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Posts from the ‘Theory’ Category

Developing Praxis in Nursing Education

Our featured article from the current issue of ANS is titled “Work-Integrated Learning: A Didactic Tool to Develop Praxis in Nurse Education” by Elisabeth Dahlborg Lyckhage, PhD, RNT, RN and Sandra Pennbrant, PhD, RNT, RN.  In

Elisabeth Dahlborg Lyckhage

Elisabeth Dahlborg Lyckhage

this thought-provoking article, the authors examine the concept of “praxis,” clarifying various meanings and proposing a view of this concept that challenges nurse educators to examine, with students, their nursing actions from a philosophical, theoretical, and practical point of view.  They provided this message about their work as nurse educators in Sweden:

Our interest in the concept of praxis was aroused some ten years ago when we noted that the concept was used in completely different ways in nursing. Sometimes one was referring to routines, sometimes to the tangible reality (as practice), sometimes to the connection between theory and practice. To deepen and clarify the meaning of the concept of praxis, in order to use praxis as the knowledge created in the

Sandra Pennbrant

Sandra Pennbrant

meeting between theory and practice, we have used work integrated learning. University West is responsible on the national level in Sweden for developing work integrated learning. It is therefore important for teachers in the nursing program to use work integrated learning as a tool for developing praxis.






While their article is featured on the ANS web site, you can download it free of charge!  We welcome your comments and responses; read the article and return here to share your ideas!


Exploring the meaning of cultural competence

The current ANS featured article is titled “Cultural Competence in Health Care: An Emerging Theory” by Isabelle Soulé, PhD, RN.  In this article, Dr. Soulé presents the outcomes of her qualitative descriptive study to examine the current state of cultural competence in health care.  In her conclusion, she states: “This exploration of cultural competence in health care and health care education is a small step toward achieving a more complex understanding of cultural competence that moves away from superficial approaches toward recognition of the interplay of the many economic, political, geographic, and social conditions that provide a context for health disparities and health care disparities in our world today.”  Dr. Soulé provided this additional reflection on the complex relational challenges of health care in a world that is culturally diverse:

         Like so many others, I am uncomfortable with the term cultural competence.  Despite it being my primary area of research, over time, I find myself using the term less and less. I am not dissuaded by the ideals it represents such as receptivity, flexibility, curiosity, inclusivity, understanding context, and humility, but rather that the term inadvertently implies an endpoint despite what is stated to the contrary. In part, perceptions concerning cultural competence are derived from the concept being nested within US healthcare systems and healthcare education which are based on competence. Competence is indeed a worthy goal, but I argue it is not globe300enough.

Cultural competence is centrally relational in nature, and high-quality relationships require awareness, flexibility, and humility. This includes being open to learn, conceive of alternate sets of values, appreciate how mind-sets develop, and understand that all behaviors make sense in context. Inevitably, individuals and communities brought up in widely varying contexts and backgrounds live in widely different realities or “truths”. This understanding has been deeply embedded in me after 15 years of working abroad with indigenous peoples and with refugee communities from all over the world. In short, these communities have been some of my most important teachers.

In a typical US healthcare encounter, power and privilege often lie firmly on the side of the healthcare provider as a result of specialized education, professional and economic status, and even national citizenship. It can be challenging to recognize this privilege and realize the distance it can place between provider and client / family / community. This makes it difficult if not impossible to negotiate a collaborative plan of care. In order to redress power imbalances between provider and client, system and community, genuine humility is required. Humility includes respecting difference and recognizing that all perspectives have value. Difference is legitimate and people who have different ways of expressing themselves and enacting health and illness are just as valued as our own. Respecting different viewpoints as equally valid can serve healthcare providers in revealing where their viewpoints may be incomplete or limited. In addition, interacting in a non-judgmental way with people who have different ways of looking at things requires asking more questions than simply giving answers – a key skill in the development of trust and empathy.

Humility, not often addressed in professional circles, can be thought of as an accurate assessment of oneself, an ability to recognize and acknowledge limitations, and a willingness to be influenced by alternate values and worldviews. Humility may not be simply overlooked in US healthcare, but may actually be perceived as antithetical to competence, professionalism, and professional practice. Because many health professionals are educated to think in these terms, they may be quick to misunderstand or reject teachings that offer an unrecognized worldview or alternate set of truths. Moreover, building partnerships where health professionals respect the expertise of the client and family in their own healthcare decisions runs contrary to how professionalism is taught and role modeled in our schools and professions today.

Interacting from a starting point of humility rather than professional expertise (competence) can generate a very different type of healthcare encounter that, in the end, can be more satisfying to both client / family as well as healthcare providers. However, to elevate the position of humility in healthcare education and systems, radical transformation will be required. A beginning point can include creating safe places for students and faculty to discuss and learn from their less than elegant cultural moments (incompetence) without judgment, and with emphasis on openness (humility) and deep learning. In this spirit, the following questions can be used to begin this conversation:

  1. What assumptions am I making?
  2. How else can I think about this?
  3. How might the other person (family, community) be thinking about this?
  4. What am I pretending to not know?

Developing cultural competence and cultural humility – may the discussion continue.

Please do engage in this conversation by sharing your comments and ideas here!  You can download this featured article on the ANS web site at no charge while it is featured.  Then return here, and let us hear from you!

Focus on transitions from a nursing perspective

Eun-Ok Im, PhD, MPH, RN, CNS, FAAN is the author of our latest featured article titled “Situation-Specific Theories From the Middle-Range Transitions Theory.”  She begins her article is a concise overview of nursing’s theoretical evolution, placing the emergence of situation-specific theory in an historical context.  Dr. Im and Dr. Afaf Meleis first introduced the concept of situation-specific theory in their 1999 ANS article titled “Situation-specific theories: philosophical roots, properties, and approach” (ANS 22:2, p 11-24).  This current article provides, in addition to the historical overview, an analysis of 6 situation-specific theories and themes reflecting commonalities and variances in the theory development process.  Dr. Im shared this message about her work:

As you can see in the picture, we had lots of snow here in Philly, and hope all of you would stay warm and safe!  🙂snow

First of all, thanks a million for this opportunity to discuss my article with my respectable colleagues and students.  This article was originally initiated because of doctoral students in my theory class in Spring, 2013.  The students wanted to know about how a situation specific theory could be developed from a middle-range theory.  Although I previously wrote about the integrative approach to development of situation specific theories, the paper might not be adequate to address the students’ questions. The students were eager to learn about the exact theory development process that had been taken in previous development of situation specific theories. Also, since our original paper on situation specific theories was written in 1999, I thought this might be the right time to evaluate how situation specific theories have been developed.  Especially, I was wondering how situation specific theories were derived from middle range theories and further developed as “ready-to-wear” theories.

As the article illustrates, the development of situation specific theories from the middle-range Transitions theory were on the same directions that were originally proposed, and I could extract several themes reflecting the commonalities and differences in the theory development process.  The reviewed situation specific theories derived from Transitions theory focused on specific phenomenon of interests with narrow foci and provided clear implications for nursing practice. They were developed using multiple sources of theorizing, but mainly based on research-evidence. They

Dr. Eun-Ok Im

Dr. Eun-Ok Im

specified, added and combined major concepts and/or sub-concepts, and they had been developed to advance nursing theory toward forms of theory applicable to specific practice situations.

In the article, based on these findings, I proposed two implications for future development of situation specific theories: (a) to continue our efforts to further develop, specify, and modify the concepts and sub-concepts of situation specific theories through “integrative approaches”; and (b) to support the situation specific theories with strong collective evidence from nursing practice and apply and evaluate the situation specific theories in practice settings. From this stance, I would like to work on further recommendations for future development of situation specific theories.

Through this blog, I hope to open a conversation on the directions for future development of situation specific theories, which would be essential for future nursing knowledge development. Any thoughts would be greatly appreciated.

I join Dr. Im in encouraging you to respond to her article, and participate in a conversation here about these ideas!  This kind of conversation is vital for the future development of our discipline!  You can download your copy of her article while it is featured at no cost, so read it today, and come back here to join the conversation!


Experience of genetic vulnerability

This current featured article addresses the fundamental focus of nursing identified by Margaret Newman and her colleagues – caring in the human health experience.  The article, titled “Theory Development From Studies With Young Women With Breast Cancer Who Are BRCA Mutation Negative” is authored by Rebekah Hamilton, PhD, RN; Samantha Kopin, BA.  Here is Dr. Hamilton’s message about their work:

I am very pleased to have this article on theory development published in ANS.  Theory development is an integral but infrequently accomplished process in grounded theory research.  It takes time…time that is generally not going to be supported by research funds, at least not at the NIH level.  For a grounded theorist one of the interesting things about theory development is considering the impact of context.  In the group of young women interviewed for this study, the influence of family history quickly became apparent in their level of skepticism over the negative result of the BRCA test.  Most of them initially stated that they simply didn’t believe the results.  Their perception of their risk for future breast cancer development was grounded firmly in their family’s experiences around breast cancer and other cancers as well.  While the young women who had no family history of early onset breast cancer were puzzled they were not influenced by past events and were much more likely to want to simply “move on”…to get over the treatments and get beyond the breast cancer.  Those with a family history did not express this idea of “moving on” because they attributed their experience to genetics…and that moves with you.

As a researcher it was encouraging and interesting to see some of the concepts developed in the first theory (Theory of Genetic Vulnerability) present in the second analysis.  The concepts of “Experiencing the family disease”, Testing for a mutation” , and “Foregrounding inherited genetic risk” were also present with the participants that had a family history of breast cancer while only “Testing for a mutation” was evident in those without a family history.  The clinical implications of this is that a nurse must realize that the “facts” that are presented to someone when faced with genetic testing must blend well enough with the family history or it will largely be discounted or at least perceived as not particularly relevant to the patient.

I recently presented the original theory at the International Family Nurses Association in Minneapolis and received interesting and supportive comments on using a mid-range grounded theory in a family practice setting to help the RN or APN guide an assessment of a patient.  It was suggested by a colleague that perhaps the most pertinent questions are not related to what brings a patient into the clinic on  that day but what they perceive to be the vulnerabilities of their families.  Would we get different answers about our patient’s concerns and perceptions of their own and their family’s risks?  Might be an interesting conversation to have!


We invite you to join the conversation here on this blog!  Go to the ANS web site to download your copy of this article at no charge!

Engaging with Nursing Theory

The current featured article by Marjorie McIntyre, PhD, RN and Carol McDonald, PhD, RN offers a significant perspective on the importance of understanding nursing theory and its philosophic underpinnings in practice. Their article is titled: Contemplating the Fit and Utility of Nursing Theory and Nursing Scholarship Informed by the Social Sciences and Humanities. They draw on their own experiences in nursing education and practice to present a framework to guide philosophic explorations that strengthen nursing practice and nursing education. Dr. McIntyre gives some background related to their work:


Marjorie McIntyre and Carol McDonald – photographer Robbyn Lanning

We were particularly thrilled to have this article published in the ANS as it is a reflection of three decades of curriculum work in nursing education and follows on and extends an earlier article published in the ANS in 1995. This article presents a philosophical framework as one possibility for organizing and interrogating knowledge, bringing together ontological assumptions of nursing with other vital epistemologies. While Carol and I have both been deeply influenced by the process of theorizing in our nursing practice, in more recent years we have come to see more clearly the place of philosophical thought in nursing. Indeed, the movement “beneath” theory, to philosophical underpinnings provides a way to more fully take up, to make meaningful the theoretical connections that are nursing practice. This opening from the extant nursing theories to broader philosophical underpinnings has created space to hold the meaning of theories from within and beyond the discipline, without relinquishing our disciplinary groundings. As nurses who have worked in highly interprofessional practice settings and have at times felt overshadowed by medicine or psychology, this work to express our theoretical situatedness, in a disciplinary sense has been closely connected to our experiences as nurses in practice and as nurse-educators.

While this article is featured, you can download and read the article!  Visit the ANS web site now and explore this and other articles in this issue!

Critical Caring Model update!

One of the best things about having a blog for ANS is the ability to update content along the way!  Adeline Falk-Rafael has provided an update on the model that she and Claire Betker used as the basis for their research reported in the article titled “The Primacy of Relationships: A Study of Public Health Nursing Practice from a Critical Caring Perspective.”  (See the recent blog post about this article).  Dr. Falk-Rafael explains this new depiction as follows:

This model of Critical Caring theory represents more of an evolution in the graphic depiction of the model than in the theory itself.  The color and artwork better depict the metaphor of the tree and are more suitable for the web than the previous black-and-white diagram and results, hopefully, in more legible text.  As in the previous model (published in ANS 35:4), the trunk of the tree, which supports the praxis branches, is comprised of the tenet of Critical Caring as a way of being, knowing, and choosing, along with 2 carative health promoting processes.  The shading  and positioning of each is helpful both in differentiating the carative processes from the tenet and in emphasizing the centrality of the latter.

I believe this model brings the elements of critical caring into focus, and helps to comprehend the whole of the process that the model represents.  Many thanks to Dr. Falk-Rafael for providing this update!

critical caring-DRAFT3

Prevention of Re-hospitalization

One of the most important preventable factors that contributes to high medical costs for the elderly is re-hospitalization.  In the current “Editor’s Pick” article, Dr. Hong Tao, PhD, RN, and her colleagues (Carol Hall Ellenbecker, PhD, RN; Jie Chen, PhD; Lin Zhan, PhD, RN, FAAN and Joanne Dalton, PhD, APRN,BC) provide specific evidence that can be used in reaching the goal of preventing re-hospitalization.  The article, titled “The Influence of Social Environmental Factors on Rehospitalization Among Patients Receiving Home Health Care Services,” summarizes a study based guided by Orem’s Self-Care theory.  The researchers conducted a retrospective study of the Outcome and Assessment Information Set (OASIS) records of 1268 elderly patients, 262 of whom were rehospitalized within the first 20 days of being enrolled in home care.  The two hypotheses of the study were supported, providing important evidence that can be considered in designing programs aimed toward prevention of rehospitalization.

Dr. Tao shared this description of how this study evolved, as well as her current and future research activities:

I embarked on this program of research during my doctoral studies supervised by Dr. Ellenbecker, whose expertise is health policy and home healthcare. Since the Prospective Payment System case mix methodology does not contain

Hong Tao and Carol Ellenbecker

Hong Tao and Carol Ellenbecker

OASIS items that are cited as triggers for social work referrals, we realized that it may be critical to find evidence that social environmental factors could be independent predictors for readmission and should be assessed to identify high-risk patients.

The findings of the study summarized in this article have led to a series of studies and expanding collaboration to sites in Wisconsin where I am now residing. In a recently conducted pilot study of Visiting Nurses and case managers we found that the early identification of changes in health condition by family members is a factor in preventing re-hospitalization. Families’ ability to identify changes in health condition in a timely manner was influenced by three primary factors: effective communication between healthcare providers and patients/families; supportive self-care/family-care guidance; and patient and family member’s perception of constricted option (e.g. the hospital is the only place/first option at all times). My future research will focus on developing an intervention to reduce re-hospitalization targeting family members of elderly patients with multiple comorbid conditions, who are discharged to home healthcare immediately following hospitalization.

This is an excellent example of research based on a nursing framework that has broad applicability for all disciplines concerned with prevention of rehospitalization.  You can download your own copy of this article now, at no charge!  Visit the ANS web site today!



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!

Aging, language and health care

How we talk and think about aging is something that most often is taken for granted.  This is not the case for Connie Madden and Kristin Cloyes who have investigated the language of aging in history, theory and research.  They point out in their featured article titled “The Discourse of Aging,” the experience of aging is common to all humans, but it remains poorly understood.  Their analysis reveals how the language of aging has shaped not only our general ideas about the “common” aging experience, but the research and theories related to aging.  Their analysis shows how language has tended to dichotomize how we think about aging as an either-or — living longer or living better.  Nursing, they believe, can make a significant contribution to understanding aging by bringing a holistic view to this experience, and challenge notions that perpetuate limited and stereotyping assumptions about aging. Here are some reflections from the authors about their work on aging:

Connie Madden: My interest in the language of aging has been fueled through my experiences as a nurse educator talking with students about their experiences and perceptions.  Through PhD course work as a student in the University Of Utah Hartford Center Of Geriatric Nursing Excellence, I have been able to expand my interest through exploring the relationship between language, perception and the practice of providing nursing care for older adults.  In a particular course, The Philosophy of Inquiry ,  Dr. Kristin Cloyes helped put those  pieces together  through examination of anti-aging and healthy aging language as it intersects in the larger aging discourse.
Kristin Cloyes: It’s always inspiring when a scholar is able to take the typical structure of a required course and shape it into something they really want to say, growing a field she or he is passionate about in new directions. In this case, the structure involved a required course paper in which I ask students toexplore a central concept in their area of interest, to identify common epistemological assumptions that shape the field and to explore how these assumptions stand up when viewed from differing frameworks. Connie used the paper to embark on an incisive analysis of assumptions about aging, and how these may shape nursing education. After I suggested that her thesis should be developed for publication, I was lucky enough for Connie to invite me to help expand and refine her ideas about the discourse of gerontology as an emerging area of study.
The credit on the illustration “The Seven Ages of Man” shown above reads:  Bartolomaeus Anglicus, Le Proprietaire des Choses tres Utiles … Paris 1510
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