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.

Selling Theory

He lounged in the chair, laptop nestled in his lap. “Here, look at this,” he waived toward his screen.

I bent over, squinting, and saw a colorful graph of lines that reminded me of a holiday decoration. “It’s a stochastic model of cellular growth….” He went on to mention the conditions that were being modeled, and I marveled at how these predictions were created.

He turned to face me. “You know, the problem with social sciences (and nursing) is it’s too imprecise. You can’t replicate the studies and find the same results. The conclusions tend to way over-estimate the sample from which the data are drawn. Your theories don’t really reflect science.”

I studied his face and tried to determine whether he was serious. He knew my work and was aware of my approach to theory as a conduit to build science and expand knowledge. I am steeped in the Continental philosophy of human science; I believe in the Truth, but also with humans living different realities and how our personal narratives intersect to create the political. I believe that language not only reflects reality, it creates it. I subscribe to the notion that discourse is important to deconstruct as power relations (hegemonies) embedded in them are often unnoticed without such analysis.

Perhaps I was taking the conversation too seriously, but such science as this young man described and the data science paradigm are oozing – flooding really – into crevices of thought and science at a pace that makes me queasy. The battle of the empirical way of knowing overshadowing other ways of knowing (Chinn & Kramer, 2018) is amplified in the call to harness the seemingly infinite data collected daily that is supposed to tell us something of the human condition. What are these data trying to tell us? Patterns may be revealed without hypotheses. Theories were unnecessary for machine learning as one statistician told me, “You use machine learning when you don’t know what you’re going to find.”

This seems heretical for a theorist. I wanted to sell theory even harder.

In automatic cognitive reactions, I convey to those around me how important theory is — that the use of theory can inform, organize, and enlighten. I thought of Sarah Szanton and Jessica Gill’s (2010) work, Society-to-Cells Resilience Theory – could it be applied to stochastic methods? I thought of other times when I “sold” theory:

  • One of my colleagues asked for input on a community engagement proposal in the context of substance use and stigma within rural communities. I steered her to the Rural Nursing Theory of Winters and Lee (2018) and their remarkable understanding of concepts unique to rural dwellers, such as insider/outsider, the meaning of work, and so forth.
  • A doctoral student examining physical activity in couples – absolutely, I told her, see Pender’s (2011) health promotion model as this will help organize the co-variates.
  • Teaching advanced theory with enrollment from other healthcare professions, including pharmacy. I boasted about nursing’s rich theoretical foundations and how nursing can inform other disciplines in myriad ways. I applaud the student when she finds a singular concept analysis within her discipline.

But then, I give pause. With recent discussions surrounding racial and ethnic disparities, and decolonizing nursing theory, I question whether I am “selling theory” with a bit too much enthusiasm. I think of all the other Truths out there based on personal experience, which is a microcosm of the political. I think of the mix of what is current politically in juxtaposition with theory, and how the tight weave of beliefs leaves me looking for solid answers and coming up empty at times.

Without reflectivity and critical appraisals of what we believe – and try to sell – we are guilty of stagnation. We are guilty of ignorant exclusion. Now, with calls to examine our fundamental assumptions framed within privilege, do we “sell theory” with the same enthusiasm? I’m uncertain, but certain of caveats. We need to acknowledge the knowledge of other theoretical possibilities we haven’t addressed. We can accept “not knowing what we don’t know,” and with just as much enthusiasm explore our ignorance. We can honor those whose work has moved us forward, and move out of the way, or ask for a place alongside, of those who are informed in new ways or in ways that we didn’t listen to before. We must be committed to inclusion and diversity of thought, of the personal as political. As theorists, we are motivated to refine, refresh, extend, edit, delete, and discount. Only when we stop these activities, only when we think “we’re done,” will we be guilty of over-selling theory.

With a sigh, I look over again at the young man with his stochastic graphs and models. He’s been pushing buttons on his laptop, growing his models, as I have been reflecting on theory’s role in nursing. I kiss him, my son, on the cheek, and say with certainty, “We both have a lot to learn.”

References

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

Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2011). Health Promotion in Nursing Practice (6th Edition). Pearson.

Szanton, S. L., & Gill, J. M. (2010). Facilitating resilience using a society-to-cells framework: a theory of nursing essentials applied to research and practice. Advances in Nursing Science, 33(4), 329-343.

Winters, C. & Lee, H. J. (Eds.). (2018). Rural nursing: Concepts, theory and practice. (5th ed.). Springer Publishing Company.

Guest Post: Mid-Range Theory: In the Gap or In The Dark?

Contributor:
Teresa Tarnowski Goodell, PhD,RN,TCRN,CWCN

A recent post by Karen Foli presents a perennial nurse educators’ problem: students finding nursing theory irrelevant in practice. A commenter wrote, “If I have a patient crashing, I’m not going to stand there and theorize about how to treat the patient!.” The remark illustrates the theory-practice gap perfectly; the notion that there is little practical utility in nursing theory “at the bedside.”

Nursing theory describes and differentiates us from other professional disciplines, yet many practicing nurses struggle to integrate theory into their practice, perhaps because nursing theory is not recognized by most practice settings. (I certainly didn’t see much of it in my 30 years in intensive care.)

“the strange fish in water…” by Biscarotte is licensed with CC BY-SA 2.0. To view a copy of this license, visit https://creativecommons.org/licenses/by-sa/2.0/

Practicing nurses swim in the water of the medical model. Just as the fish says, “Water? What water?” when asked “How’s the water?,” nurses don’t always realize that they are swimming in the water of the medical model in their practice setting. Nurses implement both nursing and medical models, yet only the latter holds sway in many practice settings.

The electronic health record serves as an indicator of the widening theory-practice gap. Filled with checkboxes for medications, procedures, and physical exams, the EHR leaves little room for documenting nursing theory-guided practice. Built on the medical model and optimized for billing and regulatory purposes, the EHR cannot capture self-efficacy, unmet needs, living with unpleasant symptoms or helping, all concepts informed by nursing mid-range theories.

The EHR is also poor at capturing individual characteristics, such as whether someone is a night shift worker who sleeps during the day. Even when mid-range theories are in the back of a nurse’s mind, quietly informing practice, they are not visible in documentation. Because they are not seen, they become less valued by nurses and other health professionals.

The theory-practice gap affects research as well. Evidence-based practice is inhibited by a lack of research guided by nursing theory. While our colleagues in medicine rarely cite a theoretical framework, one is expected, and useful, in nursing research. Nurses acknowledge that there are many ways of viewing health and illness. Still, the medical model predominates in practice settings, inhibiting broader research implementation. Individual nurses can’t implement research based on nursing theory; nursing practice must make sense to others and must be visible in the EHR. Thus, practicing nurses who decry the pointlessness of nursing theory can’t be blamed; they practice in an environment where, for example, documenting self-efficacy for breastfeeding is irrelevant to other users of the health record. There is no checkbox for it.

My cynical side says the medical model is linked to payment and regulatory oversight, and thus will continue to prevail in clinical settings. This calls upon us to ask: how then do we acknowledge, incorporate, and communicate nursing theory within our own profession, and also outside it? How do we implement evidence-based, theory-driven nursing practice when large parts of research and practice are driven by the medical model? Nurse educators have been doing this work, but we also need drivers of change in the clinical setting.

I envision a time when nurses study pharmacology, yes, but other health professionals also study Kolcaba’s Theory of Comfort (for example.) A time when the EHR captures more than medications, procedures and physical exams. When nurse informaticists play a key role in design of clinical information systems, incorporating nursing models, interventions and observations into the EHR. Improving the presence of nursing knowledge in the EHR will not only provide practicing nurses with more complete information about the person, but it will make nursing more visible to other professionals. Changing clinical settings entrenched in the medical model will be hard. How do we develop nurse change agents to get us there?

About Teresa Goodell

Gerontology, trauma, and skin/wound care clinical nurse specialist. Now retired from clinical setting, I serve on the board of a hospice and teach trauma continuing education. I’ve been an RN for 38 years and a clinical nurse specialist for 27 years. Nurse educator in academic and continuing education settings for 26 years.

The Intersections of Nursing Scholarship and Nursing Activism

In the early 1980s  when Maeona Kramer and I first began to put together ideas for a text on theory development in nursing, we were committed to addressing nursing knowledge development beyond the typical boundaries of empirical research and theory development.  We had both completed, in 1971,  doctoral degrees in Educational Psychology (Maeona at Wayne State University in Detroit, and me at the University of Utah) focusing on theory development in education (nursing doctoral degrees at the time were few and far between).  For that first edition we drew on the work of a psychologist named Zygmunt Piotrowsky (1971)  who had proposed that the development of knowledge required contributions from scholars with different personalities, some who were drawn to theoretical abstract thought, and some who were drawn to concrete empirical “laboratory” science. 

In 1987 when we embarked on the 2nd revision of our book now titled “Knowledge Development in Nursing” we introduced Carper’s fundamental patterns of knowing in nursing, which gave us a starting point for narrative clearly grounded in the discipline of nursing. In the 3rd edition (1991) we turned our attention to revising our language from the stilted tradition of what was once considered scholarly writing to language that was more accessible and gender neutral.  By 1999, we realized that simply listing and describing Carper’s patterns of knowing fell short; we needed to project ways in which knowledge is developed for each pattern of knowing.  This evolution made it possible to articulate our belief that nursing knowledge encompasses so much more than that which can be studied empirically.  However, we continued to have this sense that something was missing, and in 2008 we articulated the emancipatory pattern of knowing. 

It was the growing and compelling body of nursing literature focused on critical social theory, socio-political knowing, and social justice that gave us the impetus, in 2008, to develop the emancipatory pattern of knowing. We see this not as simply a fifth pattern of knowing, but rather as the fundamental human capability to see a situation, recognize that something is amiss, and create ways to change the situation – an ongoing process in creating nursing knowledge that is necessary for the development of knowledge related to any of the four fundamental patterns of knowing.   

We had finally arrived at the intersection of social activism and the development of nursing knowledge.  But what does this really mean?  It is now over a decade since we first conceptualized what emancipatory knowing means, and the possibilities that this pattern of knowing holds for the future development of nursing.  We have been puzzled by the fact that it took us so long to see the connections and have speculated why this might be so (the long-standing subservient positions of women and nurses, the socialization to avoid that which is political, the dominant concern with one-to-one “bedside” care, etc. etc.). 

The fact has been that nurses, dating from the earliest days of the profession, have engaged in social and political activism, but have remained reticent to fully embrace social activism as a core nursing concern. Maeona and I both had been actively involved in the 1980’s effort to advance feminism in nursing through the work of “Cassandra: Radical Feminist Nurses Network.”  In 2000, Richard Cowling, Sue Hagedorn and I  wrote “A Nursing Manifesto: A Call to Conscience and Action,” acknowledging that at its core, nursing itself is “political” in the sense that politics is the ability to advance one’s own values in a public context.  Every time a nurse acts to bring nursing values into action, bends over backwards, jumps through hoops, and does cartwheels to obtain what individuals and families and communities need to be healthy, we are acting politically.  We are activists.  

The values of our discipline, expressed eloquently in the theories and conceptual models that form our foundation, guide our thoughts, words and actions. At the same time, our intimate engagement with others as we practice nursing, also informs what we think and do, opening awareness of ways to challenge, question and re-design the nature of our discipline.  The social and political contexts we face in this moment call for a new awareness of distortions, prejudices, stereotypes, social injustices amplified by racism. What is happening in this moment of time has raised alarm bells and demands that we turn our gaze on ways in which we nurses, individually and collectively have been complicit. The situation we find ourselves in today calls for nurses, and particularly white nurses, to finally recognize the dynamics of racism that infect our own “house” and start the tedious, and yet ultimately rewarding, process of healing.

In facing this challenge, we will begin to understand the dynamics of the widespread public health crisis of racism in ways never before attempted.  The development of knowledge demands that we understand the problem, explore the dynamics that sustain the problem, seek new ways to prevent and change those circumstances that perpetrate the crisis, and heal those who are affected.  There are theories and philosophies of our discipline that can guide us as we move forward.  Here are a few to consider:

This website – Nursology.net – is accomplishing the very important purpose of bringing to the fore the rich traditions and values expressed in the theories, models and philosophies of our discipline.  And now the time has come to recognize the ways in which the practices, attitudes, philosophies and thought patterns that derived predominantly from white perspectives are lacking.  This reality now calls for activism of a type not often recognized – a sustained and determined challenge that can change our own disciplinary ways of thought and action.  This does not mean in any way that we discard or denigrate our foundation, or that we disrespect the ways in which our own scholarly work has real value.  What it does mean is that we examine our accomplishments through a new lens, and recognize ways in which we need to re-direct course.  

Take as an example my theory and practice of “Peace and Power.” This theory was inspired in part by the Brazilian scholar and activist Paulo Freire (1970), and is closely aligned with practices commonly used in native American cultures and in Quaker communities. Yet people of color have also challenged this process as reflecting colonized white privilege – despite the commitment embedded in the processes that seek to dismantle power inequities in group processes.  Part of this challenge came from the early descriptions of the process that clearly reflected the concerns of white women and defined by white feminists. The fact is that the lens through which I view these ideas bear “decolonization.” What this means exactly is still in process, requiring a deep deconstruction of the Euro-centric assumptions on which the theory and process is built.  How this will affect the theory itself remains to be seen, and may be actually accomplished by scholars of the future!  

The time has come to shift this process in to high gear – to recognize the ways we have silenced the voices of many of those we claim to serve, ways in which we have excluded nurses of color from participating in our efforts to develop the knowledge of the discipline, and ways in which white nurses have in fact dehumanized, disrespected and excluded nurses of color from full participation in the practices, leadership and development of the discipline.  This is not an activist project that can happen in one or two “training” sessions addressing “diversity, inclusion and equity.” Nor can it be accomplished by performative actions such as recruiting more people of color, or curriculum revisions.  Although of course these kinds of actions are warranted and need to happen they will not in themselves end the inequities and injustices of racism.  There are no formulas.  

I believe that the activist commitment of all nurses now and going forward is to learn all we can about the mechanisms of both systemic and everyday racism, question each choice we make in light of our growing awareness, challenge one another with loving kindness, and create spaces that challenge white privilege.  The “Overdue Reckoning on Racism in Nursing” discussion series has now ended but in those discussions we established a starting point, including important resources for becoming well informed about the challenges we face. Now we have new actions to continue this work, centering nurses of color and engaging white nurses in meaningful processes consistent with the ideals of “truth and reconciliation.”  

While these actions are labeled as “activism” they are also vital in shaping nursing knowledge going forward.  Becoming immersed in social and political activism to address the public health crisis of racism, guided by the values of our discipline, we provide the best of nursing care to heal ourselves, to heal the damaging effects of racism in our communities, and build a stronger future.  We create the ‘hermeneutic circle” of thought and action – where our actions inform how we think, and how we think shapes our action in a constant process that changes and shapes both thought and action going forward.

Sources

Freire, P. (1970). Pedagogy 0f the oppressed. Seabury Press.

Piotrowski, Z. A. (1971). Basic System of All Sciences. In H. J. Vetter & B. D. Smith (Eds.), Personality Theory: A Source Book (pp. 2–18). Appleton-Century-Crofts.

What is Reflected in a Label about Health? Non-Nursology and Nursology Perspectives

Posted the first week of March, which is designated as
National Words Matter Week

A long time ago, I read an editorial in a journal decrying the labels for women’s reproductive health issues. The point was that labels such as incompetent cervical os are pejorative words. At about the same time, I began to think about what we mean when we say that a person (called a patient or a client) does not comply with or adhere to a treatment plan. It seems to me that these words reflect the physician’s or the nursologlist’s prescriptions for the patient, which in turn, reflect the physician’s or the nursologist’s power over and control of the patient.

Indeed, Hess (1996) pointed to “connotations of paternalism, coercion, and acquiescence” (p. 19), and Bissonnette (2008) and Garner (2015) noted the power imbalance and loss of patient autonomy inherent in referring to a patient as non-compliant or non-adherent. I doubt that few if any nursologists would knowingly sanction paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Yet we continue to label patients as compliant or adherent if they do whatever they were supposed to do and as non-compliant or non-adherent if they do not do whatever they were supposed to do.

The issue, of course, is to identify a label that can be used to accurately reflect what happens between a person who is a patient and a person who is a healthcare worker as they interact in matters of health without an overlay of paternalism, coercion, acquiescence, power imbalance, or loss of autonomy.

Most, if not all, nursology conceptual models and theories include consideration of the person’s perspective of the health-related situation and may include a process that addresses how the situation is viewed and resolved. For example, the practice methodology associated with Neuman’s Systems Model includes the perspectives of both the person and the healthcare worker throughout the entire process of diagnosis, goals, and outcomes. The practice methodology associated with King’s Conceptual System is even more explicit, with mutual goal setting, exploration of means to achieve goals, and agreement on means to achieve goal. However, the practice methodologies associated with these nursology conceptual models and theories do not include a label for what happens if the patient does or does not do what had been agreed upon.

I have not yet identified a satisfactory label for what actually happens. However, I suspect that turning to nursology theories of power may provide at least the beginning of an appropriate label. For example, Barrett’s theory of power as knowing participation in change sensitizes us to the distinction between power-as-control and power-as-freedom. Barrett maintained that power-as-freedom involves awareness of what is happening, knowingly participating in choices to be made about what is happening, having the freedom to act intentionally, and being fully involved in creating changes in whatever is happening. Perhaps, then, the label could be knowing participation.

Another example is Chinn’s peace as power theory, which sensitizes us to the distinction between peace-power and power-over. The process of peace as power encompasses cooperation and inclusion of all points of view in making decisions. Accordingly, healthcare decisions are based on thoughtful choices as the person and the healthcare worker work together to promote wellness and growth. Perhaps, then, the label could be thoughtful cooperative choices.

What other label might be even more accurate? How can nursologists actualize our moral goal to do “good for the one for whom the [nursologist]” cares”? (Hess, 1996, p. 19). What label should we use to clearly reflect our ethical knowing? Hess’ (1996) discussion of ethical narrative suggests that cocreated narrative may be the accurate term. She explained, “ethical narrative is crafted by the client and [nursologist] to express the good they are seeking” and that ethical narrative is achieved “through engagement” (p. 20).

Labels, which are words, matter for many, many reasons. Labels may reflect paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Labels also may reflect racism and privilege and other words that perpetuate colonialism (McGibbon, Mulaudzi, Didham, Barton, & Sochan, 2014). We must, therefore, identify and consistently use labels that are consistent with ethical knowing in nursology, with clear understanding of “their meanings and the underlying philosophies or perspectives that they connote” (Lowe, 2018, p. 1).

This blog is adapted from Fawcett, J. (in press). Thoughts about meanings of compliance, adherence, and concordance. Nursing Science Quarterly.

References

Bissonnette, J. M. (2008). Adherence: A concept analysis. Journal of Advanced Nursing, 63, 634-643. Available from: http://dx.doi.org/10.1111/j.1365-2648.2008.04745.x

Gardner, C. L. (2015). Adherence: A concept analysis. International Journal of Nursing Knowledge, 26, 96-101. Available from: http://dx.doi.org/10.1111/2047-3095.12046

Hess, J. D. (1996). The ethics of compliance: A dialectic. Advances in Nursing Science, 19(1), 18-27.

Lowe, N. K. (2018). Words matter. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 47, 1-2.  Available from: http://dx.doi.org/10.1016/j.jogn.2017.11.007

McGibbon, E., Mulaudzi, P. M., Didham, P., Barton, S., & Sochan, A. (2014). Toward decolonizing nursing: The colonization of nursing and strategies for increasing the counter-narrative. Nursing Inquiry, 21. 179-191. Available from: http://dx.doi.org/10.1111/nin.12042 (See also https://nursology.net/2020/01/14/decolonizing-nursing/)

Nurse-Specific Trauma: Let’s Give It a Name

Welcome to Karen J. Foli, PhD, RN, FAAN who is joining the
Nursology.net blogging team! Karen is the author of the
Middle Range Theory of Nurses’-Psychological Trauma, the
Middle Range Theory of Parental Postadoption Depression
and co-author of the recently published book
The Influence of Psychological Trauma in Nursing

Karen J. Foli

When I was earning my PhD, my cognitive world opened up. I learned about how discourse not only reflects reality, it creates reality. In my estimation, The Influence of Psychological Trauma in Nursing allows us to see a reality that eluded us before. Decades later, I find my work in nurse-specific trauma reflecting truth and creating a reality that nurses experience, but couldn’t name. Therefore, their reality of it didn’t exist.

We often hear about compassion fatigue. Its etiology is linked with secondary or vicarious trauma, created by seeing others suffer and experience traumatic events. Conversations abound about how nurses need to be resilient and use resiliency as a buffer to mitigate secondary trauma and secondary traumatic stress. The issue of individual versus organizational culpability in nurse-specific trauma is one that is needed, and for another time…

In addition to secondary trauma, there are six additional nurse-specific and nurse-patient-specific traumas that I have named, described, and provided context for (Foli & Thompson, 2019): historical or intergenerational trauma; workplace violence, system-induced or medically induced trauma, second-victim trauma related to medical errors, trauma from disaster work, and insufficient resource trauma. This final type of trauma is one that I have recently coined based on a current study, the findings of which I will present at the upcoming American Academy of Nursing conference as an e-poster (Foli, 2019).

Insufficient resource trauma. Now that’s a new reality. Every single nurse I have spoken to quickly nods their head in affirming its existence. It’s the trauma that occurs when nurses do not have the knowledge/expertise, personnel, accessibility to other professionals, supplies, and tangible and intangible resources to fulfill their ethical, professional, and organizational responsibilities.

As a nurse… think of being placed in an unfamiliar patient situation with no one to call for help. Think of the shift you are working with an overload patient assignment and two of your patients “go bad.” Think of the phone incessantly ringing on your day off to come in because of short staffing and the guilt experienced because there is no way you can work another shift and be safe. Think of the medication that will be late because pharmacy made an error and the physician on call hasn’t answered the page and you need an answer stat. Think of going into a supply room for the dressing kit and the shelf is empty. But most of all, think of the patients’ call lights that go unanswered because there aren’t enough nurses to render care.

It’s not just a shortage of resources that cause insufficient resource trauma. It’s the push to do more in the time we have, including tackling the electronic health record and as we’ve known for years, sicker patients. In a recently published letter to the editor, “Decline of the American Nursing Profession,” Vignato (2019) describes the decreasing time spent with patients: “.. changes in our health care system are transitioning nurses away from a therapeutic relationship…With these time constraints, nurses are left to complete scripted tasks” (p. 255).

As a result, patients don’t obtain the care they need and deserve. The tendency to see them as tasks to do increases. Nurses leave the units at the end of their shifts feeling guilty, anxious, and isolated. It’s the stuff that kills our spirits.

A common metaphor used in understanding trauma, the iceberg, symbolizes the large mass of “stuff” that’s underneath what is visible. The proportion is such that what is above the water is a fraction of the frozen ice beneath the water’s surface. In the hidden, murky depths lies our processing of trauma, our feelings, needs, desires. Above the surface, for all to see are our behaviors that are born from trauma.

While I believe this metaphor is useful, I also assert that nurse-specific trauma, as events and habitual occurrences, are readily visible to others (Foli & Thompson, 2019). We have an audience watching most of our traumas day in and day out. But are we, our peers, our leaders paying attention?  Let’s give these traumas a name, let’s build reality, and then, let’s get to work on preventing what we can prevent and fixing what we can fix.

References

Foli, K. J. (Accepted; 2019). Nurses’ trauma: “They leave me lying awake at night.” E-poster. American Academy of Nurses 2019: Transforming Health, Driving Policy Conference, Washington, DC, October 24-26, 2019.

Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Indianapolis, Indiana: Sigma.

Vignato, J. (2019). Letter to the editor: Decline of the American nursing profession. Journal of the American Psychiatric Nurses Association, 25(4), 255-256. doi: 10.1177/1078390319826702

Are We Ready to Utilize Concept Analyses To Advance Nursology? Could This Be a Way Forward?

Rosemary, we found a recent citation of your research”, is a message I receive from ResearchGate whenever there is a new citation to my work! One message was another citation to one of my early papers (Eustace & Ilagan, 2010), which was the report of a concept analysis of HIV disclosure, published in the Journal of Advanced Nursing. Noteworthy is that this message was a report of the 50th citation to that paper. In the world of knowledge generation, this was particularly exciting news because I realized the impact the paper had for other scholars.  What I didn’t realize was the magnitude of influence the paper had in advancing nursing knowledge. This led me to some random thoughts on who exactly are these authors who cited my work and what was the context of their citations of my paper? A brief review of the citations and literature about the topic indicated that majority were from papers published in non-nursing journals and authored by non-nursing scholars. In addition, I found that some publications from nursing that examined closely related concepts did not cite my work. This surprised me but increased my curiosity about what all of this meant to me as a nursology scholar.

During a recent search of literature, I found an inspiring article by Rodgers et al. (2018) about the limitations of concept analysis. They underscored the importance of “moving knowledge development beyond the level of ‘concept analysis’ to developing a clear linkage to the resolution of problems in the discipline” (p. 451).  I asked myself, how can we do that? Do we have the theoretical and methodological knowledge to do that?  If we do, why are we still “stuck” on concept analysis per se?

These questions prompted me to reflect on my concept analysis of HIV disclosure (Eustace & Ilagan, 2010). I asked myself, what has been done to move beyond the concept analysis of HIV disclosure during the intervening years? A search for the citations using the Semantic Scholar impact search engine (https://www.semanticscholar.org) revealed that one replication of my concept analysis has been published (Kanyamura, Ncube, Mhlanga, & Zvinavashe 2016). Surprisingly, although the impact of the publication indicated was highly influential to others work, especially for background data, the impact of the analysis findings was very limited (see Figure 1). What this meant to me was that there was no indication of linkage of the concept analysis results with knowledge development. Inasmuch as this finding is consistent with Rodgers et al.’s (2018) concern that concept analyses are not being extended to resolve disciplinary problems, how, can we help nurse scholars advance science in this area? Is there a way?

Figure 1: Semantic Scholar Impact Output for the concept of HIV Disclosure by Eustace and Ilagan (2010)

One way forward is to develop clear guiding structures for nursing knowledge development as an essential step in closing the gaps between theory, research, and practice (Marrs & Lowry (2006). To help find a solution, I turned to the well-known approach of Conceptual-Theoretical-Empirical (CTE) structures in nursing that have been advocated for many years by Dr Jacqueline Fawcett (e.g. Fawcett, 1988; Fawcett, 2012). So, where do we start? I propose that nurse scholars consider the following 3 critical steps:

Step 1: Nurse Scholars need to examine where a nursing concept of interest is derived from within our nursing models/theories. For example, the case of the concept of HIV disclosure can be situated within the nursing model of HIV Disclosure developed by Bairan et al. (2007) (i.e. relationship model). It is important for the nurse scholar to indicate the purpose of the concept analysis: is there a need for clarification, development, or refinement or is there little or no literature about the concept? These queries will guide the scholar to the appropriate concept analyses methods. The selection of HIV disclosure, in my case was the lack of a clear definition and a broader perspective of the HIV disclosure process in both the Bairan et al. (2007) model and in other HIV disclosure models (e.g. disease progression (Kalichman, 1995 ); consequences model (Serovich, 2001).

Step 2: Nurse Scholars need to develop a conceptual theoretical empirical (CTE) structure for linking concept analyses to the next step in theory generation. As described by Fawcett and Gigliotti (2001), theory generation studies usually proceed from the “conceptual model directly to the empirical research methods and the data obtained is analyzed creating a new middle range theory” (p. 342). Thus, the CTE structure should direct the nurse scholar to the relevant literature for the concept analysis, which will be summarized and synthesized to identify the antecendents, attributes and consequences of the new descriptive middle-range theory of the concept of interest (see Figure 2 for an example of the CTE structure for the concept analysis of HIV Disclosure). The “C” in the CTE structure represents the HIV Disclosure Conceptual Model by Bairan et al. (2007). The “T” represents the specific concept to be analyzed, which is “HIV disclosure.” The E of the CTE structure indicates the empirical research methods used to generate the antecendents, attributes and consequences of the studied concept, as explained in Walker and Avant’s (2019) approach to concept analysis.

Figure2: Conceptual-Theoretical-Empirical Structure for Linking Concept Analyses to Theory Generation

Figure2

Step 3.  Nurse Scholars need to utilize the findings from the concept analyses to advance nursing knowledge by using the results of the concept analysis to develop/refine theory constructs, develop instruments and then progress to explanatory and predictive theories by linking other concepts of the conceptual model to theory concepts.  So how can scholars use the descriptive middle range theory from the concept analyses to advance existing theory/model development?  Figure 3 provides a CTE structure for a hypothetical study of linking the concept analysis of HIV disclosure to advance the HIV disclosure model by Bairan et al. (2007). The vital step within the CTE structure is the re-evaluation process of the theory of which I have named the “theory refinement” process. In the HIV disclosure example, the original guiding conceptual model by Bairan et al. (2007) needs to be refined utilizing the antecedents, attributes and consequences derived from the concept analysis of the HIV disclosure concept. Scholars should utilize the results of the analysis to assess the adequacy of the constructs of the HIV disclosure model and propose directions for further empirical inquiry to determine the theory’s credibility in clinical practice and advancing the discipline.

Figure 3 – A hypothetical Conceptual-Theoretical-Empirical Structure for the HIV Disclosure Concept Analysis by Eustace et al. (2010)

Here are some epistemological considerations if we choose to move forward with this approach:

  1. How can we best approach T in the CTE structure? In this case, how should nursology theorists guide scholars on how to systematically develop constructs from the descriptive middle range theory to be utilized in refining the concept for the existing theory/model?
  2. What strategic and systematic approaches should we employ to retrieve, summarize, and synthesize the evidence for concept analyses, report findings and, lastly evaluate empirical studies on the concept analyses -theory generation linkage? How can we standardize the documentation process during knowledge dissemination? For example, documenting the specific date ranges when evidence was retrieved, dates when the publication was received, revised, accepted, published online and in the journal.
  3. How should we move forward in designing shared CTE structures that are empirically adequate in nursing situations (Villarruel, Bishop, Simpson, Jemmott, & Fawcett, 2001). For instance, how can we generate a global nursing HIV theory model and also contribute to knowledge development of a global interprofessional HIV Disclosure model?

 

A Call to Action:

ARE YOU READY to end what Draper (2014) calls the “intellectual dead end” (p. 1208) of concept analyses in nursing? If so, join me in articulating and advocating for approaches that facilitate the use of concept analyses as the starting point for advancing nursing knowledge. Developing nursology focused CTE structures that link concept analyses to other relevant practice phenomena are timely and very much needed to meet the demands of the complex 21st health care delivery systems. I welcome any comments or suggestions from nursologist around the world on how we can better address this ongoing concern as we think about advancing nursing science for the Future of Nursing 2030.

References

Bairan, A., Taylor, G. A. J., Blake, B. J., Akers, T., Sowell, R., & Mendiola Jr, R. (2007). A model of HIV disclosure: Disclosure and types of social relationships. Journal of the American Academy of Nurse Practitioners, 19, 242-250.

Draper, P. (2014). A critique of concept analysis. Journal of Advanced Nursing70, 1207-1208.

Eustace, R. W., & Ilagan, P. R. (2010). HIV disclosure among HIV positive individuals: A concept analysis. Journal of Advanced Nursing66, 2094-2103.

Fawcett, J. (1988). Conceptual models and theory development. Journal of Obstetric, Gynecologic, & Neonatal Nursing17, 400-403.

Fawcett, J. (2013a). Thoughts about conceptual models and measurement validity. Nursing Science Quarterly26, 189-191.

Fawcett, J. (2013b). Thoughts about multidisciplinary, interdisciplinary, and transdisciplinary research. Nursing Science Quarterly26, 376-379.

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

Kalichman, S. C. (1995). Understanding AIDS: A guide for mental health professionals.  Washington, DC: American Psychological Association.

Kanyamura, D., Ncube, B., Mhlanga, M., & Zvinavashe, M. (2016). HIV Disclosure: Concept AnalysisJournal of Research in Pharmaceutical Science, 3(4), 1-4.

Marrs, J. A., & Lowry, L. W. (2006). Nursing theory and practice: Connecting the dots. Nursing Science Quarterly19, 44-50.

Rodgers, B. L., Jacelon, C. S., & Knafl, K. A. (2018). Concept analysis and the advance of nursing knowledge: State of the science. Journal of Nursing Scholarship50, 451-459.

Serovich J.M. (2001). A test of two HIV disclosure theories. AIDS Education Prevention, 13(4), 355–364

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 Quarterly14, 158-163.

Walker, L. O., & Avant, K. C. (2019). Strategies for theory construction in nursing. New York, NY: Pearson Education Inc.

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.

An Update from the Nursing Theory Collective

Welcome to Chloe Olivia Rose Littzen, who has now joined our
Nursology.net blogging team!
Chloe is a founding member of the
Nursing Theory Collective and
currently a PhD Student at the University of Arizona (Tuscon)

I. Introduction

In June of this year, a blog post was shared on Nursology.net by the Nursing Theory Collective, a group of scholars and students with a mission to advance the discipline of nursing/nursology through equitable and rigorous knowledge development using innovative nursing theory in all settings of practice, education, research, and policy. (Visit that post here). We are using the term nursing/nursology as at this moment in time as we continue to have discourse on the exact word choice we will use to characterize ourselves as a collective. 

To review, the Nursing Theory Collective was formed after the landmark conference, “Nursing Theory: A 50 Year Perspective Past and Future”, on March 21-22, 2019 at Case Western Reserve University. Since May, the group has met monthly to further discuss pivotal issues related to nursing theory and the identity of nursing/nursology, define their mission and vision statement, and to establish action items to drive their vision forward. Currently, the Nursing Theory Collective has 45 members from around the world including Canada, China, Colombia, and the United States, promoting a global perspective of nursing and nursing theory. 

To promote global connectivity, the Nursing Theory Collective created a WhatsApp (https://www.whatsapp.com) group for an easily accessible format that members in other countries can easily connect via their smartphones. In this WhatsApp group, members discuss pertinent issues related to nursing theory and the identity of nursing, sharing articles, actions in progress, or reminders for actions that evolved from previous meetings. Our meetings have been hosted via Zoom Video Conferencing (https://zoom.us) which enables access to participate in most countries, and has allowed us to record all meetings for future reference. A shared Google Drive was also created, enabling all members to have access previous document, to assist in the development of future action items, and to collaborate in real time. 

II. Updates 

To date, the meetings for our collective have revolved around discussions on actions items that can be taken to move the discipline of nursing and nursing theory into the future. In order to accomplish our collective goals, we have been working to define our mission, vision and values, and establishing logical action plans in the forms of scholarly writing and policy letters. In the following paragraphs, you will find a brief synopsis of all the action items that are in progress or completed. 

Mission, Vision, and Values. We have been working diligently on defining our mission, vision, and values as a collective. We recognize that this is a work in progress. We have been inspired by the vast body of prior nursing knowledge and theory work in the United States and abroad, as well as our individual philosophies of nursing. Guiding our mission, vision, and values is a concise definition of nursing theory first advanced by a working group of international nurse theorists, who proposed that nursing theory is simply “a description of what is going on” (Petrovskya, Purvis, & Bjornsdottir, 2019, p.2). Petrovskya, Purvis, and Bjornsdottir’s (2019), elegant definition, adopted from Rolland Munro, invites nurses to engage ideas beyond the theoretical paradigms most familiar to nurses educated in the United States. As this is an ongoing and open process, we invite you into the discussion and to add to our mission, vision, and values.

King Conference. In June 2019, the Nursing Theory Collective submitted an abstract that was accepted to the upcoming King Theory Conference in Washington, D.C. (King International Nursing Group, 2019). The topic of our abstract is, “Driving the Future of Nursing: A Collective Approach to Nursing Theory.” We look forward to being a part of this landmark conference. We plan to arrange a meeting of the Nursing Theory Collective at the King conference, and we welcome all members and non-members to join us for important discussions in driving nursing and nursing theory into the future. We will post details about the time and place for this get together as the date gets closer. One action item of this in-person meeting at the King Conference will be to continue the debate surrounding the adoption of the term nursology to characterize ourselves. 

III. Collaborative Efforts 

As we are a collective, we understand the importance of branching out and collaborating with individuals and groups to enable us to accomplish our mission and vision. To date, collaborative efforts have been placed into two categories: 1) Nursology, and 2) policy items related to nursing education and the future of nursing. Below is a brief synopsis of both of these efforts. 

Nursology. In 2015, Dr. Jacqueline Fawcett presented a case for changing the name of nursing to nursology (Fawcett et al., 2015). A variety of nursing scholars have echoed support for this change, but others have been questioning how this impacts on the discipline as we know it (Parse, 2019). To be mindful of all members views, we held an anonymous survey in June – July 2019 to adopt the term Nursology in our name, mission, vision and values. A total of eighteen votes were received, with 11 (61.1%) in support of adopting Nursology, and 7 (38.9%) in opposition. Members also had the option to write-in anonymously a rationale for their vote, and a variety of comments were received. For example, one member who was in support of the adoption asked “if there was an opposition for the collective to have an open discussion as to why this was.” Concerns that were raised by members in opposition included the marginalization of practicing and non-academic nurses, the validity and legitimacy of the term, and the belief that Nursology should be a term reserved for higher degrees in nursing such as the PhD. Supporters of the adoption argued that the term Nursology, while radical, would improve the strength of the identity of nursing, and has powerful implications for the general public and legislation.

Prior to the results being discussed, Dr. Fawcett kindly agreed to participate in our meeting where we discussed the adoption of the term Nursology, as well as the rationale for members in support or opposition. With this discussion, members had opportunities to further voice their opinion, and ask important questions related to the term and its meaning. For example, one member asked for whom the title nursologist should be reserved. Dr. Fawcett and other members designated the adoption of the term nursologist for all members, who have passed their licensing examination and are a registered nurse. At the end of the meeting, it was proposed as the group was undecided to adopt the term nursology into the mission, vision, and values, but also include nursing. We thank Dr. Fawcett for her involvement, and plan to keep the Nursology group updated as we move forward. Our next discussion on this topic will be in November at the King Conference in Washington, D.C.

Policy Items. In July, two members of the Nursing Theory Collective participated in a Zoom meeting with board members from the American Holistic Nurses Credentialing Corporation (AHNCC, 2019). The purpose of this meeting was to begin a discussion and collaborate on a campaign to express the need for nursing theory to be a core part of the current educational essentials, as they are being revised by the American Association of Colleges of Nursing (AACN) and the National Council of State Boards of Nursing (NCSBN). Action items from this meeting included the development of two letters focused on the educational essentials, as well as the revising of the National Council Licensure Examination for Registered Nurses (NCLEX-RN). To date, the letter to the AACN has been completed and is pending to be emailed out to key members of the essentials committee. After this, we plan to submit this letter for publication to spread the word of this important change that may impact the future of nursing. Our next step will be devising the letter the the NCSBN, we invite anyone who is interested in participating in developing this important letter. We thank the AHNCC for collaborating with us on this important project, and support them in their work as they promote a more holistic space for nurses to practice globally. 

IV. Future Efforts

While we have a significant to-do list as follow up from previous efforts, we continue to strive towards future actions in order to drive our vision for nursing and nursing theory into the future. We intend to remain vigilant about the AACN essentials, the NCSBN revision of the NCLEX, and will continue our activism aimed toward promotion of nursing theory at all levels of education. Our future actions include continuing our monthly meetings to have open discourse on the topic on nursing and nursing theory, we invite all members and non-members alike to participate. Additionally, we plan to write and submit manuscripts focused on demystifying nursing theory for practicing nurses and the educational environment. We welcome any and all ideas on how we can move forward with our goals, and hope that you would consider being a part of this movement. 

V. Conclusion and Invitation – Join us!

The next meeting for the Nursing Theory Collective is August 27th, at 2:00 PM Eastern Standard Time. We encourage all nurses and students, regardless of setting, experience, or educational level, to join us by contacting clittzen@email.arizona.edu to participate. If you are interested in joining the WhatsApp group, please email us to let us know and we will add you promptly. We also have a twitter handle, @NursingTheoryCo, and you are welcome to follow us as we plan future social media events. We plan to continue to update the community here on Nursology.net to keep everyone informed, as well as promote a movement of inclusivity to drive nursing and nursing theory into the future.

With gratitude,
The Nursing Theory Collective

References

American Holistic Nurses Credentialing Corporation. (2019). About AHNCC. Retrieved from https://www.ahncc.org/about-ahncc/

Fawcett, J., Aronowitz, T., AbuFannouneh, A., Al Usta, M., Fraley, H. E., Howlett, M. S. L., . . . Zhang, Y. (2015). Thoughts about the name of our discipline. Nursing Science Quarterly, 28(4), 330-333. doi: 10.1177/0894318415599224

King International Nursing Group. (2019). Events. Retrieved from https://kingnursing.org/content.aspx?page_id=4002&club_id=459369&item_id=976945

The Nursing Theory Collective. (2019, June 18). Moving Towards the Next Fifty Years Together [Blog post]. Retreived from https://nursology.net/2019/06/18/moving-towards-the-next-fifty-years-together/

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What makes a theory or model “nursing”?

To our readers: the Nursology.net blog exists to prompt thoughtful discussion of critical issues related to the development of nursing knowledge.  We welcome your thoughts, challenges, alternative points of view, and critical questions!  Do not hesitate to comment on this or any other post at any time!  You are our “peer reviewers” and your perspectives contribute to all in our nursology.net community!

I am often asked (as are many of my colleagues):  What makes a theory or model a nursing theory or model?  This question is close to the challenge that I addressed in my keynote address in March at the Case Western Reserve Frances Payne Bolton School of Nursing Theory conference.  This question deserves serious reflection and discussion, because how each of us responds to this question is at the heart of what we envision for our discipline moving forward. In my keynote, I noted that various definitions of nursing as a discipline point to two essential matters: 1) knowledge of the human health experience, and 2) knowledge of nursing healing [well-becoming] actions.  Here I explore the issue of nursing theories and models, and propose that like the definitions, nursing theories and models are characterized by a focus on these same two essential characteristics.

One reason that questions concerning the nature of nursing theory keep surfacing is the fact that so many nurses who embarked on activities related to the development of nursology (nursing science) were educated to be scholars (researchers, theory developers) in fields outside of, but related to nursing.  There are contemporary nurses who opt to pursue their preparation for scholarship in other disciplines, influenced by the appeal of certain lines of inquiry that are already well developed in another discipline, and recognizing the significant connection between nursing’s interests and the interests of other lines of thought.  When I say “related” what I mean is that the gaze of these other disciplines is certainly pertinent to what concerns nursing, but the central concern of nursology is not actually “at the center.”  When a nurse scholar’s central focus is on the periphery, it is likely to be better placed within the scope of another discipline.

Sally Thorne (2014) has addressed this tension often in her work, most specifically in her chapter that appears in the text “Philosophies and Practices of Emancipatory Nursing.” In this chapter titled “A Case for Emancipatory Disciplinary Theorizing” (pages 79-90), Dr. Thorne pointed to the habits of “false dichotomizing” and the allure of borrowing theories from other disciplines, both of which lead to valorizing constructions from other disciplines, while neglecting the distinct focus of nursing. False dichotomizing, in the the case of social justice concerns, is the tendency to pigeon-hole a theory as either being focused on “the individual” or on “the community” (social justice), failing to recognize that from the earliest days of theorizing in nursing, scholars have explicitly embraced both the individual and the community and the  social injustices that require nursing action.  Likewise, immersion in and borrowing from the theoretical traditions of other disciplines can lead to neglect of the complex social mandate that is central to the discipline of nursing.  Unlike other disciplines, many of which focus on building knowledge as an end in itself, nursing’s mandate to act shifts the disciplinary focus so that knowledge related to a phenomena must include a focus, or point the way to “right” or “good” nursing action.  I have addressed the challenge in nursing of developing theory with this extremely complex perspective as one of the reasons for turning to theory in other disciplines, where the focus is more limited, and this complexity is typically unacknowledged and undeveloped or underdeveloped.  (see “Thoughts About Advancement of the Discipline: Dark Clouds and Bright Lights”)

From my perspective, regardless of the theorist’s background, or the origin of methodological approaches, what defines a theoretical construction as nursing arises from a clear orientation to the values and priorities of the discipline – the direction in which nursologists focus their “gaze.”  The focus of nursing must include the two elements that centrally define our discipline: knowledge of the human health experience, and knowledge of nursing actions leading to health and well-becoming.

Every discipline has the right and the responsibility to define and to conceptualize its own knowledge, domain, practice – the field which it covers. Of course people from other disciplines, and the public, have a responsibility to challenge the discipline in any way that is needed – a process that contributes to the ongoing development of the discipline. This process was prominent during the early phases of feminist thought in which feminist scholars from all disciplines developed a “gaze” focused on the rights and well-being of women, challenged the parameters, assumptions and practices of their own, and other disciplines as well. This led to vast changes for the better in all of the sciences and the humanities.

Where nursing is concerned, or more specifically nursology, disciplinary knowledge must derive from those who have been immersed in the history, philosophy, theory, and the practices of the discipline – something that is required for any discipline. Even though, for example, I do know a lot about the field of educational psychology where I earned my PhD degree and where I completed many courses in psychology and educational psychology, I do not have the background and experience to even begin to claim that I could contribute to the knowledge base of that discipline. I have used theories and insights from other disciplines in my own work contributing to the discipline of nursing, but that is quite a different kind of scholarship than would be required to contribute to the discipline of psychology (or sociology, or anthropology, etc.). My own theorizing in nursing reflects my educational psychology background, particularly the work of Brazilian educator Paulo Friere.  While the very relevant focus of Friere’s work is on human liberation from oppressive conditions, in my work the focus shifts to the health experience involved in group interactions,  conditions which influence, perhaps even threaten human health and well-being.  Health-promoting group interactions in my work draw on the methods of Friere’s  liberation theory,  but are specifically directed toward creating group actions and interactions that are life-affirming, nurturing, and support human well-becoming.

I do not think it is helpful to dwell on the simple fact of whether or not a person contributing to the knowledge of the discipline is a nurse — not all nurses are prepared to contribute to the knowledge base of the discipline, nor should they be expected to. And there are certainly nurses whose “gaze” is directed primarily on phenomena that are rooted in other disciplines.  The key to me is where a theory or model focuses the gaze – what phenomena are central, and are those central ideas consistent with the defining focus of the discipline.  I find it difficult to imagine how someone could contribute to nursing knowledge without a nursing background, or without experience in nursing healing/ well-becoming actions, as well as a background in the history and foundational knowledge of the discipline.  Beyond this essential background from which the theoretical ideas emerge, nursing theories and models are defined by the substantive focus on the phenomena of the experience of human health and well-being, and the dynamics that contribute to nursing healing and well-becoming practices.   As we have demonstrated in gathering together for this website information about the theories and models we do have, there are many more than many nurses have as yet imagined!  But the task of clearing our mental images to more fully appreciate the possibilities in the development of the knowledge of our discipline is a huge challenge, and further focusing our gaze on these possibilities and priorities is at the heart of what matters for our own discipline.