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Posts from the ‘Practice’ Category

For a Radical Renewal of Democracy in Hospitals

Contributor: Patrick Martin

Editors’ note: Thank you to author Patrick Martin for contributing this further reflection on his article co-authored with Louise Bouchard, that appeared in ANS 43:4, October/December 2020, p. 306-321 (doi: 10.1097/ANS.00000000000003220)

The staff nurses, who gave us an interview in the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study,” recently published in Advances in Nursing Science, have felt left out of decision-making processes that prevail in hospital centers, even if decisions arising from them have a direct impact on the way in which they work. It should be noted that staff nurses who practice in hospital centers represent most of the nursing workforce. The same observation emerges from one of our research projects that is still ongoing, conducted with nurses working in different sectors of specialty care (clinical nurse specialists, pivot nurses, specialized nurse practitioners [SNP], etc.).

This situation, which is eerily similar to the one experienced by the subordinate citizen, systemically left out of places associated with the exercise of power, appears consistent with the broad trends our contemporary oligarchic societies are taking under the aegis of world governance and market globalization. Our results suggest overall that the hospital democracy is increasingly confined to hospital boards of directors and to instances in which usually nurses do not have access. In the words of some participating nurses, these instances would themselves be submitted to a strict hierarchy of command, itself dependent on guidelines, particularly ministerial directives, which would considerably affect overall positions taken by hospital centers. It should be noted that our research is taking place in Canada; our health care system is certainly a public one, which connects, however, to an entrepreneurial-style governance model that leaves more and more room for the private sector and is advocated in all care settings, a clear separation between decision makers and “implementers”.

Based on our research results, the nurses who stand out for their commitment are thereby mostly confined to instances that only have the powers of recommendations, such as the hospital councils of nurses (CN). Participation in instances where access is “open” to nurses was otherwise associated by some participants with strategies put in place by the hospital authority to ensure nurses deploy their energy with no success to make any changes whatsoever happen in constraints they live in their daily practice. Even the parity committees[1] within which union representatives have the opportunity to talk with the employer are perceived as being marginally effective for eliciting to improve conditions under which nurses work.

Although these instances may appear a priori as great opportunities to promote nurses’ interests to the employer for concrete changes can be made in work organization, the perceptions of those interviewed with access to these committees as union representatives are no way going in this sense. These testimonies rather suggest that, even within these instances, numerous techniques would be deployed by the employer in a way to paralyze the dialogue with the union and to push dispute settlements, which we think has the effect of accentuating the separation between decision makers and implementers, already very much present in hospital centers. The fact of constantly changing interlocutors with which the union must find common ground would be leveraged in many backgrounds; this context among these techniques sometimes has the effect of significantly pushing some grievance settlements, the delays may spread out more than one year. If, according to some participating nurses, this is the constant turnover of managers, which would be the source of these delays, the fact remains that the current situation benefits the employer, even if the phenomenon is not necessarily a planned strategy.

When acting for change, the Slovene philosopher Slavoj Žižek(2008a), who is very interested in political action, states that it is important to question ourselves about the possibility of efforts deployed to cause the reproduction of dominant discourse, as it would be the case when nurses are investing time and energy in committees bringing very little outcomes, the hospital governance by far prefers seeing them running around in circles in some frivolous proceedings rather than noting they organize themselves concretely to resist the hospital authority. Žižek will specify in these situations that it is sometimes better to do nothing rather than try to act the wrong way to transform the status quo. Not cooperating in the functioning of the hospital framework by refusing participation in these proceedings – of what, from the point of view for a lot of nurses who participated in our research, in no way enable to improve their situation – would thus become, in itself, an act of resistance.

Results from the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study” revealed as well that decisions are usually made in accordance with decision-making processes in hospital centers, always consistent with interests of small influential groups. Participants on numerous occasions made reference to staff nurses in their discourse, but also to link nurses who, based on tacit knowledge, the one marginalized by the good governance doctrine, had warned institutions relative to decisions, many of which would achieve savings that have proven to be serious errors. Decisions even resulted in the death of many patients.

Our results suggest in addition that ideas from nurses are usually taken into account only when they are able to demonstrate they are in fact the partners “of those who play the game of the good governance” [free translation] (Deneault, 2013, p. 41). The nurse who sees herself complimented by a manager after having proposed, through a corporate website promoting innovation, that her colleagues bring their own toilet paper to workplaces for achieving savings, is a disconcerting example of this fact.

What Good is it?

A number of participating nurses encountered in studies and questioned relating to their commitment and the registry for political actions from nurses asked us if we really thought that it was possible to “change things”, with respect to the practice of the contemporary nursing profession in different backgrounds. The situations, described and criticized by them, have effectively come to our mind the most desperate throughout data collections, many participants indeed having openly admitted to us not believe in the possibility of making favorable changes happen to conditions for exercising the nursing profession, more particularly in the hospitals. As Žižek(2012) who, in a lecture given in Toronto, emphasized being regularly confronted with similar questions relating more specifically to pessimistic representations made of the state we find the world we are living in today, we responded to these participating nurses not being exactly sure it is possible to “change things”. And definitely we still have no certainty. Although many are likely to believe that things cannot change, paradoxically, however, we can only see the hectic pace at which, right now, they are changing radically, in both different care settings and our advanced capitalist society.

Not only in capitalist dynamics, but also in all spheres of life, things are in fact already changing automatically to a hectic pace. The very nature of sociability, of what constitutes a human being is as well shifting now and, if we let these changes be deployed passively – the same is true for the comparison to care –, it is expected that we will be heading towards an articulation of the society,[2] which is going to be characterized by a new form, permitted and perverse, of authoritarianism (Žižek, 2012). For Žižek, with whom we are in agreement on this, things are thus already changing to a hectic pace and that has to give us the motivation to act concretely to ensure these changes are getting a foothold in the sense of what we want, consistent with what nurses do. If Žižek postulates we are living the end of the world as we knew it, we also believe that we are witnessing here the end of care settings as we understood them, and sort of – to the end of the nursing professional practice as we knew it. Thereby drastic changes occurred, are happening and will continue to occur and it is expected that these are going to happen in a way even more authoritarian, arbitrary and perverse, because everything seems now okay in the name of the triumphant economy, and these ways of doing things in our societies necessarily affect care settings.

It is not a matter for staff nurses to foolishly accept these changes that will continue to occur quickly, but for them to reflect on what they can do to direct/influence these as well, certainly in a sense which would be salutary to them, but more particularly so we have some humanity. Nurses could also refuse categorically these changes – or some of them –, just as they can propose new ways of looking at the nursing professional practice – and they do so increasingly. And to those who believe that no change is possible because small groups disallow any transformation to the social order, Žižek(2012) unequivocally responded it is wrong to think there is only one social class governing and manipulating what is going on. According to Žižek(2012), reality is in fact more complex, certainly disconcerting, but with no way out – because those who are standing at the top of hierarchies are as well constantly destabilized by this ever-changing world and have enormous difficulties adapting to it. They are thus always improvising, definitely with a lot of means, to promote the maintenance of their hegemonies – hegemonies which, in all of this improvisation are necessarily much more fragile than we would like us to believe. As nurses, as a group, it is extremely important to become aware of this fact, which in regard to what we experienced as a society with the COVID-19 pandemic in the last year, looks absolutely undeniable.

In accordance with the writings of philosopher Rancière (1991, 1999), we refuse, however, to position ourselves in the expert role – a posture which remains anti-emancipatory – or in the Sartre’s trend of the intellectual, by dictating to nurses how they should act to cause the desired transformations to the nursing professional practice. But we feel strongly, consistent with what Gene Sharp (2012)[3] wrote, the power exercised in a hostile way, particularly by the governance of major hospital institutions, must be thwarted by an equal or greater nurses’ collective strength, without which the policies associated with it will continue to be imposed on them. To direct in the sense which is salutary to them, but also so we have some humanity, the societal changes affecting the nursing practice, we believe as well that there is no point for nurses to set off on a crusade against capitalism even if as a group, they and patients to whom they are giving care suffer enormously from collateral effects of this socio-political way of organizing we have. As Žižek (2008b) reminds it, this reflex obsessing the “old left” (p. 29) is not conducive, especially in the way in which the reality of today’s capitalism is structured, namely from a globalized manner where it becomes, for all practical purposes, impossible to have a grip on the ongoing transformations this ideology imposes to our existences.

Like Rancière (2014) and Žižek(2012), we think it is in the radical renewal of democracy in our societies and institutions as citizens, we must deploy our energies and concrete actions, actions that will do harm to the powers-that-be and destabilize oligarchs who have literally appropriated our democracies. It is in this sense, without telling nurses what to do, but we believe it is relevant to move towards a radically renewed hospital democracy[4] as the ultimate central purpose to which their collective actions must be structured, but also their individual ones, because it is always preferable to act on several fronts. Maybe that, starting from these concerted collective and individual actions in the thoroughness of everyday living, nurses will cause the establishment of a new balance of power and they finally have the opportunity to debate on the direction that must take the nursing practice – which, need we remind is essential to life.

Deneault, A. (2013). Gouvernance : le management totalitaire. Montréal : Lux Éditeur.

Rancière, J. (1991). The Ignorant Schoolmaster: Five Lessons in Intellectual Emancipation. Stanford : Standford University Press.

Rancière, J. (1999). Disagreement : Politics and philosophy. Minneapolis : University  of Minnesota Press.

Rancière, J. (2014). Hatred of Democracy. Brooklyn : Verso.

Sharp, G. (2012). Sharp’s dictionary of power and struggle : language of civil resistance in conflicts. New York : Oxford University press.

Žižek, S. (2008a, January). Violence. Paper presented at: the London Review Bookshop, London, United Kingdom.  

Žižek, S. (2008b). Violence : Six Sideways Reflections. New York : Picador.

Žižek, S. (2012, September). Until the end of the world. Paper presented at: Toronto’s Nuit Blanche Symposium, Toronto, Canada.

[1]Given our results, the grievances of nurses can be expressed and tolerated only when they – through their representatives – are invited expressly to do so by their superiors, particularly during these parity committees.

[2] By describing this new entity of new perverse permissively authoritarian society, which will be most rigid but, in a new way, Žižek(2012) prefers not to make reference to what some people are calling a new form of fascism, because he considers that those who use this term do it because they are too cowardly to think what is really new in these ways of doing things. The term “management totalitaire”, used by Deneault (2013), appears to us, however, as a key concept to describe this new articulation of our societies.

[3] Note that these writings of Sharp (2012) do not specifically refer to the nursing reality.

[4] We think at the same time nursing actions must also be directed so we have some radical renewal of democracy in our societies because it appears unlikely that a renewal so radical of the hospital democracy is done without much larger reflections, at the societal level, isn’t it put forward in this sense?

Social Withdrawal and Migraine Headaches

Starting on March 18th, a new article will be featured for free download from the current issue of ANS!  The article, titled “Social Withdrawal as a Self-Management Behavior for Migraine: Implications for Depression Comorbidity Among Disadvantaged Women,”  is authored by Shawn M. Kneipp, PhD, RN, ANP-BC, APHN-BC and Linda Beeber, PhD, RN, CS, FAAN.  Recognizing social withdrawal as a distinct, highly nuanced coping strategy in
symptom self-management, they explore its relevance for understanding migraine-depression symptoms within the life context of socially and/or economically disadvantaged women.  They recommend further nursing research  that draws from complexity science theory and methods to better understand these dynamics and ultimately improve care.  Dr. Kneipp  shared this message about their work for ANS readers:

I would not have expected to be writing on this topic two years ago.  As is frequently the case with scientific inquiry, however, unexpected study findings, combined with ongoing clinical work and research with women who are socioeconomically disadvantaged, led me down this path.  The unexpected findings came from a

Shawn Kneipp

Shawn Kneipp

clinical trial with women in a Welfare Transition Program (WTP), which suggested headaches may be associated with job loss in the previous year.  Given the erosion of economic safety nets in the U.S. generally, and the current limits on economic assistance receipt through the Temporary Assistance for Needy Families (TANF, or ‘welfare’) program more specifically, obtaining and maintaining employment has become an even more critical social determinant of health for women who are socioeconomically disadvantaged.


Linda Beeber

From a number of prior studies, we have also known for a while that depression is highly prevalent in this group, that depression impedes women’s ability to function in the workplace, and that depression is most often present in the context of other chronic health conditions.  Despite this, there are large gaps in the literature on headache symptoms (predominantly migraines for women) in relation to socioeconomic status and self-management, in the context of other highly prevalent disorders (i.e., depression), and the associated morbidity in terms of work-related functioning.  This recognition, informed by clinical observation of how this population was often managing their migraine-related symptoms as they struggle to perform well at work, was the driving force in wanting to begin to pull the relevant disease-trajectory and self-management theoretical pieces surrounding this issue together.

The theoretical perspectives offered in this article underlie a current pilot study we are conducting to determine the feasibility of a novel data collection approach to further examine how disadvantaged women self-manage migraine symptoms. As with the majority of my research, women from the community of interest are playing a crucial advisory role in designing, conducting, and interpreting the findings from the pilot work. Given the preliminary feasibility findings, and looking to our future work in this area, nurse researchers have a great deal to contribute in the way of both theory and intervention development and testing to better manage comorbid health conditions, improve work-related functioning, and improve their odds of achieving economic self-sufficiency.

Go to the ANS web site now to download your copy of this article – it is important both in content and method.  then come back here and share your thoughts, questions and ideas – we would be delighted to hear from you!

Preventing Sudden Infant Death Syndrome (SIDS)

Our current featured article is by Sherri L. McMullen, PhD, RN, NNP-BC and Mary G. Carey, PhD, RN, CNS  title “Predicting Transition to the Supine Sleep Position in Preterm Infants.”  Their article demonstrates how good nursing care, focused on anticipating the needs of families after discharge from the hospital, can make a difference – even to the point of preventing a SIDS death.  Dr. McMullen shared this message about her article, which is based on her dissertation research:

Thank you for your interest in our article entitled “Predicting Transition to the Supine Sleep Position in Preterm Infants.” This article is work related to my PhD dissertation research and I am passionate about the topic. I had the privilege of meeting Peggy at the 2014 National League for Nursing Writing Retreat in Phoenix and I am so pleased to see my McCullen-300manuscript in press. I have been a Neonatal Nurse Practitioner for over 20 years and I decided to extend my expertise to include academia and research. I miss my submersion in clinical, but think it’s really important to research clinical practice to continually improve the care we provide patients. So much of the care we offer to our smallest patients impacts them after hospital discharge.

Positioning preterm infants supine while hospitalized and after discharge is an important aspect of infant care and its relatively new topic with little research completed to date. Preterm infants are positioned in a variety of positions while in the neonatal intensive care unit to promote optimal neurodevelopment. The preterm infant’s musculoskeletal system is pliable with risks of deformity with suboptimal positioning. The supine position is an important modifiable practice that reduces the risk of sudden infant death syndrome after hospital discharge. The retrospective research completed shows there is great variability in the clinical practice and there are three factors that predict a greater than one week transition to the supine position before hospital discharge. More research is needed to determine the optimal timing of transition and what developmental impact this transition has on the preterm infant. A balance must be found between allowing enough time for the infant to become acclimated to the supine position without impacting neurodevelopment.

You can obtain a free copy of this article while it is featured on the ANS web site!  Visit the web site today, then return here to share your comments and ideas!

Preventing Hospital Readmission

The current “Post-Hospital Nursing” featured article provides a report of a study to determine hospital admission variables that might predict a risk for re-admission.  The article, titled “Can Nurses Tell the Future? Creation of a Model Predictive of 30-Day Readmissions,” is authored by Adonica Dugger, DNP; Susan McBride, PhD; and Huaxin Song, PhD.  Dr. Dugger sent this message about this work for ANS readers:

Hello, and thank you for your interest in our article published in the current issue of Advances in Nursing Science, “Can nurses predict the future? Creation of a model to predict readmissions.”   I would also like to thank Advances in Nursing Science for the privilege of having the article published. The journey to the research for this project started, as I was a director for case management and was attempting to identify patients who may have a readmission to my hospital. I Dugger-Adonica_400thought of all the factors that I, and my fellow case managers, felt, when present, would likely predict a readmission to the hospital.   I reviewed many of the predictive models available in the literature, but I couldn’t find one I felt addressed the population of patients seen at my hospital in West Texas.   At that point I wasn’t sure what to do next, but I soon started my studies toward a DNP at Texas Tech University Health Science Center.   Soon after beginning, I met Susan McBride and learned how a predictive model was created and validated. With guidance from Dr McBride and Dr Song, I was able to examine the data and create a model to predict the patients most likely to readmit to my hospital within 30 days.

Through this project, I have learned much about how a nurse with a PhD and one with a DNP can work together to solve a problem and put the solutions into practice more quickly. These partnerships allow for a nurse’s practice to be truly evidence based and help to improve the quality of care we give to our patients in the acute care setting. I also learned the value of the data that is available as the use of electronic health records grow throughout Texas and the nation. Nurses can use this data to help prove both how and why changes to current practices should and could be made.

Since this article was submitted in April of 2014, I have moved from case management back into the surgical services area of the hospital. We are looking at ways to predict our daily, weekly, and monthly case loads, which patients may be more likely to have a post operative infection, and factors that will delay our case starts. Throughout the hospital, change is also being considered with predictive modeling, as nurses examine our patients with pressure ulcers and seek to determine if a risk scoring system specific to our patient population can be created.

You can download this article for free while it is featured on the ANS web site!  Read this article, then return here and share your comments!

Moving beyond Rhetoric to Action: Understanding Inequalities to Health Care Services

Rhetoric admonishing nurses and other health care professionals to address inequalities in health care is a common message; it is less often that we learn about concrete action to do just that!  In our current featured article, titled “Understanding Inequalities in Access to Health Care Services for Aboriginal People: A Call for Nursing Action” the authors describe a research initiative they undertook in partnership with Aboriginal people to create meaningful action addressing barriers that result in inequalities.  The authors, Brenda L. Cameron, PhD, RN; Maria del Pilar Carmargo Plazas, PhD, RN; Anna Santos Salas, PhD, RN; R. Lisa Bourque Bearskin, MN, RN; Krista Hungler, MSc have shared this very interesting description of their work:

Hello to Everyone on behalf of the Access Research Team and many thanks to Dr. Peggy Chinn and the Advances in Nursing Science Journal for the opportunity to accompany the article with a blog. Attached is an  Overview of the access initiative diagram and below is a photo of the authors of this article.

To begin: It was quite startling to come to the end of a two day community consultation workshop (2002) where ten areas identified as urgently needing health research were set aside. Instead a community request was issued to study access to

Krista Hungler, Sandra Kwagbenu, Maria del Pilar Camargo, Brenda Cameron, Elder Rose Martial, Raymonde Lisa Bourque Bearskin, and Anna Santos Salas. The photo is by Veronica Guerra Guerro

L to R: Krista Hungler, Sandra Kwagbenu, Maria del Pilar Camargo, Brenda Cameron, Elder Rose Martial, Raymonde Lisa Bourque Bearskin, and Anna Santos Salas. The photo is by Veronica Guerra Guerro

health care services for Indigenous and marginalized populations. Researchers from several health professions, healthcare professionals, community members with province-wide representation, and students of every level sat back and listened. This access research was not to be the current approach to access with numbers and statistics, i.e., how often Indigenous people saw specialist physicians, how many emergency visits. It was to be in collaboration with the Indigenous people and not couched only in terms of western research philosophies and methodologies.

From this request we sat down together and talked together for three years; at times coming to a consensus and moving forward, but other times, no movement at all. Sitting together at the table for this time was in a way, the research itself. It was an arduous, long process of building trust and relationships with each other with continuous clarifying of what was meant by each suggestion, what each step comprised that was decided upon, what possible fallout might occur. There were many issues on the table, some overt and some yet to appear but each one had to be thoroughly addressed before we could move on. Memoranda of Understandings had to be negotiated and signed, safety issues were addressed through the design of advisory groups and involvement of the people in each data gathering step was planned. We did not move forward without full agreement at the table. Others over this time period joined the table and again we renegotiated every step. During this time we agreed upon, designed and undertook three exploratory grants (Aboriginal populations in urban, inner city, and rural areas) in an open conversational manner with extensive advisory groups attached to each one as well as Elder scholars. The findings of these became the basis of our movement forward.

A focus on developing sensitive and comprehensive indicators for access to health care services for Indigenous people came into view early in the discussions. But we were also told by people participating in the exploratory grants that they had had enough of evaluation projects and reports. In the inner city exploratory grant, inner city residents took us to the Director’s office in one of the inner city agencies and pointed out the numerous reports that existed on the need for healthcare access appropriate to inner city and downtown core residents. They asked us: how will this study be different, there has been no action attached to these reports stemming over the last ten years. When will studies lead to action on the issues identified? Was there nursing action that had occurred in response to these reports? Will this work just enhance researcher’s careers or just prove that the healthcare system is doing something instead of nothing? These questions were the standard, the bottom line, which we were given not only from inner city residents but from all participants and healthcare professionals in our projects. We have learned that we must declare how particular research studies will benefit researchers as well as the knowledge development the studies would produce. We also had to plan how to move the findings to actions.

Moving forward: We placed Indigenous Healthcare workers called, Community Health Representatives (CHRs) in Canada, in healthcare sites with a high percentage of utilization by Indigenous people. This intervention turned out to be one of the cornerstones of our research initiative. This manuscript portrays some of this work. Our findings opened the door to understanding how even the most simple institutional mandated protocol when accompanied by overt rudeness or a stigmatizing comment, caused fright. And often there were unseen consequences down the road, i.e., never seeking care again until the condition was far advanced. Even if the institution triggered horrific memories of government residential schools (in Canada), the presence and health knowledge of an Indigenous CHR mitigated that fear. As well the CHR assisted them to communicate safely their healthcare history with few repercussions, judgments and racist practices from the institutions’ healthcare staff. Outcomes were more positive when the CHR was there. For further information see our Access Community report (2014) link below.

The call for action: The people in our studies talked about respect, feeling safe, undoing decades of harm from government and healthcare agencies, rejecting positioning statements from some past research and institutional practices, fighting for rights to have sensitive cultural and healthcare and Indigenous understandings at all points of access. Indeed our work to date shows a pressing need for joint interdisciplinary and intercultural efforts to reduce current health disparities through collaborative participatory work with Indigenous peoples.

Our findings suggest that nurses in particular the need to engage with Indigenous people and their culture to create safe access for them as often nurses are their first point of contact. All nurses know about the need to be aware of the social determinants of health and the health disparities that exist for certain populations. Nurses also know about the importance of honouring cultural traditions of health. But our research team is also aware that activating this knowledge in day to day practice needs additional careful attention and thought. As well increasingly so, the actions of nurses are prescribed by healthcare protocols and policies to ensure a specific outcome that is tied to an economic parameter. Caring for someone who is very ill takes a toll on the prescribed and allowable economic outcome for certain. Based on our studies to date in our specific healthcare institutions, our practicing nurses need support to take action to mitigate the growing and alarming reports of disingenuous care documented in our findings.

Perhaps it is again, sitting around a table with a social justice framework and consciousness raising activities to work toward incorporating research findings into actions. As health disparities climb even as we write this blog, the time to start this is now. There is much work to do to support nurses and other healthcare professionals who work under institutional dictates to then plan their care with the understanding that individuals and families with low SDOH need our special attention. We would also like to draw attention to the Indigenous social determinants of health identified by Loppie-Reading and Wein (2009) as a way to increase further understanding of implementing the SDOH in actual practices of nurses and allied healthcare professionals.

In undertaking specific action on identified issues, we honour the Indigenous peoples of Canada, our original inhabitants. In addition, we know that it will take a concentrated effort to achieve equity in access for Indigenous peoples and we challenge others to facilitate Indigenous communities to undertake their own studies.

We sincerely thank the Indigenous people and the communities that guided this investigation into access to healthcare services and know that this is just a very small step in addressing the health disparities of Indigenous peoples in these particular communities and wider systemic difficulties. We also learned that research on Indigenous topics must be led by Indigenous research scholars and the communities themselves. We very much look forward to your feedback and many thanks for the opportunity to do this blog.


Cameron, B. L., Martial, R., King, M., Santos Salas, A., Bourque Bearskin, R.L, Camargo Plazas, M.D.P., Hungler, K. (2014). Access Research Community Report: Reducing health disparities and promoting equitable access to health care services for Indigenous peoples: Community Report. Edmonton, AB: University of Alberta, Faculty of Nursing.

Reading, CL, Wien, F. Health inequalities and social determinants of Aboriginal Peoples’ health. Prince George, BC: National Collaborating Centre for Aboriginal Health. 2009.

The article is available while it is featured for free download on the ANS web site!  We – the authors and I – would be delighted to know your comments, and welcome your discussion related to these very important issues!  Please use the space below to let us hear from you!

Nursing as Body Work

The current “Editor’s Pick ” article from the current ANS issue is titled “Critical Perspectives on Nursing as Bodywork,” authored by Karen Anne Wolf, PhD, APRN-BC, DFNAP. In this thought-provoking article, Dr. Wolf  calls for nurses to reject the objectification of the body and instead reclaim body work as integral to a holistic perspective.

Dr. Wolf shared this message about her work for ANS readers:

Nursing as work is the focus of my scholarship. In past work, I have explored the larger structural issues in the collective history of nursing. In this paper I explore the paradoxical nature of nursing as bodywork. Scratching beneath the surface of the issues of status and power opens a window on the variety of factors that shape the work of nurses in relation to their patients. The nurse-body relationship is so fundamental to nursing work that we are blind to its social impact. This results in contradictory images and experiences. For example, nurses are revered as “most trusted” and angelic in many countries yet Wolf300exposed to persistent degradation within the media and in public discourse.

Nursing work continues to be viewed as low status despite professionalization efforts. The social discomfort with the human body contributes to the paradoxes in nursing as bodywork. The relational boundaries between nurses and patients blur ordinarily taboo spaces. The intimacy of providing physical care carries the stigma of nursing as dirty work. Yet this same intimacy throughout the sacred rituals of birth, death, and vulnerability contributes to the entrusted relationship. De-stigmatizing nursing as bodywork begins with accepting our bodywork relationship. Without such an acceptance, there is a tendency to distance nursing from the body through the increasing use of ancillary nursing workers or technology. Recognizing the paradox of nursing as bodywork is a critical to the future of the profession. I would suggest that we consciously claim and embrace the relational care for the body rather than reject it. Nurses must be mindful and respect the power inherent in their privileged and intimate relationship with patients.

Download your copy of Dr. Wolf’s article at no cost while it is featured on the ANS web site! We welcome your thoughts and comments in response!

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!

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 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!

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!

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!

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