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The middle-aged African American woman screamed profanities at the nurse, swinging her arms away from the intended intravenous needle, refusing to obey the young, rather nervous emergency department resident standing at the foot of her bed, urging her cooperation. A heart monitor beeped loudly, demanding to be heard above the chaos in that room, and a blood pressure warning flashed in red, methodically every three seconds across the screen as if to say, “help me, help me!” This was a patient in crisis, having just entered the emergency department twenty minutes prior, with a complaint of “sudden severe back pain after using cocaine”, and, yet undiscovered at that time, a ticking time bomb preparing to explode inside her chest.
Before the day was over, this patient would receive quite possibly the worst news of her life, denounce God, and be forced to consider a surgical procedure that had an 80% failure rate, without any support from friends or family.
Opioid addiction can affect anyone, regardless of race, gender, income level or social class.
It does not afford the user the freedom of choice; it is not a moral failing. It is a medical disorder that can afflict anyone without warning, leaving despair, desperation and destruction in its wake. It is the deadliest drug crisis in American history (Katz, 2017) and an existential threat to the future of the United States. Although the opioid epidemic in the US continues to escalate at an alarming pace, killing nearly 200 people every day (NIDA, 2018) the daily struggle of opioid users is often hidden from public view, cloaked in shame and stigma.
Opioid overdoses killed more Americans in 2017 than car crashes (40,000) breast cancer (42,000) or guns (37,000) (Colon, 2017). It is the leading cause of death for Americans under the age of 50. Exposing the opioid epidemic, by shining a caring light on the struggles of opioid dependence, and challenging a harsh public perception, may be the single best way to combat this formidable foe. One of the most significant ways for an emergency department nurse to help her drug-addicted patient is by implementing Swanson’s theory of caring.
(History of how Swanson’s theory came to be goes here)
Kristen M. Swanson, R.N., Ph.D., F.A.A.N.ih is a distinguished academician that has worked as the Dean of School of Nursing at the Seattle University College of Nursing, and served as a professor at Chapel Hill’s University of North Carolina. She is an alumnus of the University of Rhode Island, University of Pennsylvania, and the University of Colorado, where she earned her PhD. In 1978 in psychosocial nursing (Samuels, 2012).
The theory Dr. Swanson proposed was developed empirically through studies done in different perinatal environments in the eighties, and later refined in the nineties. The theories presented by Swanson have been adopted by various hospitals to guide their nurses’ practice. Swanson’s efforts began with a simple patient-centered question, “what does it feel like to miscarry?” Swanson’s post-doctoral work was done at a neonatal intensive care unit (NICU), this context was chosen because it was there that Swanson had delivered her second child (Samuels, 2012).
Swanson formulated concepts as she began her study, with the progress of her research, the firver theoretical categories of caring were honed. With the application of these precepts in various environments, her theories have matured but the core concepts have remained intact (Samuels, 2012). Her research focuses on caring, responses to miscarriage and interventions to promote healing after early pregnancy loss. In her theory, the ultimate goal of nurse caring is to enable clients to achieve well-being (Swanson, 1993). This theory was derived from three phenomenological studies conducted in the area of perinatal nursing.
Kristin Swanson’s middle range theory of caring (Koloroutis, 2004) borrows pieces from several other theories, including Watson’s theory of human caring, Benner’s novice to expert, Nightingale’s environmental theory, Henderson’s theory and Orem’s self-deficit care theory (Swanson, 1993). The first three major concepts of the Swanson theory are: being with, doing for, and enabling, which are three action processes.
The last are maintaining belief and knowing, which are internal practices. Swanson states that the five caring concepts aren’t specific to nursing only but can be applied to a broad range of caring relationships. However, when the five caring concepts are combined to nursing practice, caring becomes a nurturing way of relating to a valued other and towards who one has a personal sense of commitment and responsibility (McEwen & Wills, 2011). The interaction between the nurse and the patient proves mutually beneficial, as both are involved in a caring relationship.
Consider now the case of the aforementioned Mrs. C., who presented to an emergency department (ED) on a Tuesday in late January, with a complaint of “severe back pain after smoking crack.” Her only previous medical history was high blood pressure, for which her primary care physician years ago had prescribed her Losartan and Hydrochlorothiazide. During the initial nursing assessment, the patient’s blood pressure was found to be 230/118. For Mrs. C, her hypertension likely began many years prior to her presentation to the ED. Perhaps she began to notice headaches or pain in her chest, but many times high blood pressure has no symptoms and is only discovered as a result of an incidental finding when the patient is seen by a health care provider for another complaint. It is called “the silent killer” for this reason. (American Heart Association, 2019).
By the time of Mrs. C.’s arrival in the ED, her disease process had progressed to a crisis phase, and years of smoking crack cocaine combined with uncontrolled high blood pressure had weakened the walls of her blood vessels to the point where the descending aorta, part of the largest artery in her body, had begun to tear, starting at the aortic arch at the top of her thoracic cavity, and traveling down all the way to her abdomen, ending at the common iliac juncture. Immediate, sustained control of her blood pressure was required, as well as an urgent surgical consult; these interventions were necessary to attempt to correct her poor prognosis. However, from a nursing perspective, Mrs. C.’s decision to continue using crack cocaine, combined with her ambivalence in adhering to the prescribed medication and lifestyle alterations, were major contributing factors to her location in the ED on that day in late January.
Swanson defines “being with” as ‘being emotionally present to the other, striving to understand an event as it has meaning in the life of the other.” Behaviors associated with this sphere of caring include being present, listening to, sharing feelings and seeking to understand another’s point of view, as well as lightening their burden. Being with conveys to the person that the other’s experience matters to the one who is doing the caring. Nurses and other health care professionals can play a vital role in the care of persons with addiction.
When persons with addiction are approached by providers with disdain and rejection, no matter how subtly, they may reject the care offered by these providers. In fact, such negative behaviors may result in a missed opportunity for the addicted person to learn about important treatments. Incorporating harm reduction strategies and evidence-based interventions in working with persons with addiction yields the best opportunities for helping them get the care and treatment they need. Working from a theoretical model of Health Belief, respectful, non-judgmental communication and provider empathy with patient needs have also been shown to lower patient resistance to adherence (Kourakos, et. al, 2017).
In the case of Ms. C., “being with” means that the nurse, through patient and probing inquiry, learned that Mrs. C was living in a home with her son, who sold heroin and cocaine. The patient also expressed feelings of hopelessness and a mistrust of doctors, as every previous health care interaction had resulted in a feeling of inadequacy and being “lectured” or talked down to. Mrs. C. exhibited poor coping mechanisms, latent suicidal thoughts, and financial unreliability as her only sources of income were food stamps, a welfare check, and occasional prostitution.
Armed with this information, the nurse was better able to empathize with Mrs. C and the challenges she faced on a daily basis, as the “doing for” stage was entered. Swanson characterized “doing for” as “doing for the other person what they would do for themselves if they were able to do so.” Practices in this process include anticipating, protecting, preserving dignity and providing competent and skillful care. In the case of Mrs. C, deftly placing a large bore IV while discussing the patient’s fascination with turtles was every bit as important as distracting her from her fear of the cat scan test by asking her to talk about her favorite foods, and gently squeezing her hand while the surgical team surrounded her, explaining that her aorta was dissecting. The cardiac care team wanted Mrs.C. to be transferred to the University of Pennsylvania, to be seen by a vascular surgery team that had much experience in repairing difficult aortic aneurysms. They warned her that even with the available experts, her surgical options gave her an 80% mortality rate. This was upsetting to Mrs. C., who demanded, dark eyes blazing, to be discharged immediately, against medical advice.
Swanson illustrates “enabling” as “facilitating the others passage through life transitions and unfamiliar events.” In this process, empowering individuals to acquire the tools they need to be able to care for themselves is essential. In Mrs. C.’s case, the best tool for her might have been a healthy ability to cope with life-transitioning events, such as the fearful prognosis surrounding her imminently rupturing aneurysm. The nurse could help Mrs. C by validating, explaining, informing, supporting, allowing and advocating.
The nurse offered the patient information about her condition in a manner that she could comprehend, using therapeutic communication tactics, defined “as a process in which the nurse consciously influences a client or helps the client to a better understanding through verbal or nonverbal communication. Therapeutic communication involves the use of specific strategies that encourage the patient to express feelings and ideas and that convey acceptance and respect” (Kourakos, et. al, 2017.) In an honest and empathetic manner, the nurse answered Mrs. C.’s questions and drew pictures of Mrs. C.’s heart, to show her where the weak spot was, and in doing so, the patient was finally able to understand the gravity of her situation, and the sad consequences of non-adherence. Acceptance, mixed with resignation, trickled in. The nurse facilitated Project Engage, a community support program, designed to help those addicted to alcohol or drugs, to come meet with Mrs. C. at her bedside.
She was agreeable to detoxification, and willing to consider relocating to a detox facility, post discharge, where she would stop using crack cocaine, begin regularly taking her blood pressure medications, and receive the social and psychological support necessary to regain her balance. Chaplain services were enlisted to offer spiritual support for Mrs. C., who, now that she understood the significance of her diagnosis, was tearful, voiced anger at God, appeared despondent, at times wailing loudly and swearing, and at other times quietly sobbing. The nurse also conferred with the ED physician and the vascular transport team to transfer Mrs. C urgently to the University of Pennsylvania for possible life-saving surgery that she had finally agreed to, and an Uber was organized for Mrs. C.’s sister to meet her there, as the only family support system available to the patient.
Swanson defines “maintaining belief” as “sustaining faith in the other’s capacity to get through an event or transition.” She further characterized maintaining belief into “ believing in, holding in esteem, maintaining a hope-filled attitude, offering realistic optimism and going the distance.” Maintaining belief is at the heart of caring in nursing; nurses can empower patients to believe in their own capacity to successfully be able to overcome whatever brought them to the emergency department. One strives to balance maintaining belief with offering realistic optimism, engaging in courageous conversations with patients. These dialogues reveal the nurse’s faith in the patient abilities while acknowledging the patient’s limitations as opportunities for growth. When nurses care for addicted persons with care and compassion, they help these clients live as healthy a life as possible given their circumstances and the life choices they have made.
Employing Swanson’s principle of caring, in her last hurried moments with the patient, the nurse pulled Mrs. C. into a hug, squeezed her gently and whispered, “I’m glad to have met you, you can do this!” She later described this brief, final interaction with her patient as the single most important thing that occurred that day. Swanson describes “knowing” as “striving to understand an event as it has meaning in the life of the other”. Knowing” refers to understanding how others’ lives have meaning; it avoids assumptions and focuses on the one being cared for in order to better comprehend the client’s lived reality. As a nurse it is critical to know the patient, striving to understand them personally with a commitment to understanding their particular needs and motivations, as well as to understand the personal aspects of addiction, and how they relate to the patient being treated. The nurse knew that Mrs. C. should not be defined solely by her illness, and she offered Mrs. C. a steady presence, authenticity and vulnerability, ultimately demonstrating to Mrs. C. that she mattered both as a patient and a person.
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