Safe and Quality Care includes Holism

Holism | AdlerPedia

Written by Professor Kirby

My Director of Nursing (DON) accepted Mr. W. as a scheduled admission to our skilled nursing facility on a Friday evening. She did not inform the nursing staff he was a high risk for falling or allocate additional staff to monitor this patient. When the nursing staff did receive reports from the hospital, they discovered he was a high fall risk. However, it was too late to discuss the plan of care for this potential admission or if he was an appropriate admission for our setting because the DON left for the day. Unfortunately, this patient was admitted on Friday and fell five times over the weekend.

Although, none of the falls resulted in an injury but the weekend staff was overwhelmed. They made multiple phone calls to the DON in reference to their inability to safely care for Mr. W. The DON informed the staff that she needed to fill the empty beds and as a result, she had to accept this high-risk admission. Then, she instructed the nursing supervisor not to document the resident’s incidents as falls, but a purposeful change in the plane. The nursing supervisor felt this was the wrong thing to do because the resident’s cognition was intact, and he had the ability to ambulate. Her assessment was that the patient clearly fell as a result of his hallucinations. However, she followed through as instructed.

This resident’s cognition was intact, and he had the ability to ambulate.  When the management team returned on Monday, we met with Mr. W. to discuss his plan of care.  He explained he knew when he was hallucinating.  He recognized some of his ideas were not the best choice, but he would proceed with them.  He continued to fall multiple times after the first weekend, and every morning management discussed his care or lack thereof because our staff patterns did not allow for one on one nursing staff to monitor Mr. W. and we’re a restraint free facility.  Therefore, Mr. W. was placed on every 15-minute checks ongoing daily.  Also, a new policy was implemented to perform checks every fifteen minutes on every new resident for the first week on night shift only.  These two interventions produced a safer environment for Mr. W. and future new admissions.

What could we have done differently to promote a safer environment at this skilled nursing home? Or better yet, how could holistic care been implemented? First, the DON view of the patient was number or census driven admission and not person driven admission. If the DON and the nursing team, seen Mr. W. as a person and considered his needs as a whole being fall prevention would have been a priority. They DON was not mindful of the patient’s needs. According to Philbrick (2015), mindfulness is purposefully focusing on or giving your attention to a specific person or thing. Mindfulness was not implemented initially for Mr. W. during the admission process. But, later, mindfulness became a routine part of everyone’s daily routine care to ensure Mr. W’s safety. Consequently, holistic values such as standards were not instinctively initiated by nursing. Dossey and Keegan (2016) defines holistic nursing as person-centered care which involves purposeful and attentive care which aligns with both the American Nurses Association and Relationship Based Care principals, as well. Initially we failed to establish a meaningful relationship with Mr. W., and he was a number on our census. Patient-centered and relationship-based care was developed much later. Unfortunately, it was a forced relationship due to the numerous incidents of falls. However, holistic nurses recognize the physical ailment of the disease as only one aspect of the human need and therefore, the nurse strives to meet both the seen and unseen needs of the patient. The art of caring for the whole person produces hope and gives a better an outlook on life.

Dossey, B. M., & Keegan, L. (2016). Holistic Nursing: A handbook for practice. (7th edition ed.). Burlington, MA: Jones and Bartlett Learning.

Philbrick, G. (2015). Using mindfulness to enhance nursing practice. Kai Tiaki Nursing New Zealand, 21(5), 32-33.


Practices Can and Will Change- EBP

Written by Professor Kirby

Image result for random controlled trial

Evidence-based nursing practice is a result of research studies or randomized controlled trials (RCT). However, from these trials, a compilation of the evidence is gathered that determines the direction of future trials. Often, the results or findings of the research article will indicate if further studies are warranted and indicated why these studies would be beneficial. Also, the possibility of any sampling error, or selection bias that may have of skewed results of the RCT. Wong and Myers (2015) place the responsibility in the hands of the managers, educators, and clinical nurse specialists to stay abreast of recommended changes, educate and evaluate their clinicians(p. 18). However, the weight of their due diligence begins with gaining knowledge and sharing it. Consequently, after education and implementation, the manager must also evaluate their employee’s competency.

Image result for foley catheter

Let’s discuss a common nursing practice that is no longer recommended by the Healthcare Infection Control Practices Advisory Committee of 2009. As a young nurse, long-term use of Foley catheters was more prevalent in long-term care settings than it is today. Consequently, when long-term use was warranted the nurse was required to change the Foley every 30 days or once a month. Nevertheless, in 2009 new guidelines indicated that “changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised” (Gould et al., 2009, p. 13). This recommendation was a supported by quality evidence that suggested the clinicial benefits out weighed the potential harm (Gould et al., 2009, p. 10). Therefore, it was left in the hands for the manager to establish a guideline to follow for their clinical nurses. Many long-term care facilities have reduced the use of Foley catheters with the exception of use recommended by Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines.


Gould, C., V., Umscheid, C., Agarwal, R., K., Kuntz, G., Pegues, D., A., and Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Healthcare Infection Control Practices Advisory Committee, Retrieved from

Wong, P., & Myers, M., (2015). Clinical competence and EBP: An educator’s perspective. Nursing Management, 15-18.

Changing our Ways- Evidence Based Practice

Written by Professor Kirby

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Evidence-based nursing is used daily. However, some nurses are unaware that research studies have proven an approach or nursing intervention to be beneficial to practice. In other words, evidence-based practice plays an important role in the day to day care of our patients. We often perform our nursing duties as taught to us without a thought as to why we are using specific techniques. Oh, we may recognize a medical aseptic technique prevents hospital-acquired infections. However, do we recognize the history behind the discovery of aseptic technique? According to Wong and Myers (2016), evidence-based practice mandates that nurses use critical thinking skills to evaluate the nursing approaches and determine the origin of their interventions (p. 16).

Let’s evaluate the nursing philosophy of Patient-Centered Care. As nurses, we play a major factor in the healing process because we set the tone of the patient’s clinical environment. When a clinician focuses on the patient whole being they become a part of the healing process. This is considered holistic care and promotes wellness by acknowledging more than the physical need, but also, the psyhosocial, spiritual, and cultural needs. Both patient-centered care and holistic care are both considered best evidenced-based nursing practices and are derived from nursing research. Some nursing schools and health systems follow these models.

According to Emanuel et al. (2011), nurses need to ensure their practice is current and that they are equipped with the necessary skills to be flexible and adaptive. So, what happens when our practice becomes routine or ritualistic? How do you maintain patient-center care? We must not only critically evaluate our practice. But, we must be in tune with ourselves and realize when we find ourselves in a task-oriented mindset. Therefore, we can stepback and regroup to give the best of ourselves to our patients.

Emanuel V et al. (2011). Developing evidence-based practice among students. Nursing Times, 49(50), 21-23.

Wong, P., & Myers, M., (2015). Clinical competence and EBP: An educator’s perspective. Nursing Management, 15-18.

Understanding Middle-Range Theories

Author Professor Kirby

Image result for middle range theory            Sociologist Robert Merton advocated for middle-range theory and these theories are often derived from grand theories (Liehr and Smith, 2017, p. 51). Merton explains it as a theory that lies between the minor, but necessary working hypotheses that evolve in abundance in daily research and it’s a systematic effort to develop a unified theory (Liehr and Smith, 2017, p. 51).  There are two diagrams below to be used as visual aids to help everyone better understand middle-range theories.

Middle-range theories are rooted in sociology and usually are focused on social behavior and social change. However, as a result of the influence of sociology, many critics are not in favor of the use of these theories in a different disciplinary setting. Consequently, “Thorne suggests that nurses do not simply borrow theories from other disciplines, but twist and bend them to serve the disciplinary purpose” (Liehr and Smith, 2017, p. 54). The development of this theory has led to middle range theories that are more reflective of a nursing theme than a sociology theme, such as caring and comfort theories (Liehr and Smith, 2017, p. 59). Liehr and Smith (2017), emphasizes the importance of choosing a name that describes the main ideas of the theory (p. 55).

Image result for middle range theory


Liehr, P., & Smith, M.J. (2017). Middle range theory a perspective on development and use. Advances in Nursing Science Vol. 40, No. 1, pp. 51–63.

Images retrieved from the websites below:








Review of the Three Philosophical Worldviews

Author Professor Kirby

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Our discussion today will be on the three philosophical worldviews: the Reaction, the Reciprocal Reaction, and the Simultaneous Action Worldviews. The Reaction Worldview is primarily focused on the disease process and healing the physical ailment. The Reciprocal Reaction Worldview is centered on healing the whole person which consists of the physiological, psychological, spiritual, and social well-being of people. Simultaneous Action Worldview emphasizes both that internal and external extrinsic factors impact the patient’s state of wellness.


Image result for world view           My personal view is that wellness is more than just good physical health. It’s achieving overall optimum health which includes some necessary components such as a state of balance physically, mentally, and spiritually. My personal nursing view is geared toward a holistic approach to care and therefore, aligns with the Reciprocal Reaction Worldview. Consequently, it does not align with my employer’s worldview.
My employer subscribes more to the Simultaneous Action Worldview. The vision of Chandler Hall is “a vibrant open intergenerational community for people at all stages of life.” Also, the mission statement is “Together, transforming the experience of aging in the Quaker tradition.” Chandler Hall has promoted an intergenerational environment and they deeply believe this extrinsic factor benefits both the elders and staff. Although, I agree with the impact of intergenerational activities and care. However, this external factor is not beneficial to all residents and staff members. I believe incorporating a holism component would enhance the care at Chandler Hall.


Butts, J. B., & Rich, K. (2011). Philosophies and theories for advanced nursing practice. Sudbury, Mass.: Jones and Bartlett Publishers.

Chandler Hall. (2018). Mission and vision. The Kendal Corporation, Retrieved from

Fe-Male and Male Nurses – How do we measure up?

Author Professor Kirby


Feminist Caring Ethics

We are Caring! We are Nurses!

Not to be gender bias, but most male nurses I have encountered have been excellent caregivers. Now, this may be my perception because there are so few men nurses in comparison to female nurses. However, today we will discuss Feminist Ethics. So, why discuss Feminist Ethics when my opinion appears to be shewed toward discrediting this theory? Well, I am glad you asked; let me explain. My interest stemmed from a recent how observation and conversation about the “unofficial” males and female roles in our society. The consensus was the mother is usually expected to take off work to tend to the needs of the children, such as school closings, illnesses, and routine appointments. I recognize this is not the exact topic of discussion, but this is what sparked my interest in the chapter of our reading assignment.

According to Tong, some feminine theorist like Ned Nodding believes genders gravitate more to contemplate behaviors in regards to caring for others (Rich and Butts, 2018. p. 166). Also, Sara Ruddick builds on this belief by emphasizing both males and females have natural instincts. Ruddick’s theory produces solid union between nursing care and motherliness (Sander- Staudt, n.d.). According to Sander- Staudt (n.d.), Ruddick believes “both men and women can be mothers or mothering.” Also, she infers mothering is peaceful and opposes war or violence; some people object stating mothering can be demandingly violent, protective and respond fiercely (Sander- Staudt, n.d.).

Nevertheless, Feminist Ethics of Caring is a controversial subject, whether addresses personal or professional ethical needs. Also, opinions will vary from person to person and situation to situation. My personal and professional view aligns with a modified version of Ruddick’s theory. Mothering is protective, just as nursing is advocating or protecting. Therefore, we can not talk about caring and disregard protective instincts or an aggressive masculine response. Maternal thinking is not gender-specific; some male nurse can run circles around some women nurses. However, men roles in our society do not represent their extremely caring and compassionate capabilities.


Butts, J. B., & Rich, K. (2011). Philosophies and theories for advanced nursing practice. Sudbury, Mass.: Jones and Bartlett Publishers.

Sander-Saudt, M. (n.d.). Care ethics. Internet Encyclopedia of Philosophy- A Peer Rewed Academic Resource, Arizona University. Retrieved from


The Struggle Within

Author Professor Kirby


“We’re built of contradictions, all of us. It’s those opposing forces that give us strength, like an arch, each block pressing the next. Give me a man whose parts are all aligned in agreement and I’ll show you madness. We walk a narrow path, insanity to each side. A man without contradictions to balance him will soon veer off.” ― Mark Lawrence, King of Thorn

There is a biblical text that states, “when I want to do right I do wrong” (Zondervan, n.d.). Ok, so where am I going with this discussion? No one perfect….. Yes, surprise not one person falls into the perfect category. So, now, that the playing field is leveled; let’s play, shall we.
Butts and Rich (2018) introduced us to Behavior Health Theories (BHT) and emphasized how advanced practice nurses utilize these theories to evoke change in their patients (p. 244). There are many BHT, but these few are the most popular: Behavioral Health Model, Social Cognitive Theory and Theory of Reasoned Action and Theory of Planned Behavior (Butts and Rich, 2018, p. 242). Although, we will not go into depth discussing the difference in the theories; it’s important to know nurses can use a single theory or a combination of theories to achieve desired results (SImpson, 2015, p. 5). Graduate and doctoral level nurses use BHT to promote healthy choices when caring for their patients and at different stages, different strategies may be needed. We are leaders in clinical education and applying best practice. Nurses are educators by nature. It’s part of the job! How can you care for someone and not explain to them how to care for themselves? If this happens, we are doing a great disservice to our patient.
According to Dr. Simpson (2015), BHT and models can help clinicians design a successful plan that identifies lifestyle challenges for a community (p. 1). There are a variety of internal struggles, but none is uncommon to man. Smoking, obesity, opioid addiction, bulimia, anorexia, alcoholism, reckless sexual behaviors, self-destructive behaviors, and abusive behaviors toward others are all difficulties encountered by humans. We’re humans because we are flawed. However, flawed is never the goal; advancement to a better you is the aim.
The struggle begins with behavioral modifications and ends consistency.
Changing a person’s behavior starts with identifying social, economic, and cultural barriers to develop a realistic plan. This step makes adherence more feasible. Moreover, when the change takes place often people have a difficult time with maintaining that change (Rich and Butts, 2018, p.258). Could this possibly be the cause of stats successful individuals resorting to old behaviors? For example, losing significant weight only to regain it years later, or quit smoking and restarting again due to stressful circumstances. According to Rich and Butts (2018), biobehavioral factors play a significant role in maintaining some changes (p.258). Often, judgment calls by bystanders on the outside looking in point to lack of discipline which could be a contributing factor. Nevertheless, physiological symptoms play a large play in the maintenance stage of behavior modification. Also, Rich and Butts (2018), emphasize developing self-management and coping skills are necessary for positive change (p. 258).

By Charlene aka The Art of Nursing

Butts, J. B., & Rich, K. (2011). Philosophies and theories for advanced nursing practice. Sudbury, Mass.: Jones and Bartlett Publishers.

Lawrence, M. (N.D.). King of thorns. Retrieved from

Simpson, V. (2015, March). Models and theories to support health behavior intervention and program planning. Purdue University, Retrieved from

Zondervan. (n.d.). Bible gateway. Retrieved from

Compassion Fatigue is Real

Written By Professor Kirby

Compasion FatigueOften, nurses prioritize the needs of others above their own; this is greatly due to our compassionate and caring nature.  Let’s face it, it takes a special person to care for the needs of others.  This is what makes nursing an art.  However, the art of nursing includes self-care, too.  So, what happens when the nurse is depleted?  Is care compromised when nursing is no longer an art to us but a list of task to complete?

Compassion fatigue is probably more common in nursing then is acknowledged in health care.  According to Todaro-Franceschi (2015), many nurses do not realize they are experiencing compassion fatigue (p. 53). Compassion fatigue or burnout slowly develops over time which results in emotional exhaustion (Todaro-Franceschi, 2015, p.53 ). However, many nurses push through this moral distress to care for their patient. Nevertheless, the quality of care decreases because they become task oriented and their zeal for caring diminishes. Todaro-Franceschi (2015) describes the process as a natural defense mechanism to prevent overexertion of the individual (p. 53).

Lachman (2016) mentions some strategies to combat or recover from moral distress or compassion fatigue such as maintaining a balance in life and caring for yourself (p. 276). ANA (2015) Interpretative Statement Provision 5, emphasizes nurses must care for themselves in order to care for others (Lachman, 2016, p. 276). Other, strategies are to educate the staff on how to recognize signs of compassion fatigue, leaders must be supportive of the distressed staff, encourage employee assistance programs and focus on the positive are a few suggestions (Lachman, 2016, p. 277-278).

Todaro-Franceschi, V. (2015, June). The ART of maintaining the “care” in healthcare. Nursing Management, 46(6), 53–55. doi: 10.1097/01.NUMA.0000465407.76450.ab

Lachman, V. D. (2016, July-August). Compassion fatigue as a threat to
ethical practice: Identification, personal and workplace prevention/management strategies. Medsurg Nursing, 25(4), 275-278.