Welcome to Lisa Sundean, who is joining our team of bloggers!
Lisa Sundean
WCCs originated in 1993 by the Arnold P. Gold Foundation. The purpose of the WCC is to symbolize the transition into the medical practice and to remind medical students of their promise to scientific, compassionate medical care. Since 1993, several other health professions have adopted the WCC as a professional milestone and transition for students. More recently, nursing schools have begun to adopt WCCs, endorsed and supported by AACN in partnership with The Arnold P. Gold Foundation (The Arnold P. Gold Foundation, 2013).
On the surface, the symbolism of the WCC for health professionals is honorable. However, one must question the utility and deeper meaning of the WCC for nurses. First, the WCC originated for the medical profession. Are nurses still so enamored by medicine that we cannot embrace our own professional symbolism and rituals? Second, nurses understand the struggle of the profession to rise up from more than a century of medical oppression and yet, we are willing to don the white coat of physicians as a symbol of achievement and transition in the nursing profession. Are we not cloaking our students in the very cloth of oppression we seek to emancipate from? Finally, as we face the critical need to transform healthcare, we fully understand the importance of interdisciplinary and interprofessional collaboration. Such collaboration capitalizes on the unique synergies of knowledge, skills, and expertise of various disciplines and professions. Is the WCC contrary to such collaboration? Does the WCC unconsciously invoke nurses to become more like physicians rather than the unique profession it seeks to become; a profession with a unique knowledge base, a unique skill set, a unique expertise, a unique contribution to health and healthcare, and a unique set of professional traditions?
The WCC is a new tradition for the medical profession. It is fair to respect the symbolism of the ceremony for physicians. However, adoption of the WCC for nurses is questionable. Nursing scholars encourage us to find our professional voice and establish our professional uniqueness (Kagan, Smith & Chinn, 2014). The quest for that uniqueness is a road paved with rigor, creativity, dedication, and commitment to the metaparadigm of nursing. With all due respect to The Arnold P. Gold Foundation, nurses, we can do better than allow ourselves to be seduced by a medical tradition to symbolize our unique profession and identity.
References
Kagan, P. N., Smith, M. C. & Chinn, P. L. (2014). Philosophies and practices of emancipatory nursing: Social justice as praxis. New York, NY: Routledge.
The American Association of Colleges of Nursing. (July 2015). Gold Foundation and AACN to fund 60 nursing schools for 2015 white coat ceremonies. Retrieved from http://ymlp.com/zwDmlO
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”?
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:
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
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:
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.
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.
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.
According to Miriam Webster Dictionary freedom is a noun, and defined as the quality or state of being free. Freedom is the absence of necessity, coercion or constraints in choice or action.
Life, liberty and the pursuit of happiness are the hallmarks of independence. To be liberated from the constraints and restraints of the power from another, or a set of beliefs, yields a quality of life that allows for ease of speech and privilege to be and become what we want.
As nurses, we may experience coercion or constraints, even restraints in our practice. Can we liberate ourselves and define our set of beliefs to have the power to see and say what nursing is and is not?
Contemporary theorists and healers believe we may start by setting the intention for the highest healing good to occur; then see nursing within the context of a set of beliefs and values that promote caring and healing for self, system and others; we take action to liberate our selves and others of the constraints and restraints that bind us from achieving this end.
What is it like to live and work in environments that allow freedom of speech and action? Are we brave enough to challenge those who seek to imprison us in thought and behavior? Is nursing is the home of the free and the brave; or are we constrained by restrictive rules, mores and narratives?
In my research on caring and healing I have heard nursing narratives that describe transformative advocacy; looking, and seeing where the next right action enfolds … taking the next steps together, with each other, and our patients and families down a new yellow brick road that meets each persons next Freedom.
Nursing, the home of the Free and the Brave; let Freedom reign.
I worked with a DNP student as her “clinical mentor” for the last year and a half. During one of our meetings she told me that she has had to justify her decisions at every point in her nursing career. When she first became a nurse she chose a BSN program. Then in her first job she was working with all ADN nurses who treated her differently because of her 4-year degree. When a position opened up in the Emergency Department, this nurse got the job because she had a BSN and she dealt with even more fall-out.
When my colleague decided to pursue a master’s degree, she was given a hard time for choosing to become a CNS (Clinical Nurse Specialist) rather than an NP (Nurse Practitioner). Her most recent experience with having to justify her nursing career and education path was when she began an online DNP program. Why DNP and not PhD? Why online and not on campus?
My colleague’s story reminded me of discussions I’ve had in the past about how nurses treat each other and the age old “nurses eat their young.” I imagine this type of behavior happens in many professions; my biggest concern, though, is that what is known as the most trusted, the “caring” profession, would participate in it.
What is it about nurses or nursing that contributes to this phenomenon? Is it the stress we deal with in our daily jobs – leaving no energy for interpersonal relationships? Do our work settings or the people we work for cause us to feel inadequate leading to insecurities and jealousy? Does questioning ourselves lead to questioning others?
I have witnessed nurses who are incredibly loyal to each other and would do anything for one another. I have close, lifelong friendships with nurses I worked with years ago. I’ve also seen nurses treat each other unkindly and not support each other.
I believe that leadership makes a huge difference. In my experience, nurses who are valued, respected, and given autonomy treat each other better than those who feel micro-managed or not trusted. Management can make or break a nurse’s experience and maybe even how she or he treats their co-workers. That, of course, can trickle down to patient care, which is the whole point of what we do!
Leadership also happens in the classroom. Those who teach and shape nurses can encourage them to support each other and by doing so strengthen the profession. Leaders of our local, state, and national organizations can do the same. And those nurses who are on the front line, feeling the effects (good or bad) of professional relationships, can contribute to making nursing a consistently friendly profession by taking a leadership role in their workplace, or their professional organization. At the very least they can be friendly and helpful to their nurse colleagues.
I am proud to be a nurse, and I’m a passionate advocate for and supporter of the nursing profession. So when I hear stories like the one my friend told me, I get concerned. There are enough stresses and challenges in health care today. By standing together, nurses can make a difference to patients and to each other. I envision nurses as a group of health care professionals who have each others’ backs. I see nurses as being excited for another nurse who is advancing his or her career or education – an opportunity for growth as an individual, a team, a unit, and most important for improving patient care.
Filmed nearly 40 years ago, the “Politics of Caring” film provides history of the grassroots support groups and activities that we continue to build on. One of my favorite parts of the film is about 5 minutes in, when a group of nurses are discussing their frustration with hospital working conditions: “We don’t have enough staff, we don’t have enough time…” They talk about wanting to improve their working conditions, by moving to a different hospital, or unit, or leaving the hospital to work in the community described as “mecca”.
When I graduated nursing school it was not uncommon for nurses to regularly care for 8 or even 10 patients on a cardiac surgery step-down or transitional care unit. I knew this was not the way I wanted to practice nursing, and found my passion in community and home health nursing. The 2003 NurseManifest Study provided an opportunity to talk with my co-workers and colleagues locally and nationally, to better understand what changes were needed and desired by nurses to create their ideal working conditions. Some of the major findings were that nurses felt a lack of respect, a lack of voice, and a lack of unity. Now, over a decade later, my work is dedicated to research that tells the story of what it is like to practice nursing today, and that shows the value of nursing for patients and society as a whole.
Why everyone should care about nurses’ working conditions and staffing ratios was the subject of a recent New York Times Op-Ed “We Need More Nurses” by Alexandra Robbins. The op-ed piece mentions dozens of research studies providing the evidence that patients’ risk of death, infections, complications, falls, hospital and hospital readmission are greater when nurses are caring for more than 4 or 5 medical or surgical patients. Hundreds of readers’ comments brought personal stories and richness to the conversation from the views of nurses, patients, family members, physicians, administrators, and more.
Working conditions and labor force issues for nurses is an international priority, and one source of current information is the RN4CAST Consortium, consisting of nursing workforce research groups in 17 countries, including the United States. Currently the United States group, based at the University of Pennsylvania, is surveying over 250,00 registered nurses and advanced practice nurses about nursing care, patient outcomes, and general working conditions for nurses. You can learn more about their work, and the study director Dr. Linda Aiken here.
Another source of information and place for collaboration is National Forum of State Nursing Workforce Centers, comprised of nursing workforce centers in 33 states. The National Forum of Nursing Workforce Centers is a resource for finding information specific to your state, as well as about nursing workforce issues nationally. Their annual conference will be held next week in Denver, Colorado and you can download the conference brochure and registration information from their website.
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