Leading from First Principles

In Creative Nursing 2021 we are all In It Together. We chose this overarching theme more than a year ago, before COVID-19 and the murder of George Floyd brought a sea change in our awareness of what we must do to live together on this planet. The goal of our first issue (published in February), Dismantling Systems of White Supremacy, is expressed so clearly in an article by guest coeditor Tammy Sinkfield-Morey and Teddie Potter: “We came together in conversation to help us understand how we can better use our leadership to acquaint nurses with the insidious ways that systemic racism endures, persists to the point of constancy, and serves to diminish the experience of healing for all of us and destroy it for some of us.” These two nurses, growing up in the same generation only a few miles from each other, had very different career experiences; both have become strong leaders.

And leadership is what this second issue for 2021 is about. The official job title of our guest editor, Cyrus Batheja, is National Vice President of Strategic Initiatives and Transformation, Government Programs, at UnitedHealthcare, the nation's largest managed care organization. His position has empowered him to develop and implement an internationally recognized program that serves his organization's highest-risk patients—those experiencing chronic homelessness and significant health disparities. Providing dignified housing with trauma-informed supports was associated with significant decreases in emergency room visits, hospital stays, and inpatient days. In his career so far, he has known extraordinary leaders who cross traditional boundaries and take risks to achieve the greater common good. He says, “In the midst of crisis, these leaders are focused on matters of the community, uniting their work with matters of equity, including race, gender, sexuality, and class, within their thoughts and actions.” The first principle for these exemplary, admirable leaders is bettering the community.

First principles are propositions or assumptions not arising from any others. They're basic, self-evident—the most important reasons for believing or doing something. Work arising from first principles starts at the level of established science—it doesn't shape itself to fit models or parameters. Each article in this issue has at heart a principle that has motivated its authors to do their work and, via Creative Nursing, to share it with the world.

A strong belief in the community health center model as the way to provide equitable care in these times motivates Colleen McDonald Diouf, CEO of Community-University Health Care Center (CUHCC) in Minneapolis, Minnesota. The clinic serves 11,000 people annually with 62,000 visits, with comprehensive primary care, mental health care, and dental care; 80% of patients are Black, Indigenous, and People of Color (BIPOC), and the majority live at or slightly above federal poverty guidelines. Leading the clinic during what she calls the triple pandemic—COVID-19, racism, and economic downturn—required innovation and fortitude, but the disruption of the triple pandemic also created a space and time for leaders to make transformative change. The CUHCC clinic had already pivoted to telehealth and COVID-19-safe care; located in the heart of the neighborhood most severely affected by the civil unrest, it remained unharmed through the vigilant watch of the American Indian Movement patrol that kept community agencies in the neighborhood safe.

Helping leaders make high-quality decisions is the goal of Elaheh Haghgoshyie and Edris Hasanpoor of the Research Center for Evidence-Based Health Management at Maragheh University of Medical Sciences in Maragheh, Iran. They define evidence-based nursing management as “the synthesis of clinical expertise, research evidence, and patient values, to create effective patient care strategies.” Their model does have room for managers ‘reflections on their own experiences and on practical examples, as one of six sources of evidence. “To make the best use of sources of evidence, nursing leaders need to promote a culture that helps nurses dedicate time to consulting scientific evidence.”

Mary Jo Kreitzer, director of the Earl E. Bakken Center for Spirituality & Healing at the University of Minnesota, issues a call to action on behalf of nurses and other health-care professionals. She states that the pandemic hit at a time when the wellbeing of the workforce was already compromised by unacknowledged burnout, primary and secondary trauma, and moral injury. Now, “nurses, their patients, and those around them are experiencing cumulative and collective losses due to [contemporary] biological, social, and political dynamics.” Organizational well-being must focus on supporting both clinician wellbeing and the system issues that contribute significantly to stress and burnout, but actions must be meaningful and substantive. “Too frequently, we design clinical care approaches without getting input from patients, and organizational strategies without getting input from staff, and are then surprised when they fail.” The article also sounds a note of hope, with the concept of posttraumatic growth, as exemplified by the words of poet Amanda Gorman: “Even as we grieved, we grew.”

Several articles address the realities of health-care education, not as we wish it were but as it actually is. Susan Hayes Lane from Appalachian State University in Boone, North Carolina and Eileen Kohlenberg from The University of North Carolina at Greensboro want us to know that in the current landscape there is a mismatch among the demographics of nursing faculties, the programs currently in place to prepare new nurse educators, and the numbers of future students. They surveyed 53 nursing education program directors about curricular content, key issues, and areas for further development. Society assumes that all nurses are good teachers, but these authors emphasize that nurse educators need preparation for a variety of environments including universities, hospitals, community colleges, and community health settings.

Our colleagues who teach undergraduate nursing students play a crucial role in retaining people in our profession. Diane Logan at Seton Hall University in New Jersey has a passion for supporting students in the clinical environment, promoting health and wellness to produce emerging nurse leaders. She presents a blueprint for planning and implementing clinical experiences “in the most proficient way to maximize all the skills [students need] to become competent, prudent nurses.” And Stacy Christensen at Central Connecticut State University uses creative pedagogical strategies as a framework for less experienced undergraduate nursing students to go beyond the textbook and “think like a nurse.” For example, during case presentations, students stop, “rewind,” and retell the story, incorporating primary and secondary interventions they as the nurse would have used to change the outcome.

In our Patient Safety feature, Ayse Akbiyik, Dilek Sari, and Nihal Taşkiran, health professions educators in Izmir and Aydun, Turkey, highlight their concern about the incidence of medical errors made by nursing students during clinical practice. They presented their students with scenarios depicting medical errors involving patient identification, medications, falls, transfusions, health-care-associated infections, and pressure ulcers, asking them to categorize the errors and find the causes. Students had difficulty interpreting errors of patient identification, possibly partly because they are taught to refer to patients by room and bed numbers, and see this behavior modelled by nursing staff. And for the author of our Student Voice feature, Amy Johnson of the University of Illinois in Chicago, the first principle is the dignity of those who are or have been incarcerated, focusing on improving the health and well-being of these individuals who are disproportionately affected by chronic disease, mental health concerns, and substance use. She describes creative health education modules that her students provided to men finishing their prison sentences at an adult transition center. The article title contains the words Stayin ‘Alive because one of the men who learned CPR from the students saved the life of a fellow inmate using the beat of that popular song for the correct rate of chest compressions.

Nurse educators teach others besides nursing students. Maryanne Barra from Seton Hall, Samantha Singh Hernandez from the simulation center at RWJBarnabas Health in Livingston, New Jersey and Janet Czermak from the College of Mount Saint Vincent in Chatham, New Jersey, presented a day of skills training for new medical interns. A didactic lecture was followed by simulation lab practice in nasogastric tubes insertion, intravenous therapy, use of personal protective equipment, blood collection, and arterial blood gas interpretation. “Having the intellect to retain and narrate information on disease entities and treatment plans lays the foundation for medical competency; however, intellect needs to be partnered with psychomotor skills when caring for patients.” In the simulation environment, students can practice without fear of harming patients or of retribution. Leading this orientation for interns introduced nurses as partners in interprofessional collaboration.

First principles are basic, self-evident — the most important reasons for believing or doing something.

Our colleagues who teach undergraduate nursing students play a crucial role in retaining people in our profession.

The pandemic brought the cancellation of professional conferences throughout the world. But the members of the Nursing Research and Evidence-Based Practice Council at University of California: San Diego Health were determined to hold their annual Nursing Inquiry and Innovation Conference in 2020, the Year of the Nurse and Midwife, to recognize the innovative work of nurses, especially when nurses desperately needed positive reinforcement. Lilian Canamo, Jessie Bejar, and Judy Davidson recount their process in pivoting to an all-virtual conference that retained plenary speeches, breakout presentations, posters, and even an online version of the annual art exhibit; media included poetry, drawing, photography, painting, music composition, cinematography, and even mask sewing.

And, in our Reflecting on our History feature, Jackie Owens, nursing professor at Ashland University in Mansfield, Ohio and Editor-in-Chief of OJIN: The Online Journal of Issues in Nursing (the scholarly journal of the American Nurses Association), advocates for creative writing, including historical fiction, personal narratives, and poetry, as valid ways to convey nursing history to people who may not otherwise learn about it. With so many inaccurate images of nurses in the media, preserving and documenting the contributions of individual nurses and the profession is a critical foundation to support continued efforts to measure our response to societal needs.

As the days of 2021 unfold with us all In It Together, Creative Nursing will be here, providing thought leadership and a venue for the voices of nurses and our colleagues in health care. Issue 3, Engaging the Public in Public Health, coming out in August, and Issue 4, Promoting Planetary Health, coming out in November, are already full, and we have many compelling articles planned for 2022.