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.)
We, along with all members of the nursology.net management team, are very pleased to offer another resource for nursology – the Foundations of Nursology syllabus. The syllabus is offered in conjunction with our teaching strategies resources (Fawcett, 2019) as well as other nursology website resources about nursing conceptual models, grand theories, middle-range theories, situation-specific theories, and philosophies.
The syllabus is offered to all interested nurse educators in academic and practice settings. Our intent in developing the syllabus was to provide a starting point for the teaching of nursology discipline-specific knowledge, with emphasis on nursology philosophies, conceptual models, and theories. We envision the syllabus as a key foundational tool for teaching and learning the essence of the philosophic, conceptual, theoretical, and application knowledge of our discipline as a foundation for transforming health care and health care delivery.
The syllabus has been designed to address the Future of Nursing documents and various nursology organizations initiatives as well as accreditation criteria for nursology programs (such as the National League for Nursing accreditation criteria for all programs and the American Association of Colleges of Nursing criteria for undergraduate and for graduate programs).
A sample 15 week outline is provided to introduce nursology students to the history and contemporary status of the discipline of nursology and the value and approaches to nursology theory-guided practice, quality improvement projects, and research. Depending on program level, students will use, translate, and/or develop new knowledge in coming to know and engage individuals, families, and communities in the praxis of nursology and wellbecoming, as well as coming to know healthcare systems. The syllabus provides course objectives, suggested methods of instruction, course delivery methods, examples of recommended readings and resources, examples of learning activities, and a sample topical/content outline and course schedule.
We invite readers to post any questions or comments they may have about the syllabus and to recommend development of resources for any other nursology theory-related teaching needs that need to be addressed.
Guest contributor: Elizabeth “Ellis” Meiser, MSN, RN-BC, CNE
When I took a nursing theory course for the first time in my educational experience (at the doctorate level, mind you), I found myself grateful to finally be able to identify what may make learning theory difficult for me. A few years ago I was listening to a podcast in my car from the BBC. It began with a discussion on spatial navigation and transitioned into mental visualization. The topic was on how some people have a limited ability to imagine. The podcast asked listeners to close their eyes (I waited until I got to my destination to complete the exercise, don’t worry!) and picture a beach. Go ahead and do this if you can. Close your eyes and call to mind beautiful white sand, a palm tree, blue waves crashing under a clear blue sky. I settled into my seat and closed my eyes. But when I tried to see a beach, nothing happened. It was then I realized that I had a processing condition called aphantasia.
Individuals with aphantasia have difficulty imagining visually. For me, it means when I close my eyes all that happens is I stop seeing. Most people are on a spectrum of capability when it comes to visualization. Some can recall only things they have seen before, for some it may appear like something from a cartoon, and for others it is as realistic as if it were before their eyes. Perhaps it seems shocking that I would not be aware of this until my mid-twenties, but how often does it come up in conversation? I suppose I always thought when someone said “mind’s eye” or that they could “picture it” these were expressions but that they couldn’t actually do it. Turns out, most people can actually picture things when my mind is woefully dark. With an impact on my ability to remember things, I just always assumed I had a poor memory.
My lifelong struggle with having to learn about and analyze abstract ideas suddenly made sense! The blog posts from Dr. Foli and Shannon Constantinides about the concerns with teaching theory in nursing education, along with the potential impact of generational differences, jumpstarted my questioning of my own journey through abstract learning. I cannot envision physical things, words, shapes, or even colors. Without those capabilities, I wonder: what could be the main factor impacting my ability to truly grasp abstract concepts? There could even be a combination of many contributing factors. Then I wondered, does it even matter? Why do I even need to understand theories?
As I mentioned, I’ve been through nearly ten years of formal education for nursing and cannot recall a course dedicated to nursing theory. I became faculty armed with a master’s in nursing leadership and management and a handful of education classes from my music education undergrad. I had been exposed to Piaget’s developmental theory and Maslow’s hierarchy of needs. I knew how to write objectives using Blooms, and in my master’s had been introduced to a variety of leadership theories. I had not, however, explored anything on Benner, Henderson, or even anything beyond the fact that Nightingale had something to do with a lamp. I didn’t even know nursing theories existed, and when presented with them in my doctorate program, I struggled understanding them and their purpose. However, in my practice of simulation, I have recognized the impact of Jefferies on how frameworks can guide development of scenarios. I have embraced Benner by recognizing how to consider the learners, where they are within the program, and within their own growth process. Much of this required me to evaluate how to learn abstract concepts.
Ultimately, a huge hurdle on abstract thought for me must involve aphantasia, which presents for me as the inability to daydream and the absence of visual recollection. It can be hard for me to remember what I’ve read or seen. As a learner, and now as a nursing educator, I feel as if it is taken for granted that all learners have the capacity to visualize mental images. Despite this having implications for learning, aphantasia is not currently considered a learning disability. Furthermore, there has been no progress on aiding those with aphantasia in developing the ability to produce mental imagery as it seems to be a neurological deficit. I am unsure of whether identifying students with aphantasia, or to what extent they are capable of visualizing, is important. Instead, what we need to do is create a holistic learning environment that is accessible to a variety of learners and learners need to be equipped with tools that suit their learning style. Using varied education techniques to address learning styles has long since been routine, but how often have we considered the student’s ability for mental imagery? How are we sharing abstract ideas? Is it in a tangible way? Do we encourage students to reflect on how they think, process, and picture things? Perhaps we need to consider adding this to the conversation to help students assess their learning needs before we begin introducing abstract concepts.
When it comes to theory, abstract instruction, or other types of instruction, I have found myself having to use a range of resources. For example, graphs, images, and diagrams may help explain concepts, but they are difficult to recall as I cannot recreate them in my mind. Instead, I found myself using a mixture of media, videos, and having to use my trusty gel pens and notebook paper. As it is in any pool of learners, these will have different effects for different learners but include:
Make personal or emotional links to content
I find relating theories to stories extremely helpful. This means grounding abstract ideas to something that I can relate to, or experience.
Listen to podcasts or a recording of a lecture
This may be difficult for some with aphantasia as there is no visual imagery to which to connect the audio.
Write notes and draw concept maps on paper to physically forge connections
An age-old recommendation that should never have been replaced by typing and is even more effective when summarizing in my own words.
Use Flash cards, mnemonics or other rote memory tasks
While I can’t bring these to mind at a later date, I can force memorize the basic concepts before scaffolding the more abstract ones.
Involve music or rhythm
Again, this is helpful for the more basic concepts. However, there has been some evidence of links between those with aphantasia also having difficulty remembering sounds, tones, or music so this is very dependent on ability.
Teaching others or simply reading notes out loud
Yet another traditional method of evaluating learning and using kinesthetics and physicality to the party. When I get lost in reading about theory, I find that reading it out loud helps me stay on track.
It is crucial to remember that while linking learning to visual memory reportedly leads to better academic outcomes, it does not equate to higher intelligence. It certainly has an impact, but it is not the only variable to consider. Reflecting on how important the mind’s eye is to learning leads me to wonder how different schooling would have been had I known about aphantasia. For myself, I can apply it to what remains of my terminal degree and my continued lifelong learning. For others, I can write about its impact and attempt to add to the discussion on what influences how, when, and to whom we teach nursing theory and knowledge. Ultimately, we need to work with all learners to be advocates for what they need to succeed regardless of the topic at hand.
About Elizabeth “Ellis” Meiser
Ellis is a Clinical Educator of Nursing at Longwood University in Farmville, VA. They have their MSN with a focus on leadership and management, is a Certified Nurse Educator, and is certified in medical-surgical nursing. They are in their first year as a doctoral student in the online EdD Nursing Education program at Teachers College, Columbia University.
My career in nursing education has spanned the better part of a decade. For the majority of that time, I taught in an associate’s degree nursing program. At first, I was not sure if nursing education was for me. I was always a preceptor on the nursing units during my time in the hospitals, but that does not necessarily equate to being a good educator. After a semester, I was hooked. I found so much joy in showing my students not just how to do nursing, but how to be nurses. Forget “teaching to the test”! I would teach through experience, stories, relationships, respect, and caring.
Over the years, I thought I was developing into an expert nurse educator. I obtained my MSN, I passed my Certified Nurse Educator (CNE) exam, and I achieved quite a following among the student body. Until one day, it all changed. I was accused of being too personal, too attached to my stories and experiences, too outward in my sharing. I couldn’t understand why this faculty member was attacking me for being who I am, for valuing my relationship with my students, for giving them a part of me so they know I am human too. The lateral violence (let’s face it, that is what it was) became too much and I decided to move on to where I currently am, a baccalaureate nursing program.
My world has changed. I am now valued for giving my students everything that I have. For sharing not just my experiences but who I am as a person, a nurse, a mom, a friend. I care about them, and they know this. I want them to succeed beyond all ways they could imagine. I want them to learn from me; not just how to be a nurse but how to be someone who cares, who is empathetic, moral, ethical, a life-long learner, and is committed to the profession of nursing. Through my own education at Teacher’s College, Columbia University in the Online Nursing Education EdD program, now I know why. My whole nursing education career I have been guided by the Critical Caring Pedagogy (CCP).
CCP provides a framework for nursing education that, all at once, encompasses ontology, epistemology, ethics, and praxis (Chinn & Falk-Rafael, 2018). This framework consists of seven critical caring health-promoting processes: preparing oneself to be in relation, developing and maintaining trusting-helping relationships, using a systematic reflective approach to caring, transpersonal teaching-learning, creating and supporting sustainable environments, meeting needs and building capacity of students, and being open and attending to spiritual-mysterious and existential dimensions (Chinn & Falk-Rafael, 2018).
Isn’t this what I have been doing all along? All seven?! I have just come to the realization that my own practice as a nurse educator for the last decade has consisted of being in a caring and guiding relationship with my students, the foundation of CCP. I have been guided by a theory I had no formal knowledge of until now. And yet, I was faulted for it. Told I was giving too much of myself to my students. Told that I was to teach the material, not cultivate relationships. Told I made the two students out of HUNDREDS uncomfortable (yes, you guessed it, these students were academically unsuccessful and reaching for reasons for their appeal to be upheld). I almost gave up teaching. I knew I could not work in an environment that did not support my own values and approach to the teaching-learning relationship. Until I moved into my current position, where my foundation in CCP is respected, appreciated, and celebrated. To where my colleagues also practice with the guidance of CCP, whether they know it or not.
Now I can put into words what I have felt all along. Thank you, Peggy Chinn and Adeline Falk-Rafael, for providing the framework and empirics to support what I felt was the right way to teach deep down in my core. Critical Caring Pedagogy has given my teaching practice meaning and validity. I will carry this knowledge with me wherever I go, and I will never give up teaching.
Chinn, P.L. & Falk-Rafael, A. (2018). Embracing the focus of the discipline of nursing: Critical caring pedagogy. Journal of Nursing Scholarship, 50(6), 687-694. Doi: 10.1111/jnu.12426
*About Guest Contributor Erin Dolen
Erin is an Assistant Professor of Practice at Russell Sage College in Troy, NY. She is a doctoral student in the EdD Nursing Education Program at Teachers College, Columbia University. She has her MSN with a focus in Nursing Education from Excelsior College. Erin has her national certification as a Certified Nurse Educator. Her nursing background is in emergency medicine. She lives in Delmar, NY with her husband and two children.
Although many experienced nurses consider themselves as experts in their fields of practice, it is important to keep in mind that they, too, become novices when they encounter a new clinical challenge or situation such as the Covid-19 pandemic. Benner’s (1984) theory, FromNovice to Expert, is an excellent nursology theory that can guide clinical practice in the context of current health care challenges related to Covid-19. The theory includes five stages–novice, advanced beginner, competence, proficiency, and expertise. As nurses pass through these various levels of proficiency, they develop holistic clinical knowledge influenced by nursology education, experience, and intuition (Benner, 1984).
The purpose of this blog is to summarize an exemplar of a “novice to expert” nursology educational strategy developed in response to the Covid-pandemic Global Nursing Education exemplar. The exemplar is about a non-profit 501c3 organization, Dr. Gabone QHSC (Quality Healthcare Solutions and Consulting) Inc., which served global novice nurses experiencing a surge in Covid-19 cases in their clinical practice. These novice nurses, especially those assigned to “Covid-19” units experienced common challenges reported in the literature such as exposure and anxiety related to the lack of personal protective equipment and fear of the unknown (Chen, Lai, & Tsay, 2020) . As a result, they relied heavily on emerging knowledge from public health experts as well as clinical expertise from frontline workers who had already experienced the impact and management of the disease in their practice settings. Hence, to better serve the novice nurses, the organization assembled teams of interprofessional Covid-19 frontline healthcare workers from various Covid-19 affected areas to share knowledge about how they utilized their highly skilled analytical problem solving abilities, experience, and education to grasp the emerging situation, events, and behaviors via Zoom meetings.
Six educational sessions were offered as resources to heighten the opportunities for novice nurses around the world, in particular targeting Tanzanian nursologists. The topics covered included:
Challenges of Covid-19 in nursing practice across various practice settings
Typical nursing care shifts for Covid-19 patients
Medication administration and medical protocols
Infectious disease management
Effective use of PPE to prevent spread of COVID-19
Effective coping strategies to promote nurses’ individual and family well-being
Creating a culture of safety
Challenges faced by prospective health care workers.
As the frontline workers described their expert practice, they widened the novice nursologists’ perspectives and acceptance of actual and potential challenges and situations they might encounter in their practice settings. For example, the meetings provided demonstrations of how nursologists are interconnected and how they face similar challenges such as lack of PPE and fear of becoming infected. In addition, some nursologists shared ways they reused supplies while ensuring safety and efficiency for patient care.
Overall, the feedback from the participants was positive. The online mode of delivery included interactive elements such as chats, polling, and emails to facilitate discussions to move beyond the content elements and also facilitate experiential learning to develop expertise. Future recommendations for effective online global education delivery and programming include consideration of delivery time for synchronous presentations, as well as access to technology and internet service in resource poor countries and communities.
As we move forward, I call upon nursology scholars worldwide to utilize Benner’s (1984) Novice to Expert theory to examine how the lived experiences of frontline nurses during the Covid-19 pandemic facilitate knowledge development among novice nurses in clinical practice. Questions to ponder are: 1) How and what did frontline nursolgists learn during the Covid-19 pandemic? 2) What new nursing knowledge was generated by the frontline nursologists as they became the experts? 3) How can we utilize the new knowledge in nursology education and practice to manage future outbreaks/pandemics?
Please feel free to share your comments to this blog.
Benner, P. (1984). From novice to expert. Addison‐Wesley .
Welcome to Shannon Constantinides, who is joining the Nursology.net blogging team! Shannon also contributed the content on Jane Georges’ Theory of Emancipatory Compassion
As a current PhD candidate (Yay! I’m making progress) and experienced NP of about a decade (Yikes! Time flies!), I have a few thoughts on Dr. Foli’s well articulated post and associated call for action/ questions regarding nursing theory in academics. It is with a great reverence for the bright minds of this community that I share these ideas with you all. Please consider my comments simply for no more than what they are: some thoughts from a novice scholar (who happens to be a millennial).
First, the humor and humility with which Dr. Foli broached the topic of “nursing students throwing shade at nursing theory” made her post fun to read and so relatable!
Second, and not entirely related to the topic at hand (which I’ll get to), as an NP who often precepts students, I loved the question posed to students, “Are you running from something in your current job, or running toward a goal of being a nurse practitioner?” I think probably too often nurses go to NP (Nurse Practitioner) school without a clear idea of what the role and day-to-day of the job entails. On a number of occasions, I’ve gently refused to write letters of recommendation to NP school for newly graduated BSN students, because I truly believe that the knowledge and experience gained by working as a nurse is beyond measure. First and foremost, NPs are nurses. I can’t underscore enough the importance of building a strong professional foundation. Equally as important is taking the time and opportunities to explore the endless possibilities that come with nursing practice (finding what sets one’s soul on fire, so to speak). I think this goes for new-grad RNs who are fixated on any one speciality, as well. I would not be on the path that has lead me down my professional and academic journey without first practicing in a number of areas (being in the military made this an easy possibility). Having experience in a number of areas has been invaluable to my career as an APN – clinically and in broadening my understanding healthcare systems and the lived experience of health, itself.
Third, I think the struggle to connect theory to practice comes from a few places. Overall, however, I think it may be time we re-envision and modernize how we approach teaching theory, in the first place. We did this for clinical practice, right? How many of our colleagues ever trained in a sim lab, for example? Updating the what, how, and environment in which we teach doesn’t have to be limited to the parameters of the clinical side of practice. I think the sample principles apply to teaching theory, especially if we want students to learn how to integrate the two. So a few thoughts…
Why is there SO MUCH reading!?
I’ve deduced that what has seemed like an ungodly amount of reading over the course of my education has served the following purposes: 1) taught me the practical knowledge needed not kill my patients (literally), 2) exposed me to new ideas, and 3) exercised my brain and made it grow in its ability to comprehend complex and abstract ideas – just like exercising a muscle.
In regard to the amount of reading that goes along with nursing education: I had NO idea! And I say that as a naturally voracious reader who grew up in a home that purposely had no tv! Honestly, I think 99.99% of students have no idea what they’re getting into when they sign up for nursing education – at any place on the educational spectrum. Students need to be reassured, probably on repeat, that the reading has a purpose. As much as the discourse in nursing espouses that we ascribe to the anti-handholding/ law-of-equal-suffering/ eat-our-young narrative, reassuring your students is more than being nice or helpful. On a deeper level, reassuring your students demonstrates the ethics of compassion and caring that is preached in the pedagogy of the discipline.
To that point, your millennial students will also to be curious as to why you’ve selected specific reading material. I’m not saying you need to, or should, justify each reading assignment. However, giving students a general idea of why certain material is important, especially for theory and philosophy, will help create a connection to the content. I say this with love for my generation, but millennials (and post-millennials) are a different animal. We’re a “special” breed, if you will. We have been raised to question everything. Every. Thing. It’s in our DNA. And you’re just in luck, because there’s A LOT of us! By many accounts, we’re the largest generation in history! (That is, millennials – people born between 1981 and 1996, and post-millennials – people born between 1997 and the present day).
Now, to that point, let’s not also forget that the frontal lobe doesn’t fully develop until late adolescence/ early adulthood. So, some of your students who are innately left-brained, “linear” thinkers (who, inherently, may have a harder time wrapping their heads around some of the non-linear concepts in theory and philosophy), will also be young, concrete thinkers. Their brains literally have just only developed to a point of abstract thinking understanding the basic concepts related to the more esoteric ideas we talk about in theory. And this issue is compounded by unique educational, professional, and personal backgrounds and upbringings of each student.
For example, it wasn’t until my masters-level (and more so, PhD) studies, that I really started understanding some of the more abstruse, Delphic concepts in nursing theory. As a BSN and MSN grad of the CU system, I naturally gravitated to Watson’s work – but generally – the more experienced I became professionally, academically, and in life, the more I came to understand the “other” theories I was learning about in school. As an 18-year-old, direct-entry BSN student I could understand (because I saw a way to concretely apply) Orem’s self care theory, Leininger’s cultural care theory, or Carper’s Pattens of Knowing (and, yes, I now know and understand why Carper said in a 2015 interview with Eisenhauer that her work was never meant to be a theory – but try telling that to a young, brand-new, nursing student! There’s no denying a certain level of concreteness to aspects of Carper’s work. This is something I love about Carper’s model – she wanted it to be readily tangible to the user, and it is!)
In reality, it’s taken me nearly two decades to “get the hang of nursing theory” and be able to digest and truly understand the works of such thinkers as Rogers, Patterson and Zderad, or Newman. Or actually appreciate the depth, intricacy, salience, and beauty of Watson’s work. In fact, as a BSN student, I remember sitting in a guest-lecture with Dr. Newman, and being the left-brainer that I am, raised my hand said, “Um, Dr. Newman, I don’t get it…” Looking back, I’m still mortified by this encounter! I was THAT student (insert #facepalm here!).
So, really, it’s taken the better part of my adult life to develop the intellectual ability and emotional maturity needed to sit with and understand complex ideas. There are articles, book chapters, and entire texts I now consider the Holy Grail, which when I first read them specifically remember thinking, “WT_?? Is this even in English???” And to that point: don’t forget that your students are literally learning new languages! They’re not only learning the technical language of healthcare, but also the language the informs the epistemology of nursing. So, again, I think showing your students a little patience, forgiving, and compassionate grace is key.
Likewise, it’s my opinion that once we get to a certain point in our careers (as a clinicians, scholars, educators, administrators, etc.) we take for granted knowledge that has become second-nature. I can say, with complete certainty, that I fall prey to this with my own clinical NP students. What do you mean you don’t have a clear, concise, and evidence-based plan for managing your older adult patient who has insanely complicated medial, psycho-emotional, and social needs?? We have to remember that knowledge for students – whether clinical or related to theory and philosophy – is often entirely new or being presented at a depth they weren’t expected to go to in the past. In addition, with APN students where we’re building off the knowledge and experience that comes from working as an RN and RN education. As far as theory and philosophy are concerned – that knowledge is really complicated, is often brand-new, and often isn’t intuitively grounded in day-to-day nursing work and education. Your students are learning new stuff, a new language, and and learning to think in an entirely different way. Patience is key. Finding a way to foster connection to the content is key. My suggestion would be to keep Benner’s Novice-to-Expert model in the forefront of your minds when you’re working with students – especially when it comes to teaching theory and philosophy.
Middle range theory & the ladder of abstraction.
I think a lot of students aren’t exposed to middle-range theories. This statement is, of course, purely based off anecdote consisting of my own academic and professional experiences, and what sound to be similar experiences shared by my colleagues. It’s my opinion that middle-range theory may an optimal place to bridge the theory-practice gap. Certainly, this bridge will be influenced by the paradigm framing the theory or the paradigm to that which the nurse knowingly or unknowingly ascribes. However, as Smith and Liehr (2014) stated, middle range theories are more straightforward and lie in-between that which is all-inclusive and that which is highly situation-specific. In this regard, a few exemplars that made sense to me and my peers included Story Theory, the Theory of Unpleasant Symptoms, and the Theory of Caregiving Dynamics.
I also think teaching the levels of theory abstraction as described by Smith and Liehr, even at the BSN level, could help make a little more sense of nursing theory in terms of applicability. Do I apply this theory at the bedside? In a specific situation? Does it guide a certain aspect of my practice? Or, is it something that will guide the entirety of how I approach practice, patients, and the general experience of health?
I think it’s so tempting to start off with the classics: the grand nursing theories. But honestly, some (ok, basically all) of those theories are super complicated! For your newer, less experienced learners, maybe initially include something a little more concrete, like a micro theory? Help your students dip their toes in the water, so to speak, rather than throwing them directly into the deep end. I think a lot of harm can be done when faculty knowingly or unknowingly teach at a level that is over the students’ heads. Your students will get there, trust me, but keep it simple in the beginning. Help your students build a strong foundation. You’d do the same with patient care knowledge and skills, right? So, same idea for nursing theory.
Aging-out and aging-into the current sociopolitical & cultural context
I can’t stress this enough: nursing faculty have a critical place not only as clinical and scholarly role models, but in modeling the language and behavior of advocates and voice-givers. When I started my BSN in 2000, and even by the time I graduated with my NP in 2011, I didn’t really know what social justice was. I couldn’t really answer the question, “What are you doing to be an advocate?” Over the course of my PhD program, however (and thankfully so), I’ve had the amazing fortune to work with and be mentored by some exceptionally stellar minds in my quest to figure out my place as an advocate and voice-giver (especially Dr’s Peggy Chinn, Patricia Liehr, Jane Georges, Debra Hain and Deb D’Avolio… to name a few). And, boy, do I wish I’d had a social justice/ emancipatory focused curriculum as a BSN or MSN student, like our students do at FAU!
So how does this relate to teaching theory? As feminist Holly Whitaker (2019) wrote in her book, “Quit Like a Woman,” we are now, likely more so than ever, aware of our own oppression, the oppression of others, and aware of how our actions or inactions have abetted the oppression and marginalization of others. Whitaker states, and I whole-heartedly agree, that thanks to movements started by the LGBTQIA community, radical feminists, and women of color, our common vernacular now includes words like privilege, misogyny, and patriarchy. (I would also add terms like toxic masculinity and inclusivity). Likewise, I contend that our language reflects a paradigmatic shift that is occurring in society: we are moving toward a more humanistic way in how we view and interact with others. For example, we’re moving away from socially constructed and derogatory descriptors. Rather than calling someone “disabled” we acknowledge that the individual is of other-ability. Rather than being called “elderly” or “geriatric” we honor the experience that comes with older adulthood. We recognize that someone is involved in “sex work” is a “sex worker,” not a “prostitute.” We now see that the term “violence against women” is problematic in that it is passive and alleviates the blame of the perpetrator.
Students, especially millennials, are probably hip to these issues and this type of language, but this is not an assumption to make. It is your responsibility as a faculty member to stay informed and engaged in this regard. Just like you would teach from a place of best evidence regarding clinical practice and patient care, stay up to date on what’s going on in the world, the language being used, and the issues that matter to your students.
The good news is that we now have theories and books that are grounded in a social-justice paradigm! Take, for example, Georges’ (2013) Emancipatory Theory of Compassion (or really, any of Dr. Georges’ work dealing with the nature of human suffering). I adore Georges’ work (and work she’s done collaboratively with Dr. Susan Benedict) for a number of reasons, especially how she takes the concept of suffering head-on, and calls out nursing in regard to the profession’s historical (and generally unspoken) complicit involvement in oppression. Intentionally moving away from the traditional, Western narrative that has a propensity for the patriarchy, Georges’ work focuses instead on alleviating suffering through compassion, empowerment, and deconstruction of power relations. Falk-Rafael’s Critical Caring model, for example, also goes in this direction as it looks at role power relations have in public health outcomes. Likewise, I consider Kagan, Smith, and Chinn’s (2016) Philosophies and Practices of Emancipatory Nursing, and the works there within, a critical must-read for anyone wanting to study or practice nursing theory in context of today’s sociopolitical climate. To that point, a quick search on Amazon revealed a number of nursing textbooks centered around contemporary theory-based approaches for caring for vulnerable populations, approaches to healthcare policy, and approaches for healthcare advocacy.
And, to very briefly touch on the topic of technology in nursing theory: if your students are my age (I’m 37) or younger, we never knew what it was like to live without technology (let alone practice nursing without computers, smart phones, apps, EHRs, or the internet!). My husband, a physician (I know, I married the enemy), is 10 years older than me. We work in the same primary care practice. Even though he is fairly tech savvy, it’s astonishing how much longer it takes him to adapt clinical technology compared to those of us in the clinic who are a decade younger. I’m not saying this is true across the spectrum: I absolutely interact with younger clinicians who have less tech know-how than our colleagues a few decades our senior. What I’m saying is that those of us who were born into and grew up practicing nursing in the information age have a different relationship and understanding of healthcare (and view of the world, in general) than those even a decade ahead of us.
Several years ago, at the suggestion of my fairly tech savvy entrepreneur dad, I read “The World is Flat” by Thomas Friedman. My dad thought this work was incredibly forward-thinking. The concept and manifestation of a globalized humanity secondary to advances in technology was mind-blowing to him. However, I remember thinking, “yeah… so this is not a new thing to me, Dad…” Keep in mind that the world has always looked so different to those of us in the millennial and post-millennial generations. In terms of nursing theory, Watson’s work – I think especially Caring Science as Sacred Science and Unitary Caring Science – both hit the nail on the head in terms of addressing globalization and caring for a global humanity.
Additionally, the exciting thing about nursing theory in the information age is that new theories are emerging to deal with contemporary, tech-related issues! Dr. Rosario Locsin’s Theory of Technological Competency as Caring, for example, is pertinent and relatable for today’s students. A few years ago, I had the opportunity to listen to Dr. Locsin speak about his theory. I was, again, THAT student. I asked Dr. Locsin, “Are your theory and views on artificial intelligence and humanoids questioning how we define existence?” “No. Not necessarily,” he said, “But what if A.I. develops to the point where it can’t be differentiated from naturally living beings? What if a humanoid develops feelings? Can they develop feelings?” These may sound far-fetched, but the future is not that far away and technology is developing at a screaming pace! The philosophic questions, ethical dilemmas, and reality your students will face in the future will undoubtedly look like something out of a sci-fi novel – and for that I applaud Dr. Locsin for boldly going where no nursing theorist has gone before!
This next statement might be considered heresy, but for the sake of discussion, hear me out: I believe some theories are aging-out, or at least need to update their language. This is absolutely not a dig on older theories: let me be very clear about that! Some of the older theories were the embryonic origins of what, over time, have evolved into modern nursing theory and practice. Due to the social and political culture of the time, and in order to be taken seriously, the structure and verbiage of early nursing theories were informed by a patriarchal/ paternalistic, medical narrative that was dictated by an aristocracy of upper class, white, male physicians, scientists, politicians, and power-elite. People were either ill or well. Self-agency was not a thing if you were not a straight, white, cis-male. Social justice was not a thing. Human rights were not a thing. The right to health was not a thing (and arguably is still not a thing). Hearing the critical voices of underserved, under-represented, vulnerable, or marginalized populations was not a thing. Talking about energy (let alone shared energy) was definitely not a thing – or at least not a thing that was spoken of publicly or in circles of “hard science.” The male doctor gave the female nurse orders, and the female nurse would then perform prescribed actions.
I conducted a review of caring theories as a part of my comprehensive exam last summer. Again, let me be very clear: these theories were crafted by minds much more brilliant than I could ever hope mine to be, and there is indescribable wealth, depth, knowledge, and wisdom imbedded in these works. Truly, many will remain as enduring masterpieces of the discipline, and their authors have become beacons of progressive, forward-though. However. …. However, in conducting this review, I found that a few theories that by their nature of being framed by a context that no longer matches the current sociopolitical and cultural climate, have perpetuated the aforementioned narrative informed by the patriarchy and the notion of power imbalance. I believe this is antithetical to the emancipatory movement we are experiencing in nursing – and society, as a whole – where, for example, the out-dated adage of “enabling” the other should be updated to a focus on empowerment.
So, some closing thoughts:
Your students live and will work in a world that that changing at an unfathomable pace. While I believe that a great many works and ideas in nursing theory and philosophy are truly timeless and relevant, some are not. Stay up to date on what is pertinent and what is being published. Teach the classics, but also teach new, relevant theories. Try new articles. Try new textbooks. Talk to your students about what they think is timely and relevant.
And more importantly …. talk to your students. Connect with them. Millennials, in particular, like to be engaged and involved! Finding innovative and creative ways to connect with your students is especially important with the proliferation of online programs, where many students will never set foot campus. Trust me: your effort in this regard will be well worth it! Whether in the classroom or the online environment, I got the most from faculty who taught from a place of compassion and connection – where they openly and earnestly worked to understand the student perspective and got us involved and invested in what we were learning. In fact, I’m still in touch with a few faculty from both my BSN and MSN programs! (Dr’s Lea Gaydos, Lynne Bryant, Amy Silva-Smith…). Dr. Gaydos and Dr. Bryant were my BSN and MSN theory and philosophy professors, respectively, and were two of the first people I called when I had my first theory-related article published in 2019 in NSQ. It’s been nearly 20 years since I took Dr. Gaydos’ class, and I still have my term paper from that course. All I can say is: what an abomination! I was in tears, laughing, when I reread that “gem” last year!
My point is, these professors planted the seed of interest in nursing scholarship at the doctoral level. You will have THAT student. I was THAT student. Who am I kidding… I’m still THAT student! The student who wants to know “why” about everything. The student who will question everything. The student who will argue every last point on an assignment. Trust me when I say this: no matter how much shade your students throw at theory, you ARE making a difference. Because THAT one student … the one who pushed you and nearly drove you crazy … that student may be the one who grows up and wants to continue this dialogue.
Finally, and most importantly: I truly admire and respect Dr. Foli for putting herself out there. The issue she raises (students throwing shade at nursing theory) is very real and very much alive and well in the world of nursing academics. As Dr. Jane Georges once said to me, “violence can be done to students’ ideas,” and I applaud Dr. Foli in her quest to improve the academic experience for her learners.
Benedict, S. & Georges, JM. Nurses in the Nazi “euthanasia” program. Advances in Nursing Science: 2009; 32(1): 63-74.
Chinn, PL. & Falk-Rafael, A. Embracing the focus of the discipline of nursing: critical caring pedagogy. Journal of Nursing Scholarship: 2018; 50(6): 687-984.
Eisenhauer, ER. An interview with Dr. Barbara Caper. Advances in Nursing Science: 2015; 38(2): 73-81.
Falk-Rafael, A. Advancing nursing theory through theory-guided practice: the emergence of a critical caring theory. Advances in Nursing Science: 2005; 28(1): 38-49.
Georges, HM. Biopower, compassion, and nursing. In: Philosophies and practices of emancipatory nursing: social justice as praxis. Kagan, PL., Smith, MC., & Chinn, PL. (eds). New York: Routledge; 2014: 51-63.
Georges, JM. An emancipatory theory of compassion for nursing. Advances in Nursing Science: 2013; 36(1): 2-9.
Georges, JM. Evidence of the unspeakable: biopower, compassion, and nursing. Advances in Nursing Science: 2011; 34(2): 130-135.
Georges, JM. Bio-power, Agamben, and emerging nursing knowledge. Advances in Nursing Science: 2008(A); 31(1): 4-12.
Georges, JM. The politics of suffering: implications for nursing science. Advances in Nursing Science: 2004; 27(4): 250-256.
Kagan, P.N., Smith, M.C. & Chinn, P. (eds.) (2014). Philosophies and practices of emancipatory nursing. Routledge.
Lenz, E.R. & Pugh, L.C. (2014). The theory of unpleasant symptoms. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.
Locsin R. Technological competency as caring in nursing: co-creating moments in nursing occurring within the universal technological domain. The Journal of Theory Construction & Testing: 2016; 20(1): 5-11.
Smith, M.J. & Liehr, P.R. (eds). (2014). Middle range theory for nursing, 3rd ed. Springer.
Smith, M.J. & Liehr, P.R. (2014). Story theory. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.
Watson, J. Unitary caring science: the philosophy and praxis of nursing. Louisville: The University Press of Colorado; 2018.
Watson, J. Caring science as sacred science. Philadelphia: F.A. Davis Company; 2005.
Whitaker, H. (2020). Quit like a woman: the radical choice not to drink in a culture obsessed with alcohol. Random House.
Williams, L. (2014). Theory of caregiving dynamics. In: Middle range theory for nursing, 3rd ed. (Smith, M.J & Liehr, P.R, eds). Springer.
I’d finished grading the last of the master’s-level students’ theory in nursing papers. I’d turned in final grades and then, the message came through: anonymous student course evaluations were ready for my review. I took a long sip of water and put my organic, no preservative, granola bar aside.
Steady, old girl, I said to myself. You have tenure. How bad could they be? I’d done my very best in this hybrid-structured course. The graduate students met on campus about five times throughout the semester and the rest of the “class meetings” were virtual. I liked the hybrid structure as it offered the students a sense of community; yet the online component allowed them to be self-directed as adult learners. I tried to impart a rudimentary foundation of the philosophy of science, and used discourse that included logical positivism, epistemology and ontology. The course content included a deep dive into concept analysis, nursing theorists and the major health behavior theories and – I thought – many applications of nursing theory to practice decisions and interventions. Assignments were student-personalized, asking for them to express their own philosophies of nursing care, present on nursing theorists’ work, and take a stab at concept analysis or critique a published analysis.
Yet, here I sat, wanting to avoid the dreaded student evaluations. No delaying it any longer. I logged into the student evaluation portal and winced as I read the polarized comments. Many were very complimentary: “Course well organized. Grading was clear with helpful comments given on papers.” A continuation of gratifying comments: “Didn’t think I’d like theory, but I did. Liked the examples. Related it to real life. Dr. Foli’s passion really came through and helped make the class enjoyable.”
Then, one student’s comments made me stop. “Too many readings. I didn’t read most of them. I had to take time away from studying for patho and that’s what a nurse practitioner needs to know.”
Flinging the granola bar into the trash (it tasted like sawdust anyway), I reached for the Little Debbie Valentine cake.
What??? I had practically done summersaults trying to get the practice-to-theory connection in this class. And then I paused to reflect on my audience: students enrolled to become primary care nurse practitioners. Many continued to work at the bedside in highly stressful jobs. They all had personal responsibilities, some of which overwhelmed them (an ill child, a sick mother).
When I spoke to the class at the beginning of the semester, I asked them a question that I didn’t need a public response to: “Are you running from something in your current job or running toward a goal of being a nurse practitioner?” Upon hearing this question, I always looked for the nonverbal responses: heads slightly turned down, eyes glancing sideways. Mouths in grimaces. The ones that seemed to embrace the new career path continued to look directly at me.
So I knew from the beginning of the semester this was a tough audience. These folks were frontline, point-of-service providers who had witnessed and experienced nurse-specific trauma on an ongoing basis. Sadly, for the majority of them, nursing theory meant little.
They were here in this first semester graduate class to learn the facts, just the facts. Or as Chinn and Kramer (2015) describe it: empirical knowledge. As advanced practice nurses, they would be tasked to diagnose, prescribe, recommend a treatment plan, and manage illnesses. They’d also engage with the patients to promote wellness and encourage disease prevention. What did theory have to do with all that?
Well, as I read the students’ comments, I wondered what more I could do to ensure they saw the connection between all the ways of knowing (Chinn & Kramer, 2015), how to apply middle-range theories to their practices, and use theory as an organizing framework to track efforts. I wanted them to see patients as dynamic individuals, not merely as objects that may or may not adhere to a treatment plan.
As I put the Little Debbie wrapper in the trashcan, I felt invigorated (it could have been the sugar rush). They may have thrown some shade at theory, but I pulled out the course syllabus, reviewed it, and made note of how I could continue to refine the course so that every student would see the value of theory in primary care. I did this because it’s so important for our profession. Nursing theory gives us identity, ways to increase nursing science/nursology and patient care practices. As the Year of the Nurse and Midwife, the timing couldn’t be better!
What about you? If you have suggestions for me on how to strengthen the theory-to-primary care advanced practice connection in a master’s level course, please forward them in the comments below.
Or, better yet, go to Nursology’s Teaching/Learning Strategies (https://nursology.net/resources/teaching-strategies/) and complete the form to submit a strategy to strengthen the link between advanced practitioners’ theory-guided knowledge and nursing practice.
In March, 2019, Case Western Reserve University, Cleveland, OH hosted the conference: “Nursing Theory: A 50 Year Perspective, Past and Future”. One theme that emerged from the lively dialogue at the conference was that nursing theory should be introduced and integrated in all pre-licensure programs. At the same time, participants noted that many pre-licensure educators lack knowledge and skills for teaching nursing theory.
Energized by the March theory conference, several nurse educators from Northeast Ohio joined together to offer a workshop on the basics of teaching nursing theory. The workshop, Making it Real: Connecting Nursing Theory to Nursing Education, was co-sponsored by Case Western Reserve University (CWRU), Ursuline College, and Lorain County Community College. There was no registration fee, parking was free, light refreshments were provided, and 2 contact hours of CE were awarded.
Patricia Sharpnack speaking at Nursing Theory: Making It Real
We scheduled the workshop to precede a Northeast Ohio League for Nursing (NEOLN) dinner meeting and program at the same location. The event was publicized through emails to directors of pre-licensure programs and, in the spirit of collaboration, the theory group and NEOLN each publicized the other’s event.
The program was coordinated by Dr. Mary Quinn-Griffin (CWRU). The planners kept the workshop to two hours so participants could see that they did not need extensive,highly theoretical content to begin incorporating theory in their class, lab, or clinical teaching. During the first hour, Drs. Joyce Fitzpatrick and Deborah Lindell (CWRU), and Dr. Patricia Sharpnack (Ursuline College) presented content on the disciplinary perspective, nuts and bolts of theories, core concepts of nursing, and strategies for integrating nursing theory in pre-licensure education. During the second hour, the participants worked in small groups to identify, and report out on, ways they could integrate nursing theory in their teaching.
Participants engaged in a group activity
We were delighted by the response to our workshop! In two days, we filled the 35 seats and had a waiting list! So, we repeated this program in November. Evaluations were highly positive and participants suggested topics for future programs, such as in-depth discussion and application of specific theories. We look forward to Making It Real, Phase II.
Please contact Debbie Lindell for more information about our theory workshop.
The nursology.net management team is very pleased to announce a new resource for educators of nursology – Teaching/Learning Strategies. This resource is devoted to explanations of diverse approaches to teaching nursology. The first approach focuses on one way to teach the APPLICATION of nursology conceptual models and theories for practice. This teaching strategy involves teams of students role playing nursologists working within the context of various nursology conceptual models and theories that are applied to a fictional multi-generational, multi-cultural family. (See https://nursology.net/resources/teaching-the-application-of-conceptual-models-and-theories-of-nursology/) Comments about this teaching strategy are welcome.
I am confident that the creativity of all nursologists who each in academic and/or clinical settings will be evident as other approaches to teaching nursology are added to this section of nursology.net. Therefore, the management team invites all educators to use the content guidelines and forms found on the “Teaching/Learning Strategies” page to submit explanations of effective teaching strategies.
I would like to thank Deborah Lindell, a new member of our management team, for her exceptionally fine work developing the content guidelines.