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Posts from the ‘Featured Articles’ Category

Jan 13

Photostories: An innovative approach to helping people cope


In our current featured ANS article, author Jan Sitvast , RN, MA, PhD presents the results of a study exploring the effectiveness of the photo story method on self-motivation in self-management.  The article is titled “Self-management and Representation of Reality in Photo Stories.”  Dr. Sitvast has generously shared additional information about the photo-instrument, which follows his video presentation below.  Visit the ANS web site to download your copy of this interesting article at no cost while it is featured!

The Photo-instrument

Psychiatric patients often are inhibited to express their feelings and thoughts. They sometimes experience their surroundings as threatening. They can feel alienated from their surroundings because of derealisation and depersonalisation. Negative experiences and anxiety about the future can destabilise their confidence and self-appraisal.

When patients are institutionalised for a long time this also will have effects on the way they look upon their selfs. Moreover patients and clients run the risc of their individuality only being acknowledged as being ill and needing help. The communication between the patient and his environment tend to be continously coloured by symptoms and problems. Looking for a nursing intervention to offset the disadvantages of these communicationpatterns centring upon a discours of disease and disorder we found in the medium of photography a suitable aid to apply in health settings.

The Photo-instrument is a manual or protocol for implementing a set of interventions with the medium of photography. It describes the stages that are needed to have patients or clients make photos of their lifeworld. There are 12 groupmeetings. At the start the participating patients get a disposable camera and an assignment that tells them what to photograph.

After the participants have taken their pictures they are invited to express their feelings and thoughts relating to the pictures. This is done in a very structured way and is extended over a number of sessions. In the end the participants select a small number of photos for an exposition. Photo and text are then combined.

In this way photography is a means to orient and direct our care more to patients demands and attune/tune in to their experiencing their lifeworld. At the same time it fulfills the need for developing activities in the field of leisure and provides opportunities for taking up new roles.

The Photo-instrument responds to the call for more ethics in care. There is a need for ‘narrative practices’. Renowned nurses and nursing scientists stress the importance of the patient narrative and the significance of the lifeworld paradigm.

More concrete, what are the contributions of the Photo-instrument to dimensions of nursing and caring ? We distinguish the following aspects or dimensions:

Observation – Using the photo-instrument nurses can collect information on the psycho-social consequences of illnesses and disorders for living one’s daily life. It’s an intermediary observation technique and shows how patients cope with their illness outside the hospital setting.

Support -This information is the result of a dialogue of participants with the interviewing nurse. Important to notice is that the participants are owners of their photos and decide for themselves which photos are selected for further discussion. Their expressed opinions and feelings may well be elicited by the nurse but are not subject to any modification for explicit therapeutic purposes. The expressed opinions and feelings are validated in their own right, that is their sayings are accepted and acknowledged as valuable per se. And that strengthens the participants confidence.

Empowerment  – There is an element of empowerment when for once nurses don’t respond in a councilling way from a position of knowing better and having greater expertise. Now it’s up to our patients to inform us about their lifeworld. In taking upon them to photograph their world and showing us the results in an exhibition they become providers and producers of information, amusement and tangible results. The photo-instrument realizes an active involvement in the project. There are many new roles the participants can involve themselves in: writing texts for brochures and announcements, deliver a speech at the opening of the exposition, taking care of the catering of visitors, etc.

Nursing – Nursing is about activating and stimulating health and healthy behaviour. It also aims at minimalizing or reducing and taking away the negative consequences of illnesses and disorders. This supposes that nurses help patients to deal with the meaning of being ill, recovering or remaining handicapped. Taking pictures can assist the nurse in this task. Photos have one unique quality, that is they freeze time and place in an image. To get a hold on their existence and be able to cope patients need to halt their lives for one moment, to suspend the daily routine in order to have an opportunity to reflect. Offering this opportunity the photo-instrument helps integrating crises, illnesses and other life-events in the wider context of the patients’lifeworld. Moreover, making Photos implies certain awareness of the surroundings and settings you live in. The choices you have to make when selecting the places and people you want to make pictures of , highten your self-awareness. The interview questions in the sessions of the photo-instrument help people to verbalize their choices and reflect on them where they have to decide what to communicatie to spectators who come to the exhibition.

Social Skills – There is still another contribution to nursing and that’s its capacity to train social skills. Making pictures stimulates communication among people. Someone making a picture always attracts attention and is an invitation for conversation. Sharing photos you can show connects people. Organising an photo-exhibition offers opportunities to practice social skills and does an appeal to latent talents while limitations and handicaps can be reckoned with and compensated.

Conclusion – The photo-instrument has been developed in a multi-centred trial with different patient groups, in different settings, elderly patients as well as young people, institutionalised patients as well as ambulatory treated patients. There is a printed version now, available with Publishers Kavanah (in Dutch) or with the author (English version).

How to do it: A short introduction of the manual of the Photo-instrument.

The instrument contains a series of instructions how to go about in a project of between 6/7 meetings up to 12 meetings (depending on the capacities and limitations of the clients).

First meeting: explanation of the project: the participants recieve a snap-shot camera and an assignment to make pictures. During the meeting there is an opportunity to practise the use of the camera.

Second meeting: Either the participants have taken pictures in between the first and the second meeting or this meeting is devoted to making pictures. Experiences with taking pictures are exchanged. The snap-shot cameras are handed in and will be taken to the photography-shop for developing and printing.

Third meeting: The photos are returned to the participants and the group shares the collective admiring of the pictures. The instruction that follows are: go through your photos and group them together. Then everyone gets a large-sized sheet of photo-carton and is asked to glue the photos on to the sheet in the groups that have been selected. The next step is the request to think of a caption for every group of photos on the sheet and to write this down on a memo (the small sized blocks of sheets one uses in an office to stick it on your computer to remind you of tasks still to perform). The participants stick their memo’s to their groups of photo’s. A caption can be an emotion aroused by the picture or a topographical reference or whatever they can make up to be the theme or the subject of the photos

Fourth meeting: We use the same office-memos to have the participants choose two pictures per group, namely: the most beautiful picture and the picture that represents best the chosen caption. When this has been done we start rounds of interviewing the participants on their choices. Everone gets a turn. Questions to be asked are: -why is this your finest photo ? -what can be seen on the picture ? -What does the picture mean to you ? -which other picture belongs with this picture ? -in what aspects do pictures agree or differ ? -what picture shows best what you intended to tell us ? -are there pictures you wanted to make but couldn’t and for what reasons ? There is the possibility to have individual interviews but you can organise this as question rounds during the meeting itself. The relevant things the participants tell about the photos are noted down by the therapist/nurse.

Fifth meeting: The therapist/nurse has processed the notes on the computer during the interval between the fourth and the fifth meeting. Now the notes are printed and given to the participants. Every psrticipant gets a sheet with his own lines going with the photographs. They are asked to cut the sheets in lines. They can now glue the bits of paper with the lines underneath the pictures (on the carton )where the lines refer to. It’s completely up to the participants to decide whether they skip lines or add new lines or make corrections in the prints. The participants exchange their feelings, thoughts, etc. in an evaluation round.

Sixth meeting: the assignment is now to select three pictures for an exhibition. You can discuss with them what aspects they should/may take into account, for instance are they aware of any consequences of sharing certain private feelings with a greater public ? The selected pictures will be enlarged and framed for the exhibition.

Seventh meeting: The enlargements are handed out and they frame them themselves. They pick out the lines that will go with the pictures. This meeting can be used to share the preparations for the exhibition: writing invitations, is someone willing to hold a speech, producing brochures and posters, catering. Iall these tasks can be collectively done and are part of the project.

Eigth meeting: Th exhibition itself. An extra dimension can be given by having a jury giving prizes for the finest pictures or the picture that shows best the intention of the maker. Extra is also the possibility of producing a book with the photos. The exhibition can be formally opened. May-be the participants guid the visitors along their pictures. Who does the catering ?

Ninth meeting: Evaluation with all participants.

 

Dec 29

Centering Pregnancy: an group visit model for prenatal care


The current ANS “Editor’s Pick” article addresses the challenges of implementing an innovative, new model of care.  The article, titled “Using Focus Groups and Social Marketing to Strengthen Promotion of Group Prenatal Care” is authored by a team of nurse midwives: Susan C. Vonderheid, PhD, RN; Carrie S. Klima, PhD, CNM; Kathleen F. Norr, PhD; Mary Alice Grady, MS, CNM; and Claire M. Westdahl, MPH, CNM, FACNM. Members of this team have been using this model of care for over a decade, and have produced evidence of its benefits and effectiveness.  But the concept of group care remains a challenge for many clinical settings – a challenge this team of authors addressed using social marketing. Visit the ANS web site now to download your copy of this informative article at no cost while it is featured!  Dr. Vonderheid shared this message, and a video (below) providing some background on their work to promote adoption of the model in various settings throughout Illinois:

Innovations in prenatal care are greatly needed to reduce racial disparities in maternal and infant outcomes in the US. The Yale-Emory randomized clinical trial (RCT) that tested the effectiveness of CenteringPregnancy, a multifaceted group visit model of prenatal care, showed amazing reductions in preterm birth and improvements in other maternal and infant outcomes (Ickovics et al., 2007). These study findings influenced many organizations to commit resources to implement this innovative prenatal care model. Funded by the Maternal Child Health Bureau, our investigator team at the University of Illinois was initially focused on evaluating whether the effectiveness of the RCT could be replicated in non-experimental conditions in clinics throughout Illinois and identifying the potential mechanisms by which CenteringPregnancy was effective. But, as we worked with our clinic partners to prepare for the evaluation, we found that clinics faced challenges related to organizational change and some even struggled to implement CenteringPregnancy. Major challenges included

Dr. Susan C. Vonderheid

Dr. Susan C. Vonderheid

enrolling women into groups and obtaining organizational “buy-in” to create large enough groups for effective and sustainable programs. These challenges had to be addressed before conducting the evaluation. To address these challenges, we offered workshops to help clinic staff build social marketing skills to improve communication with the numerous  “customers” of CenteringPregnancy. Social marketing is the “application of commercial marketing technologies to the analysis, planning, execution and evaluation of programs designed to influence voluntary behavior of target audiences in order to improve their personal welfare and that of their society (Andreasen, 1995). Our article describes how we adapted the 3-step social marketing communication strategy previously used by Claire Westdahl (co-author) to promote breastfeeding and more recently to help other clinics implement CenteringPregnancy.

In our video (below), we role-play a clinic staff member using the 3-step social marketing strategy to “sell” group care to a key customer – a pregnant woman. Listen as the seller crafts a message that reduces the buyer’s concern (reason for not participating) and offers information about the benefits of group related to this concern to increase the chance of “buying” group care. Social marketing can be used to guide customers to understand the benefits of CenteringPregnancy (and other evidence-based innovations), and make decisions about participating that are beneficial to them. We hope this provides nurses and other health care professionals with one more tool in their toolkit when leading the charge for organizational change!

Dec 16

3 Comments

Challenges of Ethical Conflict and Moral Distress


The current ANS “Editor’s Pick” article presents a feasibility study to assess the usefulness of an innovative ethics screening tool for nurses who are dealing with critical ethical situations.  The article, titled “Barriers to Innovation: Nurses’ Risk Appraisal in Using a New Ethics Screening and Early Intervention Tool” is by Carol L. Pavlish, PhD, RN, FAAN; Joan Henriksen Hellyer, PhD, RN; Katherine Brown-Saltzman, MA, RN; Anne G. Miers, MSN, RN, ACNS, CNRN; and Karina Squire, MPH, BS, RN.  This team of authors has provided this message for ANS readers:

Have you ever stood at a patient’s side and wavered precariously between believing in the treatments you provide and

Carol L. Pavlish

Carol L. Pavlish

dreading the painful consequences? Have you ever hoped with all your heart that these treatments will work while the experienced voice inside worries they most likely will not? Have you ever turned away from yourself…your true self… just so you can come back to work the next day?

One of the most commonly-occurring ethical dilemmas that nurses encounter is silently weighing their moral obligations to patients while facing uncertainty, being surrounded by unwavering hope, and finding themselves squarely in the middle of a healthcare culture that dis-incentivizes difficult conversations. Silence is the powerful perpetrator of that culture – and we as nurses are too often its accomplice.

Joan Henriksen Hellyer

Joan Henriksen Hellyer

When researching the feasibility of applying an evidence-based ethics screening tool that encourages nurses to express concerns, we were surprised at the tenacity of their silence. We found that some nurses “let it slide” because systems see no profit in ethical deliberation and place certain demands on exactly how nurses should use their time. Hierarchical power structures can drive nurses to avoid “being the troublemaker”. Furthermore, some nurses “questioned themselves” instead of turning the question outward – outward to structures that concentrate power in the hands of a few making it all the more difficult to “query the gatekeepers.”

Speaking up is not a risk-free action in health care. As a result, concerns become “unspeakable.” Jane Georges warns us that compassion becomes more difficult and even impossible when concerns are “unspeakable.”

Katherine Brown-Saltzman

Katherine Brown-Saltzman

Without compassion, nursing care becomes mechanical at best – dangerous and alienating in its worst form. Our research seems to indicate that nurses who bring innovations to health care cannot just focus on preparing nurses for new roles. We must also challenge and change systems that find comfort in the status quo. As Peggy Chinn says in her editorial, “The time has come for nurses to come together as never before to revive some of the innovative models that existed in the past and to creatively forge ahead into uncharted territory.” We have a rich tradition of moral courage in nursing – from Florence Nightingale to Lillian Wald and many others – all of whom challenged the “unspeakable” and created conditions where health and human flourishing can actually happen.

Anne's-Picture400

Anne Meirs

Part of moral courage is reclaiming that heritage and finding our own voice to ask four key questions: a) What is wrong with this picture? b) Who benefits? c) What are the barriers to freedom from what is

Karina Squire

Karina Squire

wrong? and finally, d) What needs to change? Chinn and Kramer posed this four-question framework in Integrated Theory and Knowledge Development in Nursing (2011). The framework moves us beyond the “unspeakable” and strengthens our voices to participate actively in creating innovative systems of care – where clinicians appreciate value-laden contexts, challenge each other to dialogue about ethical concerns, and ultimately provide focused goals that honor what healthcare providers in good conscience can provide for patients.

While it is featured, this article is available to download at no cost. Then come back here and post your comments and questions  here … the authors and I want to hear from you, and we will respond!

Dec 10

9 Comments

What’s the Point of the Evidence Debate?


We have just published ahead of print an article that will be published in the first issue of 2014!  The article is titled “Particularizing the General: Sustaining Theoretical Integrity in the Context of an Evidence-Based Practice Agenda” by Sally Thorne, PhD, RN, FAAN, FCAHS and Richard Sawatzky, PhD, RN.  Dr. Thorne and Dr. Sawatzky have extended their discussion of the “evidence” debate with this message for ANS blog readers:

Although we realize that “the evidence debate” may seem like a tired topic for some readers, we think it remains one of the most important avenues through which nurses can find their grounding in why the philosophy of science really matters to our discipline. Health and public policy get made on the basis of a complex and highly

Dr. Sally Thorne

Sally Thorne, PhD, RN, FAAN, FCAHS

politicized combination of ideology and science. We tend to think about ideology as if it exists in the world of “the other” and not in our own disciplinary knowledge. And yet, we must recognize that nursing has always been driven by so much more than just empirical science or philosophy, even if we sometimes struggle with how to name, conceptualize and justify those other forms of knowledge that influence our practice.

For us, the history of theoretical and philosophical knowledge-building in nursing is quite fascinating. Although it has taken a lot of twists and turns along the way (some of them sufficiently awkward as to be downright embarrassing), once you clear away the “noise” and reflect on what many of the founding nurse theorists and scholars were struggling with, you realize that they were grappling with incredible complexities. The language they used was sometimes a bit convoluted or misleading, and the competitiveness among the individual theorists and their disciples was at times unseemly. Nevertheless they were trying to work out ways of conceptualizing the rather marvelous constellation of intellectual and behavioral competencies that characterize the practice of nursing when it is done at its best, in order that we could improve our capacity to help nurses achieve that.

Of course if nursing were derived from a simple skillset, then that theorizing and philosophizing would have been

Dr. Sawatzky

Richard Sawatzky, PhD, RN

easy.  But it is not. And that’s what makes the story so fascinating. Patients are complex and adaptive, and so are we. The social and ideational worlds within which people experience health and illness are dynamic, multilayered, and fraught with uncertainties and complexities.  The thinking nurse – that nurse we refer to as “expert” within his or her population group or setting – is always skillfully navigating that great chasm between science (which represents the general past) and context (which represents the particular moment), not to mention looking forward to considerations of possible implications for the future.

In re-entering the “evidence debate” in this manner, we wanted to juxtapose ideas about how we make sense of knowledge that comes from certain kinds of formally derived scientific processes with those that have to do with nursing’s inherent interest in the individual case. We believe that the trend towards standardized practice in health care during recent decades (e.g., reliance on general clinical practice guidelines) is increasingly at odds with notions of heterogeneity and individual differences (or “anti-standardization”), such as those prompted by field of personalized medicine. Just as many forms of medical management are moving away from population-based science (i.e., reliance on population averages) toward novel targeted and individualized therapies arising from genomics, proteomics and pharmacogenomics, we believe that nurses will need systems and structures through which to focus and strengthen individualized care and patient-centered approaches. These are not simply vague abstractions, but complex and challenging dimensions of the intellectual approach that nurses must always bring to their practice.

So for us, it seems useful to really push nurses toward clarity in what does and does not constitute evidence in the conventional sense. Slippage with how we frame the basis of what we think we know will only serve to discredit our profession as a credible contributor to the larger world that is wrestling with these evolving ideas. We are concerned that the tendency to reconceptualize certain forms of knowledge as “evidence,” in an attempt to obtain credibility, will not serve the nursing well. Nursing practice and theories are unavoidably influenced by many valuable forms of nursing knowledge that do not necessarily conform to conventional notions of “evidence.” Rather than “branding” all nursing knowledge as “evidence,” nurses are challenged to articulate what these “non-evidential” forms of knowledge are and what the basis is of their justification. We want to remobilize an enthusiasm for why nurses ought to care about the nursing theory world by bringing into focus the relevance that disciplinary thought has in the larger world of contested practices and influence upon futures.

We keep returning to this idea that the dialectic between the general and the particular is really the essential element in the uniqueness of nursing knowledge, our defining characteristic, the idea best captures what we are.  As we continue to develop our collective expertise and wisdom with regard to evidence generation and interpretation – figuring out how we learn about the patients of the future through systematic and rigorous exploration of the past – it will be imperative that we not forget the “artform” of individualized holistic care, enacting relational practice, and taking an intersectional lens on the social determinants that may be shaping the health and illness experience of the patient who is before us in the moment.

Thanks for taking this journey with us, and we look forward to a lively debate!

You can download this article at no charge now on the ANS web site!  Get it, read it, and come back here to engage in this very important, and interesting debate!

Dec 5

More on eSchoolCare


Our recent post from Dr. Lori Anderson’s featured article titled “The Development and Implementation of eSchoolCare: A Novel Health Care Support System for School Nurses” has drawn the attention of school nurses worldwide, affirming the great need for a support program like the one described in this article.  So I asked Dr. Anderson to provide a response to some of these comments here:

Thank you for the comments regarding the eSchoolCare blog posting. We take very seriously the feedback that we receive from school nurses. We built the eSchoolCare program from the ground up with strong nursing input, so it is gratifying to hear it resonates with nurses. On the other hand, your comments speak to the continued unmet needs of school nurses not only across our country, but worldwide.

One of the most popular features of eSchoolCare is the Community Forum. Nurses tell us that this is often the first place they check when visiting the site. A sample of  the topics from some recent postings: Management of diarrhea in the school, photo-screening, Definition of “medically fragile,” Vision screening for farsightedness, MA Billing, Policy for Service dogs/pets, Communicable disease-prevention, and Chronically absent students. This is a real potpourri of topics but captures the diversity of school nurse practice.  I think the Community Forum is helping to address the isolation that we have seen with school nurses and that the blog replies verify.

These are tight budgetary times and we realize that nurses may not have the funds to subscribe. We have had some very good success with local foundations and businesses sponsoring a subscription for their school nurse/s. If you would like more information on eSchoolCare, on the cost of a subscription, or ideas and sample letters for sponsorship, please emailsupport@eschoolcare.org or visit eschoolcare.org.

Thank you to everyone for commenting!  It is great to hear from you, and hope you will continue to share your ideas along the way!  If you have not already seen Dr. Anderson’s article, it is still available as a free download on the ANS web site!

Nov 30

9 Comments

Innovative support for primary care school nurses


School nurse Lori S. Anderson, PhD is the author of our current “Editor’s Pick” article titled “The Development and Implementation of eSchoolCare: A Novel Health Care Support System for School Nurses.”  In this article Dr. Anderson describes the eSchoolCare program that provides support for 97 school nurses in 67 rural school districts in South-Central Wisconsin.  The article provides background, theoretical framework, implementation and evaluation of this innovative project. Dr. Anderson shared for ANS readers her own background in school nursing, and why this project is so important for nurses who are primary care providers in schools, and for the children and families they serve:

My introduction to school nursing came early. My mother was a long-time school nurse and during my high school years I helped her out during vision and hearing screenings. I loved the independence of her work and the focus on improving the health and well being of school-age children. So following suit, my first job fresh out of nursing school was in a rural school system in southern Wisconsin.  I was responsible for 4,500 students in

Dr. Lori Anderson

Dr. Lori Anderson

six separate school buildings. I quickly learned two things, that the downside of the independent practice was a sense of isolation and that while I had hoped to make an impact on the health and wellness of students through teaching and other prevention activities, my time was largely spent caring for children with chronic health issues, some serious. The seeds for the eSchoolCare project were sown during this time. While I could pick up a phone and call my school-nurse-mother for support and expert guidance, many school nurses were and still are left looking for evidence-based resources to guide their practice and for support to decrease the sense of isolation.

Julia Lear, director of the Center for Health and Health Care in Schools at George Washington University, has used the phrase “hidden health care system” to describe the large number of professionals who provide care to children and youth in schools across the United States. Most of these professionals are nurses and the health care needs they attend to are becoming increasingly numerous and complex. The Affordable Care Act encourages community-based services, yet policy makers and those in the traditional health care arena have little knowledge about this “hidden” system of care.

Nurses are also providing care in homes, workplaces, and long-term care facilities, among others. These community settings provide challenges to nurses similar to those encountered in schools, problematic communication with traditional health services, isolation, and difficulty accessing evidence-based resources to guide care. The solution to these complex challenges will be multi-dimensional. But technology now allows us to bring resources and support to nurses in these settings in a way that we had not done before. Our eSchoolCare project uses mobile technology to bring the expertise and resources of an academic healthcare setting to the nurse in the community, decreasing their sense of isolation and providing them with evidence-based approaches to care delivery. Think of it as the online version of having a “mom” nurse expert on the other end of the phone line.

We are eager to hear your comments and ideas about this important project!  Visit the ANS web site now to download your copy of this article at no charge, and share your comments here!

Nov 18

Human Flourishing: A Nursing Ethic


Our current featured article in ANS is titled “An Innovative Professional Practice Model: Adaptation of Carper’s Patterns of Knowing, Patterns of Research, and Aristotle’s Intellectual Virtues.”  The author, nurse ethicist Barbara Bennett Jacobs, MPH, PhD, RN, translates an adaptation of Carper’s patterns of knowing into a nursing metalanguage of science, ethics, art, and advocacy.  Dr. Jacobs shared this commentary on her work that gave rise to this article:

Barbara-Jacobs300

Dr. Barbara Jacobs

The phrase “change is constant” is being used now by hospital administrators to partially explain the restructuring of departments and services that is often accompanied by acquisitions of smaller and/or regional hospitals into large corporations.  These changes in health care delivery systems are not limited to hospitals, as these corporations include, for example, agencies and services that provide home-care, out-patient services, emergency medical services and other community health care enterprises.  As the template changes, so does the status quo.  This ought to empower nurses to evaluate the status quo and suggest changes within the nursing profession for a number of reasons.  The one most obvious reason is, as Dr. Kagan opines in her guest editorial, – “to make things better.”  Better patient outcomes, better patient health, better prevention strategies, better human flourishing.

Without an underpinning in nursing knowledge, nurses will be ill-equipped to ask critical questions, to analyze the status quo, or through a process of praxis change those practices and structures that are unjust or inequitable in their practice environments.  The ethos of nursing is a strong one and ought to be visible, evident, and valued and unique from the institution’s ethos.  In order to accomplish this in the rapidly changing health care environments, imagination and innovation have the potential to make a difference.  Unfortunately, “change is not constant” in nursing education and practice to the degree it is in other realms of health care.   Take for example electronic charting – a wave of tsunami proportions.  As nurses now are more tethered to the i patient (a phrase coined by Dr. Abraham Verghese to describe the patient as data points) they are less available to move in the patient’s landscape with hopes of performing acts of aesthetic quality or to engage in such a way that is personal, intersubjective and meaningful to the patient.  Yet the technology prevails with support from some nurses, but others lament their loss of time to “be with” patients.  The question to ask is whether some innovation like electronic charting is in harmony with the voice of nursing, the ethos of nursing, and the philosophy of nursing or is it another institutional innovation that requires acquiescence and submission by the nursing population with minor input.

Thirty years ago Carper gave us an understanding of what nurses need to know to do what they need to do that is recognizable, valued, and defined as knowing that can be expressed as knowledge.  The professional practice model concept is fertile territory for planting these patterns of knowing along with other important concepts such as values, virtues, and research in such a way that the model enhances its applicability, adaptability, and usefulness to achieve the telos of nursing.  Professional practice models benefit the institution for sure but the real benefit, the real truth, the real reason to have them is to join in solidarity with those persons, families, and communities who call on nurses to answer the moral call to enhance their threatened human flourishing.

The model presented in this paper has been revised, revised, and revised again so as to reflect the thousands of patient narratives I have been blessed to experience.  The two patients in the paper are real, both having a profound impact on my current role as a nurse ethicist.  Both patients were not only medically complex requiring empiric knowing, both where vulnerable to threats to their self-determination requiring ethical knowing, both ached for meaningful personal encounters with their nurses requiring aesthetic knowing, and both changed (as did the nurses who cared for them) requiring personal knowing as a result of the covenantal relationship.  This model may not appeal to every nurse but the hope is that it will generate dialogue, reflection, and controversy.

Please consider entering in to dialogue here!  Download your copy of this article now while it is featured, and come back here to share your thoughts, challenges and questions!

Nov 6

Overcoming “status quo bias” – a call for innovative action


The first featured article from the latest ANS issue focusing on “Innovations in Health Care Delivery” is the guest Editorial by Paula N. Kagan, PhD, RN.  Dr. Kagan’s scholarship is grounded in critical/emancipatory feminist perspectives, and she is the primary Editor of the forthcoming (2014) text  Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis. Routledge Publishers. Dr. Kagan shared this message about her work, concluding with a call for action:

I have been interested in the idea of innovation for many years. I am attracted to radical change in areas such as the arts as well as nursing practice, in pedagogy, in ethics and policy approaches, and at various other points of social thought and practices. However, there is a horizon of embracing radicalism, a threshold at which there can be comfort in ambiguity and in difference and in creating drastic change. Think resistance. We do not have to stay attracted and attached to the status quo to the exclusion of real change. But how often that occurs.

Paula N Kagan, PhD,RN

Paula N Kagan, PhD,RN

During this election week, the astute Chris Hayes on MSNBC spoke about status quo bias, the human behavior characteristic that moves people to, at times irrationally, chose the status quo over options of change, some of which may be better choices than what constitutes the present circumstance. He was referring to status quo bias in decision-making, an effect demonstrated by Samuelson and Zeckhauser (1988) and applied to many fields of study.

I am perplexed at organizations that chronically spend time on improvement measures but in the end stay within the boundaries of tradition. I am perplexed at our unrelenting focus on acute care and hospital nursing. And, I am perplexed at nurse educators who prepare students to uncritically meet the status quo. We are not serving our students or the public.

Perhaps nurses can begin meetings, at any level of organization, with a consideration of the phenomena of status quo bias, resistance, and the practice of radicalism and make sure these concepts are included as ‘essential’ in the content of study for students (as well as in the practice of faculty and professional leaders) in nursing. Would that make a difference in our criticality, in our ideas of what constitutes innovation and progression?

You can read the full text of Dr. Kagan’s Editorial and download your copy on the ANS web site.  We would be delighted to engage with you here on this blog!  Leave your comments, ideas and questions here, and we will respond.

Oct 25

Overcoming that which divides


The current “Editor’s Pick” article presents what the authors, Geraldine Gorman, PhD, RN and Corinne Westing, MS, RN,  call a “union narrative as a nursing parable.”  Their article is titled “Nursing, Unionization, and Caste: The Lessons of Local 6456” which provides an account of one local unionization effort, as well as an analysis of the far-reaching implications for reaching across that which divides us to create peace in our own communities.  Corinne shared this story of the work she and Gerry have pursued together over the past 5 years:

This article started in some ways in the winter of 2009. President Obama’s first term in the White House. This was during my first semester of nursing school, in Obama’s home town. I was lucky to have as one of my first classes a course intended to help new nursing students navigate the cultural and social transition into the nursing world. Gerry and I found we were completely simpatico. When I entered the Master of Science program in my pursuit of a career in nurse-midwifery, Gerry asked me to share my knowledge and experience or labor organizing as it impacted nursing, by giving a lecture for her class to supplement the presentation

Corinne Westing

Corinne Westing

traditionally given by the Illinois Nurses Association. I had been around the National Nurses United, which represents the nurses at Cook County, University of Chicago, and a few other hospitals in the Chicago area. I had read a few things about nursing strikes over the years and was generally very sympathetic toward organized labor and nurses’ grievances.

During that time, faculty at the University of Illinois began organizing of their own accord. In the wake of the economic crisis that was deeply impacting public education, faculty had every reason to begin to explore organizing. Amidst the hostility surrounding this union drive at the College of Nursing (CON), Gerry and I—and of course other union sympathizers—began a conversation about what was going on. We struggled with the divide between unionization in some of the clinical sites the CON sends its students to and the negative reception nursing colleagues gave the union organizers at the CON. How could unionizing be accepted for rank and file nurses but not for academic nurse workers, especially those in an increasingly stratified workplace like the public university?

Over the semesters, my research into the history of nurse unionism proved challenging. I could not find one single source that could knit together this story—especially not in nursing literature. There would be hints of the back story in labor texts and historical archives. The narrative was unfolding, and it was my pleasure to try

Gerry Gorman

Gerry Gorman

to construct a coherent version that could also shed light on current conditions in academic labor, including in the nursing world.

As frustrating this journey to unearth radical nursing past proved, it also was profoundly rewarding to discover how well nurses belie the myth of the “handmaiden” or subservient comforter. Though women may be socialized to nurture, when put in collective working conditions like the hospital unit, women care workers, like all workers, will eventually struggle. And it turns out that even a tenure-driven, female-dominated academic workplace can contain the seeds of struggle.

We worked on this article through the ups and downs of the card drive at the University, and in the context of a successful strike by Chicago public school teachers. We chewed on the meaning of the mass protests against austerity and union rights just north in Madison while we watched as little organized resistance developed to take on rising tuition costs at our University. We solidarized with the movement of the 99% in Chicago and hoped that Occupy would inspire increased support for campus labor, including professors. We submitted this article in the shadow of President Obama’s second inauguration, as hope of change from above seemed to dissipate, and we struggled with where to go from here. Within UIC United Faculty, negotiations continue; still no contract, still a pressing need to build links between students, faculty, and other campus labor groups to help win this much-needed agreement.

It was an honor to work with Gerry through the process of shaping this piece to contribute to the discussion about how working conditions shape clinical and teaching practice. We are extremely grateful for the opportunity to share this work with you, through Advances in Nursing Science. We hope that this article has inspired critical thought about the roles we play in our workplaces and how, collectively, we can make nursing stronger, on the nursing unit and in the classroom.

Visit the ANS web site today to download your copy of this article while it is featured at no charge and read their account  – one which deeply honors the intent and hope to seek peace in our communities.

Oct 22

Strength Amid Struggle


The current “editor’s pick” article is a notable example of a nursing perspective that is based on people’s strengths as they face health challenges, not solely on the challenges themselves.  The article, titled “Intimate Partner Violence in Mexican-American Women With Disabilities: A Secondary Data Analysis of Cross-Language Research” is authored by Chris Divin, MSN, RN, FNP; Deborah L. Volker, PhD, RN, AOCN, FAAN; and Tracie Harrison, PhD, RN.  Ms. Divin shared this background on the work that she completed for this article with her advisors, Drs. Volker and Harrison:

I have had the privilege of being a nurse for over thirty years. Almost half of those years were spent working in Latin America. It was in Venezuela when I worked with a group of health promoters that I first learned of the complexities of intimate partner violence (IPV). Our health group started a support group for women who were living in situations of IPV. We strengthened one another as we sat on hand made cushions in a safe and hidden open air patio behind the clinic. For the “Dia Internacional de la Mujer, International Day of Women,” men, women, and children joined together to paint murals throughout the barrio addressing the reality of IPV.

Until I worked in geriatrics as a nurse practitioner, I, like many people, held the mistaken assumption that IPV is only a phenomenon affecting younger women. I was both surprised and saddened that some of the women I

Chris Divin, MSN, RN, FNP

Chris Divin, MSN, RN, FNP

cared for in their 80s continued to struggle with IPV in their relationships. I presently work as an FNP providing primary care at a domestic violence shelter one day a week where I see the acute effects of abuse. I am passionate about the work I do, not only to raise awareness about IPV but to hope, dream, and continuously wonder what more can be done about this serious but preventable public health issue.

I was reminded at the Nurses Network for Violence against Women Conference in Vancouver earlier this year that nurses are called to be natural advocates for women affected by the multi-faceted health issues of IPV, and belonging to a predominantly female profession, there is tremendous power in numbers. I am delighted to be among nurse researchers who are actively engaged in pursuing a deeper understanding of this phenomenon, especially in the area of long term effects of abuse in an aging population. Not only is it important to recognize the scars of abuse but the amazing strength, perseverance, and peace that women manifest in the midst of their adversities.

Lastly, I, a novice researcher, had the opportunity to work on this study for over a year guided by two most amazing qualitative researchers. I have expressed gratitude to Dr. Harrison repeatedly for the “goldmine” that was handed to me when I was given the opportunity to analyze some of the data that had been collected for an entirely different study; an ethnographic investigation of health disparities and disablement among Mexican-American and non-Hispanic white women aged 55-75 years. I gained deep appreciation for the complex and intricate details that go into a secondary data analysis. I also could not help but wonder how many different research questions could be answered with data obtained for an entirely different objective and study. What richness in the human story and how serendipitous that ANS was soliciting articles for their “Peace and Health” issue as we were actively analyzing these stories for glimpses of peace and health amidst multiple adversities including IPV. We are very grateful for the timing and opportunity to publish in ANS and we appreciate any questions or comments in regards to our article.

Visit the ANS web site to day to download your copy of this article at no charge!  And do make comments here … the authors of ANS articles are eager to hear from you!

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