Guest post: The privilege of agency: The political shortcomings of nursing theory

Contributor: Mike Taylor

The four metaparadigm concepts of nursing knowledge have been human beings, environment, health and nursing process; with the state of the person at the center of the definition and achievement of health goals. The idea that an individual has the wherewithal, not only in name but also but also in action, to determine what health means for them as an individual and is able to work to accomplish those same goals is the concept of agency. Among nursing’s most referenced conceptual models and theories — Orem, Parse, Newman and Roy — keep the focus of nursing’s work on the individual before us, and much less of a consideration is on the environment the person inhabits. Newman (1979) for example states that the goal of nursing “is to assist people to utilize the power that is within them as they evolve toward higher levels of consciousness” (p. 67)  The concept of individual agency is central even in theories about the praxis of nursing such as Watson’s theory of human caring where the nurse/patient dyad “is influenced by the caring consciousness and intentionality of the nurse as she or he enters into the life space … of another person. It implies a focus on the uniqueness of self and other…” (https://www.watsoncaringscience.org/jean-bio/caring-science-theory/)

Sourcehttps://www.coe.int/en/web/interculturalcities/systemic-discrimination

Agency is not something that is naturally given to a person but emerges from the process of human development. That process is frequently affected  by poor schools, environmental pollution, and the other mediators of institutional racism and poverty. The chances of an individual reaching full agency, meaning the ability to identify and actualize individual health goals,  in adulthood are much more likely when those limiting factors are not present due to privilege. Even when an individual is able to overcome early life challenges, the social environment where agency can be exercised, there are limits on who can participate based on class, race, and gender. These limitations on the exercise of agency extend to persons who either want to or are actively practicing the profession of nursing. Even when a person can overcome the intersecting influence of race, poverty and gender to become a nurse; the same barriers remain in the practice environment often limiting choice of practice arena and opportunities for advancement to leadership roles.

Nursing theory is right to place individual agency at the center of the health improvement process, but it does not address the uneven distribution of that agency and the effect that has on health. Agency is only possible where it is allowed and when individuals in disadvantaged communities  do not have the inability to develop or exercise agency, the disparities in health outcomes we see today are the result. For nursing theory to meet these health challenges it must develop beyond a focus on individual agency to an emphasis on the social and environmental conditions that limit health improvement which means challenging institutional racism and poverty among others.

To develop the concept of agency in nursing and challenge existing social barriers, I believe that it would be instructive to align the development and exercise of agency with concepts of intersectionality. An important question might be can any correlation be found between the intersectionality and the degree of effective agency as reflected in an individual’s agency and the available social environments where that agency can be exercised. My anticipation is that it would be an inverse correlation with effective agency decreasing as the number of overlapping disadvantages increase. 

Sources

Newman, M., (1979). Theory development in nursing. F.A. Davis. https://openlibrary.org/books/OL4409082M/Theory_development_in_nursing 

Caring Science & Human Caring Theory, Transpersonal Caring and the Caring Moment Defined https://www.watsoncaringscience.org/jean-bio/caring-science-theory/

About William (Mike) Taylor

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

Practice and Research Speak: The Words We Use to Describe Ourselves and Others

In March 2020, I posted a blog about the meaning of words used to describe the extent to wish a person’s (patient or client) behavior does not comply with, adhere to, or is concordant with what has been prescribed by nursologists or physicians. In December 2020, I posted a blog about the meaning of words researchers use in their research reports, such as allow, respondents, and informants. In these blogs, I pointed to the power differential that is implied in the use of these words. In the first blog, I asked why do we use compliance, adherence, and even concordance instead of a term that more accurately reflects relationship-based care; and in the second blog, why do we use allow rather than invite, and why do we use respondent or informant rather than people.

The purpose of this blog is to discuss the words we use to describe ourselves and others in the context of healthcare. Collectively, we tend to refer to ourselves (nursologists) as healthcare providers, using the same term for physicians, physical therapists, occupational therapists, social workers, and others who “provide” healthcare “services.” We refer to others (patients, clients, people) as recipients of these services.

Copyright 2021 Jacqueline Fawcett

I have used these terms in my publications for many years. Now, as I become more sensitive to the connotative meaning of words, I must question how my use of these words – provider, recipient – conveys a huge power differential, a clear instance of power-over (Chinn & Falk-Rafael, 2015; https://nursology.net/nurse-theorists-and-their-work/peace-power/), and power-as-control (Barrett, 2010; https://nursology.net/nurse-theorists-and-their-work/theory-of-power-as-knowing-participation-in-change/

In the compliance etc. blog, I referred to co-created narrative, and a comment from a reader of that blog replied that a co-created narrative is one “in which the healthcare consultant and the person consulting with him/her engage in dialogue around the recommendations offered, within an environment of mutual respect and honesty, arriving at a mutually agreed upon plan led by the person seeking input” (https://nursology.net/2020/03/17/what-is-reflected-in-a-label-about-health-non-nursology-and-nursology-perspectives/).

I thank that reader very much for her comment. Healthcare consultant instead of healthcare provider is a better term, as it at least implies peace as power (Chinn & Falk-Rafael, 2015) and power-as-freedom (Barrett 2010) perspectives, as does person who is consulting instead of recipient. I shall do my best to use these words in all future publications until the potential awkwardness or unfamiliarity with these words evolves to the familiar, conveying the dignity and mutual respect of the encounter. (Note that I wrote “do my best” rather than “try,” as I am committed to removing “try” from my vocabulary, for as Yoda tells us: DO OR DO NOT; THERE IS NO TRY.) .

Yoda Says: Do or do not. There is no try.
Yoda in Fawcett’s Art, Antiques, and Toy Museum in Waldoboro. Maine
Photo by Jacqueline Fawcett

I very much look forward to comments from readers of this blog–what are your thoughts about words that convey different types of power? Do you have suggestions for other words to convey who we are and who others are?

References

Barrett, E. (2010). Power as knowing participation in change: What’s new and what’s next. Nursing Science Quarterly, 23(1), 47-54.doi: 10.1177/089431840935379

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

Launch of BILNOC Leaders Database

We are delighted to launch a database that provides information about Black, Indigenous, Latina/x and other Nurses of Color (BILNOCs) who are (or have been) leaders and scholars who have contributed to the development of the discipline. This will be a significant resource for scholars and students who seek to recognize and honor BILNOC leaders. This database will fill a huge gap that contributes to the underrecognition of the contributions of nurses of color to the discipline.

View the BILNOC Submission Form to review the information we are seeking. You can find a link to the this form from the website “Resources” menu anytime later.

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.

Is Medicine a Trade or a Discipline or Profession?

Nursology is regarded as a discipline and a profession, which means that nursology constitutes distinctive knowledge encompassing nursological philosophies, conceptual models, grand theories, middle-range theories, and situation-specific theories (see all content on https://nursology.net and also https://nursology.net/2018/09/24/our-name-why-nursology-why-net/).Medicine, in contrast, is a trade. This assertion is based on my search of literature for several years and pondering the difference between a discipline or a profession and a trade at least since the publication of Donaldson and Crowley’s now classic 1978 article, The Discipline of Nursing. .

I asserted that medicine is a trade in two 2014 publications (Fawcett, 2014a, 2014b) and in 2017, I wrote, under the heading, Medicine is a Trade:

I have never been able to locate any obvious or explicit knowledge that is distinctly medical. A September 18, 2016 search of the Cumulative Index of Nursing and Allied Health (CINAHL Complete) using the search term “medical model” yielded 816 publications. An admittedly quick review of a random sample of the retrieved publications revealed that the term medical model was not defined but rather used in a way suggesting that any reader would know what the term means. (Fawcett, 2017, p. 77)

I have continued to ponder whether medicine should be considered a trade and have wondered why no one has challenged my assertion, at least in any publications or blogs I have seen. Therefore, on January 4, 2021, I expanded my search to other sources–Taber’s Cyclopedic Dictionary, the Oxford English Dictionary, and Wikepedia.

The 22nd edition of Taber’s (Venes, 2013) includes no entry for medical model. Medicine is defined as “the act of maintenance of health, and prevention and treatment of disease and illness” (Venes, 2013, p. 1474). No reference to the knowledge needed to perform the act of medicine is evident. The Oxford English Dictionary also includes no entry for medical model, with only a mention of the term in quotations pertaining to two words, technologizing and miasmatist.

However, two definitions of medicine imply a knowledge base (although not necessarily distinctive knowledge). One definition is: “The science or practice of the diagnosis, treatment, and prevention of disease (in technical use often taken to exclude surgery).” The other definition is: “The medical establishment or profession; professional medical practitioners collectively.”

A search of Wikipedia yielded this statement: “Medical model is the term coined by psychiatrist R. D. Laing in his The Politics of the Family and Other Essays (1971), for the “set of procedures in which all doctors are trained.” It includes complaint, history, physical examination, ancillary tests if needed, diagnosis, treatment, and prognosis with and without treatment.” (https:// en.wikipedia.org/wiki/Talk:Medical model – Wikipedia). Noteworthy is that Laing did not mention the philosophic, conceptual, or theoretical knowledge that would guide the “set of procedures in which all doctors are trained.”

The content in Wikipedia also included an important negative consequence of adherence to the medical model. This consequence is “In the medical model, the physician was traditionally seen as the expert, and patients were expected to comply with the advice. The physician assumes an authoritarian position in relation to the patient. Because of the specific expertise of the physician, according to the medical model, it is necessary and to be expected. In the medical model, the physician may be viewed as the dominant health care professional, who is the professional trained in diagnosis and treatment.” (https:// en.wikipedia.org/wiki/Talk:Medical model – Wikipedia)

My concern with the very idea of “adherence to the medical model” (or adherence to or compliance with anything put forth by a nursologist or a physician) led me to ask “what [do] 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.” (Fawcett, 2020)

My concern regarding the physician as a professional person is grounded in my inability to identify any distinctive knowledge of medicine that is necessary for the designation of professional in both the OEDO definition of medicine and in the mention in Wikipedia of the professional being “trained,” a word associated with training for a trade.

Of course, I understand that physicians possess a great deal of scientific knowledge. However, that knowledge is of various disciplines, such as anatomy, physiology, histology, and chemistry, not of medicine per se (as there is no distinctive medical knowledge that I have been able to identify),

I have concluded that the so-called “medical model” is a fiction put forth at least since Laing’s (1971) publication by members of the healthcare team (including nursologists) and the general public to ascribe a particular status to a trade. .

Please note that I acknowledge the importance of trades in society. I certainly cannot survive without many tradespersons in my life. However, I maintain that it is important to be very clear about the words we bestow on the members of healthcare teams, words that clearly reflect whether those members belong to a discipline/profession or trade. If members of a discipline/profession, it is necessary to identify the distinctive knowledge that guides practice, and research and education, too..

What do you, a reader of this blog, think? Have you been able to identify distinctive philosophic, conceptual, and theoretical knowledge that would constitute the discipline of medicine? Please add your thoughts to the comments section of this blog. Thank you very much.

References

Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113-120.

Fawcett, J. (2014a). Thoughts about collaboration—or is it capitulation? Nursing Science Quarterly, 27, 260-261.

Fawcett, J. (2014b). Thoughts about interprofessional education.Nursing Science Quarterly, 27, 178-179.

Fawcett, J. (2017). Thoughts about nursing conceptual models and the “medical model.” Nursing Science Quarterly, 30, 77-80. (Permission to provide a link to the PDF of this article was granted by the journal editor)
Fawcett, J. (2020, March 17). What is Reflected in a Label about Health? Non-Nursology and Nursology Perspectives. Blog.

Laing, R. D. (1971). The politics of the family and other essays. Routledge

Venes, D. (Ed.). (2013). Taber’s cyclopedic medical dictionary (22nd ed.). F. A. Davis.

Guest Post: Allies and Advocates – Transforming Cultural Competence

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

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

Source

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

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

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

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

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

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

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

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

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

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

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

Sources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Call to Action

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

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

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

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

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

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

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

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

References

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

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

About the contributors;

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

Kelli DePriest, PhD, RN

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

Paul Kuehnert, DNP, RN, FAAN

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

Teddie Potter PhD, RN, FAAN

Saintelmophotography.com

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

How Evidenced Based Practice Supports Inequality

Guest contributor: Mike Taylor,
Member, Nursology Theory Collective

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

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

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

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

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

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

About William (Mike) Taylor

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

Letter to the ANA

On September 26, 2020, the Nursology.net management team sent the following letter to the American Nursses Association, urging the organization to take a stand on the U.S. Presidential election candidates. We believe that given the dual pandemic of COVID-19 and racism, nursing’s strong voice of advocacy for the health of the nation must be heard. Here is the letter in its entirety:

September 26, 2020
Dr. Loressa Cole, ANA Enterprise CEO
Dr. Ernest J. Grant, President, ANA President
Dr. Debbie Hatmaker, Chief Nursing Officer, ANA Enterprise
American Nurses Association

Dear Drs. Cole, Grant and Hatmaker:


The Management Team of Nursology.net is writing to urge the American Nurses Association (ANA) to reverse its position against endorsing any candidate for President/Vice President in the 2020 election. We understand that the ANA reversed its previous policy to endorse presidential candidates based on the desire to “engage nurses in the voting process through providing accurate information and data and promoting nursing’s political advocacy role without alienating an entire contingency…acknowledging the reality of political polarization in this country” (ANA 2019 Membership Assembly Consideration of ANA’s Presidential Endorsement Process).

The recent draft of the document, Nursing’s Scope and Standards (2020), specifies nursing’s social contract with the public. The document includes nursing’s commitment to reject racism and promote equity and social justice for all. In addition, the document points to nursing’s accountability and responsibility to promote the health of all populations and to advocate for social and environmental justice, and access to high quality and equitable health care.

The proposed ANA Scope and Standards contradicts the ANA position against endorsing a presidential candidate if a particular candidate is a threat to equity, social justice, equitable healthcare and health for the population. While we respect that the Board made their decision thoughtfully, the current situation calls for a reconsideration based on the positions of the current administration that threaten public health. Scientific American, a journal who has never endorsed a candidate for president, has broken with their policy because of the dangerous anti-science views of the President

Today, the country needs to hear nursing’s voice related to this election from the ANA. We find ourselves in the midst of a perfect storm fueled by the mismanagement of a global pandemic, a health and environmental crisis from rampant fires, storms and floods attributed by scientists to climate change, and the public health crisis of systemic racism.

Many have referred to this election as the most consequential in recent history, certainly in our lifetimes. This is not the time for the nursing profession to sit out and fail to exercise our unified voice and moral authority. As the discipline focused on caring for the health and well-being of the people with an understanding of how the physical, social, political and economic environment influences health and well-being, and as the most trusted profession, the ANA must speak out against the policies of the current administration and endorse Joe Biden and Kamala Harris for President and Vice President. Please reconsider your position based on the actions taken by President Trump after your vote in 2019.

Here are a few reasons why we urge the ANA to reconsider and endorse the presidential ticket that is aligned with nursing values and actions and protects the public health:

  • The current administration’s lack of leadership to enact policies to stem the rising incidence of COVID-19 infections, including the President’s lack of providing timely information to the public that could have prevented thousands of infections and death
  • The current administration’s policies that have threatened accessibility to healthcare for millions of Americans by working to overturn the advances made through the ACA
  • The current administration’s position that denies human contributions to climate change and fails to support policies to abate its dangers.
  • The current administration’s lack of acknowledgement of the racial injustices experienced by people of color, especially Black people, at the hands of law enforcement.
  • The current administration’s policies of family separation at the border resulting in hundreds of children being placed in inhumane and dangerous conditions to their health and well-being.
  • The current administration’s lack of meaningful responsiveness to address the public health crisis of gun violence.

While the recommendations of the ANA’s Presidential Endorsement Process (2019) advocate for individual nurses to participate in election activities at the local, state and national levels and take advantage of educational opportunities to learn about the candidates that will inform their voting, nurses will look to the ANA for leadership, especially now. The ANA is the voice of the profession, and this is not the time for that voice to be silent. Without a unified position, the nursing profession is invisible, and the public trust in nursing’s commitment to protecting public health is compromised. Individual nurses can always vote their choice, but the unified voice of our profession is critical at this time in our history.

Please reverse your position and endorse the candidates that will advance policies that protect the health of the public. We cannot be silent. To be silent is to be complicit.

Thank you for your serious consideration of this request.

Respectfully,

Peggy L. Chinn, RN, PhD, DSc(Hon), FAAN peggychinn@gmail.com

Jessica Dillard-Wright, MA, MSN, CNM, RN jdillardwright@gmail.com

Rosemary William Eustace, PhD, RN, PHNA-BC

Jacqueline Fawcett, RN, PhD, ScD(hon), FAAN, ANEF

Jane Flanagan, PhD, RN, ANP-BC, AHN-BC, FNAP, FNI, FAAN

Dorothy Jones, RN, PhD, FAAN

Deborah Lindell, DNP, MSN, RN, CNE, ANEF, FAAN, Deborah.Lindell@gmail.com

Chloe Olivia Rose Littzen, MSN, RN, AE-C

Leslie H. Nicoll, PhD, RN, FAAN leslie@medesk.com

Adeline Falk-Rafael, PhD, RN, FAAN afalk-rafael@rogers.com

Marlaine C. Smith, RN, PhD, AHN-BC, HWNC-BC, FAAN

Marian Turkel, RN, PhD, NEA-BC, FAAN

Danny Willis, DNS, RN, PMHCNS-BC, FAAN

Overdue Reckoning on Racism in Nursing

Our Nursology.net community is committed to addressing the burning issue of racism, how this systemic condition has influenced the development of nursing knowledge, and how this situation can be changed (see our statement on racism in the sidebar for more information). The NurseManifest project has just announced a series of web discussions “Overdue Reckoning on Racism in Nursing” that will interest many nursologists! Starting on September 12th, and every week through October 10th! This initiative is in part an outgrowth of the 2018 Nursing Activism Think Tank and inspired by recent spotlights on the killing of Black Americans by police, and the inequitable devastation for people of color caused by the COVID-19 pandemic.

Racism in nursing has persisted far too long, sustained in large part by our collective failure to acknowledge the contributions and experiences of nurses of color. The intention of each session is to bring the voices of BILNOC (Black, Indigenous, Latinx and other Nurses Of Color) to the center, to explore from that center the persistence of racism in nursing, and to inspire/form actions to finally reckon with racism in nursing.

Lucinda Canty, Christina Nyirati and Peggy Chinn have teamed up to create the plan – you can see the details here; it is also easily accessed from the NurseManifest main menu!