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Philanthropy and the Development of the Discipline

The current issue of ANS features two articles focused on the future of nursing: “Philanthropic Foundations’ Discourse and Nursing’s Future Part I: History and Agency” authored by Shawn M. Kneipp, PhD, ANP, APHN-BC; Denise J. Drevdahl, PhD, RN; and Mary K. Canales, PhD, RN and “Philanthropic Foundations’ Discourse and Nursing’s Future Part II: A Critical Discourse Analysis of RWJF Future of Nursing Initiatives” authored by Shawn M. Kneipp, PhD, ANP, APHN-BC; Mary K. Canales, PhD, RN; and Denise J. Drevdahl, PhD, RN. Both articles are available for download while they are featured. Here is a message that Dr. Kneipp provided about their work:

Shawn Kneipp

We began our initial Future of Nursing (FON) research efforts with a 2016 presentation at the American Public Health Association (APHA) annual meeting, using critical discourse analysis to examine public health nursing’s (PHN) representation within the FON and five-year evaluation reports, Robert Wood Johnson Foundation (RWJF) nursing campaigns, and previous Institute of Medicine Reports that informed the FON. As a research methodology, discourse analysis was selected because of its usefulness in examining dominant discourses that influence nursing practice. The analysis indicated that public health was often constructed within the context of individualized care. The public/community health workforce was narrowly defined with PHN presented primarily through case studies of individualized care while population health focused on clinical population categories. This first investigation raised more questions than answers, especially regarding processes surrounding the FON’s development and the RWJF’s unique role in the effort. We were therefore well positioned to continue this work when we learned a second report was being planned.

Mary Canales

As public health nurses, our initial reactions to the planning of a second FON report that would focus on nursing’s role in addressing the social determinants of health (SDoH) was met with both a sense of validation and apprehension. On the one hand, it was validating to have nurses practicing in specialties within the profession beyond those in PHN recognize the critical role that SDoH play in perpetuating health inequities. On the other hand, we were also apprehensive about the potential for SDoH being narrowly conceptualized – and what that might mean for the scope of interventions in which nurses would be asked to engage. Specifically, nursing’s history of directing practice, education, and research endeavors at the individual level has produced a profession that overwhelmingly, and willfully, dons blinders to understanding the socially-constructed systems that differentially drive the health of the individual patients for whom care is provided, and the communities to which they belong. 

At the time the second FON process was launched, I had just stepped into the role of Chair of the APHA’s Public Health Nursing (PHN) Section. Given that populations with the worst health outcomes due to SDoH have been a long-standing focus of PHN, it seemed reasonable to expect that public health nurses as a collective, through their member organizations, would figure prominently as presenters or panel participants both within the National Academies of Science, Engineering, and Medicine (NASEM) FON committee, and at the public forums held by the FON committee. I anecdotally observed the opposite, whereby several leaders of the APHA PHN Section in collaboration with other PHN-focused organizations (the Council of Public Health Nursing Organizations, among others) regularly attempted to engage in the process, but to little avail. Ultimately, APHA PHN leaders were able to provide two minutes of testimony at the public forums. However, nurses from acute care systems were routinely given much more ‘discursive space.’ The irony of this was not lost on us, and these observations led to the systematic, critical examination of the entirety of the process and the juxtaposition of nursing as a self-regulating profession through professional organizations, the discursive space afforded nursing representation during FON processes, and what this might mean for nursing’s collective agency.  

Nightingale and Seacole: A Rivalry?

The current featured ANS article is titled “Considering the ‘Bitter Rivalry’ Within the Context of European and Colonial History of Women Healers” by Adeline Falk-Rafael, PhD, RN, FAAN. This article will be available for download at no cost while it is featured – an apt resource for the week we celebrate “Nurses’ Week”! Here is a message that Dr. Falk-Rafael provided giving some background related to this work:

I first learned about Mary Seacole from a group of Caribbean nursing students who were in my leadership course in a BScN program at York University in Ontario, Canada. They presented Seacole to the class as a nursing leader whom they admired. A number of years later, I heard Mary Seacole spoken of in disparaging terms at a nursing meeting so turned to her autobiographical account of her life and work. Her book, I believe, reveals her to have been a woman healer, providing both caring and curing services to the people she served, like women had for centuries before her.

I have also long been an admirer of Florence Nightingale. I wrote this article to honour both these 19th century nurses in the hopes of lessening what has been called a “bitter rivalry” among today’s nurses. As I reflected on the current polarized views among nurses and others, I was reminded of the historical treatment of women healers, particularly by medicine, and wondered whether a similar dynamic might be at play within nursing with regard to Mary Seacole. I draw no generalized conclusions in that regard, believing the answer is likely complex and different for each, but hope the article leads readers to consider the bitter rivalry and draw their own individual conclusions.

Mitigating Implicit Bias and Optimizing Healthcare Outcomes

Featured currently in ANS is the article titled “The State of the Science of Nurses’ Implicit Bias: A Call to Go Beyond the Face of the Other and Revisit the Ethics of Belonging and Power” by Holly Wei, PhD, RN, CPN, NEA-BC, FAAN; Zula Price, PhD, FNP-BC, RN, CNE®cl, CD(DONA); Kara Evans, MSN, RN, NPD-BC, NEA-BC; Amanda Haberstroh, PhD, MLIS, AHIP; Vicki Hines-Martin, PhD, PMHCNS, RN, FAAN; Candace C. Harrington, PhD, DNP, MSN, APRN, AGPCNP-BC, CNE, FAAN. Note that Nursing Professional Development Credits are available for this article!. The article is available to download at no cost while it is featured!

Dr. Holly Wei, Professor, Associate Dean at East Tennessee State University College of Nursing, provided this background information about the work reported here:

The current focus on health equity and racial health disparities has brought implicit bias to the forefront of healthcare delivery. As the interests in health inequity and disparity grow, we want to examine the current research on nurses’ attitudes and behaviors. The broad and pervasive impacts of implicit bias have been examined across social and cultural institutions and systems, including healthcare, education, and housing. Because nurses spend the most time with patients, they play a significant role in patients’ and families’ healthcare experiences and outcomes.

This paper presents the current state of the science of nurses’ implicit bias and the primary sources of nurses’ implicit bias – race/ethnicity, sexuality, health conditions, age, mental health status, and substance use disorders. Nurses’ implicit bias is analyzed and described using Levinas’ face of the Other and ethics of belonging, Watson’s human caring and unitary caring science, and Chinn’s peace and power theory. This paper invites nurses to go beyond ‘the face of the Other’ and revisit the ethics of belonging and power. We hope these theories can provide a guideline and call for nurses to work together with organizational leadership and other healthcare disciplines and stakeholders to mitigate implicit bias and optimize healthcare outcomes.1,2


  1. Wei H. The development of an evidence-informed Convergent Care Theory: Working together to achieve optimal health outcomes. International journal of nursing sciences. 2022;9:11-25.
  2. Wei H, Horton-Deutsch S, Sigma Theta Tau International. Visionary Leadership in Healthcare: Excellence in Practice, Policy, and Ethics. Indianapolis, IN: Sigma Theta Tau International Honor Society of Nursing; 2022.
  3. Wei H, Price Z, Evans K, Haberstroh A, Hines-Martin V, Harrington CC. The State of the Science of Nurses’ Implicit Bias: A Call to Go Beyond the Face of the Other and Revisit the Ethics of Belonging and Power. Advances in nursing science. 2023. 10.1097/ANS.0000000000000470

“Informal Caregiver”

Featured currently in ANS is the article titled “‘Informal Caregiver’ in Nursing: An Evolutionary Concept Analysis”, authored by Aimee R. Castro, MSc(A), RN; Antonia Arnaert, PhD, RN; Karyn Moffatt, PhD; John Kildea, PhD; Vasiliki Bitzas, PhD, RN, and Argerie Tsimicalis, PhD, RN. Here, nurse and PhD candidate Castro reflects on how knowledge products – including this concept analysis – keep evolving, just as Rogers argues in her methodology.

Evolving the label of “informal” care towards a strengths-based connotation

Given that April 4th was National Caregiver Day in Canada, and President Biden also declared April as Care Workers Recognition Month, April seems like an appropriate time to further reflect on the spectrum, boundaries, and potential of informal and formal caregiving work.

I think it’s important for academics – professionals whose job it is to become leading experts in specific areas of knowledge – to take theoretical leaps. We should take big swings at ideas that maybe don’t always “reveal themselves in the data” but that, based on our years of rigorous study and lived experience, bubble to the surface of our minds as potential expansions of knowledge. These inspirations most often occur in collaboration with others, and they develop slowly over time.

I was privileged enough to have just such a theoretically enriching collaboration. This conversation expanded my ideas of how the concept of “informal caregiver” might evolve even further than we suggested in our original publication, which was based on data from 48 articles. Specifically, in this post, I argue that the “informal” label can and should be reclaimed as having its own strengths that complement weaknesses arising from “formal” labels and rules.

This reflection came about during a lunch and learn presentation of our concept analysis with the palliative care research network of Quebec (RQSPAL). The moderator, Psychology PhD candidate Émilie Cormier, pointed out that we had defined “informal” by what it was not – i.e., not paid, not trained, and not formally organized. But what if we had defined it by what it is – more individualized, and perhaps, creative, than formalized or standardized roles can be? She also shared how in her work with palliative care populations experiencing homelessness, she’s noticed that sometimes clients’ formal care providers (such as their social workers and nurses) become clients’ informal caregivers during end-of-life. Such formal roles may transition into more informal relationships over the years, because of these populations’ often more limited informal support networks.

We talked about the freedom and opportunities that can arise when we’re allowed to drop the boundaries and responsibilities created by our formal titles, and instead be informal creative collaborators in the life journeys of others. And we reflected on the moral distress that can also arise, when our clinician orders and institutional rules tie our hands, preventing us from truly supporting patients’ individual needs (homeless shelters that restrict certain prescriptions comes to mind; as do hospital units that don’t allow pets to be with patients at end-of-life, and standards that require waking patients up early to take their blood pressure or give insulin, but that ignore the consequences of sleep deprivation). There’s also something here to consider about how patient-centered care necessitates critical thinking and adaptations of formal rules. After all, no set of guidelines can ever fit every patient’s unique needs.

As Rogers’ methodology recognizes, no paper or concept is ever “finished”. So, having authored this initial concept analysis of “informal caregiver”, I’d like us to consider evolving it further: What if “informal” can be seen as a strength, not just less-than-or-equal-to “formal” work, but rather – offering creative opportunities to color outside the lines of formal guidelines? What if we need both, informal (freer and more creative) and formal (standards and structure) dimensions in all of our caring roles?

For further information on Aimee Castro’s research, as well as to connect, please follow her on Twitter (@AimeeRCastro) and visit: .

Nurses’ Health-Seeking Behaviors

The current featured article is titled “Factors Involved in Nurses’
Health-Seeking Behaviors: A Qualitative Study
” authored by Tahereh Najafi, PhD, MSc, BScN, RN; Forough Rafii, PhD, MSc, BScN, RN; and Sara Rahimi, BScN, MSN, RN. The article is available for free download while it is featured.. Sara Rahimi has provided this background information about the work reported here:

The motivation to do this research was created in my mind when I lost one of my experienced nurse friends due to metastatic pancreatic cancer shortly after a late diagnosis. He had been experiencing some clinical symptoms for a long time, but he often ignored them or sought treatment with the help of his knowledge. After this painful incident, as a nurse educator, I realized in my interactions with nurses that most of them spend all their time working at the patient’s bedside and taking care of them, and they do not care about their health as much as they should. So this question was formed in my mind, why do nurses delay seeking health even though they know the importance of early referral and timely treatment? What factors affect nurses’ health-seeking behavior (HSB)? Therefore, as a Ph.D. candidate in nursing, I decided to devote my dissertation to this topic. My review of the existing literature did not reveal much information on this topic, and I decided to explore these factors as a qualitative study by conducting unstructured interviews with nurses. Interviews with nurses allow a deep understanding of their experiences when facing health problems. By content analysis of the conducted interviews, five major concepts were developed: fear, trust/distrust, excuse, access, and support. This article sheds light on the barriers and facilitators of nurses’ HSB in a country like Iran that faces a shortage of nursing workforce and a high population of communicable and non-communicable diseases. Recognizing nurses’ HSB is important in ensuring the health of the nursing workforce and providing quality care to patients by a healthy workforce. This study helps health policymakers and managers to be aware of the barriers to nurses’ HSB and use this information to plan to improve health or change the poor health behaviors of nurses. Future research is needed on how nurses’ HSB can affect their behavior with patients and their care.

I would like to thank my dear mentors, Professor Forough Rafiei and Professor Tahereh Najafi who guided me in doing this research.

Unitary Appreciative Nursing Praxis

We are delighted to introduce a new feature in ANS called “Visions: Scholarship of Rogerian Nursing Science. This new section maintains the long tradition of the journal that has been produced by the Society for Rogerian Science since 1993. The first article in this section is titled “Unitary Appreciative Nursing Praxis” authored by W. Richard Cowling III, PhD, RN, AHN-BC, SGAHN, ANEF, FAAN, and it is available for no-cost download while it is featured. Here is a message from Dr. Cowling giving some background about his work, and what inspires him in his research and practice!

Last week at the Virtual Nursing Theory Week conference, during a dialogue, Jacqui Fawcett asked a question along the lines of “how do you know its nursing?”  This was in response to several participants describing what nursing was like for them and why they thought it was unique.  This made me think of my first encounters with nursing as a young 15-year-old boy who was doing volunteer work in a local hospital.  When I experienced what nurses were doing with and for patients, I fell in love with that work.  This was in 1964.  In 1979 I found myself in a course on nursing science taught by Martha Rogers, and it was then that for the first time I learned about a conceptual system that helped me make sense of nursing as I experienced and loved it.  Unitary appreciative nursing praxis (Cowling, 2023) is a culmination of the journey I have been on since those days in that class.  Unitary appreciative nursing is the embodiment of the science of unitary human beings as a praxis as I have grown to understand and know if from inquiry projects with women in despair who experienced various forms of abuse as children.  The article is an attempt to clarify the nature of a praxis of nursing that has the wholeness of human beings and their worlds as the central focus and uses patterning of that wholeness as a reference point for participating knowingly in illuminating and unlocking the emancipatory strivings of people in health care.  It offers a framework and process for the realization of ideals set forth in the Nursing Manifesto that evoked the creation of The last paragraph of the article expresses my deepest desires for nursing and its potential for the betterment of humankind which was the intent of the science of unitary human beings:

“If ever there was a need for innovative praxis models, it is now. The people, families, groups, and communities we care for need models that demonstrate how nurses can more effectively meet anger with compassion, loneliness with love, fragmentation with wholeness, and despair with aspiration. Unitary appreciative nursing is not a remedy for all of these, but it provides the possibility for nurses and people they care for to mutually engage in this journey borne out of fear and desperation in our daily personal and societal lives using appreciation as a means for recognizing and embracing the wholeness and oneness available to us all” (p. 115).

Increase, Protect, and Support: Illuminating the Contributions of African American Nurse Scientists

Featured currently in ANS is the article title “African American Perceptions ofParticipating in Health Research Despite Historical Mistrust” authored by Marie Campbell Statler, PhD, RN; Barbra Mann Wall, PhD, RN, FAAN; Jeanita W. Richardson, PhD; Randy A. Jones, PhD, RN, FAAN; and Susan Kools, PhD, RN, FAAN. Here Dr. Statler describes her program of research and the challenges faced by African American Nurse Scientists:

‘If I can help someone on the journey, then my living will not be in vain’: African American perceptions of participating in health research despite historical mistrust. 

My program of research centers around developing participant-centered and community-based research strategies that eradicates health disparities in the hardest hit African American communities. The intersectionality between my lived Black experience and my work as a clinical research nurse led to an interest in understanding the motivational behaviors and interactions of African Americans’ participation in health research despite a legacy of research mistreatment. As a former clinical nurse researcher, I understood research as a promising approach to advancing health and its connections to eliminating health disparities. Likewise, I understood the historical undertones that profoundly impacted the health of Black communities coupled with the shared cultural experiences with my Black patients. Therefore, with amazing coauthors and mentors Dr. Susan Kools, Dr. Barbra Mann Wall, Dr. Jeanita W. Richardson, Dr. Randy A. Jones and the gracious contributions of the African American Research Participants, this study was explored. 

Qualitative description methodological approach allowed for an essential historical exploration, contextualization of relationships, and rich descriptions of new areas that motivate African American Research Participants (AARP) to research participation through a critical lens (Crenshaw et al., 1995; Green & Thorogood, 2018; Neergaard, Olesen, Andersen & Sondergaard, 2009; Sandelowski, 2000). Research highlighting the barriers to research participation is abundant, therefore, as part of a larger study that included thirty-three research participants, this study captured the perceptions of nineteen AARP that participate in health research.

Through researcher reflexivity and a deep historical reexamination, this study explored the perspectives of AARP that facilitate participation in research and provided a rich description of motivational factors, behaviors, and interactions of AARP that impact their participation in health research despite the legacy of justifiable distrust of research. In addition, utilizing community- engagement research strategies, the researcher collaborated with the Michigan Center for Urban African American Aging Research (MCUAAAR), and the Healthier Black Elders Center (HBEC) for participant recruitment and community research approval. Furthermore, this study was supported by a grant from the National Institutes of Health, 5P30 AG015281, and the Michigan Center for Urban African American Aging Research. More importantly, the findings from this study were disseminated back to the community. 

This article offers several AARP experiences with research participation, their narratives revealed salient motivational factors including altruism towards improving population health including the health of the African American community. Furthermore, the study revealed the significance behind participants feeling respected and valued by their researchers and their experiences with race concordance in the researcher-participant relationship. Conversely, when participants were asked about their research experiences, several AARP expounded on experiences of mistreatment in health care settings which led several participants to seek Black health care providers and alternative forms of health information.

This is an area that warrants a deeper understanding and developing strategies to improve patient-provider relationships. Despite a historical legacy, the participants in this study were not deterred from participating in research and balanced their decision making with healthy skepticism. Just as important, this article offers the counterstories from AARP as to why they participate in health research and offers strategies to improve participant-researcher encounters. Therefore, it is essential that African Americans that choose to participate in research are treated as experts and collaborators in joint efforts to improve population health through inclusive research.  

Crenshaw K., Gotanda N., Peller, G., & Thomas, K. (Ed.) (1995). Critical Race Theory: The Key 

Writings That Formed the Movement. New York, NY: The New Press. 

Green, J. & Thorogood, N. (2018). Qualitative Methods for Health Research: 4th Edition. Thousand Oaks, CA. SAGE. 

Neergaard, M. A, Olesen, F., Andersen, R. S., & Sondergaard, J. (2009). Qualitative description: Poor cousin of qualitative health research? BMC-Medical Research methodology, 9, 52-56. doi: 10.1186/1471-2288-9-52 

Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334- 340. doi:10.1002/1098-240x (200008);2-g 

Evaluation of Kumpfer’s Resilience Framework

We are currently featuring the article titled “An Analysis and Evaluation of Kumpfer’s Resilience Framework” authored by Zhihong Zhang, MS, RN; Karen F. Stein, PhD, RN; Sally A. Norton, PhD, RN; and Marie A. Flannery, PhD, RN. The article is available to download at no cost while it is featured. Here is a message about this work that first author Zhihong Zhang has provided for ANS readers:

My research program aims to investigate resilience in older adults with cancer. I am seeking a theoretical framework that can guide this examination. One such framework is Kumpfer’s resilience framework (KRF), which has been widely used with adults and youths, including those with cancer. KRF is an integrative framework that organizes evidence of resilience and its predictors into a single model. It was originally developed by Karol L. Kumpfer in 1999, based on research with at-risk youth. However, the strengths and weaknesses of KRF have not been evaluated since its publication. To address this gap, we utilized Walker and Avant’s method to review 41 related publications and assess KRF’s origin, meaning, logical adequacy, usefulness, generalizability, parsimony, and testability, with the goal of informing future research on resilience.

Our findings suggest that KRF is a useful, generalizable, and testable framework that has been applied to diverse populations experiencing various adversities. However, we identified areas for improvement in terms of meaning, logical adequacy, and parsimony. Consequently, we proposed a revised diagram of KRF that enhances clarity regarding inferred relationships, consistency in concept labels, logical structure, and parsimony. This revised diagram highlights the dynamic process of resilience in a feedback loop and the complex interactions among its predictors following stressors (Figure 1).

Figure 1 Revised diagram of Kumpfer’s resilience framework

Explanations for this revised KRF diagram:

  • Stressors activate the adaptation process. Resilience is a dynamic process of positive adaptation that results from interactions between environmental factors, person-environmental transactional process, and internal factors, as well as the influence of past resilience and past adaptation outcomes.
  • Individuals with resilience have positive adaptation outcomes, whereas those without resilience have negative adaptation outcomes. The feedback from adaptation outcomes also influences future resilience, with positive adaptation outcomes strengthening future resilience and negative adaptation outcomes weakening it.
  • The feedbacks from current resilience may affect future interactions between environmental factors, person-environmental transactional process, and internal factors. Individuals with resilience, for example, may reshape their environments, change internal factors, or modify the person-environmental transactional process to better adapt to stressors.

LGBTQI+ Migrants’ Experiences with Nurses in Canada

We are now featuring the ANS article titled ““Ally Theater Is a Problem:” LGBTQI+ Migrants’ Experiences With Nurses in Canada” authored by Roya Haghiri-Vijeh, PhD, RN, BN, MN, and it is available for free download while it is featured! Here is Dr. Haghiri-Vijeh’s description of her work that she shared for ANS readers!

My research and professional journey with a focus on needs of migrant 2S/LGBTQI+ communities started over a decade ago. 2S/LGBTQI+ stands for Two-spirit, lesbian, gay, bisexual, trans, queer, intersect and the “+” is inclusive of diverse sexual orientations (e.g., pansexual), gender identities, and gender expressions (e.g., nonbinary) that are not explicitly named in the initialism. Several years ago, a nurse, who was in an administrative role and claimed to be focused on advocacy for marginalized people in Canada, told me, “You should reconsider your topic, because it won’t be safe to return to Iran for a visit by being engaged in this work!” I should add that this nurse had a visible “positive space” sign on their desk. This comment highlighted personal values that may impact how nurses engage in allyship and advocacy.

Both stigma and discrimination, including a lack of knowledge of and a sense of discomfort in providing care to 2S/LGBTQI+ migrants, manifested themselves in my encounters with nurses, nursing students, faculty, and administrators. I heard comments such as, “They are in Canada now. It is safe here!” Despite the work of nurses as well as allied social and healthcare scholars, practitioners, and activists, some nurses continue to have a limited understanding of the experiences of 2S/LGBTQI+ migrants in the Canadian context, and 2S/LGBTQI+ migrants continue to have troubling experiences with nurses.

Within my research study, I analyze 2S/LGBTQI+ migrants’ encounters with nurses by applying a Gadamerian hermeneutic approach with intersectionality as an analytical lens. I conducted 18 semi-structured, in-depth, individual interviews. Two groups of informants participated in this study: (a) sixteen 2S/LGBTQI+ migrants who received care from nurses and other healthcare professionals in Canada; and, (b) five nurses or nursing students who experienced, observed, heard, or witnessed the provision of nursing care to 2S/LGBTQI+ migrants. Approaching analysis from an intersectional lens, I observed how 2S/LGBTQI+ migrants’ experiences were shaped by considerations of physical, mental, and spiritual well-being, which intertwined with race, ethnicity, migration status, sexual orientation, gender identity, and gender expression. Furthermore, I found that migration status added another layer of complexity to the marginalization of 2S/LGBTQI+ people, which required intentional allyship from nurses.

In this article, the concept of “ally theater” is used as a metaphor to depict meaningless acts of allies’ support for 2S/LGBTQI+ migrants. I underscore how the nursing profession has claimed to be affirming of diverse communities; nevertheless, nurses can do better, which is beyond one dimensional, performative act in education, practice, and policy. Drawing on normative ideologies underpinning performative allyship, a theoretical discussion with selected findings is presented on how 2S/LGBTQI+ migrants experienced cynical comments and unsacred seriousness in play with nurses in practice. In addition, nurses’ genuine acts of allyship with 2S/LGBTQI+ at various practice settings are presented.

Caring for Gender Minority Persons

ANS is currently featuring the article titled “Gender Minority Persons’ Perceptions of Peer-Led Support Groups: A Roy Adaptation Model Interpretation” Ralph Klotzbaugh, PhD, FNP-BC and Jacqueline Fawcett, PhD, ScD (hon), RN, FAAN, ANEF. The article is available for free download while it is featured, and we welcome your comments here! Drs. Klotzbaugh and Fawcett each share their comments about this work here:

Ralph’s comments

This project required a methodological approach that I was not initially used to working with.  My prior research has utilized quantitative methods, but I knew given the substantial gaps in knowledge related to transgender and gender diverse (TGD) communities, that a quantitative approach to this project would not have been appropriate.  I could have taken what is known from the bit of existing literature specific to TGD communities that is out there (for example community support and its relation to resilience and effects on reducing depression, anxiety, etc.) and utilized standard depression and anxiety scales to measure the effect of support group attendance among TGD participants over a period of time.   However, this approach would have made a lot of assumptions about why people who identify as TGD attend support groups.  Might this assumption (in spite of supportive research findings as well as best intentions) disinterest, or possibly offend potential participants?  This was a moment in learning how to reign in one’s enthusiasms based on one’s academic knowledge and expertise, and to allow and encourage those who identify as TGD and who attend these support groups to discuss why they attend support groups. 

This approach necessitated a qualitative approach, and the data from this project were for me, infinitely more insightful than any existing quantitative instruments  could have revealed.  It was a time-consuming iterative process well worth all our efforts, particularly given the complexities of intersectional considerations within this project. For me, the approach to data through qualitative methodologies made me necessarily question the potential ‘messiness’ that might be true of more traditionally objective quantitative methods.  Checking one’s biases is expected as part of the iterative process in qualitative methods.  This however is not often, if ever, a focus of quantitative methods.  And yet, how are studies using quantitative methods constructed?  What questions are being asked?  What demographics collected and why?  What identities are we leaving in? Leaving out?  What are the potential findings that we may never know of if we are too busy constructing (knowingly or unconsciously and without thought) what we believe will be true, to be true, and/or insist on proving?  I recommend every nurse researcher make a deliberate effort to step outside of their usual methodologies and thus to become uncomfortable in the process. 

Jacqueline’s Comments

It was an honor to join Ralph as we wrote this paper. My contribution was to interpret the themes Ralph discovered in the data within the context of the Roy Adaptation Model (RAM).  As that occurred, Ralph and I discovered that the content of the RAM led us to review the data again and determine whether one or more other themes were missing. This was an excellent example of how use of an explicit nursology conceptual model can truly guide the analysis of qualitative data. We have to wonder what the initial data analysis would have revealed if we had started with the RAM as the guide for the design of the study and the analysis of the data.

Of course, we have to acknowledge that our selection of the RAM for this paper introduces a bias, namely that the study was about adaptation. What would the study design and data analysis looked like if we had selected a different nursology conceptual model, for example, Orem’s Self-Care Model or Levine’s Conservation Model or Johnson’s Behavioral System Model? Had we selected any one of these conceptual models, a bias would still have been evident. Thus, it is imperative for all researchers to recognize that bias always exists in the conduct of research and that bias goes beyond the ANS requirement to declare the cultural, racial, and gender perspectives of the author(s).

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