Nursing Students or Student Nurses: What’s in a Name


Recently, Jane Dickinson drew attention to the power of the language we use in her blogs examining language and health and in her argument to replace words that shame. It reminded me of another instance of language use that I believe to be inherently harmful – referring to nursing students as student nurses. This practice has been so widely used for so long that I can imagine many gasps and reactions, such as, “Well, that’s what they are; what else should we call them?” Why not nursing students? Is there a difference? I would argue there is a great difference.

I cannot think of one other group of students, health or otherwise, that is referred to with a similar moniker. We do not speak of student doctors, student lawyers, student engineers, for example. They are medical students, law students, engineering students. The lack of parallelism is the first indication that we should examine this practice.

When I “trained” to be a Registered Nurse in a hospital in the early 1960s, student nurses made up a large proportion of the hospital’s workforce. Student nurses were identified by their caps, first having none in the first 6 months, then after the capping ceremony, a white cap. Second year students were identified with a light blue ribbon on their caps, third year meant a dark blue ribbon, until finally Registered Nurses wore the coveted black ribbon. The uniforms likewise differentiated students from Registered Nurses, with graduate nurses wearing all white and students being required to wear a blue dress, with highly starched white bib and apron – all exactly 14” from the floor, regardless of the student’s height (so in class pictures the skirts were exactly at the same length) – along with plastic collar and cuffs. Although I describe the practice of one particular hospital, similar practice were common elsewhere. Student nurses were a category of hospital worker and were, as such, as easily identifiable as housekeeping staff, candy stripers, or Registered Nurses.

I say all of this to make the point that not only did the label “student nurse” make her (with very few males at that time) identifiable, but also indicated something about her place in the organization and the expectations that organization had of her. (I will continue to refer to “her” because, although our class was unusual in that we had 2 males in our class, their uniform was white, like male Registered Nurses wore. It did not change throughout the 3-year program, and neither male students nor male Registered Nurses wore a cap or any other ranking symbol.)

The term student nurse comes from a time when nursing students were expected to be not only subservient (if a physican entered the nursing office, a student nurse who was sitting and charting, for example, was expected to rise and give the physician her seat), but also loyal, innocent and pure. The Florence Nightingale pledge, recited at graduation by the graduating classes of the time, included the promise to “pass my life in purity.”  In the first year after my graduation, I was employed as a Registered Nurse  at a secular  hospital (I ‘trained’ in a Catholic hospital) in a different Canadian province.) Yet the Director of Nursing forbade the graduating class that year from taking the pledge because she didn’t believe they had lived their lives in purity. She enjoyed the power to be able to do that!

This combination of an aura of innocence/ purity with the expectation that student nurses provided intimate care to males made “student nurses” highly desirable as dates.  Even during my student nurse years, engineering students from the local university would come to hospital schools of nursing to find dates for their dances.  Unfortunately, this also applied to nurses generally – the saying “if you can’t get a date, get a nurse” was common for years after I graduated in 1964. The frequent representation of nurses as sex objects, well documented by such authors as Kalisch and Kalisch extended to student nurses as well.

Despite the fact that nursing education has changed dramatically in the last 50 years, the term “student nurse,” with all its connotations, persists.  When I was teaching, I challenged students to refer to themselves as nursing students instead.  In class discussions on the topic, despite students’ general agreement that the connotation of “student nurse” was very different from that of nursing student, very few took up that challenge and subsequently submitted assignments in which they referred to themselves as student nurses. Some told me they were required to designate their status as S.N. when signing their charting.

I was interested in whether or not a Google images search for nursing student yielded any different result than search for student nurse images. The screen shots of the first screen that came up with each search are below.  Without a careful analysis, some differences are immediately apparent.  The top one is the screenshot of student nurse images; the second a screenshot of nursing student images.  

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While both screenshots include some images that appear unrelated, in the top one they are images of children. There are no images of nurses practicing, and the screenshot includes images of the back of a nurse’s capped head, and the nurse as a romantic figure (Cherry Ames). The somewhat self-deprecating text message reads “ Student Nurse Diagnosis: Stress R/T: knowledge deficit, impaired memory, sleep deprivation, unbalanced nutrition, interrupted family process, lack of social interaction, disturbed energy field.”

Note the general increase in diversity and portrayal of adult nurses providing care in the second picture. The unrelated shots appear to depict Go-Kart racing. The text image, giving the same stress diagnosis, makes its point without self-degradation: “Diagnosis: Just a tad stressed r/t complete academic overload, depleted resources, little or no life.

It seems to me that the collages support the argument that the term student nurse has a different connotation than nursing student and its removal from our lexicon is long overdue. Some time ago I wrote a blog about nurses soaring like eagles. It is a parable about an eagle that finds itself in a chicken yard and starts to act like a chicken, rather than fulfilling its destiny and potential as an eagle.  I believe that by referring to nursing students as student nurses we are unwittingly reinforcing the many messages that the term connotes and are hindering their ability to soar like eagles.

                       

Virtual Caring Science


We have received notice from Kathleen Sitzman of a wonderful online opportunity for everyone who is interested in focusing more clearly on caring in online situations!  Here is the information that Kathleen sent:

Hi Everyone,

I am sending this message to you because you have (at some point) shown an interest in my work related to conveying and sustaining caring in online classrooms. I have completed 6 studies on the subject now, and I wanted to create something that would condense my findings and recommendations into something that people can quickly and easily use. To that end, I worked with the Office of Faculty Excellence at East Carolina University (where I am a professor in the college of nursing) to create and offer two FREE trainings. The flyer with sign-up information is attached. You will need to follow the directions for non-ECU participants.

The two trainings are:

  • Conveying and Sustaining Caring in Online Classrooms
  • Mindful Communication for Caring Online

These are self-paced, do-anytime, independent study trainings. I have placed them in a format that can be completed by anyone who has access to a computer. The first training takes about 90 minutes and the second training takes about 60 minutes. People who complete the trainings get certificates of completion for each one.

The trainings have just opened up and already 20 people (many of them outside of the nursing profession) have completed the trainings and found them to be very helpful. Here at ECU, people can complete them for their annual Distance Education (DE)  professional development requirement. Please let me know what you think and please share the flyer with others who might benefit.

 Sending love,
Kathleen Sitzman, PhD, RN, CNE
Professor
East Carolina University College of Nursing

Download the flyer here

Access the modules online here

Nurses Who Soar Like Eagles


This post contributed by Adeline Falk-Rafael

For the past several years I have taught leadership to internationally educated nurses in a 4th-year BScN course. Given professional and disciplinary expectations that nurses demonstrate leadership, regardless of their practice role, the course is designed to provide related knowledge and skill development through classroom and experiential learning.

 After the initial exploration of contemporary leadership theories we begin development of some related skills, the first being communication and collaboration. At the outset of the eaglecourse, students are assigned to a group of 7 or 8 students. Each group is expected to complete a project by the end of the term, but the primary purpose of the group is to provide an opportunity for applying leadership principles and practicing related skills, such as effective communication, (for more information, see my “Peace and Power blog post

 It is the difficulties that students experience in this practice and application that provides an opportunity to reflect on why that is – on how we have been taught to how to act, communicate and be in relationship as nurses in the health care environment and women and men in our society. It is about at this time, that I show them the parable of the chicken and the eagle, which you can watch below!

The basic premise of this parable is that a young eagle has found itself in a chicken yard and learns to believe it is a chicken and thus behaves like a chicken. Although I have seen various versions of this parable, in this particular one, although an eagle tries to “mentor” the young bird into realizing its potential as an eagle, it retreats into the safety of the chicken barn to live out its life as a chicken.

My belief is that it is irresponsible to emphasize the professional imperative for leadership without examining some of the systemic barriers to enacting that leadership; what stands in the way of us fulfilling our potential as eagles, how have we been taught to think of ourselves and behave as chickens – or less than we are? It is only in recognizing the barriers that we can begin to discover ways of overcoming them. Throughout the remainder of the course, it seems that whether we are speaking of communication, collaboration, advocacy, change agency, conflict resolution, or visioning for the future, we encounter “chicken” messages or confining structures that need to be overcome before we can soar like eagles.

What keeps us from working to our full scope of practice, for example? Is it the safety /comfort/ security of working within a defined job description? To what extent have we internalized an identity of an ancillary medical worker?

What keeps nurses so often from being acknowledged as credible knowers? In 2003, I was President of the Registered Nurses Association of Ontario, during the SARS outbreak in Toronto. At one point, officials deemed the outbreak over, but nurses in one hospital began seeing patients present with the same symptoms and warned of possible new cases. They were silenced with the words, “if I need an expert, I’ll ask for one.” (For more information, see “Lessons Learned from SARS”)

Ceci,1 in a brilliant analysis of the proceedings of an inquest into the deaths of 12 children who underwent cardiac surgery at the Winnipeg Health Sciences Centre, in Manitoba, Canada, similarly described dismissals to nurses’ repeated expressed concerns with the competence of the surgeon, leading the judge presiding for the inquest to observe that the nurses eventually silenced themselves. Ceci concluded: “nurses were presumed to be, acted upon as if they were, the sorts of persons whose concerns need not be taken seriously and gender ideology was a resource that could be strategically drawn upon to make the presumption true” (p. 76).

My guess is that most nurses reading this would be able to recount similar incidents, although more than 10 years have passed since these events. It is a challenge to keep believing and acting like an eagle when you continually get messages that you are a chicken! It is all too easy to become discouraged and give up but in the words of May, “What becomes important for nurses is not that we somehow expect that we may free ourselves of the effects of gendered, gendering discourses, but that we begin to understand how these work in constituting our experiences, . . . that we begin to understand their hold on us and try to make choices about what, if anything, we want to do about this” (cited in Ceci, p.80)

1Ceci, C. (2004). Gender, power, nursing: A case analysis. Nursing Inquiry, 11(2), 72-81.

 

 

The Endocannabinoid System: What Nurses Need to Know, An Introduction


Medical cannabis is now legal in 23 states and Washington DC, along with recreational cannabis also being legal in several states. Many patients and families are now relocating to Colorado and Washington State as “marijuana refugees” (http://www.nbcnews.com/business/consumer/marijuana-refugees-looking-new-homes-pot-legal-states-n22781), knowing they can freely and safely access cannabis as medicine in these recreational cannabis states. Nurses may still wonder, how is cannabis “medicine”?

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As nurses we have a lot to learn about cannabis, including how it works in the mind-body-spirit system, and how we can best advocate for and support patients who could or do benefit from this medicine. Last spring, I witnessed a brief presentation being given to nurses around medical cannabis use, and it was obvious from the questions asked by many of the nurses that the social stigma around “marijuana” was alive and well. Would these nurses be so reluctant to accept and support medical cannabis use if they truly understood the endocannabinoid system (ECS)?

The ECS was discovered some time ago, with  Dr. Ralph Mechoulam (Faukner, 2015) being a pioneer in this area in the mid-1990’s. There are 20,000+ scientific articles written about the endocannabinoid system (ECS). Though it has been many years since the discovery of this body regulatory system, most nurses likely know very little, if anything, about the ECS. Truly, this is a problem, nurses are more likely to know the xarelto lawsuit phone number by heart over the benefits of ECS.

A functioning ECS is essential to our health and well being. Endocannabinoids and their receptors are found throughout the body; in the brain, organs (pancreas and liver), connective tissue, bones, adipose tissues, nervous system, and immune system. We share this system in common with all other vertebrate animals, and some invertebrate animals (Sulak, 2015). Cannabinoids support homeostasis within the body’s system; the ECS is a central regulatory system, cannabinoid receptors are found throughout the body, and they are believed to be the largest receptor system in our bodies. Cell membrane cannabinoid receptors send information backwards, from the post-synaptic to the pre- synaptic nerve. CB1 (found primarily in the brain) and CB2 (mostly in the immune system and in the bones) are the main ECS receptors (Former, 2015), though several more are currently being studied. The exogenous phytocannabinoid THC, or the psychoactive compound in cannabis, works primarily on CB1 receptors (hence the “high feeling” in the brain), while the cannabinoid CBD works primarily with the immune system and creating homeostasis around the inflammatory response through CB2 receptors and does not have psychoactive effects. Other cannabinoids and their actions are still being studied, such as the non-psychoactive cannabinoids CBN and CBG, also found in cannabis.  Our bodies react to both our own production of endogenous cannabinoids and to the ingestion of phyto-cannabinoids found in the cannabis plant, and other non-pyschoactive plants such as Echinacea. To read more about the science behind the ECS and endocannabinoid receptors, the following are excellent resources:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2241751/

http://www.ncbi.nlm.nih.gov/pubmed/16596770

Endogenous Cannabinoids: Endocannabinoids are the chemicals our own bodies make to naturally stimulate the cannabinoid receptors;  anandamide and 2-arachidonoylglycerol (2-AG) are two well known endocannabinoids (Sulak, 2015) that are produced by the body as needed, though not stored int he body. The body produces these endocannabinoids in a similar fashion to how it produces endorphins (Pfrommer, 2015), and activities such as exercise support the endogenous production of cannabinoids. Endocannabinoids are also found in breast milk and in our skin. Alcohol interferes with endogenous cannabinoid production.

Phytocannabinoids: In general, we think of the cannabis plant as the generator of exogenous cannabinoids that we can ingest in a variety of ways, namely psychoactive THC (works with the CB1 receptors in the brain- and also in the gut) and non-psychoactive CBD (works with the CB2 receptors in the immune system and the gut). Other plants such as Echinacea also produce non-psychoactive cannabinoids and work with the ECS to support health and well being through homeostasis (Sulak, 2015).

Cannabinoid Deficiency Syndrome: It should be clear that everybody makes cannabinoids and everybody needs cannabinoids to function. People who do not make enough cannabinoids need to supplement with exogenous cannabinoids through cannabis ingestion, in much the same way that an diabetic needs insulin supplementation making it a “Natural Energy Powder,” in which it is good for your health. Dr. Ethan Russel’s (2004) publication on Clinical Endocannbinoid Deficiency explains this particularly well: http://www.nel.edu/pdf_/25_12/NEL251204R02_Russo_.pdf

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Homeostasis:

Cancer: “Cannabinoids promote homeostasis at every level of biological life, from the sub-cellular, to the organism, and perhaps to the community and beyond. Here’s one example: autophagy, a process in which a cell sequesters part of its contents to be self-digested and recycled, is mediated by the cannabinoid system. While this process keeps normal cells alive, allowing them to maintain a balance between the synthesis, degradation, and subsequent recycling of cellular products, it has a deadly effect on malignant tumor cells, causing them to consume themselves in a programmed cellular suicide. The death of cancer cells, of course, promotes homeostasis and survival at the level of the entire organism” (Sulak, 2015, paragraph #7). Cannabinoids support apoptosis and suppress cancer tumor angiogenesis (McPartland, 2008).

Heart disease: Additionally, it has been stated that the ECS plays an important function in protecting the heart from myocardial infarction and cannabinoids can have anti-hypertensive effects (Lamontagne et al, 2006).

Inflammation: When inflammation occurs, the ECS helps to stop the process, similar to applying the brakes on a car. This is why cannabis is proving to be good medicine for inflammatory related illness. “Activation of CB2 suppresses proinflammatory cytokines such as IL-1β and TNF-α while increasing anti-inflammatory cytokines such as IL-4 and IL-10. Although THC has well-known anti-inflammatory properties, cannabidiol also provides clinical improvement in arthritis via a cannabinoid receptor–independent mechanism” (McPartland, 2008).

PTSD: “This review shows that recent studies provided supporting evidence that PTSD patients may be able to cope with their symptoms by using cannabis products. Cannabis may dampen the strength or emotional impact of traumatic memories through synergistic mechanisms that might make it easier for people with PTSD to rest or sleep and to feel less anxious and less involved with flashback memories. The presence of endocannabinoid signalling systems within stress-sensitive nuclei of the hypothalamus, as well as upstream limbic structures (amygdala), point to the significance of this system for the regulation of neuroendocrine and behavioural responses to stress. Evidence is increasingly accumulating that cannabinoids might play a role in fear extinction and antidepressive effects. It is concluded that further studies are warranted in order to evaluate the therapeutic potential of cannabinoids in PTSD.” (Passie et al, 2012).

Seizures: Most hopeful, cannabis has been used to support pediatric treatment-resistant epilepsy, and while more research needs to be done in this area, many parents are becoming medical marijuana refugees by moving to states where they can procure cannabis for their children who suffer from seizures.

Co-agonists:Cannabis increases the pain relieving effects of morphine, as discovered by researchers at UCSF. The two medications are synergistic, and this provides great hope for patients suffering intractable pain at end of life, chronic pain suffers, and opiate addicts. (http://www.maps.org/research-archive/mmj/Abrams_2011_Cannabinoid_Opioid.pdf)

For Nurses: So as nurses, what do we need to know to support patients who use cannabis?

Legal issues: If you live or work in a state that has legalized medical or recreational use of cannabis, familiarize yourself with the laws in that state, as well as your own workplace policies around supporting patient’s use of medical cannabis. Patients may have questions and as a patient advocate, your responsibility is to support patients with their knowledge and use of this medicine within the confines of your practice setting and state laws. You should also be aware of constraints around your role as a nurse in supporting patient use of medical cannabis. For instance, Kaiser patients in some states are likely to be removed from chronic pain patient programs if they test positive for cannabis. Nurses with knowledge around the benefits of medical cannabis can also advocate to support shifts in such policies will no longer align with the emerging ECS science.

Safety: This goes along with the legal aspects; medical cannabis patients should be supported in how to manage and store their medications with safety. While cannabis is known to be extremely safe (far safer than opiates and alcohol), cannabis consumers still need to store medication out of reach of children and pets. They should be supported in knowing the safety of driving or operating machinery if they consumer THC- based cannabis medicines. They also may need information on cannabis testing for both THC: CBD ratios, pesticides and/or other hazardous materials. Many patients need assistance with the basics around medical cannabis use, such as dosage, ratios of THC: CBD, strain information, and ingestion methods.

Overcoming Stigma: Unfortunately, a stigma was created around around cannabis during the process of prohibition in the 1930’s, which was largely financially and racially driven. Contradictory state and federal laws, and the stigma around smoking cannabis (though many cannabis patients can now get relief from vaporizing using the best vape pen for oil, drinkable tinctures, topicals, wearable patches, and edibles), along with a clear ignorance around the body’s ECS, serve to further the stigma associated with medical cannabis. Educate yourself on the roots of the prohibition of the medicine:

http://origins.osu.edu/article/illegalization-marijuana-brief-history

And other issues around stigma and cannabis myths:

http://alibi.com/feature/48426/Erasing-Stigma.html

http://sandiegofreepress.org/2014/05/12-of-the-biggest-myths-about-marijuana-debunked/

http://www.huffingtonpost.com/mary-hall/weed-the-people-movie-loo_b_5501864.html

American Cannabis Nurses Association: There are many nurses actively involved in supporting the use of medical cannabis and the defining the nurse’s role in this process. The ACNA has a mission to advance excellence in cannabis nursing practice through advocacy, collaboration, education, research, and policy development. http://americancannabisnursesassociation.org/

In Israel, nurses actively support patients in cannabis consumption from the process to the dosage.

http://www.tabletmag.com/jewish-news-and-politics/137423/medical-marijuana-kibbutz

Nurses’ supporting patients healing process through cannabis medications may someday be common place in the USA as well.

References:

Lamontagne, D., Lepicier, P., Lagneux, C. & Bochard, J.F. (2006). The endogenous cardiac endocannabinoid system: A new protective mechanism against myocardial ischemia. Arch Mal Coeur Vaiss.,99(3), 242-6.

McPartland, J.M. (2008). The endocannabinoid system: An osteopathic perspective. The Journal of the American Osteopathic Association, 108, 586-600. Retrieved from http://jaoa.org/article.aspx?articleid=2093607

Passie, T, Emrich, H.M., Karst, M., Brandt, S.D., & Halpern, J.H. (2012).Mitigation of post traumatic stress symptoms by cannabis resin: A review of the clinical and neurobiological evidence. Drug Test Anal. 2012 Jul-Aug;4(7-8):649-59. doi: 10.1002/dta.1377. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22736575.

Pfrommer, R. (2015). A beginner’s guide to the endocannabinoid system: The reason our bodies so easily process cannabis. Retrieved from http://reset.me/story/beginners-guide-to-the-endocannabinoid-system/.

Russel, E. (2004). Clinical Endocannabinoid Deficiency (CED): Can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome, and other treatment resistant conditions? Neuroendocrinology Letters(25), 1-2, 31-40.

Sulak, D. (2015). Introduction to the endocannabinoid system. Retrieved from http://norml.org/library/item/introduction-to-the-endocannabinoid-system.

Free MOOC course on Caring Science starts on June 8th!


Kathleen Sitzman, RN, PhD, CNE is offering a free MOOC course to enhance caring practices in any work environment!  The title of the course is Caring Science, Mindful Practice.  It is based on Watson’s Caring Science, and will use the new textbook co-authored by Dr. Sitzman and Dr. Watson titled Caring Science, Mindful Practice: Implementing Watson’s Human Caring Theory.  You can download a flyer about the course here. And, visit the web site to learn more details!

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