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Posts from the ‘Research’ Category

Storytelling, narrative inquiry, health inequities and health outcomes

These four “topics” do not often appear in the same context together, but that is exactly what authors Nicole Y. Pitre, PhD, RN; Kaysi E. Kushner, PhD, RN; Kim D. Raine, PhD and Kathy M. Hegadoren, PhD, RN have accomplished in their featured article titled “Critical Feminist Narrative Inquiry: Advancing Knowledge Through Double-Hermeneutic Narrative Analysis.”  This article describes an innovative approach to research that holds great potential for creating sustainable social change that supports positive health outcomes, especially for those whose “voice” is rarely heard.  Dr. Pitre shared this message about her work:

Critical feminist narrative inquiry is a research methodology that evolved from Dr. Kaysi Kushner’s work on theoretically triangulated critical feminist grounded theory (also published in ANS in 2003). I developed this approach to narrative inquiry through my doctoral work under the supervision of Dr. Kushner and Dr. Hegadoren, and with the support of Dr. Raine, all members of my supervisory committee and co-authors of this article. I am particularly grateful to them for their guidance as I developed this method of narrative analysis. We are delighted that this article is published in ANS.

My work was inspired from my reflections on the following assertion: “Know that no one is silent though many are not heard. Work to change this” (Anonymous). Narrative inquiry is known to be a method designed to give voice to participants through the stories that they wish to share. While I found that during the interview process narrative inquiry approaches were consistent with a feminist agenda, I soon realized that existing methods of narrative analysis did not provide a foundation or strategies to examine stories from a theoretically triangulated critical feminist perspective. I concluded that current approaches did not allow for participant’s voices to be fully heard, nor did these permit an explication of the constraining and silencing social, structural, and ideological conditions and practices that shaped their experiences. This integration is the aim of critical feminist narrative inquiry.

Critical feminist narrative inquiry constitutes a means for participants’ voices to be heard and to influence social action toward change. Through critical feminist narrative inquiry, it also is possible to uncover women’s or men’s strengths, challenges, and reflexive choices and decisions as they strive to manage adverse conditions. The use of critical feminist narrative inquiry ultimately allows the researcher to reveal the conditions that create and perpetuate marginalization, vulnerability, and stigmatization and that limit agency and identity in a person’s life.

We believe that this evolving methodological innovation has the potential to support the work of nurse researchers who are dedicated to expose and to act upon health inequities and social injustice. We greatly appreciate this opportunity for dialogue and we welcome your comments and thoughts.

While this article is featured, it is available for free download!  So visit the ANS web site now!

Philosophic inquiry for nursing: a crucial connection

Because nursing is a very “practical” endeavor, the crucial underpinnings of philosophy are sometimes difficult to recognize.  But in this article the authors, Pamela J. Grace, PhD, RN, FAAN and Donna J. Perry, PhD, RN, explain why this is such a critical connection.  Their article titled “Philosophical Inquiry and the Goals of Nursing: A Critical Approach for Disciplinary Knowledge Development and Action” is currently featured on the ANS  web site.  Dr. Grace and Dr. Perry provided this interesting background to their work:

From Pamela Grace: The idea for this paper had been germinating a long time and went through several iterations. It benefited from the critique and suggestions of many colleagues, doctoral students and the ANS reviewers but we are sure that there is much more that can be said and we look forward to an ongoing dialogue.

A very early version of the paper was presented as part of a 4-paper symposium sponsored by International Philosophy of Nursing Society (IPONS) members and accepted for presentation at the Royal College of Nursing (RCN) 2010 Research Conference. IPONS is a forum for philosophical dialog and has among its aims: “to promote and establish philosophy of nursing, and health care in general, as a credible and important field of philosophical and critical inquiry” and that was the intent of the symposium to highlight the role and importance of philosophical thought for disciplinary purposes.

The shape of this version emerged as a result of co-teaching a doctoral seminar at Boston College with Donna Perry in the Spring of 2012. The course was focused on understanding philosophical and socio-political influences on health policy and ways in which nursing research can be use to inform and shape health policies. I used a much rougher draft of the paper as one of the assigned readings. Donna’s insightful and helpful suggestions on the manuscript, ideas about the hierarchical structure, and addition of Lonergan’s thoughts really helped refine the paper in a way that we believe makes it broadly useful to the profession.

The original and more personal reason for the paper is that, over my many years as a practicing nurse both in critical care settings and later in primary care as an ANP, I struggled with the healthcare environment – how it often and sometimes in subtle ways undermines good practice or fails to meet the needs of individuals and their communities. This struggle led me to doctoral studies in philosophy. I was hoping to learn ways of addressing practice problems. In this environment I was free and indeed encouraged to question everything. The skills and perspective gained I took with me into nursing academia only to discover that this sort of probing inquiry, that is not afraid to question how various projects and different levels of curricula meet nursing goals, seems to be losing ground as a valued a mode of knowledge development.

FYI the International Philosophy of Nursing Society  (IPONS) annual conference is in the US this year (Atlanta) Sept 7-9th.

From Donna Perry: My interest in philosophy stemmed from my undergraduate education at Saint Anselm College. The curriculum there was centered in an innovative and engaging humanities foundation which integrated scholars and scholarship from multiple disciplines. I took several extra courses in philosophy and found that it provided a helpful lens for all my future studies. When I started doctoral work at Boston College I purposefully sought out the philosophy department where I was introduced to the work of Bernard Lonergan, S.J. who had taught at BC. His cognitional philosophy provides a rich account of interior human consciousness. My own research focuses on transformative decision making around social issues that impact health. I found that Lonergan’s philosophy provided a deep and encompassing viewpoint from which to address issues of concern to humanity and to nursing.

When Pam extended an invitation to work with her on this manuscript I eagerly accepted. Not only was the topic of interest but I felt that it was critically important to address the importance of philosophical inquiry in nursing. It is important to note that this manuscript continued to evolve after submission. Reviewers who generously shared their time and thoughtful comments were instrumental to this process. The reviewers’ comments on the initial manuscript raised questions about the broad scope we had ascribed to philosophical inquiry. As all good questions do, these caused me to think critically about our paper. The different activities we had described were all important elements of philosophical inquiry. But clearly we needed to develop a way to differentiate and organize these different components. The process of bringing some clarification to this range of philosophical activities gave me the insight into developing a taxonomy for philosophical inquiry. Our hope is that this taxonomy might be helpful for scholarly development in the profession as we seek to address the many contemporary challenges to health and further the human good.

If you have not already, visit the ANS web site and download your copy of this very interesting article at no charge!

Designing Evidence-based Practice

If you are interested in a model for designing approaches in practice that are evidence-based, this is the article for you!  The article is titled Development and Testing of an Intervention to Improve Outcomes for Partners Following Receipt of an Implantable Cardioverter Defibrillator in the Patient” and is authored by Cynthia M. Dougherty, PhD, FAHA, FAAN, ARNP; Elaine A. Thompson, PhD, RN; and Peter J. Kudenchuk, MD, FACC, FAHA.  Go to the ANS web site while this article is featured, and you can download a copy of the article free of charge!

This “Editor’s Pick” article describes how the authors used the results of three research studies to design and test a “patient and partner” nursing intervention for patients in the time after they return home from receiving an implantable cardioverter defibrillator. Dr. Dougherty has shared this photograph of the team that worked on this project, and a brief description description of their work:


P+P Research Team, University of Washington, School of Nursing, 2012

Back Row:  Dr. Elaine Thompson (Author), Lisa Foley, Susanne Steffes, Chayna Davis, Lisa Hales, Mary Strasser.

Front Row:  Pagna Prom, Seieun Oh, Caylene Castagno, Dr. Cynthia Dougherty (Author).

Since 1990, Dr. Dougherty has been working with patients who suffer cardiac arrest and receive an ICD and their families.  This research program spans numerous iterations in the technological development of the implantable defibrillator (ICD) as well ever changing patient populations who are eligible to receive the ICD.  The paper outlines a series of investigations that have lead to the formal testing of the patient and partner (P+P) intervention after ICD study, currently funded by the National Heart, Lung, and Blood Institute of the NIH.


Nurse Fatigue and Patient Harm

The current “Editor’s Pick” article focuses on the “Future of Nursing” Report’s first recommendation, that nurses practice to the full extent of their education and training.  The article, titled  “Hospital Nurse Force Theory: A Perspective of Nurse Fatigue and Patient Harm” presents an evolving theoretical framework for reaching this goal.  This is a fascinating article that reflects a coming together of hospital and academic nurses to address one of the most vexing of nursing challenges – nurse fatigue.  But the background of how this work evolved is equally fascinating!  Read the background story here, by lead author Diane Drake:

In November 2005, I received an email from Dr. Michele Luna, the Mission Hospital quality manager about an idea to study nurse fatigue and adverse events prompted by reading a publication by Ann E. Rogers and others about sleep and nurse fatigue. I had recently begun consulting at Mission Hospital as the nurse research

L to R: Dr Michele Luna, Dr Linsey Barker Steege, Dr Diane Drake

scientist after finishing a post-doc at UCSF in cancer symptom management. I knew very little about quality management and was curious why a PhD nurse was the quality manager at a community hospital. Fortunately I knew something about fatigue research, and was interested to talk with Dr. Luna about hospital nurse fatigue.

During the next few years, Dr. Luna and I read and discussed many reviews, studies, and dissertations to help clarify the complex relationships and sometimes confusing definitions of nurse fatigue and patient safety. Our initial ideas resonated with a nurse fatigue dissertation we read by Dr, Linsey Barker Steege, a human engineer, who I contacted by phone in 2010 at the University of Missouri to discuss nurse fatigue theory.

By December 2010 Dr. Luna and I agreed to formalize our discussions into a plan of research and received approval from Linda Johnson, RN, MSN, Mission Hospital Chief Nursing Officer, to convene a study team and conduct nurse fatigue investigations. Our study team members included graduate nursing research students who were also Mission Hospital nurse managers, Mary Olivas, RN, MSN, Gerri Mazza, RN, MSN and staff nurse Anne Faust, RN, MSN. Mission Hospital Clinical Director, Connie Gagliardo, RN, MN, doctoral nursing student Teri Arruda, NP and University of Missouri Human Engineer, Dr. Linsey Barker Steege also joined the study team and participated in monthly study meetings by conference call and attending annual meetings. By the first year, we completed our survey design including items and concepts that were important to our theory.

During a monthly study team meeting, we reviewed a compelling paper about the unspeakable in nursing, published in ANS, my favorite nursing journal, written by Dr. Jane Georges, a professor at University of San Diego School of Nursing where our team member Teri Arruda was a doctoral student. One Saturday in December 2011 Dr. Luna and I met for lunch near San Diego with Dr. Georges to ask her opinion about publication of our work.  Dr. Georges assured us the work was worthy to consider for ANS publication and her contributions were essential to the success of this publication. Dr. Georges also contributed to the evolution of the model during our discussions about the physics of nurse force and the importance of studying and preventing hospital nurse fatigue and patient harm.

The current evolution of the Hospital Nurse Force Theory was considerably advanced when we realized the study domains of hospital, nurse, fatigue and harm were inadequate to describe and measure the essential and dynamic force and belief that hospitals exist for nursing care and essential nursing practice requires the recognition and prevention of patient harm. Optimal hospital nurse force is the combination of nurse wellness, professionalism and education in sync (yin-yang) with the hospital environment and resources.

Our theoretical discussions have guided our research strategy to apply empirical methods over three phases of research: 1) design and administration of a survey to test the prevalence of hospital nurse fatigue and test the effect of interrelated hospital and nurse variables on nurse fatigue and patient harm, 2) validate self-report measures with clinical tests of physical, mental, and emotional fatigue and wellness, and 3) design and test interventions to mitigate or prevent hospital nurse fatigue and patient harm.

In February 2012, 420 Mission Hospital RNs completing a 100-item online nurse force and fatigue survey. Summary of the findings is underway as well as a publication to validate survey domains in cooperation with Dr. Mary Wickman, nurse researcher at St. Jude Hospital in Fullerton, CA a sister hospital of Mission.

Mary Olivas, RN, MSN and I presented the Hospital Nurse Force and Fatigue (HNF&F) theory at the International Sigma Theta Tau Research conference in Brisbane, Australia in July 2012. Connie Gagliardo RN, MSN and I presented the theory to the Nebraska Nursing Association in Lincoln, NE in September 2012 and had the pleasure to meet with Dr. Ann E. Rogers, the keynote speaker whose research has been inspirational to our research.

Several new investigations have begun as a result of the study team collaborations. Nurses Olivas, Mazza and I have collaborated on a secondary and qualitative analysis with Dr. Barker Steege, revisiting her nurse fatigue

lower left to right, Dr Linsey Barker Steege, Gerri Mazza, RN, MSN, Dr Michele Luna, Dr Diane Drake, Mary Olivas, RN,MSN, Connie Gagliardo, RN, MN and Anne Faust, RN, MSN.

dissertation. Shanghayegh Parhizi a doctoral student of Dr. Barker Steege has joined the study team to use the survey data for dissertation source. Dr. Barker Steege and her colleague at the University of Missouri, Dr. Kalyan Pasupathy have joined me to conduct data mining on fatigue and wellness in night shift nurses, preliminary work to evaluate breast cancer risk and screening practice of night nurses.

The study team continues to meet monthly with plans to design and test interventions to promote hospital nurse force, test methods to mitigate nurse fatigue and prevent patient harm.  We welcome your comments and questions by email at

This story, I hope, will be an inspiration to others who have an idea you want to pursue with a team of colleagues!  Visit the ANS web site today, and download your copy of this inspiring article!

Transition from student to professional: High-Stakes clinical simulation

Clinical simulation has become a standard teaching and learning approach in nursing education. Dr. Mary Ann Cordeau’s article titled “Linking the Transition: A Substantive Theory of High-Stakes Clinical Simulation”  reports the findings of a grounded theory study that reveals a 4-stage transition experienced by students as they learn caring as a professional nurse.  Dr. Cordeau describes her research:
I have been involved in developing clinical simulation as a teaching/learning/assessment strategy at Quinnipiac University for the past seven years. During that time, I have conducted one-on-one simulations, group simulations, and most recently have been involved in streaming scenarios from the laboratory to the classroom. When I began to examine the clinical simulation literature, I learned the majority of the research was quantitative.  There was very little information on the student’s perspective of the clinical simulation experience. My background in history and phenomenology led me to focus on the qualitative aspect of clinical simulation. My initial research examined the lived-experience of high-stakes clinical simulation. The results of that study greatly influenced my approach to using clinical simulation with junior and senior nursing students.  The next logical step in examining clinical simulation was to use grounded theory to reveal the social psychological problem and process used to cope with the problem. At the time I was conducting the grounded theory study, I was teaching Transitions theory to the junior nursing students.  I began to see a connection between Linking and Transitions. Discussing my thoughts with colleagues and expert nurse researchers prompted me to examine Linking as fostering the situational transition from student to professional nurse.
 I would like to thank all of the students who participated in the studies and everyone who advised and supported me on my journey of discovery.
Visit the ANS web site today to download your copy of this very interesting article!

Transitions to Independent Living for Developmentally Impaired Young Adults

Dr. Geraldine Pearson,PhD, PMH-CNS, FAAN, in her featured article titled “The Transition Experience of Developmentally Impaired Young Adults Living in a Structured Apartment Setting,” reports the findings of a study conducted with young adults with a history of pervasive developmental disorders.  The young adults were all no longer eligible for child services in their area, and were transitioning to independent living.  It is rare that researchers turn directly to people who experience such extensive physical and psychologic challenges as participants.  Dr. Pearson’s work with her participants yielded impotant insights into their experience, as well as very important  explanations of methodologic adjustments that needed to be taken into consideration in the conduct of this research. She shared this description of her work in this message for the ANS blog:

Peggy asked me to begin this blog about my my paper published on the July-September 2012 online issue of ANS. titled “The Transition Experience of Developmentally Impaired Young Adults Living in a Structured Apartment Setting”. It detailed my dissertation research with a population of chronically disturbed young adults. I learned so much from these young adults trying to grow up with chronic psychiatric and developmental impairments and very little family support. The research is fairly clear in defining the need for parental figures to guide and assist as these individuals pass into adulthood. I think of these young people as I read the recent statistics about so many college graduates moving back home with their parents. While economics are cited as the predominant reason for this, I also wonder how many of them feel the need for family support as they face an unfriendly economic environment where living is expensive. My research participants were attempting to grow up using limited public resources for housing and expenses. Most appeared to live at the poverty line and they clearly struggled.

There were also some unique moments as I conducted the interviews in participant living environments. One young man proudly spoke of the “crickets” that were darting up his kitchen wall. He seemed oblivious to the fact that he was actually infested with roaches!

Participants were polite, eager to talk about their lives, longing for someone to talk with them. At the conclusion of the research interviews I was left to ponder the plight of this population, their quality of life, and what we, as mental health professionals, might be doing to improve their living. I didn’t come away with clear answers. In the end, the research cemented my passion about caring for these individuals, whether children, adolescents, or young adults. It is such an honor to have this paper published in ANS!

I believe you will find this featured article to hold valuable insights for all nurse scholars, not just because of the substance of the article, but as an exemplar of approaches to nursing research with those who are most vulnerable, and whose experience remains essentially unknown.  Visit the ANS web site now to download your free copy!

Choosing contentment in the midst of life transitions

Susan Bonis’ featured article, which describes a philosophic (hermeneutic) study,  is an example of scholarship that some assume is far removed from the practical realm of nursing practice.  But to the contrary, this thought-provoking article sheds light on one of the most vexing challenges of human practice – how do people come to a sense of enduring serenity (contentment) in the midst of the disharmony created by serious health challenges?  As Dr. Bonis states in her article: “Evidence-based practices begin with understanding the science that underpins the discipline. Nursing is a human science; therefore, it is essential to understand the basic human phenomena that underpin being human, such as contentment.” (see page 274 of her article, available for free download until 9/30/12).

Dr. Bonis examined the published memoir of Dawn Prince-Hughes, a researcher of primate identity and culture.  The memoir, titled “Songs of a Gorilla Nation: My Journey through Autism,” recounts Prince-Hughes’ experience of coming to understand her own journey living with autism.  Dr. Bonis’ hermenuetic interpretation of the memoir, cast in the perspective of the nursing human becoming philosophic framework, provides the basis for her analysis of the experience of contentment.  As a reader of this article, you may not share for yourself the human becoming philosophy, but you will find connections between this philosophy and the most fundamental of nursing concerns.  For me one of the fundamental nursing concerns that this article addresses is that of promoting high-level wellness.  Dr. Bonis describes the process of  contentment as a paradoxical living calm-turbulence in challenging situations – a process that seems to me as central to the basic nursing concept of high-level wellness.  In her conclusion, Dr. Bonis states that “As humans live rhythms of contentmentdisharmony, contentment is glimpsed in serene and pleasurable moments of feeling listened to, understood, cared for, loved, and respected, as well as in moments when they trust, unburden, and laugh while all-at-once acquiescing to arduous situations.” (See page 282). What an inspiring image for nursing practice, and for the outcomes that I believe we all seek!

Let us know your thoughts and responses to this featured article!  Leave your comments here – and we will respond!

Nursing perspectives on culture and health

The article now featured in our “Editor’s Picks”by Martha Baird illustrates perfectly, to me, many of the features that characterize nursing perspectives.  The article, titled “Well-being in Refugee Women Experiencing Cultural Transition,” recounts two research studies that Dr. Baird conducted.  These studies provided evidence from which she developed a situation-specific theory of wellness among South Sudanese refugees in her community.  The concepts that stand out as specific concerns for nursing include culture, wellness, transition, family, relationships and health.  Here Dr. Baird describes the experience of this research, and the South Sudanese family who helped make her work possible:

The research that led to the Theory of Well-being in Refugee Women in Cultural Transition would not have been possible without the help and guidance of Rebecca Mabior and John Akuei, my friends, translators, and interpreters. They have not only served as culture brokers between the South Sudanese community and myself, but have become part of our extended family.

John and Rebecca came to the US in 2001 as refugees. John was one of the Lost Boys of Sudan from the Kakuma Refugee Camp in Kenya. Rebecca came from Khartoum, the capital of Sudan, where she was practicing as a registered nurse. She and John met in the US, married, and have three children Atem 8 years, and Akon and Akuei, 3 year-old twins (see family picture). Their families still live in South Sudan and have never met their three children. Since South Sudan became a separate nation on July 9, 2011, they are able to visit their homeland for the first time in over 10 years. Next year, their oldest son, Atem will meet his grandparents for the very first time.

Working with the Sudanese refugee community on these two research projects has taught me the importance of long-term and sustainable relationships with the communities we are serving and hoping to effect positive health change.

From the author: Denise Drevdahl

Meet Denise Drevdahl (right in the photo), with her co-author Kathleen Shannon Dorcy (left) with one of their “buddies” on the Oregon coast!  Denise and Kathleen wrote the current featured article  “Transitions, decisions, and regret: Order in chaos after a cancer diagnosis”.  Their research explores the dilemma of entering an experimental treatment in the midst of a life-changing illness.  I was particularly inspired by the closing sentences in their article: “It is not so much the ability to remain stable and unchanged that should be the goal of care encounters, rather the goal should be flexibility and responsiveness to new paths and ways to traverse the unknown terrain and transitions together. Chaos, it seems, does give us the opportunity to see the world differently.” In reflecting on their ANS article, Denise wrote:

Kathleen and I are honored that our article was selected as an Editor’s Pick for the current issue of ANS. I have had the pleasure of teaching with Dr. Shannon Dorcy since 1996 and then working with her since 2004 on the research project that generated the data for the present manuscript. It has been a collaboration that has endured over time even though we come from different clinical backgrounds and expertise (mine in community/population health; Kathleen’s in cancer and cancer research). Despite (or perhaps because) of these differences, we share many commonalities, including an abiding interest in issues of social justice, as well as an ongoing commitment to examining concerns central to nursing through “a different lens.” A prime example is Kathleen’s inspiration to use a model of epigenetics to illustrate the transitions that occur in those participating in cancer research. This line of research has generated an interest in examining how physician/researchers, research nurses, and IRB members understand the differences between research and treatment. That, along with our continuing work on bringing social justice to nursing practice, education, and research promises to keep us working together far into the future.

From the Author: Lynn Rew

It is a pleasure to introduce Lynn Rew, lead author on one of my Edtitor’s Picks for the current issue.  I suspect that most ANS readers have had some connection to the experience of adolescence, either personally or professionally!  The current “Editor’s Pick” article by Lynn Rew and her colleagues Diane Tyler, Nina Fredland and Dana Hannah reports a research study that sheds light on changes that occur during this highly-charged experience.  Their research provides significant evidence that can guide nursing practice, research and theory development.  Their article is titled “Adolescents’ Concerns as They Transition Through High School”, and while it is featured you can download it for free from the ANS Web site!

Here is a message from Dr. Rew about her experiences of working with adolescents, and some background on the experience of conducting this study:

Not everyone shares my enthusiasm for studying adolescents. Having been an adolescent and parenting two adolescents, I am always curious about how they  change so rapidly and adapt (or not) to these changes. I want to know what adolescents are thinking and doing and why. I began with a longitudinal study of pre-adolescents (4-6thgraders) and found that, for the most part, they engaged in health and safety behaviors; however, when they made the transitions from grade school to middle school and then to high school, many of these behaviors were replaced with what I called health-risk behaviors.

Data for this article came from a longitudinal study of over 1200 adolescents who reside in rural areas in central Texas. For the analysis, I assembled a team that included two family nurse practitioners and a pediatric nurse practitioner.  We met often to determine how we would analyze the written responses of these kids to the prompt, “My main concern is . . .” This writing experience was fun and exciting, not only because we enjoyed reading and interpreting these responses, but also we began to recognize strengths and talents in each other that we hadn’t known before.

Faculty often complain that there is never enough time to write, but when you have a team of nurses who are willing to learn, not only from analyzing the data, but also from each other, writing becomes a joy! I was blessed to be part of such a team.

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