSGC), where my expertise as a nursologist would provide a unique perspective on various issues tackled within the board.

Besides being part of the MSGC, my role as a consultancy nursologist is to assist the institution by providing insights, technical inputs, and expertise grounded on nursology on the following matters:

  • Development of a nursing research unit that focuses on human-health research and EBP grounded on nursology
  • Practice innovation with an emphasis on palliative care and caring science
  • Creation of a Center for Caring Practice

I also give short lectures on nursology and other nursing-related topics when needed. I was also given a permanent column for their newsletter aptly called “The Nursologist Corner,” where I share my opinion on issues concerning nursing, health, and wellness sent to me by various members of the community

This was the initial nature of my engagement with the institution as we are continuously exploring the nature of this partnership since this is the first of its kind in the Philippines. The PCMC Nursology Initiative Program is initially under the Executive Director’s Office, and the consultant nursologist liaise directly with the executive director.

During the contract signing, I gave a message to the administrators and nurse managers present, emphasizing that although society needs the expertise of nurses as clinicians, it is not the end-of-it of nursing. There is more to nursing than bedside practice. It is not the clinical skill that makes a nurse a nurse; it is our unique perspective and appreciation of things grounded in our disciplinary body of knowledge. I believe that one of the essential roles of a nursologist in a hospital is the empowerment of nurses and, with it, the advancement of their clinical practice. Nursologists help in creating systems and processes that allow for the empowerment of nurses to happen.

For so long, nurses in the Philippines are seen as second-class health care providers, merely skilled technicians, simply because it seems that some nurses have forgotten their unique disciplinary perspectives and are operating in a system that is not grounded in nursing. As I envision, a nursologist could help nurses remember who they are and the unique perspective they could offer.

An initiative such as the consultant nursologist might offer another model for bridging the gap between the science that is nursing and the art by which it is practiced in the clinical setting.

Memorandum of Agreement signing with Dr. Julius Lecciones, PCMC’s Executive Director,
June 10, 2021
Dr. Lecciones giving his opening message and sharing the story of how the Nursology Initiative came to be. The short program was department managers of various offices and nurse supervisors (those in green scrub suits).
Dr. Lecciones and me surrounded by the audience at the signing ceremony

About Rudolf Cymorr Kirby P. Martinez, Ph.D

Rudolf Cymorr Kirby P. Martinez, Ph.D., is currently the consultant nursologist of Philippine Children’s Medical Center and is a full-time Professor at San Beda University College of Nursing. He also teaches part-time at the graduate school program of Arellano University, Florentino Cayco Memorial School Graduate School of Nursing, and Holy Angels University – School of Nursing and Allied Medical Science. He is an advocate of nursology, caring science, and palliative care and consider himself a scholar of Rogerian Science of Unitary Human Being. His current advocacy includes the decolonization of nursing education through the integration of caring science and indigenous culture and folkloric practices into the nursing curricula.

COVID-19 Through the Lens of Nursing Theories

Contributor: Navninder Kaur, MSN, CMSRN


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

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

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

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

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

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

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

About Navninder Kaur

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

Examining the Evolving Role of the BSN-Prepared Nurse outside Acute Care Settings: A Nursing – Shared Theory/Conceptual Model Approach

Co-Contributor: Katunzi Mutalemwa

The purpose of this blog is to describe a baccalaureate (BSN) prepared nursologist’s, Katunzi Mutalemwa personal lived pre-internship clinical learning experience in primary care at a local community-based non-governmental outpatient clinic run by The Tanzania Doctors with African CUAMM  in collaboration with a local District hospital.

Katunzi’s reflections have been interpreted within the context of nursology discipline-specific knowledge of Neuman’s Systems Model (NSM), and the Theory of Self-Care of Chronic Illness (TSCC), as well as the Expanded Chronic Care Model, a model shared with public health.

Inasmuch as the ECCM is a shared model, the starting point for the interpretation is the nursology discipline-specific conceptual model that is NSM (Villarruel et al., 2001). Whereas the NSM guided the overall understanding of the reflections, the concepts of the TSCC guided some of the specific actions described, as did the ECCM. The NSM provides a nursology conceptual foundation that takes into considerations the multiple levels of client/client system influences – the physiological, psychological, socio-cultural, developmental and spiritual interacting factors and environmental stressors. The model has the potential of advancing the future of nursology in the area of expanded nursing scope of practices and services in response to chronic disease management.

Katunzi’s reflections highlight the role of the BSN-prepared nursologists in the management and prevention of chronic diseases beyond the walls of the acute care settings (i.e., community-based primary health care settings)

The main ideas seen in this blog are consistent with the World Health Organization’s (2020) State of World Nursing publication, the nursology.net blog Primary-care-primary-nursology-and-the-attending-nursologist, the AACN White-Paper on the Vision-Academic-Nursing; the Health Resources & Services Administration (HRSA) 2018 call for Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program as well as several journal articles on the role of the primary care nursologist (e.g. Anderson et al., 2012; Bodenheimer, & Mason, 2016; Borgès Da Silva et al., 2018; Epping-Jordan, 2002; Lipstein, et al., 2016; Norful, et al., 2017).  The description of the roles and responsibilities discussed in this blog acknowledge the varied contextual nursing scope of practices across the globe.

Katunzi’s Nursing Context/Situation

The personal reflections demonstrate how a BSN-prepared nursologist practices within the Tanzania Nursing and Midwifery Council (TNMC) (2014) general nurse full scope of practice. The TNMC’s major role definitions of a general nurse prepared at the baccalaureate level are: 1) Accountability, Ethical and Legal Practice; 2) Care Provision, Health Promotion, Leadership and Management and, 3) Professional, Personal and Quality Development. For instance, the care provisions and leadership definition of the TNMC general scope of practice, the BSN-prepared nurse roles includes, but is not limited to developing practice guidelines, representing nursing at the management meetings, preparing and presenting nursing budgets at management team meetings, participating in nursing research and utilizing research results in provision of nursing care, providing comprehensive nursing care and carrying out nursing management independently, formulating relevant policies about patient and client care, and reviewing performance appraisal for nurses. According to the TNMC, if assigned, a BSN-prepared nurse is also allowed to prescribe medications for persons with some acute, emergency conditions and chronic illnesses and to prescribe physical therapy and other rehabilitative treatments in keeping with existing protocols.

Katunzi’s reflections

Community Resources and Policies and, Health Care System (Concepts of the ECCM)

As a BSN-prepared nurse completing a pre-internship clinical learning opportunity in a private community-based clinic (NSM community as the client system), I was mentored into the primary care role by a team of nurses and other healthcare providers. I was involved in the management of clients living with diabetes and heart diseases (adults and adolescents) (NSM developmental variable) trice a week and also participated in conducting monthly supervisions in satellite health centers. I learned to assure patients/clients maintained a maximum level of wellness by keeping stressors and stress responses at a minimum through effective, efficient care at three levels of prevention (NSM prevention as intervention). Utilizing a holistic approach (NSM physiological, psychological, socio-cultural, development, and spiritual variables), I was exposed in health counseling, medication administration, health teaching, case management and care coordination services (NSM prevention as intervention]. I worked closely with nurses in other satellite health centers within the clinic’s catchment area. The collaboration strengthened patient treatments and improved care. I regularly participated in conducting home visits and tracking down patients who were lost to follow-up careI dealt with barriers such as clients’ religious and traditional beliefs that hinder adherence to prescribed regimen (NSM socio-cultural and spiritual variables).

As a part of the learning process, I practiced advocacy and I was able to participate in regular district administrative meetings to negotiate consultation fees and cost of drugs with district authorities (NSM socio-cultural variable). I improved my nursing skills in individual/family and community assessment while fulfilling this role. For instance, I was able to share with the authorities how financial challenges forced clients to take half doses of their prescribed medication and intentionally caused missed follow-up visits. Likewise, I noted that other clients opted to traditional herbal treatments as they were perceived to be cheaper than hospital medications. I was able to see how self-medication practices (Concepts of the TSCC) can harden caring of chronic patients. Some patients opt to buy drugs in stores rather than visit the clinic or hospital. Some of the challenges were attributed to lack of transportation and health illiteracy on disease processes (NSM socio-cultural variable). I called attention to the impact of laxed drug dispensing policies on clients’ lives.  For example, I shared how clients with contraindicated medication can easily procure the drugs from a local drug store, making them at risk of readmissions and possibly death. In addition, as a community health educator, I advised patients and their families to participate in community development projects such as livestock keeping, small scale agricultural that helped them to earn extra money for buying drugs and supporting individual and family their well-being (NSM socio-cultural and spiritual variables ).

Delivery System Design and Self-Management Support(Concepts of the ECCM)

The community clinic was centered at a District Hospital and operated synergically with ten other health centers within our catchment area (NSM community as the client system). I learned to assure the provision of self-care maintenance, self-care monitoring, and self-care management services (Concepts of the TSCC). For instance, I was involved in caring for chronic disease patients especially type 1 diabetic patient by empowering and preparing clients to manage their health through effective and safe self-injection practice. I provided health education on regular testing to control glucose levels as well as insulin-self administration.  Assessing clients’ health literacy levels in the treatment process was a crucial piece of my practice role. I developed peer guided groups with an interpofessional team comprising of a nutritionist and physician. In addition, I conducted monthly supervision at each of the ten assigned health centers. During the supervisory visits, I was involved on assessing the overall patient’s adherence practice to nursing care and follow up (Concepts of the TSCC). I also participated in conducting professional development seminars to nurses on management of patients living with chronic diseases, how to conduct referrals and improve protocols to manage patients with diabetic ketoacidosis and heart failure (NSM variances from wellness). I completed frequent home visits with nurses and other providers to assess the client’s progress, adherence practices and storage of medications (concepts of the TSCC), as well as delivered promotional health messages to patients and families (NSM primary prevention as intervention).

Decision Support and Clinical Information System (Concepts of the ECCM)

I learned how to make clinical decisions in chronic disease management consistent with scientific data and patient preferences. For example, when I saw patients with medical adherence issues, I made sure I educated the clients on possible consequences and let the clients make informed decisions (NSM primary prevention as intervention). I always acknowledged the challenging presence of scientifically unproved treatment plans attributed to the growing number of traditional doctors involved in client’s health care decisions (NSM individual as the client system). I always paid attention to gender-based influences (NSM socio-cultural and spiritual stressors) in medication adherence NMS-. For instance, I was able to determine that men attended treatments when they had severe signs and symptoms of an illness and/or at advanced stage of disease. To address this social determinant among some of the men, I participated in initiating the use of mobile phones to trace patients on monthly basis. This initiative had a positive impact on “no show” clients who had access to mobile phones.

Implications for nursologist scholars

Katunzi’s reflections have implications for advancement of nursology discipline-specific knowledge and future professional transformations. The evolving role of the nursologist  in primary care (Wojnar & Whelan, 2017) calls for a well-rounded RN (Swan, et al, 2006) and, most importantly, a BSN-prepared global nursology  workforce (Wojnar & Whelan, 2017). Use of the ECCM requires ongoing research — or review of existing research – to determine the validity of the model as a shared theory/model (Villarruel et al., 2001) that is useful in new nursing education curricula (Humphrey, 2019),  reimbursement (Funk & Davis, 2015) and regulatory models (Start, 2020) situations that fit BSN-prepared nurses’ full scope of nursologists’ practice and meet clients’ health and social needs in places where people live, learn and play.  

We would like to learn from our nursology.net readers on their perceptions of these questions:

  1. What does the future of nursology hold for the role of the BSN-prepared nursologist in primary care, especially in the United States where primary care is regarded as a major role of advanced practice nursologists holding master’s and/or Doctor of Nursing Practice degrees?
  2. How can nursologists overcome the barriers and maximize contextual opportunities to fulfill their roles? 
  3. What barriers may influence effective adoption of applicable borrowed and shared theories/models in nursology-led chronic disease management interventions?

We welcome nursologists at different levels of practice (i.e., LPN, ADN, BSN, DNP, PhD-prepared) to share their stories of how they provide primary care services (or ambulatory care or community-based care), in private or public health care systems.  Please share your thoughts in comments section below

References

Anderson, D., St. Hilaire, D., Flinter, M., (May, 2012). Primary Care Nursing Role and Care Coordination: An Observational Study of Nursing Work in a Community Health Center OJIN: The Online Journal of Issues in Nursing, 17, 2, http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No2-May-2012/Primary-Care-Nursing-Role-and-Care-Coordination.html

Barr, V, Robinson, S, Marin-Link, B, Underhill, L, Dotts, A, Ravensdale, D, & Salivaras, S. (2003). The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model, Hospital Quarterly, 7(1), 73-82.

Bodenheimer, T., & Mason, D. (June, 2016). Registered nurses: Partners in transforming primary care. In Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June. http://64.62.135.154/docs/macy_pubs/Macy_Monograph_Nurses_2016_webPDF.pdf

Borgès Da Silva, R., Brault, I., Pineault, R., Chouinard, M.-C., Prud’homme, A., & D’Amour, D. (2018). Nursing Practice in Primary Care and Patients’ Experience of Care. Journal of Primary Care & Community Health, 9, 1-7 https://doi.org/10.1177/2150131917747186

Epping-Jordan, J., (Ed.) (2002). Innovative care for chronic conditions: building blocks for action: global report (document no. WHO/NMC/CCH/0201). World Health Organization Global Report. https://www.who.int/diabetes/publications/icccreport/en/

Funk, K. A., & Davis, M. (2015). Enhancing the role of the nurse in primary care: the RN “co-visit” model. Journal of general internal medicine30(12), 1871-1873.

Health resources & Services Administration (2018).  Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program. Retrieved from https://www.hrsa.gov/grants/find-funding/hrsa-18-012

Humphrey, B., L., Mixer, S. J., Thompson, K., Davis, S., Elliott, L., Lakin, B., … & Niederhauser, V. (2019). Transforming RN roles in community-based integrated primary care (TRIP): Background and content. Issues in mental health nursing40(4), 347-353.

Lipstein, S. H, Kellermann, A. L., Berkowitz, B., Phillips, R., Sklar, D., Steele, G. D., & Thibault, G. E. (September, 2016). Workforce for 21st century health and health care: A vital direction for health and health care. National Academies of Medicine. https://nam.edu/wp-content/uploads/2016/09/Workforce-for-21st-Century-Health-andHealth-Care.pdf.

Norful, A., Martsolf, G., de Jacq, K., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic review. International journal of nursing studies74, 15-23.

Start, R., Brown, D. S., May, N., Quinlan, S., Blankson, M., Rodriguez, S. R., & Matlock, A. M. (2020). Strategies for creating a business case that leverages the RN role in care coordination and transition management. Nursing Economics38(4), 203-217.

Swan, B. A., Conway-Phillips, R., & Griffin, K. F. (2006). Demonstrating the value of the RN in ambulatory care. Retrieved from https://jdc.jefferson.edu/cgi/viewcontent.cgi? article=1012&context=nursfp

The Tanzania Nursing and Midwifery Council (2014). Scope of Practice for Nursing and Midwives in Tanzania. United Republic of Tanzania.

Wojnar, D. M., & Whelan, E. M. (2017). Preparing nursing students for enhanced roles in primary care: The current state of pre-licensure and RN-to-BSN education. Nursing Outlook65(2), 222-232.

Villarruel, A.M., Bishop, T.L., Simpson, E.M., Jemmott, L.S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14, 158-163. 

Does Informed Consent Exist for Black Patients?

Contributor: Harriet Omondi MSN, APRN, FNP

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

Source

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

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

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

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

References

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

About Harriet Omondi

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

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Guest post: The Overlooked Impact of Case Management during the COVID-19 Pandemic

Contributor:
Christy McDonald, BSN, RNC, Case Manager

I have witnessed an amazing workforce in our hospitals during this pandemic. While physicians and nurses are clearly lifesavers at the bedside, hospital rooms are scarce. These frontline workers need the partnership of nurse case managers to arrange safe discharges and free up beds for those waiting in the ER. But this partnership provides much more than just discharges.

Nurses have a unique perspective that is vital in every area. This idea was explained well in 1952 by Hildegard Peplau, “mother of psychiatric nursing,” who understood the strength of nurses that could create a personal connection with their patients. She created a Theory of Interpersonal Relations, where she named 6 main roles for nurses which could be applied individually according to the needs of the patient. This differentiation of roles including counselor, surrogate, teacher, stranger, resource person, and leader can help nurses today in many different areas of care beyond psychiatric nursing. I believe it has been very beneficial for RN case managers working alongside bedside nurses to fulfill these roles for patients during this pandemic.

These behind the scenes case managers efficiently arrange placement while taking the time to comfort patients and family members, filling the role of counselor, which allows the patient to express their feelings to the case manager. In a time of urgency, these nurses can be a listening ear for family members to process their worries and discuss medical conditions. Often information has been relayed, but family members don’t want to take time away from the bedside staff with clarifying questions. The loved ones value the time and sacrifice given so highly that they are willing to forgo understanding. I personally filled the role of surrogate, which allowed me to fill in for family, when I had a patient who never told his bedside nurse he was a vegetarian because he didn’t want to bother her. He was only eating the bread of his sandwiches. I was able to speak with his spouse who informed me of his diet, and quickly messaged the nurse who changed his meal that very day. The teacher role is something nurses are excellent at providing in normal circumstances, however this pandemic has created a unique need for patients to be educated on a novel virus.

As with all nurses, case managers connect with their patients and loved ones, and want the best outcome for all involved. This in it’s simplest form if fulfilling the stranger role by offering the decency that should be given to any human. However we know that we often connect deeper with the emotions of a patient. For example, a fellow case manager cried with a family member about no visitation policies, because we all mourn the necessary changes needed to slow this pandemic. While continuing these much needed conversations, case managers arrange for home health or skilled nursing admissions. If we can find placement for recovered patients, those who are sick and waiting in holding areas of the ER can receive care from our skilled floor nurses. I worked tirelessly to find an open bed in another state for a pt while discussing end of life decisions with another family, fulfilling both the resource role providing information and the leader role offering direction with the patient’s wishes. It takes so many people working together to provide care in these unprecedented circumstances we find ourselves fighting.

Nurse case managers truly maintain the flow of care so we can provide the maximum benefit to as many patients as possible. Without nurse case managers there would be nowhere for our loved ones to go. And with them we can fulfill the necessary roles as described by Peplau needed to care for our patients.

About Christy McDonald

Christy is a hospital case manager in a large metro healthcare system. She had the privilege of being a bedside NICU nurse for 17 years before moving into Case Management. She has cared for those in public schools, remote Haiti, and the hospital setting. She serves on the Board of Directors for a Haitian NICU and children’s home.

Guest post: Aesthetic Knowing: A Transformative Encounter

Contributor: Bibiane Dimanche Sykes

Knowing is an elusive concept. It is fluid, and it is internal to the knower (Chinn & Kramer, 2018). Carper (1978) identified four fundamental patterns of knowing for an understanding of the conceptual structure of nursing knowledge. The four patterns are classified logically to elucidate aspects of empirics, personal knowledge, ethics and aesthetic knowing in nursing. Here, the pattern of aesthetic knowing is demonstrated through the actions, comportment, thoughts, behaviors and exchanges of the nurse’s relationship with the patient. It is aesthetic knowing that allows us to navigate when faced with nuanced situations.

The Call

It was late on a Tuesday morning. I was pleased to finally have a few days of rest from work and was already planning how I was going to spend my second day off, when I heard the ring tone from my phone. I glimpsed at the phone screen and noticed that it was a number I was unfamiliar with, so I decided to skip the call and told myself that they can always leave me a voice message if it is important. Ten minutes later, I heard the same familiar ringtone of my phone. This time it was coming from work. “Oh my,” I thought, what could it be…. did I forget to enter a note on the computer, or have I failed to sign the medication sheet? When I picked up the phone, the Director of Nursing at the subacute nursing facility I worked for was on the line. She mentioned that Ms. Smith’s situation took a turn for the worse; her condition had weakened overnight. According to Nancy, the Director of Nursing, Ms. Smith had been asking to see me since yesterday, and it was her nephew whose desperate call I had moments earlier ignored.

Nurse-Patient Relationship

Ms. Smith was a 75-year-old widow who moved about 7 months ago to the hospice unit where I worked as a charge nurse. Her overall health and well-being had since deteriorated. Her cancer had metastasized to other adjacent organs of her body, and treatment was no longer a viable option. She had very little family support. Her only living relative was a nephew who visited occasionally. Although she had many other disciplines assigned to her care, she seemed to gravitate more towards me. I also enjoyed her company and spent many hours of my free time listening to her joys and regrets about life. I would play her favorite songs, encourage her to eat, to bathe, and to take her medications, before her pain became unbearable. She looked forward to the days I was at work, and I would always stop by her room for a chat whenever I had the chance. She confided in me and shared many of her life and death expectations, which included the minute details of her imminent death and funeral wishes. She and I developed a bond and maintained a caring nurse-patient relationship that encompassed understanding, trust and compassion.

The Encounter

It was already afternoon when I rushed into Ms. Smith’s room that Tuesday. She seemed agitated; however, she immediately became calm at the sound of my voice, telling her that it was going to be okay. As I was helping her take her prescribed medications, she appeared to be hallucinating. She kept on saying something about not being able to get on the bus. She was becoming restless and continued to repeat this for about an hour. I finally approached her and asked why she was not able to get on the bus. She opened her eyes for the first time since I entered her room and mumbled, “they wouldn’t let me, I don’t have money to pay for it.” I was devastated at the thought of that. I knew this day would come but still I was becoming emotional. I reminded myself that I needed to stay on course to help fulfill her wish of an undisturbed, smoothed transition. I thought for a second, what could I do to alleviate her suffering at this moment? I searched in my pocket and found a quarter. I slipped it into her hand and whispered in her ear, “use this for your bus fare, it’s going to be fine.” I felt her tight squeeze as she received the quarter, and less than five minutes later, Ms. Smith peacefully took her last breath with poise and dignity.

Aesthetic Knowing

Aesthetic knowing is what makes possible knowing what to do and how to be in the moment, instantly, without conscious deliberation (Chinn & Kramer, 2018). I am currently an adjunct professor, teaching nursing fundamental to first year students. Every semester, I share this experience with my students. It serves as the perfect introduction to the conceptual framework of the nursing discipline through the patterns of knowing (Carper, 1978). The patterns of knowing in nursing ultimately presents a tool for developing abstract and theoretical thinking in the classroom. It allows for broader, clearer perspectives and self-integration of the concepts of empirics, personal knowledge, ethics and finally aesthetic in nursing education (Carper, 1978). This transformative encounter that I had experienced with my patient embodies the true essence and elements of aesthetic knowing.

Sources

Carper, B. (1978). Fundamental patterns of knowing in nursing. ANS. Advances in Nursing Science, 1(1), 13–23. https://doi.org/10.1097/00012272-197810000-00004

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

Aesthetic Knowing. (2021, February 2). https://nursology.net/aesthetic-knowing/

About Bibiane Dimanche Sykes

Bibiane Dimanche Sykes is a student in the Doctorate of Nursing Education (EdD) Program at Teachers College, Columbia University. She earned a Master of Science degree in Nursing Education at Mercy College in Dobbs Ferry, New York. She’s an Adjunct Professor at Mercy College in Dobbs Ferry, New York and also works as a Clinical Nurse Quality Assurance in New York City. Bibiane is a wife and mother of 4 sons. She enjoys reading, traveling and prides herself in giving back to the community. She serves her community through various philanthropic and nursing organizations.

Guest Post: Restriction of Visits to Hospitalized Child? An Emerging Need for Theory-Informed Nursing Intervention during Pandemic

Contributor: Ana Filipa Paramos

In Portugal during the pandemic crisis, we have made it impossible for the family to be present during the child’s hospitalization, resulting in increased levels of separation anxiety and stress, with potential negative consequences for the child’s recovery process. Let’s talk about a specific case of a child with a prolonged hospital stay in the middle of a pandemic and unable to have his father visit during the hospitalization. The little boy was accompanied by his mother, but the family nucleus of this child includes his mother and father. Did they speak by cell phone? Yes, they did, but the physical presence and eye contact are not replaceable by a phone call. One afternoon of that long hospitalization, I found the child angry, crying and looking away from our approach, as if he almost blames us for the impossibility of the father being present during the hospitalization. I wondered how we could make this situation less stressful and anxious for the child.

The adoption of a humanistic approach through the use of the Humanistic Theory of Nursing proposed by Josephine Paterson and Loretta Zderad was needed. According to Paterson and Zderad (2007), nursing is seen as an experience lived among human beings that responds to a human need. This theory requires the recognition of the human being as a unique being, endowed with his singularity and, simultaneously, that there is an understanding of the individual characteristics, experiences and needs of each patient (Paterson & Zderad, 2007). Through the dialogue established between me and the child, I understood that his father’s visit was extremely important for the child, since he had a very strong connection with the father.

During our dialogue, there were tears, uncontrollable tears in the child’s eyes. Unable to allow the father’s entry, I asked myself, “How will I be able to respond to this child’s needs?” It was at that precise moment that we decided to place the child’s bed next to the window, allowing the child to establish eye contact with his father, that long awaited and desired eye contact. Immediately after the father’s visualization, a smile and happiness emerged in the child. This contact allowed the immediate decrease in the levels of separation anxiety experienced by the child.

© 2021 Ana Filipa Paramos
Child’s bed next to the window, allowing the child to establish eye contact with his father

in Humanistic Nursing Theory, the concept of nursing does not only address patients’ wellbeing but also patients’ better being, helping them to make the health/disease situation experience as human as possible (Paterson & Zderad, 2007). We must remember that each patient is a person with needs, anxieties, fears and desires that have to be met, regardless of whether we are in the middle of a pandemic or not. We have to try to make the hospitalization experience as less stressful and as comfortable as possible for the patient and, in this case, the father’s visit was an emerging need of this child. Not being a normal visit, the establishment of eye contact through the window was the closest it could be, and it brought immediate happiness to the child. I heard the word “thank you” associated with a look of tenderness and tranquility. Unable to show my smile behind the mask, my eyes shone, and a tear appeared in the corner of my eye, such was the happiness I also experienced at the moment. My experience with the child was an enriching moment for both of us and allowed us both to develop, becoming more and better, of that I have no doubt. We cannot forget that times are difficult and challenging for everyone, but the experiences lived with the patients cannot be put aside in our daily nursing practice.

References

Kleiman, S. (2010). Josephine Paterson and Loretta Zderad’s Humanistic Nursing Theory. In M.E. Parker & M. C. Smith (Eds.), Nursing Theories and Nursing Practice (3rd ed, pp. 337–350). Philadelphia: F.A. Davis Company.

Paterson, J., & Zderad, L. (2007). Humanistic Nursing. http://www.gutenberg.org/ebooks/25020

Wolf, Z. R., & Bailey, D. N. (2013). Paterson and Zderad’s Humanistic Nursing Theory: Concepts and Applications. International Journal of Human Caring, 17(4), 60–73. https://doi.org/10.20467/1091-5710.17.4.60

About Ana Filipa Paramos

I have finished my Nursing Degree in 2016, at Escola Superior de Enfermagem de Lisboa (ESEL). In 2016, I started working as a general nurse at Centro Hospitalar Lisboa Central, more specifically at Hospital Dona Estefânia. From 2016 to 2019 I worked at the pediatric surgery/ pediatric burn unit and in the beginning of the pandemic, I have integrated the pediatric respiratory unit/ COVID, where I currently am.

In 2020 I entered the Master Nursing Course of the Health Sciences Institute of Universidade Católica Portuguesa (Lisbon). This post was made in the nursing theories curricular unit, with the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).