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Synergy Model for Patient Care

The current featured ANS article is titled “Description and Evaluation of the AACN Synergy Model for Patient Care Employing the Critique Frameworks of Chinn and Kramer (2011) and Fawcett and DeSanto-Madeya (2013)” authored by Soyun Hong, MSN, RN and Eunkyung Kim, MSN, RN, nurse scholars at Yonsei University in Seoul, Republic of Korea. While this article is featured, you can download the full PDF at no cost. The authors shared this background about their work for ANS readers:

This study aims to describe and evaluate the AACN Synergy Model for Patient Care that aligns nurses’ competencies with the needs of patients and their families, developed by the American Association of Critical-Care Nurses. The description focuses on objectively explaining the theory, while the evaluation is based on established standards to determine its viability for application in nursing practice. This study applies Chinn and Kramer’s (2011) theoretical description method and Fawcett and DeSanto-Madeya’s (2013) theory analysis method to evaluate the AACN Synergy Model for Patient Care. The results show that the AACN Synergy Model for Patient Care makes it possible to confirm the concepts and characteristics of nursing by providing a theory that explains nursing practice within the health care system. Further, the AACN Synergy Model for Patient Care is a framework that properly matches patients’ characteristics with nurses’ competencies in achieving optimal outcomes and nurses’ satisfaction at its core. The current description and evaluation of the AACN Synergy Model for Patient Care suggests that it is a well-developed middle-range theory with social and theoretical significance. Moreover, it is an effective framework for nursing practice and research to visualize the impact of nursing.

AACN Synergy Model for Patient Care

Racial Discrimination and Pregnant African American Women

The current ANS featured article is titled “Perceived Racial Discrimination in the Pregnant African
American Population: A Concept Analysis
” authored by Megan R. Mileski, MSN, RN; Maria R. Shirey, PhD, MBA, MS, RN, NEA-BC, ANEF, FACHE, FNAP, FAAN; Patricia A. Patrician, PhD, RN, FAAN and Gwendolyn Childs, PhD, RN, FAAN. While the article is featured you can download and read it at no cost! Here is a message about this work from the primary author, Megan Mileski:

Megan Rutland Mileski

I am currently a PhD candidate at the University of Alabama at Birmingham School of Nursing conducting a dissertation entitled “Exploring the Relationship Between Chronic Stressors and Protective Factors and Preterm Birth Risk in an African American Pregnant Population”.  My primary research interest is to better understand the relationship between perceived racial discrimination and adverse birth outcomes such as preterm birth and maternal mortality/morbidity rates in the United States, particularly in the South.  I hope to build a program of research with this as my focus and found it critical to first define “Perceived Racial Discrimination in the Pregnant African American Population.”

Family Satisfaction in Adult Intensive Care

The current ANS featured article is titled “Family Satisfaction in the Adult Intensive Care Unit: A Concept Analysis” authored by Cristobal Padilla Fortunatti, MSN; Joseph P. De Santis, PhD, APRN, ACRN, FAAN and Cindy L. Munro, PhD, RN, ANP-BC, FAAN, FAANP, FAAAS. The article is available for download at no cost while it is featured, and we welcome you comments here about this work. Here is the message for ANS readers from the authors about this work:

Cristobal Padilla

            In the context of family-centered care, the concept of family satisfaction has received increased attention as a construct that attempts to encompass the evaluation of salient experiences by family members while navigating the critical illness of a loved one. This concept analysis provides an initial framework for family satisfaction in the adult ICUs that includes attributes such as adequate communication with health care providers, emotional support, closeness to the patient, comforting environment, decision-making involvement, and nursing care of the patient. In light of this work, some of the challenges that remain in the understanding, conceptualization, and measurement of family satisfaction in the ICU are:

  • Studies on family satisfaction in the ICU studies only assessed a single-family member rather than the entire family. The use of the concept of “family satisfaction” may incorrectly suggest that the satisfaction of all the members of the family is measured.
  • Fulfilling ICU family members´ needs and expectations fall on healthcare providers. ICU’s stressful nature, high workload, and lack of communication skills training may prevent them, particularly nurses, to have more frequent and meaningful interactions with family members.
  • Current family satisfaction in the ICU questionnaires does not involve the evaluation of the expectations regarding the items/topics measured. Thus, higher family satisfaction levels may be the reflection of lower expectations and conversely, lower family satisfaction may be attributed to higher expectations.
  • Within family satisfaction in the ICU literature, the use of the concept “dissatisfaction” or to classify family members as satisfied v/s dissatisfied based on arbitrary cut-off scores may not have enough theoretical support. Furthermore, it oversimplifies the complex nature of family satisfaction, leading to an inaccurate picture of the quality of care delivered to ICU family members.
  • Incentives for healthcare institutions to improve family satisfaction in the ICU are almost non-existent. The high costs of the ICUs and the absence of incentives to support and improve the experiences of family members in current reimbursement schemes represent a significant barrier to the improvement of family satisfaction.

Symptom Management for Adults with Cancer

The current ANS featured article is titled “Symptom management Theory: Analysis, Evaluation, and Implications for Caring for Adults with Cancer” by authors Asha Mathew, MBA, MSN, RN, RM; Ardith Z. Doorenbos, PhD, RN, FAAN; and Catherine Vincent, PhD, RN; College of Nursing, University of Illinois, Chicago. The PDF of the article is available for download at no cost while it is featured, and we encourage readers to share your responses here. Asha Mathew sent this summary of their work for ANS blog readers:

Asha Mathew Solomon

Theories of symptom management help nurse researchers organize the intricate relationships within the symptom experience. Our article presents a detailed analysis of the Symptom Management Theory (SMT) using Fawcett and De-Santo Madeya’s criteria for theory critique. To examine the application of SMT among adults with cancer, we performed a systematic review and identified 20 research studies that operationalized SMT concepts and propositions in adults with cancer. Further, using Silva’s evaluation criteria for empirical testing of a theory, we identified that only 35% of the studies had used the SMT to an adequate extent. We concluded that using SMT in longitudinal studies and comparing cancer-related outcomes with and without use of SMT are warranted.

Ethical Leadership and Moral Sensitivity

The current ANS featured article is titled “Effect of Ethical Leadership on Moral Sensitivity in Chinese Nurses: A Multilevel Structural Equation Model” by Na Zhang, PhD; Xing Bu, MBA; Zhen Xu, PhD; Zhenxing Gong, PhD and Faheem Gul Gilal, PhD. This article from researchers in China and Pakistan will be available for download while it is featured. We invite you to engage here with the authors and other ANS readers about this work! Here is a message from Dr. Zhang about this work:

This article aimed to explore the relationship between ethical leadership (a contextual factor at the higher organizational level) and nurses’ moral sensitivity (the individual outcome at a lower level), a cross-sectional quantitative study design was used. Participants were 525 nurses at 65 various departments in public tertiary hospitals. These results showed that ethical climate played a mediating role in the relationship between ethical leadership and nurses’ moral sensitivity. Moreover, nurses’ employment type moderated the mediating effect of ethical leadership on their moral sensitivity. Additionally, the link between ethical climate and moral sensitivity of contract nurses was stronger than that of nurses employed by the state.

Commonalities in Nursing Perspectives among Six Countries/Regions

Our current featured ANS article is titled “Commonalities in Nursing Perspectives Among 6 Countries/Regions” authored by Eun-Ok Im, PhD, MPH, RN, FAAN; Reiko Sakashita, PhD, RN; Chia Chin Lin, PhD, FAAN; Eui Geum Oh, PhD, RN, FAAN; Hsiu-Min Tsai, PhD, RN, FAAN; Wipada Kunaviktikul, PhD, RN, FAAN; Lian-Hua Huang, PhD, RN, FAAN; Hsiu-Hung Wang, PhD, RN, FAAN; and Linda McCauley, PhD, FAAN, FAAOHN. Dr. Im provided this description of the evolution of this work for ANS readers:

The idea of this manuscript started with a question from one of my PhD students who came from a different discipline (cannot remember exactly which discipline she came from). As I remember, the question was raised during a PhD class on how nursing is different from other health-related disciplines and what would be unique aspects of nursing research.  As a group, we had a discussion on many unique aspects of nursing research including our holistic approaches, our caring views, our unique contextual understanding, etc. At the end of the specific class, all of us agreed that nursing research would be different from other disciplines’ research because of these unique perspectives. Then, the specific student raised a question, “what is a nursing perspective?”  I remember that I talked about nursing scholars’ historical discussions on nursing perspectives (e.g., its foci on human beings as a whole, understanding human experience in different stages of health, a practice-oriented discipline, a health-oriented discipline, etc.). However, after the meeting, I felt a dire need for defining a nursing perspective in this interdisciplinary world and thought about what I could do about it.  I suggested the specific student to do an independent study with me so that we could define a nursing perspective together through a systematic literature review, and she agreed to work on it.  However, due to her busy life as a PhD student, she dropped off from the project. Then, I have tried to revive the idea of this paper with several different PhD students, but the efforts with PhD students did not work after all. Looking back on it, it would be a very difficult task for a PhD student to define a nursing perspective even through a systematic literature review.

After a few years passed, I became to get involved with leaders from several Asian countries. Through international workshops and conferences, we became to get engaged in discussions on many different issues/concerns related to nursing across the globe.  Then, I proposed this project on nursing perspectives to the leaders.  All of us naturally became interested in this topic because all actually experienced the same phenomenon with an increasing number of interdisciplinary collaborative projects and witnessed the struggles of nursing students from other disciplines. 

As soon as we began to work on this project on nursing perspectives, this article was written very quickly and smoothly with the inputs from the leaders. This topic was a timely topic for all of us across the globe. All of us have been thinking of this topic throughout our career. Eventually, the paper became a very interesting paper that could reflect nursing perspectives across six different countries/regions. This paper includes only the themes reflecting the commonalities in nursing perspectives across the countries/regions, but we had other themes reflecting differences in nursing perspectives across the countries/regions.  Yet, since the purpose of this paper was to find out the essence of nursing perspectives that could cross the countries/regions, we just focused on the commonalities in nursing perspectives.

As discussed in the paper, nursing perspectives are circumscribed by cultural and historical contexts of individual countries/regions; nursing perspectives are inclusive of philosophical pluralism; nursing perspectives are women-centered and care-oriented holistic views; nursing perspectives are ethical and humane perspectives; nursing perspectives respect human beings’(persons’), families’, and/or communities’ own views and experiences; and nursing perspectives assume diversity in nursing phenomena.  While some of these characteristics of nursing perspectives were expected and discussed from the beginning of the project, others were identified later at the end of the project.  Interestingly, all of us agreed that nursing perspectives had more similarities than differences across the countries/regions.

Based on the findings on commonalities in nursing perspectives across the countries/regions, we made several suggestions for future nursing researchers while acknowledging the limitations of this work.  With historical evolutions and revolutions of nursing, the characteristics of nursing perspectives could change, but some essential characteristics will not change. Actually, these essential characteristics need to be retained throughout different generations of nurses. This paper provides some of these essential characteristics of nursing perspectives that we should keep across different generations of nurse researchers throughout the world.

The characteristics of nursing perspectives that we found and reported in this paper, however, may not be applicable to nursing perspectives in different geographical areas.  Maybe, a nursing perspective in African or South American countries might have different characteristics that are not included in this article.  Maybe, after some time has passed from now, our future nurse researchers who will read our paper would say that they need to work on what a nursing perspective is because the characteristics of nursing perspectives that we wrote in this paper may not be applicable to future nursing.  As we did for this paper, they would feel like that a nursing perspective needs to be re-defined with all the changes that our next generation would meet.  Maybe, at that time, some nursing activities could be delegated to robots and nursing researchers may think some main tasks/responsibilities of nurses in our generation would be obsolete and not applicable to their nursing phenomena.  I think our efforts to define a nursing perspective is not only a difficult task, but also a continuous task that we should take across time points and across geographical areas.

I want to say thanks to Dr. Chinn for this great opportunity to open a dialogue with my respected colleagues across the globe. I hope this blog could continue our discussions on what a nursing perspective is, and it could initiate international dialogues on nursing as a discipline within current interdisciplinary environments.  To conclude this blog, I am attaching a picture of roses blooming on my front yard.  When we moved to our new home, we thought these would be weeds, so we planned to eliminate these. However, as the temperature got warmer, these turned out be roses.  Maybe, some characteristics of nursing perspectives that we are currently thinking as obsolete would turn out to be “roses” in our future generations, which is the reason that we should continue our dialogues on nursing perspectives. Indeed, we never expected this COVID19 pandemic. This pandemic has obviously brought nursing care for patients with infectious diseases back to the center of nursing care, and might be making some changes in nursing perspectives across the globe.  We never know.

Call for emergency action to limit global temperature increases, restore biodiversity, and protect health

Lukoye Atwoli, editor in chief, East African Medical Journal; Abdullah H. Baqui, editor in chief, Journal of Health, Population and Nutrition; Thomas Benfield, editor in chief, Danish Medical Journal; Raffaella Bosurgi, editor in chief, PLOS Medicine; Fiona Godlee, editor in chief, The BMJ; Stephen Hancocks, editor in chief, British Dental Journal; Richard Horton, editor in chief, The Lancet; Laurie Laybourn-Langton, senior adviser, UK Health Alliance on Climate Change; Carlos Augusto Monteiro, editor in chief, Revista de Saúde Pública; Ian Norman, editor in chief, International Journal of Nursing Studies; Kirsten Patrick, interim editor in chief, CMAJ; Nigel Praities, executive editor, Pharmaceutical Journal; Marcel GM Olde Rikkert, editor in chief, Dutch Journal of Medicine; Eric J. Rubin, editor in chief, NEJM; Peush Sahni, editor in chief, National Medical Journal of India; Richard Smith, chair, UK Health Alliance on Climate Change; Nick Talley, editor in chief, Medical Journal of Australia; Sue Turale, editor in chief, International Nursing Review; Damián Vázquez, editor in chief, Pan American Journal of Public Health.

Corresponding email:

Wealthy nations must do much more, much faster

The UN General Assembly in September 2021 will bring countries together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the biodiversity summit in Kunming, China, and the climate conference (COP26) in Glasgow, UK. Ahead of these pivotal meetings, we—the editors of health journals worldwide—call for urgent action to keep average global temperature increases below 1.5°C, halt the destruction of nature, and protect health.

Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades.1 The science is unequivocal; a global increase of 1.5°C above the pre-industrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse.2 3 Despite the world’s necessary preoccupation with covid-19, we cannot wait for the pandemic to pass to rapidly reduce emissions.

Reflecting the severity of the moment, this editorial appears in health journals across the world. We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory.

The risks to health of increases above 1.5°C are now well established.2 Indeed, no temperature rise is “safe.” In the past 20 years, heat related mortality among people aged over 65 has increased by more than 50%.4 Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical infections, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality.5 6 Harms disproportionately affect the most vulnerable, including among children, older populations, ethnic minorities, poorer communities, and those with underlying health problems.2 4

Global heating is also contributing to the decline in global yield potential for major crops, falling by 1.8-5.6% since 1981; this, together with the effects of extreme weather and soil depletion, is hampering efforts to reduce undernutrition.4 Thriving ecosystems are essential to human health, and the widespread destruction of nature, including habitats and species, is eroding water and food security and increasing the chance of pandemics.3 7 8

The consequences of the environmental crisis fall disproportionately on those countries and communities that have contributed least to the problem and are least able to mitigate the harms. Yet no country, no matter how wealthy, can shield itself from these impacts. Allowing the consequences to fall disproportionately on the most vulnerable will breed more conflict, food insecurity, forced displacement, and zoonotic disease—with severe implications for all countries and communities. As with the covid-19 pandemic, we are globally as strong as our weakest member.

Rises above 1.5°C increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state. This would critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change.9 10

Global targets are not enough

Encouragingly, many governments, financial institutions, and businesses are setting targets to reach net-zero emissions, including targets for 2030. The cost of renewable energy is dropping rapidly. Many countries are aiming to protect at least 30% of the world’s land and oceans by 2030.11

These promises are not enough. Targets are easy to set and hard to achieve. They are yet to be matched with credible short and longer term plans to accelerate cleaner technologies and transform societies. Emissions reduction plans do not adequately incorporate health considerations.12 Concern is growing that temperature rises above 1.5°C are beginning to be seen as inevitable, or even acceptable, to powerful members of the global community.13 Relatedly, current strategies for reducing emissions to net zero by the middle of the century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere.14 15

This insufficient action means that temperature increases are likely to be well in excess of 2°C,16 a catastrophic outcome for health and environmental stability. Critically, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed.17 This is an overall environmental crisis.18

Health professionals are united with environmental scientists, businesses, and many others in rejecting that this outcome is inevitable. More can and must be done now—in Glasgow and Kunming—and in the immediate years that follow. We join health professionals worldwide who have already supported calls for rapid action.19 1

Equity must be at the centre of the global response. Contributing a fair share to the global effort means that reduction commitments must account for the cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond. Wealthier countries will have to cut emissions more quickly, making reductions by 2030 beyond those currently proposed20 21 and reaching net-zero emissions before 2050. Similar targets and emergency action are needed for biodiversity loss and the wider destruction of the natural world.

To achieve these targets, governments must make fundamental changes to how our societies and economies are organised and how we live. The current strategy of encouraging markets to swap dirty for cleaner technologies is not enough. Governments must intervene to support the redesign of transport systems, cities, production and distribution of food, markets for financial investments, health systems, and much more. Global coordination is needed to ensure that the rush for cleaner technologies does not come at the cost of more environmental destruction and human exploitation.

Many governments met the threat of the covid-19 pandemic with unprecedented funding. The environmental crisis demands a similar emergency response. Huge investment will be needed, beyond what is being considered or delivered anywhere in the world. But such investments will produce huge positive health and economic outcomes. These include high quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions.22

These measures will also improve the social and economic determinants of health, the poor state of which may have made populations more vulnerable to the covid-19 pandemic.23 But the changes cannot be achieved through a return to damaging austerity policies or the continuation of the large inequalities of wealth and power within and between countries.

Cooperation hinges on wealthy nations doing more

In particular, countries that have disproportionately created the environmental crisis must do more to support low and middle income countries to build cleaner, healthier, and more resilient societies. High income countries must meet and go beyond their outstanding commitment to provide $100bn a year, making up for any shortfall in 2020 and increasing contributions to and beyond 2025. Funding must be equally split between mitigation and adaptation, including improving the resilience of health systems.

Financing should be through grants rather than loans, building local capabilities and truly empowering communities, and should come alongside forgiving large debts, which constrain the agency of so many low income countries. Additional funding must be marshalled to compensate for inevitable loss and damage caused by the consequences of the environmental crisis.

As health professionals, we must do all we can to aid the transition to a sustainable, fairer, resilient, and healthier world. Alongside acting to reduce the harm from the environmental crisis, we should proactively contribute to global prevention of further damage and action on the root causes of the crisis. We must hold global leaders to account and continue to educate others about the health risks of the crisis. We must join in the work to achieve environmentally sustainable health systems before 2040, recognising that this will mean changing clinical practice. Health institutions have already divested more than $42bn of assets from fossil fuels; others should join them.4

The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5°C and to restore nature. Urgent, society-wide changes must be made and will lead to a fairer and healthier world. We, as editors of health journals, call for governments and other leaders to act, marking 2021 as the year that the world finally changes course.

Competing interests: We have read and understood BMJ policy on declaration of interests and FG serves on the executive committee for the UK Health Alliance on Climate Change and is a Trustee of the Eden Project. RS is the chair of Patients Know Best, has stock in UnitedHealth Group, has done consultancy work for Oxford Pharmagenesis, and is chair of the Lancet Commission of the Value of Death. None further declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

This editorial is being published simultaneously in many international journals. Please see the full list here:

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:


1          In support of a health recovery.

2          Intergovernmental Panel on Climate Change. Summary for policymakers. In: Global warming of 1.5°C. An IPCC special report on the impacts of global warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty. 2018.

3          Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services. Summary for policymakers: the global assessment report on biodiversity and ecosystem services. 2019.

4          Watts N, Amann M, Arnell N, et al. The 2020 report of the Lancet Countdown on health and climate change: responding to converging crises. Lancet 2021;397:129-70. PubMed PubMed

5          Rocque RJ, Beaudoin C, Ndjaboue R, et al. Health effects of climate change: an overview of systematic reviews. BMJ Open 2021;11:e046333. PubMeddoi:10.1136/bmjopen-2020-046333 PubMed

6          Haines A, Ebi K. The imperative for climate action to protect health. N Engl J Med 2019;380:263-73. PubMed

7          United Nations Environment Programme and International Livestock Research Institute. Preventing the next pandemic: zoonotic diseases and how to break the chain of transmission. 2020.

8          IPCC. 2019: Summary for policymakers. In: Climate change and land: an IPCC special report on climate change, desertification, land degradation, sustainable land management, food security, and greenhouse gas fluxes in terrestrial ecosystems. Forthcoming.

9          Lenton TM, Rockström J, Gaffney O, et al. Climate tipping points—too risky to bet against. Nature 2019;575:592-5. PubMed

10        Wunderling N, Donges JF, Kurths J, Winkelmann R. Interacting tipping elements increase risk of climate domino effects under global warming. Earth System Dynamics Discussions, 2020: 1-21.

11        High Ambition Coalition.

12        Global Climate and Health Alliance. Are national climate commitments enough to protect our health?

13        Climate strikers: Open letter to EU leaders on why their new climate law is ‘surrender.’ Carbon Brief 2020.

14        Fajardy M, Köberle A, MacDowell N, Fantuzzi A. “BECCS deployment: a reality check.” Grantham Institute briefing paper 28, 2019.—a-reality-check.pdf

15        Anderson K, Peters G. The trouble with negative emissions. Science 2016;354:182-3. PubMed

16        Climate action tracker.

17        Secretariat of the Convention on Biological Diversity. Global biodiversity outlook 5. 2020.

18        Steffen W, Richardson K, Rockström J, et al. Sustainability. Planetary boundaries: guiding human development on a changing planet. Science 2015;347:1259855. doi:10.1126/science.1259855 PubMed

19        UK Health Alliance. Our calls for action.

20        Climate Action Tracker. Warming projections global update: May 2021.

21        United Nations Environment Programme. Emissions gap report 2020. UNEP, 2020.

22        Markandya A, Sampedro J, Smith SJ, et al. Health co-benefits from air pollution and mitigation costs of the Paris Agreement: a modelling study. Lancet Planet Health 2018;2:e126-33. doi:10.1016/S2542-5196(18)30029-9 PubMed

23        Paremoer L, Nandi S, Serag H, Baum F. Covid-19 pandemic and the social determinants of health. BMJ 2021;372:n129. PubMed

Identifying Coping Mechanisms for Veterans Suffering Moral Injury

The current ANS featured article is titled “Moral Injury in Veterans: Application of the Roy Adaptation Model to Improve Coping” authored by Michael Cox, DNP, MHA, RN; Vonda Skjolsvik, DNP, RN, CHSE; Becki Rathfon, MS, CCMHC; and Ellen Buckner, PhD, RN, CNE, AE. We invite you to download this article at no cost while it is featured, and return here to leave your comments and questions! Dr. Cox has shared his personal reflections about this article for ANS readers:

Michael Cox

The concept that one’s morally transgressive behavior may result in lasting harm to the individual’s well-being is thoroughly documented in historical literature, as ancient cultures struggled to explain and cope with warrior reintegration. In more modern times, Civil War soldiers were diagnosed with “soldiers’ heart” or profound melancholy. In WWI, the condition was described as “shell shock.” WWII introduced the term “battle fatigue,” and the Vietnam Veterans were diagnosed with Post Traumatic Stress Disorder (PTSD). However, mental health professionals are beginning to understand that these terms do not fully capture war’s moral and ethical implications. As a result, they fail to fully capture the soldiers’ challenges as they transition into civil society.

Shortly after the start of the wars in Afghanistan and Iraq, my military colleagues and I began to recognize the harmful effects of deployment. The concerns about our comrades’ psychological well-being escalated as current treatment modalities proved to be ineffective. The inability to explain our observations prompted us to refer to these soldiers “as broken.” Currently, 22 veterans commit suicide each day in the United States, and the rate of suicide among veterans 18 to 34 years of age has risen 80% compared to the civilian population.

Acknowledgment that the suffering of these soldiers does not resolve upon exiting the military; prompted our team to explore the concept of moral injury (MI) in relation to veteran suicide. MI is the damage done to one’s conscience or moral compass when the person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical code of conduct. Our study describes the struggles veterans face as they try to reassemble their lives post-war.

Breaching moral boundaries has created dissonance between the veterans’ conscience and subconscious thoughts regarding right and wrong, resetting the individual’s fundamental identity and impeding their ability to develop relationships and maintain group identity. This inner struggle helps explain the previously determined feelings of betrayal, guilt, and irredeemablity frequently seen in veterans with MI. Unfortunately, I feel like I am reliving the past as the trauma experienced by our health care providers due to Covid-19 is manifesting in the same manner that we witnessed in those returning from deployment. It creates an environment where clinicians, similar to our veterans, struggle to reconcile the incongruence between their perceived ethical standards and those they are witnessing daily. Exploring the implications of this moral discord may be necessary to avert a similar crisis in our healthcare professionals. 

Nursing With the People

The current featured ANS article is titled “Nursing With the People: Reimagining Futures for Nursing” authored by Jessica Dillard-Wright, PhD, MA, RN, CNM and Vanessa Shields-Haas, MSN, MA, RN, FNP-BC, SAFE-ME – available to download at no cost while it is featured! The authors describe what this article adds to the literature as being “. . . a robust discussion of nursing’s resistance to and complicity with structures of white supremacy and neoliberalism. This then serves as a platform to engage a radical imagination for the future of nursing.” The authors shared this message about their work:

L-R – Jess, Vanessa

Nursing is limited only by what we can imagine as possible. With “Nursing With the People: Reimagining Futures for Nursing,” we (Vanessa and Jess) are hoping to invite a broader dialogue in nursing around what is possible for our discipline, where we have been, where we are going, and what shapes the terrain we navigate. The circumstances of the ongoing COVID19 pandemic and the inequities laid bare in the wake of civil protests against police brutality demands our full attention. To this end, in our paper we recognize the deeply political nature of nursing work, attending to the ways our profession has, by turns, upheld oppression and fostered liberation. We sketch out a brief schema for thinking about change in nursing, outlining approaches including reform, whistleblowing, and radical resistance, recognizing the complexities and complicities of our disciplinary history. We use the tensions that arise when we complicate our history to invoke a radical imagination for nursing, a doorway to alternate possibilities for the future of health, wellbeing, nursing, and healthcare.

This paper is, in some ways, a culmination of sorts. We first “presented” what would eventually become this paper at Nursing Mutual Aid’s 2020 Twitter conference, a radical and unique event designed to connect nurses to one another in a time when sheltering in place led us to seek connection in new ways. We presented a more refined version of the topic at the 2021 Nursing Theory Conference, where ideas, engagement, and feedback from participants in that space propelled us forward. Our collaborative scholarship here was forged through our grassroots efforts with Radical Nurses Collective, a space for organizing and action. The kernel for Radical Nurses Collective was planted in another radical space, the 2018 NurseManifst Nurse Activism Think Tank organized by Peggy Chinn. “Nursing With the People” creates a tidy sort of symmetry that way.

In many other ways, it is a starting place – a foundation for dreaming up what is just, what is equitable, what is possible, if we choose to see it. We hope you read our paper. We hope you share your thoughts here. We want to know what you see for the future of nursing, for the care we provide. And we want to build that together. We invite you to contemplate nursing’s past to understand where we find ourselves now. We welcome you to activate your radical imagination. To paraphrase the inimitable Ursula Le Guin, we close with the reminder that, although the structures and systems that exist seem immutable, at points past “so did the divine right of kings. Any human power can be resisted and changed by human beings.” What it takes is imagination and collective will. We hope you will join us.

Biopower in the Dual Pandemics of COVID-19 and Racism

The current featured article of the latest issue of ANS is titled “‘I Can’t Breathe’: Biopower in
the Time of COVID-19: An Exploration of How Biopower Manifests in the Dual Pandemics of
COVID and Racism” authored by Christine R. Espina, DNP, MN, RN and Robin A. Narruhn, PhD, RN. This article is available at no cost while it is feature on the ANS website! Here is a message about this work from Dr. Espina:

Fissures, rupture, chaos, and change. These words describe the past 16 months of the COVID-19 pandemic. In an interview, Paul Farmer stated, “…pandemics reveal a lot about a society. They expose all the fissures and cracks of the ravages of history. And so looking back at previous epidemics…we’ve really seen again and again that social disparities shape not only the epidemics, but our responses to them” (Garcia-Navarro, 2020). Farmer ends his interview on a more optimistic note by saying that we, as a collective, can improve our response. In a similar vein, novelist Arundhati Roy writes, “historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next” (2020). The artist-activist Kill Joy visualized Roy’s quote as an erupting volcano as depicted here:

Kill Joy, Pandemic as Portal, 2020
Christine Espina

As academic-activists, we imagine centuries-old forces—the “ravages of history”—rumbling beneath the earth’s surface converging and erupting. The pandemics are further manifested in the extreme global climate change we are experiencing now. For BIPOC communities, the ground has always trembled with racism and health inequities. The virulence of COVID and structural racism expose the fragility of the protective factors of white privilege and other intersecting privileges. With these recent and public ruptures, a portal has opened more opportunities for some to choose an increased conscientization.

In early 2020, we were trying to make sense of the violent events converging publicly in our communities and across the nation: increased mainstream media attention to and public outrage at racist, state-sanctioned murders of George Floyd, Breonna Taylor, Daunte Wright, and countless others, police violence against Seattle and Portland protestors, the political downplay of this novel disease clearly and disproportionately impacting low-income BIPOC communities…just to name a few of the events troubling us.

Robin Narrhun

Agamben’s theory of biopower (2005) provides a useful framework to understand the eruption of the dual pandemics of COVID and racism. Biopower begets violence–whether acute acts of violence like police brutality and the murders of Black and Indigenous peoples or the chronic, slower violence of health inequities among BIPOC communities due to structural racism. We have been struck by Jane Georges’ work (2008; 2011; 2013) on Agamben’s theory of biopower and its relevance to nursing. It clicked for us: all these recent connected events were biopower at play before our very eyes.

In our paper, we connect Agamben’s theory of biopower with examples and illustrations from the dual pandemics, with the hope of showing how theory can provide a way to understand and name injustice. We also explore nurses’ ethical and moral responsibilities and introduce actions for nurses—particularly nurse educators—to respond to these dual pandemics. We look forward to the realization and praxis of a more just and equitable world.


Garcia-Navarro, L. (2020). Anthropologist Paul Farmer’s new book explores the failures of an Ebola epidemic. [Interview]. National Public Radio; Weekend Edition Sunday.

Georges, J. M. (2008). Bio-power, Agamben, and emerging nursing knowledge. Advances in Nursing Science, 31(1), 4–12.

Georges, Jane M. (2011). Evidence of the unspeakable: Biopower, compassion, and nursing. Advances in Nursing Science, 34(2), 130-135.

Georges, Jane M. (2013). An emancipatory theory of compassion for nursing. Advances in Nursing Science, 36(1), 2-9. https://doi/org/10.1097/ANS.0b013e31828077d2

Kill Joy. (2021). Justseeds Artist Cooperative. Non Commercial-No Derivs CC BY-NC-ND Creative Commons License. Retrieved on July 12, 2021:

Roy, A. (2020, April 3). The pandemic is a portal. Financial Times.

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