Monday, 14 September 2020

Commentary on Darbyshire et al (2020)


Commentary on Darbyshire et al (2020) ‘The Culture Wars, nursing, and academic freedom’ Journal of Advanced Nursing doi:10.1111/jan.14507

William P Ball RN

PhD Student, School of Health and Social Care, Edinburgh Napier University, UK


I enjoyed reading the recent editorial by Darbyshire et al (2020) which calls us as Nurses to stand against what seems to be an increasingly polarised and reductive popular discourse around contentious issues. I share many of their concerns about academic freedom and the observation that Nurses collectively seem to be shying away from speaking truth to power.

As a Registered Nurse and Population Health researcher, I particularly agree that the Nursing profession will always be closely invested in: “women's health; child development; surgery; science and evidence; pathophysiology; ethics; social justice; health inequity; sexuality; and more”, which obliges our engagement with such issues, even in the face of potential social media-led backlashes.

I wonder whether the major reason for a lack of engagement from the profession is mainly based on an individualistic attitude of self-defence? The relative lack of engagement related to social justice and equity issues is particularly striking to me. Anecdotal interactions suggest such issues are perceived to be ‘too political’ by some outside and even some within the profession. I believe this reflects a history of passively and collectively allowing orthodoxy to go unchallenged – a presumed requirement to be politically neutral, rather than just a desire for self-preservation through avoiding controversy and the personal or professional repercussions which may follow.

As Bell (2020) writes concerning the role of nursing in anti-racism, we have: “a nursing culture that is not consciously situated in a broader socio-political context.” This results in a profession and systems of education which are ‘politically soft’ – promoting apolitical approaches whilst also failing to acknowledge our role in reinforcing systemic oppressions. The profession may be best placed to address the issues raised through conscious and reflective processes like decolonisation (Moorley et al, 2020) in practice, education and research.

The authors also appeal to the long-term public support and good-will shown towards Nurses, as reflected in polling data which regularly rates us as the most trustworthy profession (Reinhart, 2020). It may be possible to leverage this public support in the discussion of contentious issues, although the extent to which this trust is dependant upon misconceptions about Nurses and Nursing is not known. If Nursing voices become more prominent or overtly political, public perceptions are likely to change, perhaps eroding the image of trustworthiness.

This issue is perhaps best exemplified by the rhetoric around Nursing work presented to the public in mainstream and social media. There has been widespread public recognition of the important work undertaken by healthcare staff during the COVID-19 crisis. Nurses (and other professions) have variously been described as ‘Angels’ and ‘Heroes’, with an abundance of war-like metaphors. Whilst this language is well-intentioned and probably used instinctively it contributes to ‘mysticisation’ of Nurses and Nursing work. Such stereotypes have the potential to be damaging to the Nursing profession in the long-term and should be vigorously challenged (Stokes-Parish et al, 2020).


Darbyshire, P., Patrick, L., Williams, S., MacIntosh, N., Ion, R. (2020), The Culture Wars, nursing, and academic freedom. Journal of Advanced Nursing. doi:10.1111/jan.14507

Bell, B. (2020), White dominance in nursing education: A target for anti‐racist efforts. Nursing Inquiry. doi:10.1111/nin.12379

Moorley, C, Ferrante, J, Jennings, K, Dangerfield, A. (2020), Decolonizing care of Black, Asian and Minority Ethnic patients in the critical care environment: A practical guide. Nursing in Critical Care. 25: 324– 326.

Reinhart, R. J. (2020), Nurses continue to rate highest in honesty, ethics. Retrieved from‐continue‐rate‐highest‐honesty‐ethics.aspx

Stokes‐Parish, J., Elliott, R., Rolls, K. and Massey, D. (2020), Angels and Heroes: The Unintended Consequence of the Hero Narrative. Journal of Nursing Scholarship. doi:10.1111/jnu.12591


Editorial note: entries to JAN interactive are not reviewed and are published at the discretion of the Editor-in-Chief and may be subject to editing or removal by Wiley. We welcome replies, rejoinders, comments and debate on all entries provided they are not offensive or personal.




Monday, 7 September 2020

Response to the commentary written by Carmen Tung

Paolo IOVINO (Corresponding author), MSN RN University of Rome Tor Vergata, Rome, Italy. Email: Tel: +39 3479392534. ORCID: 0000-0001-5952-881X

Maddalena DE MARIA, MSN RN University of Rome Tor Vergata, Rome, Italy. Email: ORCID: 0000-0003-0507-0158

Maria MATARESE, MSN RN University Campus Bio-Medico, Rome, Italy. Email: ORCID: 0000-0002-7923-914X

Ercole VELLONE, MSN RN University of Rome Tor Vergata, Rome, Italy. Email: ORCID: 0000-0003-4673-7473

Davide AUSILI, PhD, MSN, RN Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy. Email: ORCID: 0000-0001-5212-6463

Barbara RIEGEL, PhD, RN, University of Pennsylvania, Philadelphia, United States. Email: ORCID: 0000-0002-0970-136X

We would like to thank Carmen Tung for her comments on our article “Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis”. We particularly appreciate the interest she has demonstrated in the self-care research.

Self-care is considered an important strategy for ensuring well-being and keeping control of illnesses. Individuals who benefit most from self-care are typically those affected by one or more chronic conditions. We agree with Tung that self-care maintenance (SCM) is an important step in taking care of oneself. This mostly happens because SCM is the first set of behaviors that are taught by healthcare providers and the least challenging to understand for chronically ill individuals when it is time to return home after hospitalization. Self-care is also performed by healthy individuals; this is particularly evident in the situation we are living in these days when, above and beyond the disastrous effects that COVID-19 is having on society, the pandemic is changing the way people take care of themselves. Handwashing and social distancing are two examples of basic self-care behaviours that, among many others, are put into practice to prevent infections in the community. Currently, our research team is investigating the impact of the COVID-19 outbreak on the self-care behaviors of people affected by multiple chronic conditions. We hope our study will offer healthcare providers important information about how to strengthen these behaviors that may reveal particularly vulnerable.

We also think that patients undergoing lung transplant, such as those referred to by Tung, could bring to light interesting dynamics regarding the self-care process. We agree with her that these individuals possess a high level of skill and long experience with regard to self-care. Post-transplant populations typically have a history of one or more chronic conditions prior to transplant. In our opinion, this has contributed to sharpening their knowledge and expertise related to self-care behaviours.

Problems with depression are, unfortunately, present in the post-transplant population; this has been observed by one of the authors, who is engaged in the clinical care of patients undergoing bone marrow transplantation. We particularly advocate herein the recommendation emphasized by Tung: a systematic screening of depression is vital in these fragile populations, especially because we have found that this mental health problem can negatively impair self-care behaviors. This relationship is rather worrisome because self-care includes medication adherence, which is important in maintaining immunosuppression and reducing the risk of organ rejection. Cukor et al. (2009) found that depression was the only significant predictor of low medication adherence in kidney transplant patients. Another study found that this mental health problem diminished in the short term after hematopoietic cell transplantation but then increased significantly over the following years (Kuba et al., 2017). This finding is important because screening for depression symptoms should not terminate at post-transplant discharge; rather, ideally it should be carried out as part of the early post-transplant check-ups and continue from there. Independently of the outcome, screening for depression should also be accompanied by self-care educational interventions.

In our study (Iovino et al., 2020), we found a small or even absent effect of depression on self-care monitoring and management. This was probably due to presence of caregivers, because in our sample, families were a constant presence for their loved ones. We envisage that this would also be the case for transplant patients. According to our clinical experience and evidence from research (Lonning et al., 2018), post transplantation carries a renewed desire to live a healthier life. In particular, patients who do not undergo transplants following cancer may perceive their past chronic illness as no longer a threat. The fact that the disease is finally eradicated brings new hope and motivation to take better care of themselves. We could also hypothesize that people perceive self-care monitoring and management behaviors as being more important than SCM as they ensure well-being and survival. For example, the high number of drugs post-transplant patients must take (e.g. immunosuppressors and corticosteroids) are linked to serious side effects that need to be recognized and detected promptly to avoid complications. This may induce patients to conduct more intense monitoring.

Regarding the study mentioned by Tung, we suggest that, when investigating self-care, she consider all three self-care dimensions (self-care maintenance, monitoring and management) in the analyses since self-care practices are highly intercorrelated (Riegel et al., 2012). By taking all of them into account, adjustment of each behaviour’s estimate is warranted. Also, we suggest measuring self-care self-efficacy. This variable, defined as the belief in one’s own abilities to perform self-care, is known to act as a mediator in the relation between self-care behaviours and outcomes (Vellone et al., 2016). Lastly, we would recommend considering other confounding factors, above and beyond caregiver support, such as cognitive status, age, social support, and quality of life to obtain results that are less likely to be biased.


Cukor, D., Rosenthal, D. S., Jindal, R. M., Brown, C. D. & Kimmel, P. L. 2009. Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int, 75, 1223-1229.

Iovino, P., De Maria, M., Matarese, M., Vellone, E., Ausili, D. & Riegel, B. 2020. Depression and self-care in older adults with multiple chronic conditions: A multivariate analysis. J Adv Nurs. , 76 (7), pp. 1668-1678.

Kuba, K., Esser, P., Mehnert, A., Johansen, C., Schwinn, A., Schirmer, L., Schulz-Kindermann, F., Kruse, M., Koch, U., Zander, A., Kroger, N., Gotze, H. & Scherwath, A. 2017. Depression and anxiety following hematopoietic stem cell transplantation: a prospective population-based study in Germany. Bone Marrow Transplant, 52, 1651-1657.

Lonning, K., Midtvedt, K., Heldal, K. & Andersen, M. H. 2018. Older kidney transplantation candidates' expectations of improvement in life and health following kidney transplantation: semistructured interviews with enlisted dialysis patients aged 65 years and older. BMJ Open, 8, e021275.

Riegel, B., Jaarsma, T. & Stromberg, A. 2012. A middle-range theory of self-care of chronic illness. ANS Adv Nurs Sci, 35, 194-204.

Vellone, E., Pancani, L., Greco, A., Steca, P. & Riegel, B. 2016. Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model. Int J Nurs Stud, 60, 191-9.