The power of wholeness, consciousness, and caring a dialogue on nursing science, art, and healing

Adolescent Relatedness Through the Lens of Unitary Caring Theory

Caring as a central focus within nursing has evolved into a relational ontology to guide practice and enhance well-being. Caring praxis has the potential to address the complexities of adolescent development and to allow for authentic engagement, breaking down the barriers of resistance to care. It is clear from the alarming statistics related to the prevalence of anxiety and depression in adolescents that teens are in distress. The authors in this article examine the construct of relatedness in adolescence through the lens of the theory of unitary caring and propose a trans-theoretical transdisciplinary model of relatedness that informs adolescent practice.

Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care

In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.

A Unitary Theory of Healing Through Touch

Touch has been linked empirically to healing outcomes; therefore, developing theories about the dynamics between touch and healing is important for nursing. A practice-based theory is described within a Unitary Science perspective emerging from the findings of a qualitative descriptive study of the experiences of persons with advanced cancer receiving touch (massage and simple touch) during hospice care. Seventeen participants were interviewed. Through content analysis and retroductive constructivist theory development, healing through touch was described as a dynamic process cocreated by healer and healee, characterized by the simultaneous activities of sensing , reflecting , and connecting . Interpretation of findings from a unitary lens led to an overarching theme of touch as sanctuary and explication of theoretical alignment with the concepts of wholeness, awareness, and presence.

Unitary Appreciative Nursing Praxis

The purposes of this article encompass describing the development of unitary appreciative nursing praxis since the conception of a unitary pattern-based nursing practice over 30 years ago; explicating unitary appreciative nursing praxis in its current state; and clarifying the elements and dimensions of a unitary appreciative nursing praxis model. The body of this work is linked to a greater call for nursing care that transcends the fragmentation and medicalization of the human experience and advocates for nursing that liberates rather than manipulates those who are most vulnerable. Further exploration of praxiological knowing and refinement in conceptual-theoretical development is advocated.

Translating Authentic Nursing Knowledge From One Era to Another

As time passes, concepts change. The risk to nursing theories is that concepts can shift so far away from a theorist's originally intended meaning that future scholars might misunderstand or misuse what will become historically time-bound theories. To preserve authentic nursing knowledge, the process of conceptual matching and translation is proposed. Two thought experiments are used to demonstrate conceptual translation.

Unitary Caring Science: A Hermeneutic-Phenomenological Research Method

All phenomenological research, including descriptive phenomenological methods, are theory based. The knowledge in a discipline is built using discipline-specific methods. The purpose of this article is to develop and describe the processes of a mode of inquiry specific to caring in nursing theories housed within the unitary caring paradigm. Morgan's practical framework examining ontological-epistemological-methodological linkages was used to develop the unitary-caring hermeneutic phenomenological research method The method is specific to conducting hermeneutic phenomenological research within Watson's unitary caring science and Smith's theory of unitary caring. The method includes a process of linking and interpreting themes generated from the textual analysis of participant descriptions of the caring phenomena to concepts in the specific unitary caring theory that informs the researcher's a priori theoretical perspective to develop a theoretical understanding of the experience and contribute to the development of unitary caring nursing science.

Revisiting 'Discipline' in Relation to Caring Science as Sacred Science: Revisiting Discipline of Nursing

The purpose of this manuscript is to invite a revisiting of the concept of the "discipline" of Nursing, with attention to the spiritual consciousness of "Nurse" within the sacred concept of self-caring and caring-healing consciousness. The notion of including the spiritual, evolving consciousness of "Nurse," in harmony with evolution of Professional Nursing, is congruent with a mature disciplinary matrix of caring science as sacred science. This congruence between Nurse/Nursing contributes to the evolution of Nursing, Holistic Practices and Era III unitary transformative disciplinary thinking.

Increasing the capacity to provide compassionate care by expanding knowledge of caring science practices at a pediatric hospital

BACKGROUND

The emotional aspects of patient care affect care givers' capacity to remain present, safe and caring. As demands increase and capacity decreases care providers are at risk for compassion fatigue (CF).

LOCAL PROBLEM

Our organization treats children with complicated diagnoses. Nurses carry a heavy emotional burden due to prolonged exposure to suffering with chronically ill children, ethical dilemmas, and an onus to also care for the parents.

METHODS

Our program highlights theory guided practices that honor the complexities of caring for others and creates opportunity for the care giver to slow down and prioritize how they care for themselves.

INTERVENTIONS

Caritas Circles, a small group intervention program, was developed to offer a deeper exploration of Jean Watson's Caring Sciences practice and theory using intentional practices to pause, be present and find peace in the midst of caring for sick children.

RESULTS

Quantitative and qualitative measures show improvement in care providers' ability to prioritize their own needs as they care for others. Care providers noted the need to have organizational support for resiliency, a connection to purpose as a care provider, and opportunity to let go of the emotional residue found in their role.

CONCLUSIONS

Organizations can no longer afford to ignore the emotional labor that care givers experience. This program highlights the need for hospitals to prioritize this type of experiential intervention and offer time during work hours where providers are honored and cared for, so they can continue to care for patients and families.

Spiritual Knowing: Another Pattern of Knowing in the Discipline

Fundamental patterns of knowing in nursing have historically served to clarify the substance and structure of the discipline, significantly contributing to nursing's body of knowledge. In this article, we continue the scholarly conversation on patterns of knowing in nursing by advancing spiritual knowing as a pattern of knowing that helps advance nursing's agenda toward universal well-being and critical during this time toward interdisciplinarity. Implications for nursing are explored in relation to enduring and new questions that require our attention related to human beings, their environments, and healing.

Brainwave Self-Regulation During Bispectral IndexTM Neurofeedback in Trauma Center Nurses and Physicians After Receiving Mindfulness Instructions

Fifty-seven level I trauma center nurses/physicians participated in a 4-day intervention to learn relaxed alertness using mindfulness-based instructions and EEG neurofeedback. Neurofeedback was provided by a Bispectral Index^TM (BIS) system that continuously displays a BIS value (0-100) on the monitor screen. Reductions in the BIS value indicate that power in a high-frequency band (30-47 Hz) is decreased and power in an intermediate band (11-20 Hz) is increased. A wellbeing tool with four positive affect and seven negative affect items based on a 5-category Likert scale was used. The wellbeing score is the sum of the positive affect items (positive affect score) and the reverse-scored negative affect items (non-stress score). Of functional concern were four negative affect items rated as moderately, quite a bit, or extremely in a large percent. Of greater concern were all four positive affect items rated as very slightly or none at all, a little, or moderately in over half of the participants. Mean and nadir BIS values were markedly decreased during neurofeedback when compared to baseline values. Post-session relaxation scores were higher than pre-session relaxation scores. Post-session relaxation scores had an inverse relationship with mean and nadir BIS values. Mean and nadir BIS values were inversely associated with NFB cognitive states (i.e., widening the visual field, decreasing effort, attention to space, and relaxed alertness). For all participants, the wellbeing score was higher on day 4 than on day 1. Participants had a higher wellbeing score on day 4 than a larger group of nurses/physicians who did not participate in the BIS neurofeedback trial. Eighty percent of participants demonstrated an improvement in the positive affect or non-stress score on day 4, when compared to day 1; the wellbeing, non-stress, and positive affect scores were substantially higher on day 4 than on day 1. Additionally, for that 80% of participants, the improvements in wellbeing and non-stress were associated with reductions in day 3 BIS values. These findings indicate that trauma center nurses/physicians participating in an EEG neurofeedback trial with mindfulness instructions had improvements in wellbeing. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03152331. Registered May 15, 2017.

The Medicalization of Nursing: The Loss of a Discipline's Unique Identity

The authors propose that the evolution of the role development for generalist and advanced practice nursing is increasingly at odds with the contemporary scholarship of the discipline and ultimately betrays the unique identity and autonomy of the nursing profession. The development of the evidence-based practice movement in medicine and nursing is explored as the predominant theoretical framework guiding nursing practice. Professional challenges and recommendations to reclaim the unique nature of nursing are discussed with attention to the implications for the educator, clinician, and scholar.

Perspectives on the Unitary Transformative Person-Environment-Health Process for the Knowledge Base of Nursing

Nursing knowledge development continues to face significant challenges, as there is not yet widespread acceptance of the important role of nursing theory in research, education, and professional practice. The purpose of this article is to describe perspectives on person, environment, health from different levels of knowledge development for the discipline of nursing. The authors recommend continued discourse among nurse scholars to advance the discipline of nursing globally.

Regenerating Nursing's Disciplinary Perspective

As we approach the 50th anniversary of the first national symposium on nursing theory development, the need to clarify nursing's disciplinary perspective is just as relevant as it was 50 years ago. The purpose of this article is to regenerate the disciplinary perspective by analyzing the literature on the focus of the discipline of nursing, synthesizing the themes and suggesting areas of knowledge development for the discipline, and imagining ways to move forward in claiming, clarifying, and strengthening the discipline. The 4 themes identified were human wholeness, health/healing/well-being, human-environment-health relationship, and caring. Nine areas of inquiry generated from the disciplinary perspective were suggested.

Nursing perspectives on Integral Theory in nursing practice and education: An interpretive descriptive study

While for decades nursing has advocated for theory-informed practice, more recent attention has tended to focus on mid-range theory rather than the earlier focus on developing grand theory to encompass all of nursing practice. However, there has been continued interest in the holistic nursing community on grand theory and, in particular, on Integral Theory. Although Integral Theory's four-quadrant (AQAL) perspective is familiar in nursing, little is known about how it is being used by nurses in direct practice. The purpose of this interpretive descriptive study was to provide a practice-based perspective on Ken Wilber's Integral Theory in professional nursing practice. The following research question was investigated: How does Integral Theory assist nurses in describing and understanding their professional work? Nurses participating in this study used Integral Theory as a map or heuristic that gave structure to an inquiry process in professional nursing practice and in nursing education in a manner that was holonic, multiperspectival, and self-reflective. Challenges constraining nurses' use of Integral Theory included its intricacy, as well as contextual factors in practice environments. Implications for nursing practice and education for the use of Integral Theory's meta-framework are described.

Learning receptive awareness via neurofeedback in stressed healthcare providers: a prospective pilot investigation

Objective

Because physicians and nurses are commonly stressed, Bispectral Index™ (BIS) neurofeedback, following trainer instructions, was used to learn to lower the electroencephalography-derived BIS value, indicating that a state of receptive awareness (relaxed alertness) had been achieved.

Results

Ten physicians/nurses participated in 21 learning days with 9 undergoing ≤ 3 days. The BIS-nadir for the 21 days was decreased (88.7) compared to baseline (97.0; p < 0.01). From 21 wellbeing surveys, moderately-to-extremely rated stress responses were a feeling of irritation 38.1%; nervousness 14.3%; over-reacting 28.6%; tension 66.7%; being overwhelmed 38.1%; being drained 38.1%; and people being too demanding 52.4% (57.1% had ≥ 2 stress indicators). Quite a bit-to-extremely rated positive-affect responses were restful sleep 28.6%; energetic 0%; and alert 47.6% (90.5% had ≥ 2 positive-affect responses rated as slightly-to-moderately). For 1 subject who underwent 4 learning days, mean BIS was lower on day 4 (95.1) than on day 1 (96.8; p < 0.01). The wellbeing score increased 23.3% on day 4 (37) compared to day 1 (30). Changes in BIS values provide evidence that brainwave self-regulation can be learned and may manifest with wellbeing. These findings suggest that stress and impairments in positive-affect are common in physicians/nurses.

Trial Registration ClinicalTrials.gov NCT03152331. Registered May 15, 2017

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3756-0) contains supplementary material, which is available to authorized users.

Quantum Caring Leadership: Integrating Quantum Leadership With Caring Science

The authors of this article integrate two historically parallel yet disparate fields of nursing, caring science theory and nursing quantum leadership science. Through a nursing, discipline-specific unitary paradigm lens, intersecting principles of caring science and quantum leadership science are uncovered. The result is a model for unitary, discipline-specific, nursing healthcare leadership: Quantum Caring Healthcare Leadership. Ontological congruence is uncovered among the philosophical-ethical-theoretical principles of caring science and the unifying disciplinary structural concepts from quantum leadership. The result is a model for discipline-specific, healthcare leadership. This convergence is potentially theory-generating for both unitary science and healthcare leadership. In this model, both quantum leadership and caring science are transformed and metamorphosed into a new unitary, discipline-specific entity to guide further advancement of knowledge, theory, and discipline-specific healthcare leadership and practice.

At the intersection of self and not-self: finding the locus of 'self' in autoimmunity

Individuals with chronic autoimmune disease experience a sense of vulnerability. In part, this relates to the struggle for finding the meaning of the illness. The consequent existential distress may manifest in an unseated sense of personhood. Insight into the mechanism of this state of powerlessness and of perceived loss of agency is central to establishing a supportive clinician-patient relationship. This present exposition underscores the concept of autoimmunity as one that represents a demarcation in the psyche: one that is not just a threat to our sense of self-hood but also to our humanity. Autoimmunity exposes the challenge imposed on the relating of the self to one's own self and hence is an ontological challenge. The breach of the boundary between self and not-self that is caused by the autoimmune process culminates in feelings of alienation.

Cross-cultural adaptation and validation of the Chinese Comfort, Afford, Respect, and Expect scale of caring nurse-patient interaction competence

AIMS AND OBJECTIVES

To investigate the construct validity and reliability of the Chinese Comfort, Afford, Respect, and Expect scale, which can be used to determine clinical nurses' competence. The results can also serve to promote nursing competence and improve patient satisfaction.

BACKGROUND

Nurse-patient interaction is critical for improving nursing care quality. However, to date, no relevant validated instrument has been proposed for assessing caring nurse-patient interaction competence in clinical practice. This study adapted and validated the Chinese version of the caring nurse-patient interaction scale.

DESIGN

A cross-cultural adaptation and validation study.

METHODS

A psychometric analysis of the four major constructs of the Chinese Comfort, Afford, Respect, and Expect scale was conducted on a sample of 356 nurses from a medical centre in China. Item analysis and exploratory factor analysis were adopted to extract the main components, both the internal consistency and correlation coefficients were used to examine reliability and a confirmatory factor analysis was adopted to verify the construct validity.

RESULTS

The goodness-of-fit results of the model were strong. The standardised factor loadings of the Chinese Comfort, Afford, Respect, and Expect scale ranged from 0.73-0.95, indicating that the validity and reliability of this instrument were favourable. Moreover, the 12 extracted items explained 95.9% of the measured content of the Chinese Comfort, Afford, Respect, and Expect scale.

CONCLUSIONS

The results serve as empirical evidence regarding the validity and reliability of the Chinese Comfort, Afford, Respect, and Expect scale.

RELEVANCE TO CLINICAL PRACTICE

Hospital nurses increasingly demand help from patients and their family members in identifying health problems and assisting with medical decision-making. Therefore, enhancing nurses' competence in nurse-patient interactions is crucial for nursing and hospital managers to improve nursing care quality. The Chinese caring nurse-patient interaction scale can serve as an effective tool for nursing and hospital managers to evaluate the caring nurse-patient interaction confidence of nurses and improve inpatient satisfaction and quality of care.

What End-of-Life Care Needs Now: An Emerging Praxis of the Sacred and Subtle

Conscious Dying Institute is paving a new path in the realm of end of life care; one emerging from awareness, humanity, dignity, caring consciousness, and a return to the sacred. The purpose herein is to discuss the emerging theoretical perspectives of Conscious Dying Institute and to address their implications for broadening the scope of nursing and end of life care. In educating nurses about their own authentic selves, they return to their personal-professional purpose, awaken to a heightened awareness of needs for self and other, and influence a global shift in how end of life care is viewed, addressed, and delivered.

Caring Science: Transforming the Ethic of Caring-Healing Practice, Environment, and Culture within an Integrated Care Delivery System

In early 2010, leaders within Kaiser Permanente (KP) Northern California's Patient Care Services division embarked on a journey to embrace and embed core tenets of Caring Science into the practice, environment, and culture of the organization. Caring Science is based on the philosophy of Human Caring, a theory articulated by Jean Watson, PhD, RN, AHN-BC, FAAN, as a foundational covenant to guide nursing as a discipline and a profession. Since 2010, Caring Science has enabled KP Northern California to demonstrate its commitment to being an authentic person- and family-centric organization that promotes and advocates for total health. This commitment empowers KP caregivers to balance the art and science of clinical judgment by considering the needs of the whole person, honoring the unique perception of health and healing that each member or patient holds, and engaging with them to make decisions that nurture their well-being. The intent of this article is two-fold: 1) to provide context and background on how a professional practice framework was used to transform the ethic of caring-healing practice, environment, and culture across multiple hospitals within an integrated delivery system; and 2) to provide evidence on how integration of Caring Science across administrative, operational, and clinical areas appears to contribute to meaningful patient quality and health outcomes.

The Culture of Nurses in a Critical Care Unit

Critical care nurses have to adapt to a fast-paced and stressful environment by functioning within their own culture. The objective of this study was to explore and describe the culture of critical care nurses with the purpose of facilitating recognition of wholeness in critical care nurses. The study had a qualitative, exploratory, descriptive, and contextual design. The ethnographic study included data triangulation of field notes written during 12 months of ethnographic observations, 13 interviews from registered nurses, and three completed diaries. Coding and analysis of data revealed patterns of behavior and interaction. The culture of critical care nurses was identified through patterns of patient adoption, armor display, despondency because of the demands to adjust, sibling-like teamwork, and non-support from management and medical doctors. An understanding of the complexity of these patterns of behavior and interaction within the critical care nursing culture is essential for transformation in the practice of critical care nursing.

Intention in Nursing Practice

The purpose of this column is to explore the meaning of intention in nursing practice and distinguish it from the concept of intentionality. The notion that nurses engage in a purposeful act of setting intention prior to delivery of nursing care is introduced, and nursing implications for setting intention in practice is offered.

Spiritual Healing in the Aftermath of Childhood Maltreatment: Translating Men's Lived Experiences Utilizing Nursing Conceptual Models and Theory

This article presents an explication of spiritual healing situated within 3 nursing conceptual models (Neuman's systems model, Rogers' science of unitary human beings, and Roy's adaptation model) and 1 middle-range theory (Watson's theory of human caring), all of which include a focus on spirituality. These models and the theory are the vehicle for translation of themes of spiritual healing extracted from data provided by 30 adult male survivors of childhood maltreatment into nursing practice. This discipline-specific translational scholarship advances the profession of nursing.

"What's New about Freud?"

This is a response to a recent Issues in Mental Health Nursing editorial, titled "What's New about Freud?" This response aims to point out the relationship between Freud's psychoanalytic theory; Cowling, Smith, and Watson's (2008) nursing as unitary caring science praxis; and this author's future as a nurse researcher.

A hermeneutic phenomenological understanding of men's healing from childhood maltreatment

PURPOSE

To describe and interpret men's experience of healing from childhood maltreatment.

DESIGN

Hermeneutic phenomenological.

METHOD

In-depth interviews. Community-based purposive, maximum variation sampling approach. Recruitment occurred through posting flyers and advertisements. Verbatim data were analyzed and themes of the meaning of healing were identified.

FINDINGS

The meaning of healing was interpreted as "moving beyond suffering." Five themes were identified to capture the multidimensional nature of the phenomenon: (a) breaking through the masculine veneer, (b) finding meaning, (c) choosing to live well, (d) caring for the self using holistic healing methods, and (e) engaging in humanizing relationships.

CONCLUSIONS

Men who survived childhood maltreatment have needs to heal holistically mind, body, and spirit. Meeting their needs requires the provision of highly compassionate humanistic healing environments and healing-promotive nursing care.

The development of a mind-body-spirit certification program in nursing

Stress and anxiety experienced by patients particularly during hospitalization can be positively affected by an approach to care that emphasizes the uniqueness of the patient, the patient-provider relationship, and mind-body-spirit interventions. Although patients seek care that addresses stress and promotes relaxation within the hospital environment, there is evidence that there are lost opportunities aimed at addressing these concerns within the current health care environment. Nursing leadership at Massachusetts General Hospital and the Massachusetts General Hospital Institute of Health Professions recognized a need to address this gap in knowledge that exists in the practice setting. The purpose of this article is to describe and discuss the development and implementation of a program in mind-body-spirit nursing that was developed collaboratively between the Massachusetts General Hospital Institute of Health Professions and the Benson-Henry Institute of Mind Body Medicine at Massachusetts General Hospital.

Implications of holding ideas of evidence-based practice in nursing

The author of this paper examines emerging implications of holding ideas about evidence and evidence-based practice. Evidence has a very specific role in the delivery of safe clinical care, but it is creating a serious problematic for the practice of nursing. It is proposed that: evidence-based practice be re-situated or reconstructed as a collective and organizational responsibility and not the responsibility of individual nurses in practice; nurses re-focus on articulating a more ethical foundation for praxis, one that emerges from nursing philosophy and one that is co-constituted with persons/families/groups; and nurse leaders and educators establish teaching-learning and practice environments that enable a peer-to-peer process of critical review and curious inquiry of available evidence in the contexts of shared work.

The integrality of situated caring in nursing and the environment

Much emphasis has been placed on the importance of the environment as a determinant of health; however, little theoretical work in nursing has specifically articulated the importance of the nursing practice environment as a factor in patient outcomes. This work advances the unitary-transformative-caring paradigm by focusing on the concept of integrality and exploring the nursing meta-paradigm concepts (nursing, environment, human being, and health) through integral philosophical inquiry.

The Process of Healing Transformations

This article presents an emerging model of healing transformations to guide nurses in caring for those living with a chronic illness. A review of the literature on chronic illness and its relationship to lifestyle behavior change and transformative nursing practice is included. Derived from qualitative narratives, this work reports the clusters of phenomena within each phase of the model. The model emerged from data gathered during 36 in-depth interviews with 18 men and women living with chronic skin wounds. During two interviews, each participant shared important life stories and meaningful reflections on living with a chronic skin wound. Using the theory of health as expanding consciousness, analysis of each participant’s life story revealed individual life patterns and patterns across participants. These patterns were validated and reflected on with participants during the second interview. Synthesizing participants’ patterns of responses, the model of healing transformations emerged. Developed from clients’ experiences, the model of healing transformations provides rich insight into the nature of healing and the central role of the nurse practicing from a holistic perspective in this process. Nurses make a positive difference in the healing trajectory of those living with chronic illnesses such as chronic skin wounds.

The applied philosopher-scientist: Intersections among phenomenological research, nursing science, and theory as a basis for practice aimed at facilitating boys' healing from being bullied

This article uses an exemplar of phenomenological research of middle school boys, experiences of being bullied as applied philosophy and science to illuminate the intersection of the moral and scientific realms for theory-oriented research and practice. As a consequence, a clear foundation for advancing nursing science and envisioning innovative nursing practice with boys who experience being bullied is provided. Included is a weaving together of phenomenological perspective for research and practice, Roger's (nursing) Science of Unitary Human Beings (SUHB), and SUHB-derived middle range theories of self-transcendence and power.

Wholeness and life patterning: unitary foundations for a healing praxis

Unitary appreciative nursing is a healing praxis that is grounded in an evolving theory of wholeness and life patterning. The theory regards people as having the potential for transforming their health through participating knowingly in change focused on appreciating their wholeness and life patterning. In unitary appreciative nursing, people generate their own knowledge through appreciation and participation in the wholeness of life patterning. This knowledge facilitates and advances their flourishing and well-being in a healing praxis. The conceptual presuppositions and theoretical propositions that were generated or affirmed arising from a healing praxis are clarified and explicated with women who have experienced abuse and despair.