A Nursing Manifesto for 2030: Human Care Against Extraction and Exploitation (green paper)

August 31, 2026September 12, 2026 / renataem5f99684f1a / Leave a comment

Renata E. Mares MIPH, BScN, BA Kin

Aug 22, 2026

Please use this document in any way that you wish. You can freely use this document (with citation; see our creative commons license in the footer of this and all pages on this site) The format for citing the document is shown at the end of the table of contents. If you wish to have other ideas integrated into this document, or included on this web site, please contact us or the author directly renata@adaptablefolks.com

1.     Introduction
2.     Planetary Health is Nursing Work
3.     Commercial Determinants of Harms and Health: Get Political
4.     Nursing Is Not a Buffer for System Failure
5.     Against the Medical-Industrial Complex
6.     Our Commitment
7.     A Call to Conscience and Action
8.     About the Author
9. Reference list (see image)

Citation: Mares, R. E. (2026). A Nursing Manifesto for 2030: Human Care Against Extraction and Exploitation (green paper). https://nursemanifest.com/2026/08/31/a-nursing-manifesto-for-2030-human-care-against-extraction-and-exploitation-green-paper/

Foreword

I came across this incredible blog post about A Nursing Manifesto 2000 written by three incredible nurses and academics: Richard Cowling, Peggy Chinn, Sue Hagedorn in 2000 and I thought to develop a parallel manifesto which brings together some of the books I have been reading over the past 5 years post-pandemic and some which reaches further back to the 80s 90s, 2000s, till present time.

The world have shifted quite a bit since this manifesto was developed and shared. In and of itself, it reads like something to aspire to. Maybe when I started my nursing career as a new graduate back in 2008, it would have been something to aspire to in my own work, career, research and teaching. But now I find some pretty troubling things not only missing from this manifesto as historical accounts, including the troublesome origins of the nursing and medical profession / culture, but it needs to be updated for the year 2030 and beyond.

But first, take some time to read and get familiar with A Nursing Manifesto 2000: https://nursemanifest.com/a-nursing-manifesto-a-call-to-conscience-and-action/

Below is the introduction to A Nursing Manifesto: A Call to Conscience and Action written in 2000. I am sharing here just the initial Introduction, but please do have a read of the entire manifesto as it discusses the ideals and principles, inspiration, concerns, vision and suggestions for actions. It also describes the authors and their positionality and about the art contained within this blog.

A Nursing Manifesto: A Call to Conscience and Action (2000)

by Richard Cowling, Peggy Chinn, Sue Hagedorn

Introduction (excerpt)

“As nurses, we reach for meaningful expressions of our values, too often finding overwhelming constraint and resistance, sometimes within ourselves and sometimes imposed from without. We are calling for a movement to awaken those precious and powerful ideals that are rooted in nursing’s worldwide historical traditions. We call forth the written and spoken voice of nursing to be claimed and reclaimed. We seek to inspire the fullest expression of the heart of nursing through individual and collective acts. We believe there are profound possibilities in claiming our individual and professional sovereignty” … link to full manifesto here: https://nursemanifest.com/a-nursing-manifesto-a-call-to-conscience-and-action/#intro

My initial thoughts on this this first paragraph would be:

Awakening the so called ‘precious and powerful ideals’ is definitely a good thing, but how does nursing as a profession and value-based career wrestle with the monolith it has created the lack of diversity over the course of centuries
Rooted in nursing’s worldwide historical traditions: would these discuss how Nightingale-like nursing is rooted in supporting war and military efforts? Would these traditions address the issues of explicitly racism, sexism, and harmful medical cultural administrative practice over the course of the centuries? Our current professional associations are build as empires where lack of diverse leadership opportunities persist and patriarchal hierarchies are celebrated as excellence.
Attrition in nursing and healthcare is at crisis levels, yet no one talks explicitly about trauma and cPTSD experienced not from patients, toxic teams, but administrative and regulatory practices. Anyone care to elaborate here?

As I was reading this incredible manifesto and remembering back to the year 2000, I started to draw both parallels and the need to advance these exact thoughts to the years 2030 and beyond. At first I had the idea of taking each section and paragraph and write my thoughts in support and opposition. But then I thought, why not take all that I have read and know and develop something totally new yet complementary. Building upon my elders’ work.

Believe it or not, I have a fear of writing my own voice and ideas down. I don’t want to hurt feelings and I do get intimidated by folks who are much more qualified than myself, and therefore, I have the feeling that maybe I should not share what I have to say. I am now slowly building back my lost confidence and also recognizing that part of nuanced and critical thinking is (sometimes) getting things wrong, and sometimes right but too soon. So, I want to share both what I might be thinking that is wrong and also my worries about the nursing profession that I love so much. After nearly 20 years in this profession across specialties like orthopedic/trauma, medical/surgical units, mental health, public and community health, policy and education, I feel that I did my authentic best in trying to build the new and not getting lost in the challenges of the past. However, burnout happens to all of us, some more resilient than others. I am accepting that I might have pushed too hard for change and lacked the skills of relationship building. My past of being a refugee and immigrant female child who grew up in post-Communist Romania and Hungary could add to some of these reasons. The urgency to alleviate struggles for others was a real cause and drive for me. I never understood how a bunch of smart people could just sit around the table and talk about action, while people were struggling. Access to healthcare is access to people’s tax dollars. Talking was seemingly a waste of time from my perspective, as an early career public health nurse. I was searching to find people who felt the same urgency (or at least understood my motivations) as I did to act and help get folks out of poverty, get access to health and social services, and not just talk about it in meetings.

I may have been naïve and rushed. I was give the privilege of a profession to do good and alleviate harms. However, without trusted relationships, money doesn’t flow and people remain in poverty, in struggles that are the result of structures and systems I wanted to adapt. Some lessons we learn the hard way. I am now re-learning to build the confidence to talk, share ideas, and build relationship among people who are looking to advance the only huma-centered profession still remains. (I might be biased in this view) Is the last human job a nurse? Or so I assume in this manifesto. Or maybe the last human jobs are human-collaborations across sectors. Yes, that sounds more like it. But first we need to pivot (yes, just like that couch on a Friends episode from Feb 1999) and pay those human-collaboration jobs a fair wage.

Therefore, I am using my LinkedIn platform to share my ideas of A Nursing Manifesto for 2030: Human Care Against Extraction and Exploitation – a draft (2026) paralleling what has been written in 2000 and adding in some of my ideas from the list of resources that I will share at the very end of this writing. It might give future nurses in undergraduate and graduate studies something to ponder beyond the status quo of the nursing/ healthcare profession and education. We need to get out of ‘our’ status quo cultural box.

As always, I am open to discussions and opposing views that are shared respectfully.

1. INTRODUCTION

‘We’ are nurses (diverse with complex/ adaptive skills professionals) at a time when care is being remade by machines, markets, and systems that measure human worth in data points, risk scores, productivity targets, and billing codes.

We do not reject technology.

We reject technology without accountability.

Artificial intelligence, automation, surveillance, and predictive systems have entered hospitals, homes, clinics, long-term care, and public health. They promise efficiency while too often deepening abandonment. They sort people by profitability, automate denials, intensify workloads, erase human judgment, and place the burdens of flawed systems on those already made vulnerable by racism, colonialism, poverty, disability, gender oppression, and displacement.

We have seen what happens when an algorithm is treated as neutral while it inherits the inequities of the world that trained it. We have seen staffing systems call exhaustion as ‘optimization’. We have seen virtual care become a substitute for accessible, relational care. We have seen automation used not to relieve nurses of harmful labour, but to eliminate jobs, deskill practice, and demand that fewer workers do more with less.

This is not innovation.

It is extraction.

We are nurses practicing amid converging emergencies: widening inequality, climate breakdown, poisoned water, forced displacement, worsening chronic illness, automated exclusion, and healthcare systems increasingly governed by commercial interests rather than public need.

We affirm that health is inseparable from the conditions in which people are born, grow, work, live, age, and die. Health begins with breathable air, safe homes, nourishing food, clean water, meaningful connection, cultural continuity, freedom from violence, and a stable living planet. No hospital, algorithm, drug, or procedure can compensate for a society that systematically destroys these foundations.

The medical-industrial complex has transformed illness into revenue, crisis into market opportunity, and health into a commodity distributed according to wealth, insurance status, postal code, citizenship, and institutional power. It profits from endless treatment while neglecting clean air, safe housing, food security, living wages, disability justice, mental health, reproductive freedom, and the conditions that allow people to live well before they become patients.

We reject the fiction that health care exists apart from the world. The same systems that commodify illness extract from workers, communities, lands, and waters. The medical-industrial complex profits from treatment while underinvesting in prevention; corporations profit from pollution while public systems absorb the resulting disease; technology firms market “innovation” while shifting social, environmental, and clinical risks onto patients, caregivers, and frontline workers.

This is not an accident. It is a political choice.

We refuse to accept a healthcare system that calls itself advanced while people wait in pain, workers burn out and become patients themselves (Chapman, 2023), communities are poisoned, and the planet warms. (Check out the underlying drivers of planetary harms by Planetary Health Alliance website: culture, values, behaviour, consumption, population size/demographic changes, technology) https://planetaryhealthalliance.org/what-is-planetary-health/

Nursing must be more than the human face placed on an inhumane system. Our role is not to make austerity appear compassionate, to absorb the moral injury created by unsafe conditions, or to quietly compensate for decisions made by executives, insurers, technology firms, regulators and governments far from the bedside.

Our ethical obligation is to care and to confront what makes care impossible.

2. Planetary Health is Nursing Work

Planetary health is not an optional specialty or a future concern. It is present in every heat-related illness, asthma exacerbation, contaminated water supply, food insecurity assessment, infectious-disease outbreak, wildfire evacuation, pregnancy complication, mental-health crisis, and preventable death.

We recognize the health of people as inseparable from the health of lands, waters, ecosystems, and climate. Indigenous peoples have long carried knowledge of these relationships and of stewardship, reciprocity, and collective responsibility. Nursing must listen, learn, and act without appropriating that knowledge or repeating colonial systems of control.

We will advocate for health systems that reduce rather than export harm: low-carbon care, ethical procurement, less waste, resilient infrastructure, safe transportation, sustainable food systems, and emergency planning led with (not imposed upon) affected communities.

Clean water is a health right, not a commercial asset. Water insecurity, contamination, privatization, boil-water advisories, drought, flooding, and inadequate sanitation are nursing concerns because they produce infection, chronic disease, reproductive harm, trauma, displacement, and death. We will name water injustice as a clinical and public-health emergency, especially where it follows colonial dispossession, industrial pollution, and neglect of rural, remote, and Indigenous communities.

3. Commercial Determinants of Harm and Health: Get Political

We confront the commercial determinants of health: the corporate practices that shape exposure to harm, access to care, public policy, and the very definition of health.

Industries profit when people consume products that damage their bodies or environment, including tobacco and nicotine corporations, alcohol producers, ultra-processed food companies, fossil-fuel industries, extractive mining interests, pharmaceutical monopolies, private equity firms, surveillance platforms, and vendors of unaccountable health technology, and digital-addictive designs and digital-afterlife industries. Their influence reaches advertising, research, regulation, education, political lobbying, clinical guidelines, and data infrastructure.

We reject the normalization of harm as “consumer choice” when choices are engineered through marketing, pricing, scarcity, misinformation, racism, design inequity and unequal power.

We also recognize that commercial power can shape health positively only when it is democratically governed, transparent, and subordinated to the public good. Products, technologies, and services must be assessed not simply by revenue or technical novelty, but by their effects on equity, ecological sustainability, worker safety, community control, and long-term health. (my favourite slogan: war brings neither peace nor climate justice, defund military spending).

4. Nursing Is Not a Buffer for System Failure

Nursing is not low-paid emotional labour designed to absorb the failures of health and social systems. It is not a flexible reserve workforce to be stretched during crises, disciplined through precarity, or replaced by automation when budgets demand it.

Nursing knowledge is scientific, relational, ethical, political, and ecological. Nurses assess changing conditions, interpret uncertainty, build trust, notice patterns others miss, coordinate care across fragmented systems, protect rights, respond to suffering, and advocate for structural change. This expertise cannot be reduced to tasks, scripts, dashboards, or a layer of “human oversight” added after an algorithm has already shaped a person’s options.

We reject the use of artificial intelligence and automation to intensify work, monitor workers, remove professional judgment, automate benefit or treatment denials, or redirect accountability away from corporations and institutions. A nurse must never be expected to legitimize a harmful system simply because a person remains nominally “in the loop.”

Technology must serve care, not govern it. Any system used in health care must be transparent, independently audited, accessible, privacy-protective, environmentally accountable, and open to challenge by patients, families, nurses, and communities. It must be assessed for bias, labour impacts, energy and water use, supply-chain harms, and effects on access, not only for accuracy or cost savings.

5. Against the Medical-Industrial Complex

The medical-industrial complex converts suffering into revenue. It treats health as a market, patients as customers, records as assets, and workers as costs to be minimized. It normalizes private equity, monopolies, predatory pricing, medical debt, pharmaceutical profiteering, commercialization of data, and the outsourcing of public responsibilities to corporations.

We refuse a health system that boasts of technological progress while people cannot obtain primary care, medication, safe housing, home care, reproductive services, mental-health support, palliative care, or culturally safe care.

We oppose austerity disguised as efficiency. We oppose privatization disguised as innovation. We oppose surveillance disguised as safety. We oppose extraction disguised as care.

A just health system must be universal, public, adequately funded, community-rooted, culturally safe, accessible, and accountable to the people it serves. It must invest upstream: in income security, public housing, education, food sovereignty, disability justice, harm reduction, clean water, healthy ecosystems, and meaningful public-health capacity.

6. Our Commitment

We therefore commit ourselves to:

Defend human dignity over speed, profit, automation, and institutional convenience.
Defend health as a collective right and reject its treatment as a commodity.
Identify and confront commercial practices that produce illness, environmental destruction, inequity, and barriers to care.
Follow the leadership of communities most affected by environmental injustice, commercial exploitation, and institutional neglect.
Insist that every artificial intelligence system used in health care be transparent, independently audited, explainable, contestable, and governed with meaningful public and worker participation.
Refuse algorithms that reproduce discrimination or replace clinical judgment, informed consent, and relationships of trust. Stand against racism, colonialism, ableism, sexism, homophobia, transphobia, class exploitation, and xenophobia in health systems and society.
Demand that technology reduce harmful work and expand access to care, not intensify surveillance, cut staffing, deskill nursing, or deny services. My post on nursing profession and branding https://www.linkedin.com/feed/update/urn:li:activity:7496682545108025345/
Organize for safe staffing, fair wages (like programmers and coders once were paid), public health infrastructure, union rights, and workplaces where nurses can speak honestly without retaliation (regulatory harms have still not been addressed explicitly and attrition continues to crisis levels). My post on trauma: https://www.linkedin.com/feed/update/urn:li:activity:7496346149822287873/ ; my post on regulatory harms https://www.linkedin.com/feed/update/urn:li:activity:7496353936921071616/
Treat climate disruption as a health emergency created by unequal systems of extraction, and advocate for care that protects communities and the living world.
Stand with patients and communities against medical debt, privatization (yes Canada, you too), predatory pharmaceutical practices, corporate consolidation, and the commodification of suffering (CDoH, 2022). post on global power demand by 2030 https://www.linkedin.com/feed/update/urn:li:share:7255265303691997184/
Advocate for public, universal health systems free from corporate capture and private-profit priorities.
Center the knowledge and leadership of Indigenous peoples, Black communities, disabled people, migrants, low-income communities, and all those harmed first and worst by unequal systems. (Can we please collect wealth tax, and stat? Harrington, 2025)
Protect the right of every person to understand, question, and refuse the technologies affecting their body, records, treatment, and future. (Once people lose mental capacity, at any age, what happens to their digital footprint and logins. Read up on digital-afterlife industry) my post: https://www.linkedin.com/feed/update/urn:li:activity:7496323674120048640/
Practice solidarity across professions, sectors, and borders, because no individual nurse can solve harms produced by structural power.
Protect clean water, sanitation, healthy ecosystems, and climate stability as indispensable conditions of health.
Treat nursing expertise as essential to governance, policy, technology design, climate adaptation, public health, and community-led care, not as inexpensive labour or an afterthought in executive decisions.
Build care systems based on solidarity, reciprocity, prevention, justice, and ecological repair.

7. A Call to Conscience and Action

In 2030, conscience requires more than compassion.

It requires courage. Not only to speak for/with patients, families and communities, but to speak against professional toxic culture, leadership, and stagnant professional envelopment. It requires collective action against the systems that manufacture illness and call the consequences unavoidable.

It requires us to ask not only, “Can this technology be used?” but “Who does it serve? Who exposed to/ bears its risks? Who profits? What forms of care, labour, and life does it displace?” Who is left waiting, excluded, displaced, or silenced?

I have held a role as a nurse informatics, merging duplicate files because IBM refused to adapt their infrastructure. Are informatics professionals seen as human-in-the-loop or human-exploited-in-the-loop?

It requires us to understand that a healthy society cannot be built on exhausted workers, disposable patients, automated exclusion, or a damaged planet. We CAN however, pivot workforce roles and pay people to do human jobs, like witnessing and delivering care where it’s needed. (Pugh, 2026)

Care cannot be ethical if it relies on ecological destruction. Innovation cannot be just if it is built on surveillance, dispossession, or underpaid labour. Health cannot exist where water is unsafe, homes are unaffordable, ecosystems are collapsing, and human needs are subordinated to corporate return.

We will not be reduced to exhausted labour, automated compliance, or human cover for decisions made by machines and markets.

We call on nurses to reclaim our collective (yet, diverse) voice. We call on health workers to organize. We call on institutions to place care above revenue (wealth tax helps here). We call on governments to regulate health technologies in the public interest and to fund universal, accessible, community-rooted health care.

We call on the public to reject a future in which the right to health is determined by an algorithm or a balance sheet.

Care is not a product. Health is not a privilege. People are not (just) data to be extracted and sold.

The planet is not expendable.

We will not be silent witnesses to systems that harm in the name of progress.

We will practice, organize, resist, and build a future in which care remains human, collective, just, and sustainable.

We are nurses. We are advocates, clinicians, educators, organizers, researchers, knowledge holders, and defenders of the conditions required for life.

We will care for people and we will fight for the world in which people can be well.

8. About the Author

The Nursing Manifesto 2030 builds upon and expands The Nursing Manifesto 2000, the pioneering work of Richard Cowling, Sue Hagedorn, and Peggy Chinn. In the age of AI, provenance is one of the most important forms of acknowledgement, demonstrating that ideas and thoughts never simply appear, but are cultivated, grazed, turned over, and digested with time, patience, and communal support. The original authors all came from white, middle-class backgrounds and grew up in diverse regions of the United States (New York, Hawaii, Virginia), with relatively privileged access to education, travel, and cultural experiences. Yet early in their lives, each followed personal and political paths that challenged the status quo, often to the chagrin of family and friends. Though not always overtly “political” on the surface, their journeys reflected a deep yearning for peace, justice, and the caring, nurturing values they perceived to be at the heart of nursing. They came together to prepare the text for A Nursing Manifesto 2000, informed by their shared awareness of the deeply political nature of personal choices.

Renata E. Mares, author of The Nursing Manifesto 2030: Human Care Against Extraction and Exploitation (green paper), brings both continuity and distinct difference to this legacy. Born in 1984 in Oradea, Romania, a region marked by Hungarian legacies and Romanian cultural tensions since the 1920s (Treaty of Trianon), she became a refugee at age four when her family fled the communist regime in 1988. She grew up in post-communist Hungary (schooling) and Romania (summer vacations), experiences that shaped her social justice and ethical compass, and led her to challenge oppressive and racist systems throughout her nursing career. Her father and brother spend fiver years (1990-95) in Rochester, New York in hopes for her mother and herself to follow but at that time families could not easily join. Her family immigrated to Guelph, Ontario, Canada in 1996 and has called this place home even across her decades of travel and nursing. Since nursing school in Canada (2003–2008) and continuing through diverse roles in ortho-trauma, med-surg, rehabilitation, mental health, long-term care, public health, outbreak management, policy consulting, education, and global humanitarian work (2009–2019), she has consistently challenged the status quo, even when it meant alienating friends, colleagues, and family. Today, she firmly believes nursing remains the most human-centered profession, uniquely positioned to challenge profiteering practices, build regulatory and safety guardrails through healthy public policy, and resist automation of human-care work. Grateful to the original manifesto authors for helping her articulate the political nature of her own choices, she writes in hopes that reflection, awareness, and philosophy will offer others the same healing she has found through two decades of honest practice in nursing and across the health system.

9. References

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Nurses’ Concerns with COVID19: Update April 1, 2020

April 1, 2020April 2, 2020 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 4 Comments

Ongoing Issues: By now, most of us know the obvious: nurses and other healthcare professionals do not have the PPE that they need to practice safely. Nurses are testing positive for COVID19. The Defense Production Act has not been activated to produce more PPE and ventilators, and nurses and other providers are even fired for speaking out about it or organizing ways to access more PPE (Doctors and Nurses Fired for Speaking Out ).

Nurses’ Skill Level: Nurses are worried about being asked to do work they aren’t prepared to do. A former student of mine, who has been in more of an administrative role, is extremely concerned with being asked to go back into a hands-on medical surgical or even ICU in a supportive role. Practicing beyond one’s skill level or expertise is just one area of concern that is likely to grow as more nurses become ill, or refuse to work, or are otherwise unable to work.

Volunteer calls: From California to NYC to Maine, nurses are being asked to submit their names to volunteer to work. Most of these nurses will be paid, and it is an effort to organize our resources.

Nurses on the Front Line: The stories I am hearing from nurses are war-time hell-like, maybe even worse then you have heard of if you don’t have direct contact with nurses on the front line.

An example is a story a friend of mine posted from his friend in NYC: in the ER, there may be 7-10 COVID+ vented patients waiting for ICU placement. Some patients are lying on the floor in the ER because there are no beds. People are being taken to rooms on the floors and passing away before they even get seen by a nurse on that floor. Medications like propofol, ketamine, versed, and fentanyl are being run without pumps because there are no more pumps. Supplies are running out. Med Surg nurses are being forced to run drips and vents that they have not been trained on.

Pay Issues: In Utah, nurses and doctors are being asked to take pay cuts, and there is concern that this will create a great deficit of providers in this state when professionals go elsewhere to work (Utah’s largest medical provider announces pay cuts). Meanwhile, note this lovely NYC serene skyline shot, with pay that must recognize the obvious inherent hazard pay for these positions.

(nurses recruitment add, contact information removed)

Populations and Outcomes:

Much preventative and maintenance care for those with chronic and even acute illnesses is now taking a back seat. A positive note is that telemedicine and telehealth are being used much more widely, and this may have a favorable effect on how we care for populations in the future.

Dr. Chinn forwarded a first-hand account to me of a nurse who is working in Brooklyn. She is concerned about how this illness is impacting Latinx populations, as they are often members of “essential worker” populations, and they also live in large households. This nurse states that these patients are at higher risk for death, and often experience death with less dignity. She also sees all staff getting sick, from direct care providers to janitors, and patient care technicians.

Anecdotally, in one social media group, I heard the nurses estimating that survival rate once a patient is ventilated is only around 14-20%. This is devastating to be surrounded around so much futile care and facilitating so much end of life care without perhaps the time and space it requires to do this well. (Edited: national statistics show a recovery rate of about 50% post ventilator initiation).

Heartbreak: I am hearing heartbreaking stories of nurses sending off their children to grandparents or ex-spouses, so they won’t be exposed in the household should the nurse become sick themselves or accidentally contaminate the household. Nurses who can’t hug or hold their loved ones are aching inside every day. Nurses dying. Nurses looking around at their colleagues and they might wonder, who will be the next to not be at work, which one of us might end up in the ICU? Nurses may know that much of the care they are providing is futile or palliative, which creates moral distress. I am very concerned when I hear of nurses working multiple shifts, with one nurse posting that she had worked 13 shifts in a row, another posting about minimal sleep, and losing 10 pounds already. They don’t have time to eat and when they go shopping, the stores are lacking in supplies. There is no question in my mind that nurses are being put at greater risk not only due to exposure, but also due to physical, mental, emotional, and spiritual stressors.

Post-Traumatic Stress: We could say nurses are stressed, or maybe we should just be truthful and say that nurses are being traumatized. I have great fears of nurses leaving the profession after this, and I also have great fears about the health of the population in general. I am fearful for those on the front lines without access to proper PPE. This sort of chaos we are experiencing may lead to positive change eventually, but for now, it’s extremely uncomfortable, painful, confusing, infuriating, and even disorienting.

We need to take good care of ourselves and take good care of one another.

I am reaching out with loving-kindness to all nurses:

May all nurses be safe

May all nurses be at ease

May all nurses be loved

May all nurses know personal healing

Namaste

A Nurse’s Perspective on Cannabis (Marijuana), Legalization, and Safety.

October 16, 2016December 21, 2017 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / Leave a comment

I am a Registered Nurse with 22 years of experience, and I have had an anti-prohibition stance in regards to marijuana (cannabis) for 30 years. I was fortunate that when I moved from California to Maine 6 years ago, I was introduced to Maine’s amazing medical cannabis program. I have also been able to study and learn more about the medicinal benefits of this sacred herb through my involvement with the American Cannabis Nurses Association (I now sit on ACNA’s board of directors) and by going to cannabis clinician conferences, such as Patients Out of Time.

Cannabis is on the ballot in 9 states this November, for either legalization for adult use or medicinal consideration. As nurses, we are often concerned with safety, so the following are my thoughts on safety issues and the end of prohibition of cannabis. If you are unfamiliar with how cannabis works in the body and why it such a safe herbal medicine, I suggest you first visit my blog posting on what nurses need to know about cannabis: https://nursemanifest.com/2015/07/14/the-endocannabinoid-system-what-nurses-need-to-know-an-introduction/.

Let’s consider the following issues:

Access: The idea of increased access for adults over age 21 is compelling on many levels. As many have stated before me, all cannabis use is medicinal due to the way the herb interacts with the body’s own endocannabinoid system. (http://thejointblog.com/all-marijuana-use-is-medicinal/; https://halcyonorganics.com/all-cannabis-use-is-medical/). Patients who cannot access cannabis legally to support their healing because they did not have a documented qualifying condition may now have access to this safe effective herbal medicine. Sites like http://www.drugguardians.com are being created with impunity and are helping the population become informed by third parties, decentralizing the source of knowledge about drugs. As legal access increases, black market issues will likely dissipate which creates a safer environment for all citizens. Meanwhile, we know that in legalized states, teen cannabis use drops significantly, effectively decreasing access for younger folks, which is often a concern for those who are considering legalization or medicinal programs (http://www.usnews.com/news/articles/2014/08/07/pot-use-among-colorado-teens-appears-to-drop-after-legalization).

Quality: In Maine, our ballot calls for testing and proper labeling of cannabis products sold at both recreational stores and recreational cafes. This is a major step forward to ensuring safe use of quality cannabis products for both patients and recreational users. Many patients now are being encouraged to start low and go slow with their dosing of their medication, and proper labeling will help to ensure that people can use cannabis with comfort knowing the relative psychoactive effects increase as THC levels of the cannabis products increase. Additionally, products will be tested for pesticides and contaminants, further ensuring the medicine and products people are accessing is safe.

Smoking: I often hear that medical providers are very concerned with the idea that smoking cannabis may be harmful to the person. While there may be some minimal changes to lung structures, there is no strong correlation with COPD and lung cancer in cannabis smokers (http://www.ncbi.nlm.nih.gov/pubmed/23802821; http://www.ncbi.nlm.nih.gov/pubmed/21859273). However, there are many ways to ingest cannabis, and vaporizing cannabis is a way to inhale the medicine without having contact with some of the combustive byproducts that are related to any perceived risk of smoking cannabis. For more therapeutic effects, regular users of cannabis and those seeking its healing properties are generally encouraged to use edibles and tinctures, as they target whole body homeostasis more effectively.

OUI/ DUI: Driving under the influence of any psychoactive medication is obviously an issue. However, levels of THC in the body do not directly equate to impaired driving in the same way that alcohol does, secondary to the way THC is metabolized in the body and how it remains in the body due to it being a fat soluble substance (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456923/). “Stoned drivers” do not pose the same risk to the public’s well-being as “drunken drivers” do; indeed “stoned” drivers tend to drive more slowly. Researchers from UCLA have called for more efforts to be made around lowering acceptable blood alcohol levels to truly curb issues around impaired driving (http://www.nytimes.com/2014/02/18/health/driving-under-the-influence-of-marijuana.html?_r=0), as being at .08 BAL leads to an eleven fold increase in the risk for being in a car accident, while driving under the influence of cannabis leads to a two-fold increase of being in an accident (texting while driving has a two fold increase and talking on the phone while driving has a 3 fold increase in risk for car accidents) (http://www.huffingtonpost.com/sam-tracy/putting-marijuana-dui-in-_b_6023136.html). Driving or operating machinery while under the influence of cannabis is unacceptable and indicates a risk, however in Colorado since legalization of recreational use of cannabis was initiated, DUI fatalities have decreased (https://www.washingtonpost.com/news/the-watch/wp/2014/08/05/since-marijuana-legalization-highway-fatalities-in-colorado-are-at-near-historic-lows/?utm_term=.64fa02a0cc5e). It should be noted that Colorado made a concerted effort to promote safer driving conditions and decreasing driving while intoxicated once they ended cannabis prohibition. all states should be making efforts to combat intoxicated and unsafe driving practices.

Children: When cannabis was made recreationally available in Colorado, it appeared that more children were being accidentally exposed to cannabis (http://www.usatoday.com/story/news/nation/2014/04/02/marijuana-pot-edibles-colorado/7154651/). I would posit however that once the plant became legal, more parents were willing to seek medical attention if their child had accidentally ingested cannabis infused edibles or other cannabis products. Additionally, the relative number of cannabis ingestion issues versus other toxic substances truly remains quite low in Colorado at 6.4% of all “poisoning” cases treated within the pediatric population (http://www.cnn.com/2016/07/27/health/colorado-marijuana-children/index.html). There has not been a single reported death from a child (or any person) ingesting cannabis (unlike other ingested toxins, such as laundry pods: http://www.cnn.com/2014/11/10/health/laundry-pod-poisonings/index.html). So while we will need to educate consumers about the risks of pediatric access and ingestion of cannabis, the risks remain relatively low. In most cases, children recover quickly from cannabis intoxication, with hospitalization for supportive care only, which generally lasts 1-2 days and generally leads to no lasting side effects (http://health.usnews.com/health-news/news/articles/2013/05/27/kids-poisoned-by-medical-marijuana-study-finds
). Both the states and the individual companies who will be selling cannabis should be responsible for educating the public around ensuring pediatric safety should a state chose to legalize. Ideally some of the tax dollars generated from cannabis sales would be geared toward education of the public on safe cannabis consumption and storage.

Teen Use: Teen cannabis use has actually declined as more states legalize or become medicinal cannabis states (https://www.washingtonpost.com/news/wonk/wp/2014/12/16/teen-marijuana-use-falls-as-more-states-legalize/). This in part may be due to tougher regulations making it harder for teens to access cannabis, and a decrease in black market availability of cannabis.

Pregnancy: Dr. Melanie Dreher, the Former Dean of Rush University school of nursing, is a nurse who researched the Ganga culture in Jamaica for over ten years, and determined that there were no adverse outcomes to the fetuses who were exposed to cannabis (https://www.youtube.com/watch?v=K9WorIM0RhA; https://www.youtube.com/watch?v=RDV5HhmP4UI). A recent study also reported that cannabis use is safe during pregnancy (though caution may still be advised)(http://www.scienceworldreport.com/articles/47194/20160910/marijuana-safe-during-pregnancy-experts-encourage.htm) and breast feeding while using cannabis also appears to have minimal risks (http://cannabisclinicians.org/breastfeeding-and-cannabis/).

Harm Reduction: Cannabis has been studied as a harm reduction tool, particularly when it comes to addiction and treating folks for pain related issues. Physicians have called for neuropathic pain to be treated with cannabis instead of opioids (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295721/). We also know that cannabis can decrease the need for escalating doses of opioids, and assist people who are opioid dependent in either decreasing thier doses of opiates or completely overcoming their addiction (http://nationalaccesscannabis.com/press-release/opiate-study-press-release/).
For an overview of the body’s endocannabinoid system and the issue of biological harm reduction, please see here: http://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-2-17

Overdoses with opioids have fallen in states where medicinal and legal cannabis are available (http://www.nytimes.com/roomfordebate/2016/04/26/is-marijuana-a-gateway-drug/overdoses-fell-with-medical-marijuana-legalization; and https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose). With high rates of opioid addiction plaguing our country, it makes sense to legalize cannabis now to help address this issue.

Self-Medicating: People self-medicate with substances on a daily basis; from alcohol to caffeine to tobacco. People self-medicate with herbs as well from turmeric to Echinacea, to vitamins and natural thyroid supplements. With legalization and regulation, people have a better chance of using safe, monitored, quality herbal cannabis medicine. For most of our recorded human history, cannabis was used as a healing herb. This came to a halt when cannabis prohibition became a global stance. Additionally, legalization opens the door for more open discussions between healthcare providers and patients. Healthcare providers such as nurses and doctors must become educated around the body’s endocannabinoid system and the therapeutic use of cannabis to create homeostasis and support healing.

Pathways for New Healing Products: Currently, many new cannabis products that are available in legal states are not available to medicinal patients in states where only medicinal cannabis is legal. For instance, various teas, salves, edibles and patches that are available in Colorado, Washington, or Oregon are not yet always available for medicinal patients in other states. Once states have a legalized cannabis regulation processes in place, it may be that people can access items such as a topical sub-dermal patches to deliver cannabis medicine or specific cannabinoids. A person may be able to use a CBD (a non-psychoactive cannabinoid) only patch during the day to help with issues like, pain, anxiety, nausea, and depression, and a CBN patch (another non-psychoactive cannabinoid) at night to help with sleep. In this example, the person would have minimal if any exposure to the psychoactive effects of THC in cannabis, and yet they may experience a greater quality of life. From a justice perspective, people deserve to make choice around the medicines they would like to utilize for their own healing, particularly when the medicines are safe.

Social Justice Issues and Policing: Recently, the chiefs of police in Maine came out against the yes on 1 ballot initiative to legalize marijuana in Maine. It is interesting to me that this organization stated they are “unprepared to address legalization issues,” when certainly looking at the legalization issues in Colorado and Washington should provide plenty of data and solutions to common issues. I would posit that there would be fewer marijuana trafficking issues and convictions, and the police could turn greater attention to bigger and more harmful issues in Maine, such as the opioid crisis and OUI related to alcohol ingestion. Additionally, cannabis legalization is a step toward social justice given the illogical, irrational, and unsuccessful war on drugs (http://www.sfgate.com/opinion/article/Marijuana-legalization-a-step-toward-social-5848468.php, http://theweek.com/articles/542678/why-pot-legalization-also-fight-social-justice). Legalizing cannabis should free up our law enforcement agencies to fight crimes that cause greater damage, even as it lowers the need for them to be addressing black market cannabis issues.

I would like to close with my final thought:

All cannabis is medicinal. Our bodies have our own endocannabinoid systems; we make our own endogenous cannabinoids. However when we become deficient in these cannabinoids, we may become ill and need to seek exogenous sources of cannabinoids, or support our own bodies in creating more endocannabinoids. Cannabis is a safe effective medicine with a low rate of addiction and minimal if any withdrawal symptoms, similar to caffeine. Ingestion of cannabis itself has never lead to a death (unlike many prescription and OTC drugs, alcohol, and nicotine products), and it is time we begin to move beyond the government’s ineffective “prohibition of marijuana” stance and take steps toward effective access for all adults.

In the states where cannabis is a ballot initiative, I urge us as nurses and other healthcare providers to explore the data around cannabis as a medicine and consider our roles as advocates for patient access to the healing support this medicine can provide.

Expressing Gratitude For Our Global and Local Nursing Leaders

June 29, 2016June 29, 2016 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 1 Comment

I have been fortunate to have been supported and influenced by many of nurses’ contemporary leaders: I studied with Dr. Jean Watson prior to completing my dissertation by taking 6 units of doctoral level electives with her at UCHS. I had contacted Dr. Watson during my Masters studies, and I was amazed at how approachable she was via email. Watson’s Theory of Human Caring has influenced and directed my work in a way that is immeasurable on many levels; being with her and spending a week in sacred center, studying emerging sacred-caring science concepts brought me to a new vision of how nursing education can and should be practiced.

I also stumbled upon the work of Dr. Peggy Chinn and the nurse manifest project during my early doctoral studies, and soon found myself embraced by the NurseManifest community. I was blessed to have been part of the first Nurse Manifest research project team, and the experience of presenting our findings together was monumental in my life as an emerging nursing scholar.

While Dr. Watson and Dr. Chinn epitomize the amazing academic and scholarly accomplishments of Nurses’ Living Legends, they both also remain approachable, kind, caring, and generous. They reflect back to us a deep love for nursing, coupled with calls toward caring and a level of social justice activism that is highly needed in our process of supporting both local and global healing. There are many other nurses whom I might call “global nursing leaders” who share in this attitude, commitment, and consciousness toward change.

I am also frequently touched by the leadership capacity of my nursing students; the willingness to change their lives, spread their wings, and find ways to bring caring, holism, and healing to the “local” bedside in environments where these concepts often remain fringe in the face of allopathic approaches. The many global nursing leaders inspire nursing students, and the continuum to me is clear; students and nurses need these leaders to raise our consciousness, build our confidence, and lead us into our own leadership capacity at the local level. We need global leaders to shine a light on our professional paths and support our deepening understanding of both self as nurse and our profession’s capacity to create nursing qua nursing as the norm.

I am honored to be working with my RN-BSN students this fall in their leadership coursework. We will look at Chinn’s Peace and power work and also explore leadership through holistic concepts. We will examine burnout and how we can recover or support others in their recovery through self-care. In analyzing our workplaces, we will explore Sharon Salzberg’s (a registered nurse and globally known meditation teacher) Real happiness at work: Meditations for accomplishment, achievement, and peace as a supportive tool for self-exploration around workplace issues.

Many nursing students struggle to perceive themselves as “local nurse leaders”, and I strive to support them to tap into their own leadership capacities, to create the types of healthcare workplaces where they can thrive and support the healing of their patients through integrative modalities and caring consciousness. I do believe one way to provide this platform for students’ emerging leadership is to create a caring environment for students, to support their own healing processes, and to role model shared leadership processes and self-care-healing for, and with, students. In this way, I humbly express my deepest gratitude for those global nursing leaders who have shone their light on my own professional and healing path when it was often far from clear where I was headed.

The Prison System and Social Justice

May 3, 2016 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 2 Comments

I recently came across an article in the New Yorker entitled Madness by Eyal Press. The full article can be viewed here: http://www.newyorker.com/magazine/2016/05/02/the-torturing-of-mentally-ill-prisoners. The article looks at one Florida prison, where mentally ill patients have suffered horrible mistreatment by the prison system. Our largest provider of healthcare for the mentally ill in the United States is the prison system, and yet our leading mental health researchers and providers tend to shy away from or ignore this enormous vulnerable population.

I will warn you that you may find aspects of the Madness article disturbing, and it leads us as nurses to consider many social justice issues, including the right to adequate care, proper diagnosing, safety, and support for health and healing. As the United States has the highest incarcerated population of any country, nurses need to consider how we as a society and a culture care for and treat our very vulnerable mentally ill population. The challenges of advocating for these prisoners and one’s own potential vulnerability when working in this system are clearly highlighted in the Eyal Press article. Until we recognize the mentally ill incarcerated population as traumatized human beings in need of deep caring and support as they proceed along their own healing journey, true transformation of our systems toward ones that can offer rehabilitation and reduce recidivism may remain elusive.

I also found this article to be heart wrenching on a personal level. My brother died in prison at the age of 45, and the unit where he died is indeed either this particular unit as described in the Madness article, or one very similar to it in Florida.

My brother Bryan was a star elite athlete in his youth, holding a national age-group track record set at the Junior Olympics when he was around 15 years old. After sweeping many state championships in high school track, he received an athletic scholarship to a school in the midwest, and while he had been a “difficult hyperactive child” deeper signs of his mental illness began to emerge. He ran up huge gambling and credit care debts, and one Christmas he returned home from school having lost about 25 pounds with no good explanation for why this had occurred.

When he was about 25 years old and had finished college, Bryan had a full psychotic breakdown. He spent several months in a psychiatric facility as they strived to diagnosis and stabilize him. My brother was bipolar with schizoaffective disorder, and sometimes his life was relatively calm, like when he married his first wife and they dreamed many dreams together….other times not so much, like when in the midst of another psychotic break he held a knife to his first wife’s throat; or the time he totaled his own car using his own hands and a crowbar; or when he was found running naked on the Nike compound in Oregon.

In 2008 Bryan went off his medications for unknown reasons. He became incredibly manic, delusional, and he was certainly having hallucinations. He left his wife and young daughter and moved into a shelter setting, which he was kicked out of due to fighting with others. Simplifying the story a bit, I will just say that he was found tampering with his estranged wife’s car at her place of work and the police were called; a high speed chase ensued and my brother was charged with aggravated battery with a deadly weapon (I believe he struck one of the officers with something once his car was forced to a stop), aggravated fleeing and eluding police, and resisting an officer with violence. About two months after his arrest, upon the advice of his free public attorney, my brother took a plea deal and he was sentenced to 3 years in the Florida State Prison System. I believe his mental illness, which he had been struggling with for over 20 years, was never clearly considered in the charges or in his placement. The copy of his charges is here: https://bailbondcity.com/fldoc-inmate-CARROLL/130350 .

As sometimes happens within families of those suffering from mental illness, my brother and I had been estranged on and off for most of our adult lives. My brother would sometimes become violent, threatening, and manipulative when he was off his medication, and I desired a peaceful life for me and my young family. Our childhoods were traumatic, and while I can’t speak for my brother, my adverse childhood experiences were a “5”/ 10, which indicates trauma to the point of potentially having adverse effects on health and low stress resilience. I am certain that my brother also had a high ACES score, and that his mental health issues were compounded by our traumatic youth and family life. [If you want to learn more about how adverse childhood experiences impact one’s health, I have presentation that covers that here, slide 16 begins the information around the ACEs concepts: https://voicethread.com/myvoice/#thread/4492225/22882928/24864974 }.

Due to our previous estrangement and my own challenges with balancing caring for a newborn baby and toddler, and working as an adjunct nurse faculty for several different schools, I did not reach out to my brother prior to his incarceration or during that time, though we had been in touch on and off for the three years prior, when our mother had passed away suddenly from a massive MI. So, my father and stepmother kept me informed of Bryan’s prison life and while they did not visit him, they often scanned and forwarded his letters to me. It was clear to me that during his less than one year in prison, he declined rapidly; he claimed to be taken off all of his medications and we know he was transferred to a psychiatric unit (either the same one in this article or another one like it). In the two months prior to his death, he mentioned several times that he was dying or he was going to die, that things were very bad in prison. I encouraged my stepmother and father to reach out to him and the system, which they did not do, and I found that since I was not on Bryan’s “list” I had no rights around communication with him and within the system.

Via an email on the morning of March 28, 2009, I found out that Bryan had died in prison. The official county coroner’s autopsy stated that at the age of 45 Bryan had died of “moderate heart disease”, though it contrarily also noted no signs of stroke or MI. As his sister, I had no rights to request or pay for a second independent autopsy, and my family refused to have one performed, instead opting for an immediate cremation. Over the 7 years since his death, I know I have been suffering from complicated grief; I have felt powerless to create change in the prison system and sometimes I have felt scared to use my voice to call for change and for social justice in the way we manage the health of our growing prison population. I have felt fearful of being stigmatized and ashamed for having a relative who was incarcerated.

However, when I think of the many social justice issues the Madness article brings up, I begin to feel angry; and that anger is now motivating me to speak out and find ways to support the creation of healing within our justice systems.

I know that part of my own healing journey involves moving beyond telling my brother’s story, and beginning to move toward taking action in supporting an end to the injustices our incarcerated vulnerable populations suffer. I recently have been in connection with a beautiful resource at the Maine Prison Hospice Project (http://mainehospicecouncil.org/?q=content/hospice-corrections-partnership-maine-state-prison ), and I hope to help support their research efforts around the benefits of prisoners being of service during and after their incarceration period. I hope to someday serve as an example of how nurses on their own healing path strive to heal in conjunction with others; with those whom we serve. Imagine what we can do when we truly believe we are all on this path together, as interconnected unitary human beings; then the movement toward social justice becomes a part of our calling on this life’s journey.