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Posts from the ‘Featured Articles’ Category

Apr 18

“Informal Caregiver”


Featured currently in ANS is the article titled “‘Informal Caregiver’ in Nursing: An Evolutionary Concept Analysis”, authored by Aimee R. Castro, MSc(A), RN; Antonia Arnaert, PhD, RN; Karyn Moffatt, PhD; John Kildea, PhD; Vasiliki Bitzas, PhD, RN, and Argerie Tsimicalis, PhD, RN. Here, nurse and PhD candidate Castro reflects on how knowledge products – including this concept analysis – keep evolving, just as Rogers argues in her methodology.

Evolving the label of “informal” care towards a strengths-based connotation

Given that April 4th was National Caregiver Day in Canada, and President Biden also declared April as Care Workers Recognition Month, April seems like an appropriate time to further reflect on the spectrum, boundaries, and potential of informal and formal caregiving work.

I think it’s important for academics – professionals whose job it is to become leading experts in specific areas of knowledge – to take theoretical leaps. We should take big swings at ideas that maybe don’t always “reveal themselves in the data” but that, based on our years of rigorous study and lived experience, bubble to the surface of our minds as potential expansions of knowledge. These inspirations most often occur in collaboration with others, and they develop slowly over time.

I was privileged enough to have just such a theoretically enriching collaboration. This conversation expanded my ideas of how the concept of “informal caregiver” might evolve even further than we suggested in our original publication, which was based on data from 48 articles. Specifically, in this post, I argue that the “informal” label can and should be reclaimed as having its own strengths that complement weaknesses arising from “formal” labels and rules.

This reflection came about during a lunch and learn presentation of our concept analysis with the palliative care research network of Quebec (RQSPAL). The moderator, Psychology PhD candidate Émilie Cormier, pointed out that we had defined “informal” by what it was not – i.e., not paid, not trained, and not formally organized. But what if we had defined it by what it is – more individualized, and perhaps, creative, than formalized or standardized roles can be? She also shared how in her work with palliative care populations experiencing homelessness, she’s noticed that sometimes clients’ formal care providers (such as their social workers and nurses) become clients’ informal caregivers during end-of-life. Such formal roles may transition into more informal relationships over the years, because of these populations’ often more limited informal support networks.

We talked about the freedom and opportunities that can arise when we’re allowed to drop the boundaries and responsibilities created by our formal titles, and instead be informal creative collaborators in the life journeys of others. And we reflected on the moral distress that can also arise, when our clinician orders and institutional rules tie our hands, preventing us from truly supporting patients’ individual needs (homeless shelters that restrict certain prescriptions comes to mind; as do hospital units that don’t allow pets to be with patients at end-of-life, and standards that require waking patients up early to take their blood pressure or give insulin, but that ignore the consequences of sleep deprivation). There’s also something here to consider about how patient-centered care necessitates critical thinking and adaptations of formal rules. After all, no set of guidelines can ever fit every patient’s unique needs.

As Rogers’ methodology recognizes, no paper or concept is ever “finished”. So, having authored this initial concept analysis of “informal caregiver”, I’d like us to consider evolving it further: What if “informal” can be seen as a strength, not just less-than-or-equal-to “formal” work, but rather – offering creative opportunities to color outside the lines of formal guidelines? What if we need both, informal (freer and more creative) and formal (standards and structure) dimensions in all of our caring roles?

For further information on Aimee Castro’s research, as well as to connect, please follow her on Twitter (@AimeeRCastro) and visit: https://aimeecastro.com/irespite-services-irepit/ .

Mar 10

1 Comment

Evaluation of Kumpfer’s Resilience Framework


We are currently featuring the article titled “An Analysis and Evaluation of Kumpfer’s Resilience Framework” authored by Zhihong Zhang, MS, RN; Karen F. Stein, PhD, RN; Sally A. Norton, PhD, RN; and Marie A. Flannery, PhD, RN. The article is available to download at no cost while it is featured. Here is a message about this work that first author Zhihong Zhang has provided for ANS readers:

My research program aims to investigate resilience in older adults with cancer. I am seeking a theoretical framework that can guide this examination. One such framework is Kumpfer’s resilience framework (KRF), which has been widely used with adults and youths, including those with cancer. KRF is an integrative framework that organizes evidence of resilience and its predictors into a single model. It was originally developed by Karol L. Kumpfer in 1999, based on research with at-risk youth. However, the strengths and weaknesses of KRF have not been evaluated since its publication. To address this gap, we utilized Walker and Avant’s method to review 41 related publications and assess KRF’s origin, meaning, logical adequacy, usefulness, generalizability, parsimony, and testability, with the goal of informing future research on resilience.

Our findings suggest that KRF is a useful, generalizable, and testable framework that has been applied to diverse populations experiencing various adversities. However, we identified areas for improvement in terms of meaning, logical adequacy, and parsimony. Consequently, we proposed a revised diagram of KRF that enhances clarity regarding inferred relationships, consistency in concept labels, logical structure, and parsimony. This revised diagram highlights the dynamic process of resilience in a feedback loop and the complex interactions among its predictors following stressors (Figure 1).

Figure 1 Revised diagram of Kumpfer’s resilience framework

Explanations for this revised KRF diagram:

  • Stressors activate the adaptation process. Resilience is a dynamic process of positive adaptation that results from interactions between environmental factors, person-environmental transactional process, and internal factors, as well as the influence of past resilience and past adaptation outcomes.
  • Individuals with resilience have positive adaptation outcomes, whereas those without resilience have negative adaptation outcomes. The feedback from adaptation outcomes also influences future resilience, with positive adaptation outcomes strengthening future resilience and negative adaptation outcomes weakening it.
  • The feedbacks from current resilience may affect future interactions between environmental factors, person-environmental transactional process, and internal factors. Individuals with resilience, for example, may reshape their environments, change internal factors, or modify the person-environmental transactional process to better adapt to stressors.

Mar 2

1 Comment

Caring for Gender Minority Persons


ANS is currently featuring the article titled “Gender Minority Persons’ Perceptions of Peer-Led Support Groups: A Roy Adaptation Model Interpretation” Ralph Klotzbaugh, PhD, FNP-BC and Jacqueline Fawcett, PhD, ScD (hon), RN, FAAN, ANEF. The article is available for free download while it is featured, and we welcome your comments here! Drs. Klotzbaugh and Fawcett each share their comments about this work here:

Ralph’s comments

This project required a methodological approach that I was not initially used to working with.  My prior research has utilized quantitative methods, but I knew given the substantial gaps in knowledge related to transgender and gender diverse (TGD) communities, that a quantitative approach to this project would not have been appropriate.  I could have taken what is known from the bit of existing literature specific to TGD communities that is out there (for example community support and its relation to resilience and effects on reducing depression, anxiety, etc.) and utilized standard depression and anxiety scales to measure the effect of support group attendance among TGD participants over a period of time.   However, this approach would have made a lot of assumptions about why people who identify as TGD attend support groups.  Might this assumption (in spite of supportive research findings as well as best intentions) disinterest, or possibly offend potential participants?  This was a moment in learning how to reign in one’s enthusiasms based on one’s academic knowledge and expertise, and to allow and encourage those who identify as TGD and who attend these support groups to discuss why they attend support groups. 

This approach necessitated a qualitative approach, and the data from this project were for me, infinitely more insightful than any existing quantitative instruments  could have revealed.  It was a time-consuming iterative process well worth all our efforts, particularly given the complexities of intersectional considerations within this project. For me, the approach to data through qualitative methodologies made me necessarily question the potential ‘messiness’ that might be true of more traditionally objective quantitative methods.  Checking one’s biases is expected as part of the iterative process in qualitative methods.  This however is not often, if ever, a focus of quantitative methods.  And yet, how are studies using quantitative methods constructed?  What questions are being asked?  What demographics collected and why?  What identities are we leaving in? Leaving out?  What are the potential findings that we may never know of if we are too busy constructing (knowingly or unconsciously and without thought) what we believe will be true, to be true, and/or insist on proving?  I recommend every nurse researcher make a deliberate effort to step outside of their usual methodologies and thus to become uncomfortable in the process. 

Jacqueline’s Comments

It was an honor to join Ralph as we wrote this paper. My contribution was to interpret the themes Ralph discovered in the data within the context of the Roy Adaptation Model (RAM).  As that occurred, Ralph and I discovered that the content of the RAM led us to review the data again and determine whether one or more other themes were missing. This was an excellent example of how use of an explicit nursology conceptual model can truly guide the analysis of qualitative data. We have to wonder what the initial data analysis would have revealed if we had started with the RAM as the guide for the design of the study and the analysis of the data.

Of course, we have to acknowledge that our selection of the RAM for this paper introduces a bias, namely that the study was about adaptation. What would the study design and data analysis looked like if we had selected a different nursology conceptual model, for example, Orem’s Self-Care Model or Levine’s Conservation Model or Johnson’s Behavioral System Model? Had we selected any one of these conceptual models, a bias would still have been evident. Thus, it is imperative for all researchers to recognize that bias always exists in the conduct of research and that bias goes beyond the ANS requirement to declare the cultural, racial, and gender perspectives of the author(s).

Mar 2

1 Comment

Modification of a Grounded Theory of Postpartum Depression


Appearing in the current issue of ANS is the article titled “Teetering on the Edge:
A Third Grounded Theory Modification of Postpartum Depression” authored by Cheryl Tatano Beck, DNSc, CNM, FAAN. Dr. Beck is widely known for her long research career that explores the challenges of postpartum depression using a variey of research methods and exploring conceptualizations and experiences in different cultural contexts. Her article is available to download at no cost while it is featured, and we welcome your comments here! Dr. Beck shared this message about her work for ANS readers:

Over 2 decades ago Glaser (2001) alerted grounded theorists that once their substantive theory was completed, their work should not end there. Glaser stressed that modification never stops for a grounded theory. A Glaserian grounded theory should be continually modified by constant comparison of new literature that has been published or new data the grounded theorist had collected. By continually modifying a grounded theory, the researcher can produce a theory with a higher level of theoretical completeness. Researchers can increase the scope of their grounded theory by choosing which groups to use for comparison.

My original grounded theory study of postpartum depression, Teetering on the Edge, was published in 1993. The photo I included in this blog is one of me interviewing a mother of twins regarding her experien:ces of postpartum depression. The sample for the original study included all Caucasian women. For 30 years I have been modifying my grounded theory to increase its transferability to other ethnic groups of women at risk for developing postpartum depression. Another reason for modifying Teetering on the Edge a third time was for educational purposes. I teach qualitative research methods to PhD students in nursing and other disciplines at the University of Connecticut. When it’s time in the semester to cover classic Glaserian grounded theory methods, I search databases for examples of modified grounded theories to share with my students but do not have much luck. More modified grounded theories need to be conducted and published to help educate our PhD students and qualitative researchers about this valuable option.

Feb 27

2 Comments

Caring in the Context of Risk


The first article in the current issue of ANS is titled “Caring in the Context of Risk: Moving Beyond Duty” authored by Darcy Copeland, PhD, RN. The article is available to download at no cost while it is featured! Dr. Copeland shared this important message about her work investigating workplace violence!

Discussion of ethics or ethical frameworks is extremely rare in workplace violence literature. I have been investigating workplace violence for many years and view the phenomenon, in part, as an occupational hazard. When healthcare systems across the country were faced with a novel occupational hazard (coronavirus infection), there was swift and relatively agreed upon guidance regarding provider obligations and duties in the face of this risk. A duty-bound approach to decision making in the context of infectious disease seemed to work. I wondered if a duty-bound approach to decision making regarding the provision of care in the context of risk posed by patient violence would be similarly helpful.

I determined that a duty-based framework was insufficient to capture the contextual nuances and moral complexity of providing nursing care to hospitalized patients who exhibit violent behavior. I propose that examination of professional duties is one framework that can be used to guide our actions but might be insufficient if used in isolation of other frameworks. In the article I describe additional ethical frameworks and explore how they may also be used to guide decision making in the context of risk associated with violent patient behavior. These frameworks include virtue ethics, ethics of the everyday, and care ethics.

Nursing has a very long history of using virtue ethics to inform appropriate professional behavior. Virtues are characteristics that make one a “good” person/nurse and are not dependent on roles or duties. An internalization of nursing values results in a lack of distinction between being a good person and being a good nurse. Decision making utilizing this framework focuses our attention on what behaviors would maintain individual and disciplinary character in given situations.

Ethics of the everyday implores us to utilize our conceptions of “right” behavior in normal, everyday work to inform our behavior in circumstances that we deem as extraordinary, or at least out of the ordinary. This framework reminds us that we enact values as we live our ordinary lives, that everyday living is morally significant. How we conceptualize nursing and the provision of nursing care under “normal” circumstances can be used to inform decisions about the provision of care when “big” issues arise.

Finally, given the centrality of caring for others in nursing the inclusion of care ethics as a framework was obvious. This framework situates caring as occurring in the context of a relationship between two people – a caregiver and a care recipient. This perspective recognizes care as a complex site of power dynamics; it also draws attention to the humanity, needs, and vulnerability of both people. Attention to these aspects of care draw attention away from rules or duties that may be difficult to implement in complex situations.

Workplace violence is a major issue in nursing. It is also a complex issue that does not lend itself to standardized, algorithmic approaches. The more tools nurses and nurse leaders have in their tool box to determine how to respond to this issue the better.

Dec 13

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The Patient Experience


The current featured article in ANS is titled “The Patient Care Experience as Perceived by Hispanic Patients With Chronic Illness Undergoing Transplant: A Grounded Theory” authored by Silvinia Gamilia González Cuizon, PhD, RN and Eileen K. Fry-Bowers, PhD, JD, RN, CPNP, FAAN. Download this article while it is featured at no cost, and share you comments related to the article here. Dr. Cuizon shared this background about the development of the theory for ANS readers:

In my time as a clinical nurse and through my interactions with patients, I developed an interest in the issues surrounding the patient experience. Cultivating a “good” experience from an unfortunate time was always important to me. Not many people want to be in the hospital, let alone be sick, so making the experience as “good” as possible mattered to me. Along the way, I also found my clinical practice was increasingly influenced by The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This survey was developed to be an objective measurement of patient experience with the aspiration to gauge consumer perspectives about their hospital care.  While I do feel the patient experience matters, I did start to ask myself questions such as: Are we really capturing the patients’ needs? Is this truly a reflection of our care?  

As I transitioned into an administrative role, my perspective on the patient experience broadened to understand its hospital wide impact.  Quarterly, Centers for Medicare & Medicaid Services Hospital Value Based Purchasing (HVBP) Program withholds 2% from this quality indicator domain. If a hospital performs at the national benchmark and or achievement threshold, they gain back the 2% withholdings. If a hospital does not meet the metric, they lose their 2% withholdings1. Additionally, coming from a safety-net hospital, I noted additional challenges in meeting such metrics.  Safety-net hospitals exist to deliver care to individuals who struggle with social determinants of health and live in less-than-ideal locations nationwide. The majority of these patients are uninsured or underinsured, battle more comorbidities, and have poorer health outcomes than their more affluent counterparts because of systemic health inequities plaguing this country2.  I began to ask myself: how do these fiscal implications impact safety-net hospitals? Do they exacerbate health inequities or do they improve them?

My Doctoral program gave me a platform to further discover the complexities of this multi-dimensional phenomena. My examination of existing literature demonstrated substantial evidence to support differences in the patient experience perspective among traditionally underserved populations, including racial and ethnic minorities. Historically, surveys such as HCAHPS were not developed with this particular group in mind.3  This was evidenced by the minority response rate reported in the HCAHPS three state pilot test guiding the development of the HCAHPS survey4.  This was the impetus for my dissertation research. 

 The findings reported in this article focus on the experience of Hispanic transplant patients receiving care at a safety-net healthcare system. The patient interviews allow for an in-depth understanding of their perception of a positive hospital experience.  Four major interdependent and co-occurring concepts were developed:

  • Comfort
  • Communication
  • Connection
  • Care

Ultimately, the study findings confirmed important attributes of a Hispanic patient’s experience, such as communication and care, already measured by the current HCAHPS survey. Additionally, factors such as connectedness and comfort were important and need to be further examined. This study highlights the role culture plays in interpretation of one’s experience as a patient.  Due to the evolving nature of culture and societal norms and the enormous role the patient experience plays in health care, further refinement of this concept can provide already socially marginalized populations, such as the Hispanic population, a voice and the positive health outcomes they deserve. It will also provide clinicians a better understanding of what constitutes an optimal patient experience. With such high stalks it is imperative we get it right.

References:

  1. CMS. (2021). CAHPS® Hospital Survey (HCAHPS) Quality Assurance Guidelines V16. 0.
  2. Kirch, D. G. (2016). In the Search for Measures that Matter, Star Ratings Miss the Mark. Retrieved from https://news.aamc.org/patient-care/article/search-measures-matter-star-ratings-miss-mark/
  3. Stewart, AL., Nápoles‐Springer A, Pérez‐Stable EJ. (1999). Interpersonal processes of care in diverse populations. The Milbank Quarterly, 77(3), 305-339.
  4. Medicare, C. f., Services, M. (2003). HCAHPS three-state pilot study analysis results. Baltimore, MD. Available online at                                                                                      http://www/.cms.hhs.gov/HospitalQualityInits/downloads/Hospital3State_Pilot_Analysis_Final200512. pdf.

Nov 29

Maternal Role Attainment


The current ANS featured article is titled “The Evolution of Maternal Role Attainment: A Theory Analysis” authored by Bridget J. Frese, PhD, RN, CNM, CNL and My Hanh (Theresa) Nguyen, PhD, PMHNP-BC. This article is available to be downloaded at no cost while it is featured, and there are Continuing Education (Professional Development) units available if you complete the CE test! We also welcome your comments about this article here! The authors have provided the following background about their work, and a slide set presenting the main points of the article.

Brenda Frese
My Hanh (Theresa) Nguyen

I am a certified nurse-midwife and my co-author, My Hanh (Theresa) Nguyen, is a psychiatric mental health nurse practitioner.  Although in different nursing disciplines, our passion overlaps in supporting the mental health of new parents with a focus on maternal mental health.  Underlying this passion is the recognition and understanding of the joys and challenges that happen with the transition of becoming a mother.  Our article is a theory analysis of Reva Rubin’s theory of maternal role attainment (1967) which was updated by Ramona Mercer, who changed the name to the theory of becoming a mother (2004).  Using the theory analysis developed by Walker and Avant (2011), Dr. Nguyen and I highlight the strengths of this important theory as well as offer suggestions to update concepts and language that are inclusive of all people and families. In addition, we offer novel visualizations of Rubin’s and Mercer’s theories as they evolved over time.  The theory of maternal role attainment and becoming a mother is relevant to any nurse who works with patients or clients during this exciting time of growth, development, and transition for families.  This not only includes labor and delivery nurses and midwives, but also prenatal, postpartum, neonatal, pediatric, community health, and psychiatric nurses.  As we continue to learn more and grow our nursing profession, it is important to remember those nurses who have come before us, such as Rubin and Mercer, and continue to keep their work alive and relevant.

Caption: Mercer’s “Becoming a Mother”

  1. Pregnancy: commitment, attachment, and preparation
  2. Birth to 2-6 weeks postpartum: acquaintance, learning, and physical restoration
  3. 2 weeks to 4 months postpartum: moving toward a new normal
  4. Around 4 months: Achievement of the maternal identity
    The process of becoming a mother involves an initial four stages that overlap and move in a linear fashion. The four stages lay a foundation for the continual evolution that continues after the achievement of maternal identity. This process happens in the context of family and friends, who are situated in the larger community, which is situated in society.

Nov 15

Conceptual and methodological Issues in Symptom Cluster Research


The current ANS featured article is titled “Advances in Conceptual and Methodological Issues in
Symptom Cluster Research: A 20-Year Perspective” authored by Carolyn S. Harris, BSN, RN; Marylin Dodd, PhD, RN; Kord M. Kober, PhD; Anand A. Dhruva, MD; Marilyn J. Hammer, PhD, RN; Yvette P. Conley, PhD; and Christine A. Miaskowski, PhD, RN. The article is available for free download here while it is featured, and we welcome you to read the article and share your comments here. Carolyn Harris shared this message about her work for ANS readers:

Carolyn Harris

My program of research is centered on the identification of phenotypic characteristics and molecular markers that place patients with cancer at increased risk for a higher symptom burden. This research is informed by several years of experience as an oncology nurse where I witnessed firsthand the complexity of effective symptom management. For example, while patients with cancer often report multiple, co-occurring symptoms, these symptoms are often assessed and treated one-by-one. In addition, the symptom experience of these patients is highly variable: with some patients reporting several severe and distressing symptoms and others reporting a lower number of symptoms with lower severity. As described in this paper, symptom cluster research has the potential to address these important clinical issues and improve the symptom experience of patients with a variety of chronic conditions. This paper provides conceptual clarity for the application of two analytical approaches to symptom cluster research and describes novel methods that have recently emerged to facilitate our understanding of symptom clusters.

Oct 31

Access to Care


The October – December 2022 issue of ANS (45:4) is just published! The first ANS featured article in this issue is titled “Access Denied: Nurses’ Perspectives of Access to Oncology Care Among Indigenous Peoples in Canada” authored by Tara C. Horrill, PhD, RN; Donna E. Martin, PhD, RN; Josée G. Lavoie, PhD; and Annette S. H. Schultz, PhD, RN. You can download and read this article at no cost while it is featured, and we welcome your comments about this work here! Dr. Horrill shared this information about this work for ANS readers:

Tara Horrill

My program of research centers on health and healthcare inequities in the cancer care sector. The research findings reported in “Access Denied…” represents one component of a multiple methods study that investigated issues of access to cancer care among Indigenous Peoples in Canada, and was the final component of my doctoral dissertation. My interest in issues of inequitable access to cancer care and Indigenous Peoples was born out of my experiences as a clinical oncology nurse, and repeatedly seeing Indigenous patients be diagnosed with advanced cancers, often cancers that we have the ability to detect early and treat. As I started to ask questions of clinicians around me as to why we were seeing these patterns, the responses I received often attributed these late diagnoses to “lifestyle” choices or increased cancer risk. Yet there seemed to be more to the picture that I wasn’t hearing, and I wondered about issues of accessibility, which formed the basis of my dissertation research. The findings reported in this article focus specifically on interviews with oncology nurses to understand their perspectives on the barriers to and facilitators of access to oncology care, which has not yet been explored in existing literature. We were particularly interested in nurses’ perspectives as they provide the bulk of clinical care, daily navigate the tensions between individual patient experiences of illness and suffering and the health system in which they work, and also have experiences of caring for Indigenous patients over time and various practice settings. Nurses provided important insights into many of the challenges surrounding access to oncology care and drew attention to the actual and potential work of oncology nurses in addressing these inequities. It seems the role of nurses is not often considered in relation to healthcare access, however these findings open space to not only see the valuable work being done by nurses, but to consider where and how we, as a profession, could better to confront inequities in access to oncology care for Indigenous Peoples by addressing healthcare access at all levels.

Oct 20

Rethinking Cheating on Written Exams


The current ANS featured article is titled “Redefining Cheating on Written Exams: A Shift Toward Authentic Assessment to Promote Universal Design for Learning in the Context of Critical Caring Pedagogy” authored by Laura A. Killam, MScN, RN; Marian Luctkar-Flude, PhD, RN, CCSNE; Sara Brune, MA, RN; and Pilar Camargo-Plazas, PhD, RN. Please visit the ANS website to download this article at no cost while it is featured, and share our comments about this article here! Laura Killam shared this message about their work:

Nurse educators have a responsibility to prepare students for ethical and safe client care, which is why significant efforts are put into preserving the academic integrity in assessments. We believe that authentic open-book take-home exams are a tool that can be structured and delivered in a way that minimizes cheating possibilities. This article explores how to enact Critical Caring Pedagogy by role modeling integrity during value-based dialogue. In addition we discuss why students may cheat and how educators can design their exams in a way that prevents cheating possibilities (see Figure). We hope that this discussion stimulates discussion and debate around how to create (nearly) cheat-proof authentic exams.

A Student-Centered Approach to Authentic Written Exams

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