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Complicated Grief

The current featured ANS article is titled “Complicated Grief of Immediate Family Caregivers: A Concept Analysis” authored by Tina M. Mason, MSN, ARNP, AOCN, AOCNS and Cindy S. Tofthagen, PhD, ARNP, AOCNP, FAANP, FAAN. The article is available to download at no cost while it is featured, and we invite you to get your copy, read it, share your ideas about this timely topic here, and respond to the questions posed in this message from Ms. Mason:

Tina Mason

Grace was the sole caregiver for her husband Bob of 46 years. Their son had died while on duty years prior. Grace managed the household and volunteered weekly at a local hospital. Bob was diagnosed with metastatic melanoma but succumbed to the illness in less than 3 months. Six months later, Grace had not returned to her volunteer work. Her appetite was poor and she was not receptive to visitors. She was described as apathetic and her house untidy. Grace was drinking more wine than her usual with-dinner glass. Grace reported to her provider that she felt intense sadness and wished she could be with her husband soon.

It is estimated that over 10 million people suffer from complicated grief in the United States. Complicated grief is the term used to describe prolonged and intense grief that interferes with normal activities and is accompanied by self-destructive thoughts and/or behaviors. The aim of this concept analysis is to provide a clear understanding of the concept of complicated grief and its consequences following the loss of an important relationship.

Nurses, as well as our multi-disciplinary colleagues, need a better understanding of complicated grief in order to intervene early. Because there are so few formal resources available for caregivers in healthcare settings, the authors hope this concept analysis will spur both awareness of the problem and conversation about integrating formal caregiver support programs into practice. Such programs can facilitate awareness of complicated grief, identification of high-risk individuals, as well as early intervention. What types of caregiver support resources are there in your place of employment or community and after reading the article, what types of resources do you think would be most helpful?

Planned ANS featured topics!

As ANS readers have noticed, we no longer devote entire issues to a specific topic, but we do announce topics to feature in each issue.  This provides a good balance between our tradition of calling forth scholarship on timely issues in nursing and health care, and an open door for the wide range of topics that nurse scholars are exploring.  Here are the topics we have planned for the next 6 issues:

Best Evidence for Nursing Practice
Vol 43:2 –  June 2020
Manuscript due date: October 15, 2019 ​
Vol 43:2
Even though the ideal of practice based on evidence has flourished over several decades, the achievement of consistently sound practice, in nursing and in other disciplines as well, still eludes even the most well-intentioned practitioners.  For this issue of ANS we seek manuscripts that explore this dilema, examing questions such as ‘what constitutes evidence?” and “what constitutes the best evidence?” We also seek manuscripts that provide exemplars of best evidence and best practices. 

Methods for Nursing Knowledge Development
Vol 43:3 –  September 2020
Manuscript due date: January 15, 2020
Vol 43:3
We seek innovative approaches to knowledge development in relation to all patterns of knowing in nursing. We also welcome manuscripts that critique any methodologic approach, manuscripts that explore the philosophic, including ethical underpinnings related to the development of nursing knowledge, and manuscripts that address the critical connections between practice and knowledge development approaches.
Humanizing Precision Science
Vol 43:4 –  December 2020
Manuscript due date: April 15, 2020
Vol 43:3
One of the trends of our time is the development of “precision science” – a trend that deserves careful consideration going forward. We seek manuscripts for this issue that provides assessment, explanation, evaluation and critique of this trend in light of the underlying foundations of nursology. This featured topic intentionally calls for both rigor and creativity that provides avenues for discussion and possible new directions in the development of our discipline.
Social Influences on Health
Vol 44:1 –  March 2021
Manuscript due date: July 15, 2020
Awareness of social influences on health (often called social determinants of health) has grown in recent decades as social, political and environmental challenges have increasingly threatened the health and all it inhabitants.  For this issue we invite articles addressing specific nursing approaches related to these issues, and advances in nursing knowledge that forms a foundation for nursing’s contributions to this important area of focus.
Historical Trauma & Health
Vol 44:2 –  June 2021
Manuscript due date: October 15, 2020
Nursing has a long history of practice and scholarship related to the care of people who experience trauma of all types. However, the health effects of historical trauma only recently have begun to be conceptualized and understood as a significant determinant of health.  For this issue of ANS, we invite scholarship that addresses this important connection and provides a clear perspective founded on nursing’s fundamental values. We welcome research reports, philosophic, including ethics analysis, and exploration of theory and evidence guided practice.

Paradigm Shift in Nursing?

The current ANS featured article, available for free download, is titled “Implications for Paradigm Shift in Nursing A Critical Analysis of Thomas Kuhn’s Revolutionary Science and Its Relevance to Nursing” by Ahtisham Younas, MN, BSN and Karen Parsons, PhD, RN. I join the authors in inviting you to download this article, read it and share your thoughts below!  Here is a message from Mr. Younas about this work:

Ahtisham Younas

I am excited to have the article published in ANS. The impetus of this paper dates to the time when I taught nursing theories and models to undergraduate nursing students in Pakistan. The students mostly commented that these theories and models are so complex, and they questioned the relevance of these models for actual nursing practice. At that time, I used case studies to demonstrate the application of these theories and encouraged students to develop nursing care plans using theories of their choice during their clinical. Later, during my master’s program, I studied various nursing paradigms that serve as the foundations of these nursing theories and models. I became curious to learn about the motivation of nursing scholars to develop these paradigms. I was finally able to satisfy my curiosity in my doctoral program when I studied Thomas Kuhn’s work in the nursing philosophy course. I found out that nursing scholars developed nursing paradigms based on Kuhn’s concepts.

   The first time I read Kuhn’s book “The Structure of Scientific Revolutions,” I was blown away and mumbled to myself, “Should I take it seriously?”. I had these feelings because I found some of Kuhn’s arguments quite strange and controversial, particularly the discussion about the paradigm shift. Therefore, I reread the whole book and decided I should analyze this work, explore its relevance for nursing science, and outline the positive and negative implications. I wrote this paper for the nursing philosophy course but later made substantial changes before submitting it to ANS.

   Kuhn has been one of the most cited scholars across various scientific disciplines with over one hundred and three thousand citations. His revolutionary science includes different stages, starting from normal science to paradigm shift. Simply Kuhn argues that a scientific discipline practice under a certain paradigm, but when all the discipline-specific problems cannot be solved under the paradigm, a new paradigm is generated that replaces the older paradigm. The major issues with Kuhn’s science were; the vagueness of ideas, multiple interpretations of the word “paradigm,” inconclusiveness of ideas, issue of incommensurability of paradigms, and the use of case studies from physical sciences to support his arguments.

   Based on the analysis, we noted that Kuhn’s paradigm thinking could be useful to advance the body of nursing knowledge. However, Kuhn’s science was developed for physical and laboratory sciences, and he argued that a single paradigm is adequate to guide a discipline. Hence, we concluded that Kuhn’s science is not robust enough to guide sciences such as nursing because nursing deals with multifaceted human universal health phenomena which change and transform continuously. We proposed that instead of developing more nursing paradigms, it is better to develop middle range and situation specific theories. Such theories are more practical and can help nurses guide their actions in different situations by considering the contextual factors influencing those situations.

   One of my future works is to explore and develop an approach that can help bring various nursing paradigms together to inform nursing practice and knowledge development. The approach does not entail developing a single paradigm, rather it focuses on utilizing the useful aspects of each paradigm to guide research inquires. I would end this message with a question, “Do you think nursing can be conformed under a single paradigm as Kuhn’s envisioned for other physical sciences?”

   I am hopeful that you all read this article and please share your answers, comments, and critiques.

Disability, Justice and Health Inequities

We are currently featuring the ANS article titled State of the Profession The Landscape of Disability Justice, Health Inequities, and Access for Patients With Disabilities authored by Alina Engelman, DrPH, MPH; Claire Valderama-Wallace, PhD, MPH, RN; and Sahar Nouredini, PhD, RN.  In this article, the authors make a compelling case for addressing healthcare inequities for people with disabilities using an intersectional social justice approach.  We are also offering continuing education for this article, and invite you to download the article at no cost while it is featured, and share you comments below!  Here is a message from the authors about their work –

from left: Dr. Sahar Nouredini, Dr. Claire Valderama-Wallace and Dr. Alina Engelman

We see our article as a clarion call for the nursing profession to address health inequities of patients with disabilities — in part, by more readily welcoming disabled practitioners into our own ranks and shifting the orientation of the nursing curriculum away from the colonial project of the medical model to one that is rooted in inclusion and anti-oppression. This article is the result of an interdisciplinary collaboration and relationship building among public health and nursing faculty at California State University, East Bay who bring varied social and methodological perspectives to the issue. Alina Engelman, DrPH, MPH is an Assistant Professor of Health Sciences, and Claire Valderama Wallace, PhD, MPH, RN and Sahar Nouredini, PhD, RN are Assistant Professors of Nursing. We strive to nurture each other as women faculty and friends.

This article originated from a dialogue among colleagues deeply concerned about the failure of health professions to fully come to grips with equitable and accessible care for patients with disabilities. Particular responsibilities and positionalities brought this topic and lens to the forefront as this area of concern must not be seen nor treated as just within the purview of people with disabilities.

Professor Engelman identifies as deaf and her work as an activist, educator and academic have focused on health disparities facing the deaf and hard-of-hearing, including emergency preparedness communication, and community-based HIV/AIDS services in Kenya. Among other health sciences courses, she teaches global health and disability and is a member of the Community Health Commission in the City of Berkeley.

Professor Valderama-Wallace identifies as a lifelong learner calling for antiracist and anticolonial nursing education, research, practice, and policy. She stands upon the shoulders and fierce efforts of ancestors, scholars, friends, and communities. Her research focuses on social justice in nursing education and is also preparing a project focusing on the experiences and perspectives of Filipinx health workers.

Professor Nouredini identifies as a teacher-learner, activist and researcher. Her research interests include environmental justice, occupational health inequities and the integration of environmental health in nursing curriculum and creating a more inclusive community health nursing curriculum.

Our article provides an overview of the health and health care access disparities faced by people with disabilities, followed by an overview of various models of disability with recommendations for the application of specific models to the nursing curriculum and nursing practice. Our article makes the case for an intersectional social justice approach to nursing education by contextualizing the current state of affairs within historical and contemporary models of disability. By doing so, we can better prepare future nurses to address root causes of inequity and to better care for people with disabilities.

We invite you to read our article about the state of our profession in terms of disability justice, consider how the topic is lived, maintained, and shaped where you practice, educate, and develop policy. We share this with the Future of Nursing Study Team for their consideration as a Future of Nursing Initiative would be grossly incomplete without an intentional effort to be inclusive of people with disabilities as colleagues, classmates, and community members we aim to serve. In doing so, we aim to uphold the highest standards of the nursing profession.



Nurses Experiences with Assisted Death

In the current featured open access ANS article, the authors present the outcome of their synthesis of literature focused on nurses experiences with assisted death.  The article is titled  “Ethical, Policy, and Practice Implications of Nurses’ Experiences With Assisted Death:Synthesis” authored by Barbara Pesut, PhD, RN; Sally Thorne, PhD, RN; Madeleine Greig, MSN, RN; Adam Fulton, BScN; Robert Janke, MLIS; and Mathew Vis-Dunbar, MLIS.  Because this is an open access article, you can download and read it at any time!  As the primary author Barbara Pesut states in the video message below, we are eager to hear your responses and comments to this work.  Dr. Pesut has also invited readers to contact her for more information or to discuss this topic!  Please view the video – it is a compelling explanation of the importance of nurse presence in this situation, the important judgments that nurses form, and their role in supporting and advocating for the patient.  

An Exemplar of Middle-Range Theory Revision: Self-Care of Chronic Illness

The current featured ANS article is an open access article, which means it is permanently available for all readers.  The article is titled “Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness” authored by Barbara Riegel, PhD, RN, FAAN; Tiny Jaarsma, PhD, RN, FAAN; Christopher S. Lee, PhD, RN, FAAN; and Anna Stromberg, PhD, RN, FAAN. Their article provides insight into this specific middle-range theory, but also serves as an exemplar of theory development and revision. We are eager to know your comments and responses to their work!  Here is a message from Dr. Riegel about their work:

Barbara Riegel

The purpose of our theoretical refinement was to disambiguate relationships between symptoms and the behaviors of self-care maintenance, monitoring and management within Middle-Range Theory of Self-Care of Chronic Illness. Since the Middle-Range theory was first published in 2012, our group has received a lot of positive feedback and the theory has been used extensively. We also have had external requests from investigators and even federal institutions about how to harmonize insights from theories focused on self-care with those focused on symptoms. Moreover, and as part of the theory-data process of theoretical refinement, we also had internal motivation to provide clarity on aspects of the theory related to symptoms.

Salient new themes explicated in this theoretical revision include that symptoms can be viewed as being part of self-care (e.g. the appraisal, detection and interpretation of bodily

Tiny Jaarsma

changes as symptoms are essential to self-care monitoring), as barriers or facilitators of self-care (e.g. motivate or blunt self-care behaviors), as outcomes of self-care (e.g. optimal symptom control), or in interaction with self-care of (e.g. moderation) depending on the research question being posed. Further, the interpretation of bodily changes as symptoms is complex and prone to heterogeneity such that multiple clinical phenotypes likely exist in how patients can engage in self-care monitoring and management.

We learned a great deal from one another and from the work of several other self-care and symptom scientists in this process, and are excited to see how the revised theory will be used to help guide innovative research. Please follow us at:


Christopher S. Lee

Anna Stromberg

Reconceptualizing the Electronic Health Record for a new decade: A Caring Technology?

Our first featured article in ANS 42:3 is titled “Reconceptualizing the Electronic Health Record for a New Decade: A Caring Technology?” authored by Catherine Robichaux, PhD, RN; Mari Tietze, PhD, RN-BC, FHIMSS; Felicia Stokes, JD,MA, RN; and Susan McBride, PhD, RN-BC, CPHIMS, FAAN. This article examines and critiques a 2009 article published exactly 10 years ago in ANS that focused on the electronic health record and propose a virtue ethics framework for the future (see Dilemmas, Tetralemmas, Reimagining the Electronic Health Record). It is available for free download while it is featured, and we welcome your comments related to this important topic!  Here is a message from Dr. Robichaux about this work:

L to R – Felicia (Liz) Stokes, Mari Tietze, Catherine Robichaux

We are very happy to have this article published in the Critique and Innovation issue of ANS. This is our second collaborative publication and we each bring different experiences and perspectives to the complicated issues inherent in the development and use of the electronic health record (EHR). Susan and Mari are nurse informaticists, researchers and educators, Catherine’s background is ethics and education, and Liz (Felicia) is a nurse ethicist, policy expert and attorney. As with our first article, this manuscript evolved from Susan and Mari’s research exploring nurses’ experiences with the EHR in which the participants described a wide range of advantages and disadvantages.  Recognizing that it had been ten years since passage of the HITECH act in 2009, we were interested in whether some of the problems

Susan McBride

described in their research were identified ten years ago. Through our literature review, we discovered the article by Petrovskaya, McIntyre, and McDonald, Dilemmas, tetralemmas, reimagining the electronic health record.  This article beautifully analyzes advanced technologies with the ethical and philosophical constructs of caring in nursing.  Rather than viewing the use of technology and caring practice as an either/or dilemma, they suggested application of the tetralemma, a Buddhist approach which expands the range of choices.

Although positive aspects of the EHR have been realized since 2009, many problems identified by Petrovskya et al. continue. We discuss these ongoing challenges to patient safety and nursing practice and suggest integration of polarity thinking with the tetralemma as a viable approach to resolution.  Petrovskya et al. also addressed the potential negative impact of the EHR on ethical nursing practice and we explore the relevance of virtue ethics and technomoral wisdom in revisioning the EHR as a caring technology.

We believe that the roles of nursing leadership, education, research and organizational accountability are all critical in addressing the issues identified in this article.  We hope this discussion is helpful to readers and we look forward to your comments.



New! ANS Vol 42 No 3 is now available!

This new issue of ANS features a number of articles that carry ou the tradition of articles that build on past content published in ANS – known as “Critique and Innovation” (also called replication in the past).  Browse the titles of all of the articles in this issue here and watch this blog for more information featuring each of the articles as they become available to download at no cost!

This issue opens with a commentary titled “Peer-Review Mentorship: What It Is and Why We Need It” by Kristen R. Haase, PhD, RN; Laura Dzurec, PhD, PMHCNS-BC, ANEF, FAAN.  Dr. Dzurec, who has served on the ANS review panel for many years, and Dr. Haase, who is early in her academic career,  worked together in to explore in depth the nature of peer review and how it is conducted for papers submitted to be considered for publication in ANS.  The plan we have for mentoring is proving to be highly successful, with mentees moving on to become peer reviewers for either ANS, or for other nursing journals.  If you are interested in participating in this program, take a look at the description of this plan (also accessed from a link in the sidebar of this blog) and let me know of your interest!

Creating Authentic Caring Relationships with Children Who are Technology-Dependent

In our current featured article the authors explore ways to create authentic caring relationships based on Watson’s Caring Science.  The article is titled “Caring for Children Who Are Technology-Dependent and Their Families The Application of Watson’s Caring Science to Guide Nursing Practice” authored by Sydney Breneol, BScN; Lisa Goldberg, PhD and Jean Watson, PhD. This article is accredited for Continuing Education, and you can download this article at no charge while it is featured on the ANS website. We would be delighted to hear from you in response to the ideas in this article!

Here is a message from the lead author, Sydney Breneol, about this work:

Sydney Breneol

This article was developed during my nursing theories and philosophy course in my first year of doctoral studies. We were encouraged to philosophically explore a topic that had meaning to us. At a young age, I was diagnosed with a chronic illness. Throughout my hospitalization, I developed strong relationships with many of the nurses who cared for me and was personally impacted by the positive effect nurses could have on their patients’ outcomes. These nurses displayed compassion and care and were integral to my recovery. These experiences have largely influenced my career as a registered nurse and doctoral student. My doctoral work focuses on improving health care for children with medical complexity and their families. This article focuses on those children requiring medical technology to sustain or optimize life. These children often experience frequent admissions to hospital. It is critical that nurses work to develop and foster a caring relationship with children who are technology-dependent and their families. This critical review examined the experiences and unmet care needs of children who are technology-dependent and their families. Findings from this review of the literature were analyzed using Watson’s Caring Science to explore how nurses can create an authentic caring relationship and environment for these children and their families within the hospital setting.

Breastfeeding in Disaster Relief Camps

Our current featured article addresses a health challenge that has become far too common in our era of climate change. The article is titled Breastfeeding in Disaster Relief Camps: An Integrative Review of Literature by Shela Akbar Ali Hirani, BScN, MScN, IBCLC, RN; Solina Richter, RN, DCur; Bukola Oladunni Salami, MN, PhD, RN; and Helen Vallianatos, PhD.  We invite you to download this article at no charge while it is featured, and return here to share your thoughts for discussion.  Shela Hirani prepared this information about her work for ANS blog readers:

Shela Hirani

Protecting breastfeeding practices of women is essential to reduce the number of child deaths and illnesses during emergency response. Disaster relief camps are one of the most vulnerable settings for mothers and young children where women are exposed to the risk of discontinuing their breastfeeding practices. In low middle-income countries like Pakistan where infant and child mortality is high, disasters and internal displacements result in a further increase in infant mortality and morbidity rates caused by suboptimal breastfeeding practices and subsequent rise of childhood malnutrition. To examine the factors that affect breastfeeding practices of displaced mothers in disaster relief camps, an integrative review of the literature was undertaken.

The review suggests that the breastfeeding experiences, behaviors, and practices of displaced mothers are shaped by a combination of gender-based, sociocultural, economic, and geopolitical factors. The literature review revealed gaps in knowledge on facilitators and barriers that shape the breastfeeding practices of displaced mothers residing in disaster relief in Pakistan. In view of the vulnerability of displaced mothers and rising child mortality rates in disaster relief camps in Pakistan, this review suggests a pressing need to explore a wide range of factors affecting breastfeeding practices of internally displaced mothers in the disaster relief camps in Pakistan. Research in this area is essential to design and execute context-specific and need-based programs, policies, and practices to protect, promote, and support breastfeeding practices of internally displaced mothers in disaster relief camps in Pakistan.

A thorough understanding of wide range of factors affecting breastfeeding practices of displaced mothers will develop nursing knowledge, guide future research by nurses involve in care of mothers and young children in disaster relief camps, and facilitate key stakeholders (health care professionals, policy makers and relief agencies) to develop context-specific supportive interventions, improve breastfeeding practices in relief camps, and potentially decrease deaths of young children.

In the year 2018, I travelled to the Northern region in Pakistan (Chitral) where thousands of families affected by natural disasters are residing in a variety of temporary settlements (disaster relief camps), mainly tents, transitional shelter and huts built out of mud and brick. I undertook a critical ethnographic study to examine the facilitators and barriers to breastfeeding practices of internally displaced mothers residing in disaster relief camps in Pakistan.



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