Uncertainty is, in many ways, a human condition—each of us most likely feel uncertain about something at least some time in our life. However, the current covid-19 pandemic has brought forth a time of what is great uncertainty for many people worldwide. What, though, is the meaning of uncertainty and the outcome of feeling uncertain?
Merle Mishel’s Theory of Uncertainty in Illness tells us that uncertainty is “the inability to determine the meaning of illness-related events” (Mishel as cited in Clayton Dean, & MIshel, 2018, p. 49). More generally, uncertainty is defined as “The state of not being definitely known or perfectly clear; doubtfulness or vagueness. . . . the quality of being indeterminate as to magnitude or value” (Oxford English Dictionary, 1921/1989).
Mishel’s theory also tells us that uncertainty may be regarded as a danger or an opportunity. What are dangers associated with uncertainty during the covid-19 pandemic? Mental health problems, such as anxiety and depression, have been cited as a danger—Chinn wrote of the “Hidden Risks of Physical Distancing and Social Isolation” during the current pandemic. Foli wrote about the psychological trauma experienced by nurses caring for people with covid-19.
What are opportunities associated with uncertainty during the covid-19 pandemic? Media attention to the inequities of health care based on race is an opportunity to highlight what nursologists have known at least since the time of Florence Nightingale. The nursology.net management team has crafted a statement in support of the elimination of health care inequities that is visible in the sidebar of this website. The statement reads in part, “We are dedicated to building praxis in nursing that reflects the tradition of nursing’s dedication to social justice, that addresses injustice, and that welcomes dialogue and action focused on creating needed change within nursing and healthcare.” All nursologists have an opportunity, on which we must now capitalize, to be at the forefront of developing and applying knowledge to overcome finally widely recognized racial-based health care inequities. We must grasp the opportunity given to nursologists by the media and wider society to be recognized as competent and compassionate carers of people critically ill with covid-19. By doing so, we will actualize #neverforget, which Balakrishnan (2020) used to refer to climate change but is perfect for nursology especially at this time.
Michsel’s Revised Theory of Uncertainty in Illness tells us that the outcome of feeling uncertain is a new life perspective. What is a preferred new live perspective? Are nursologists and all citizens of our planet willing to a new value system to guide the way we live and interact with others?
Although Mishel’s theories are about uncertainty in illness, many other facets of life involve uncertainty. For example: Will my car start today? Will public transportation be on time? Will the meal I ordered or cooked myself be delicious? Will my family member or friend like the gift I purchased for her or him? Will my partner always love me? Extended to knowledge development, we know that inferential statistics used to test theoretical hypotheses do not produce results that are “facts” or “laws,” but instead are numbers that represent a certain level of probability – we are, for example, 95% (p = 0.05) or 99% (p = 0.01) certain about some result but %5 or 1% uncertain about the result. Thus, much of what we know empirically is under conditions of uncertainly.
Clearly, if we are to live comfortably with uncertainty, we need to be comfortable with learning that which is not yet certain (if it can ever be certain!). Within the context of theory development, we can learn from rejection of our hypotheses. Indeed, Popper (1963) maintained that rejection of hypotheses is desirable as the next hypothesis will be better–we will have a better theory. Glanz (2002) added, “There is as much to learn from failure as there is to learn from success” (p. 546). Knowing “what is not” advances theory development by eliminating a false line of reasoning before much time and effort are invested. Thus, wanting to be certain may be a trap that leads to arrogance or a barrier to accepting at least a certain extent of uncertainty. Paraphrasing Barry (1997), who wrote about truth in science, we can indicate that one can reach certainty “no more than one can reach infinity” (p. 90).
Barry, J. M. (1997). Rising tide: The great Mississippi flood of 1927 and how it changed America. New York, NY: Touchstone/Simon and Schuster.
Clayton, M. F., Dean, M,, & MIshel, M (2018), Theories of uncertainty. In M. J. Smith & P. R. Liehr (Eds.). Middle range theory for nursing (4th ed., pp. 49-81). New York, NY: Springer.
Glanz, K. (2002). Perspectives on using theory. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed., pp. 545-558). San Francisco: Jossey-Bass.
“I can’t breathe.” If these words were uttered in any healthcare setting in the country, an influx of healthcare providers would rapidly respond, attempting to save the person’s life by providing immediate care. These words not only represent the recent murder of George Floyd, but mirror the racial inequities that exist for those who are struggling to breathe most in the worst pandemic in modern history.
As a nurse bearing witness to these atrocities in the city of Minneapolis, I have observed nurses organizing themselves to respond as a collective to these unthinkable problems in real-time by taking immediate action to both maintain safety and fight for justice. These nurses are engaging in emancipatory nursing, a form of nursing that has the potential to dismantle power systems that privilege some over others due to economic means, social status, or hierarchies that create health inequity.1 Nurses must struggle to find the freedom to uncover the dominant health practices that foster Western ideals of health and minimizes nurse’s role to that of a ‘helper’ or a ‘do-gooder.’2
The words, “I can’t breathe,” should call all nurses to action, first to look inward at our role in perpetuating systemic issues related to race and injustice, and then to respond as a collective to undo generations of harm that have traumatized communities and individuals for far too long. Witnessing a man struggle to find oxygen to survive, at the knee of someone who has sworn to protect and serve — undoubtedly warrants a public health crisis be declared and calls for immediate nursing action.
Many nurses voiced, in their stories, frustrations of the constantly changing guidelines from the CDC or the Minnesota Department of Health (MDH) that have often created fear and conspiracy theories amongst some mostly well intended people. Unfortunately, while engaging in self-reflection, many of the nurses reported they lacked the energy to continue to participate in social media platforms as the push back from others on these sites felt frustrating and belittling with little change observed. Some nurses felt compelled to take a break from social media sites altogether because of the backlash experienced while trying to dismantle misinformation, such as information regarding wearing a mask in public spaces. Others have taken on this opportunity to do more and respond to needs in innovative ways outside of traditional systems.
Kagan, Smith, and Chinn have provided a framework of action to inspire us to break these shackles in place — known as ‘emancipatory action’ — which require four vital characteristics to be deemed such work. These elements include: “facilitating humanization, disrupting structural inequities, self-reflection, and engaging in communities.”1(p6) While strategically these four elements of emancipatory action have not been used together to tackle the racism that has existed in our care settings for the last 100 hundred years to my knowledge, I have witnessed them being practiced independently by nurses responding to the endless crises that have resulted from the COVID-19 virus and the recent racial justice unrest. While collecting stories from nursing students and nurses in my role as the director of the Health Commons and an assistant professor of nursing at Augsburg University, it is clear that during this pandemic we have taken on the burden of not only caring for patients in practice settings, but also have felt a moral obligation to provide health education to people in social circles, families, and communities.
Take for example Sarah Jane Keaveny, RN, public health nurse, activist, and Augsburg University nursing alum. While buildings closed in response to guidelines set by government bodies due to COVID-19, those who were experiencing homelessness were left with limited options. Typically those in the homeless community access the skyway system, light rail, public library, and other public spaces for shelter, toileting, and rest. But, as the social quarantine measures continued to heighten, more buildings closed, leaving them with limited options to get their basic needs met. One individual experiencing homelessness said to me while at the Health Commons , “It’s like no one cares that we are still out here. I haven’t met anyone with this disease, but I will know people who will die from it because of all these rules.”
Sarah Jane connected with the existing resources of outreach workers and community members engaged in mutual aid to respond to those displaced by social structural inequities in the pandemic through establishing Mobile Outdoor Outreach Drop-in (MOODI) where meals are offered and connections to resources are made everyday of the week at a local park. In addition, while many of the shelters began moving individuals experiencing homelessness into nearby hotels, many of those left on the streets formed or joined existing encampments. Because of the increased numbers in the unsheltered community, disproportionately representative of people of color or indigenous peoples, outreach workers were forced to secure food and water for this marginalized group rather than address long term housing or health issues. Sarah Jane has demonstrated emancipatory action through nursing practice and community engagement; while uplifting human dignity, she engages in communities to respond as a collective, outside of institutions or systems that have limited capacity to respond in the urgent manner required in this pandemic.1
As the infection rates of the pandemic heightened, where black and indigenous populations are dying at alarming rates in comparison to their white counterparts, came the news of George Floyd’s murder by Minneapolis police officers when he was arrested for allegedly using a counterfeit 20 dollar bill at a local grocery store.3 Nurses in our state are coming to know all too well the appalling racial health inequities that exist due to systemic racism; systems of oppression including slavery, Jim Crow laws, redlining, and mass incarceration all tie directly to both wealth and health.4 While emancipatory knowing asks nurses to analyze root causes, such as inquiring why inequities of income related to race exist in the first place, it also requires us to take action in response to undoing these injustices.
The unrest, riots, and violence in response to George Floyd’s death resulted in further displacement of those who were living on the streets of Minneapolis; homeless encampments were destroyed due to false accusations of riot participation, curfews were enforced, and members of the National Guard were deployed. One nurse practitioner, Rosemary Fister, demonstrated disruption of racial policies in this moment when she fought for change in real-time. As people living on the streets sought to find protection from the rubber bullets and tear gas released, she organized herself and others to respond to those left without protection due to structural inequities, or “a host of offenses against human dignity including…poverty, social inequalities….war, genocide, and terrorism.” 5(p8) She was able to negotiate shelter at a local hotel for the unhoused to seek temporary protection.
As those who sought refuge in this space continued their stay past the days of the unrest, later named The Sanctuary Hotel, Rosemary envisioned a way to mobilize and change the policies and procedures relied upon in current systems. She helped organize volunteers to operate the hotel in solidarity founded on the principles of mutual aid, where everyone had membership and human connections were made. Knowing that the complexities of previous traumas and suffering wouldn’t simply end by having shelter, and as more barriers presented themselves, she knew the hotel stay for those unsheltered had to come to an end.
However, this story has inspired a movement in Minneapolis to care for those displaced, to tackle issues of poverty through various means, to approach change using all forms of knowledge while forging a plan ahead with the very people experiencing the targeted oppression as means of disrupting structural inequities. Rosemary has engaged in social justice work in ways that will shape the discipline for the future to come.
These stories of nurses engaging in elements of emancipatory action while caring for marginalized communities in innovative ways during a pandemic and during social unrest, has shed light on what nursing practice can embody. Many nurses fail to recognize, and most have yet to understand, the root source and impact of racial health disparities, which offers an opportunity to challenge our beliefs in what nursing practice should or shouldn’t entail as we are called to respond to unjust situations through collaborative action.1
Whether providing care in our acute care settings or shaping our communities, nurses can no longer ignore the words, “I can’t breathe” as we collectively gasp for air.
Katie is an Assistant Professor of Nursing at Augsburg University and is the Director of the Health Commons. She has taught at Augsburg University since 2009 where her primary responsibilities are in the graduate program in courses focused on transcultural nursing, social justice, and civic agency. She also practiced for over eight years in an in-patient hospital in both oncology-hematology and medical intensive care. She has a Masters of Arts in Nursing degree focused on transcultural care and a Doctor of Nursing Practice in transcultural leadership, both from Augsburg University. Katie has been involved in the homeless community of Minneapolis for over 15 years and has traveled to over twenty countries. She lives with her husband and three children in Stillwater, Minnesota.
About Kaija Freborg
Kaija Freborg is the Director of the BSN program at Augsburg University and has been teaching as an assistant professor in the undergraduate and the graduate nursing programs since 2011. Her focus in teaching includes transcultural nursing practice as well as addressing social and racial justice issues in healthcare. She obtained a Doctor of Nursing Practice degree in Transcultural Nursing Leadership in 2011 at Augsburg before teaching at her alma mater. Currently her scholarly interest in whiteness studies has her engaging in anti-racist activism work both in nursing education and locally; her aspirations include disrupting and dismantling white supremacy within white nursing education spaces. Previously Kaija had worked at Children’s Hospitals and Clinics in Minneapolis, in both pediatrics and neonatal care, for over 15 years
Although not the only global challenge we face, COVID-19 has the world’s attention while disrupting so many familiar routines. For those so fortunate, there is the new normal of working from home and countless conference calls that seem to blur one day into the next, almost erasing the confines of time while confining us to a physical space. When things get back to “normal” what will that look like?
For those in service industries, there is the chaos of being the person in the midst of unsafe places whether the grocery store, a bus or as an employee in a hospital. Making connections while fearing, am I safe? Do I have what I need to protect myself/ my family? And, sometimes knowing you do not have what you need, and in that moment, your awareness of the disparity of those who have and those who do not is heightened. What will it be like when things get back to “normal?
Then there are those who in a whirlwind, may have lost their job. Now they are struggling to pay bills, perhaps visiting food banks for the first time mixed in with home schooling young children or a full house of grown children now back to the safety of their childhood home. When and what will be that return to “normal”? For every scenario, there is opportunity, freedom and new ways of being. There is also potential binding or unraveling. But no matter the reality, there are the chants to “get back to normal”
This idea of “getting back to normal” raises the question; “What would Margaret say?” We think the answer is …actually, not very much. She would smile gently and acknowledge each person who spoke and told his or her personal story. She would be present and authentically listen. Her silence would spur more stories until in the sheer dizziness of it all, the cacophony would stop and everyone would look to her and wonder what she is thinking. Again, silence and this time the room would go quiet. Finally, she would speak: “I’m just curious about people wanting to go back to normal, what do people think of that?” Then she would sit and wait for us to react…and we would. We would discuss how we cannot “go back” and about the opportunity in the chaos. What went well in nursing practice during COVID – 19 that was reflective of nursing and what did not? She would smile, as we would envision a new future that informed by COVID-19, and the inequities of an illness, linked to an environmental crisis and manifested in our most vulnerable. An illness that has stuck down older adults, minorities and is on a path to literally destroying second and third world countries. Go back? No, we would not be going back we would be envisioning a new future, one with boundaryless opportunities.
There is for some, an increased awareness, that the inequities of COVID-19 along with the murder of George Floyd and other racial incidences has heightened the issue of structural racism that has always been simmering under the surface. Go back? Oh no, we will not go back. Not to complacency, not to a world where nurses today are lauded for their actions during a crisis, but who will return to being a hidden entity, part of the bed charge. No, we are now in a world that recognizes, yes there were many deaths, but because of nursing care, because of nursing’s commitment to meeting the person where they were at, commitment to delving into knowing other, upward of 85% of those who had COVID and were hospitalized were successfully discharged. Yes, nursing care! It was the authentic presence of nurses who connected with patients in new ways and journeyed with them on a path of discovery, nurses learning to recognize the pattern of the critically ill when the normal mode of communication was no longer possible, and nurses who transformed the care environment. It was not a cure or a vaccine that made the difference; it was “the difference nursing makes” that made the difference.
The COVID-19 virus made visible a pattern of turbulence and disruption within the global whole. Lack of awareness to growing social challenges, loss of freedom creation of boundaries and isolation confounded the environment within which the virus emerged. Within this context, the virus took on new meaning and yielded variety of responses. Using the theoretical lens of Health as Expanding Consciousness, Margaret would reflectively and carefully suggest that being exposed to the global and dramatic changes of the day has already begun to reshape/repattern us. She would envision the voice of nurses advocating on behalf of patients, on behalf of the myth of curing rather than healing, on behalf of older adults, racial and ethnic minorities. Margaret would not support “going back”; instead, she would reflect on the meaning of the unfolding pattern emerging before us …within the context of an illness.
The event COVID-19 has served to make visible the invisible for society as a whole. Recognition that we are all connected and interrelated. The actions and behaviors of one individual directly affecting the very life of another. Response to the virus has revealed a complex, dynamic human pattern of the whole within a dynamic and changing environment. As the illness experience is unfolding, individual responses shaped by factors including vulnerability, gender, age and the older adults, race, ethnicity, compromised health status, poverty, lack of insurance, homelessness, exposure to environmental stressors and population density, and personal responses to life challenges have been made visible. Compromised relationships, sustained loneliness and disconnection challenged human becoming and threatened choices about health and wellness. Rather than creating new problems, COVID-19 has manifested not only a serious disease but made visible longstanding global societal challenges that have gone unnoticed or suppressed.
Margaret would caution that “fixing” the illness (i.e. treating to cure) without addressing the whole person/environment interaction that include people and events surrounding the individual experience, could lead to a reoccurring manifestation of the underlying pattern in new ways (e.g. inequities and disparities in care). She would stress the importance of collaborating with individuals and groups in dialogue, she would identify what is meaningful, to acknowledge the collective increased awareness, and seek to uncover an underlying pattern of the whole. COVID-19 then becomes a stimulus for active discussion, identifying barriers that compromise moving forward as individuals and as a society. The insights gained through information and connecting with another create opportunities for new insights, actions and freedom to participate knowingly in actions that promote transformative change.
The importance of relationship is core to advancing the process of discovery. Partnerships that are open and evolving allow pattern to emerge and potentially increase the realization that we are all interdependent and connected within and across environments. Recognizing that what affects one-person or community can have a reciprocal impact on another. Within the discovery process there is freedom to hold on to what gives new meaning to one’s being and what binds and threatens our freedom to become and engage in sustainable holistic healing. No, Margaret we are not going back. And she would smile, knowing we are with new heightened awareness and renewed energy, accelerating toward new potentials and transformation.
Newman, M. A. (2008). Transforming presence: The difference that Nursing makes. Philadelphia: F. A. Davis.
Smith, M. C. (2011). Integrative Review of Research Related to Margaret Newman’s Theory of Health as Expanding Consciousness. In Nursing Science Quarterly (Vol. 24, Issue 3, pp. 256–272). https://doi.org/10.1177/0894318411409421
On Friday, June 12th, the Nursology Theory Collective hosted a live webinar titled, “Diversity, Equity, Inclusion, Justice, and the Future of Nursing Theory.” In this webinar, Dr. Lucinda Canty and Patrick McMurray addressed the interrelated concepts of diversity, equity, inclusion, and justice in nursing. They discussed nursing’s homogeneity and how the absence of diversity in our discipline contributes to and reinforces inequity, injustice, and exclusion, even as our professional organizations purportedly value social justice and strive to reduce health inequities.
It is long past time for nurses and nursologists alike to take a stand and actively work towards an antiracist future for nursing. This is nonnegotiable and the time for action is now. We challenge you as readers of Nursology to watch this insightful webinar, reflect on your role in advancing equity and justice, and comment how YOU are going to contribute to transforming nursing into a more diverse, equitable, inclusive, and just discipline.
We understand that this topic may be uncomfortable – and if so, we encourage you to reflect and unpack that discomfort. Maybe you feel defensive as if you have done nothing personally to warrant interrogating your own positionality. Maybe this resonates with you because you see and know this truth as congruent with your own experience.In the words of Monica McLemore, “this can all be different,” if we choose to make it so. The starting place for this is critical self-reflection which paves the way for antiracist growth which creates the possibility for community-building and envisioning new futures for nursing. Embracing the discomfort we can become a more diverse, equitable, inclusive, and just discipline. As Patrick McMurray stated, “nursing is an act of justice,” and it can be if we do the work.
In Solidarity, The Nursology Theory Collective
For more background on this webinar as well as the presenters, please click here.
Guest Contributors*: Andra Opalinski and Patricia Liehr
We are responding to Dr. Foli’s request in her blog titled “Say It Ain’t So: Graduate Students Shade Nursing Theory!” where she stated…”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…”
WE BEGIN WITH DEFINITIONS
Throwing Shade: (verb) subtly disrespecting or ridiculing someone or something.
Shade: (noun) a comparative darkness caused by shelter from direct light.
We ARE the theory-practice connection.
As nurse educators who appreciate the theory-practice connection, we had been pondering Foli’s post and then Constantinide’s follow-up about graduate students throwing shade at nursing theory. Not knowing the meaning, we took the “throwing shade” descriptor quite literally and thought how we often prefer to find shade on sunny Florida days!!! In the midst of our extended pondering and thoughtful conversations came COVID-19; and a virtual class that we co-hosted with NP students to discuss the use of Story theory in practice; and THEN, we serendipitously came across a 2020 calendar page with a haiku by Tomihiro Hoshino entitled “In the Shade.” This haiku accompanies his calendar painting of a redbud tree with hanging red pods amidst green foliage:
In the shade of leaves, They shyly sway, Pods like strips of paper With girlish wishes Written on them
Moving along to a class with NP students.
In this class, we were talking about Story theory and the practicality of using it when working with patients. Story Path, a way to pursue story-sharing was the specific lesson (Liehr & Smith, 2020). Clare, an ER nurse, volunteered to share a recent practice story with the class.
“I was caring for an elderly patient in the Emergency Room who had just tested positive for COVID-19. However, this day, the provider I was working with was resistant to putting the patient on a ventilator.” As Clare reflected on the situation she shared, “I remember asking myself, is the provider just being lazy because the patient is elderly with a poor prognosis? However, I also knew, this doctor reads a lot of research. I still couldn’t help but question the decision. The patient did in fact improve without ventilator assistance,” giving Clare pause….thinking about the juxtaposition of knowledge with practice. As Clare’s recounting of the story concluded, Clare was asked to consider how her COVID-19 experiences may influence the future. The rawness of her sharing was palpable as she elaborated on the pause noted in her story: “I never knew nursing would get to this point. I am becoming suspicious of everyone, even co-workers. I stand away from everyone and wear masks all the time. I am challenged with what feels like lacking compassion. I don’t spend time in the rooms like I always did before, or place a hand on an arm to show comfort because we are thinking, is this the next COVID patient. I do make sure there is a phone in every room and I call often to check on the patients. It just feels less personal. It feels unnatural.”
Hmmm…lacking compassion feels unnatural. There is a theory and/or a philosophical perspective in this sentiment. We could go with Meyeroff’s ideas (1971) about caring as a way of ordering one’s values so that one feels “in place” rather than “out of place” in the world. We could go with Watson’s Transpersonal Caring Moment (Watson, 2018) where people come together in a human-to-human, spirit-to-spirit connection that is meaningful, authentic and intentional. These are just two examples providing context that allows for locating self in the theory-practice connection; many others could be the philosophical/theoretical lens providing context.
Then the class was asked, “What have you learned from Clare’s story that resonates with your own practice?” Anna was quick to answer, “Everything is fluid and flexible right now, we have protocols, but they change day by day, they are evolving and there is a lot of uncertainty. We have to be able to allow flexibility in new ways. I can’t get into my usual groove.” Then THE question was posed. “Is theory real for you in your everyday practice? If not, it’s ok to say so.” Perhaps the most insightful answer was Brad’s response. “We are taught many theories, but challenged to know how to apply them. I don’t have theory on my mind when I am in front of my patient. It may be subconscious, but I’m not thinking, I’m applying Leininger or Watson right at this moment.”
Brad is right…we don’t expect that nurses live real-time practice checking in with theoretical/philosophical perspectives. However…the perspectives are there and stepping back and reflecting on nursing circumstances may enable forward movement with theory-guided intention and with knowledge-building for the discipline.
Pondering We ARE the theory-practice connection
As the nurse theorist-practitioner team that we are, we have great appreciation for the comments of these practicing nurses who happen to be graduate students. We wondered …Could the shade granted by COVID-19 bring theory out of the shade for students when they don’t even know it? You see, we are educators in a setting where nursing theory is highly valued and caring theory is the organizing spine of our curriculum. Has caring theory become so naturally interwoven in their practice that these NP students know something is amiss but they have difficulty naming it beyond descriptors like “unnatural” or “I can’t get in my groove”? We can only hope….but we can also plan to honor the shade by:
remembering that we are always working from a theoretical perspective – we have only to step back from any nursing situation and consider the principles/concepts that are guiding our actions;
creating opportunities to share our practice stories with the knowledge that the implicit theory woven into the practice threads can come alive through scholarly engagement that is open to authentic expression and that gently supports exploration and maturing of an individual nurse’s own thinking;
holding the theory-practice connection as a truth that just takes time and professional maturity for appreciation but it is a truth that can be readily described when nurses have a mentor who helps with connecting the practice-theory dots;
pairing theorists and nurse practitioners to forge opportunities for growing nursing knowledge grounded in our practice.
Though there is little positive to say about COVID-19 these days, it may be that the pandemic granted some shade for us to reflect on the theory-practice connection in a way that can guide understanding. After all, We ARE the theory-practice connection. Let’s own it.
Now….what do you think – we would like to hear from you. How do you see our plan to honor the shade as an integral dimension of developing practice-scholars AND growing the discipline of nursing?
Liehr, P. & Smith, M.J. (2020). Claiming the narrative wave with story theory. ANS, 43(1), 13-27.
Meyeroff, M. (1971). On caring. Harper & Row: New York.
Watson, J. (2018). Unitary caring science: The philosophy and praxis of nursing. Louisville, CO: University Press of Colorado.
About the contributors
Andra Opalinski, PhD, CPNP-PC, NC-BC is a pediatric nurse practitioner and an Associate Professor at the Christine E. Lynn College of Nursing, Florida Atlantic University. She is an advocate for child and adolescent mental health promotion. Her current areas of interest include community-based participatory research with elementary through high school students using mindfulness interventions for self-regulation and stress management skill building. She also uses visual anthropology through photographs to explore perspectives of health of vulnerable populations. Right now, you’ll find her working remotely, doing the best she can to keep her household of 5 under strict physical distancing, and using the visual anthropology approach to document her family’s physical distancing experiences.
Patricia Liehr PhD RN is currently the Associate Dean for Nursing Research and Scholarship at the Christine E. Lynn College of Nursing, Florida Atlantic University (FAU). She is the co-author of story theory and the co-editor of Middle Range Theory for Nursing. Most of her scholarly work has focused on peace, from personal through mindfulness; to global through coming to know both sides (Pearl Harbor; Hiroshima) of surviving the bombings of WWII. Story-gathering has played a major role in her research endeavors and she highly values the place of nursing practice stories for disciplinary knowledge development. Right now, as she moves toward an August retirement from FAU, she is imagining all the things she will do with new-found time.
One of the first “lessons” in my now-long-ago nursing education was “the nursing process.” This was in the early 1960s, almost a decade before anyone spoke of nursing theory, but the University of Hawaii (my alma mater) had modeled the curriculum on that of the University of California at Los Angeles (UCLA) which was designed around the ideas of Dorothy Johnson. These ideas would ultimately become known as Dorothy Johnson’s Behavioral Systems Model (See also the history of the UCLA School of Nursing, pgs 43-48).
Of course this same problem-solving process is widely used in many walks of life, and many see it as a mere pragmatic outline for making good decisions and forming appropriate action – a necessary process but several degrees removed from developing foundational knowledge of the discipline. In reflecting on the situation in which we find ourselves today I fear that as a discipline we have not adequately faced the realities before us as a discipline and as a society – both as a problem, and as a health experience. As I wrote in my January 20th post titled “Decolonizing Nursing”
Despite the fact that race and racism so repeatedly rise to the surface with a clear intent to address this issue, there is typically little or no substantive discussion that begins to reach deep down into explanations or understanding of what is really going on (see https://nursology.net/2020/01/14/decolonizing-nursing/)
I know that I am not alone in recognizing this challenge, but I continue to wonder — when and how will this begin to change? This is not merely a “political” matter — it is a matter of life and death, of health and sickness. It is a pandemic of proportions far beyond the COVID-19 pandemic, and it has been infecting our lives for decades. In recent weeks we have witnessed the public killing of George Floyd by a Minneapolis police officer, of Ahmaud Arbery shot down while jogging in February, and Breonna Tayler, an EMT with plans of becoming a nurse, killed by police in her own home in March. Then just a few days before this post published, the killing in Atlanta of 27-year-old Rayshard Brookes, shot in the back several times by police after indicating that he was able and willing to walk home to his sister’s house.
These tragic murders in plain sight, coupled with widespread recognition of the over-proportioned number of Black and Brown people suffering from COVID-19 – give us a glimmer of opportunity to finally act. The calls for change are so pervasive and so sustained, that those of us ready and willing to make change have a real opportunity to do so. And so I return to my earliest nursing education and the foundational ideas that have been baked into my very fabric – the processes of active listening and observation that are vital to assessing and “diagnosing” a problem(1).
One of the notable signs that appears in all of the protests says “I see you, I hear you.” For me, this is a key to meeting the challenge before us. It starts with our interactions among our own colleagues. Throughout my nursing career I have seen many Black nurse colleagues come and go, and every single one of the nursing faculty I have served with have repeatedly decried how “difficult” it is to recruit and retain Black nurse faculty. Yet all too rarely have I witnessed concerted, deliberate efforts by the predominantly White(2) faculty to stop, step away from our privilege, seek the authentic stories of our Black colleagues, and actively hear (understand) their experience. Equally egregious is the fact that there are myriads of situations that, viewed through a lens of anti-racist awareness, could be instantly recognized as potentially harmful to a Black person, even dangerous. But over and over again we turn a blind eye, and fail to act. I have all too often been just as complicit in all of this as anyone else – we have all been caught up, and participate in a systemic web of injustice. And I suspect that this pattern is not unique to academics – that it runs deep in every setting where nursing is practiced.
Further, there is the all-too often deflection of the problem by the insistence that the “problem” is not unique to Black people – that all lives matter. Of course all lives matter and Black people are not the only ones who suffer injustice and discrimination. But this sentiment turns the lens away from the specific voices, experiences, and challenges faced Black people. We can listen to all people – but until we listen to, and sincerely seek to understand, Black people and recognize the experiences of trauma and harm that Black people uniquely suffer, and how we participate, we will not be able to truly understand the problem.
It is undeniable that the prejudice and hate toward Black Americans, and people of African descent in many other countries is profound and amplified by the historical trauma of slavery and in the United States, the fall-out of the civil war fought to end slavery in the United States. I hear many White nurses in my circle expressing true outrage about this situation and we are all sincere in our desire to see it change, yet the problem persists. Until we White nurses face the reality of our privilege and the injustices that flow from this, until we learn ways to step away from our privilege and engage in serious anti-racism work, until we create spaces in which we can authentically engage with our Black colleagues to understand the problem, the injustices in our own house will remain.
We can all shift in the direction of being part of the solution. There are signals that point us in the direction of actions we can all take – particularly those of us who are White – to seize this moment, start to address the scourge of racism in our own house, and make real change. The circumstance of the COVID-19 shift to virtual reality offers ample opportunities for all of us to engage in antiracism work! Here are a few examples that I can personally recommend – if you start searching, you will find many many others!
Nurse Caroline Ortiz organized a “platica” (Spanish for discussion) held on March 9th over Zoom. Caroline recorded the session, which you can access here: https://vimeo.com/397047962. You can organize similar discussions – we are all now expert Zoom organizers!
Practice generosity of spirit toward your nursing colleagues – each of us are being challenged in this moment to examine our own attitudes, actions and words. Many of us are just starting on this journey. This demands kindness and understanding toward one another as we work together, often in uncomfortable situations, to make meaningful change. Let us call forth the best we can be, and support one another with compassion and understanding when we mis-step.
Consider how application of many tenets of our own nursing theories can be activated in the quest to address racism. Consider Peplau’s approach to meaningful interpersonal relationships, the very important insights from Margaret Newman “Health as Expanded Consciousness,” and any one of several theories of caring such as Watson’s Theory of Human Caring, or Boykin and Schoenhofer’s Theory of Nursing as Caring, While these and other nursing theories were not created specifically to address racism and social injustice, we certainly can draw on their wisdom to bring nursing perspectives to the center in our anti-racism work.
Make your own video, as a nurse, speaking to these issues and how your values, ideas, nursing perspectives inform your actions to fight racism! Post it on YouTube or Vimeo .. and then share it with us – we can consider posting on Nursology.net or another nursing website. See this wonderful video (below) by de-cluttering expert Mel Robertson for inspiration!
Ultimately the concept of active listening formed a basis for the essential processes of “critical reflection” and “conflict transformation” in my heuristic theory of Peace and Power.
See this excellent article from the Center for the Study of Social Policy on the capitalization of the terms “Black” and “White,” which I consulted in refining this post: Nguyễn, A. T., & Pendleton, M. (2020, March 23). Recognizing Race in Language: Why We Capitalize “Black” and “White” | Center for the Study of Social Policy. Center for the Study of Social Policy. https://cssp.org/2020/03/recognizing-race-in-language-why-we-capitalize-black-and-white/
We, the Nursology Theory Collective, in light of the current events surrounding the murders of George Floyd, Breonna Taylor, and Tony McDade, cannot be silent.
In partial answer to this, we have included our anti-racism position statement below, and invite you, as nurses and nursologists, to join us this Friday, June 12th from 4:00 – 5:00 PM EST to discuss the future of nursing theory and its interrelationship with diversity, equity, inclusion, and justice. We understand that many of us don’t know where to start, but it is in times like these that as the most trusted profession in the United States we must use our privilege to create a more equitable and just world and do something. It’s time we actively listen, learn, unlearn, discuss, and take a stand for those who have been oppressed for hundreds of years, raise their voices, and be better together.
To join this event, please register here in advance to save your seat.
We support the protests in the names of George Floyd, Breonna Taylor, and Tony McDeade, recognizing that their murders are some of the innumerable instances of anti-Black violence that corrode our collective consciousness
We condemn police brutality, a state-sanctioned violence, and recognize its deleterious and disproportionate impact on the lives of Black people
We recognize the collusion of white supremacy, capitalism, and patriarchy as the root cause of the ongoing violence that is experienced by Black people
Structural racism and white supremacy are public health crises, socially-constructed, legally-entrenched systems of power that benefit and privilege white people
We will act to dismantle the structural racism that has characterized the status quo in the United States for over 400 years as a critical, urgent, and essential nursing intervention
We recognize our disciplinary complicity with white supremacy, capitalism, and patriarchy, which has shaped modern nursing from its beginnings
We collectively commit to do the work: to continue reading and promoting anti-racist work, donate to funds and support initiatives that advance antiracist work, divest from groups that promote hate, promote Black leadership and cite Black scholars, speak out against racism in all its forms, hold space to support and center this essential work while acknowledging this as a forever initiative
We commit to uphold anti-racism and anti-oppression, and acknowledge that this commitment must be an ongoing and eternal process
The statement above is a collaborative project, commenced on June 1, 2020. We invite you to join us in this initiative, continue the dialogue, create a better world, amplify Black voices, and show that #BlackLivesMatter.
The Nursology Theory Collective is a group of scholars and students that formed after the landmark conference, “Nursing Theory: A 50 Year Perspective Past and Future”, on March 21-22, 2019 at Case Western Reserve University. The mission of the Nursology Theory Collective is to advance the discipline of nursing/nursology through equitable and rigorous knowledge development using innovative nursing theory in all settings of practice, education, research, and policy.
A man and a woman were fishing on the river bank when they saw a woman struggling in the current. They rescued her. Soon, they saw a man struggling. They rescued him, too. This continued all afternoon. Finally, the exhausted pair decided to go upstream to find out where and why so many people were falling in. They discovered a beautiful overlook along the river’s edge without any warning signs or protective barriers. The couple went to community leaders to report the number of victims they had rescued and explained the connection to the unprotected overlook. Community leaders agreed to install a protective guard and post warning signs. Preventing the problem saves resources, energy, and lives.” (see “The Upstream/Downstream Parable)
Critical Caring is a way of being-in-relation that seeks to protect and enhance human dignity. It is informed by multiple ways of knowing (Chinn & Kramer, 2017) and guided by a caring/social justice ethics in which advocacy for social justice becomes an expression of caring for individuals, groups, communities, or populations. It encompasses both downstream and upstream nursing practice. (Falk-Rafael & Betker, 2012a) The “critical” aspect of the theory reflects both the theory’s roots in contemporary critical social theories and in the work of Nightingale, who I would argue, espoused the tenets of what became known as critical social theory decades before it was formalized by the Frankfurt School in the 1930s.
Although originally proposed as a middle-range theory of public health nursing (Falk-Rafael,2020), Critical Caring’s seven carative health promoting processes (CCHPs) can readily provide guidance to nurses practicing in the context of the COVID-19 pandemic, regardless of setting. The CHPPs are focused on simultaneously meeting the needs of individuals, groups, and/or communities and building their capacity (CHPP 6) , i.e., helping them to regain/maintain whatever degree of control over their life is possible to maximize their health potential (Falk-Rafael, 2001, Falk-Rafael & Betker, 2012a).
Critical caring begins with the preparation of one’s self (CHPP1) and involves taking measures to monitor, care for, and protect one’s own physical-mental-spiritual health. Examples related to COVID-19 include physical distancing when in public and use of appropriate personal protective equipment. (See series of posts on that topic by Carey Clark). Appropriate PPE provides protection for the nurse and also contributes to the downstream aspect of CHPP 5, relating to the provision and maintenance of a safe and supportive physical environment for the patient/client. Other measures to create a safe environment include such fundamental principles as the separation of infected people from non-infected people, a principle well understood by Nightingale but ignored in some of the long-term care facilities in Ontario, ravaged by COVID-19.
Central to critical caring is establishing and maintaining a helping-trusting nurse-patient relationship (CHPP 2), a carative process that can be complicated by the use of the necessary PPE. Transparent face shields and/or mask inserts may be a great help in that regard when they are available. Touch, even through gloved hands, and verbal communications become even more important in establishing and maintaining a human-to-human connection, and in being able to gain some understanding of the patient’s lived experience of the situation and providing some measure of comfort.
Relationship is also essential in the mutuality required in CHPP, 3 the systematic reflexive approach to identifying the health goals of clients and working with them, to the extent possible, in achieving those goals. This process requires a knowledgeable approach by the nurse whose expertise is available to facilitate patients’ understanding and decision-making.
Likewise, relationship, characterized by mutuality, is central to CHPP 4, transpersonal teaching-learning. Whether situated in acute care, focused on treatments or medications, or in the community, focused on issues such as requirements of quarantine or self-isolation, transpersonal teaching-learning is an interactive process in which evidence-informed information and guidance are provided within the context of the patient /client’s understanding, lived experience, hopes and fears. Perhaps in no instance is relationship more important than in the face of death when the nurse can offer a comforting presence and an openness to the patient’s way of finding meaning in the experience (CHPP7). That may involve holding a phone to a patient’s ear or a tablet in front of a patient so that families can virtually be present and connected with their loved one in their final moments.
Although the coronavirus does not discriminate, the pandemic has highlighted societal economic and social inequities that significantly increase the risk of contracting COVID-19, not only in Canada and the U.S., but also globally. Some of the reasons relate to the need for poorer people to continue to work in jobs away from home, often in the provision of essential services. Moreover, they are more likely to rely on public transit to get to work; they may be less able to physically distance from family members because of crowded living situations, and/or may lack adequate health care. In situations that might allow work at home, economically disadvantaged people may not be able to afford the necessary electronic equipment; similarly their children may not be able to complete aspects of online education. In even more dire circumstances, homeless people are extremely vulnerable as advice for staying home and frequent hand washing are simply not options for them. Physical distancing is not possible in homeless and respite shelters in which cots are placed closely together.
The COVID-19 pandemic has highlighted societal inequities which, in many aspects, bear a striking resemblance to those Nightingale experienced more than 150 years ago. Her approaches and solutions included downstream nursing by, for example, training nurses to care for those in workhouse infirmaries where paupers were required to come if they were ill because they could not afford care in hospitals. But what is sometimes overlooked, is that she also advocated for solutions at a societal level, far upstream from the workhouses. Nightingale’s approach has been called “radical” because it advocated for public policy changes to correct the systemic issues at the root of the health problems seen downstream. Her actions led not only to improved nursing care, but also to social change that reduced economic and social inequities. Whereas her workhouse reforms are well known, the principle driving them, equitable access to health care based on need rather than affordability, and her proposal that those reforms should be paid for through progressive taxation, are less well known. Nightingale’s proposed changes included the legislative framework for the Metropolitan Poor Act and culminated, decades later, in the British government taking responsibility for that nation’s health through the National Health Service (Falk-Rafael, 2005). But Nightingale did not stop there; she advocated, for example, for income security, pensions, and education for all because of her conviction that these were measures that promoted the public’s health. Approximately 100 years later, at the primary health conference in Alma Ata, world health leaders came to a similar conclusion, issuing the Declaration of Alma Ata, and raising awareness of what became known as social determinants of health.
It seems to me that homeless shelters may be today’s workhouse equivalents. Addressing the underlying social and economic (upstream) issues that have contributed to the health inequities exposed by the pandemic challenge us to political advocacy for upstream policy changes. Cathy Crowe, a Canadian nurse activist, has long advocated for policies, such as affordable housing, to allow poorer people to afford housing. And, like Nightingale, she is also concerned with conditions downstream, in respite and homeless shelters. During the pandemic, she, with others, has brought attention to and tirelessly advocated for the City of Toronto to mandate 6’ spacing between cots in homeless shelters. To its shame, the City only agreed to this spacing many weeks later, after she and other advocates filed a lawsuit claiming that shelter crowding conditions were a violation of the Canadian Charter of Rights and Freedoms.
A second pandemic focal point in Canada, especially in Quebec and Ontario, are long term care (LTC) facilities. In Canada, long-term care is under provincial jurisdiction, and is not publicly insured under the Canada Health Act. Provinces and territorial jurisdictions may depend on one or more types of funding of LTCs, such as for-profit or private organizations, municipal and/or provincial funding, In Ontario, all LTC facilities receive some provincial funding.
Personal health is inherently political. McDonald asserted that “Nightingale knew that good health required decent social conditions, work, adequate housing, clean air and water.” CHPP 5 refers to providing, creating, and/or maintaining supportive and sustainable environments, including both immediate physical environments but also social, political, and economic environments (Falk-Rafael, 2020). Improving those environments requires public policy change. To reduce health inequities, policy changes are needed that serve to redistribute a nation’s wealth throughout the population, rather than allow it to accumulate in the top 1%. As Nightingale knew, the increased revenue from such taxation has the potential to fund other programs such as universal, publicly funded health care, including elder care, and education. Policies such as those to establish minimum wages or a guaranteed basic income help to reduce economic inequities; policies such as affordable housing and rent control help to reduce homelessness.
A healthy population depends on healthy public policies. Political action to effect necessary changes can range from informed voting to the comprehensive, systematic approach Nightingale used: taking advantage of powerful connections, providing well-reasoned arguments, and supporting those arguments with data obtained through reading, consulting with experts, and, if necessary, her own investigations. I believe, like Nightingale, it is nurses who need to take the lead in promoting policy changes to improve the public’s health because it is nurses who work at the intersection of public policy and personal lives.
Chinn, P.L. & Kramer, M. K. (2019) Knowledge development in nursing: Theory and process. (10th ed.), New York: Elsevier
Falk-Rafael, A. R. (2020). Adeline Falk-Rafael’s Critical Caring Theory. In Nursing Theories and Nursing Practice (5th ed.) M.C. Smith (Ed.), pp. 502-521. Philadelphia: F.A. Daviis.
Falk-Rafael, A. R., & Betker, C. (2012). Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: “The Trombone Slide” of Nursing. ANS. Advances in Nursing Science, 35(2), 98–112. https://doi.org/10.1097/ANS.0b013e31824fe70f
More and more discussion is happening about the words we use in nursing. There are many words we need to move away from or change, and it will likely not happen in my lifetime. We are, however, making progress, and that’s what truly matters. Nursing faculty who teach their students more effective, helpful, and empowering messages are making a difference. Articles that focus on (and use!) strengths-based, person-centered language are moving the needle, as they say.
In addition to compliance and adherence, which Jacqueline Fawcett wrote about recently, training is a word that is prevalent in nursing. It’s time to change that. I often say, “we train animals; we educate people.”
Right now, nursing’s world is being rocked by COVID-19. We’re hearing many stories about PPE, which fit in with the training vs. educating question. Nurses are trained in the use of PPE, likely from their very first day. They are told how to put them on, take them off, perform tasks while wearing PPE, and so on. While they may get a little background on stopping the spread of infection through using these precautions, I’m guessing it really is training. When it comes to caring for patients who are sick and isolated; however, nurses call on their education. They use all five patterns of knowing (empiric, aesthetic, ethical, personal, and emancipatory) (Carper, 1978; Chinn & Kramer, 2018) to provide the best and most comprehensive care possible despite the horrific conditions surrounding them. Nurses are comforting those who are dying alone, and administering medications and ventilation to those who are struggling to breathe. Those skills are not the result of training. They come from being taught, supported, and guided, both in the classroom and in the clinical setting.
My work is in diabetes care and education. Training is a word that is prevalent in the diabetes arena. In fact, while diabetes professionals prefer and typically say, diabetes self-management education, the Center for Medicare and Medicaid Services (CMS) insists on calling it diabetes self-management training. I’ve noticed that as a professional group, we seem to have given up on trying to change that.
The reason it matters in diabetes is that we are working with human beings. Training means basically telling someone to do something a certain way. Like I mentioned earlier, we train animals. Animals don’t understand the rationale behind performing a trick or coming when they are called. Teaching means to explain, support, and educate. It is much broader than training, and it leads to autonomy, understanding, and engagement, rather than compliance or nonadherence. Humans not only have the capacity to understand, they deserve to know the why, what, and how.
The reason it matters in nursing, is that it’s the subtle difference between a profession and a trade. Nurse scholars have been asking whether or not nursing is an applied science, a basic science (Barrett, 2017) or a science at all (Whall, 1993). We’ve been asking what sets us apart from other health professionals. We’ve wondered why other professions don’t use or reference our knowledge base.
Peggy Chinn, in her keynote address at last year’s Nursing Theory: A 50 Year Perspective, Past and Future conference, stated that it’s time to examine our own assumptions and actions (Chinn, 2019). When we refer to being trained as a nurse, or having been trained at a particular school, what are the underlying assumptions? Do we really see nursing as a trade, with trained workers? Or do we see ourselves as professionals who are educated and have a distinct body of knowledge that prepares us to work autonomously?
If we ever hope to change the messages in nursing and health, we have to start with ourselves. We have an opportunity to lead by example, and state proudly that we are educated, informed, and engaged in a valuable profession. We teach future nurses to also engage in the discipline, and we teach patients to engage in their health and well-being – at whatever level that is possible.
Transitioning from training to educating is consistent with caring (Chinn & Falk-Rafael, 2018; Newman, Sime, & Corcoran-Perry, 1991; Watson, 1997), humanism (Paterson & Zderad, 1976), empowerment (Funnell, 1991) and many other nursing concepts. Please join me in removing the word and the mentality of training from our messaging in nursing. Let’s educate instead.
Barrett, E.A.M. (2017). Again, what is nursing science? Nursing Science Quarterly, 30(2), 129-133.
Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-24.
Chinn, P.L. (2019, March). Keynote Address: The Discipline of Nursing: Moving Forward Boldly. Presented at “Nursing Theory: A 50 Year Perspective, Past and Future,” Case Western Reserve University Frances Payne Bolton School of Nursing. Retrieved from https://nursology.net/2019-03-21-case-keynote/
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.
Chinn, P.L. & Kramer, M.K. (2018). Knowledge development in nursing: Theory and process. Elsevier.
Funnell M.M. , Anderson, R.M. , Arnold, M.S. , Barr, P.A., Donnelly, M., Johnson, P.D., Taylor-Moon, D., & White, N.H. (1991). Empowerment: An idea whose time has come in diabetes education. The Diabetes Educator, 17, 37-41.
Newman, M.A., Sime, A.M., & Corcoran-Perry, S.A. (1991). The focus of the discipline of nursing. Advances in Nursing Science, 14(1), 1-6.
Paterson, J. G., & Zderad, L. T. (1976). Humanistic nursing. Wiley.
Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10(1), 49-52.
Whall, A.L. (1993). Let’s get rid of all nursing theory. Nursing Science Quarterly, 6(4), 164-165.