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The Newsletter of the American Nurses Association–MaineQuarterly publication distributed to approximately 15,600 RNs and LPNs in Maine.

ANA-MAINE

JOURNALSUMMER 2020

President’s Message

National Student Nurses Association: All Lives Matter Only When African American Lives Matter . . . . . . . . . . . . . 2

Advocacy and Coalitions Legislative Summary . . . . . . . . . . . . . . . . . . . . . . 3

Academic Leaders Publish Statements in Response to Racism . . . . . . . . . . . . . . . 4

A Dance With Life - A Hospice Story . . . . 6Masks Help to Stop the Spread of the

Coronavirus . . . . . . . . . . . . . . . . . . . . . 7Sigma Theta Tau statement about

diversity and inclusion - Sigma News . . 8A Nurses Prayer . . . . . . . . . . . . . . . . . . . . 8Membership . . . . . . . . . . . . . . . . . . . . . 15

Index

“We are one people with one family. We all live in the same house. We must lay down the burden of hate.Do not get lost in a sea of despair. Be hopeful, be optimistic.” – John Lewis, Civil Rights Icon, United States Congressman

Nursing is justifiably frontline news this year and the recipient of public appreciation . As we recognize the bicentennial of the birth of Florence Nightingale, who was born in 1820, as our profession’s founder, the World Health Organization declared 2020 to be “the year of the nurse .” Our profession is nationally recognized among the tireless and trusted front line care givers for the thousands of COVID-19 patients who have been hospitalized during the pandemic and ill with the coronavirus .

At the same time, the pandemic also brought to the forefront the inequities in American’s health care system . Data collected by the Kaiser Foundation and

reported by AARP, during the pandemic, described how minority groups, especially African Americans, Hispanics, Native Americans and other minority populations are disproportionately being affected by the virus . This is especially evident in communities where access to health care is not available to everyone . How would Florence Nightingale respond to these challenges?

“Florence Nightingale: Nursing and Health Care Today,” by Lynn McDonald, published in 2018, by Springer Press, quotes Nightingale’s definition of health, as “a state of complete physical, mental, and social well-being and not merely the absence of disease .”

In fact, McDonald explains how the Nightingale definition was adopted by the World Health Organization (WHO, 2017) . Moreover, the WHO expanded the description to include health care as a fundamental right of every human being .” The WHO also specified primary health care to be the chief means to this end . Nightingale did not use ”rights language” herself, but her steadfast support for providing access to quality care for the very poorest members of society was an early step toward this understanding . In fact,

The Nightingale Society reports that Nightingale was the first person, in 1866, to call for quality hospital care for all, specifically that workhouse infirmaries, the only recourse for 80% of the population, should provide as good of care as the best hospitals in the suburbs (the workhouses were not typically located in the suburbs) .

During the Crimean War (1853-1856), Nightingale worked constantly at a British base hospital, earning her the nicknames “the Angel of the Crimea” and “the Lady with the Lamp” (because she made nighttime rounds to tend to patients while carrying a lamp) .

Using her experiences in the Crimea, she wrote an 830-page report with proposed reforms for

Catherine Snow, RN, PMHRN-BC

President’s Message continued on page 2

ANA-Maine Journal Has Gone Green!The ANA-Maine Journal has gone green! Starting

with the May 2020 issue, ANA-Maine Members will receive the publication in print and electronic form . Non-members have three options available if they wish to continue to receive critical statewide nursing updates from American Nurses Association-Maine:

1) Subscribe your email address on line at https://tinyurl .com/ANAMEJournal to receive a free digital copy

2) Request a physical subscription to receive a paper copy . Subscriptions are free and are available by emailing our publisher at sales@aldpub .com or by calling 800-626-4081 .

3) Become a member of ANA-Maine and receive both a digital and print version in addition to all of the other membership benefits . You can join at https://www .anamaine .org .

If you have questions or comments about the ANA-Maine Journal contact info@anamaine .org or by phone at 877-810-5972 ext . 700 . We look forward to hearing from you .

Page 2 ANA Maine Journal August, September, October 2020

Volume 16 • Number 3

Published by theAMERICAN NURSES ASSOCIATION-MAINEa constituent member association of the

American Nurses AssociationE-mail: info@anamaine .org

Web Site: www .anamaine .org

P .O . Box 647 Kennebunk, ME 04043

ANA-MAINE BOARD OF DIRECTORS

Catherine Lorello-Snow, RN, PMHRN-BCPresident, South Portland

Catherine .snow@anamaine .org

Robert Abel, MSN, RN, CHPH, CCM, CMCPresident-Elect, Portland

Joanne Chapman, MEd, MSN, RN, NE-BCTreasurer, Falmouth

Jennifer Morton, DNP, MPH, PHNA-BCSecretary, Eliot

Mary Doherty, MSN, APRN, BC-PNP Director, Standish

Joyce Cotton, DNP, APRN-CNSDirector, Kennebunk

Suzanne Parkman, PhD, RN, CNEDirector, Falmouth

Erin Stratton, PhD, MS, RNDirector, Camden

Marianne Tarraza, PMH-NP, RNDirector, Cape Elizabeth

Contents of this newsletter are the opinion of the author alone and do not reflect the official position of ANA-MAINE unless specifically indicated . We always invite leaders of specialty organizations to contribute .

ANA-MAINE EDITORIAL COMMITTEEMichelle L . Schweitzer (Editor)

Juliana L’Heureux, BS, RN, MHSA (Co-Editor)Patricia Boston, MSN, RN, RRT

Jean Dyer, PhD, MSN, BSN, CNE

We welcome submissions, but we reserve the right to reject submission of any article . Send to publications@anamaine .org . CE calendar listings are without charge .

Attribution: We do not knowingly plagiarize . We encourage our authors to fact check their material but we do not assume responsibility for factual content of ads or articles .

For advertising rates and information, please contact Arthur L . Davis Publishing Agency, Inc ., PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, sales@aldpub .com . ANA-Maine and the Arthur L . Davis Publishing Agency, Inc . reserve the right to reject any advertisement . Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement . Published quarterly every February, May, August and November .

Acceptance of advertising does not imply endorsement or approval by ANA-Maine of products advertised, the advertisers, or the claims made . Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use . ANA-Maine and the Arthur L . Davis Publishing Agency, Inc . shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product . Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ANA-Maine or those of the national or local associations .

Postal Address corrections: This list of addressees is obtained from the Maine State Board of Nursing (MSBON) each issue . To keep your address current for these mailings, simply notify the MSBON of any needed changes in your postal mailing address .

Permission must be obtained from ANA-Maine to replicate or reproduce any content from ANA-Maine Journal.

Published by:Arthur L. Davis

Publishing Agency, Inc.

www.anamaine.org

Association statementAs an organization that represents students from

multiple backgrounds and cultures the National Student Nurses’ Association (NSNA) acknowledges all who are impacted by the recent tragedy which took place in our nation .

On May 25, 2020, the African-American community suffered the loss of George Floyd . His death was preceded by that of Ahmaud Arbery, Breonna Taylor, and many other African-American men and women . The injustice surrounding their deaths must be shared and acknowledged by all people . Families have endured the heartache of losing a mother, father, daughter, or son . Far too many lives have been lost due to racial prejudice and police brutality . Enough is enough .

The injustices seen in this country are the consequences of 400+ years of oppression and have caused mental, emotional, and physical distress throughout generations . The African-American community has witnessed racial injustice throughout their lives creating fear, anger, sadness, and extreme emotional anguish . The impact of racism across the

nation fuels the flames within the African-American communities to address the ongoing systemic inequities of racial injustice .

NSNA stands with those who peacefully protest to eliminate injustice . COVID-19 is still prevalent across our nation . All protesters are urged to wear masks, bring water, and practice social distancing as best as possible . Health inequity in the African-American community makes this essential for all who come together to stand in solidarity .

To all nursing students and nursing faculty in the African-American community, we see you and hear your voices to end oppression . As an organization that affirms and supports diversity and inclusion by refusing to engage in or condone discrimination, NSNA stands with you to eradicate racial injustice . We understand that all lives will matter only when African-American lives matter . We must recognize and continue to eradicate racial disparities in our nation .

This statement is published on the NSNA website . For more information contact Sarah Zhou, Communication Specialist nsna@nsna .org .

National Student Nurses Association: All Lives Matter Only When African

American Lives Matter

military hospitals with poor conditions . Upon coming back home, she was treated as a hero, and Queen Victoria gave her an engraved broach, known as the Nightingale Jewel, along with $250,000 .

Nightingale used the money to fund a hospital and a nurse training school . She is revered as an inspirational heroine because she overcame daunting challenges, especially during the terrible conditions in the Crimean war hospitals; but she returned to England to become a social reformer and nursing leader .

New England nurses are particularly fortunate to have access to over 200 of Nightingale’s personal correspondence dating from 1851-1900, preserved at the History of Nursing Archives, at Boston University’s Gotlieb Archival Research Center . Established in 1966, with help from the United States Public Health Services, and the Boston University School of Nursing, this archive contains, in addition to Nightingale’s documents, an extensive book collection as well as the personal and professional papers from nursing leaders, records, and histories about schools of nursing from nearly every state and some foreign countries .

Nightingale was an “indefatigable seeker of knowledge,” wrote Lydia Flanagan in the American Nurses Association History “One Strong Voice.” Although Nightingale expressed her wish to care for the sick at an early age, she was not instinctively knowledgeable about how to care of the sick . Rather, she aspired to obtain all the knowledge she could

accumulate for the purpose of being an effective nurse . Moreover, she documented this knowledge, which is how we can continue to admire her wisdom and vision today . Nursing has been rated by the Gallup poll as the most trusted profession . We are honored to receive this recognition . Furthermore, we gratefully acknowledge how Florence Nightingale’s inspirational legacy encourages us to advance our professional growth while continuing to provide quality patient care .

President’s Message continued from page 1

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August, September, October 2020 ANA Maine Journal Page 3

Juliana L’Heureux

AUGUSTA, Me- This was certainly a year for the ANA-Maine’s history book! In fact, the January 23, 2020 Nurse Advocacy Day at the Maine State House was celebrated just prior to the onset of Maine’s coronavirus pandemic response .

During Maine’s 129th legislative session, the ANA-Maine experienced excellent visibility in the State House, hosting educational seminars and participating as a coalition partner to support several public policy initiatives . Foremost was the support for LD 798 “An Act To Protect Maine Children and Students from Preventable Diseases by Repealing Certain Exemptions from the Laws Governing Immunization Requirements .”

For the past five years, ANA-Maine has been a partner with the Maine Public Health Association (MPHA) and other health policy groups for the purpose of strengthening the state’s vaccine laws . This coalition evolved into an advocacy group named Maine Families For Vaccines, also known as No on One, during the November ballot initiative . This law received strong voter support in the November 2019 election, in spite of a campaign to repeal it, led by anti-vaccine groups . In fact, by a large majority, the Maine voters allowed for the law’s implementation .

On January 23, 2020, ANA-Maine led the Nurse Advocacy Day in the State House Hall of Flags with recognition for Dr . Nirav Shah, director of Maine’s Center for Disease Control and Prevention and Pat Endsley, president of the Maine Association of School Nurses . They were honored because of their dedication to support public health . Appreciation is extended to our program partners Laurie Belden, executive director of the Home Care and Hospice Alliance of Maine, Lisa Harvey McPherson and Andrew Gagnon with the Organization of Maine Nurse Executives and Colleen Hilton, from Northern Light Home Care . Two nurse legislators, Representative Anne Perry of Calais and Representative Michele Myer of Eliot, participated and spoke during the program . This year, the Advanced Practice Registered Nurse (APRN) anesthetists joined the nursing organizations in the Hall of Flags exhibits .

Needless to say, this past legislative year should be preserved in a time capsule, because it will be difficult to predict when another advocacy day can be scheduled in the State House while social distancing to prevent the coronavirus spread is enforced . Moreover, when the 130th legislature opens in January, there will be competition from many groups that want access to the new legislators . Therefore, the circulation of the ANA-Maine quarterly journal is an important communications tool because the publication supports special opportunities to reach all nurses, the legislators and public policy groups . Obviously, the newspaper is also a membership recruitment and marketing communication .

Advocacy and Coalitions Legislative SummaryANA-Maine has been a voice for all nurses since

1914, when the Board of Nursing was established by the legislature . Over the decades, professional credibility and visibility has been established with leaders in Augusta . During the COVID-19 pandemic response, ANA-Maine can consider returning to the grass roots advocacy efforts that were effective in the past . This requires constituent connections with legislators . Each ANA-Maine member would consider establishing a relationship with the legislator who represents their community . This personal connection can create a grass roots presence with many legislators . But we need to make a commitment to do this and someone must be willing to oversee the details, especially if a legislator is going to require information about specific legislation . Another suggestion is for the quarterly journal to feature a “legislator of the month” and recognize an individual based upon their support for our mission and nursing education . Continuing the positive momentum we have developed in Augusta will need creative thinking in the new normal of not knowing how we can plan to congregate in the future .

Nevertheless, the pandemic has not deterred ANA’s public policy efforts . By a consensus of ANA’s national members, the annual lobby will be convened using telecommunication . The September 3 and 4, 2020 meeting will be “virtual” and details will be published this summer .

Please contact Juliana L’Heureux at Juliana .LHeureux@anamaine .org if you are interested in learning more and would like to become involved in ANA-Maine advocacy .

Representative Anne Perry (left) of Calais is a retired nurse practitioner and Representative

Michele Myer of Eliot is a registered nurse. They were legislators who sat on the Health

and Human Services Committee in the Maine Legislature's 129th session.

Dr. Nirav Shah is director of the Maine Center for Disease Control and Prevention and Patricia

Endsley is the president of the Maine Association of School Nurses and she is the school nurse

in Wells, Maine. They were recognized for their public health leadership during the January 23,

2020 Nurse Advocacy Day in the Maine State House Hall of Flags.

Page 4 ANA Maine Journal August, September, October 2020

Juliana L’Heureux

This summer's edition is going out at a time when our universities and colleges are facing multiple challenges, the kind that could not have been foreseen, even a year ago .

I reached out to the Maine universities and college presidents to obtain their published statements in opposition to racism . I selected the statements from the institutions where there are nursing curricula in their academic programs . I received the statements that were published either on websites or from their letters, sent to the academic communities, and collated them into the attached article . I have also shared the book cover from "How to be an Anti-racist," as referenced by Dr . Glenn Cummings in his statement to USM . In fact, USM Provost Uzzi personally gave me and others at USM a copy of the book and I have been reading it .

Academic Leaders Publish Statements in Response to Racism

Maine Universities and Colleges Presidents’ Messages to End Bigotry and Racism

This series of academic letters about opposition to racism were published by Maine’s universities and college presidents . They were selected for reprint in this article from the academic institutions where nursing degrees and advanced practice programs are included in the curricula . Our appreciation is extended to all academic leaders who published similar statements to voice a collective voice against racism . If there are other letters, please make us aware of them and we will print them in subsequent publications and on line .

Following are the statements from the nursing programs’ academic leaders:The University of Maine and University of Maine at Machias, joins

with millions of people across the globe to decry the violent and needless death of George Floyd at the hands of rogue police officers in Minneapolis earlier this week . As a community our anguish is palpable . This act of violence must rally us to continue our fight to eliminate racism, inequality and violence in our society . We are defined by our humanity, and the actions of the perpetrators were unnecessary, unacceptable and abhorrent . Bigotry, out of control power, and cruelty are vile reminders of why we must continue to work together as antiracists and as a community where inclusivity and respect define us .

We send our condolences and hopes for justice to George Floyd’s family and friends . This heinous act reminds us, once again, that as a community our efforts to push back the darkness of inequality and hate must continue .

Joan Ferrini-Mundy, Ph .D ., President University of MaineRobert Q . Dana, Ph .D ., Vice President for Student Life and Inclusive Excellence, and Dean of Students May 31, 2020

University of Southern Maine Stand Against Racism - “Our Ultimate Call is to Love,” Dr. Glenn Cummings

Last week our nation received an abhorrent reminder that racism is far more than a societal ill, soon to be cured . Racism lies deeply embedded in every corner of the American landscape . And it is often lethal .

Violent injustice has permeated our history . Now, however, the portal of technology brings millions of Americans to the recorded killing of George Floyd being suffocated in the custody of four Minneapolis police officers who ignored his desperate pleas for mercy . He joins a four-hundred-year column of black victims of white brutality, most recently Breonna Taylor, Ahmaud Arbery and Tony McDade, among many .

This incident occurs against the backdrop of COVID-19, which has put on display how racism operates within the fiber of America . The virus disproportionately impacts communities of color as a direct result of carefully-crafted racial policies in housing, healthcare and employment .

As a university, USM stands against these injustices . We make a collective and individual call for accountability and justice . Today, we bear witness to the precarity of black lives, both at the hands of individuals, and at the hands of our systems and policies . Today, we are angry, disgusted and saddened . Today, we stand in solidarity with all those calling for an end to this legacy of racial violence . We remember that our ultimate calling is love .

But dismantling this legacy requires more than somber reflection . It requires action . So USM will take two immediate actions:

1 . USM will require all university police personnel, as well as all leadership staff (assistant directors and above) in Student Affairs, to complete the Racial Equity Institute program . REI will give our officers and staff tasked with overseeing disciplinary concerns a deeper understanding of the race-based structures of our history . To the credit of the leadership in both areas, full endorsement to this expectation came swiftly and supportively .

2 . USM will place philanthropic resources for Promise Scholars and Access to Education as one of our top priorities for fundraising in the campaign ahead . These scholarships highlight the potential for civic leadership in our student body and help erode the financial inequities that create barriers to higher education .

USM will also continue its Common Read Discussion Groups of Ibram Kendi's "How to be an Anti-Racist," and we call on every member of the USM Community to both read Kendi’s book and take part in a discussion group . Sign-up here to join a group: usm .maine .edu/read .

The USM leadership team has been its own “How to be an Anti-Racist” discussion group for months . We have finished the book and moved on to other materials, deepening our understanding of how oppression operates and perpetuates itself . We ask every department at USM to do the same .

Additionally, this summer 20 faculty and staff members will participate in USM's first ever Antiracist Institute . And I am pleased to announce that Dr . Kendi has rescheduled his postponed 2020 Commencement address and public lecture for May 2021 .

As Kendi states: “One either allows racial inequities to persevere, as a racist, or confronts racial inequities, as an anti-racist . There is no in-between safe space of ‘not racist' ."

USM stands with those committed to dismantling racial inequities . Racism not only limits — it also kills . To stand silent in this moment is to stand with racism . Please stand as an anti-racist with USM .

Thank you, Dr . Glenn CummingsPresident, University of Southern Maine June 1, 2020

To the University of Maine Augusta Community:During these troubling times for our state and nation, it is important to

remind everyone that University of Maine Augusta (UMA) is committed to ensuring an inclusive environment for all members of our community . This includes people of all abilities, races, ethnicities, genders, sexual orientations, nationalities, religious traditions, socioeconomic classes, and ages .

At the beginning of this year, a UMA team of faculty began developing a charge for a new Council on Diversity, Equity, and Inclusion that would help guide the UMA community to understand, address, and meet this commitment . This fall we will share this team’s work and establish the Council on Diversity, Equity, and Inclusion and will seek the participation of our faculty, staff, and students .

We are grateful to have the Holocaust and Human Rights Center as a member of our Augusta campus community and support its efforts to provide programming on the topics of diversity, equity, and inclusion . This week the HHRC will hold a panel discussion on how racism is shaping the pandemic response, structural inequality, and implicit and explicit bias on June 7, in a program titled, Racism is a Virus Too.

Our hearts go out to the family of George Floyd and the many other individuals who have lost family, friends, and loved ones simply because of the color of their skin . Much work remains to be done to address the systemic, disparate treatment and economic inequalities faced for generations by many in this country . Each of us must also continue our own journey of awareness on the issues of racism, diversity, equity, and inclusion .

Sincerely, Rebecca M . Wyke, Ed .D ., President University of Maine Augusta June 3, 2020

A message from Raymond J. Rice, University of Presque Isle President

August, September, October 2020 ANA Maine Journal Page 5

University of New England Dear UNE Community, Shock . Anger . Outrage . Despair . Like all of us in the Nor’easter community, I felt a

mix of raw emotions when I saw the video of George Floyd’s senseless killing in Minneapolis . These feelings were only intensified by coming on the heels of another video documenting the murder of yet another African American man, Ahmaud Arbery, while out on a run in a suburban Georgia neighborhood . Our hearts go out to the family and friends of Mr . Floyd and other victims of hate . We grieve with them, while realizing that we can’t possibly know the full depth of their personal pain . These events are stark reminders of the terrible legacy of our country’s original sin, and the unfinished work we face to ensure that our ideals are realized for all Americans . Right now, our community is spread across the nation, both because of the pandemic and because of our robust cohort of online learners . As a result, many of you may be close to the front lines of these acts of hate, and the protests that are happening in their wake . For those of us still in Maine, it might be tempting, especially for those of us who are white, to believe that such incidents could not happen here . It’s true that we are blessed to live in a peaceful place that tends not to experience the level of racial enmity and violence that is far too common in our country . But we are not immune . In the spring of 2018, two men violently attacked an African American man as he exited a convenience store in downtown Biddeford, only a few miles from our campus . The attackers, yelling racial slurs, didn’t even know the victim, and targeted him without provocation, merely because of the color of his skin . And that is just one extreme example of the very real racism that people of color still experience in our state . But the larger point is that George Floyd, Ahmaud Arbery, and the countless other victims of racial violence are our brothers and sisters . When any person falls victim to such hateful brutality, it harms us all . It tears at the very fabric of our humanity . These senseless killings must represent a call for action . We are called to redouble our struggle for justice . We must all contemplate ways we can work productively – both as individuals and collectively – to bring about the kind of world we want to leave for our children . This work is at the very core of our mission at UNE . We are united by our vision of making the world a better place, and we cannot improve the health of individuals and communities without a commitment to anti-racism . As a community of educators and learners, we have a responsibility to consistently examine our own prejudices and to evaluate our privilege and how we use it . We are obligated to condemn racism and other forms of intolerance, and to embrace our diverse humanity . As we contemplate these horrific events, let us each commit to individually doing the work to realize our collective vision .

Warmly, James D . Herbert,Ph .D ., President, University of New England, June 3, 2020

Dear members of the Saint Joseph’s College Community

In 1938, the African-American poet Langston Hughes wrote “Let America Be America Again .”

The poem beginsLet America be America again .Let it be the dream it used to be .Let it be the pioneer on the plainSeeking a home where he himself is free .(America never was America to me .)Let America be the dream the dreamers

dreamed—Let it be that great strong land of loveWhere never kings connive nor tyrants schemeThat any man be crushed by one above .(It never was America to me .)O, let my land be a land where LibertyIs crowned with no false patriotic wreath,But opportunity is real, and life is free,Equality is in the air we breathe .(There's never been equality for me,Nor freedom in this "homeland of the free .")

Hughes’ poem, using the language of his time not ours, nevertheless captures the emotion of marginalized people of all races who struggled to find a place in early 20th century America . 80 years after Hughes wrote “Let America Be America Again” we continue to see—daily—the images of pain and suffering his poem captured .

I am the poor white, fooled and pushed apart,I am the Negro bearing slavery's scars .I am the red man driven from the land,I am the immigrant clutching the hope I seek—And finding only the same old stupid planOf dog eat dog, of mighty crush the weak .

The killings of George Floyd, Ahmaud Arbery, and Breonna Taylor and the pain inflicted on peaceful protesters by those in positions of power who should know and be better and by those ready to profit from the suffering of others, are painful reminders of how far we are from the dream of this place .

The poem’s central plea is one we instantly recognize .

O, let America be America again—The land that never has been yet—And yet must be—the land where every man is

free .But the events of the past week have made one

thing abundantly clear .We can no longer simply ask to “let America be

America again .”

Each of us, and all of us, need to make America a place where every person is truly free .

By the end of the poem, Hughes’ speaker has come to this realization .

Sure, call me any ugly name you choose—The steel of freedom does not stain .From those who live like leeches on the people's

lives,We must take back our land again,America!

Inspired by the activism of the Sisters of Mercy and their commitment to the critical concern of anti-racism, informed by Pope Francis’ idea of “integral ecology,” and energized by the courage of peaceful protesters, Saint Joseph’s College is committed to this work—the work of building sustainable communities grounded in radical hospitality .

We cannot simply stand and watch in the hope that something else, someone else will let the dream of America be realized .

Through our actions—large and small, direct and indirect—we either advance the dream or we turn our back on it .

Wherever you are today, please join with Monks everywhere to make our communities safer places for all who continue to believe in the goodness and promise of people committed to integrity, motivated by respect, fueled by compassion, strengthened by faith, and striving for excellence and justice .

Sincerely, James S . Dlugos, Ph .D . President, Saint Joseph's College of Maine

June 3, 2020

Husson University: A message from President Clark responding to the recent acts of racial violence

At Husson, our founding values emphasize character and humility . This includes valuing diversity and respecting people whose life experiences and perspectives may be different than our own . We should take pride in and respect each other’s differences . Discrimination of any sort is unacceptable .

One of the fundamental bedrock tenets of morality is that we should treat others the way that we ourselves would want to be treated . As we watch and experience protests across our county in reaction to the death of George Floyd, I hope that as a campus community, we will take this opportunity to reflect on ways we can bring about a society that values fairness and justice for all . Beyond reflection, every person who is part of our university family has a responsibility to treat others in ways that affirm their dignity as human beings .

Even though our campus community is physically separated as a result of the coronavirus, I hope I can count on you to stand in solidarity with Husson University and all who work to make our country a more just and equitable society .

Robert A . Clark, Ph .D ., CFA, Husson University President, June 3, 2020

Husson University Post Script - In addition to this statement, when students and faculty return to the Husson University campus in the fall 2020, we will be working to deepen and develop our faculty’s understanding of issues raised by the Black Lives Matter movement . We will be reviewing our curriculum to make sure that it affirms the dignity of every human being with special attention paid to challenging racism and oppression . Our student life programs will focus on increasing cultural awareness and sensitivity among our student body, and we will be sponsoring a town hall where anyone can share their concerns about Husson University with our senior management team . Finally, to make sure we are getting feedback on a regular basis, we are forming a student advisory council comprised of students of color . These students will help the University better understand what we are doing well and where we can improve .

Dear Members of the University of Maine Fort Kent CommunityIt seems as though at every turn you are experiencing another challenge . First the disruption caused by a world-wide pandemic and then the senseless murder of George Floyd and

other innocents . We are heartbroken over these events and we cannot imagine how much they have hurt you .

UMFK has always been considered a safe-haven for students and employees: a space where we can come together and share ideas and dreams . We do not condone violence, and we recognize that it is our responsibility to support increased education about equality and about the disparity black Americans have historically experienced . We will continue to support our students and employees by fostering a safe, open, and inclusive environment for all .

We are proud of our students and employees who have taken part in peaceful protests and demonstrations . We are proud of our students and employees who have taken the time to educate themselves further on the racial disparities in our country . You represent the change this world needs to see! As we look to the future, I know we will emerge stronger and more unified .

I look forward to the future you are shaping- one of equality and inclusivity .Warmest regards, Tex Boggs, Ph .D ., Interim UMFK President, June 4, 2020

Page 6 ANA Maine Journal August, September, October 2020

Mary Crosby “This narrative is a well-intentioned attempt to provide hope and motivation

as patients and their caretakers endure the hardships associated with aggressive treatment,” Mary Crosby .

Sitting on a hard examination table in a cold office holding her flimsy hospital gown closed, the patient listened as her doctor offered two options: another 10 rounds of the same chemotherapy she had just completed or a stronger experimental chemo with a slightly higher possibility of shrinking her tumor, but accompanied by serious side effects .

Weak and emaciated, she thought about the previous year, her weekly trips to the hospital for blood work and treatment, debilitating nausea, vomiting and worsening pain, all with no progress in her battle against cancer . Was there a third

A Dance With Life - A Hospice Storyoption? What if she chose to stop treatment altogether? The doctor brushed this notion aside as “giving up the fight .” He encouraged her to go home and think seriously about her decision . So often the dialogue about terminal illness invokes the metaphorical language of a battle . The patient takes up the noble fight against a fierce enemy, such as cancer or Parkinson’s disease, and an army of friends and family join in the rallying cry of support for the brave warrior .

This narrative is a well-intentioned attempt to provide hope and motivation as patients and their caretakers endure the hardships associated with aggressive treatment . To be victorious is to be in remission, to prolong life, to defeat a prognosis . But the battle narrative can be a disservice . A battle means hunkering down and enduring debilitating side effects, prolonged hospitalizations and decreased participation in life events . The focus shifts from living to accruing days, placing distance between the diagnosis and some imagined end point . In our attempt to win ourselves more time, we sacrifice the quality of time we have left . And when we “fight” disease we leave ourselves only two possible outcomes – victory or defeat . Those of us working in the field of hospice often receive our patients at the end of their “fight” with terminal illness . They’ve lost hope in their ability to conquer disease .

Our goal is to redefine hope, not by treating the disease, but by treating the patient and their caregivers as a whole . Through physical, emotional and spiritual support, we pull people out of the dark trenches of battle and into the light of living, which includes the uniquely human ability to conceptualize and process death . And, by allowing patients the space for that process, hospice focuses on life: on spending time with family and friends, realizing values and priorities, and even pursuing projects that went neglected before diagnosis .

Not surprisingly, people with terminal illness who receive hospice care live longer than those who do not . But more importantly, they live better . An estimated 1 .5 million Americans receive hospice care annually . Care is individualized to meet the unique needs of every patient and their caregivers . Hospice professionals visit patients in their homes, in hospitals or in specialized facilities to deliver pain and symptom management, personal care, emotional support and other services, such as massage therapy . As hospice leaders, we help people reframe how they think about terminal illness . “Victory” can be as simple as feeling pain-free enough to take a walk on the beach or comfortable enough to enjoy dinner at a restaurant, a series of small steps that make up a life worth living . Hospice care frees people from the pressure of having to fight an unwinnable battle without feeling like they’ve lost .

We occupy a space in the health care system wherein people can talk about living with terminal illness not as a “fight” but as a dance, a beautiful performance orchestrated by the patient with support from their family, friends and a team of hospice professionals . Within this space, quality of life improves, patients find more physical and emotional comfort, and death becomes less about the fear of defeat and more about the peace of transcendence . Against the wishes of her doctor and members of her family, the patient chose the third option . She stopped treatment and elected to receive hospice care . Our team of experts had the honor of caring for her for the last year and a half of her life . During this time, she went to Broadway shows, enjoyed meals at restaurants with her friends, attended weekly Mass and even published a book of poetry . Her joy for living was contagious . It was not victory over death, but neither was it defeat . Because it was not a battle at all: It was a dance .

Mary Crosby is president and CEO of East End Hospice, a nonprofit hospice serving the North and South Forks of Long Island, New York, including the Hamptons .

This article is reprinted with permission from the author and it was originally published in Holy Cross Magazine, Fall 2019 .

NURSINGACCELERATED B.S.N.

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August, September, October 2020 ANA Maine Journal Page 7

Jeremy Howard research scientist at the University of San Francisco

This research review was published in The Conversation, an electronic public newsletter . “We believe in the free flow of information . Republish our articles for free, online or in print, under a Creative Commons license .”

Jeremy Howard is a research scientist at the University of San Francisco . In late March, 2020, he wrote about how he decided to use public mask-wearing as a case study to show his students how to combine and analyze diverse types of data and evidence .

It appeared that universal mask-wearing could be one of the most important tools in tackling the spread of COVID-19 . Yet the people around him weren’t wearing masks and health organizations in January 2020, in the U .S ., were not recommending their use .

Along with 18 other experts from a variety of disciplines, he participated in a review of the research on public mask-wearing as a tool to slow the spread SARS-CoV-2 . Their research is awaiting peer review at the Proceedings of the National Academy of Sciences .

On May 14, he was among 100 of the world’s top academics that released an open letter to all U .S . governors asking that “officials require cloth masks to be worn in all public places, such as stores, transportation systems, and public buildings .”

Currently, the U .S . Centers for Disease Control and Prevention recommends that everyone wears a mask – as do the governments covering 90% of the world’s population . So what is this evidence that has led myself and so many scientists to believe so strongly in masks?

The evidence that first convinced him was a laser light-scattering experiment . Researchers from the National Institutes of Health used lasers to illuminate and count how many droplets of saliva were flung into the air by a person talking with and without a face mask . The paper was recently published but a YouTube video showed the experiment in early March . The results are shockingly obvious in the video . When the researcher used a simple cloth face cover, nearly all the droplets were blocked .

This evidence is only relevant if COVID-19 is transmitted by droplets from a person’s mouth . It is . There are many documented super-spreading cases connected with activities – like singing in enclosed spaces – that create a lot of droplets .

The light-scattering experiment cannot see “micro-droplets” that are smaller than 5 microns and could contain some viral particles . But experts don’t think that these are responsible for much COVID-19 transmission .

While just how much of a role these small particles play in transmission remains to be seen, recent research suggests that cloth masks are also effective at reducing the spread of these smaller particles . In a paper that has not yet been peer-reviewed, researchers found that micro-droplets fell out of the air within 1 .5 meters of the person who was wearing a mask, versus 5 meters for those not wearing masks . When combined with social distancing, this suggests that masks can effectively reduce transmission via micro-droplets .

Another recent study showed that unfitted surgical masks were 100% effective in blocking seasonal coronavirus in droplets ejected during breathing .

If only people with symptoms infected others, then only people with symptoms would need to wear masks . But experts have shown that people without symptoms pose a risk of infecting others . In fact, four recent studies show that nearly half of patients are infected by people who do not themselves have symptoms .

This evidence seems to be clear and simple: COVID-19 is spread by droplets . A piece of cloth blocks those droplets and the virus contained in those droplets . People without symptoms who don’t even know they are sick are responsible for around half of the transmission of the virus .

We should all wear masks .Nevertheless, after going through all of this strong evidence in late March and

early April, he wondered why mask-wearing was controversial in the Western world . He suggested there were three key problems .The first was that most researchers were looking at the wrong question – how

well a mask protects the wearer from infection and not how well a mask prevents an infected person from spreading the virus . Masks function very differently as personal protective equipment (PPE) versus source control .

Masks are very good at blocking larger droplets and not nearly as good at blocking tiny particles . When a person expels droplets into the air, they quickly evaporate and shrink to become tiny airborne particles called droplet nuclei . These are extremely hard to remove from the air .

However, in the moist atmosphere between a person’s mouth and their mask, it takes nearly a hundred times as long for a droplet to evaporate and shrink into a droplet nuclei .

This means that nearly any kind of simple cloth mask is great for source control . The mask creates humidity, this humidity prevents virus-containing droplets from turning into droplet nuclei, and this allows the fabric of the mask to block the droplets .

Unfortunately, nearly all of the research that was available at the start of this pandemic focused on mask efficacy as Personal Protective Equipment, rather than as a prevention to halt the spread of the virus . This measure is very important for protecting health care workers, but does not capture their value as source control . In his research he developed the point of view that wearing masks are extremely effective at preventing coronavirus spread, as his review of the literature showed .

The second problem was that most medical researchers are used to judging interventions on the basis of randomized controlled trials . These are the foundation of evidence based medicine . However, it is impossible and unethical to test mask-wearing, hand-washing or social distancing during a pandemic .

Experts like Trisha Greenhalgh, the author of the best-selling textbook “How to Read a Paper: The Basics of Evidence Based Healthcare,” are now asking, “Is Covid-19 evidence-based medicine’s nemesis?” She and others are suggesting that when a simple experiment finds evidence to support an intervention and that intervention has a limited downside, policymakers should act before a randomized trial is done .

The third problem is that there is a shortage of medical masks around the world . Many policymakers were concerned that recommending face coverings for the public would lead to people hoarding medical masks . This led to seemingly contradictory guidance where the CDC said there was no reason for the public to wear masks but that masks needed to be saved for medical workers . The CDC has now clarified its stance and recommends the public use of homemade masks while saving higher-grade masks for medical professionals .

Results of mask-wearing: numerous studies suggest that if 80% of people would wear a mask in public, then COVID-19 transmission could be halted . Until a vaccine or a cure for COVID-19 is made available, the cloth face masks might be the most important tool we currently have to fight the pandemic .

Given all of the laboratory and epidemiological evidence, the low cost of wearing masks – which can be made at home with no tools – and the potential to slow COVID-19 transmission with wide scale use, policymakers should ensure that everyone wears a mask in public .

Masks Help to Stop the Spread of the Coronavirus

Page 8 ANA Maine Journal August, September, October 2020

SILVER SPRING, MD – Issued on June 1, 2020, the following statement is attributable to the American Nurses Association (ANA) President Ernest J . Grant, PhD, RN, FAAN:

“As a nation, we have witnessed yet again an act of incomprehensible racism and police brutality, leading to the death of an unarmed black man, George Floyd . This follows other recent unjustified killings of black men and women, such as Ahmaud Arbery and Breonna Taylor to name a few .

Protests have erupted in cities across the country and the world in response to a persistent pattern of racism in our society that creates an environment where such killings occur . Justice is slow and actions to ensure real change are lacking .

As a black man and registered nurse, I am appalled by senseless acts of violence, injustice, and systemic racism and discrimination . Even I have not been exempt from negative experiences with racism and discrimination . The Code of Ethics obligates nurses to

American Nurses Association President Condemns Racism, Brutality and Senseless Violence against Black

Communitiesbe allies and to advocate and speak up against racism, discrimination and injustice . This is non-negotiable .

Racism is a longstanding public health crisis that impacts both mental and physical health . The COVID-19 pandemic has exacerbated this crisis and added to the stress in the black community, which is experiencing higher rates of infection and deaths .

At this critical time in our nation, nurses have a responsibility to use our voices to call for change . To remain silent is to be complicit . I call on you to educate yourself and then use your trusted voice and influence to educate others about the systemic injustices that have caused the riots and protests being covered in the news . The pursuit of justice requires us all to listen and engage in dialogue with others . Leaders must come together at the local, state, and national level and commit to sustainable efforts to address racism and discrimination, police brutality, and basic human rights . We must hold ourselves and our leaders accountable to committing to reforms and action .

I have a deeper moral vision for society, one in which we have a true awareness about the inequities in our country which remain the most important moral challenge of the 21st century . This pivotal moment calls for each of us to ask ourselves which side of history we want to be on and the legacy we will pass on to future generations .”

The American Nurses Association (ANA) is the premier organization representing the interests of the nation's 4 million registered nurses . ANA advances the nursing profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health care issues that affect nurses and the public . ANA is at the forefront of improving the quality of health care for all . For more information, visit www .nursingworld .org .

Sigma Theta Tau statement about

diversity and inclusion

Sigma NewsDiversity of membership is what makes any

profession stronger and nursing is no exception . Since 1922, the Sigma Theta Tau International Honor Society of Nursing (Sigma) has embodied the attributes of our founders: love, courage and honor . We pride ourselves on being a diverse, inclusive global organization that does not discriminate, and we firmly believe diversity in our membership makes us stronger . Although we are a politically neutral organization, we take seriously our responsibility of ensuring a welcoming and respectful environment for our members worldwide .

Sigma remains committed to the value and active engagement of a global community of nurses . We represent fairness, equality, inclusivity, and respect by the very nature of our core tenets and are against any form of discrimination . We will continue to welcome and celebrate our members’ rich diversity as we always have .

Sigma will remain a voice within the US and world in support of our core values, including diversity and inclusiveness . We will continue to work collaboratively with members from all our global regions to fulfill our mission of developing nurse leaders anywhere to improve healthcare everywhere .

About Sigma Theta Tau International chapters in Maine are Kappa Zeta-at-Large and Omicron Xi at-Large . The Honor Society of Nursing, Sigma Theta Tau International (STTI) is a nonprofit organization whose mission is advancing world health and celebrating nursing excellence in scholarship, leadership, and service . Information about STTI can be found online at www .nursingsociety .org

Catherine Snow, ANA-Maine President

In response to Governor Mills' mandate and the State of Maine CDC recommendations to stop the spread of the coronavirus, ANA-Maine will not hold its annual in-person business meeting in Freeport this year .

The annual business meeting, including the announcement of scholarship recipients and new ANA-Maine board Directors and Officers, will be a virtual event . More information will be shared on our website www .anamaine .org in the coming weeks .

ANA-Maine Annual Business Meeting

Going Virtual in September 2020

**VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE

The ballot to elect the 2020-2021 ANA-Maine board of directors will be live on August 17 . All ANA-Maine members will receive an email with the link to access the electronic ballot and

instructions on how to submit your vote . NOTE – Only active ANA-Maine members will be eligible to vote . If you are not currently a member

but want the opportunity to vote, there’s still time to join! Visit www .anamaine .org and click on ‘Become a Member .’

**VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE** VOTE

Vote For Your New ANA-Maine Board Beginning 8/17/20

August, September, October 2020 ANA Maine Journal Page 9

Reprint permission from author: Jennifer A. Klimek Yingling, Utica College

AbstractIn this article, classic grounded theory captures the

processes of 12 women who had completed initial treatment for breast cancer . The qualitative data analysis reveals the basic social process of negotiating emotional order that describe how breast cancer survivors perceive their illness and decide to take action . From the data, five stages of the process of negotiating emotional order emerge: 1) Losing Life Order, 2) Assisted Life Order, 3) Transforming 4) Accepting, and 5) Creating Emotional Order . This study may help healthcare providers who care for breast cancer survivors understand the depth of perpetual emotional impact that breast cancer survivors endure . This study will potentially serve as a path for future research and aid in the understanding of the

Negotiating Emotional Order: A Grounded Theory of Breast Cancer Survivors

psychological impact that breast cancer has upon survivors .

Keywords: breast cancer, survivor, chemotherapy, emotional order

What Sparked This ResearchI cared for a patient who I had gotten to know as

her child often visited the emergency department due to hemophilia . She was a pleasure to work with, strong, level headed, and upbeat . On this particular day she was the patient . Her complaint was simple: a cough and she clearly wasn’t herself emotionally . I was surprised to discover, when I took her past medical history, that she was a breast cancer survivor . After I discussed her chest x-ray results I sensed she was still upset and filled with uncertainty . Then the lightbulb went on . I asked her directly if she was

concerned if the cancer was recurring . She said yes and her tears flowed . I do believe if I had not dug a little deeper into her emotional state she would have left the emergency department with much of the same emotional duress that she initially had . This interaction sparked my research as it was clear that breast cancer survivors endure a process after treatment ends . For these survivors the treatment is over but the emotional aspect of breast cancer is not . It also became evident to me that health care providers need to know more about this process in order to be able to treat patients holistically .

Negotiating Emotional Order: A Grounded Theory of Breast Cancer Survivors

Breast cancer is the most prevalent cancer found in women worldwide (American Cancer Society [ACS], 2016; Ferlay et al ., 2104) . In the United States, it is

Negotiating Emotional Order...continued on page 10

Page 10 ANA Maine Journal August, September, October 2020

estimated that 3 .5 million women have been diagnosed with breast cancer; 245,000 will be newly diagnosed; and, approximately 40,000 women will succumb to breast cancer annually (ACS, 2016; Breastcancer .org, 2016) . Early detection and improved treatment is credited to the rising population of women who are breast cancer survivors (Howlader et al ., 2015; McCloskey, Lee, & Steinburg, 2011) . Concerns about the psychosocial ramifications of chronic illness have a long history . The Institute of Medicine (2009), American Cancer Society (2015), and the American Society of Clinical Oncology (2015) resonate concern about psychosocial hindrances regarding cancer patients, citing them as a critical area needing improvement within the nation’s health care system .

The literature suggests breast cancer survivors endure psychological stressors after the completion of treatment including the following: loneliness (Marroquin, Czamanski-Cohen, Weihs, & Stanton, 2016; Rosedale, 2009), anxiety and depression (Walker, Szanton, & Wenzel, 2015), uncertainty (Dawson, Madsen, & Dains, 2016; Mishel et al ., 2005), and fear of recurrence (McGinty, Small, Laronga, & Jacobsen, 2016) . The phenomenon of breast cancer survivorship has been identified with qualitative methods, yet is lacking explanatory theory (Allen, Savadatti & Levy, 2009; Pelusi, 1997) . Qualitative analysis uses inductive rather than deductive investigation of a clinical phenomenon for capturing themes and patterns within subjective perceptions to generate an interpretive account to inform clinical understanding . Inductive methods are used by the researchers to discover and generate theory (Artinian, Giske, & Cone, 2009; Glaser, 2008) . Therefore, grounded theory was chosen to study the process of survivorship in women who have completed treatment for breast cancer .

MethodA Glaserian grounded theory design was chosen to

explore the process of transition survivorship in women who have completed treatment for breast cancer . Grounded theory allows the researcher to explore a phenomenon and build theory from concepts going through processes and transitions (Glaser & Strauss, 1967; Glaser, 2008) . The ACS defines cancer survivor as “anyone with a history of cancer, from the time of diagnosis through the remainder of their life” (ACS, 2016, p . 3) . This definition was used for inclusion criteria for this project . Prior to commencement of the research, approval from the university’s institutional review board was secured . A purposive sample was sought and participants were self-identified breast cancer survivors in a suburban community in Northeast United States . A presentation was made at a local

breast cancer survivorship group . Flyers were posted in community centers, libraries, and public places including areas that reach numerous individuals . Based on these recruitment efforts, 12 women were interviewed during a four-month period .

Data Collection

All participants received written and verbal information about the study and gave informed consent . Data were collected by completing the following: a demographic data form, approximately one-hour individual in-depth interviews, observational notes, and field notes . All of the data was handled in a confidential manner . Each interview session lasted approximately one hour in length . Broad open-ended questions were used to stimulate discussion of thoughts and feelings about extended survivorship . Focused questions and prompts were used to elicit more specific information from participants about their actions to attain and maintain psychosocial health after the completion of breast cancer treatment . The focus questions also elicited information about processes used to modify and maneuver through adversities after completion of treatment . Each participant was asked to describe situations when she knew something had changed in her health and psychosocial status after the completion of treatment for breast cancer . Participants were asked to answer the questions until they felt they had no information to add to the topic .

Data Analysis Data analysis took a Glaserian approach in which

data collection, analysis, and memoing were ongoing and concurrent throughout the research . Each interview was digitally taped and transcribed . Atlas ti software was used as a depository to code, store, and memo during analysis . Data was coded line by line to fracture the data into nouns formed from a verb or gerund . The interviews were re-coded on three different occasions . After the initial interview was coded, the second interview was coded in a similar fashion and the data were examined for common constructs that were clustered . Subsequent interviews were open-coded and compared with ideas and relationships described in the researcher’s memos . As the categories unfolded, some categories were re-coded or combined with other categories . At the conclusion of the last interview, all codes were sorted to certify fit . Once a core variable or category was identified, coding became selective . The researcher continued the interviews and coding until saturation of the core variable was achieved . On saturation, theoretical coding was used to intersect categories within the data . Exploration of the literature for substantive codes that were significant was conducted each day . Extensive memo taking was used via manual notes and also as freehand drawn visuals created by the researcher to capture the researcher’s mind set .

TrustworthinessFor the purpose of this paper, a conglomerate

of trustworthiness criteria grounded from the recommendations of Glaser (1978, 1998, 2001) was employed . The researcher who conducted this study had scant exposure to extended breast cancer survivors in her personal and professional realm . Techniques to establish credibility included prolonged engagement and peer debriefing . Theoretical sampling and constant comparison took place when data, analytic categories,

interpretations, and conclusions were discussed and tested with study participants throughout the interview process . Prolonged engagement developed rapport and participant trust . To address transferability, the following groups of data was included in an audit trail: 1) raw data, 2) data reduction and analysis notes, data reconstruction and synthesis products, 3) process notes, 4) materials related to intentions and dispositions, and 5) preliminary development information . The researcher kept a reflexive journal to record methodological decisions and the rationale for the decisions, the planning and management of the study, and reflection upon the researcher’s own principles, feelings, and interests . Lastly, external audits were conducted by several researchers not involved with the research process on several occasions .

The Theory of Negotiating Emotional OrderThe main concern of the women is the struggle for

emotional order . The meaning inherent in the basic social process of Negotiating Emotional Order is that women who have been diagnosed with breast cancer strive for emotional order by negotiating control of the negative feeling of threats to their mortality and to live their daily lives . The process described in the theory of Negotiating Emotional Order changes as the situation of the breast cancer survivors’ changes . As time passes, the women move from discovering an abnormality to a time after treatment ends . This process is dynamic and perpetual in nature because the threat of cancer recurrence remains until the end of the breast cancer survivor’s life . For some women, negotiating emotional order is achieved even when the cancer recurs or metastasizes .

The participants’ actions and decisions illuminate the perpetual struggle to negotiate emotional order . For some, order is compartmentalizing negative thoughts and emotions that they could not control . For others, they accept the fact that they cannot control cancer but project order onto other aspects of their lives . The struggle for emotional order is present from the time the survivor found the abnormality into long-term survivorship and at times is cyclic . Five stages of the process of negotiating emotional order emerges from the data: 1) Losing Life Order, 2) Assisted Life Order, 3) Transforming, 4) Accepting, and 5) Creating Emotional Order .

Losing Life OrderDuring this time period, the realization of the threat

of breast cancer disrupts emotional order with intense fear and uncertainty of the future . The breast cancer survivor often makes decisions and acts on her instincts to placate the immediacy that she feels prior to starting treatment, often seeks information from the Internet, popular literature, media and from others who have experienced breast cancer . Unfortunately, their need for immediacy is often not met by the health care community, so they take matters into their own hands and act .

Many of the participants voice that this time period is difficult, as they have multifaceted family roles as wives, mothers, and children of parents of their own causing additional emotional turmoil . The participants continue or attempt to continue with their family roles by working, caring for children, and maintaining their households . The breast cancer survivors voice that they don’t have time to let cancer get in the way emotionally as they are too busy with family and work responsibilities . The participants speak of emotional duress when they see their families react to their illness and chose to protect their families by concealing their emotions . One participant talked about why she concealed her emotions: “The emotional impact it had on my family was horrible . . .I felt like I had to be strong for them . . .I would not show any emotions about being sick .”

Losing order encompasses two properties of disorder: losing emotional order and losing physical order . Upon discovering an abnormality, and then confirming breast cancer, the breast cancer survivors report loss of control of their bodies, which causes emotional duress . This stage marked the survivors’ first sense that cancer cannot be controlled . Loss of emotional order is represented by feelings of sadness, anger, immediacy, loneliness, fear, and uncertainty . This stage is hallmarked by emotional chaos and decision making . Approaches the women use in this stage

Negotiating Emotional Order...continued from page 9

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August, September, October 2020 ANA Maine Journal Page 11

are: taking matters into own hands and concealing to maintain family order .

Assisted Life OrderSurprisingly, although treatment is a physically

draining endeavor, the breast cancer survivors voice that it is a time of respite when they focus on physical well-being rather than the emotional disruption that is occurring . During this phase, the women are often consumed with treatments of surgery, chemotherapy, and/or radiation . The participants state they feel proactive and protected while under the frequent care of health care providers . This participant’s narrative exemplifies the feeling of being assisted emotionally and physically by health care providers: “While you’re getting chemotherapy, you think you’re doing something to kill off any additional cancer that the surgery didn’t get . You have certain protection .”

The breast cancer survivors verbalize feeling lonely, despite having much social and family support, and purposely seek out other women who endured breast cancer for emotional support . Breast cancer survivors seek emotional support from formal and informal support persons . The participants also discuss a phenomenon where other breast cancer survivors would approach them after hearing about their diagnosis and come to their assistance to provide support . The importance of this camaraderie is evident in this narrative: “I didn’t know people that have been through this…people came out of the woodwork . People that I had known that I didn’t know that had cancer who shared their stories with me .” Some of the breast cancer survivors express the need to have a connection with someone who has experienced breast cancer . Some women seek formal support groups for this need and continue to use them after treatment is completed .

The second stage of negotiating emotional order is assisted life order that occurs when the breast cancer survivor enters treatment and focuses all of her energy into physical well-being . At the same time, survivors entrust their life order into the hands of health care providers and rely on social support to carry them through the time that they are in treatment . During this time, the breast cancer survivor keeps physically and emotionally occupied with the routine of appointments and treatment . During this time, the women feel treatment is a sanctuary and they express that during this time they feel lonely in their current experience . During the second period, they engage with others with formal training or personal experience with breast cancer to establish emotional order .

TransformingAt this stage of the process, the breast cancer

survivors report a cutting point or a crossroads and make a change in thought process . They are autonomously responsible for their physical and emotional well-being . This autonomy is a sharp contrast to their behavior while in treatment, where they live day to day and do not think about the future . Once treatments end, survivors must take the wheel and navigate into their life and the future . It does appear that this cutting point is an emotionally charged timeframe: the temporary sanctuary of treatment ends and many survivors feel the need to take subjective responsibility of their emotional order . The survivors speak about the need to reach inward to claim emotional order to live their lives beyond breast cancer .

During this stage, the threat changes from the fear of the diagnosis of cancer to the fear of cancer . The fear of cancer can be recurrence of breast cancer, occurrence of a new cancer, and/or cancer metastasis . The process of beginning to move on from the emotional effects of the diagnosis of breast cancer begins shortly after the end of treatment . Fear is initially intense then becomes manageable over time for many . Several women note the recurrent fear abates somewhat after the first year and even more after five years . The fear of recurrence also can return many years after the completion of treatment . This dread is especially true if the breast cancer survivor discovers new symptoms or abnormalities that lead her to believe the cancer has returned . Often waiting for the results of diagnostics causes extreme anxiety and fear of recurrence .

The interviewed participants ranged from three months to twenty-four years post treatment . Despite

the variation of time since the ending of treatment, all of the participants discussed levels of fear of recurrence . Often, the fear of recurrence affects their daily lives initially until they set cancer apart from living their present life . Several of the participants state it is not so much an inherent process rather an active decision to take control of their feelings of fear and move onward . In this stage, the turning point is the active decision to leave breast cancer in the past and focus on the present and future . Another participant, who is thirteen years post treatment, discussed this decision: “I told myself, I have to make a move here . You can curl up in a ball and die or I can move on . I started moving on .”

When the breast cancer survivors leave treatment, they are at a crossroad in which feelings of loss and confusion are produced . After adjuvant treatment ends, the breast cancer survivors must remap their lives and begin to strive for a new normalcy in their lives . The threat at this stage changes from the diagnosis of cancer and is replaced with the fear of recurrence . The breast cancer survivors often revisit their own mortality during this time and these feelings can cause loss of emotional order . During this time the breast cancer survivor transforms, remapping their life course and also moving on from fear .

Accepting Uncertainty of the future also causes emotional

distress for breast cancer survivors . The reality that none can control their own mortality or cancer, is an aspect of the emotional trajectory that the breast cancer survivors struggle with initially . Once breast cancer survivors make this realization, they can then subjectively gain order of their emotions . This action is autonomous as no one else but the breast cancer survivor can complete this task . One participant spoke about this decision: “There are things that I can change and there are things that I am powerless over . It’s distinguishing and I do have control over what I’m thinking .”

Although the breast cancer survivor attempts to control her emotions, she often will come to the realization that she can keep her emotions in order rather than control them so that she can move on in her life and get serenity with the past diagnosis of breast cancer . Several of the participants state the turning point occurs when they realize they cannot control cancer or their feelings, and thus accept order versus control . As the threat of recurrence is no longer an issue, they accept their mortality and are living in the present day . A participant reflection on this concept: “We’ll all go some day . It’s just my time might come sooner than expected . A part of life .”

Feelings of emotional loss of control can be triggered by reminders after treatment ends . Reminders include physical reminders, body image reminders, diagnostics, and society cancer awareness . Although gaining realization of their own mortality, living with reminders forces the breast cancer survivors to cope on a daily basis with the fear of recurrence as they are reminded by physical and cognitive aftermath of breast cancer . Additionally, diagnostics and health care visits can elicit feelings of fear . Breast cancer survivors also voice that breast cancer or cancer awareness activities in the community and media also trigger feelings of fear . The impact of reminders is showcased by one participant’s remarks: “I worry about it all the time .

Every ache and pain I have . When my bones hurt I wonder if it is bone cancer . Every time I have to have a mammogram, I pray it’s not there .”

Creating Emotional OrderInherently, human beings have emotions . One of

these emotions is fear in response to a threat . As the threat of cancer recurrence has a perpetual quality in women who have been diagnosed with breast cancer, the emotional aspect of cancer recurrence is long-standing . Since she cannot fully control her emotions, the breast cancer survivor will compartmentalize negative feelings of uncertainty and fear to achieve emotional order . To protect themselves emotionally, several of the participants speak about triaging these emotions to the back of their heads and putting these feelings away . One participant illustrates this behavior: “It’s probably because I pushed it to the back of my head because I don’t want to deal with those emotions .”

Once the breast cancer survivor accepts the fact that there are aspects of her life she can control and there are aspects over which she has no power, she will begin to create emotional order . Having control over actions and or parts of her life allows the breast cancer survivor to have emotional order . During times of emotional distress, they also increase their attempts to distract themselves from their emotions . This increase in activity temporarily increase with times of stress . Often, after the breast cancer survivor feels well, she redefines the actions in which she participates . Survivors express themselves by participating in activities that they enjoy or want to experience but did not have the courage to do so prior to diagnosis . Breast cancer survivors also talk about controlling their family roles and home environment . The breast cancer survivor might demonstrate control by creating a household routine or enumerating familial activities . Distracting self with other aspects of life also is a way that breast cancer survivors create emotional order . By immersing themselves back into their daily routines of work, marital, household, and family roles, survivors limit the amount of time they have available to think about the fear of recurrence, which is similar to using activity to occupy time during the assisted life order stage .

Social comparison through self-evaluations is another way that these participants achieve emotional order . Breast cancer survivors use social comparison as a method to create emotional order by viewing their experience as better than others who experienced poor outcomes . As a defense mechanism, if the breast cancer survivor views her experience as positive then she reaffirms she is a survivor . Social comparison is evident almost unanimously in the data . Participants speak often of reflecting on the experience they endured and feel lucky . While exploring this code the

Negotiating Emotional Order...continued on page 12

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researcher asked the participants what they meant by luck or being lucky . Consistently the participants talk about luck as comparing outcomes as better or worse . For example, when asked what she meant by having better luck, a participant replied: “Well I was thinking someone maybe had the same surgery as me, did better than me .” Here is an example of a breast cancer survivor socially comparing her experience as worse than another person’s experience .

In addition to evaluating the actual treatment outcomes and evaluating the way that they physically dealt with treatment, the breast cancer survivors also evaluate the entire experience of breast cancer by reflection . The ability to reflect onto the past experience to find benefits and assign positive outcomes related to the cancer allow the survivor to make sense of the experience and create emotional order . In many ways, the survivors feel everything that they endured was worth what they became . Many reflect back and feel they gained knowledge of self-meaning knowing their bodies and emotions and realized they have abilities to endure adversity that they did not know before the experience of breast cancer . The breast cancer survivors reflect back in awe of the emotional stamina that they had during adversity and were proud of their accomplishments . One participant states: “It is amazing . Yeah if someone had told me I could write a book, become a massage therapist and learn the body the way I have . I would have said no way .”

“I feel like I know these people . You have been through what they have been through .” This participant’s narrative sums up the transparent common bond the participants feel with other cancer survivors . To create emotional order, the breast cancer survivors help others as a way to help themselves emotionally . Planned helpfulness allows the breast cancer survivor to create emotional order by gaining satisfaction through assisting others . Often breast cancer survivors employ ambiguousness until they are ready to disclose their survivorship status . This opacity allows them to experience empowerment and also allows them life choices-a common theme throughout the interviews . Breast cancer survivors plan and decide how they would help others; many are grateful for the acquaintance disclosure and guidance they receive early in their disease trajectory and want to pay forward some type of comfort to others who are enduring cancer .

Once survivors accept the fact that they cannot control their mortality and cancer, the breast cancer survivor creates social order to protect herself emotionally . Breast cancer survivors are acutely aware that their actions do not guarantee that cancer will not return, but in this stage they want to maintain a status of being physically and emotionally healthy . One participant communicates: “What work do I need to do . I am a survivor and want to be a survivor for a long time .” Although reminders often trigger fear, the survivors often use methods to create emotional order, to find balance and not allow feelings of fear to overcome them . Breast cancer survivors protect themselves by controlling their actions, compartmentalizing negative feelings, using social comparison and/or engaging in planned helpfulness .

Creating Emotional Order allows breast cancer survivors to transcend the fear of recurrence by controlling their actions, compartmentalizing negative feelings, and using social comparison and planned helpfulness . Although they cannot control their emotions or control cancer, they can control the way they react to emotions and take control of their life actions . Many of the participants shelve their negative emotions in order not to let the psychological aspect of breast cancer interfere in their daily lives . The participants show evidence that the survivors can regress between stages of this theory, but after their initial passage through the stages progress forward quickly and resiliently .

LimitationsThere are several limitations in this research .

First, the researcher attempted to recruit a variety of participants from diverse social and demographic backgrounds through flyers posted in public places . Despite this attempt to obtain a diverse population, all the participants are White and hold high school education or equivalency and most of the sample had three or more years of college education . Most of the participants are married or partnered . Economic and insurance status information is not included in the demographic data . Expanding the demographic sample might have allowed modifiability of the theory to explore additional relationships between these variables and the process of survivorship .

Finally, grounded theory analyses are population specific . This research represents the primary step in theory development . The aim of grounded theory construction is to hone and develop a theory in the attempt to produce formal theory . Testing the applicability of this theory may be appropriate in other populations who face severe illnesses, for example

individuals as they face the aging process, individuals who are facing a terminal illness, veterans returning from war diagnosed with post-traumatic stress disorder, men facing prostate cancer, and/or women facing infertility .

DiscussionThe aim of this study is to contribute to the

knowledge of breast cancer survivorship . This research contributes to the literature as a lack of holistic research exists on the process of extended survivorship that involve the fragments of the process of survivorship . Breast cancer is a significant and prominent healthcare challenge for many women in the United States . Negotiating emotional order is identified as the core category allowing women to survive emotionally after completing treatment for breast cancer . Five stages were identified including the following: Losing Life Order, Assisted Life Order, Transforming, Accepting, and Creating Emotional Order . The grounded theory of negotiating order integrates and highlights the importance of recognizing emotional health in breast cancer survivors .

This research challenges a staple in cancer survivorship literature that is reported by Mullan (1985) in several ways . First, in the current study, breast cancer survivors described the process of survivorship beginning before diagnosis with the discovery of an abnormality . This variation in the genesis of process of survivorship is different from Mullan’s (1985) model in which the process of survivorship is said to begin with diagnosis . Second, a new stage that represented transitional survivorship or Stage III: Transforming is described in the current study as the period immediately following the completion of treatment . Third, Mullan (1985) described extended survivorship as ending once the survivor enters remission . Although most breast cancer survivors interviewed for this study entered remission, several experienced recurrences or metastatic breast cancer so Mullan’s model excluded the process that these individuals endured .

Lastly, in this study extended survivorship appeared to be a continuous state rather than a conduit to permanent survivorship as Mullan (1985) described in his model . Mullan (1985) stated permanent cancer survivorship begins once the person is considered cancer free and can successfully return to their normal physical and emotional abilities prior to the cancer diagnosis . The survivors in this study describe extended survivorship to have a perpetual nature rather than being permanently cured physically or emotionally . They also challenge the fact they would return to “normal .” One of the participants states, “It was a rough road . Trying to figure out who I was, where I belong . Because they say your life goes back to normal, there is no normalcy . I don’t feel I am normal today .” This idea is significant as many breast cancer survivors may feel the need to feel “normal” due to the extensive publication of Mullan’s (1985) model . The use of Mullan’s (1985) model by many credible cancer authorities may prove to be confusing and frustrating to breast cancer survivors who lack the feeling of normalcy after treatment is completed and into extended survivorship .

The theory of Negotiating Emotional Order supports several existing theories that describe how individuals handle severe illnesses beyond cancer . This work complements several authors who described survivorship beyond the biomedical model that

Negotiating Emotional Order...continued from page 11

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psychosocial and environmental factors influence (Collins, 1995; Festinger, 1954; Folkman & Greer, 2000; Taylor, 1983; Walker, Jackson, & Littlejohn, 2004) .

The construct of control can be found in the literature in multiple patient populations including breast cancer (Warren, 2010), cardiac disease (Svansdotti et al ., 2012), patients with obsessive compulsive disorder (Kang, Namkoong, Yoo, Jhung, & Kim, 2012), diabetes (Hughes, Berg, & Wiebe, 2012), and sexual assault (Frazier, Morlensen, & Steward, 2005) . In this study, loss of emotional control is important, as it serves as a catalyst shaping the decisions and actions of the participants . Additionally, controlling actions were used later by the participants as a means to cope, thus creating emotional order . This theme is analogous with Folkman’s (1984) description of control as dynamic coping mechanism with shifting appraisal as result of a stressful encounter or environment .

Benefit finding and planned helpfulness that are reported are consistent with Taylor’s (1983) proposed theory of cognitive adaptation in response to threatening events as both are displays of a search for meaning in the experience and attempts of mastery to restore self-esteem . It may also be noted that Taylor (1983) linked an individual’s sense of control to positive cognitive adaptation . Lastly, social

comparison is evident in this group . This observation echoes Festinger’s (1954) work hypothesizing that social comparison is done to promote self-normalcy . Social comparison in this population is a mechanism to negotiate emotional order by improving the survivors’ positive perception of their situation and is consistent with the work Collins (1995) reported .

Implications for PracticeThis research affords a glimpse into the experience

of survivorship from the perspective of women who have completed treatment for breast cancer and how they survived emotionally from the detection of an abnormality into extended survivorship . This work aids in the development of a broad understanding of the processes that individuals endure when faced with a serious health status alteration . This information might aid health care providers to understand the immediacy that breast cancer survivors experience during the disease trajectory and the concept that the fear of recurrence can last perpetually and be an issue that is important to survivors until the end of their lives .

A lesson that can be taken away from this work is that women are continuously attempting to create emotional order and this clearly indicates they need support to continue well after treatment ends . In terms of theory, the identification of the process used

by breast cancer survivors to negotiate emotional order may be helpful for health care providers who care for, educate, and design nursing interventions for this population . This study of survivorship after breast cancer establishes the beginning process of generating a formal grounded theory on survivorship that could, through further theoretical sampling, be extended beyond this patient population . Building on existing theory, this qualitative data analysis may help explain the mechanisms used by populations who have experienced a life-threatening illness personally or while supporting a loved one .

AcknowledgementsI would like to thank the breast cancer survivors

who shared their personal survivorship journey for this research . I also thank Dr . Elise Lev, Dr . Karen D’Alonzo, Dr . Claudia Beckman, Dr . Louise Dean Kelly and Naomi Tobes for their encouragement and invaluable contributions to this work .

Declaration of Conflicting Interests The author declares no potential conflicts of interest

with respect to the research, authorship and/or publication of this article .

Negotiating Emotional Order...continued on page 14

Page 14 ANA Maine Journal August, September, October 2020

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negotiating-emotional-order-a-grounded-theory-of-breast-cancer-survivors/

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August, September, October 2020 ANA Maine Journal Page 15

MeMbershiPFOR YOUR INFORMATION

Scholarship Opportunities – ANA-Maine is currently accepting scholarship applications from qualified nursing students . Visit our website at www .anamaine .org for more information and to apply . The application deadline is August 15 .

Annual Business Meeting – In response to Governor Mills' mandate and the State of Maine CDC recommendations to stop the spread of the coronavirus, ANA-Maine is planning a virtual session of our annual business meeting . This meeting will include announcement of scholarship recipients and new Directors and Officers . More details will be shared on our website in the coming weeks .

ANA-Maine Board of Directors Ballot – The electronic ballot to vote for the open seats on the ANA-Maine Board of Directors will be available on August 17 . ANA-Maine members will receive an email with the link to the ballot along with instructions to complete the voting process . Your vote counts! Please take a few minutes to submit your ballot .

Washington, D.C. – U .S . Senators Susan Collins and Angus King announced that the Maine Department of Health and Human Services (DHHS) has been awarded a total of $3,023,728 to help provide free immunizations to eligible low-income children throughout our state . This funding was awarded through the Centers for Disease Control and Prevention’s (CDC) Immunization and Vaccines for Children Program (VFC) .

The VFC program is a federally funded program that provides vaccines at no cost to children from low-income families . The program protects individuals and communities from vaccine-preventable diseases through provision of federal funds and contracts to purchase and distribute vaccines, vaccine preventable disease surveillance, provider and public education, and evaluation .