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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).

Modification of a Grounded Theory of Postpartum Depression

Appearing in the current issue of ANS is the article titled “Teetering on the Edge:
A Third Grounded Theory Modification of Postpartum Depression” authored by Cheryl Tatano Beck, DNSc, CNM, FAAN. Dr. Beck is widely known for her long research career that explores the challenges of postpartum depression using a variey of research methods and exploring conceptualizations and experiences in different cultural contexts. Her article is available to download at no cost while it is featured, and we welcome your comments here! Dr. Beck shared this message about her work for ANS readers:

Over 2 decades ago Glaser (2001) alerted grounded theorists that once their substantive theory was completed, their work should not end there. Glaser stressed that modification never stops for a grounded theory. A Glaserian grounded theory should be continually modified by constant comparison of new literature that has been published or new data the grounded theorist had collected. By continually modifying a grounded theory, the researcher can produce a theory with a higher level of theoretical completeness. Researchers can increase the scope of their grounded theory by choosing which groups to use for comparison.

My original grounded theory study of postpartum depression, Teetering on the Edge, was published in 1993. The photo I included in this blog is one of me interviewing a mother of twins regarding her experien:ces of postpartum depression. The sample for the original study included all Caucasian women. For 30 years I have been modifying my grounded theory to increase its transferability to other ethnic groups of women at risk for developing postpartum depression. Another reason for modifying Teetering on the Edge a third time was for educational purposes. I teach qualitative research methods to PhD students in nursing and other disciplines at the University of Connecticut. When it’s time in the semester to cover classic Glaserian grounded theory methods, I search databases for examples of modified grounded theories to share with my students but do not have much luck. More modified grounded theories need to be conducted and published to help educate our PhD students and qualitative researchers about this valuable option.

Caring in the Context of Risk

The first article in the current issue of ANS is titled “Caring in the Context of Risk: Moving Beyond Duty” authored by Darcy Copeland, PhD, RN. The article is available to download at no cost while it is featured! Dr. Copeland shared this important message about her work investigating workplace violence!

Discussion of ethics or ethical frameworks is extremely rare in workplace violence literature. I have been investigating workplace violence for many years and view the phenomenon, in part, as an occupational hazard. When healthcare systems across the country were faced with a novel occupational hazard (coronavirus infection), there was swift and relatively agreed upon guidance regarding provider obligations and duties in the face of this risk. A duty-bound approach to decision making in the context of infectious disease seemed to work. I wondered if a duty-bound approach to decision making regarding the provision of care in the context of risk posed by patient violence would be similarly helpful.

I determined that a duty-based framework was insufficient to capture the contextual nuances and moral complexity of providing nursing care to hospitalized patients who exhibit violent behavior. I propose that examination of professional duties is one framework that can be used to guide our actions but might be insufficient if used in isolation of other frameworks. In the article I describe additional ethical frameworks and explore how they may also be used to guide decision making in the context of risk associated with violent patient behavior. These frameworks include virtue ethics, ethics of the everyday, and care ethics.

Nursing has a very long history of using virtue ethics to inform appropriate professional behavior. Virtues are characteristics that make one a “good” person/nurse and are not dependent on roles or duties. An internalization of nursing values results in a lack of distinction between being a good person and being a good nurse. Decision making utilizing this framework focuses our attention on what behaviors would maintain individual and disciplinary character in given situations.

Ethics of the everyday implores us to utilize our conceptions of “right” behavior in normal, everyday work to inform our behavior in circumstances that we deem as extraordinary, or at least out of the ordinary. This framework reminds us that we enact values as we live our ordinary lives, that everyday living is morally significant. How we conceptualize nursing and the provision of nursing care under “normal” circumstances can be used to inform decisions about the provision of care when “big” issues arise.

Finally, given the centrality of caring for others in nursing the inclusion of care ethics as a framework was obvious. This framework situates caring as occurring in the context of a relationship between two people – a caregiver and a care recipient. This perspective recognizes care as a complex site of power dynamics; it also draws attention to the humanity, needs, and vulnerability of both people. Attention to these aspects of care draw attention away from rules or duties that may be difficult to implement in complex situations.

Workplace violence is a major issue in nursing. It is also a complex issue that does not lend itself to standardized, algorithmic approaches. The more tools nurses and nurse leaders have in their tool box to determine how to respond to this issue the better.

Distant Reiki Intervention During the COVID-19 Pandemic

The current ANS featured article is titled “Experiences With a Distant Reiki Intervention During the
COVID-19 Pandemic Using the Science of Unitary Human Beings Framework
” authored by Jennifer DiBenedetto, PhD, RN-BC. You can download this article at no cost while it is featured on the ANS website! Here is a message from the author about her research:

One of my research interests centers on mind-body therapies and its integration into conventional medicine to offer non-pharmacologic interventions to manage psychological and emotional distress in the community. A mind-body therapy I am especially interested in researching is Reiki therapy. Reiki therapy is a holistic healing modality that facilitates an exchange of life force energy to promote wellness in its recipient. As a Reiki Master and Registered Nurse, I enjoy integrating Reiki therapy into both my nursing practice and to clients in my local community.

When this study was designed and conducted, I was employed as a critical care nurse during the COVID-19 pandemic. I witnessed the way nurses cared for patients with COVID-19 and the effect it had on the emotional and mental health of patients, nurses, and the community. With stress and anxiety being especially high, along with my personal passion of engaging in self-care and practicing Reiki, it sparked my desire to research distant Reiki and its impact on perceived stress and anxiety using Rogers’ Science of Unitary Human Beings Framework. Distant Reiki was selected for this article due to its ability to offer healing in a socially distant way within the human-environmental field pattern.

This article stretches the lens of what is traditionally published in studies employing Rogers’ framework, particularly in its mixed method design and the interpretation of the qualitative and quantitative results. There is also novelty in the reconceptualization of the terms “stress” and “anxiety” by noting these patterns as perceptions of stress and anxiety. Further emphasis is given on the intentional presence of the nurse who is delivering the distant Reiki and how the openness allowed for the nurse and participant to engage in a mutual and dynamic process of generating new patterns. This pattern change is achieved through the promotion of participant awareness, self-reflection, self-discovery, and human choice. Verbal accounts from the participants, along with the instrument scores, support a transformative experience in fostering mental wellness, wellbecoming, and self-care. Future research into how nurses can use healing modalities into their practice, such as Reiki, to foster the nurse-patient relationship is needed.

The Patient Experience

The current featured article in ANS is titled “The Patient Care Experience as Perceived by Hispanic Patients With Chronic Illness Undergoing Transplant: A Grounded Theory” authored by Silvinia Gamilia González Cuizon, PhD, RN and Eileen K. Fry-Bowers, PhD, JD, RN, CPNP, FAAN. Download this article while it is featured at no cost, and share you comments related to the article here. Dr. Cuizon shared this background about the development of the theory for ANS readers:

In my time as a clinical nurse and through my interactions with patients, I developed an interest in the issues surrounding the patient experience. Cultivating a “good” experience from an unfortunate time was always important to me. Not many people want to be in the hospital, let alone be sick, so making the experience as “good” as possible mattered to me. Along the way, I also found my clinical practice was increasingly influenced by The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This survey was developed to be an objective measurement of patient experience with the aspiration to gauge consumer perspectives about their hospital care.  While I do feel the patient experience matters, I did start to ask myself questions such as: Are we really capturing the patients’ needs? Is this truly a reflection of our care?  

As I transitioned into an administrative role, my perspective on the patient experience broadened to understand its hospital wide impact.  Quarterly, Centers for Medicare & Medicaid Services Hospital Value Based Purchasing (HVBP) Program withholds 2% from this quality indicator domain. If a hospital performs at the national benchmark and or achievement threshold, they gain back the 2% withholdings. If a hospital does not meet the metric, they lose their 2% withholdings1. Additionally, coming from a safety-net hospital, I noted additional challenges in meeting such metrics.  Safety-net hospitals exist to deliver care to individuals who struggle with social determinants of health and live in less-than-ideal locations nationwide. The majority of these patients are uninsured or underinsured, battle more comorbidities, and have poorer health outcomes than their more affluent counterparts because of systemic health inequities plaguing this country2.  I began to ask myself: how do these fiscal implications impact safety-net hospitals? Do they exacerbate health inequities or do they improve them?

My Doctoral program gave me a platform to further discover the complexities of this multi-dimensional phenomena. My examination of existing literature demonstrated substantial evidence to support differences in the patient experience perspective among traditionally underserved populations, including racial and ethnic minorities. Historically, surveys such as HCAHPS were not developed with this particular group in mind.3  This was evidenced by the minority response rate reported in the HCAHPS three state pilot test guiding the development of the HCAHPS survey4.  This was the impetus for my dissertation research. 

 The findings reported in this article focus on the experience of Hispanic transplant patients receiving care at a safety-net healthcare system. The patient interviews allow for an in-depth understanding of their perception of a positive hospital experience.  Four major interdependent and co-occurring concepts were developed:

  • Comfort
  • Communication
  • Connection
  • Care

Ultimately, the study findings confirmed important attributes of a Hispanic patient’s experience, such as communication and care, already measured by the current HCAHPS survey. Additionally, factors such as connectedness and comfort were important and need to be further examined. This study highlights the role culture plays in interpretation of one’s experience as a patient.  Due to the evolving nature of culture and societal norms and the enormous role the patient experience plays in health care, further refinement of this concept can provide already socially marginalized populations, such as the Hispanic population, a voice and the positive health outcomes they deserve. It will also provide clinicians a better understanding of what constitutes an optimal patient experience. With such high stalks it is imperative we get it right.


  1. CMS. (2021). CAHPS® Hospital Survey (HCAHPS) Quality Assurance Guidelines V16. 0.
  2. Kirch, D. G. (2016). In the Search for Measures that Matter, Star Ratings Miss the Mark. Retrieved from
  3. Stewart, AL., Nápoles‐Springer A, Pérez‐Stable EJ. (1999). Interpersonal processes of care in diverse populations. The Milbank Quarterly, 77(3), 305-339.
  4. Medicare, C. f., Services, M. (2003). HCAHPS three-state pilot study analysis results. Baltimore, MD. Available online at                                                                                      http://www/ pdf.
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