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Posts from the ‘Featured Articles’ Category

Reducing Nurses’ Moral Distress

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 Omnipresence of Cancer

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.

Maya Zumstein-Shaha

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

Jacqueline Fawcett

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.

Understanding Older People’s Cognitive Function

Our current featured article is titled “The Contribution of Documentation Systems to How Nurses Understand Older People’s Cognitive Function in
” authored by Elaine Moody, PhD, RN; Alison Phinney, PhD, RN;
Geertje Boschma, PhD, RN; and Jennifer Baumbusch, PhD, RN. Please download this article at no cost while it is featured; we welcome your comments! Here is a message that Dr. Moody provided for ANS readers about this work:

Elaine Moody

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.

Men’s Decision to Become Nurses

Our current featured article is titled “Men’s Decision-Making to
Become Nurses: Gendered Influences and Fit With Gender Role Conflict Theory
” authored by Chad E. O’Lynn, PhD, RN; Tom O’Connor, EdD, MSc Ad Nursing, BSc, PG Dip Ed, Dip Nur, RGN, RNT; Liliana L. Herakova, PhD; and Peter Kellett, PhD, RN. The article is available to download at no cost while it is featured, and we welcome your feedback and comments here! Dr. O’Lynn sent this message about this work:

Chad E. O’Lynn

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.

Spiritual Coping

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:

Karen Dunn

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.

Honoring the Legacy of Anne Zimmerman

The current featured ANS article is titled “The View From Anne’s
Shoulders: Preserving and Honoring the Legacy of Our Leaders
” authored by Geraldine Gorman, PhD, RN; Brigid Lusk, PhD, RN, FAAN;
Rebecca Clay, MSN, RN. You can download this interesting article at no cost while it is featured, and we welcome your comments here! Dr. Gorman provided this message giving more background about this work for ANS readers here:

Geri Gorman

Anne Larson Zimmerman, 1914-2003, was an extraordinary woman, world citizen, activist and nurse. Likely you do not know her name. She blazed through the world before we digitalized. She leaves only a ghostly thread of internet references. But in the Special Archives section of the University of Illinois at Chicago’s Health Sciences library, boxes of her donated papers attest to an extraordinary life. Human rights activist, labor leader, staunch proponent of nursing in general and of every individual nurse in particular, Anne’s star shines brightly in our firmament. But how would we know? How many will visit the special archives and take the time to delve into the boxes that hold Anne’s life?

Dare we, then, to tell a story?

We are not very good at that anymore, we nurses. We disparage our stories for fear they will make us seem less rigorous, less scientific. Instead of stories we exchange data. And nurses like Anne will not be found there. So if we want to celebrate our leaders and heroes, the ones who inspire and edify us, we are well advised to tell their stories before they slip from our collective memory.

I knew Anne only for the last seven years of her life but her impact was indelible. I was a new nurse and an old PhD student struggling with a dissertation which told the story of one the Midwest’s last surviving VNA’s. Anne’s glory days as international human rights ambassador, ANA president, INA Executive Director and union champion were behind her. Voted a Living Legend by the ANA, she described her retirement years as time spent “not so much in consultation as in consolation.” She believed in the importance of the story I struggled to tell and she helped me to organize the VNA nurses in one last glorious act of public resistance before the proud organization was gobbled up by a corporate health care system. When she died at age 89, nurses acclaimed and unheralded packed the Chicago church for a celebration of her magnificent life.

By that time I was new faculty at the College of Nursing at UIC. I spoke to the incoming nursing students about the importance of knowing our history—the good and the bad—but our textbooks really stopped telling the stories of individual nurses somewhere in the early part of the twentieth century. I told them about Anne but the weight of her insistent legacy grew heavier from year to year.

By 2015, a full twelve years after her death, Anne’s voice was a constant presence in my life and teaching. It was payback time. Dr. Brigid Lusk, nursing historian, had joined our faculty. I engaged Brigid in discussions about a performance which had been gestating within me for a decade. I envisioned nurses and nursing students rediscovering and recreating and Anne’s life, told in her own words and in those of her colleagues and friends and legions of admirers. I wanted us to pull those boxes from the stacks and dig in. There was a story which must be told. Brigid agreed.

Amy Spreitzer, Rachel Renee Gage and Jocelyn Mallard, who portrayed Anne at different times in her career, standing in front of a portrait of Anne’s hands.

And so we did. Through 2015 till the end of 2016 we composed a celebration of Anne’s struggles and accomplishments against a backdrop of events from the twentieth century with which her life intersected. Nursing students immersed themselves in the papers from those boxes. They interviewed Anne’s family and surviving colleagues. They created an historical timeline replete with images that defined her life and the evolving century. I wrote the story into a script and we added music. Twenty-three students and nurses brought it to life in three separate performances in 2016, one of which took place at the American Association for the History of Nursing’s annual conference.

Rachel Reichlin with Anne’s closet friend, the late Peg Stafford, RN, FAAN, who Rachel portrayed in the performance

At all the performances, Anne’s friends, admirers and family members co-mingled with those who were hearing her story for the first time.
I am grateful to ANS for its breadth of vision and understanding. It is no easy task to publish the account of a such a project—one that extols the intrinsic worth of storytelling—in our professional journals. We are wary of narratives for the reasons I outlined; they can threaten the staunchness of our rigor, make us look fuzzy and dreamy, like the ‘sentimental women’ image which has haunted the profession. But oh my Lord—do we need a revolution in our thinking!

Rachel Neuschatz in front of photo of Anne holding her daughter, Nancy

As we wait for science to save us from ourselves, to concoct that magic vaccine which will deliver us from the wages of our societal sins, we gravitate toward stories to comfort us, to ease the rawness of this historical moment. The statistics which flash across our screens numb us but the stories of health care workers who confront the pandemic ennoble us, give us hope. Studies about structural racism do not compel us to march in the streets but the story of a man’s murder detailed by a public countdown of minutes inspired a spontaneous movement. What kept so many of us glued to our screens during John Lewis’s long and eloquent memorial were the details of the life of the man from Troy. We are ravenous for such stories. And too seldom do our professional journals feed that hunger. Instead we are offered a steady stream of dry and formulaic articles in which the author’s voice and the precious human details are obscured beneath a mountain of statistical data.

So I appreciate the opportunity to share Anne’s story through the account of the performance we created: While I am Here: the life and legacy of Anne Larson Zimmerman. May it inspire you to celebrate the heroes you have known and to encourage nursing’s literature to bestow upon them their deserved place in the record, not as a statistic but as a vibrant story demanding a telling.


Words Matter: Sex and Gender

The current featured article in ANS is titled “Words Matter: Sex and Gender as Unique Variables in Research” authored by John R. Blakeman, MSN, RN, PCCN-K, who completed his PhD degree earlier this year! Download this article at no cost while it is featured – it is accredited for Continuing Education and you can access the CE test on the ANS website to receive credit! Here is a message from Dr. Blakeman about this work:

The impetus for this paper can be traced back to a conversation I had with several of my friends about two and a half years ago, when I was still a PhD student.  We were all sitting around a campfire and discussing a wide array of topics.  At one point during the conversation, a friend of mine noted that she was excited to be attending a “gender reveal party” for one of her friends the following weekend.  At that point, another friend asked, “I wonder why they call them ‘gender’ reveal parties and not ‘sex’ reveal parties, since we find out the baby’s sex and not their gender?”  And that is when the conversation became very interesting  What followed was confusion and division among the group.  

Some of us had a solid understanding of the differences between sex and gender – the idea that biologic sex is really about the 23rd chromosome’s configuration and that gender is socially constructed and variable from society to society.  However, others viewed and used the terms sex and gender interchangeably.  We debated the necessity of these two terms and the importance of distinguishing them.  A few of my friends even admitted that they preferred to use the term gender because it seemed less offensive than the word sex.

Of course, this discussion with my friends led me to develop this paper.  After I left the celebration that night, I began to think about the nursing literature.  How do nurses use the terms sex and gender?  Do we use these terms correctly?  Do we even give these two terms a second thought when designing a study?  As I read several journal articles, I realized that many authors had used the terms sex and gender synonymously and that there was not great clarity in the nursing literature.  As a result, I decided to write a paper that would specifically highlight this issue.

Indeed, measuring and operationalizing sex and gender can present a number of challenges as noted in the manuscript.  There are sometimes more questions than answers, and I certainly do not purport to have all of the answers.  However, I hope that this paper stimulates thought and critical reflection among nurse scientists.  This paper is meant to serve as an initial stimulus for discussion and action.  I hope that we, as nurse scientists, can continue to refine our thinking on this issue and do our best to incorporate these two variables precisely in the research and theoretical work that we conduct. 


Visual Elicitation in Applied Qualitative Health Research

The first featured article for the newly published ANS Vol 43:3 is titled “Visual Elicitation: Methods for Enhancing the Quality and Depth of Interview Data in Applied Qualitative Health Research” authored by Elizabeth R. Orr, MSc; Marilyn Ballantyne, PhD; Andrea Gonzalez, PhD and Susan M. Jack, PhD. We invite you to access this article at no charge while it is featured! Here is a message from Elizabeth Orr about this work!

Elizabeth Orr

Reaching the stage of data collection or generation is often a momentous occasion in the life of a research project. It follows long hours of planning and revising study protocols, completing ethical review and the frequently arduous task of participant recruitment. So how do you ensure this stage of research is meaningful and productive? What factors threaten to derail this stage of your project and what strategies can be adopted to mitigate this risk? These were the driving questions behind my exploration of arts-based research methods and the decision to incorporate visual elicitation strategies into my study exploring the transition home from NICU for adolescent mothers.

Using my PhD project – the NICU-to-Home Transitions study – as a study example, this article focuses on the operational or ‘how to’ aspects of incorporating visual elicitation tools or tasks within a semi-structured qualitative interview for the purpose of generating rich qualitative data. The considerations for planning and execution described in this article represent the deliberations that guided my adoption of these methods; however because they are presented as general strategies they can be applied broadly across study populations and contexts – particularly when factors such as power differentials or developmental processes threaten achieving the depth or detail required for the selected study design.

Generating rich, in-depth data and thus saving valuable time and resources was the impetus for exploring innovative approaches to qualitative interviews and the incorporation visual elicitation into my study protocol. However, the reason I will consider such activities in future studies – in addition to their contribution to rich and detailed interview data – is the value and meaning such tasks can have for the research participant (this was neither anticipated nor planned for). When a parent-participant asked me to keep their drawings so they could continue adding to them beyond the interview encounter I realized the methods I had carefully chosen – albeit for a different purpose – were meaningful for the participants in a way that would not be possible through semi-structured interviewing alone. It is my hope that with the clear guidance given in this article for the use of visual elicitation in qualitative data generation, that others will explore, adopt and experience the possibilities these methods hold.

Social Capital

Our latest featured article is titled “Social Capital: A Concept Analysis” authored by Kristi K. Westphaln, PhD, RN, CPNP-PC; Eileen K. Fry-Bowers, PhD, JD, RN, CPNP, FAAN; and Jane M. Georges, PhD, RN. I join the authors to invite you to download this article while it is featured, and return here to share your comments. This is a message from Dr. Westphain giving background about this work:

Kristi Westphaln

Social capital is broadly defined as the resources obtained via social membership and engagement. I first encountered it in the “life lab” during a health care mission in Tachloban City in the Philippines, where I helped care for survivors of Hurricane Yolanda. This was my first experience with international disaster relief and I wasn’t sure what to expect in terms of how the people were coping with such devastating losses. I became friends with a young woman who shared her story of how three tsunami waves unexpectedly swept her out of her home. She told me that the tsunami scene from “The Impossible” was authentic. And, how she was the only person in her family to survive. Another young man recalled how he had to cling to a pole for 4 hours to prevent being washed away by the storm; he vividly remembered bodies floating by as he held on for his life. Almost everyone I met had lost homes, beloved family members, and/or friends to the storm. Despite this, people didn’t want to solely talk about the trauma they experienced. Many of their narratives were centered within the context of how their community came together to take care of each other. They found homes for the homeless, cleaned the debris, attended church, and found ways to make each other laugh. It seemed to extend beyond resilience or coping.

This concept analysis emerged from a desire to better understand how membership and interactions within social networks foster individual and collective capacity. Some of the shared themes across the literature on social capital from multiple disciplines include a socioecological perspective (most frequently at the community level), an asset-based philosophy, structural and functional dimensions, and benefits/rewards for membership and participation within social networks. Given that nurses frequently interact on the front lines of patient care while also navigating the complex connections among individuals, families, and the health care system; this manuscript focuses on the definition and uses of social capital within the discipline of nursing.

The operational definition derived from this analysis was consistent with definitions used within the literature from multiple other disciplines. Dissimilar to the literature from other disciplines, the most common themes at the intersection of social capital and nursing were the nursing workforce and workplace (hospital settings) rather than involving patient- or community-oriented applications. I’m optimistic for further investigation on how nursing and social capital contribute to optimizing public health. Relational aspects of health are often difficult to articulate and measure, however they represent important foundations for growth, development, and sustainability from individual people to entire populations.

Mutuality in Caregiving

ANS is currently featuring the article titled “Family Caregiver-Receiver Mutuality: A Concept Analysis” authored by Brennan P. Streck, MSN, RN, CNE; Diane Wind Wardell, PhD, RN, WHNP-BC and Geri LoBiondo Wood, PhD, RN, FAAN. We invite you to download this article at no cost while it is featured, and share your comments here! Brennan Streck shared this background information about this work for ANS blog readers!

This concept analysis came to be after I dove into the literature on caregiver-patient (often called caregiver-receiver, as in this paper) dyads. I am an oncology/stem cell transplant nurse by training. Anecdotally, my nursing and medical colleagues noticed that our patients with positive reflections of their caregivers and those who seem to have stable, fruitful relationships tended to have better outcomes. This phenomenon is well documented in the literature; many studies have found that social support is an integral part of healing. Thus, caregiver research has become more popular over the last decade or so. Caregivers are being considered for their potential role in patient outcomes now more than ever. Studies are evaluating whether some characteristics (either those that make up the caregiver or patient as individuals, or those which are dyadic in nature) are associated with better health outcomes.

At the top of the list of characteristics that may prove important is the obvious: the dyadic relationship. As nurses, we often witness the nuances of our patients’ personal lives. We sometimes notice when patients seem to have strong support systems while others do not, and when some patients and their caregivers have healthy/bonded relationships while others’ are tumultuous. In the ideal case scenario, a sick patient would recruit a caregiver to help them get through an illness. The relationship between patient and caregiver should benefit both people; it should be mutualistic. When it isn’t mutualistic, the relationship suffers, which can ultimately affect the health of both involved individuals. There is a term that describes the mutualistic relationship between patients and caregivers. I came across this term a few times while researching the phenomenon of the patient-caregiver relationship. That term was mutuality.

I decided to perform a concept analysis on mutuality because it is, for lack of a better explanation, a rather “flowery” concept. Many people may not truly know what it means, because it is a rather altruistic term that lives in a metaphysical space. However, if mutuality could be clearly and succinctly defined, then the odds of inclusion in future studies would be improved, and we (the research community) would reap the benefits of understanding how mutuality impacts dyadic relationships.

I’m passionate about its inclusion in future research because I think it may be an important concept for dyadic frameworks, and despite having a psychometric scale already developed to measure it, it had never been properly defined. Thus, I performed a wide concept analysis by sifting through interdisciplinary literature, categorizing definitions and attributes, and ultimately arriving at an empirically-supported definition. In doing so, I hoped I could highlight mutuality as a concept for inclusion in caregiver-receiver studies.

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