Due to technical difficulties with my webinar last week I decided to make a recording of my presentation that is now available as a YouTube video. The length is just under 30 minutes. I hope you will join me for “lunch” or “tea” to experience the video, and share your thoughts and critique here or on the Advances in Nursing Science Journal blog.

This presentation covers some of the ideas from my recent paper “The Integrality of Situated Caring in Nursing and the Environment” published in the current issue of Advances in Nursing Science. I sincerely look forward to the dialogue that I hope this presentation and paper will provoke. Don’t be shy, please share your thoughts.

What prompted me to get permission to “reprint” the dream was a request, by email, from a school in Australia that was facing a routine accreditation review of their curriculum, and in the documents that they had on record describing the curriculum there was a reference to a “dream of a healing house” that was not cited, but that folks involved with the program believed to have been published by me at some point along the way!  They were contacting me to see if this was the case, and if so, where was it published.  I still do not know what their curriculum materials contain, but of course I provided the information they needed and urged them to keep working to make this a reality!

This kind of connection continues to pop up regularly with the NurseManifest project – someone somehow hears about or sees the web site, and either emails or comments when we meet about how much the web site means to them.  So far we have done no promotion, and I wonder what might happen if we were to find more ways to let folks know we exist?  But regardless, I am so very glad that the ideas are “out there” as part of a much wider and deeper trust that we can make a difference!

If you have had experiences that affirm the possibility that our ideals can, or actually are coming into action, please share here!  Just share a comment about what you have experienced, and let’s build a “log” of things that affirm our conviction that the ideals can be real!

I just watched the film “The Politics of Caring” featured on the nursemanifest.com website and oh, does it make some powerful statements about politics in nursing that are still relevant today! A core messages in the film is the importance of improving hospital working conditions, both for the nurses, and for the safety and health of patients. Growing out of my involvement in the NurseManifest Project, much of my current work directly focuses on research about the nursing work environment, including nurse staffing and management practices.

One of the defining moments of my nursing education was learning about the concept of “Upstream Thinking” in my senior year Community & Public Health Nursing course. We learned about John Snow’s classic work on the London Cholera Epidemic of 1854 and read Patricia Butterfield’s seminal ”Thinking Upstream” article (Adv Nurs Sci 1990;12(2):1-8) that challenged nurses to think beyond one-to-one caring relationships and embrace the social, environmental and political determinants of health. This was reinforced the following year in my graduate nursing theory course, with the addition of Butterfield’s then new paper, “Upstream Reflections on Environmental Health” (Adv Nurs Sci 2002;25(1):32-49). While nursing education programs are working to integrate new content in (epi)genetics, (epi)genomics and environmental health it is more important than ever to emphasize the interconnectedness (or integrality) of human beings and the environment.      

The macro-level and micro-level (holographic) ways that human beings, including nurses, are interconnected with their environment and each other will be the main focus of a free webinar/seminar that I’m giving next week and hope you will be able to attend. The presentation is titled Redefining the Metalanguage of Nursing Science: Contemporary Underpinnings for Innovation in Research, Education and Practice  and will be on Wednesday, Feb 8, 2012 (12-1:30 EST) at the University of Pennsylvania, Barbara Bates Center for the Study of Nursing History. This presentation will utilize images and narrative to explore the ideas presented in my new paper, The Integrality of Situated Caring in Nursing and the Environment, currently featured on the Advances in Nursing Science website. To register for the webinar: https://www2.gotomeeting.com/register/210662026

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog was viewed about 3,000 times in 2011. If it were a cable car, it would take about 50 trips to carry that many people.

Click here to see the complete report.

My first question: why are physicians more involved in the fate of nursing than nurses? I have tried not to let this get under my skin, but now it’s starting to itch!!

My second question: were these challenges anticipated when the powers that be decided to create the DNP and then make it mandatory as of 2015?

My third question: why have we still not found a solution to the entry-level-of-practice-for-nurses question?

Unfortunately I was left with far more questions than ideas after reading this article, but one thing I thought of is, couldn’t physicians be called “physicians” and nurse practitioners be called “nurse practitioners” and PAs be called “physician assistants,” etc.? If someone introduces themself as “Dr. So and So” that would reflect their educational background/degree, and then they would immediately clarify their role. I, for one, prefer to be called “Jane” by my patients, but I always let them know that I am a nurse and certified diabetes educator. I’m not sure what outcome(s) we’ll see from this physician-led legislation, regarding who can be called “Doctor,” but it seems that if someone earned a doctorate and wants to be called that, it’s their prerogative. There are a lot more doctors out there than just physicians, after all.

Thoughts?

While the non-profit Sutter Health has real profits in the near billion dollar range, we are left wondering why it is the nurses’ benefits are being cut even as the heads of the organization walk home with millions of dollars of “bonuses” each year.

http://www.bizjournals.com/sanfrancisco/news/2011/03/25/sutter-healths-2010-profits-surge-30.html

I think the nurses are in some respects justified in taking this stance and going on strike; they are working together to stand in solidarity (though up to 40% of the nurses at the various hospitals crossed the picket lines and reported to work). On the other hand, I feel that the strike does not create an atmosphere for discussion and dialogue that might be meaningful. This action in and of itself seems unlikely to create a path for communication between administrators, decision makers, and the nurses. The union itself also prevents much of this direct communication and may prevent the working nurses from communicating their concerns outside of the union’s presence.The strike does create some obstacles and safety concerns for patients, administrators, nurses crossing the strike line, and the replacement nurses.

I have thought a mass exodus of the nurses, or many immediate resignations, would be more effective, though highly unlikely to happen for obvious financial reasons. For each nurse who quit, Sutter would lose at least $60, 000 in training a new nurse to replace them. These expenses could add up very quickly if a good chunk of the nurses walked away from their positions. Sutter may have problems with hiring new nurses in relation to the higher costs of benefits, the reduction in vacation pay, and the elimination of paid sick leave. Paid sick leave can help to stop the spread of illnesses like the flu (have we already forgotten H1N1?), but perhaps I am digressing a bit here.

It would be interesting to poll the public and get their perception of striking nurses, professionalism, empowerment, and the image of nurses. From the current state of the media coverage, it is difficult to tell where the public stands on this.

We do know that the nurses have now been locked out until Tuesday, as at least two of the hospitals have a minimum contract of five days for their temporary staff contracts. These contracts are likely very expensive and in no way are saving Sutter any money, which was the reason given for changes in the benefits. http://www.baycitizen.org/blogs/quality-of-life/nurses-who-went-strike-told-not-come/

The issue of unions, strikes and walk-outs is prime for nursing researchers to continue to explore: what are the outcomes of strikes, do the nurses feel or experience a sense of empowerment through the process, what is the public’s perception of nurses’ unions and strikes, and so on.

During the August conference of INANE (International Academy of Nursing Journal Editors) in San Francisco, the 130+ nursing journal editors and publishers heard a presentation by Susan Hassmiller, the Senior Advisor for Nursing for the Center to Champion Nursing in America.  In response to her presentation, the group decided to initiate a coordinated effort across as many nursing journals as possible, to further the possibilities for the achievement of the report’s recommendations.  So far, the INANE web site has a listing of editorials and resources that have appeared in various nursing journals over the past year or so; in the spring of 2012, many of the journals will carry focused messages about the report, articles, and other content that provides evidence and resources for their readers in moving forward.  I would encourage folks to browse this list … it is impressive, and many of the editorials are well worth looking up and reading.  Also, if you want to see Susan Hassmiller’s presentation from the INANE conference, you can find it here (scroll down to the Friday 8:00 session).

So my question for readers of the Nurse Manifest blog: can we both challenge and cooperate?  I fully agree with many of the challenges that came forward in our discussion in June, including skepticism about the source of the report, and the fact that the report’s recommendations are in fact what we might call “lame.”  However, the cold hard truth is that the recommendations of the report, which of course should already be reality, are far from real.  If we were to achieve the report recommendations as reality, do we not have a better outlook for achieving not only the fundamental goal of better health care and better nursing care, but also the ideal of seeing nursing at the center of health care policy-making.  If we simply sit on the sidelines and challenge the report, then we isolate ourselves from the places where mainstream change might be possible.  If we simply cooperate with the report without questioning some of the assumptions and directions, then we ourselves may all too easily be drawn into an abyss of the status quo.  So bottom line, to me, there is no simple way forward.  But I favor moving forward, challenging ideas and actions where possible to be heard, and with as much cooperation as possible with those who follow a more mainstream path than many of us follow!

This is another excerpt form the Nurse Manifesto, a document that calls us as nurses to create avenues of change for the future of the profession. As I reflect upon this excerpt, and our identity as a profession. Where did we come from and where are we headed? How can history inform the future of our profession, and how is it we can come together to create meaningful change?

Nurses Honor the Past By Wearing Caps For A Day

In 2002, I wrote an article about the nursing shortage and how in some respects, the profession has created our oppressive cycle by not coming together to empower ourselves and take control of future and our practices (Clark, 2002). Perhaps reflective of the greater culture, we tend to enact lateral violence, and repeat actions that keep us divided over our differences versus united in the quest to provide the greatest healing opportunities for our patients. We see that our own oppression grows, as we widen the gaps between administration/ managers and practicing nurses, and the dominance of nurse educators over students. Focusing on our differences, creating small factions, failing to care for ourselves, not committing to being lifelong learners, and spreading ourselves thin all contribute to our professional oppression and keep us from focusing on our common goals.

I believe that we can each start right where we are at. The first step is caring for yourself that you may also better for care for others, patients and colleagues alike. Creating work environments of healing and caring is a common goal we can share and explore together on the local level. We can commit to creating a consciousness for change in nursing and healthcare.

As the over-arching professional organization, it would be wonderful if the American Nurses Association could begin to bring us together on a national level. It seems the state nursing associations on many levels are more likely to create local action, but they also need assistance in gaining participation and increasing membership numbers. In my small state of Maine at our statewide meeting last year a quorum was not established as there simply were not enough members present to meet that mark.

I imagine a professional world where each donate some of our time every year toward taking action on the local-statewide level, whether that is writing a letter to congressional representatives, or serving our larger communities, or perhaps sharing our expertise about the human experience. I have served on the local school board, where I helped to foster much-needed changes in the kitchen and the nutritional program, and now I serve on the early education advisory council in my town, where I share and learn about childhood development and teaching and evaluation skills. Churches are another great place to provide healing services and demonstrate your expertise as a nurse. Serving in communities helps us to unit with the community and our patients; this unification process can also foster change as we grow our partnerships and empower communities and individuals toward creating the healthcare system of the future.

One great way to come together is to join a specialty nurses association and attend their conference. I have found great comfort, support, and enthusiasm in the American Holistic Nurses Association; it is rejuvenating to leave the conference and begin to take action based on what was learned there. I have found that the AHNA has a great commitment to changing the future of the nursing profession, and empowering nurses on a meaningful manner.

Lastly, how do we empower the future nurses to realize the potential of our profession? They must understand the path that nursing has traveled, the change process, self-care, and their potential contribution to the unveiling of the new paradigm of healing in our future.

Nurses in the Future

References:

Clark, C. S. (2002). The nursing shortage as a community transformational opportunity. Advances in Nursing Science, 25(1), 18-31.

Cowling, R., Chinn, P.L., & Hagedorn, S. (2000). The Nurse Manifesto.
Retrieved August 12, 2011 from
http://www.nursemanifest.com.

The Peace and Power process breaks down barriers by challenging ideological beliefs and behaviors that alienate and divide us from one another (Chinn, 2008). This process begins with an honest personal inventory and evaluation of sociocultural mores and conditioning that inform our beliefs. It is from this starting point that we can begin to see the power of our thoughts and feelings. How we act and react creates experiences of nurturance and shared power; or of conflict and derision. “Power is the energy from which action arises” (Chinn, p.17). There are many kinds of power, but Chinn’s definition here spurs the notion of advocacy for the use of power as energy. Energy to free, to heal, to care, to make a better, more loving, understanding, healthy, kind and just world.

What are you thinking and feeling right now about what power means to you and your current (personal and professional) life experiences?

Consider the French philosopher Michel Foucault’s (b.1926- d.1984) ideas of power: Foucault (1982) said “Power is everywhere and in everything.”  He believed the effects of power are linked with knowledge, competence and qualification; and that power is a socialized and embodied phenomenon. He also believed that power is discursive rather than (but can be) coercive. Discursive means “running to and from” and involves the use of language (discourse). Indeed, power is communicated in language (verbal and nonverbal).

We often think power means “power over” and attach negative meaning to it, but for Foucault power takes on a socialized, knowledge based meaning; and helps us to see what Peggy means by ”power as energy for action.” For a further explanation of Foucault’s beliefs and influences please follow the link below:

http://www.powercube.net/other-forms-of-power/foucault-power-is-everywhere/

As we critically examine the concept of power, we can look at the socialized and embodied beliefs, behaviors and practices that divide and join us.

Watson (2012) suggests we ask ”who is this spirit filled person before me?” As we interact with our environment, and those in it, we can ask this question, and go deeper and wider to ask: what are the sociocultural, internal, external, subjective, even global and historical influences and experiences that inform this person and her or his views of self, other and world?  What are the influences of power upon and within this person?

Breaking down barriers to personal and professional advocacy for integral health and human caring can begin with examining power in all its many manifestations.

References

Chinn, P. L. (2008). Peace and Power: Creative leadership for building community. Jones and Bartlett. Sudbury, Ma.

Foucault, M. (1982). The subject and power. Critical Inquiry, 8(4), 777-795.

Watson, J. (2012). Human caring science: A theory of Nursing. Jones and Bartlett. Sudbury, Ma.

Here is another quote from the document that may be of interest to examine with some depth:

The situation we find ourselves in has been created from an array of forces. While economic issues have helped create a situation in which nurses cannot practice nursing, we, as nurses, have participated by remaining silent. Our professional sovereignty is threatened. The health of global humankind is at risk. It is now time to ask ourselves, who benefits from the situation as it now exists? As long as we know that the current situation inhibits the fullest expression of nursing’s highest values, and that people who need our care are not receiving the best we can offer, we know that we, and those we serve, are not benefiting. If nurses are to significantly contribute to a mission of caring for people and communities, we must find our voice, acting now to create situations in which our values come to the center and from which we can realize our best intentions.  (Cowling, Chinn, & Hagedorn, 2000, paragraph 3).

I have to agree that healthcare is big business here in the USA, a place where democracy, free enterprise, and capitalism have created a healthcare system which profits in the billions of dollars every year. For more information on the profit status of insurance companies, I found this link helpful and easy to follow: http://www.huffingtonpost.com/2011/05/14/health-insurance-companies-make-record-profits_n_861946.html.

As nurses we have in many aspects blindly given over our practice to the regulating agencies and facilities where we work. Instead of as a profession deciding the services we can and will provide, which includes enacting our core values of caring and presence for those on a healing journey, we have chosen to allow our practices to be largely dictated to us. I believe that the high rate of burn out among nurses, and the great professional exodus of many new nurse graduates, is related to the inability to enact a caring-healing presence at the bedside.

So how is that we find our voice in order to create the type of transformative change that is so desperately needed in our healthcare system? While I believe joining a professional nursing organization is a place to start, I think we have found that having over one hundred specialty organizations in nursing has in some ways defeated our ability to come together and create a single strong voice. The American Nurses Association also has it challenges with membership and creating true, meaningful action. As the largest number of healthcare providers in the USA, a clear strong united voice and resultant action that demonstrates how our values can be realized in the healthcare system.

I think partnering with patients offers the profession a lot of hope for the future. As patients demand more access to complimentary and alternative modalities, nurses are the ones who could be enacting these interventions. Patients also know the importance of a caring presence at the bedside as they journey through suffering and the healing process. Patients are also some of our greatest teachers, as they remind us over and over again of the importance of nursing and the urgency of the need for loving kindness and caring in our professional actions. The rewards of nursing are indeed encapsulated within the patient-nurse transpersonal experience, and we have failed on many levels to support one another in explicating, teaching, supporting, and enacting the intricacies of this process.

I also believe that there is great hope for the future: each of us has the power to enact and create the kind of nursing practices we envision. Many of my students have found that by changing their views of themselves and the world, and begin to take action in creating change in how they practice nursing. With an emphasis on self-care and holism, the students often find themselves empowered to begin to solve workplace issues. They begin to return to the sacredness of their work, and enact their own healing journeys.

I suppose the questions remains in how to continue to reach the many, many nurses who are suffering in oppressive work situations. How can we best support and empower these nurses to take back their practices, and accordingly allow for our true nursing values of caring, compassion, empowerment, and patient advocacy to emerge?

Reference:

Cowling, R., Chinn, P.L., & Hagedorn, S. (2000). The Nurse Manifesto.
Retrieved June 27, 2011 from http://www.nursemanifest.com.