The Nursology Initiative in the Philippines

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

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

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

Why “Nursology”?

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

Launching the Nursology Initiative

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

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

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

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

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

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

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

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

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

About Rudolf Cymorr Kirby P. Martinez, Ph.D

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

Culture Shock, Grief and Nursing Theories

Contributor: Aisha Chahal, MSN, CMSRN

Culture shock is a state where people experience the stages of honeymoon, frustration, adaptation and acceptance. It is an intense feeling that follows the grief process. I had first-hand experience with all these stages of culture shock when I came to the land of opportunities, the United States of America, in 2012. I started my first job as a bedside Registered Nurse. It felt like I had accomplished the purpose of my life by getting a job at Yale-New Haven Hospital. Yale seemed like a place in heaven. It was beautiful to see that people could order food over the phone and a beautiful tray with fancy food items arrive at the bedside within a few minutes. Nurses only had four to five patients instead of the thirty that I had cared for earlier in my career. Patients had call bells and people responded to those bells. There were computers, scanners, medication dispensing machines and robots to deliver supplies. I was in the honeymoon phase.

But then came frustration as food items were thrown away if patients did not like them. Computers took away my time to be with my patients. The machines, robots, and technology had turned people into objects. I barely had time to know my patients or colleagues on a personal level. But I adapted and accepted by learning to fit into the situation. I learned that all this was crucial for patient safety, evidence-based practice, patient satisfaction scores and reimbursements.

After 8 years, I relived the stages of culture shock while learning in-depth about nursing theories in my doctorate program and educating nursing students on nursing theories at the same time. Nursing theories fascinated me and sparked my interest to learn more about the focus and identity of nursing discipline. Learning new concepts, making connections, discussing with nurse educators and colleagues, listening to some of the theorists themselves send me into the honeymoon phase once again.

I was determined to start my clinical day with the students by discussing a nursing theory. With all enthusiasm, I showed up at 6.45 am to meet my students and talk about nursing theories starting with Florence Nightingales’ framework and Watson’s Caring theory before we see our patients. Then once again, I experienced the frustration phase as students were disinterested, inattentive, unpassionate, and incurious which was exactly the opposite of what I was prepared for. I stopped the talk in the middle and let them start their routine patient assessments. I was deeply saddened by reliving the experience as I knew that I would have to adapt and accept the reality just like I did a few years back.

But this time, instead of accepting, I felt challenged to change the norm. Students viewed the content of nursing theories as dry, complicated to understand, of no practical use, and grade-lowering. The next week, I planned to discuss Neumann’s System Model with the vision that students can feel and experience the essence of the theory and view clients as an open system responding to various stressors in the environment. Instead of theory, I started our discussion with the theorist, Betty Neumann. We discussed how she grew up on a farm and took care of her sick father who died at the age of 36, which created her passion for nursing. Her mother was a devoted self-taught midwife. We talked about her academic, professional, and volunteer work. I shared images and videos depicting her life and vision. Then we discussed her vision of creating the nursing theory and related concepts of the theory.

Students were completely engaged, asked questions, and seemed ready to minimize the theory-practice gap. In the post- clinical conference that day, students were able to identify intra, inter and extra-personal stressors for their clients. They also identified the interventions they performed or planned to perform at primary, secondary and tertiary levels of prevention. They developed a deeper connection to the theorist, theory, clients and themselves. They identified who they are in relation to the focus of nursing discipline. After that week, we continued discussing a theorist and a nursing theory each week before clinical and each student-patient interaction is now guided by the concepts of that theory. Every week, we now look forward to our discussion of nursing theories and viewing people from different perspectives to provide competent and compassionate nursing care

I invite all the nursing students, nurse educators, nurse scholars, and nurse researchers to prevent nursing theories from following the similar pattern of stages of culture shock and grief. Instead of frustration, anger, denial, adaptation, and acceptance, our collaborative efforts can lead to a focused nursing discipline in which every nurse is changing lives by using the strong foundational pillars of nursing theories.

About Aisha Chahal

Aisha Chahal, MSN, CMSRN, is a doctoral nursing student in the Online Nursing Education EdD program at Teachers College, Columbia University. Aisha has completed her Masters of Science in Nursing Education in 2019. She is a clinical instructor at Western Connecticut State University. She has have 10 years of clinical experience in medical-surgical nursing. Her passion is exploring effective teaching-learning strategies to educate nursing students on Transcultural Nursing.

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.

The Definition of Health: Thoughts from Japan

Health is a central concept in most if not all versions of the metaparadigm of nursology (Fawcett, 2019). I have defined health as “human processes of living and dying” (Fawcett & DeSanto-Madeya, 2013, p. 6) and conceptualize health as inclusive of wellness, illness, and disease within that process. I deliberately separated wellness from illness and disease when I realized many years ago that the term, promotion of health, could mean that nursologists’ activities were directed toward promotion of illness and disease as well as wellness, rather than indicating that nursologists’ activities are directed toward promoting wellness and preventing illness and disease.

The St. Mary’s College School of Nursing Library. –A Repository of Nursology Knowledge

However, I recently realized that my conceptualization of health is Euro-centric and reflects my privilege as a white, Anglo-Saxon nursologist (Chinn, 2020). Accordingly, when I had the honor of speaking virtually with faculty and graduate program learners at St. Mary’s College Graduate School of Nursing in Kurume, Japan, in February 2021, I invited the learners to share their thoughts about health by responding to three questions. The questions and their responses constitute most of the remainder of this blog.

• The first question is: What is your definition of health?

• Inasmuch as the nursology curriculum at St. Mary’s College School of Nursing is based on the Roy Adaptation Model (RAM), I then asked this question: To what extent is your definition of health consistent with the Roy Adaptation Model definition of health, which is: “A state and process of being and becoming an integrated and whole human being” (Roy, 2009, p. 48).

• Finally, I asked: How does your definition of health affect what you think and do as a nursologist?

GRADUATE PROGRAM LEARNER TAKAKO TANAKA’S THOUGHTS ARE:

I define health as a feeling of harmony between body, mind, and living in society. Even if people have a disease or disability, they can be considered healthy if they feel that they are able to do what they want to do, while coping with their environment. My definition of health is similar to that of the RAM, in that human health in the RAM is not just a high or low level of health. Instead, it is about growth and development as we interact with our environment. Output behavior, when healthy, is positive adaptive behavior. According to the RAM, if energy is not spent on maladaptive coping, this energy can promote healing and enhance health, even in states of illness. I also believe that if people have a lifestyle disease, for example, and can controls the disease by going to the hospital and taking appropriate medication to stabilize the disease, and are able to live as members of society, then they are healthy. My definition of health has been informed by my work in public health nursing, as I learned to always value the concept of health promotion. Individually and collectively, I want to help people understand their health problems and support them to achieve independence and self-determination on their own, which will likely lead to illness prevention. Furthermore, I believe that it is essential to create an environment that supports health.

GRADUATE PROGRAM LEARNER MIHO YOSHIOKA’S THOUGHTS ARE:

I define health as a state in which subjective well-being and objective health indicators are in marvelous harmony. Subjective well-being differs depending on the culture, customs, and environmental values of each individual; and even if they have a disease or handicap, I think that they are in health if they feel well-being within themselves. However, I ask if there is a possibility of being a detriment to themselves, such as leaving the illness to their own discretion, are they truly healthy? Therefore, I dare to consider that a state in which these conflicting things are in marvelous harmony can be called health. The RAM emphasis on an interaction between the person and the environment is consistent with my idea of subjective well-being. The RAM emphasizes that health behaviors based on individual values are adaptive and can never be measured by the values of others, which helps me to understand that whether people consider themselves healthy is a complete affirmation of their diverse values. However, the RAM contention that health behaviors cannot be measured is not consistent with the inclusion of objective aspects of health in my definition. In recent years, people’s lifestyles and values have changed, and subjective well-being, an aspect of my definition of health, has also diversified. The practice of providing sensitive care for the different needs of each individual requires a holistic understanding of that individual. A nursologist is the professional who is closest to the client. By paying attention to and engaging with the client, I think that we can become aware of the needs of that person and provide individualized nursology that protects human consideration and dignity. I also think that nursology, which requires being close to the client, is important in terms of developing trust and respect for their subjective well-being. Moreover, I think that nursology practice is caring for others, which is essential for curing and healing. Therefore, the attitude of facing each individual, the full use of professional knowledge and experience with dignity to maintain and improve well-being, and cooperation with clients while caring for them, are all affected by my definition of health and by our thinking and acting as a nursologist.

GRADUATE PROGRAM LEARNER MASUMI OKA’S THOUGHTS ARE:

I define health as a state of understanding and accepting of one’s condition, and also a quest for health itself. Although the World Health Organization (1948) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” I regard health as the way of understanding the state of experiencing a disease or disability, accepting one’s response to the disease or disability, and trying to become satisfied and fulfilled despite the disease or disability. My definition also incorporates a holistic perspective that includes the meaning of healing, and I think that it is also a love of one’s existence, including existence with others. There are subjective and objective aspects to health, but factors such as ideals, goals, and prejudices toward health are the driving force behind the quest for health. I believe that human beings are creatures that constantly seek “health” and have the power to control their way of life. In other words, the act of pursuing “health” itself becomes human empowerment, and I think that it also affects one’s quality of life. My definition of health has been greatly influenced by the RAM definition of health. Being and becoming a whole and integrated human being can be interpreted as a quest for health, so that process is health itself. The RAM considers health from the perspective of human goals and the significance of existence, and lack of integration is said to denote inadequate health. The facilitation of the process of integration is seen as care for my idea of a “quest for health” and is consistent with all human care required of nursologists. My definition of health has a great influence on my thinking and behavior as a nursologist. I believe that supporting the acceptance of people with a disease or disability and considering together with them is caring for their “quest for health.” Quality of life changes significantly depending on how disease or disorder is perceived and understood. As a nursologist, I think that by being involved in the process of accepting illness and disability and supporting people’s ability to satisfy themselves, they can accept and love their existence. As a nursologist, I would like to continue to study and learn the potential “investigative power of health” of human beings and contribute to the development of the science of nursology in the future.

GRADUATE PROGRAM LEARNER TATSUNARI HARA’S THOUGHTS ARE:

My definition of health has two aspects: it is the situation in which people think of their condition as being “good” despite any physical malady they might have, and it is also the process they are going through in changing or adapting to their condition to become “better” in terms of their own understanding of the word. My definition of health has been greatly influenced by the RAM, as I learned nursology through the RAM. My definition of health is, however, more abstract than that of the RAM, as my definition emphasizes the largely subjective nature of health. My definition of health has influenced by thoughts and actions. Thus, I understand that nursologists strive to establish a caring connection to patients by ascertaining what kind of state they think is good, their goals and abilities required to attain that state, how they perceive their current situation, and what their values are. Furthermore, as I work in rehabilitation nursology, I see many of the patients leave the hospital with remaining disabilities to go on with their lives. Therefore, we nursologists may be required to change our ideas about health so that we can work together with the patients while thinking about how to establish health in their lives, and encourage any necessary changes they may need to make.

GRADUATE PROGRAM LEARNER MIHO ISHIBASHI’S THOUGHTS ARE:

I think that health is not a concept that opposes illness, but a process in which a person interacts with the environment as a human being and tries to become a person looking positively toward their hopes and wishes. Health in the RAM is an integrated overall condition or process. Nursologists say that by promoting adaptation, they contribute to human health, quality of life, and dignified death. I think that for people to be the people they are, nursologists have to understand the hopes and wishes of what the people want to be and do, as well as understand and support them physically, mentally, and socially. I believe it is necessary to understand the environment surrounding a person, think about the influences that affect their health, and consider how to manage these aspects to make people healthy. I think it is necessary to act as a nursologist to understand people’s hopes and wishes people and to help them attain these hopes and wishes.

GRADUATE PROGRAM LEARNER YUKIE NAKANISHI’S THOUGHTS ARE:

I think of health as being familiar with one’s self, having the ability to deal with problems, and having the ability to make decisions. The notion of health in the RAM as a state of integration is consistent with my thoughts about health. Until I entered graduate school, I was convinced that “health” was not having any illnesses or disability. However, even if one has an illness or a disability, I have now come to think that true health is the ability to face oneself, accept what one has become, and move forward toward the future. While studying the RAM and bioethics, I have learned it is important to learn that “person” equals “life”, and that it is equally important to think about a person’s “purpose of life” and “meaning of life” while practicing nursology. Nursologists are practitioners of caring, so I have realized that it may be inadequate to not understand what health is. In the future, I would like to continue learning so I can augment my humanity and human power, learn more about the attitudes necessary for caring, and put them to practical use.

CONCLUDING NOTE:

As I began to write this blog, I realized that I did not know the Japanese word for health; Google translate provided an answer: Kenkō, which is written in Japanese characters as 健康 (https://translate.google.com/?sl=en&tl=ja&text=health%20&op=translate)

I was remiss in not having invited the St. Mary’s College Graduate School of Nursing faculty and learners to share the word each uses for health. Therefore, I do not know whether their responses reflect a Euro-centric or Japanese meaning for the word.

When I sent a draft of this blog to Eric Fortin, of the St. Mary’s College School of Nursing faculty, he replied with his interpretation of the Japanese characters for health. I am, therefore, indebted to Mr. Fortin (personal communication, April 26, 2021), who wrote “健 means ‘humans build,’ and ‘康’ means “breathing space, . , , probably implying the lack of obstruction or disease. So, ‘humans building breathing space’ implies being healthy.”

REFERENCES

Chinn, P. (2020, January 14). Decolonizing nursing. nursology.net. https://nursology.net/2020/01/14/decolonizing-nursing/

Fawcett, J. (2019, March 21) Questions and Answers about our Discipline: Name and Metaparadigm. Paper presented at the Nursing Theory: A 50 Year Perspective Past and Future Conference. Sponsored by Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. nursology.net. . https://nursologycom.files.wordpress.com/2019/03/cwru-paper-fawcett-3-28-19.pdf

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

Roy, C. (2009). The Roy adaptation model (3rd ed.). Pearson.

World Health Organization. (1948). Preamble to the constitution. World Health Organization. https://www.who.int/about/who-we-are/constitution

Guest Post – Emancipatory Nursing in Chile

Contributor: Luz Galdames, PhD (Nursing)

Today, more than twenty years after nursing was incorporated into the Chilean Health Code in 1997 as an autonomous profession, one begins to see how nurses empower themselves defending their rights at the institutional, social and political level. This is seen through events such as the establishment of the National Nursing Directorate at the Ministry of Health and the role that nursing has had in the Covid-19 pandemic. Nurses are raising their voices. In the political sphere, nurses are campaigning as representativeness to draft the new Chilean Constitution, defending/advocating care as a constitutional right and guarding professional autonomy. Another important example of nursing empowerment is the growing generation/development of nursing scientific associations. These organizations seek to socialize what nurses do, the ongoing research in different areas of care and the development of profession itself. Currently, there are more 40 scientific nursing societies in the country.

In 2005, through the Health Authority Law 19,937, self-managed hospitals were established, which brought with them an important change in their administrative organization. It implied that hospitals in their structure should consider the Medical Directorate and the Subdirectorate of care management, both with direct dependence of the hospital management. Historically, nursing had depended on the medical directorates. In this context, the nursing professional association of the time and, the scientific societies (in that period there were no more than ten) defended before the authority of the Ministry of Health and the Comptroller General of the Republic, that by then nursing was the only profession that in its definition evidenced care management as a component of its role. As a result of these negotiations in 2007, by means of the General Administrative Norm No. 19 of the Ministry of Health, it recognized the nursing profession as the most suitable for implementing the care management model in self-managed hospitals.

In this context, “Nursing Care Management” was defined as the professional practice of the nurse based on the nursing discipline, the science of caring (based on Watson’s philosophy and theory), understanding the exercise of the profession as the application of professional judgment in planning, organization, motivation and control of the provision of timely, safe, comprehensive care that ensures continuity of care and is based on the institution’s strategic policies and guidelines. This achievement was constituted a demonstration of empowerment of the nurses of the decade.

However, even when the definition indicated that “care management” was based on the science of caring, the care provided to people was mainly focused on the biomedical model. The National Directorate of Nursing: it is specified through Exempt Resolution No. 1443, on August 20, 2019, during the mandate of the Minister of Health Jaime Mañalich who formalized the appointment of the National Director of Nursing. Being a milestone for the profession, providing from the central level, support to direct and guide the care of people, develop the nursing structure for the health sector, ensure that the nursing care management sub-directorates are not only considered in in-hospital care, but also in primary care.

In parallel, there have been other relevant events in the country, which show the awakening of nurses as a professional group. An example has been the number of nurses who present themselves to the process of electing representatives to the constituent assembly, in defense of care as a constitutional right, as well as the defense of the autonomy of the profession and the rights of nurses.

Another event that has led to the empowerment of nurses has been the Covid-19 Pandemic, which has resulted in the defense of the right of profession, the union of the group to be in the spaces where decisions are made. Likewise, the growth of scientific Societies that bring together nurses for a common purpose, whether it is around the care of people, such as the defense of the rights of the profession (see the list of Scientific Societies below).

The immunization of the population through the vaccine for Covid-19, means another instance in which the nurses raised their voices to defend the vaccination process as a historical nurse’ s responsibility. To respond to the vaccination demands, other healthcare professionals were called by the authorities as volunteer. This led, the nurses defended before the authorities, that although the voluntary participation of other professionals in vaccination is recognized, the vaccination programmeshould be under the supervision of the nursing staff only. Highlighting that, vaccination does not only imply the act of inoculating the vaccine, but an entire process of organization, administration, register and following up.

One of the last events that brings together nurses as an empowered group is the call that the National Director of Nursing makes to Scientific Societies to be part of a Technical Working Table, with the purpose of generating strategic collaboration links in for the development of protocols for the management of care and research in the discipline of Care.

Photo of group meeting from the Scientific Societies

Scientific Societies

  • Agrupación de enfermeras holísticas de Chile (AEHCh)
  • Agrupación de enfermeras y enfermeros ecologistas
  • Agrupación de enfermeros perioperatorios (AGEPCH)
  • Asociación chilena de enfermería en estomas heridas y/o continencias (ACCHIEHC)
  • Asociación chilena de enfermeros educadores en diabetes (ACHIENED)
  • Capítulo de enfermería de la Sociedad Médica de Cuidados paliativos
  • Capítulo de enfermería de SOCHIQUEM
  • División de enfermería intensiva de la sociedad chilena de medicina intensiva (SOCHIMI)
  • Federación Latinoamericana Esterilización FELACEH
  • Fundación de enfermería Gestión del Cuidado
  • Fundación latinoamericana de enfermería en cuidado humanizado (FLECH)
  • Sociedad de Enfermera Latinoamericana en Heridas (SELH)
  • Red Nacional EBE Chile
  • Red Chilena de Enfermería en Lactancia Materna (REDCHIELM)
  • Red Chilena de Enfermeros En Odontología (RECHIENFOD)
  • Red de Enfermería en Informática Chile
  • REDENFI Chile
  • Red Chilena de Gestión del Cuidado REDGECU
  • Red de Enfermería en Salud del Adulto Mayor- Chile (REDESAM)
  • Red Chilena de Historia de la Enfermería
  • Red en Salud Ocupacional (RedENSO Chile)
  • Red iberoamericana de investigación en educación en enfermería-RIIEE Chile
  • Red Internacional de Enfermería en Cuidados Paliativos – Chile (RienCupa)
  • Red internacional de enfermería quirúrgica -RedIEnQu Chile
  • Sociedad Chilena de Enfermería en Salud Ocupacional (SOCHENSO)
  • Sociedad chilena de enfermeras de salud escolar (SOCHIESE)
  • Sociedad Cientíca chilena de enfermeras del niño y adolescente (SOCHENA)
  • Sociedad Chilena de Enfermería en Cardiología y Cirugía Cardiovascular (SOCHICAR)
  • Sociedad Chilena de Enfermería en Donación, Procuramiento y Trasplante (SOCHIENFDPT)
  • Sociedad Chilena de Enfermería Oncológica (SEOC)
  • Sociedad científica de enfermería comunitaria y familiar (SOCHIENFA)
  • Sociedad chilena de enfermeras comunitarias (SOCHIENCO)
  • Sociedad Chilena de Enfermería Prehospitalaria, Agrupación Científico-Técnica. (SOCCHIENPRE)
  • Sociedad chilena de prevención y control de infecciones asociadas a la atención en salud, (SChIAAS)
  • Sociedad Chilena de Enfermeras de Pabellones Quirúrgicos y Esterilización
  • Sociedad Chilena de Terapia de Infusión (SOCHITEIN)
  • Sociedad científica de atención temprana, rehabilitación e inclusión
  • Sociedad Científica Docente Estudiantil de Enfermería UACh Pto Montt (SOCIDENF)
  • Sociedad de enfermeras de diálisis y trasplante renal (SENFERDIALT)
  • Sociedad Chilena de Enfermería Geronto-Geriátrica
  • Sociedad de Enfermeras Dermoestéticas (SOCHIEDE)
  • Sociedad de Profesionales en Esterilización de Chile
  • Sociedad Chilena de Simulación Clínica (SOCHISIM

About Luz Galdames

Luz Galdames Cabrera Ph.D. in Nursing, Mg. Instructional Design, Nurse-Midwife, Research Professor, School of Nursing, Faculty of Sciences, Universidad Mayor. Researcher in project “Development and validation of the prototype dressing with copper nanoformulation for the treatment of infected chronic wounds, Universidad Mayor, Project ID18I10085 Funded by the Fund for the Promotion of Scientific and Technological Development FONDEF 2018-2020. Director of the Nursing Specialization Program in Adult Oncology at the Universidad Mayor. Member of the International Center for Nursing Research CIIENF of the Chilean Association of Nursing Education. Coordinator of the international Care Management Network. Founder and President of the Chilean Network of Care Management Last publication Galdames l., Enders B., Pavez A. Self-regulation, Autonomy and Identity of Nursing as a profession. Science and Nursing Magazine. 2019 24 (4). Doctoral thesis Care Management: Understanding the Meanings of the Social Role and Professional Autonomy of the Nurse in Chile. Funded by the Vice-rectory for Research and Doctorate as a start-up project, Universidad Andrés Bello Chile 2014.

It’s Time We Raise Nursologists!

Report from the 2021 Virtual Nursing Theory Week

Contributors:
Christina Nyirati
Sharon Stout-Shaffer

At the time of the 2021 Virtual Nursing Theory Week, Christina Nyirati and Sharon Stour-Shaffer presented the baccalaureate curriculum they designed and now implement at Heritage University located on the Yakama Reservation in Washington State. This is the only session that was recorded during the conference; it represents the value of nursing knowledge in shaping the present and future of nursing as a discipline. The following is a brief description and a video of their presentation.

The first Heritage University BSN Program Outcome reads “The Graduate of the Heritage University BSN Program explains how nursing’s fundamental patterns of knowing –personal, aesthetic, ethical, empirical and emancipatory –contribute to understanding the complexity of nursing care in the treatment of human response”.

Carper’s (1978) Fundamental Patterns of Knowing in Nursing is the foundation of the BSN Program. Freshmen study discrete courses in each of Carper’s fundamental patterns: personal, aesthetic, ethical, and empirical knowing. The Personal Knowing course is founded on personal knowing as a precondition for nursing care. Students practice various methods of reflection to develop personal knowing in every moment of nursing care. The Aesthetics of Nursing course is grounded in assumptions from Nightingale’s theory of nursing arts and aesthetics as a fundamental pattern of knowing in nursing. An experiential course, based in the principles of performing arts, the focus is on the act of care; Students explore and apply dramatic arts foundational to holistic nursing care competencies. The Ethical Knowing course emphasizes the practice of ethical comportment in nursing care. The Empirical Knowing course students introduces students to fundamental theories, concepts, evidence, and competencies pertaining to generation of nursing knowledge.

Senior year features the community as the unit of nursing care, and is founded on Chinn and Kramer’s (2019) emancipatory knowing in nursing. The Policy, Power & Politics of Nursing course focuses on the professional nurse role in taking responsibility for shaping social policy. The two Community Oriented Nursing Inquiry and Practice and the Community Based Participatory Research courses center on principles of socially just reflective action to overcome health inequities.

Faculty developed rubrics to evaluate how students integrate the fundamental patterns of knowing nursing into clinical practice. Students complete reflective writing assignments during clinical practice each semester from sophomore through senior year.

About the contributors:

Christina Nyirati, RN, PhD

Christina Nyirati is Professor of Nursing at Heritage University on the Yakama Nation Reservation in Washington, where she serves as the founding Director of the BSN Program. Dr. Nyirati came to Heritage from Ohio University and The Ohio State University, where she directed the Family Nurse Practitioner (FNP) Programs. She practiced more than 30 years as an FNP in primary care of vulnerable young families in Appalachian Ohio, and worked to reduce dire neonatal and maternal outcomes. Dr. Nyirati challenges FNP educators to consider nursing knowledge as the essential component of the FNP program as the Doctor of Nursing Practice (DNP) evolves and becomes requisite for entry into advanced practice. Now at Heritage Dr. Nyirati prepares nurses in an innovative undergraduate curriculum faithful to the epistemic foundations of nursing. Two cohorts have graduated from the Heritage BSN Program. They openly proclaim and use their powerful nursing knowledge to correct inequities in their communities.

Sharon Stout-Shaffer, PhD, RN

Sharon Stout-Shaffer, PhD, RN, Professor Emerita, Capital University, Columbus, Ohio; Adjunct Faculty, Heritage University, Toppenish, Washington; Nursing Education Specialist, S4Netquest, Columbus, Ohio. Sharon has over 30 years of experience in educational administration and teaching in both hospital and academic settings. Her career has focused on developing education based on a nursing model that includes concepts of holism and healing.

Her Ph.D. in Nursing from The Ohio State University focused on the psychophysiology of stress and relaxation-based interventions to promote autonomic self-regulation and immune function in people living with HIV. She has attained certification in Psychosynthesis, Guided Imagery, and more recently, the Social Resilience Model; she has presented numerous papers on integrating holism into curricula as well as caregiver wellbeing and resilience including Adelaide, Australia, 2011; Reykjavik, Iceland, 2015; American Holistic Nurses Association Phoenix, 2016 & Niagara Falls, 2018.

During her tenure as Director, Post-Graduate Programs at Capital University, Sharon taught the graduate theory course and co-developed a theoretically grounded holistic healing course as the foundation for graduate study; the graduate program has been endorsed by the American Holistic Nurses Credentialing Center. Since her retirement, she has co-developed and implemented numerous educational interventions designed to develop the Therapeutic Capacity of working nurses and nursing students. This work includes concepts of centering, compassion, managing suffering, the psychophysiology of resilience and essential contemplative practices to develop stress resilience, deal with moral distress and promote long-term wellness. She is currently teaching courses in Personal Knowing and Nursing Ethics for undergraduate nursing students at Heritage University. Her most recent publication is dedicated to holistic self-care and self-development. (Shields, D. & Stout-Shaffer, S. 2020). Self-Development: The foundation of holistic self-care. In Helming, M., Shields, D., Avino, K., & Rosa, W. Holistic nursing: A handbook for Practice (8th). Jones and Bartlett Learning, Burlington MA.)

Theorizing as Emancipatory Action; Emancipatory Action as Theorizing

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

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

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

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

What is “critical’ –

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

What is “emancipatory”

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

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

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

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

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

Sources:

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

Guest post: 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.