Nurses Stimulate Innovation in Health Care by Wielding leadership, Vision, and Compassion using the Art and Science of Nursing

Rather than imitate the past or consort with “what’s most popular,” nurses inspire innovation in health care by wielding leadership, vision, and compassion.

In “’Blameless’: Using Popular Entertainment Media to Build Social Context in Nursing Students,” the authors discuss a unique class that used popular media to help prepare students for entering nursing work with diverse populations. When nursing students meet a patient, their first impression may be one of “someone lying on a stretcher or hospital bed.” The authors hold that clinical encounters mold a student’s concepts of “patient,” “nurse,” and “nursing practice.” With time and experience, that student becomes a working nurse and develops an ability to glance at a patient and more widely view a person’s greater world—and how that context can influence a patient’s current and potential future state of health. During the pandemic, the opportunities to develop this skill through meeting people in person and visiting clinical sites was limited for educators and students. In response, the course in this study utilized popular media as a way for students to supplement their clinical skills. While watching “real” people with “real” problems, students were guided to enrich their understanding of the social context and complexities they were seeing, and look for contexts where physical and mental illness had the potential to thrive. Looking at a problem and effectively putting innovative and resourceful ideas into action is part of the science and art of nursing.

In “Nurse Practitioners and Barriers to Practice in Primary Care,” authors outline the professional, social, and legal blockades that can prevent medical institutions from meeting the primary care needs of the public. This paper discusses how nurse practitioners are in a unique position to encourage states to expand access to primary care through professional advocacy and public awareness. Having a vision for better meeting communities’ healthcare needs and bringing nurses and nurse practitioners more fully into the fold to advocate for critical changes is part of the science and art of nursing.

In “The Role of the Nurse Practitioner and Emergency Preparedness,” the authors share insights on how to promote the competencies necessary for nurse practitioners to serve in the many roles emergency management calls for. In a time when uncertainty is the norm, communities experiencing disasters rely on healthcare providers more than ever. Nurse practitioners are skilled in crisis communication, maintaining situational awareness, hazard risk assessment, and adaptive management. Such skills provide a sound foundation for nurse practitioners’ roles in leadership, analysis, and clinical first responder and supplemental surge capacity. As such, nurse practitioners are in a unique position as leaders in emergency preparedness and emergency situations—another example of the science and art of nursing. Artists train for years honing their skills in order to depict their unique perspectives of the world through various mediums. Their work may astound and change observers and society at large. It is no wonder nursing students cultivating their profession’s craft were successfully educated through use of others’ craft. Using methods and facts accumulated through time, the scientist asks questions, interprets findings, and proposes actions which shape the future. As artists and scientists, nurses work to collectively improve health, mitigate suffering, and advance our profession. Nurse unions succeed in channeling the power of the profession to ensure nurses have what they need to equitably deliver the care society demands.

Anne Bové, MSN, RN-BC, CCRN, ANP

Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k

Meredith King-Jensen, PhD, MSN, RN

Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN

Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

“blameless”: using Popular entertainment media to build Social Context in Nursing Students

Nancy Scanlan, PMHNP-BC Shannon Hanshaw, PhD, RN, CNE

n Abstract

Significant challenges face educators as they prepare nursing students to work with diverse populations. Educators capitalized on high levels of media viewing to build social context among students.

A pilot nursing course used the television series Shameless to explore issues of social justice and equity. Students engaged in analysis involving the interrelationship of medical and psychiatric illnesses, and environmental conditions. A mixed methods approach to data analysis was used. Students were surveyed regarding their ability to apply what they learned to real-world situations, and content analysis of qualitative comments was conducted.

One hundred percent of students who completed the survey (n = 27) reported that the course impacted their ability to understand the connection between mental and physical health and their ability to apply medical and psychiatric knowledge to real-world situations. Three themes were identified: bringing issues to life and illuminating the material, application of learning to clinical nursing practice, and breadth and depth of material

Educators must prepare students to care for individuals of varying backgrounds and social circumstances. The use of entertainment media is a nontraditional strategy for teaching concepts that can bridge the gap between the classroom and the practice setting.

Keywords: media, social justice, social determinants of health, nursing education

Introduction

Nursing students are often unfamiliar with the social determinants of health, tending to see a patient’s mental or medical illness as an isolated occurrence without social context. The Centers for Disease Control and Prevention (CDC) define these determinants as the conditions in the places where people live, learn, work, and play that affect their health. (Centers for Disease Control [CDC], 2021). Undergraduate nursing programs may not have clinical opportunities for students to learn about those from different backgrounds and about the social and cultural factors that influence health. Preparing nurses to address the social determinants of health is a key principle for promoting more equitable health outcomes for patients, families, and communities. Educators must find engaging ways to help students understand social and cultural issues, and television has the potential to assist with this. The purpose of this study is to examine the use of television media to facilitate understanding of social and cultural issues in undergraduate nursing students.

Background

Entertainment education can provide “unconventional perspectives on social issues” (Klein, 2011) and can be used to illustrate social determinants of health. Entertainment media as provided by Showtime, Netflix, etc., can be used by educators to take advantage of a medium that is already used by many college students daily. Looking at the years 2013–17, a study found 74.1% of 20- to 24-year-olds watched television for approximately 2.17 hours on any given day (Krantz-Kent, 2018). According to a 2021 report by the U.S. Bureau of Labor Statistics, that number has grown. Television viewing was the top leisure activity of Americans, occupying 2.9 hours per day and accounting for over half of people’s total leisure time (U.S. Department of Labor, Bureau of Labor Statistics, 2022).

Few can argue the influence of media on our daily lives and cultural values. Even when it is not intentionally designed to teach, media carries messages about social interactions and about the nature and value of groups in the society that can influence attitudes, values, and actions among its viewers. It serves as a source of information about the world, whether viewers seek entertainment or enlightenment (Huston et al., 1992). Entertainment television content can offer unconventional perspectives on social issues that are important in a nursing context. Understanding different cultures helps provide meaningful and patient-centered care, and a responsibility of nurse educators is to educate students regarding “culturally congruent care” (Leininger, 2012). There is limited research on the effect of television media on nursing students’ knowledge and values; however, nursing has used film viewing as a method of teaching psychomotor skills for decades. A systematic review by Hoffman and colleagues (2018) suggests that the integration of entertainment television into medical education is feasible and acceptable and that further study is needed to determine if this type of entertainment education increases nursing students’ understanding of social context and health.

In the 2018–19 academic year, 45 out of 48 students in the authors’ nursing classes had watched at least one full season of the popular television show Shameless (Abbot, 2011–2021), which ran for 11 seasons. The series allows viewers to experience vicariously the social, medical, and psychiatric issues of characters from the South Side of Chicago. It portrays the saga of the poverty-stricken Gallagher family, whose children fend for themselves due to absentee, alcoholic parents. Issues of sexuality, substance abuse, racism, and poverty are addressed in an irreverent, insightful way. Executive producer John Wells described the Shameless writing staff as “really damaged people” who had experiences similar to those portrayed on the show (Rochlin, 2011). The popularity of the show offers the potential for a huge educational impact on a large fan base.

Psychiatric and medical-surgical nursing educators collaborated on the development of the course “Blameless,” which used this television series to explore the issues of homelessness, racism, sexuality, substance abuse, organ failure and transplantation, access to medical care, trauma, and mental illness. The course description and content list are displayed in Appendix A. Students were assigned specific episodes of Shameless to view and provided a series of questions for reflection prior to viewing. Students then participated in class discussion regarding the issues and assigned topics.

For many students in the course, the show was their only source of context for the kinds of social factors that influence health explored on the series. Klein (2011) described the phenomena in which viewers observe social issues in entertainment television and then take that background with them to other experiences where they encounter that issue. Viewing the television show Shameless provided a context from which students could draw to engage in larger discussions of social issues.

method & research Design

A mixed methods approach was used to collect and analyze data on the pilot course and the second offering of “Blameless.” The college Institutional Review Board determined that completion of the survey implied consent and the study was exempt.

Sample & Setting

The pilot for the elective nursing course during fall of 2019 enrolled nine students. In fall 2021 the course was offered again, and enrolled 23 students, for a total sample size of N = 32. Of the 32 total students, 30 were female and two were male. Sixteen were unlicensed students in a bachelor of nursing program, and 16 were registered nurses with their associate degrees who were enrolled in a bachelor’s completion program. Table 1 displays the sample demographics.

The course was offered at an upstate New York SUNY college. It was initially offered on campus, delivered in a face-to-face format, but the modality was changed to a virtual course delivery during the pandemic.

educators must find engaging ways to help students understand social and cultural issues, and television has the potential to assist with this.

The course began with the analysis of adverse childhood experiences (ACE) among the characters, using the CDC-Kaiser Permanente Adverse Childhood Experiences Study (Felitti et al., 2019). This study was based on confidential surveys of over 17,000 Health Maintenance Organization members from Southern California and uncovered how ACEs are strongly related to the development of risk factors for disease and well-being throughout life. Survey questions related to physical and sexual abuse, neglect, divorce, mental illness, substance abuse, and incarceration (American Academy of Pediatrics, 2014). The influence of ACE was followed throughout the course as students analyzed characters with addiction, depression, and sociopathy. Individuals’ emotional and physical responses to trauma and household dysfunction were explored, along with the socioeconomic and cultural factors that contributed to their illnesses.

Table 1

Sample Demographics (N = 32)

The interrelationship between medical and psychiatric illness was emphasized throughout the course. Physiological, psychological, and social factors can each have an impact on health and wellness. Changes to physiological or psychological processes, or social factors can increase the likelihood that someone living with a mental illness or medical illness will develop a comorbidity (Evans et al., 2005; Leucht et al., 2007). Students engaged in critical analysis involving the interrelationship of medical illness and psychiatric illness. They were able to draw from the experiences of the characters in the show to gain insight and deeper understanding of how the conditions in which individuals live can impact health, both medically and mentally.

An anonymous survey was completed by all nine enrolled students at the end of the “Blameless” course. The students completed an 11-item Likert scale which contained items regarding course content and the ability to apply concepts such as social justice, the connection between mental and physical health, and the impact of social determinants on health. A copy of the Likert scale survey is included in Appendix B. The subsequent offering of the course composed of 23 students used a standardized university Course Opinion Survey which addressed general satisfaction with teaching methods. Additionally, qualitative data was gathered through the survey.

Data Analysis

The in-person pilot course used an 11-question survey to collect quantitative data regarding the understanding of concepts such as socioeconomic status, environment, and experiences on health.

Qualitative data were reviewed using content analysis to identify themes. Student comments were coded and analyzed for repeated themes. Researchers reviewed coding and emerging patterns and came to consensus on the themes identified.

Findings & Discussion

One hundred percent of students who completed the surveys (n = 9) in the pilot offering agreed with statements regarding the positive impact the course had on their ability to understand the connection between mental and physical health and their ability to apply medical and psychiatric knowledge to real-world situations. The 18 students who completed surveys following the second offering of the course revealed similar satisfaction with class content. Comments were collected and analyzed using a qualitative approach. A sample of these comments follow:

It was interesting and I often found myself watching the YouTube videos that played after the assigned ones out of interest.

We covered a surprisingly wide range of topics. The content was engaging and never felt lacking.

The design of the course shows a deep thoughtfulness into how to grab our attention and illuminate the material.

I was pleasantly surprised by the depths this course went to and the thought-provoking discussions. It brought issues to life in such a way that I sometimes recall the discussions and videos while at work when interacting with certain patients.

The instructor stimulated my interest in the subject more so than I expected.

More classes should be set up this way.

The subject matter is very interesting and I felt very involved in all discussion.

I love how this was incorporated with our nursing practice! It made me reflect on topics such as mental illness, addiction, pain management, and barriers to health care.

The researchers identified three themes: bringing issues to life and illuminating the material, application of learning to clinical nursing practice, and breadth and depth of material.

Bringing issues to life and illuminating the material —students indicated that the course was engaging and grabbed their attention. The topics were interesting and presented in a way that fostered deeper understanding of the concepts of culture, socioeconomic status, and social determinants of health.

Application of learning to clinical nursing practice —students indicated that they recalled course content while interacting with specific patients during their clinical practice.

Breadth and depth of material—students identified that there was a wide range of topics and were surprised by the depth of thought-provoking discussions and course materials.

Researchers initially developed the pilot course to address the gap between knowledge and clinical practice related to the impact of culture and socioeconomic status on health. Both qualitative and quantitative data results indicate a positive influence on closing this gap. Based on these results, the course was integrated into the nursing curriculum.

Integrating popular entertainment television with guided analysis may be an innovative way to ... build social context for students.

limitations & Strengths

A strength of this study was that the content could be delivered virtually or in person, which was especially useful during the pandemic. Limitations of the study were that two different evaluation tools were used, and the course was face-to-face during the first pilot and online for the second offering. Other limitations were a small sample size, a primarily female sample, and the fact that students self-selected into this elective course. It would be worthwhile to explore the long-term impact of such a course on students’ values using a mixed methods research strategy.

Implications for Nursing Practice

Nursing students care for a microcosm of society and often begin their education with limited knowledge of the cultural and socioeconomic factors that drive mental and medical illnesses. Creative approaches to teaching students about the social context in which illness develops is needed. Integrating popular entertainment television with guided analysis may be an innovative way to address this need and build social context for students.

“Blameless”: Using Popular Entertainment Media to Build Social Context in Nursing Students

Abbot, P. (creator). (2011–2021). Shameless [TV series]. Showtime, John Wells Productions Warner Bros.

American Academy of Pediatrics. (2014). Adverse childhood experiences and the lifelong consequences of trauma. https://cdn.ymaws.com/ www.ncpeds.org/resource/collection/69DEAA33-A258-493B-A63FE0BFAB6BD2CB/ttb_aces_consequences.pdf

Centers for Disease Control and Prevention. (2021). Social determinants of health: Know what affects health . https://www.cdc.gov/ socialdeterminants/

Evans, D. L., Charney, D. S., Lewis, L., Golden, R. N., Gorman, J. M., Krishnan, K. R. R., Nemeroff, C. B., Bremner, J. D., Careny, R. M., Coyne, J. C., Delong, M. R., Frasure-Smith, N., Glassman, A. H., Gold, P. W., Grant, I., Gwyther, L., Ironson, G., Johnson, R. L., Kanner, A. M., Katon, Valvo, W. J. (2005). Mood disorders in the medically ill: Scientific review and recommendations. Biological Psychiatry (1969), 58(3), 175–189. http://doi:10.1016/j.biopsych.2005.05.001

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., Marks, J. S. (2019). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 56(6), 774–786. (Reprinted from American Journal of Preventive Medicine 1998; 14(4): 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8)

Hoffman, B. L., Hoffman, R., Wessel, C. B., Shensa, A., Woods, M. S., Primack, B. A. (2018). Use of fictional medical television in health sciences education: a systematic review. Adv in Health Sci Educ, 23, 201–216. https://doi.org/10.1007/s10459-017-9754-5

Huston, A. C., Donnerstein, E., Fairchild, H. H., Feshbach, N. D., Katz, P. A., Murray, J. P., Rubinstein, E. A., Wilcox, B. L., & Zuckerman, D. (1992). Big world, small screen: The role of television in American society. University of Nebraska Press.

Klein, B. (2011). Entertaining ideas: Social issues in entertainment television. Media, Culture & Society, 33(6), 905–921. https://doi. org/10.1177/0163443711411008

Krantz-Kent, R. (2018). Television, capturing America’s attention at prime time and beyond. Beyond the numbers (United States. Bureau of Labor Statistics), 7(14), 1–11. https://www.bls.gov/opub/btn/volume-7/ television-capturing-americas-attention.htm

Leininger, M. (2012, January 25). Madeleine Leininger Interview Part 1 [Video]. YouTube. https://www.youtube.com/watch?v=a4GTo_uthZQ

Leucht, S., Burkard, T., Henderson, J., Maj, M., & Sartorius, N. (2007). Physical illness and schizophrenia: a review of the literature. Acta Psychiatrica Scandinavica, 116(5), 317–333. https://doi.org/10.1111/ j.1600-0447.2007.01095.x

Rochlin, M. (2011, January 2). The family that frays together. The New York Times.

U.S. Department of Labor, Bureau of Labor Statistics (2022, June 23). American time use survey, 2021 results [Press release].

Appendix A elective Course Description

Course name and number: N ur 317; blameless

Course credit hours: 3 credits

Course description: This course focuses on medical and psychiatric conditions of characters in media. Individuals’ emotional and physical responses to trauma are explored, in the context of the social and economic determinants of health. Concepts considered are population health, equitable care, culture, social justice, and diversity with focus on health restoration. Will cover mature content which some may consider offensive. This course includes simulated learning experiences.

Required course materials:

Access to “Shameless” on Showtime or Netflix, selected episodes from Seasons 2, 3, 4, 8, 9.

Suggested course materials:

Boyd, M. A., Luebbert, R. (2021). Psychiatric nursing: Contemporary practice (7th ed.). Wolters Kluwer.

Hinkle, J., & Cheever, K. (2021). Brunner & Suddarth’s Textbook of MedicalSurgical Nursing (15th ed.). Wolters Kluwer.

Course Topic Outline:

I. Patient Responses to Psychiatric Stressors

A. Adverse Childhood Events (ACEs)

1. Emotional and physical abuse

2. Neglect

3. Sexual abuse

II. Patient Responses to Medical Trauma

A. Sensory-perceptual alterations

B. Emergency/disaster situations

III. Patient Responses to Environmental Influences

A. Nutrition

B. Housing

C. Transportation

D. Access to medical care

E. Adaptation to complex situations

IV. Substance Abuse

V. Trauma-informed care

VI. Patient Responses to Alterations in Health

A. Hepatic failure

B. Traumatic injury

VII. Perspectives on Social Justice

A. Vulnerability and resiliency in health

B. Ethics of organ transplantation

C. Social assistance programs

D. Social determinants of health

Course Student Learning Outcomes:

At the end of this course, the student will be able to:

1. Assume the role of the professional nurse by incorporating standards of professional practice;

2. Apply the nursing process in assessing, planning, and providing patient-centered care to individuals and families experiencing complex alterations in health function;

3. Employ a systematic process to make decisions using the best available research evidence, theory, expertise, and patient preferences;

4. Actively prevent or limit unsafe or unethical care practices through promotion of a culture of safety;

5. Engage in teaching and learning activities that promote best healthcare practices among patients and colleagues;

6. Demonstrate effective professional communication through verbal, non-verbal, written and electronic methods;