Our current featured ANS article is titled “A Nursing Perspective on Infant Bed-Sharing: Using Multidisciplinary Theory Integration” authored by Marissa G. Bunch, MSN, RN, CPNP and Sadie P. Hutson, PhD, RN, WHNP, BC. Download this article at no cost while it is featured to learn more about the topic of bed-sharing, as well as the authors’ approach to theory integration. Here is a message provided by Marissa Bunch (now Dr. Bunch!) about this work:
After over a decade of work with families as a pediatric nurse practitioner, I recognized that philosophies of parenting and infant care advice often conflicted with what families were actually practicing in their homes. When it came to bed-sharing, there was a glaring mismatch between what I was telling caregivers and what many of them were actually doing; many were afraid to disclose that they were sleeping alongside their infant, despite the high prevalence of families who have shared a bed across cultures and throughout history.
While there is a large push to encourage caregivers to eliminate bed-sharing due to an association with infant death, there is also a surprising lack of clear evidence that an unimpaired caregiver poses an inherent danger to their child during sleep. The evidence that is available varies depending on which theoretical viewpoint the researcher adopts. This article calls for nurses to acknowledge the various theories guiding this research and how those paradigms frame research results. The knowledge I gained from immersing myself in the theory behind infant bed-sharing informed my dissertation research with caregivers from Appalachia who shared a bed with their infants. I wanted to give my patients a voice and bring into the open what I was hearing behind the clinic doors. This article is part of the foundation for that work.
The title of the current ANS featured article is “I Cannot Afford Off-loading Boots: Perceptions of Socioeconomic Factors Influencing Engagement in Self-management of Diabetic Foot Ulcer” authored by Idevania G. Costa, PhD, RN, NSWOC; Deborah Tregunno, PhD, RN and Pilar Camargo-Plazas, PhD, RN. The article is available to download at no cost while it is featured! Here is a message from Dr. Costa about this work:
During my experience providing care for individuals with chronic conditions for almost two decades and delivering wound care for marginalized people (e.g., low-income and minority groups) in society, I witnessed patients facing several struggles to achieve the desired outcomes, being oppressed and prevented from being actively involved in decision-making about their own care. They were victims of a biomedical model that often places individuals as passive subject in their own care and prevents them from taken on a more active role in order to achieve better outcomes. Because biomedical model is also paternalistic and focus on disease rather than on a person as whole, individuals are often prevented from understanding their roles and acquiring the abilities needed to manage their chronic conditions.
Thus, when I embarked on the journey of writing my doctoral thesis, I wanted to approach the topic by challenging the status quo of a biomedical model and therefore giving voices to research subjects. I wanted to provide them with the opportunity to help us to understand their needs, motivations and struggles of having a chronic wound while navigating in a social world. I also wanted to consider questions, such as how do healthcare providers might better meet the needs of individuals with chronic wounds (e.g. diabetic foot ulcer) if they looked beyond just the illness itself? I believed that to address my goals I needed to use a methodological approach that would view individuals in society as active subjects working collectively and sharing experiences to re-construct their world and realities. I was fortunate enough to have had two amazing co-supervisors (Drs. Tregunno and Camargo Plazas) who guided me through this process of learning about a variety of methodologies and choosing one that would be the best fit to my research questions and philosophical assumptions. With their guidance I embarked on the journey of writing a grounded theory (GT) study. They provided me directions and allowed me to make a decision about which version of GT to use in my study.
After reading and learning about the main versions of grounded theory and doing a literature review, I noticed sparse studies focusing on individuals’ needs, motivations and struggles to manage their chronic wounds. There was no published study showing a theoretical model depicting the factors that influence individual’s engagement in self-management of a multifaceted chronic wounds such as diabetic foot ulcer (DFU). In response to this research gap, and to contribute knowledge on how to improve self-management and health outcomes of DFU from patients’ unique experience, I decided to use constructivist grounded theory to understand the processes of engagement in self-management described by individuals with active DFU, and develop a theoretical model depicting the factors that influence their ability to actively engage in their own care (Figure).
Ultimately, I want to invite healthcare providers, particularly, wound care professionals and policy makers, to take a look in this paper as it uniquely uncovers inadequacies in diabetes knowledge and inequalities in access to wound care services and resources for individuals living with DFU. These findings provide a foundation to guide clinicians and policy makers in improving diabetes care in order to reduce the risk of developing DFU in the first place, and ultimately, to improve self-management of diabetes and DFU. Finally, these findings also highlight the need to ensure the necessary self-management education program, services, and resources to facilitate individuals’ engagement in self-management of a multifaceted condition are in place.
In my own undergraduate nursing program at the University of Hawaii, we heard an often-repeated phrase reminding us that we were being prepared to be “change agents.” Throughout my career I have often reflected on this “charge” and the reality that so little changes – particularly when we consider the challenges that nurses face in putting many of the ideals of nursing into practice. In our current featured article title “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study” the authors Patrick Martin, PhD and Louise Bouchard, PhD, address this long-standing tension. They conclude that what is needed is a radical renewal of democracy in hospitals. Dr. Martin provided this background information about their work:
The aim of this study on which we had a great time working together was to explore the lived experiences of politically engaged staff nurses working in a hospital centre; to portray the social order that exists there; to describe the way in which the nurses would ideally like to practise; and to record their ideas and the action they have taken individually and collectively for fostering change in the social order and the practice of nursing. Epistemologically, this qualitative study was based on a view of reality as complex, mutable, and dependent on individual perception, which suggests a comprehensive, contextualized approach to human action and politics and, hence, to the consideration of the political views of the participating nurses.
The linkage between lived experience, normative ideals and political action has been explored from a dialectical, praxeological, postmodernist perspective which constitutes a reflection not only on what is but also on what ought to be. Such a reflection may, under certain conditions, lead to transformative action. We cannot say that the results of this study have contributed to the current changes, however these have been widely published in the mass media and we can now see a small revolution taking place in the nursing field in Quebec (Canada).
These results indicate a gradual deprofessionalization and increasing technicization of nursing. Our findings point, too, to an intensifying drift towards authoritarianism in hospitals with the adoption of the semantic register of the market economy along with the notions of efficiency, performance and optimization. Viewed as little more than high-performance robots, staff nurses find themselves excluded from decision-making processes. They have thus been deprived of the freedom to express opinions about or criticize decisions taken by the top ranks of the hospital power hierarchy (rather than by the nurses themselves) regarding the way nursing is practised. Disciplinary power in hospitals, exerted through technological policies such as constant surveillance, reprisals and fear, the technicization of care, and mandatory overtime contribute to the staff nurses’ subjectivation. Their clinical judgment has been devalued, their group solidarity undermined, and their union organization brought to heel. They have thus been diverted from demanding the realization of their rights and their ideals of emancipation and been reduced to the role of subordinates.
Accordingly, although the nurse participants want to take action in the hospital to humanize care and achieve professional self-determination, the practical purpose of much of the action we recorded was, rather, their own protection and survival in a dehumanizing hospital system. There are, nonetheless, staff nurses who raise conscientious objections, resort to individual or collective non-cooperation or engage in acts of civil disobedience with the aim of establishing a new power relationship, one that must necessarily be put in place for their demands, which would otherwise be ignored in this system of hospital governance, to be taken seriously.
Unless the antagonistic exercise of power in this system of hospital governance is thwarted by the exercise of equal or greater power on the part of nurses working collectively, they will continue to be subjected to its political philosophy and objectives. It emerges from their discourse that nurses collective action must focus on the radical renewal of hospital democracy, which, as a new power relationship, will enable staff nurses to fully participate in discussions of the orientation of their practice.
About the authors:
Patrick Martin is a nurse activist and an associate professor at the Laval University’s Faculty of Nursing. He is also a researcher at the Quebec Heart and Lung Institute. His research interests include the organization of work, social relations and power structures in which nurses’ experiences are rooted and strategies for nonviolent action. The central axis of his research program proposes to examine the system of constraints inherent in the social world in which nurses and nurse managers operate, as well as the effects of this system on their health and workplace safety. He investigates these elements by focusing on their relationship to politics, allowing them to envisage individual and collective courses of action to reduce these constraints in a perspective of sustainable health at work.
Louise Bouchard is a retired professor from the Faculty of Nursing at the University of Montreal, after teaching for over 30 years. She campaigned for many years on feminist committees, both in the local union and in the Fédération québécoise des professeures et professeurs d’Université. Her political commitment is continuing to recognize nurses’ freedom of conscience, particularly in the ideological context of medicalization and biopower.
As a doctoral student, I decided to explore my observations further. My mentor, Dr. Mary McCurry, and I conducted a pilot study of the experiences of former dementia caregivers following the care recipient’s death. The study findings supported my observations from clinical practice. We also found that depressive symptoms and sleep disturbances persisted for as long as a decade after caregiving ended. The findings provided a foundation for my doctoral dissertation, which involved the development and testing of the Post-caregiving Health Model. This article provides a detailed description of the development of this model.
The Post-caregiving Health Model highlights a stage of caregiving that has been neglected in previous research: the stage we refer to as “post-caregiving” or the time following the death of a care recipient. Based on the Transactional Theory of Stress, the model emphasizes the effects of appraisal, emotion, and coping on long-term post-caregiving health outcomes using a holistic perspective. We intend to utilize this model to guide our future research on post-caregiving health outcomes and as a foundation for developing and testing interventions that target effective coping for caregivers after caregiving ends.
Our current featured article is titled “Freirean Conscientization With Critical Care Nurses to Reduce Moral Distress and Increase Perceived Empowerment: A Pilot Study” by Nancy A. Bevan, PhD, APRN, ACNS-BC and Amanda M. Emerson, PhD, RN. Dr. Bevan sent this message giving ANS readers some background about this work:
Moral distress in nursing is a significant problem that needs to be understood and addressed. This paper reports some of the findings from my doctoral dissertation work that explored using Freirean Pedagogy as the theoretical basis for an educational intervention for nurses who have suffered moral distress. I have always been interested in research on the health of nurses. My long career in critical care nursing piqued my interest in moral distress in nurses because I have experienced it myself and witnessed it in others.
While reading the literature, I became intrigued by the discussion of nurse’s relative powerlessness as one of the causes of moral distress. There is strong evidence linking powerlessness arising from structural hierarchies embedded in health care to moral distress in nursing; this has led some to argue that nurses are an oppressed group. Based on that, like other oppressed groups, nurses may lack insight into their oppression and struggle ineffectually to overcome it on their own. A Freirean educational intervention was created with the help of an international expert in Freirean pedagogy and piloted in nurses who have suffered moral distress. Results showed improved moral distress and mixed results in perceived personal and group empowerment. Further study is warranted, but we need to take care of our nurses, and start finding ways to address moral distress in a concerted way.
The current ANS featured article is authored by Maya Zumstein-Shaha, PhD, RN; Carol Lynn Cox, PhD, RN, FHEA; and Jacqueline Fawcett, PhD, ScD (Hon), RN, FAAN, ANE, titled “The Omnipresence of Cancer: Two Perspectives.” The article is available at no cost while it is featured; please share your comments and ideas related to this article here! Dr. Zumstein-Shaha shared the following message, and the video below, about this work.
In the article entitled “The Omnipresence of Cancer: Two Perspectives”, which is appearing in ANS volume 43, issue 3, is authored by Maya Zumstein-Shaha, PhD, MScN, RN, Carol Lynn Cox, PhD, RN FAHE, and Jacqueline Fawcett, RN, PhD, ScD (hon), FAAN, ANEF. In this article a midrange nursing theory is proposed aiming at enhancing the care of patients with oncological malignancies. This theory is timely as cancer remains one of the most frequent causes for death around the globe and diagnostics and treatments are changing rapidly.
Carol Lynn Cox
Therefore, oncology care is also facing changes regarding aims and objectives as well as methods of supporting persons with cancer and their members of the family.
The authors of this publication have worked across countries – namely Switzerland and the United States – to describe nursing knowledge development and theory construction. The collaborative work has yielded the second perspective of this theory, namely the re-interpretation of the study findings from which the theory emerged in
the light of a grand theory in nursing.
In the video below, the theory’s development is briefly described, and a schematic is provided along with a brief summary.
This paper reports on some of the findings from my doctoral dissertation that explored how nurses working in acute care settings came to understand the cognitive function of older patients. We noted that while nursing literature has reported that nurses miss cases of cognitive impairment and fail to identify conditions such delirium, there was very little written about how nurses build their understandings. We approached this topic from a perspective that recognized the important of the healthcare environment on nurses work and were attuned to social relations in the research process. In the course of the research, we found that the documents that nurses used to communicate, report and archive aspects of their work were shaping how they understood the cognitive function of older patients. This is an element of healthcare settings that can potentially be improved to better reflect the current best evidence about how to support people who have, or are risk of having cognitive, impairment. As the COVID-19 pandemic is drawing more and more attention to the situation of older people in our communities, and the ways that healthcare settings are structured to provide their care, it is an opportune time to consider ways to reorient these settings to the needs of an older population.
This paper is the result of a lot of professional soul-searching, and thinking about how nurses are treated and treat one another in different environments. As nurses we can, in many ways literally, do anything—but we have allowed ourselves and our profession to be held back by outdated ideas about who and what we are. I wrote this paper because I feel so strongly that we have come to a critical point in our professional, educational, and scientific growth. This moment is for nursing both laden with potential and weighed down by tradition. It is time for us to shed once and for all the old ideas that position nurses as subservient to other disciplines, as ministering angels, as perfect “ladies,” rather than as the independent, creative, scholarly, assertive, and forward-thinking professionals that we are. At this historical and professional moment, it seems to me fundamentally important that nurses call openly and honestly for the implementation of social justice in our professional and personal communities, and that we start with cleaning our own “house”—our educational, scientific, and practice institutions. Who we are as a profession must not be constrained by stereotypes about gender, race, sexual orientation, religion, appearance, socioeconomic background, or anything else that we would not allow to influence our provision of safe, effective, non judgemental care.
Our international research team came together out of our mutual interest in men’s experiences in nursing. While acknowledging patriarchy as the dominant explanatory paradigm of gendered structures and inequities in healthcare (and in nursing in particular), we were concerned with the lack of literature describing specific gendered constructs and processes based in patriarchy that might account for the lack of gender diversity in the nursing workforce. In the current study, we used a specific temporal context—the process of deciding to pursue a nursing career—to examine the interplay among gendered constructs and contrasting messages while using Gender Role Conflict (GRC) as a sensitizing framework. Our findings yielded a decision-making model that extends previous research. Further, we believe GRC to be a theoretical model well-suited to study phenomena related to men in nursing and support the development of meaningful strategies to improve gender diversity in nursing.
Our current featured article is titled “A Philosophical Analysis of Spiritual Coping” authored by Karen S. Dunn, PhD, RN, FGSA and Sheria G. Robinson-Lane, PhD, RN. While this article is featured it is available to download at no cost, and we invite you to read this article then return here to leave your comments and questions. Here is the message Dr. Dunn provided about her work:
This journey began with my dissertation mentor at the Institute of Gerontology (IOG) at Wayne State University working as a research assistant on the “Active Project” while achieving a PhD in nursing. The first conversation I had with her was to review the research literature on the study of chronic pain in older adults to determine what research on this topic I could pursue for my project. The study of chronic pain in older adults was my dissertation mentors’ area of research, and so my project had to fit with her expertise. At this time, finding a new area of inquiry in the study of chronic pain was a difficult task because many researchers had published extensively on the topic of pain.
After months of reviewing the research literature, I started to see a recurrent finding in the evidence indicating that many older adults reported using prayer and/or some form of religious practice to cope with chronic pain. The research evidence, however, was limited as to how effective this form of spiritual coping was in dealing with chronic pain. Most often, spiritual coping was cited in a long list of strategies, yet, was not the focus of the article. I was so excited that I finally found a new line of inquiry that I could investigate.
Unfortunately, the excitement I felt had diminished when I told my mentor and faculty at the IOG my topic of interest. Their responses were like other researchers that neuroscience offers a better explanation for the relationships between the use of spiritual coping and positive/negative health outcomes. They suggested I would have to expand my line of inquiry to include more researchable topics other than “Aging and Spirituality.” So as my nurse scientist journey continued over the years of study, my final program of research became “Holistic self-care practices used by older adults to maintain bio-psycho-social and spiritual wellness with an emphasis on aging and spirituality.”
Although I expanded my program of research, my expertise in aging and spirituality matured. What I found very promising was within the last decade, a growing body of evidence within the nursing literature regarding the importance of fostering spiritual wellness in people had emerged. Although it is common nursing practice to assess a patient’s religion upon admission, this was usually the only interaction on this topic. Patients, however, began to report the desire for health care providers to pray with them. Many nurses, especially nurses working in oncology or hospice, began to do more in-depth spiritual assessments to determine spiritual needs. Nurses began to argue that if the practice of nursing is truly holistic, then the need to address all wellness domains (bio-psycho-social-spiritual) is essential and the study of each domain is warranted.
Even with this growing body of evidence, a question continued to remain in my mind, “How does one change the negative perspectives on the study of spirituality within the scientific community?” It was my hope that maybe a philosophical analysis on spiritual coping would begin a dialogue to change these perspectives. As I began contemplating what methodology to use for the philosophical analysis, I was contacted by Sheria Robinson-Lane who is the second author on this article. Sheria was referred to me from a colleague who knew my work on religious coping to assist her with similar work. I told her that I was thinking about doing a philosophical analysis on spiritual coping and so our collaboration began.
After months of reviewing the last five years of research on spiritual coping, three themes emerged: (1) enhanced physical, psychological, and social well-being, (2) resilience, and (3) self-transcendence. These three themes were found to be philosophically congruent with three postmodern philosophical approaches and multiple extant nursing theories and therefore relevant to nursing science. It is my hope that this article will provide a substantive argument for the continued study of spiritual coping and its significant relationships to health and wellness.
The essential purposes of ANS are to advance the development of nursing knowledge and to promote the integration of nursing philosophies, theories and research with practice. We expect high scholarly merit and encourage innovative, cutting edge ideas that challenge prior assumptions and that present new, intellectually challenging perspectives. We seek works that speak to global sustainability and that take an intersectional approach, recognizing class, color, sexual and gender identity, and other dimensions of human experience related to health.
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The ANS Blog provides a forum for discussion of issues raised in the articles published in Advances in Nursing Science. We welcome all authors and readers to post your comments and ideas on the blog! If you would like to be an author on this blog, let us know!
The journal Editor is Peggy L. Chinn, RN, PhD, FAAN. Dr Chinn founded the journal in 1978.
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A wonderful serenity has taken possession of my entire soul, like these sweet mornings of spring which I enjoy with my whole heart. I am alone, and feel the charm of existence in this spot, which was created for the bliss of souls like mine. I am so happy, my dear friend, so absorbed in the exquisite sense of mere tranquil existence, that I neglect my talents. I should be incapable of drawing a single stroke at the present moment; and yet I feel that I never was a greater artist than now.