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Keeping the Nurse in the Nurse Practitioner


Editor’s note:
See information about the 2nd Annual Nursing

Theory Conference and future conferences here

Our current ANS featured article is titled “Keeping the Nurse in the Nurse Practitioner Returning to Our Disciplinary Roots of Knowing in Nursing” by Sylvia K. Wood, DNP, ANP-BC, AOCNP. In this article, Dr. Wood examines the factors that have shaped nurse practitioner education and provides the case for restoring nursing roots as central in the future.  The article is available for download while it is featured – we welcome your comments and responses to this challenge!  Here is a message from Dr. Wood about her work:

Sylvia Wood

Attending the 50th Anniversary 2019 Case Western Reserve theory conference, I was deeply moved to listen to the wise voices of nurse theorists leading our profession, warning us of current threats in losing our disciplinary perspective. Having attended an open session for the Future of Nursing 2020-2030 just two days earlier, and journey as a Ph.D. candidate, created a confluence of events that compelled me to bring this article forward. It is my honor to present it in this issue of ANS. As a nurse practitioner and nurse educator, I have witnessed both the loss of nurse theory-driven practice and diminished presence in our curricula. This article provides a historical background for the context of the issue, existing challenges for academic educators are presented with an analysis of the current literature and recommendations are offered.

For many years in NP practice, these questions never left my mind, what is it that NPs know and do that make them so distinct from other providers and why is their care so valuable in its own right? Why is what they know not made visible? I often observed that NPs, including myself, could not find the words to explain our nursing, our nursing knowledge, how this nursing knowledge shaped what we did in practice, or trace that knowledge back to nursing theory and nursing science. Nevertheless, the result of our NP care significantly improved patients’ health outcomes, healing, wellness, wholeness, and quality of life.

As NP practice has become more sophisticated, there has been a necessary expansion of education from other sciences and health-related disciplines. However, there is a decreasing emphasis on the theoretical foundations of nursing and nursing science, unmooring practice from its anchor to nursing. The result obscures not only NPs’ identity, and the relevance of our practice compared to other providers, but the nurse-sensitive patient outcomes as a consequence of it. The theoretical basis of nursing knowledge (nursology) is what distinguishes nurse practitioners from other health care providers and drives the results associated with it.

2020 is the Year of the Nurse and Midwife. It is also a critical time when the demand for NPs is on the rise, and NPs are advocating for full practice authority. Therefore, in honoring our contract with society, we have an ethical and moral obligation to know, articulate and demonstrate the scientific foundation underpinning the distinction of our practice by returning to our disciplinary roots of knowing in nursing to keep the nurse in the nurse practitioner.

 

Reprinted with permission: Baldwin, M. (2009). Tree of Life~Hope. [Web Image of Oil Painting]. EBSQ Self Representing Artists.

The autonomy of a profession rests more firmly on the uniqueness of its knowledge, knowledge gathered ever so slowly through the questioning of scientific inquiry. Nursing defined by power does not necessarily beget knowledge. But knowledge most often results in the ascription of power and is accompanied by autonomy (Fuller, 1978, p. 701).

Source:

Fuller, S. (1978). Holistic man and the science and practice of nursing. Nursing Outlook, 26, 700-704

Teaching Authentic Nursing Knowledge


The current ANS featured article is titled “Proposing Standards for Teaching Authentic Nursing Knowledge,” authored by Debra R. Hanna, PhD.  This article appears at a time when many nursing faculty are realizing the importance of re-claiming and emphasizing nursing’s own body of knowledge and are discussing effective ways to do so.  The article is available at no cost while it is featured; we invite you to consider Dr. Hanna’s ideas and return here to share your comments and reflections on her work.  Dr. Hanna shared this message about her work followed by slides summarizing her main points:

Debra Hanna

This article is based on a speech I gave at the Case Western Reserve Nursing Theory conference on March 22, 2019 called Differentiated Standards for Teaching Nursing at Four Learner Levels. As I worked on the manuscript, I began to consider a wider scope of concerns that relate to how we teach authentic theoretical nursing knowledge.

Questions I’ve wondered about are: Which teaching standards might ensure that authentic nursing knowledge would be well taught at each learner level? When do nursing students learn to speak with the true words of authentic nursing knowledge? In fact, what is authentic nursing knowledge? What are nurses’ true words?

Authentic theoretical nursing knowledge has been incrementally set aside in official curricular documents for nearly two decades. Maybe one reason we’ve relinquished authentic nursing knowledge is that we never developed standards for how such knowledge should be taught at each learner level. In this article I present my thoughts about a simple structure of four learner levels that lead to four types of nursing practice.

The article has four sections. The history of our first curricular standards precedes a section on authentic nursing knowledge and ideas from Paolo Friere about true words. The next section shows that some teaching standards exist for prelicensure and graduate education. Yet, hardly any standards exist for teaching authentic nursing knowledge at each learner level. The final section differentiates curricular standards from teaching methods from teaching standards. This section is where proposals for new teaching standards are made.

From November 15, 2019 until January 15, 2020 the American Association of Colleges of Nursing called for a National Faculty meeting so that academic nurse educators could discuss proposed revisions to the AACN Essentials curricular documents. The next step will be regional meetings to collect feedback on the proposed AACN Essentials. This article offers timely ideas that might be useful for that important National Faculty discussion.

The Theory of Wisdom-in-Action for Clinical Nursing


The current ANS featured article is titled “Development of a Theory of Wisdom-in-Action for Clinical Nursing” authored by Susan A. Matney, PhD, RN; Kay Avant, PhD, RN; Lauren Clark, PhD, RN; and Nancy Staggers, PhD, RN. You can download this article at no cost while it is featured!  Here is a message from Dr. Matney about this work:

Susan A. Matney

The article presented in Advances in Nursing Science describes the emerging Theory of Wisdom-in-Action (WIA) for clinical nursing. The theory was developed in three phases, In Phase 1, a preliminary theory was developed deductively using derivation and synthesis, based on theories and models from psychology, education, and nursing. Pertinent concepts were identified and nursing-specific definitions created. In Phase 2, a constructivist grounded theory approach inductively captured the experience of wisdom in nursing practice, based on wisdom narratives from 30 emergency department nurses. The resulting grounded theory focused on two processes, technical and affective, juxtaposed on a foundation of expertise. In the final Phase 3, the two theories were synthesized into the Theory of WIA for Clinical Nursing. The theory describes two antecedent dimensions, person-related and setting-related factors, and two types of wisdom processes. General wisdom processes apply to patient care and describe the actions nurses take during a stressful or uncertain situation. Personal wisdom develops afterwards, as a feedback loop with reflection, discovery of meaning, and learning, followed by increased knowledge and confidence.

The theory illustrates how wise nurses practice using their head, their heart, and their gut. The following fictional story demonstrates WIA:

Jane Everywoman was practicing in the emergency room when she received a 42-year-old female patient into the trauma room with a head injury sustained during a bike accident. Jane has 10 years of experience and is the charge nurse for this patient. The patient was non-responsive and had been resuscitated. Jane called the trauma team and they began advanced trauma life support measures. Synchronously, Jane calls the family and notifies them that their wife and mother is in the hospital. The distraught family comes to the hospital and Jane puts them in a private room and visits them routinely to empathically give them updates. During the resuscitation, Jane gets the feeling that she should bring the family into the room, which she finally does. The family was only there for a short time when the doctor tells the nurse to remove them from the room. The patient ends up dying. Weeks later, the patient’s husband finds Jane in the emergency room and thanked her for doing everything they could to save his wife, communicating with him, and bringing the family into the trauma room. He said it was the hardest and best thing she could have ever done because it showed him that everything was being done to save his wife and helped him start the grief process.

The theory of WIA for clinical nursing general wisdom attributes include expertise, a technical nursing process, and affective processes, influenced by insight and intuition. Jane had expertise and was performing the technical skills needed to resuscitate the patient (head). At the same time, she used emotional intelligence to communicate with the family (heart). She also listened to her gut and brought the patient’s family into the trauma room during the resuscitation.

Wisdom is critical for all areas of nursing practice. The nascent Theory of Wisdom-in-Action for Clinical Nursing provides a working framework for translating wisdom in clinical nursing practice into theoretical and practical terms, depicting both the science and the art of nursing. This novel theory displays how nurses practice with wisdom during stressful and uncertain situation. The theory still needs refinement and testing but we feel it reveals that wisdom in action requires clinical skills, experience, knowledge, and affective proficiency.

Catching the Narrative Wave in Research and Practice


The current ANS featured article is titled “Claiming the Narrative Wave With Story Theory” authored by Patricia Liehr, PhD, RN and Mary Jane Smith, PhD, RN, FAAN. The article is available for download at no cost while it is featured. In this article, the authors clarify the nature, the importance, and the benefits of narrative in both research and practice.  Download the article now, and share your comments for discussion here!  This is a message provided by Dr. Liehr for ANS blog readers:

Mary Jane Smith (right) and Patricia Liehr (left_

Near the end of our STORY-WAVE paper, we say: “In order to attend to unique health challenges for those in our care, nurses must embrace the idea that listening to another’s story is as essential as any other vital sign.” Hardly any nursing action occurs without some understanding of the context that has supported an individual’s presenting health challenge. In fact, another’s story can tie together other pieces of clinical data in a way that makes sense; that enables human-centered precision care. Story is a vital sign; story theory proposes a way for nurses to think about, collect and analyze practice and research stories.

Just recently, while talking with a nurse who has spent the last 30 years working in the emergency room, the conversation turned to what energizes her and keeps her passion for nursing alive. In a move to South Florida about a decade ago, she was introduced to the population of Jewish patients who bear the history of the Holocaust, branded onto their wrists. She has invited these older adults to talk about the marking, thereby offering an opportunity to “make visible” what can easily be overlooked in an emergency room visit. “…sometimes they pause and I can see that they are considering what I have asked but almost all of them speak to me about the Holocaust. I LOVE caring for these older adults.”  We believe that stories like these create a context for caring; in this case, infusing advanced ER knowledge and sophisticated skills with recognition of person that makes a difference in well-being.

In 2020, the Year of the Nurse and Midwife and the 200-year anniversary of the birth of Florence Nightingale, it is definitely time to claim the narrative wave. Why????….because story is central to our practice and our research. In the last line of our STORY-WAVE paper we say: “Story theory can help nurses raise recognition of stories from practice and research as valuable guiding evidence, thereby claiming the narrative wave as an integral facet of disciplinary knowledge development.”….that’s why.

Theory-guided Practice: Application of Transitions Theory


Our first featured article from the latest ANS issue (coming soon!) is titled “Reducing 30-Day Readmissions Through Nursing Science: An Application of Transitions Theory With Best Practice Guidelines” by Bridget Stixrood, MSN, RN, CNL.  In this article, Ms. Stixrood provides an exemplar of theory-guided practice!  While the article is featured, you can download it at no cost.  We welcome your feedback and comments!  Here is a message from the author about her work and her perspective:

Bridget Stixrood

I am honored to present my article outlining the Transition Management Model to this issue of ANS.

 The Transition Management Model was completed as a part of my MSN program. The goal of the project was to improve care transitions for patients and reduce 30-day readmission rates for an Independent Health Network. At this unique healthcare setting nurse care coordination was utilized to manage care for complex Medicare and Medicaid covered individuals. Upon initial design of the project I quickly became inspired and energized by the application of nursing science to frame best practice guidelines. I found that nursing theory provides enough flexibility to adapt to the unpredictable nature of healthcare politics, policies and emerging best practice guidelines.

This project underscores the overwhelming importance of nursing practice to improved health outcomes and reduced 30-day readmission rates. I believe some project success could be attributed to the holistic nature of nursing practice. As nurses we look at an individual’s whole health story including spiritual, mental, physical and environmental.

Behavioral health was particularly difficult to address in the Transition Management Model. Those with mental illness have an added barrier to care when they are symptomatic and need a higher level of management. Applying the Transition Care Model to mental health transitions could be a next step for this project. Improving community partnerships and using nursing science to address the complexities of healthcare in the US is desperately needed. I am curious about what types of breaks in healthcare delivery are you seeing in your community? How can we build a practice that maintains integrity despite what political constructs we work within?

This article is meant to be read as a catalyst and an example of how nursing theory, in this case Transitions Theory by Meleis, can be a useful tool in navigating the complex health stories of our patients and the healthcare environment we function within.

I obtained my MSN from Pacific Lutheran University in 2018. I obtained my Clinical Nurse Leader certification soon after graduation. After working as a labor and delivery nurse for a year while also working at the Pierce County Jail, I fell in love with nursing in the jail setting. I am currently working as a nurse at the King County Correctional Facility. I am passionate about nursing science, mental health care and public health.

I look forward to reading your comments and strengthening our practice together.

A Concept Analysis of Prodromal Myocardial Infarction Fatigue


Currently our featured ANS article is titled “Prodromal Myocardial Infarction Fatigue: A Concept Analysis” by John R. Blakeman, MSN, RN, PCCN-K.  Please download the article at no cost while it is featured, and return here to share your comments and feedback!  Here is John’s message about his work, including a presentation that he prepared featuring this work:

Symptom research is complicated. Because symptoms are, at their core, a human experience, each individual may perceive, attribute, and react to them in different ways. Because of the unique context in which they occur, symptoms cannot reliably be reduced to single, simple, objective pieces of data. Prodromal myocardial infarction (MI) fatigue is no different.

About six years ago, I began my adventure into the world of MI symptoms, especially MI symptoms experienced by women. I had heard about symptom differences between men and women, but, up to that point, I had not closely examined these symptoms in any comprehensive, systematic way. As I dove into the literature, one of the major themes that I identified was that fatigue was a particularly prevalent symptom experienced by women before an MI. However, fatigue was conceptualized in a variety of ways.

Symptom research is a messy business, partly because this research necessarily involves a considerable amount of self-report data. It is not uncommon to see multiple different descriptions of a given symptom. In the case of prodromal MI fatigue, I read a number of descriptions. Some research participants across studies had described this fatigue as “tiredness,” while others might have opted for the term “weakness.” Still others simply used the term “fatigue.” Study participants also provided an array of descriptions regarding the severity and intensity of this symptom. I recognized that this central, latent construct of prodromal MI fatigue was really made up of a number of other constructs, and I wanted to comprehensively review the literature to identify what exactly this latent construct of prodromal MI fatigue “looked like.” Out of this desire came the present concept analysis.

I learned that there was not a simple, neat definition that could be created, though I was able to identify several general commonalities across the many documents that I reviewed. I also recognized the need to further investigate prodromal MI fatigue, and I am now completing a qualitative study focused on women’s experiences of prodromal MI fatigue. This concept analysis helped frame my understanding of the symptom and guided me as I designed my study. Is there more work to do? Absolutely. I expect, and would hope, that this concept will be further refined and that researchers will be able to use this increased knowledge to improve care and patient outcomes. Indeed, if prodromal MI fatigue can be recognized early, morbidity and mortality can likely be reduced due to early intervention, prior to MI.

 

Women with Coronary Heart Disease and Depression


The current ANS featured article, free to download while it is featured, is title “Clarifying the Concept of Depression in Women With Coronary Heart Disease” authored by Sydney Buckland, MSN, APRN-FNP; Bunny Pozehl, PhD, APRN-NP, FHSFA, FAHA, FAAN; and Bernice Yates, PhD, RN, FAHA.  Sydney Buckland shared the following message with ANS readers about her work; I join her in inviting your comments and ideas related to this work!

Sydney Buckland, Ph.D., APRN, FNP-C
Staff portrait taken in the Michael F. Sorrell Center for Health Science Education on the UNMC campus in Omaha on Thursday, August 15, 2019.

My PhD dissertation work (which I completed in May, 2019) brought together three topics I’ve been passionate about for decades: cardiology, mental health (particularly depression), and the health of women. The intersection of mental health and coronary heart disease (CHD) finally began to be explored in earnest in the late 1990s, with lots of attention being paid to depression in particular. But as I immersed myself in this literature, it became clear to me that there was a rather glaring problem: the way depression was being defined. Or perhaps more accurately, the way it was not being defined. Even though authors would define other variables such as a myocardial infarction with very clear and specific criteria, nobody was defining depression. The official (DSM) diagnostic criteria for depression were never cited, and the vast majority of studies relied on screening instruments rather than clinical diagnostic interviews to determine depression status. What this did, in effect, was to turn the items included on the depression screening instrument into the de facto definition of depression. Given the huge variety of screening instruments, including those that do not follow DSM criteria and/or do not contain somatic symptoms, I wondered how many women with depression were being missed because of the choice of screening instrument.

I decided to write a concept analysis, really diving into what depression in women with CHD “looked like”. Since most of us are not trained to do a diagnostic interview, and diagnostic interviews are lengthy, the reality is that screening instruments will continue to play a central role in identifying (at least initially) those who have depressive symptoms. I wanted researchers and clinicians to be able to make an informed choice regarding a screening instrument to use with this population – one that matched women’s experienced symptoms and followed DSM criteria.

I am delighted to share my concept analysis with the ANS readership and truly hope that by clarifying this concept, women with CHD who are experiencing depressive symptoms will be identified, treated, and ultimately experience better health outcomes.

Movement and Mobility


Our current featured article is titled “Movement and Mobility: A Concept Analysis” authored by Elizabeth Moulton, MSc; Rosemary Wilson, PhD; and Kevin Deluzio, PhD. These concepts seem simple on the surface, even though both are integral to a large proportion of nursing care, they are often taken for granted. But as this article shows, they are far from simple, and are vital to a person’s health and well-being.  We welcome your comments and responses to this article – you can download it at no cost while it is featured, and then return here to share your comments!

Here is a message Elizabeth Moulton shared about this work:

When I began my PhD studies I knew that I was interested in how people moved and how this affected their overall mobility. I had worked for several years in a lab where we measured human movement with sub-millimetre accuracy. Yet, as I sat down to write my thesis proposal, I found that I was unsatisfied with how the terms movement and mobility were used in the literature. They were often used interchangeably and their relationship with one another was unclear.

This concept analysis was written as the first part of my PhD thesis. While writing it, I had the chance to go back to the fundamental definitions and explanations of movement that were introduced in high school Physics. Mrs. Jones’s clear explanation of how we know something is moving was the first thing to come to mind when establishing the defining attributes of movement. I expanded as the project progressed to encompass definitions found in the literature and my clinical experience as a nurse. These concepts were linked to the International Classification of Functioning, Disability, and Health to align them with an already well-established framework.

This concept analysis is the basis of all future works for my thesis. It has been used to assess tools that claim to measure movement and/or mobility in a scoping review and has been used in a paper that explores the operationalization of the concepts from theoretical definitions to definitions that can be used to establish measures for clinical and research purposes.

I’m delighted to share this concept analysis that has been fundamental to the progression of my research and hope that others will be able to benefit from it.

Ethics of Prison Palliative Care


The current ANS featured article is titled “Towards a Guiding Framework for Prison Palliative Care Nursing Ethics” by Helen Hudson, MSc(A); David Kenneth Wright, PhD.  In this article the authors interweave four strands of analysis—contextual, relational, social, and political—to produce a framework to guide ethical action in prison palliative care nursing.  This article is available to download at no cost while it is featured, and we welcome your comments here!  Here is a message about this work from the author Helen Hudson:

Helen Hudson

Most nurses have little cause to think about prisons or prisoners on a day-to-day basis, yet prisoners’ health needs are extensive. Markers of social disadvantage, including racialization, poverty, mental health issues and illiteracy, are overrepresented among prisoners throughout the Western world, reflecting a lack of access to the determinants of health prior to incarceration. As the global prison population ages, more and more people are dying behind bars of illness or age-related causes.

This paper came about as I examined the literature on palliative care for prisoners in anticipation of starting a doctorate on the topic, only to find that most scholarship engaged with the how questions, without considering the why. That is, end-of-life conditions and palliative care practices – where they exist – are described without much interrogation of why so many people are ending their lives in prison, or what that means, ethically, for the nursing discipline. Though the ethical challenges in this field of nursing are well described, to our knowledge no overarching framework has been put forward for understanding and addressing them. Together with my doctoral supervisor David K Wright, RN, PhD, CHPCN(C), I wrote this paper to address that gap. In it, we articulate an ethical analysis of palliative care nursing for prisoners throughout the illness and grieving trajectory (that is, not solely at end of life), both within and outside of prison facilities. Drawing on literature from various health disciplines – nursing, bioethics, medicine, social work, and public health – as well as prison studies and critical criminology, we synthesize perspectives that illuminate moral questions for practice, research, policy, education, and political action.

I’m excited to share this paper with the ANS readership and look forward to engaging with your comments.

Exploring the Meaning of Quality of Life


The current ANS featured article is titled “Analysis and Evaluation of Conceptual Model for Health-Related Quality of Life Employing Fawcett and DeSanto-Madeya’s Critique Framework” by Min Kyeong Jang, PhD, KOAPN, RN and Catherine Vincent, PhD, RN.  In this article, the authors examine the meanings of this construct in research and in practice, and point to the importance of adequate definitions and meanings for both research and practice.  You can download this article at no cost while it is featured; we hope you will and will also share your responses to the authors’ work here!  Dr. Jang shared this information about this work for ANS readers:

We are delighted that Advances in Nursing Science (ANS) invited us to contribute to the ANS blog. In the field of nursing, health-related quality of life (HRQOL) has been a significant issue that is essential to holistic assessment of patients’ health. In 1994, Wilson and Cleary developed a HRQOL model, and in

Dr. Carol Ferrans with Dr. Min Kyeong Jang

2005, this model was revised by Ferrans and colleagues to clarify the relationships among the theory concepts, expanding it into an ecological model. The revised HRQOL model was recognized for its promise for future use in HRQOL research and practice, but no previous authors had formally critiqued the model. In our article, we provide a comprehensive analysis and evaluation of the HRQOL model, which we hope will be useful for advanced nursing care and research.

In this article, we identified how the relevant concepts and propositions of the HRQOL model align with the nursing metaparadigm and maintain consistency. In addition, we found that this HRQOL model can easily and comprehensively be applied to improve nursing research and practice. One example is that this HRQOL model can be applicable as a guide for synthesizing an integrated literature review. Guided by HRQOL model, Min Kyeong and colleagues identified and synthesized essential key factors influencing mammography screening among breast cancer survivors from 2000 to 2017, published in the Oncology Nursing Forum. (Figure 1 – An example of applying the HRQOL model). Guided by the HRQOL model, the conceptual model of factors influencing surveillance mammography adherence was able to integrate all relevant key factors. Also, we believe that the most important advantage of using the HRQOL model is to ensure comprehensively covering important factors, some of which can be easily overlooked.

Briefly, Min Kyeong Jang, PhD, RN, KOAPN has been involved in cancer treatment and research for more than 10 years, while simultaneously developing expertise in methodological studies. To be specific, HRQOL is one of her research interests, and Dr. Carol Ferrans, PhD, RN, FAAN (Harriet H. Werley Endowed Chair in Nursing Research) was her PhD mentor (See photo above – Drs. Jang and Ferrans). To develop accurate QOL instruments for use in Korean health care research, Dr. Jang guided the translation of all 15 versions of the Ferrans and Powers QOL instrument, and she also studied the methodologies of theory analysis and theory development with Dr. Catherine Vincent as her guide (co-author).

In collaboration with various research teams, Min Kyeong Jang has been pursuing investigations involving QOL, cancer-related symptoms, chronic pain relief interventions, exercise program development, and sarcopenia, with the ultimate goal of enhancing survivorship care for cancer patients. She is currently working as a postdoctoral fellow at both the University of Illinois Cancer Center and University of Illinois at Chicago College of Nursing with Dr. Ardith Z. Doorenbos and colleagues. She believes that the HRQOL model merits examination to further assess its applicability and usefulness within nursing science; thus, she is applying this model to provision of supportive care for patients.

Jang, M. K., Hershberger, P. E., Kim, S., Collins, E., Quinn, L. T., Park, C. G., & Ferrans, C. E. (2019, November). Factors Influencing Surveillance Mammography Adherence Among Breast Cancer Survivors. In Oncology nursing forum (Vol. 46, No. 6, p. 701). Used by permission

 

 

 

 

 

Figure 1.  An example of applying the HRQOL model

Jang, M. K., Hershberger, P. E., Kim, S., Collins, E., Quinn, L. T., Park, C. G., & Ferrans, C. E. (2019, November). Factors Influencing Surveillance Mammography Adherence Among Breast Cancer Survivors. In Oncology nursing forum (Vol. 46, No. 6, p. 701).

 

Figure 2.  Drs. Jang and Ferrans

 

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