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School Nurses Building Healthy Environments

Our current featured article is titled “School Discipline Experiences Among Youth With Disabilities From the Perspective of School Nurses” authored by Hannah E. Fraley, PhD, RN, CNE, CPH; Gordon Capp, PhD, LCSW; and Teri Aronowitz, PhD, APRN, FNP-BC, FAAN. Download this article at no cost while it is featured — we welcome you comments below. Here is a message from Dr. Fraley about this work:

As an early career scientist and scholar, I have been building the science surrounding prevention of

Hannah Fraley

youth violence, particularly trafficking, among youth attending schools in the U.S. A large focus of my work has been on evaluating and building awareness among school nurses   regarding how youth experiencing violence and trafficking present in schools so that school nurses can identify and prevent trafficking, given survivors of trafficking consistently report that they are often misperceived in care interactions as “trouble” and “behavioral”. In these foundational studies, we have identified another common theme brought forward by school nurses- youth with disabilities are particularly misunderstood in schools and it is known in literature that they are a population of youth most at risk for violence. This led my colleagues and I to further explore our qualitative data through secondary analysis exploring the perspectives school nurses have regarding discipline practices in school among youth with disabilities using the Peace and Power Conceptual Model.

Our findings highlight youth with disabilities can experience unjust, harsh disciplinary practices because they are misunderstood and mislabeled, fueled by lack of awareness, and understanding among school faculty. These attitudes shape the power-over dynamics in schools, perpetuating the unjust experiences of youth with disabilities, our most vulnerable youth. Particularly, school nurses in our study have shed light on minority youth with disabilities disproportionately experiencing harsh discipline, including unjust, unwarranted restraints and seclusion, kicked out of classrooms and schools, and sent to residential placements, placing them at higher risk for exposure to violence and the juvenile justice system. School nurses’ perspectives of these youth also often conflicted with other colleagues, creating power-over dynamics, such as being left out of planning teams for youth with disabilities and their input disregarded. Bringing to light the disparate discipline experiences of youth with disabilities in our schools is critical to work towards rebuilding emancipatory school systems that promote social-emotional school-wide programs and restorative justice practices, consistent with peace-power dynamics. Findings from this secondary qualitative data analysis have set the stage for my future study with adults with disabilities exploring their past school discipline experiences. Because people with disabilities are often understudied, hearing directly from people with disabilities themselves about their school discipline experiences will not only serve to inform my future work with school faculty, but will serve to bring their voices and experiences forward.

Social Cohesion in Health

Our current featured ANS article is titled “Social Cohesion in Health: A Concept Analysis” authored by Hailey N. Miller, PhD, RN; Clifton P. Thornton, MSN, CPNP; Tamar Rodney, PhD, PMHNP-BC; Roland J. Thorpe Jr, PhD and Jerilyn Allen, ScD, RN. We invite you to download this article at no cost while it is featured, and share your thoughts here! Dr. Miller shared this background about this work:

Hailey Miller

Early on in my PhD program, I grew an interest in understanding the social determinants of health, specifically as they relate to cardiometabolic diseases. While conducting a literature review to narrow my dissertation research question, I identified a gap in the literature surrounding the relationship between social cohesion and obesity. At the same time, I noticed the heterogeneity in how dimensions of the social environment, specifically social cohesion, were conceptualized and operationalized in literature. This made using the findings to draw conclusions and inform my dissertation work difficult. As a result, my colleagues and I decided to conduct a concept analysis on social cohesion. The findings from this concept analysis were integral to the development of my dissertation and the interpretation of my findings. It is my hope that readers find this article useful in informing their future work, as well.  

Collaboration – DNP and PhD

Our current featured article is titled “Constructing Doctoral Leadership Scholarly Role Boundaries Through Intraprofessional Nursing Education,” available for download while it is featured. The authors are Peggy Jenkins, PhD, RN; Jacqueline Jones, PhD, RN, FAAN; Alexis Koutlas, MSN, RN, NE-BC; Suzanne Courtwright, MSN, RN, PNP; Jessica Davis, FNP, AOCNP, ACHPN and Lisa Liggett, RN, MSN, CCRN. In this video, Dr. Jenkins is joined by three of her co-authors who recently completed their DNP programs, to discuss the value of DNP and PhD collaboration.

Peggy Jenkins
Jessica Davis
Alexis Koutlas
Lisa Liggett

NICU to Home Transitions for Adolescent Mothers

The latest featured article is titled “The Complexity of the NICU-to-Home Experience for Adolescent Mothers: Meleis’ Transitions Theory Applied” by
Elizabeth Orr, MSc; Marilyn Ballantyne, PhD; Andrea Gonzalez, PhD and
Susan M. Jack, PhD. This article presents an exemplar of the application of nursing theory in nursing practice, and is available to download at no cost while it is featured. The primary author, Elizabeth Orr, provided this message about this work:

Elizabeth Orr

As a nurse in a busy Neonatal Intensive Care Unit (NICU) you quickly become accustomed to the ‘revolving door’ nature of admissions, transfers and discharges – as one infant leaves the unit, they are swiftly replaced by another. During my 13 years as an RN in the NICU, I found admissions very fulfilling; the whole team would spring into action, working together to stabilize a critically ill infant or prepare newborns and their families for urgent surgery. Discharges and transfers were somewhat less satisfying. Being well enough to be discharged from intensive care was always something to be celebrated, however I often found myself wondering how infants and families fared post discharge; hoping someone in the community would notice, and tie up any loose ends that may have gone overlooked on account of the complexity and acuity of the NICU patient population and environment. These feelings of uneasiness at discharge – in particular with the more vulnerable adolescent mother/baby dyads in the NICU – served as the impetus to explore the NICU-to-home experience further.

The importance of successful care transitions and the need for novel patient- and family-centered care approaches to ensure safety in the hospital-to-home process is becoming a recognized priority within healthcare. However, while exploring the existing literature on NICU-to-home transitions, what I found striking was the primary and often exclusive focus on the discharge event. Very little attention was given to the fact that, according to Meleis’ Transitions Theory, at the time of discharge from NICU adolescent mothers are experiencing at least 4 transitions: (i) a health-illness transition—NICU admission; caring for an infant with increased risk of developmental-delay/complex health needs; (ii) a developmental transition—becoming a mother; (iii) a situational transition—discharge home from the NICU and notably, these 3 transitions occur within the context of a fourth transition; (iv) the developmental transition of the adolescent mother to adulthood.

This paper applies Meleis’ Transitions Theory to the example of hospital-to-home transitions for adolescent mothers and their infants and argues for and increased recognition of the importance of overlapping and intersecting transitions and an overall more holistic, theory-informed approach to understanding hospital to home care transitions.



Examining Infant Bed-Sharing from a Nursing Perspective

Our current featured ANS article is titled “A Nursing Perspective on Infant
Bed-Sharing: Using Multidisciplinary Theory Integration
” authored by Marissa G. Bunch, MSN, RN, CPNP and Sadie P. Hutson, PhD, RN, WHNP, BC. Download this article at no cost while it is featured to learn more about the topic of bed-sharing, as well as the authors’ approach to theory integration. Here is a message provided by Marissa Bunch (now Dr. Bunch!) about this work:

After over a decade of work with families as a pediatric nurse practitioner, I recognized that philosophies of parenting and infant care advice often conflicted with what families were actually practicing in their homes. When it came to bed-sharing, there was a glaring mismatch between what I was telling caregivers and what many of them were actually doing; many were afraid to disclose that they were sleeping alongside their infant, despite the high prevalence of families who have shared a bed across cultures and throughout history.

 While there is a large push to encourage caregivers to eliminate bed-sharing due to an association with infant death, there is also a surprising lack of clear evidence that an unimpaired caregiver poses an inherent danger to their child during sleep. The evidence that is available varies depending on which theoretical viewpoint the researcher adopts. This article calls for nurses to acknowledge the various theories guiding this research and how those paradigms frame research results. The knowledge I gained from immersing myself in the theory behind infant bed-sharing informed my dissertation research with caregivers from Appalachia who shared a bed with their infants. I wanted to give my patients a voice and bring into the open what I was hearing behind the clinic doors. This article is part of the foundation for that work.


Socioeconomic Factors Influencing Self-management of Diabetic Foot Ulcer

The title of the current ANS featured article is “I Cannot Afford Off-loading Boots: Perceptions of Socioeconomic Factors Influencing Engagement in Self-management of Diabetic Foot Ulcer” authored by Idevania G. Costa, PhD, RN, NSWOC; Deborah Tregunno, PhD, RN and Pilar Camargo-Plazas, PhD, RN. The article is available to download at no cost while it is featured! Here is a message from Dr. Costa about this work:

During my experience providing care for individuals with chronic conditions for almost two decades and delivering wound care for marginalized people (e.g., low-income and minority groups) in society, I witnessed patients facing several struggles to achieve the desired outcomes, being oppressed and prevented from being actively involved in decision-making about their own care. They were victims of a biomedical model that often places individuals as passive subject in their own care and prevents them from taken on a more active role in order to achieve better outcomes. Because biomedical model is also paternalistic and focus on disease rather than on a person as whole, individuals are often prevented from understanding their roles and acquiring the abilities needed to manage their chronic conditions.

Thus, when I embarked on the journey of writing my doctoral thesis, I wanted to approach the topic by challenging the status quo of a biomedical model and therefore giving voices to research subjects. I wanted to provide them with the opportunity to help us to understand their needs, motivations and struggles of having a chronic wound while navigating in a social world. I also wanted to consider questions, such as how do healthcare providers might better meet the needs of individuals with chronic wounds (e.g. diabetic foot ulcer) if they looked beyond just the illness itself? I believed that to address my goals I needed to use a methodological approach that would view individuals in society as active subjects working collectively and sharing experiences to re-construct their world and realities. I was fortunate enough to have had two amazing co-supervisors (Drs. Tregunno and Camargo Plazas) who guided me through this process of learning about a variety of methodologies and choosing one that would be the best fit to my research questions and philosophical assumptions. With their guidance I embarked on the journey of writing a grounded theory (GT) study. They provided me directions and allowed me to make a decision about which version of GT to use in my study.

After reading and learning about the main versions of grounded theory and doing a literature review, I noticed sparse studies focusing on individuals’ needs, motivations and struggles to manage their chronic wounds. There was no published study showing a theoretical model depicting the factors that influence individual’s engagement in self-management of a multifaceted chronic wounds such as diabetic foot ulcer (DFU). In response to this research gap, and to contribute knowledge on how to improve self-management and health outcomes of DFU from patients’ unique experience, I decided to use constructivist grounded theory to understand the processes of engagement in self-management described by individuals with active DFU, and develop a theoretical model depicting the factors that influence their ability to actively engage in their own care (Figure).

Ultimately, I want to invite healthcare providers, particularly, wound care professionals and policy makers, to take a look in this paper as it uniquely uncovers inadequacies in diabetes knowledge and inequalities in access to wound care services and resources for individuals living with DFU. These findings provide a foundation to guide clinicians and policy makers in improving diabetes care in order to reduce the risk of developing DFU in the first place, and ultimately, to improve self-management of diabetes and DFU. Finally, these findings also highlight the need to ensure the necessary self-management education program, services, and resources to facilitate individuals’ engagement in self-management of a multifaceted condition are in place.

Fostering Change in the Practice of Nursing

In my own undergraduate nursing program at the University of Hawaii, we heard an often-repeated phrase reminding us that we were being prepared to be “change agents.” Throughout my career I have often reflected on this “charge” and the reality that so little changes – particularly when we consider the challenges that nurses face in putting many of the ideals of nursing into practice. In our current featured article title “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study” the authors Patrick Martin, PhD and Louise Bouchard, PhD, address this long-standing tension. They conclude that what is needed is a radical renewal of democracy in hospitals. Dr. Martin provided this background information about their work:

The aim of this study onDSC_0130 (1) which we had a great time working together was to explore the lived experiences of politically engaged staff nurses working in a hospital centre; to portray the social order that exists there; to describe the way in which the nurses would ideally like to practise; and to record their ideas and the action they have taken individually and collectively for fostering change in the social order and the practice of nursing. Epistemologically, this qualitative study was based on a view of reality as complex, mutable, and dependent on individual perception, which suggests a comprehensive, contextualized approach to human action and politics and, hence, to the consideration of the political views of the participating nurses.

The linkage between lived experience, normative ideals and political action has been explored from a dialectical, praxeological, postmodernist perspective which constitutes a reflection not only on what is but also on what ought to be. Such a reflection may, under certain conditions, lead to transformative action. We cannot say that the results of this study have contributed to the current changes, however these have been widely published in the mass media and we can now see a small revolution taking place in the nursing field in Quebec (Canada).

These results indicate a gradual deprofessionalization and increasing technicization of nursing. Our findings point, too, to an intensifying drift towards authoritarianism in hospitals with the adoption of the semantic register of the market economy along with the notions of efficiency, performance and optimization. Viewed as little more than high-performance robots, staff nurses find themselves excluded from decision-making processes. They have thus been deprived of the freedom to express opinions about or criticize decisions taken by the top ranks of the hospital power hierarchy (rather than by the nurses themselves) regarding the way nursing is practised. Disciplinary power in hospitals, exerted through technological policies such as constant surveillance, reprisals and fear, the technicization of care, and mandatory overtime contribute to the staff nurses’ subjectivation. Their clinical judgment has been devalued, their group solidarity undermined, and their union organization brought to heel. They have thus been diverted from demanding the realization of their rights and their ideals of emancipation and been reduced to the role of subordinates.

Accordingly, although the nurse participants want to take action in the hospital to humanize care and achieve professional self-determination, the practical purpose of much of the action we recorded was, rather, their own protection and survival in a dehumanizing hospital system. There are, nonetheless, staff nurses who raise conscientious objections, resort to individual or collective non-cooperation or engage in acts of civil disobedience with the aim of establishing a new power relationship, one that must necessarily be put in place for their demands, which would otherwise be ignored in this system of hospital governance, to be taken seriously.

Unless the antagonistic exercise of power in this system of hospital governance is thwarted by the exercise of equal or greater power on the part of nurses working collectively, they will continue to be subjected to its political philosophy and objectives. It emerges from their discourse that nurses collective action must focus on the radical renewal of hospital democracy, which, as a new power relationship, will enable staff nurses to fully participate in discussions of the orientation of their practice.

About the authors:

Dr. Martin with new baby daughter!

Patrick Martin is a nurse activist and an associate professor at the Laval University’s Faculty of Nursing. He is also a researcher at the Quebec Heart and Lung Institute. His research interests include the organization of work, social relations and power structures in which nurses’ experiences are rooted and strategies for nonviolent action. The central axis of his research program proposes to examine the system of constraints inherent in the social world in which nurses and nurse managers operate, as well as the effects of this system on their health and workplace safety. He investigates these elements by focusing on their relationship to politics, allowing them to envisage individual and collective courses of action to reduce these constraints in a perspective of sustainable health at work.

Louise Bouchard is a retired professor from the Faculty of Nursing at the University of Montreal, after teaching for over 30 years. She campaigned for many years on feminist committees, both in the local union and in the Fédération québécoise des professeures et professeurs d’Université. Her political commitment is continuing to recognize nurses’ freedom of conscience, particularly in the ideological context of medicalization and biopower.

A Post-caregiving Health Model

           Our first featured article from ANS 43:4 is titled “The Post-caregiving Health Model: A Theoretical Framework for Understanding the Health of Former Family Caregivers of Persons with Dementia” authored by Kristin Corey Magan, PhD; Mary K. McCurry, PhD; Kristen A. Sethares, PhD; Meg Bourbonniere, PhD; Salimah H. Meghani, PhD; and Karen B. Hirschman, PhD. While this article is featured, you can download it at no cost from the ANS website! We invite you to do so, and share your responses here! Dr. Magan shared this background information about this work for ANS readers:

As a doctoral student, I decided to explore my observations further. My mentor, Dr. Mary McCurry, and I conducted a pilot study of the experiences of former dementia caregivers following the care recipient’s death. The study findings supported my observations from clinical practice. We also found that depressive symptoms and sleep disturbances persisted for as long as a decade after caregiving ended. The findings provided a foundation for my doctoral dissertation, which involved the development and testing of the Post-caregiving Health Model. This article provides a detailed description of the development of this model.

The Post-caregiving Health Model highlights a stage of caregiving that has been neglected in previous research: the stage we refer to as “post-caregiving” or the time following the death of a care recipient. Based on the Transactional Theory of Stress, the model emphasizes the effects of appraisal, emotion, and coping on long-term post-caregiving health outcomes using a holistic perspective. We intend to utilize this model to guide our future research on post-caregiving health outcomes and as a foundation for developing and testing interventions that target effective coping for caregivers after caregiving ends.


Reducing Nurses’ Moral Distress

Our current featured article is titled “Freirean Conscientization With
Critical Care Nurses to Reduce Moral Distress and Increase Perceived Empowerment: A Pilot Study” by Nancy A. Bevan, PhD, APRN, ACNS-BC and Amanda M. Emerson, PhD, RN. Dr. Bevan sent this message giving ANS readers some background about this work:

Moral distress in nursing is a significant problem that needs to be understood and addressed.  This paper reports some of the findings from my doctoral dissertation work that explored using Freirean Pedagogy as the theoretical basis for an educational intervention for nurses who have suffered moral distress. I have always been interested in research on the health of nurses. My long career in critical care nursing piqued my interest in moral distress in nurses because I have experienced it myself and witnessed it in others.

While reading the literature, I became intrigued by the discussion of nurse’s relative powerlessness as one of the causes of moral distress. There is strong evidence linking powerlessness arising from structural hierarchies embedded in health care to moral distress in nursing; this has led some to argue that nurses are an oppressed group.  Based on that,  like other oppressed groups, nurses may lack insight into their oppression and struggle ineffectually to overcome it on their own. A Freirean educational intervention was created with the help of an international expert in Freirean pedagogy and piloted in nurses who have suffered moral distress.  Results showed improved moral distress and mixed results in perceived personal and group empowerment. Further study is warranted, but we need to take care of our nurses, and start finding ways to address moral distress in a concerted way.

The Omnipresence of Cancer

The current ANS featured article is authored by Maya Zumstein-Shaha, PhD, RN; Carol Lynn Cox, PhD, RN, FHEA; and Jacqueline Fawcett, PhD, ScD (Hon), RN, FAAN, ANE, titled “The Omnipresence of Cancer: Two Perspectives.” The article is available at no cost while it is featured; please share your comments and ideas related to this article here! Dr. Zumstein-Shaha shared the following message, and the video below, about this work.

Maya Zumstein-Shaha

In the article entitled “The Omnipresence of Cancer: Two Perspectives”, which is appearing in ANS volume 43, issue 3, is authored by Maya Zumstein-Shaha, PhD, MScN, RN, Carol Lynn Cox, PhD, RN FAHE, and Jacqueline Fawcett, RN, PhD, ScD (hon), FAAN, ANEF. In this article a midrange nursing theory is proposed aiming at enhancing the care of patients with oncological malignancies. This theory is timely as cancer remains one of the most frequent causes for death around the globe and diagnostics and treatments are changing rapidly.

Carol Lynn Cox

Therefore, oncology care is also facing changes regarding aims and objectives as well as methods of supporting persons with cancer and their members of the family.

The authors of this publication have worked across countries – namely Switzerland and the United States – to describe nursing knowledge development and theory construction. The collaborative work has yielded the second perspective of this theory, namely the re-interpretation of the study findings from which the theory emerged in

Jacqueline Fawcett

the light of a grand theory in nursing.

In the video below, the theory’s development is briefly described, and a schematic is provided along with a brief summary.

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