Research Highlights – January 2022

Study begins to define what it means to be a nurse  

Tulla Landis

Assistant Professor Tullamora Landis of the Washington State University College of Nursing led a study published recently in the journal Nurse Educator on perceptions of professional identity in nursing.  

Professional identity, described as someone thinking, acting and feeling like a nurse, is “a frequent topic in regulatory, educational and practice environments,” the study notes. Yet the definition of professionalism in nursing is unclear.  

Nurturing professional identity was one of the main recommendations from the Carnegie Foundation for the Advancement of Teaching in a study on preparing various professions for practice.  

In response, 50 nurse leaders in practice, education and regulation from the United States and Canada gathered in 2018 to begin defining professional identity in nursing. A second group refined those recommendations in 2019. The study surveyed almost 1,200 nurse educators using a new professional identity scale developed by the researchers.  

The result was four key elements of professional nursing identity: values and ethics, knowledge, leadership and professional comportment. Each of those “domains” had a group of attributes that were ranked “moderately important” or “very important” by participants.  

For example, under values and ethics, the attributes deemed important by 98% or more of respondents were integrity, caring and empathy.  

The attributes deemed most important overall were being an effective communicator (99.9%), integrity, (99.8%) and being trustworthy (99.8%). The domain with the most items identified as moderately to very important was professional comportment, with examples including being respectful, patient-centered, self-aware, collaborative and resilient.   

The study’s authors noted that diversity and inclusivity did not make the cutoff for important attributes, but the groups included them because other studies have demonstrated their importance in professional identity development.  

The study, which was highlighted recently by the American Association of Colleges of Nursing, recommends that nurse educators provide students with opportunities to practice some of the important attributes.  

In the realm of professional comportment, for example, a nursing program might use role-playing or simulation activities that reinforce collaboration and teamwork, or resilience-building exercises.  

The next steps are to refine and test the lists with new participants, and for nursing educators to integrate the important attributes into courses, simulation and curricular standards, the study said.  

Said Landis, the study’s lead author, “During the last two years of the pandemic, the profession of nursing has been challenged like never before, and nurses have been pushed to their limits. We need to continue to focus on supporting the professional identity of nursing and ensure that nurses are recognized as valued members of the health care team.”  

Study: “National Study of Nursing Faculty and Administrators’ Perceptions of Professional Identity in Nursing,” Nurse Educator. By Tullamora Landis, PhD, RN-BC, CNL; Nelda Godfrey, PhD, ACNS-BC, RN, FAAN, ANEF; Celestina Barbosa-Leiker, PhD; Cynthia Clark, PhD, RN, ANEF, FAAN; Janice G. Brewington, PhD, RN, FAAN; M. Lindell Joseph, PhD, RN, FAAN, FAONL; Susan Luparell, PhD, RN, CNE, ANEF; Beth Cusatis Phillips, PhD, RN, CNE, CHSE; Kristen D. Priddy, PhD, RN, CNS; and Kary Anne Weybrew, MSN, RN. 

Massage is one tool that could help reduce inequities in treating pain   

Enrico De Luca teaches caring massage to healthcare workers in Thailand
Enrico De Luca teaches Caring Massage techniques to healthcare workers in Thailand.

A decade ago, the Institute of Medicine said new strategies were needed to reduce barriers to pain care.  

In an editorial published in the journal Pain Management Nursing, Associate Professor Marian Wilson and Enrico De Luca, of University ‘Sapienza’ of Rome, Italy, say there’s still much work to be done.  

Wilson and De Luca lay out persistent disparities in pain management. People with lower incomes, less education, from underrepresented groups, or living in rural areas all might have fewer options for pain management than others.  

In some cases it’s a matter of insurance. Nonpharmacologic therapies such as yoga, meditation, massage, nutritional supplements and acupuncture all have been shown to be helpful for pain management, but “the under- or uninsured will likely not be granted the same treatment opportunities and will bear more out-of-pocket cost burden” for such treatments, Wilson and De Luca say.  

Other inequities exist in the prescribing of opioids. People in rural communities are more likely to receive opioids than their urban counterparts, in part due to lack of access to non-medicine pain management approaches. And when opioids are prescribed, non-Hispanic white people have been found to receive higher dosages than other patients for the same conditions.  

“From the available data to date, it does not appear that equity exists in treatment for chronic or acute pain management,” Wilson and De Luca write.  

In this context, the authors discuss opportunities for nurses to improve pain management and equity in pain care delivery. An example is Caring Massage, an affordable, accessible tool used by nurses to reduce pain, discomfort, and improve sleep. Massage and caring touch have also been found to alleviate nurses’ compassion fatigue and improve nurse-patient relationships.  

Wilson and De Luca conclude, “It is time for an atmosphere of pain care abundance where safe, effective pain treatment options are plentiful and address all pain forms for all types of human beings.”  

Editorial: “Equitable Integrative Pain Care: Are We There Yet?”, Pain Management Nursing. By Marian Wilson, PhD, MPH, RN, PMGT-BC; and Enrico De Luca, PhD, MEdu, RN.  

Related: Dr. Marian Wilson’s COMFORT study – “Community-Engaged Options to Facilitate Opioid Reduction” – is ongoing. In collaboration with the Spokane Regional Health District, the University of Washington Institute for Translational Health Science and the Rayce Rudeen Foundation, Dr. Wilson is investigating how adults prescribed opioids for chronic noncancer pain respond to non-opioid options of massage therapy, yoga therapy, chiropractic and physical therapies for pain-related symptoms.  

Workplace adjustments could be the answer to nurses’ burnout  

Nurse holds N95 mask
Nurses were facing understaffing and increased workload before COVID-19 entered the picture, but the pandemic has added even more burden to the nursing profession.

Nurses were battling burnout long before the COVID-19 pandemic, says a new paper authored by Clinical Assistant Professor Angela C. Brittain of the WSU College of Nursing in Vancouver, published in the Journal of Professional Nursing.  

Aspects of the work environment, both in healthcare and in nursing education, were the cause, the paper says. Things like understaffing, increased duties and work hours, and reduced autonomy were present before the pandemic.  

Since 2020 new stressors have been added, such as inadequate resources and exposure to high-risk environments.  

The result has been “prolonged trauma, lasting post-traumatic stress disorder symptoms, and increased rates of suicide,” Brittain writes.  

Despite the causes of burnout being primarily workplace-related, potential interventions tend to focus on nurses themselves. For example, two of the largest nursing professional organizations have called for nurses to receive resiliency training to combat burnout.  

Writes Brittain, “If we understand that burnout is related to factors in the work environment, and one of those primary factors is workload – why are we advocating for an increase in workload for faculty and nurses through resiliency training? The mere suggestion that nurses and faculty should provide and undergo training in order to prevent burnout implies that the fault originates with them.”  

Workplace changes might be more successful in reducing burnout, the paper suggests. For example, following mandatory nurse-to-patient ratios that account for patient acuity, adequate staffing, increased nurse autonomy and the end of mandatory overtime. For faculty in nursing education, increased collaboration and communication could improve working conditions.  

“It is time to listen to nurses and nursing faculty about what they are experiencing and what they need,” Brittain writes. “Nurses across the nation are crying out for help – are we listening?”  

Paper: “Is resilience training the answer to burnout?,” Journal of Professional Nursing, by Angela C. Brittain, PhD, RN 

MN student studies effect of racism on breastfeeding rates 

Black woman nursing a baby
Black women have the lowest breastfeeding rate of any race or ethnicity in the United States and the gap is widening.

Dozens of studies and papers have documented the low rates of breastfeeding among Black mothers in the United States, but few have delved into how systemic and institutional racism contribute to the issue.    

Melissa Petit decided to take up that challenge as a Master of Nursing student at the Washington State University College of Nursing. She was lead author on a paper published in the Journal of Nutrition Education and Behavior, with three WSU College of Nursing faculty members as co-authors.   

As a longtime registered nurse and lactation consultant, Petit said she knew she wanted to examine breastfeeding as her master’s degree project. Black women have the lowest breastfeeding rate of any race or ethnicity in the United States and the gap is widening even though breastfeeding has proven and extensive health benefits for mothers and babies.   

Petit was struck by “the lack of research through the lens of race” to explain the disparity, she said.   

She reviewed more than three dozen previously published studies and papers on the subject, then used critical race theory and the social-ecological model to look at factors that might contribute to low breastfeeding rates for Black women. Despite its recent notoriety, critical race theory is useful to examine the root causes of health disparities, such as housing, education and employment, Petit said.   

A few examples noted in her paper:   

  • Breastfeeding education helps increase breastfeeding rates, but breastfeeding literature is dominated by images of White mothers, offering little in the way of role-modeling to women of color.   
  • Healthcare providers may have subconscious bias about who breastfeeds and who doesn’t, leading them to offer less help to some mothers based on those assumptions – a situation Petit said she personally witnessed as a nurse.   
  • A healthcare facility’s designation as a “Breastfeeding Friendly Hospital” has been effective in increasing breastfeeding rates for Black women. But Breastfeeding Friendly Hospitals are more prevalent in ZIP Codes with larger White populations, and less prevalent in ZIP Codes with larger populations of people of color.    
  • The United States offers no paid family leave for new mothers, limiting the time a lower-income woman might spend with her infant and disrupting the establishment of breastfeeding routines.   

Perspective: “Examination of Factors That Contribute to Breastfeeding Disparities and Inequities for Black Women in the U.S.,” Journal of Nutrition Education and Behavior. By Melissa Petit, MN PH, BA, RN, IBCLC; Denise A. Smart, DrPH, MPH, BSN, RN; Victoria Sattler, PhD, MN, RN; Natsuko K. Wood, PhD, RN.