key: cord-1002663-3fyezbvl authors: Levarity, Breanne R. title: Health Disparity, Natural Disaster, and COVID-19: Perspectives From a Bahamian American Nurse date: 2021-10-18 journal: Holist Nurs Pract DOI: 10.1097/hnp.0000000000000478 sha: 7e49a4c296ff4cbabdb67d87bc933f7e650d7d28 doc_id: 1002663 cord_uid: 3fyezbvl Trauma clusters are formed when 2 or more disasters occur simultaneously and/or consecutively. These disasters have the propensity to potentiate health disparities. The purpose of this article is to share thoughts about critical caring theory and how the theory can inform holistic nursing action when health disparity amplifies trauma clustering. involved staying in what is left of your home, or in tents for those who completely lost their home, consistently washing hands in brackish water, and being told to buy essentials that were already scarce. When asked how they are doing, people say things like: It was comforting to see other countries helping us with recovery, but now that the whole world is in trouble, we cannot expect for the same. We were doing our best to quickly recover and now we are at a standstill. We don't know when we will recover from this and now, I don't know if we will ever recover from this. This is really rough. Important to this Dorian/COVID-19 trauma cluster is the added burden of health disparity. The purpose of this article is to share thoughts about critical caring theory and how the theory can create a lens for holistic nursing action when health disparity amplifies trauma clustering. A caring theory that addresses inequalities such as Falk-Rafael's critical caring theory can be used as an approach to guide nurses responding to overlapping trauma such as that occurring in the Bahamas. Falk-Rafael describes critical caring theory as a middle-range theory grounded in Watson's caring science, Nightingale's writings, and feminist, critical social theories. 1 The theory highlights the importance of "health nursing" and addresses the social and economic conditions that contribute to poor health and support systems that benefit some members of society at the expense of others. Emancipation from these systems is the goal of critical caring theory. Critical caring theory is depicted as the roots, trunk, and branches of a tree. Each part of the tree is a representation of the theory dimensions. Roots include Watson's Human Caring Science, Nightingale's work, and feminist, critical social theories. Preparation of the self; developing and maintaining a helpingtrusting relationship; and being/knowing/choosing are concepts integral to the trunk. 1 The tree branches identify nursing actions that rest on being rooted in the discipline of nursing and supported through the holistic "trunk" concepts. Applying critical caring theory to inform holistic care when trauma clustering is amplified by health disparity requires attention to the "trunk" concepts of critical caring theory. Each trunk concept will be briefly described and related to the idea of trauma clustering for populations living with health disparities, specifically the Bahamian people. The preparation of self as nurse includes self-care activities such as centering, becoming aware of personal biases, or acknowledging power structures related to a given situation. Researchers have found that nurses felt mentally and emotionally unprepared when asked to participate in trauma-inducing disaster events 2 such as those experienced by the Bahamian people. This is because they are often worried that the situation may be more than what they can manage, or they are concerned about personal harm or harm to their families' well-being. Holistic nursing practice recommends reflective journaling as a self-care tool that can foster self-awareness. 3 Reflective writing provides purposeful engagement inclusive of thoughtful self-observation to discern thoughts and feelings about practice situations. Studies reveal that journal-guided reflection allows for self-evaluation as one explores relationships with others, recognizes mistakes, and processes difficult situations, identifying gaps in knowledge such as those that may create the context for a disaster event. 4 Awareness of the social, political, and economic structures that influence actions is an important element of self-preparations. 1 The Commonwealth of the Bahamas is an archipelago consisting of 700 islands and cays where almost 90% of the population is Afro-Caribbean heritage. 5 The Bahamas is a highly developed, developing country with laudable advances in finance, health, and education. 6 However, according to a 2019 Latin American Economic Report, the Bahamas has the second highest economic and social inequality in the Caribbean. 7 The country gained its independence in 1973 from the United Kingdom and continues to operate under a parliamentary government inherited from the British. During this time, the Bahamas experienced a severe income inequality gap that was closing until 1990 when the gap started to increase again. 8 This suggests a divide between the rich and poor, alluding to a power structure that contributes to social injustice. Health care services are provided through 3 hospitals, 28 health centers, and 68 clinics that serve the entire population of approximately 388 000. Most health care structures are in the capital of Nassau, New Providence, where 70% of the population of the Bahamas lives. 9 Fortunately, the capital was minimally affected by Dorian's wrath and the island and its health care systems were able to accommodate the needs of evacuees from affected islands. 10 While reflecting on this information, the vulnerability of the system creeps into thought. This centralized health care system and the people it serves are subject to substantial strain when trauma multiplies. Furthermore, distance from centralized services directly impacts recovery ability. 11 Tourism and international financial services are the main economic industries in the Bahamas. However, the delivery of health care relies on a combination of the government-assigned budget, direct out-of-pocket payment, and private health insurance payment. Currently, a National Health Insurance (NHI) program is in the works to reduce out-of-pocket cost and increase equitable access to health care, 12 but trauma clustering has significantly disrupted progress as the overall health care infrastructure of the affected islands has been severely damaged. Knowing the sociopolitical community context is critical to self-preparation for holistic nursing practice, and critical caring theory guides the nurse to come to know the community from a sociopolitical perspective. Although this sort of knowledge may call the nurse to access obscure references, such as local newspapers, knowledge of context adds depth to understanding, especially in times when a population is managing multiple traumas simultaneously. Falk-Rafael suggests that it is imperative that nurses demonstrate their concern for the comfort and safety of the community. 1 Helping-trusting relationships do not come easily, but a community must know that their nurses care about their comfort and safety. One important component of this relationship is making sure that we know the community's health priorities so that we can give voice to their needs and engage with the community to address needs. To know health priorities, we must participate in meaningful communication that allows the community to know there are nurses who are willing and ready to listen and to help. Developing trust is the foundation to beginning and maintaining a relationship, 13 and there are many opportunities to cultivate trust through seemingly small gestures. Traumatic events are known to have physical, emotional, spiritual, and psychological effects. 14 Holistic nursing practice is predicated on supporting psychological well-being and maintaining peace and harmony in interpersonal relationships. 15 Therefore, it is imperative that the holistic nurse know how to establish a comfortable and relaxed environment. The Bahamas is a country of hospitality, dedicated to welcoming others. For instance, it is a deeply rooted Bahamian value that a genuine smile goes a long way. A smile exudes openness and friendliness that facilitates a point of connection and a caring occasion, which Watson describes as a moment of interaction between the nurse and another. 16 For the Bahamian people, a heartfelt smile is a trust-building interaction that can establish a foundation of connection. Any point of connection provides an opportunity for communication. When this connection is formed, it is essential to bring an open mind and a nonjudgmental spirit. This entails attending to and being respectful of the communities' values and beliefs. A slight misinterpreted facial expression or remark can disrupt the connection and hinder the caring moment. One approach for the holistic nurse is to engage in story-sharing, thoughtfully listening to what matters most and attending to the meaning ascribed to the challenge being described. 17 Falk-Rafael refers to attending to the client's psychological well-being by disclosing a personal story in common with the client, thus strengthening the connection between the nurse and the client. 1 In a qualitative study conducted by Falk-Rafael and Betker, 13 nurses alluded to being fully present by engaging in activities or attending events with members of the community as a path to a point of connection. Meaningful follow-ups are a good way to remain in contact, to grow trust, and to continue the relationship-building process. A follow-up call or a kind word shows concern and lets the individuals know they are not forgotten. Moreover, keeping promises is also important as this is a definitive action that deepens trust while developing relationships. In summary, trusting relationships, which are critical to holistic nursing practice with vulnerable communities, happen through open-minded, nonjudgmental engagement where the nurse connects with another through gestures such as a heartfelt smile, story-sharing, or following up on promises made. While these nursing approaches seem simplistic, they are central to holistic nursing practice. Therefore, they warrant consideration and, given their emergence from nursing theory, they become part of a bigger disciplinary context. In some ways, this third concept is woven into the first two. To prepare oneself for practice guided by critical caring theory and work to develop and maintain trusting community relationships, the holistic nurse has attended to being, knowing, and choosing. Each of these conceptual threads will be considered as substantive content infusing the trunk with strength. • Being: From the theoretical perspective, being involves building relationships and being engaged with family, groups, or communities. 1, 13 Being occurs as the nurse prepares self to bring an open mind and nonjudgmental stance that builds trust. • Knowing: Critical caring theory describes five ways of knowing: aesthetic, personal, ethical, emancipatory, and empirical knowing. b Aesthetic knowing is a process of acknowledging the uniqueness and honoring the lived experience of each individual and situation. 1 In this case, the nurse recognizes the occurrence of trauma clusters and how they can affect the lives of those who experience them. In work with the Bahamian community, the holistic nurse will grasp the whole of the picture with an appreciation of cultural values; listen to stories; and share personal stories that are relevant and offer a smile that comes from the heart. b Personal knowing involves being open and attending to spiritual and existential dimensions of self. 1 Awareness is one of the foundational components to addressing personal values and biases that may interfere with informed decision-making. It is important to be open, nonjudgmental, and respectful to the community, their culture, and their ways of making meaning of their life circumstances. It is a matter of reflecting on community-guided solutions to eliminate the health care disparities that are exacerbated in the face of trauma clustering. b Ethical knowing is identifying disparities and recognizing that such inequalities and social injustices impair human dignity. 1 This involves targeting and tending to the basic, physical, and psychosocial needs of a community, including those most vulnerable. It is important to tend to the needs of everyone no matter their status or nationality. Disaster has the propensity to expose those who are more and less fortunate than others. It also threatens the privacy of individuals who live in fear of being discovered, like undocumented individuals who tend to hide during recovery in fear of deportation. 18 It is important to recognize that differentiation is a nonfactor when it comes to the health and the needs of everyone no matter their status or nationality. b Emancipatory knowing denotes a way of choosing and involves political advocacy in relation to public policy that can prevent or mitigate disparities and social injustice. 1 It is about empowering the community to bring about effective change. Emancipatory knowing helps nurses understand the barriers that create unfair and unjust social conditions and surfaces the meaning of being excluded from health care decisions. 19 Engaging in dialogue, and listening intently to those who are frequently marginalized, is an approach to understanding the existing barriers and social injustices that undermine health and human dignity. These actions can create a voice for the people to uncover the factors that inhibit social justice and human rights and provide a platform to address the issues revealed. b Empirical knowing is having a sound knowledge base specific to the community and understanding that the negative impact from traumatic events are chronic stressors that can exacerbate health disparities. 1 There are many public health concerns following traumatic events. Common infectious diseases and conditions, such as influenza and other respiratory ailments caused from mold, pose a threat after hurricane impact. Psychological stressors are also a concern as long-term postdisaster effects. As it is important to provide health care services to those in need, it is equally important to take preventive measures that can mitigate these conditions. This requires a holistic approach that focuses on advocacy and the integration of health into disaster risk-reduction strategies from local to national levels and making sure appropriate resources are funneled to disaster response and reconstruction plans. 20 The goal is to provide services that are designed to meet the environmental needs of a community by increasing resilience among the vulnerable population. • Choosing: Choosing refers to ethical knowing intertwined with all the ways of knowing. It is the act of being involved in a caring-trusting relationship where the primary concern is to protect and enhance human dignity. 1 Choosing involves knowing and deciding the right thing to do within that relationship. As nurses attend to the voice of the people who experience social injustice, it is important to use the community's words as evidence for change in policy decision making. When Lilly and John first heard about COVID-19, they gazed in disbelief upon the foundation where their home once stood prior to Hurricane Dorian. After the hurricane, the elderly couple lived in 3 different homes with family or friends before they decided to dwell in a tent on their property. After Dorian, they braved long lines in the hot sun to obtain drinking water provided by disaster care teams. They endured the crowds as donated materials slowly became available to recreate "home." Things were looking better as they moved forward toward the beginning of 2020, but COVID-19 became a reality a few months later and their forward movement was abruptly challenged along with their hope. The couple grew weary with less outside support due to travel restrictions and social distancing orders. The fear of contracting the disease was a persistent threat as they stood among the crowd to obtain basic needs. Rebuilding "home" came to a halt with global shutdown and import restrictions. Despite how much the situation of back-to-back trauma increased their vulnerability, Lilly and John continued to do what they could to survive. It seems paradoxical for a nation to experience a divide after 2 traumatic situations were experienced together: a divide that can be seen and felt by others but uncovered by the voices of those who notice. Before that divide approaches criticality, the holistic nurse will listen to answer the calls of those voices and work with intentionality to bring togetherness and rebuild a better, safer, and healthier nation. Preparation is key to addressing the unequal social consequences of trauma clusters. As disasters continue to strike, we must remember the future depends on what we do now. This means we must listen to the personal stories of those who experience social injustice and take action to rectify them. 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