Doane & Varcoe's (2008) article I mentioned "how the discipline has inadvertently adopted epistemologies that are contrary to nursing values and goals" and goes on to note "there has been little exploration into embodiment/disembodiment and the living relation of epistemology and ontology (p. 289)."
I so glad Barb mentioned she works in an institution that uses Watson's Caring Science to guide nursing practice. The integration of caring standards might help to clarify the focus of nursing care in the larger context of overall care which is shared with biomedical oriented providers with biomedical outcome goals.
Nerissa's alma mater has in their philosophy statement that: "Nursing is the art and science of caring. The focus of nursing is to provide a caring presence and to create an environment that facilitates healing of persons, families, groups, and communities. Caring, as the essence and central focus of nursing, is what makes persons, their environments and interpersonal concerns meaningful. Caring in action consists of philosophical, interpersonal, and technical components that interface to facilitate caring interactions and caring environments. Professional nurse caring combines cognitively and culturally learned behaviors, actions, and techniques that enable the creation of healthy, healing environments for nurses, clients, and colleagues. The ethics of care and responsibility involves moral agency, interdependence, and professional integrity."
My work is centered on the idea that nursing is situated caring shaped by interior and exterior environments. Interior environments referring to concepts like mental attitude; personal philosophical of nursing, ethical/moral & cultural orientation... while exterior environments include educational training, work setting, systems issues, human/material resources, etc. How we define caring and what it means to be a caring nurse is shaped by all these dimensions and can change over time. Grounding in paternalistic, biomedical education seems like it would be extremely influential in one's conceptualization of caring as a second career nurse.
I notice my inbox filling with other's response and will stop here for now and add this to the mix.
Olga Jarrin, RN, MS, PhD Candidate
University of Connecticut
School of Nursing
--- On Wed, 11/19/08, Barb Gingher <[log in to unmask]> wrote:
> From: Barb Gingher <[log in to unmask]>
> Subject: Re: Fw: Re: dignity -- say what?
> To: [log in to unmask]
> Date: Wednesday, November 19, 2008, 4:42 AM
> The electronic medical record has gotten the nursing staff
> in our organization back to tthe bedside and patient care.
> As Jean Watson is our theorist of choice, we now have caring
> standards incorporated into the EMR. Many of our patients
> have researched their disease process and are making
> intelligent decisions in regard to their own healthcare.
> Those who are not as savy can be educated in a supportive
> way and if we cannot change the direction, so be it,
> however we are no longer "tied" to the chart. A
> simple statement of understanding and feedback from patients
> satisfies documentation needs.
>
> Barb, RN, MA, MS
>
>
>
>
> "The past is our definition. We may strive, with good
> reason, to escape it, or to escape what is bad in it, but we
> will escape it only by adding something better to it.”
>
> Barb Gingher
>
> --- On Wed, 11/19/08, Nerissa Belcher
> <[log in to unmask]> wrote:
>
> From: Nerissa Belcher <[log in to unmask]>
> Subject: Fw: Re: dignity -- say what?
> To: [log in to unmask]
> Date: Wednesday, November 19, 2008, 4:31 AM
>
> Once again I assumed the default setting for this group was
> "reply to
> all" so I accidentally sent my reply to an individual.
> That message is
> being forwarded to the group.
>
>
> Nerissa
>
>
> --- On Wed, 11/19/08, Nerissa Belcher
> <[log in to unmask]> wrote:
>
> > From: Nerissa Belcher <[log in to unmask]>
> > Subject: Re: dignity -- say what?
> > To: "Chris Hanks"
> <[log in to unmask]>
> > Date: Wednesday, November 19, 2008, 4:10 AM
> > Hi everyone,
> >
> > It appears my position has been mis-interpreted. What
> > I'm trying to say is we need to provide quality
> medical
> > care while respecting our patients. As for protecting
> > ourselves with documentation if only it were not
> necessary.
> > In the USA, however, nursing is much more about
> > documentation than patient care. I'm a new nurse
> but was
> > a podiatrist for twenty years. The same rules applied
> to me
> > as a foot doctor. Documentation requirements in the
> USA (UK
> > too?) are out of control. But, like it or not if we
> wish to
> > retain our employment we do what we're paid to do.
> Which
> > is to document. A major reason I got out of podiatry
> is I
> > wasn't paid to document. Each and every ridiculous
> new
> > documentation requirement to come down the pike did
> not come
> > with any funding for it. As advantage of nursing is as
> > ridiculous as the requirements are if someone wants to
> pay
> > me good money to write for the 10,000th time my
> nursing
> > focus about pain control and preventing falls (hint to
> the
> > administrators - I got the ideas well before writing
> them
> > down for the 100th time) then so be it. I can cash my
> checks
> > in good faith.
> >
> > Getting back to patient care the ethical issue is when
> > quality care conflicts with patient desires. I
> disagree with
> > Stephen Padgett who seems to think that since medical
> > standards change over time we should assume patients
> are as
> > likely to be accurate in their medical assessments as
> nurses
> > and other trained medical professionals. Fact is the
> > patients are likely to know less about what works than
> we
> > do. If they decide not to follow our advice then we
> should
> > support them in doing so but not put our jobs at risk
> by
> > failing to document the discussion.
> >
> > Additionally I wish to point out that patients will
> more
> > likely follow our advice if we show confidence in
> ourselves.
> > I.E. if we really believe we don't have a clue,
> since
> > things are always changing, patients will be prone to
> not
> > following our advice. IMO part of being a professional
> is in
> > keeping up with our studies so our advice is as
> current as
> > research allows.
> >
> > Nerissa
> >
> > --- On Wed, 11/19/08, Chris Hanks
> > <[log in to unmask]> wrote:
> >
> > > From: Chris Hanks
> <[log in to unmask]>
> > > Subject: Re: dignity -- say what?
> > > To: [log in to unmask]
> > > Date: Wednesday, November 19, 2008, 3:26 AM
> > > Dear all
> > > Thank you Olga for the reference, I will read
> this.
> > > I have to say that I fully agree with
> Stephen's
> > > eloquent outburst. And there is no reason not to
> be
> > > passionate in decrying a situation which is
> commonly
> > > encountered (though there are delightful
> exceptions).
> > > As I read Stephen's contribution I did feel
> for
> > > Nerissa, as I think that I recognise the anxiety
> of
> > the new
> > > nurse placed in a stressful environment, however,
> I
> > feel it
> > > crucial that the points Stephen makes are carried
> into
> > > practice. I have been having discussions with
> senior
> > > undergraduate student nurses regarding these
> ethical
> > issues
> > > for many years; the students express positive
> patient
> > > centred ideals. When I visit practice areas or
> teach
> > some
> > > post qualifying classes, it saddens me that often
> the
> > ideals
> > > appear lost. In particular it worries me how
> often
> > nurses
> > > think that they know best, sometimes blessed with
> only
> > > scanty second hand knowledge, and no inclination
> to
> > > question.
> > >
> > > Thanks Stephen
> > >
> > > From Chris Hanks
> > > Senior Lecturer
> > > University of Plymouth
> > > England
> > >
> > > ________________________________________
> > > From: A list to promote discussion of
> philosophical
> > issues
> > > in nursing [[log in to unmask]] On
> Behalf
> > Of
> > > Olga Jarrin [[log in to unmask]]
> > > Sent: 19 November 2008 01:31
> > > To: [log in to unmask]
> > > Subject: Re: dignity -- say what?
> > >
> > > Medical facisim, lol... and after days of
> dialogue on
> > how
> > > we ought to disagree and present our arguments!
> > Stephen,
> > > Nerissa is an ex-podiatrist and new nursing grad
> (oh
> > the
> > > wonders of google). I'm going to take a
> different
> > tack
> > > and reference the latest issue of ANS 31(4),
> 283-295.
> > > Gweneth Hartrick Doane & Colleen Varcoe's
> > article
> > > Knowledge Translation in Everyday Nursing: From
> > > evidence-based to inquiry-based practice
> addresses
> > their
> > > "deeply felt concern with the profound
> disparity
> > that
> > > often exists between what nurses know and what
> nurses
> > > do." They go on to give an example of a
> nurse who
> > > provided care to one of the authors in a way
> > inconsistent
> > > with her education. The authors wonder briefly if
> > workplace
> > > stress or culture might explain the incongruence
> > between the
> > > nurse's perception of her nursing practice
> and the
> > > author's perception of her nursing care.
> > >
> > > Here is another side of Nerissa, something she
> wrote
> > just a
> > > year ago:
> > >
> > > I'm in nursing school with one semester to
> go.
> > Student
> > > nurses are taught to be supportive of all their
> > patients.
> > > This includes Christians, atheists, minorities,
> gays,
> > etc.
> > >
> > > I agree strongly with this approach. Nurses
> should
> > provide
> > > the best care they can and not attempt to impose
> their
> > > opinions on the people they care for.
> > >
> > > Nerissa Belcher
> > > September 23, 2007
> > >
> > >
> > >
> > > --- On Tue, 11/18/08, Stephen Padgett
> > > <[log in to unmask]> wrote:
> > >
> > > > From: Stephen Padgett
> > > <[log in to unmask]>
> > > > Subject: Re: dignity -- say what?
> > > > To: [log in to unmask]
> > > > Date: Tuesday, November 18, 2008, 7:20 PM
> > > > I don't know where to begin to say how
> much
> > this
> > > message
> > > > disturbs
> > > > me. The astonishing arrogance and
> self-regard of
> > it is
> > > > matched only by the
> > > > wild self-pity. Oh, poor us! Forced to do
> more
> > > > documentation, to protect
> > > > ourselves from vengeful patients who had the
> > temerity
> > > - the
> > > > cheek!-- to
> > > > refuse our always-excellent advice! But now
> they
> > > regret it,
> > > > don't they?
> > > > they wish they'd listened to us,
> they'll
> > try
> > > to
> > > > "re-invent themselves"
> > > > (whatever that means) to blame us for their
> > lapses,
> > > but we
> > > > know better,
> > > > don't we? don't we always?!
> > > >
> > > > and that this should arrive in my
> inbox
> > under
> > > the subject
> > > > heading
> > > > "dignity"!!
> > > >
> > > > No, Nerissa, this isn't dignity or
> > respect
> > > or even
> > > > nursing in my
> > > > book. This is medical fascism. First off, it
> > > conveniently
> > > > ignores all
> > > > the mistakes *we* make, all the ways our
> > > "advice"
> > > > changes with the
> > > > latest research, the shifting fashions and
> > priorities,
> > > the
> > > > season. It
> > > > ignores all the nonsense we say to people...
> > > >
> > > > Have you been a patient recently,
> Nerissa?
> > Or a
> > > family
> > > > member of
> > > > one? I don't wish you any ill health,
> but it
> > is an
> > > > excellent way to shake
> > > > off professional arrogance. To be the
> recipient,
> > as
> > > opposed
> > > > to the
> > > > dispenser, of so much well-intentioned and
> > utterly
> > > useless
> > > > (if not
> > > > downright offensive) advice that nurses,
> doctors,
> > and
> > > > others dish out
> > > > everyday is a profoundly humbling
> experience. And
> > have
> > > you
> > > > looked
> > > > recently at the data on patient lawsuits
> &
> > > malpractice
> > > > claims? Most
> > > > clinicians wildly over-estimate their actual
> risk
> > of
> > > being
> > > > sued.
> > > >
> > > > And that's not even the main
> issue. The
> > main
> > > issue is
> > > > simply that
> > > > people do not give up their rights to make
> > choices
> > > when
> > > > they come into the
> > > > healthcare system. It's astonishing to
> me
> > that we
> > > > continue to have
> > > > to debate this in health care. And no,
> Nerissa,
> > > you're
> > > > not the only one
> > > > who thinks like this -- this attitude is all
> too
> > > common
> > > > among the
> > > > providers I meet. Not everyone, not by a
> long
> > shot,
> > > but far
> > > > too many. It's
> > > > the seamy side of professionalism - the
> "we
> > know
> > > > better" side.
> > > >
> > > > Whether you agree with a patient's
> > choices -
> > > whether
> > > > you think
> > > > they make the most sense from a medical
> > standpoint,
> > > whether
> > > > they are
> > > > congruent with YOUR careplan -- is not the
> point.
> > The
> > > point
> > > > is, it's
> > > > their call. This ethical orientation is
> > fundamental to
> > > our
> > > > system of
> > > > professional relationships -- it helps to
> counter
> > that
> > > > "we know better"
> > > > pull - and it is very disheartening to hear
> you
> > wave
> > > that
> > > > away because
> > > > people making the *wrong* choices might
> become
> > > > "problems" later on -
> > > > problems for us, of course. (Poor us!)
> > > >
> > > > "Warning" people is fine,
> > documenting
> > > is always
> > > > a good idea, but I
> > > > think you need to do more than just
> "consult
> > with
> > > the
> > > > ethics people." I
> > > > think you need to have a long talk with them
> > about
> > > what
> > > > you're in charge
> > > > of and what you're not.
> > > >
> > > > Stephen Padgett
> > > >
> > > >
> > > > On Tue, 18 Nov 2008, Nerissa Belcher wrote:
> > > >
> > > > > Hi Ms. Davis,
> > > > >
> > > > > IMO, if a patient deliberately chooses
> to
> > > increase
> > > > their risk despite
> > > > > nurses advising them of the danger then
> they
> > are
> > > > problems waiting to
> > > > > happen. We all know the drill. The
> > > > nurse/doctor/therapist, etc. didn't
> > > > > warn them firmly enough, or document
> well
> > enough,
> > > or
> > > > consult the ethics
> > > > > people. I support free choice but we
> need to
> > be
> > > very
> > > > aware that people
> > > > > reinvent their pasts to claim ignorance
> of
> > things
> > > > later. Sadly, still
> > > > > more documentation for nurses needs to
> be
> > > completed in
> > > > anticipation of
> > > > > problems.
> > > > >
> > > > > Nerissa
> > > > >
> > > > >
> > > > > --- On Tue, 11/18/08, Davis, Betty
> > > > <[log in to unmask]> wrote:
> > > > >
> > > > >> From: Davis, Betty
> > > <[log in to unmask]>
> > > > >> Subject: RE: dignity
> > > > >> To: "Nerissa Belcher"
> > > > <[log in to unmask]>
> > > > >> Date: Tuesday, November 18, 2008,
> 3:10
> > PM
> > > > >> You stated, "Show them respect
> > unless
> > > doing
> > > > so harms
> > > > >> their medical
> > > > >> care." Does that imply that
> > > noncompliance or
> > > > >> disagreement with the plan
> > > > >> of care warrants disrespect? That
> > statement
> > > seems
> > > > to
> > > > >> disallow free
> > > > >> choice.... And, please, be
> gentle....
> > > > >>
> > > > >> Betty W. Davis, PhD, RN, CNE
> > > > >> Assistant Dean, Nursing
> > > > >> Program Head, Associate Degree
> Nursing
> > > > >> Meridian Community College
> > > > >> 910 Hwy. 19 North
> > > > >> Meridian, MS 39307
> > > > >
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