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Database Integrit

The first ANS featured article in the newly released Volume 44:2 is titled “Integrity of Databases for Literature Searches in Nursing Avoiding Predatory Journals” authored by Marilyn H. Oermann, PhD, RN, ANEF, FAAN; Jordan Wrigley, MA, MSLS; Leslie H. Nicoll, PhD, MBA, RN, FAAN; Leila S. Ledbetter, MLIS, AHIP; Heather Carter-Templeton, PhD, RN-BC, FAAN; and Alison H. Edie, DNP, APRN, FNP-BC. The article is published open access, which means it is available at no cost from the date of publication going forward. Here is an informative explanation of this article by co-author and librarian Jordan Wrigley – followed by the transcript of her video.

Jordan’s narrative for the ANS Blog

Librarians and information professionals are valuable collaborators in data-based research where intimate understanding of the “behind the scenes” aspects of digital systems and human-information interaction are needed. This may include bibliometrics, metadata, meta-analyses, text mining, and content analysis among others. Librarians are also experts in understanding information-seeking behaviors and often facilitate research literacies including efficient literature searching and evaluation.

This project combined several of these aspects in the context of nursing publication. The goal of this project was to identify to what extent articles originating from potentially predatory and low-quality journals were penetrating databases commonly searched by nursing scholars and students. To achieve this, novel data collection strategies were required to create an original dataset. This included use of unique searching syntax across multiple databases and triangulation with authoritative sources to confirm data validation.

To create the dataset that would be the basis of this manuscript, I created a search algorithm based on journal metadata, such as International Standard Serial Number or ISSN, in one database. Then I translated it to the syntax of other databases. However, because low-quality journals do not consistently participate in processes such as ISSN registration, this dataset also required merging ISSN data with other metadata including journal titles, dates of publication, and publisher. Automated digital processes in databases are also imperfect, sometimes allowing low-quality articles to slip in through non-typical means such as being referenced in valid studies. This also needed to be accounted for in the dataset. The final dataset for this article allowed the team to make informed recommendations for nursing teaching faculty when facilitating research literacies as well as clinicians and researchers when considering where to search for literature.

Data- and digitally-intensive research is often more nuanced and complicated than it first seems. There is an endless amount of data to be used to inform research and teaching practices in nursing as well as other fields. Librarians and information professionals have intimate knowledge of the “behind the scenes” of data and human-information interaction. Please consider engaging a librarian or information professional as a collaborator in a research project to identify the potential unexplored areas of data-based research. Thank you for watching or listening to this video and, to learn more about our team’s findings based on this dataset, have a read of our “Integrity of Databases for Literature Searches in Nursing: Avoiding Predatory Journals” in Advances in Nursing Science.

For a Radical Renewal of Democracy in Hospitals

Contributor: Patrick Martin

Editors’ note: Thank you to author Patrick Martin for contributing this further reflection on his article co-authored with Louise Bouchard, that appeared in ANS 43:4, October/December 2020, p. 306-321 (doi: 10.1097/ANS.00000000000003220)

The staff nurses, who gave us an interview in the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study,” recently published in Advances in Nursing Science, have felt left out of decision-making processes that prevail in hospital centers, even if decisions arising from them have a direct impact on the way in which they work. It should be noted that staff nurses who practice in hospital centers represent most of the nursing workforce. The same observation emerges from one of our research projects that is still ongoing, conducted with nurses working in different sectors of specialty care (clinical nurse specialists, pivot nurses, specialized nurse practitioners [SNP], etc.).

This situation, which is eerily similar to the one experienced by the subordinate citizen, systemically left out of places associated with the exercise of power, appears consistent with the broad trends our contemporary oligarchic societies are taking under the aegis of world governance and market globalization. Our results suggest overall that the hospital democracy is increasingly confined to hospital boards of directors and to instances in which usually nurses do not have access. In the words of some participating nurses, these instances would themselves be submitted to a strict hierarchy of command, itself dependent on guidelines, particularly ministerial directives, which would considerably affect overall positions taken by hospital centers. It should be noted that our research is taking place in Canada; our health care system is certainly a public one, which connects, however, to an entrepreneurial-style governance model that leaves more and more room for the private sector and is advocated in all care settings, a clear separation between decision makers and “implementers”.

Based on our research results, the nurses who stand out for their commitment are thereby mostly confined to instances that only have the powers of recommendations, such as the hospital councils of nurses (CN). Participation in instances where access is “open” to nurses was otherwise associated by some participants with strategies put in place by the hospital authority to ensure nurses deploy their energy with no success to make any changes whatsoever happen in constraints they live in their daily practice. Even the parity committees[1] within which union representatives have the opportunity to talk with the employer are perceived as being marginally effective for eliciting to improve conditions under which nurses work.

Although these instances may appear a priori as great opportunities to promote nurses’ interests to the employer for concrete changes can be made in work organization, the perceptions of those interviewed with access to these committees as union representatives are no way going in this sense. These testimonies rather suggest that, even within these instances, numerous techniques would be deployed by the employer in a way to paralyze the dialogue with the union and to push dispute settlements, which we think has the effect of accentuating the separation between decision makers and implementers, already very much present in hospital centers. The fact of constantly changing interlocutors with which the union must find common ground would be leveraged in many backgrounds; this context among these techniques sometimes has the effect of significantly pushing some grievance settlements, the delays may spread out more than one year. If, according to some participating nurses, this is the constant turnover of managers, which would be the source of these delays, the fact remains that the current situation benefits the employer, even if the phenomenon is not necessarily a planned strategy.

When acting for change, the Slovene philosopher Slavoj Žižek(2008a), who is very interested in political action, states that it is important to question ourselves about the possibility of efforts deployed to cause the reproduction of dominant discourse, as it would be the case when nurses are investing time and energy in committees bringing very little outcomes, the hospital governance by far prefers seeing them running around in circles in some frivolous proceedings rather than noting they organize themselves concretely to resist the hospital authority. Žižek will specify in these situations that it is sometimes better to do nothing rather than try to act the wrong way to transform the status quo. Not cooperating in the functioning of the hospital framework by refusing participation in these proceedings – of what, from the point of view for a lot of nurses who participated in our research, in no way enable to improve their situation – would thus become, in itself, an act of resistance.

Results from the research project being discussed in the article “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study” revealed as well that decisions are usually made in accordance with decision-making processes in hospital centers, always consistent with interests of small influential groups. Participants on numerous occasions made reference to staff nurses in their discourse, but also to link nurses who, based on tacit knowledge, the one marginalized by the good governance doctrine, had warned institutions relative to decisions, many of which would achieve savings that have proven to be serious errors. Decisions even resulted in the death of many patients.

Our results suggest in addition that ideas from nurses are usually taken into account only when they are able to demonstrate they are in fact the partners “of those who play the game of the good governance” [free translation] (Deneault, 2013, p. 41). The nurse who sees herself complimented by a manager after having proposed, through a corporate website promoting innovation, that her colleagues bring their own toilet paper to workplaces for achieving savings, is a disconcerting example of this fact.

What Good is it?

A number of participating nurses encountered in studies and questioned relating to their commitment and the registry for political actions from nurses asked us if we really thought that it was possible to “change things”, with respect to the practice of the contemporary nursing profession in different backgrounds. The situations, described and criticized by them, have effectively come to our mind the most desperate throughout data collections, many participants indeed having openly admitted to us not believe in the possibility of making favorable changes happen to conditions for exercising the nursing profession, more particularly in the hospitals. As Žižek(2012) who, in a lecture given in Toronto, emphasized being regularly confronted with similar questions relating more specifically to pessimistic representations made of the state we find the world we are living in today, we responded to these participating nurses not being exactly sure it is possible to “change things”. And definitely we still have no certainty. Although many are likely to believe that things cannot change, paradoxically, however, we can only see the hectic pace at which, right now, they are changing radically, in both different care settings and our advanced capitalist society.

Not only in capitalist dynamics, but also in all spheres of life, things are in fact already changing automatically to a hectic pace. The very nature of sociability, of what constitutes a human being is as well shifting now and, if we let these changes be deployed passively – the same is true for the comparison to care –, it is expected that we will be heading towards an articulation of the society,[2] which is going to be characterized by a new form, permitted and perverse, of authoritarianism (Žižek, 2012). For Žižek, with whom we are in agreement on this, things are thus already changing to a hectic pace and that has to give us the motivation to act concretely to ensure these changes are getting a foothold in the sense of what we want, consistent with what nurses do. If Žižek postulates we are living the end of the world as we knew it, we also believe that we are witnessing here the end of care settings as we understood them, and sort of – to the end of the nursing professional practice as we knew it. Thereby drastic changes occurred, are happening and will continue to occur and it is expected that these are going to happen in a way even more authoritarian, arbitrary and perverse, because everything seems now okay in the name of the triumphant economy, and these ways of doing things in our societies necessarily affect care settings.

It is not a matter for staff nurses to foolishly accept these changes that will continue to occur quickly, but for them to reflect on what they can do to direct/influence these as well, certainly in a sense which would be salutary to them, but more particularly so we have some humanity. Nurses could also refuse categorically these changes – or some of them –, just as they can propose new ways of looking at the nursing professional practice – and they do so increasingly. And to those who believe that no change is possible because small groups disallow any transformation to the social order, Žižek(2012) unequivocally responded it is wrong to think there is only one social class governing and manipulating what is going on. According to Žižek(2012), reality is in fact more complex, certainly disconcerting, but with no way out – because those who are standing at the top of hierarchies are as well constantly destabilized by this ever-changing world and have enormous difficulties adapting to it. They are thus always improvising, definitely with a lot of means, to promote the maintenance of their hegemonies – hegemonies which, in all of this improvisation are necessarily much more fragile than we would like us to believe. As nurses, as a group, it is extremely important to become aware of this fact, which in regard to what we experienced as a society with the COVID-19 pandemic in the last year, looks absolutely undeniable.

In accordance with the writings of philosopher Rancière (1991, 1999), we refuse, however, to position ourselves in the expert role – a posture which remains anti-emancipatory – or in the Sartre’s trend of the intellectual, by dictating to nurses how they should act to cause the desired transformations to the nursing professional practice. But we feel strongly, consistent with what Gene Sharp (2012)[3] wrote, the power exercised in a hostile way, particularly by the governance of major hospital institutions, must be thwarted by an equal or greater nurses’ collective strength, without which the policies associated with it will continue to be imposed on them. To direct in the sense which is salutary to them, but also so we have some humanity, the societal changes affecting the nursing practice, we believe as well that there is no point for nurses to set off on a crusade against capitalism even if as a group, they and patients to whom they are giving care suffer enormously from collateral effects of this socio-political way of organizing we have. As Žižek (2008b) reminds it, this reflex obsessing the “old left” (p. 29) is not conducive, especially in the way in which the reality of today’s capitalism is structured, namely from a globalized manner where it becomes, for all practical purposes, impossible to have a grip on the ongoing transformations this ideology imposes to our existences.

Like Rancière (2014) and Žižek(2012), we think it is in the radical renewal of democracy in our societies and institutions as citizens, we must deploy our energies and concrete actions, actions that will do harm to the powers-that-be and destabilize oligarchs who have literally appropriated our democracies. It is in this sense, without telling nurses what to do, but we believe it is relevant to move towards a radically renewed hospital democracy[4] as the ultimate central purpose to which their collective actions must be structured, but also their individual ones, because it is always preferable to act on several fronts. Maybe that, starting from these concerted collective and individual actions in the thoroughness of everyday living, nurses will cause the establishment of a new balance of power and they finally have the opportunity to debate on the direction that must take the nursing practice – which, need we remind is essential to life.

Deneault, A. (2013). Gouvernance : le management totalitaire. Montréal : Lux Éditeur.

Rancière, J. (1991). The Ignorant Schoolmaster: Five Lessons in Intellectual Emancipation. Stanford : Standford University Press.

Rancière, J. (1999). Disagreement : Politics and philosophy. Minneapolis : University  of Minnesota Press.

Rancière, J. (2014). Hatred of Democracy. Brooklyn : Verso.

Sharp, G. (2012). Sharp’s dictionary of power and struggle : language of civil resistance in conflicts. New York : Oxford University press.

Žižek, S. (2008a, January). Violence. Paper presented at: the London Review Bookshop, London, United Kingdom.  

Žižek, S. (2008b). Violence : Six Sideways Reflections. New York : Picador.

Žižek, S. (2012, September). Until the end of the world. Paper presented at: Toronto’s Nuit Blanche Symposium, Toronto, Canada.

[1]Given our results, the grievances of nurses can be expressed and tolerated only when they – through their representatives – are invited expressly to do so by their superiors, particularly during these parity committees.

[2] By describing this new entity of new perverse permissively authoritarian society, which will be most rigid but, in a new way, Žižek(2012) prefers not to make reference to what some people are calling a new form of fascism, because he considers that those who use this term do it because they are too cowardly to think what is really new in these ways of doing things. The term “management totalitaire”, used by Deneault (2013), appears to us, however, as a key concept to describe this new articulation of our societies.

[3] Note that these writings of Sharp (2012) do not specifically refer to the nursing reality.

[4] We think at the same time nursing actions must also be directed so we have some radical renewal of democracy in our societies because it appears unlikely that a renewal so radical of the hospital democracy is done without much larger reflections, at the societal level, isn’t it put forward in this sense?

Theory Development Process of Situation-Specific Theories

The current ANS featured article is titled “Theory Development Process of Situation-Specific Theories” authored by Eun-Ok Im, PhD, MPH, RN, CNS, FAAN. In this article, Dr. Im described the development processes used in fifteen situation-specific theories published in refereed journals. This article is available at no cost whiled it is featured, and we encourage you to take advantage of its availability! Dr. Im shared her reflections about her work in this message:

Since my first article on situation-specific theories was published in Advances in Nursing Science in 1999, my thoughts on situation specific theories have grown. I have started this year with an unusual excitement because of the upcoming first book on situation-specific theories from Springer Nature that I have worked on with Dr. Afaf Meleis. The book is a collection of the works by many theorists who gave their thoughts on and have developed and used their own situation-specific theories. On this blog, I am including a picture of little red fruits on a tree that I found in Atlanta, GA this winter (American Holly tree?) in order to illustrate my feelings about all the theoretical works related to situation specific theories that we have done. A collection of our little pretty fruits that we produced despite all the challenges!!!

While working on the first book on situation specific theories, I became to wonder what theoretical development process had been used in the actual development of situation-specific theories. During the same time period, I was invited to several international conferences/workshops/seminars related to theory development, and many of them asked me to give presentations on theory development process of situation-specific theories. Also, over the past several years, I have been asked by PhD students on how they could develop their own situation specific theories through their PhD dissertation works.  When I published the article on the integrative approach to situation-specific theories in 2005, I thought I gave clear guidance for theory development process of situation specific theories. However, many junior and senior scholars were wondering how situation-specific theories had been actually developed during the past two decades.  Because of these inquiries by many nursing scholars and PhD students, this paper was initiated.

While working on the paper, I was very glad to find that I was right about the theory development process of situation specific theories that I proposed in 2005.  For instance, all the situation-specific theories that were reviewed were developed through various combinations of induction and deduction using unique theory development strategies. The situation-specific theories were developed using multiple sources of theorizing (including multiple theories and multiple research studies) in various, but no homogenous steps.  I thought these findings were reasonable and natural considering the high specificity and diversity that situation-specific theories are supposed to provide and respect. 

I also had an interesting finding that situation-specific theories were developed from all types of theories including grand theories, middle-range theories, and situation-specific theories.  Considering the lowest level of abstraction in situation-specific theories, the derivation of situation-specific theories from grand theories and middle-range theories was recommended by many scholars, but situation-specific theories were actually developed based on all types of theories/theoretical works. Considering the characteristics of situation-specific theories (e.g., respecting diversity and contextuality, direct linkages to research and practice), it would be understandable to see the derivation of situation-specific theories from all types of theories and theoretical works.

Based on the expected and unexpected findings on theory development process of situation-specific theories, I made several suggestions for future theoretical development of situation-specific theories in this paper.  Especially, I thought it would be essential and important for future theorists to be creative and innovative in their theoretical efforts to develop situation-specific theories. All situation-specific theories were developed in their own unique ways that would fit with the specific populations and particular nursing situations that they aimed to describe, explain and predict. Without openness to new and creative methods, it would be difficult for theorists to develop situation-specific theories that could exactly fit with their unique populations and nursing situations.  

Especially when considering all the evolutions and revolutions that nursing discipline might need to go through with new changes in nursing environments (e.g., COVID19 pandemic), the openness would be a key to success in our future theoretical journeys. Indeed, with the start of COVID19, health care systems went through drastic changes including the rapid adoption of telemedicine and telehealth. With the changes, nursing situations became to involve telenursing procedures in many aspects of practice, and nurses have been on the frontline of health systems to take care of COVID19 patients through both in-person and non-in-person encounters. Are we ready to provide theoretical lenses that could support all these changes in nursing practice and care?  What if robots began to replace some components of nursing care? Maybe, these would not be necessary worries and concerns at this moment, but we never expected the COVID19 as well. 

Again, many thanks to Dr. Chinn to provide me with this great opportunity to dialogue with my respected colleagues; I missed our dialogues during this pandemic while staying at my little place. Hope this blog could initiate some fruitful discussion on situation-specific theories.  Also, to conclude this blog, I want to mention that this is the year of Golden Cow, White Ox, or Metal Bull in Asian culture, which will bring good fortune to all of us.  With the new good luck, I hope the COVID19 pandemic would disappear and we could get together soon.  

Best wishes for all of us.

Eun-Ok Im

Discrimination-fueled mistrust of hospice care

The current ANS featured article is titled “Mistrust Reported by US Mexicans With Cancer at End of Life and Hospice Enrollment” authored by Margaret L. Rising, PhD, JD, RN; Dena Hassouneh, PhD, RN, FAAN; Patricia Berry, PhD, CNP, GNP-BC, ACHPN, FPCN, FAAN; and Kristin Lutz, PhD, RN. The article is available to download at no cost while it is featured! Here is the abstract giving a summary of the outcome of the grounded theory approach used in this work:

Margaret L. Rising

Hospice research with Hispanics mostly focuses on cultural barriers. Mindful of social justice
and structural violence, we used critical grounded theory in a postcolonial theory framework
to develop a grounded theory of hospice decision making in US Mexicans with terminal cancer. Findings suggest that hospice avoidance is predicted by mistrust, rather than culture,
whereas hospice enrollers felt a sense of belonging. Cultural accommodation may do little
to mitigate hospice avoidance rooted in discrimination-fueled mistrust. Future research with
nondominant populations should employ research designs mitigating Eurocentric biases. Policy makers should consider concurrent therapy for nondominant populations with low trust
in the health care system (p. E14)

Rising, M. L., Hassouneh, D., Berry, P., & Lutz, K. (2021). Mistrust Reported by US Mexicans With Cancer at End of Life and Hospice Enrollment. ANS. Advances in Nursing Science, 44(1), E14–E31.

Conceptual Framework of Self-Advocacy

The current ANS featured article is titled “A Conceptual Framework of Self-advocacy in Women With Cancer” authored by Teresa H. Thomas, PhD, RN; Heidi S. Donovan, PhD, RN; Margaret Q. Rosenzweig, PhD, CRNP-C, AOCNP, FAAN; Catherine M. Bender, PhD, RN, FAAN; and Yael Schenker, MD, MAS, FAAHPM. In this article the authors discuss new insights about the process of self-advocacy. Here is a message from Dr. Thomas about this work:

Teresa Thomas

The past two decades have seen increasing attention put on “patient-centered care.” Healthcare systems and providers strive to put the patient at the forefront of their services. But what about the patient? What are we asking patients to do when we attempt to be patient-centered? How are we asking them to do so? And importantly, are all patients equally able to engage in patient-centered care?

Our team’s research in patient self-advocacy strives to answer these questions in the context of women with cancer. What happens when a woman with cancer encounters a challenging situation?  How does she assert her values and priorities to ensure her needs are met? This article presents our conceptual framework of self-advocacy among women with cancer.

Through our work with women with cancer, we know that not all individuals can speak up for themselves. Individuals quickly learn that if they don’t assert themselves, their care will at best not meet with needs and at worst be mismanaged and lead to their own poor health:

    • Individuals get lost in the healthcare system because they don’t know how to question their providers or seek clarification about their health.
    • Individuals hesitate to share the side-effects of treatment with their social circles because they don’t want to be considered a burden.
    • Individuals neglect their needs for the sake of not being perceived as rude or questioning.

Two observations drive this work. First, we noticed that research in patient empowerment and self-management focused on supporting patients in performing the tasks of managing their illness. While critical, we also recognize that individuals need support in doing more than just the “tasks” of being a patient. We want to create a language and framework that recognize the individual holistically and point to ways in which they can use their strengths to address their health concerns.

Second, we noticed a lack of patient-driven solutions to addressing disparities and inequities in outcomes. While equipping patients with self-advocacy skills cannot overcome the intertwined systems that perpetuate health inequities, there are ways in which patients can actively assert themselves to address challenges in their healthcare and social support networks.

We encourage others – by engaging in our article – to explore the concepts of self-advocacy, critique and refine this framework, and ultimately develop evidence-based ways to support individuals in achieving the goals of patient-centered care.

Theory of Suicide

The current featured ANS article is titled “The Three-Step Theory of Suicide: Analysis and Evaluation” authored by Avery M. Anderson, BA, BSN, RN and Mary Beth Happ, PhD, RN, FGSA, FAAN. This article is available for download at not cost while it is featured. Watch this informative 3-minute video of Mr. Anderson discussing this work!

Sexual Assault in the Lives of Ethnic Minority Women

Our current featured article is by the prolific social-justice team from the University of Wisconsin Milwaukee – Ashley Ruiz, BSN, RN; Jeneile Luebke, PhD, RN; Maren Hawkins, BA; Kathryn Klein, BA; Lucy Mkandawire-Valhmu, PhD, RN. This current article is titled “A Historical Analysis of the Impact of Hegemonic Masculinities on Sexual Assault in the Lives of Ethnic Minority Women Informing Nursing Interventions and Health Policy.” The article is available for download at no cost while it is featured. Below is a message from primary author Ashley Ruiz about this work:

In this article, we urge readers to consider how hegemonic masculinities are created, upheld, and sustained, due to intersecting systems of oppressions (the totality of which are also referred to as the matrix of domination).  A dominant ideology that refers to how masculine traits are constructed and idealized, hegemonic masculinities are learned social practices that ultimately lead to justifying the acceptability of violence, such as sexual assault.  In this article, we identify four ways in which hegemonic masculinities are used to justify sexual assault, specifically in the lives of ethnic minority women (social order hierarchies, “othering” dynamics, negative media/mass communication depiction, and economic labor division).  We draw from the literature to demonstrate specific ways in which sexual assault in the lives of ethnic minority women in the States are historically situated specifically in relation to colonization and slavery.  This history, upheld by hegemonic masculinities, demonstrates the past and present justification of sexual assault in ethnic minority women’s lives.  We call for nurses to recognize and understand this history as a basis for their approach to effectively meeting the healthcare needs of ethnic minority women who have experienced sexual assault. Understanding this history can help contribute to the implementation of effective interventions and health policies that disrupt hegemonic masculine ideologies by calling for a cultural shift in US society that no longer tolerates violence against women while ensuring the provision of opportunities for women’s healing.  

Sexual Disparities for Black Females

The current ANS featured article (available at no cost while features) is entitled “Black Female Sexuality: Intersectional Identities and Historical Contexts” authored by Natasha Crooks, PhD, RN; Randi Singer, PhD, MSN, MEd, CNM, RN, and Audrey Tluczek, PhD, RN, FAAN. Dr. Crooks provided this information about this work:

As a Black female researcher, my passion lies within addressing sexual health disparities and social inequities Black girls and women face throughout the life course. The motivation for my research stems from my clinical experiences in women’s sexual and reproductive health. I began investigating the experiences of Black female sexual development for my dissertation and have built upon this work by including adolescent girls. Many women from the study described how their intersectional identities and historical context influence their sexual development, aligning intersectionality to the findings of my grounded theory study.

Intersectionality is an important framework to use in nursing as it emphasizes the historical context, which is often absent in nursing theory. Intersectionality is a concept many of us may be familiar with; however, there is a lack of understanding particularly in nursing regarding its use. There is a complexity and discomfort in discussions of intersectionality as it describes social hierarchies (i.e., power and privilege) as well as consequences of those concepts (i.e., internalized oppression and historical trauma), especially as nurses and the field of nursing are predominately white. However, nurses are at the forefront of social justice and have a responsibility to provide culturally safe care. We thought it was important to discuss how research on Black female sexuality led to the development of an expanded intersectionality model and how it could inform research, theory, practice, and education.

We believe this work is timely considering the social awakening the Black Lives Matter movement has shed light on and the injustices Black communities face. In this article, we highlight many of the social inequities, which have led to historical trauma among Black women. We wanted to demonstrate the importance of intersectionality in relation to health, as well as the importance of historical context in health care. Historical context is critical in examining social inequities and health disparities among underrepresented populations. This framework may be useful in understanding how systemic issues have impacted health disparities, such as the disproportionate death rate of COVID-19 cases within Black communities.

Satisfaction Outcomes for Women “Choosing to Go Flat” after Mastectomy

The current ANS featured article, available at no cost while it is featured, is titled “Satisfaction Outcomes in Women Who “Choose to Go Flat” After Mastectomy: An Integrative Review,” authored by Tracy E. Tyner, MSN, APRN, ACNP-BC; Mikyoung A. Lee, PhD, RN. We invite you to download the article while it is featured, and share your comments related to their integrative review. Here is a message provided by lead author Tracy Tyner about this work.

Tracy Tyner

Tracy Tyner

Imagine, if you can, being diagnosed with breast cancer or you are at high-risk based on genetic or familial factors. After thoughtful and careful consideration and conversations with your healthcare team, you have decided to undergo a mastectomy and forego breast reconstruction, an option recently defined by the National Cancer Institute (2020) as Aesthetic Flat Closure, or in lay terms, “going flat.” Aesthetic flat closure is defined as a surgical procedure to remove excess fat and skin, followed by tightening of the skin to create a smooth, flat, nicely contoured chest wall, and can occur at the time of mastectomy or after reconstructive breast implant or autologous breast flap removal. After the mastectomy, you awaken to discover that you did not receive a flat closure but instead found excess amounts of skin along your chest wall with unexpected tissue deformities. Imagine looking at your chest wall with these deformities every day for the rest of your life. The potential short and long-term physical and psychological sequela these women experience is infinite.

Mikyoung Lee

Healthcare journalists are reporting similar events from women all across the country. In speaking with women who have undergone aesthetic flat closure, I have heard both amazing and disturbing stories surrounding their flat closure experiences. As a nurse practitioner with a family history of breast cancer, I felt a duty to answer the call from these women by enrolling in a Doctoral Nursing Program with a research focus on patient-reported outcomes in women choosing mastectomy with aesthetic flat closure.

To better understand this population, the authors, Tracy E. Tyner and Dr. Mikyoung A. Lee, set out to identify satisfaction outcomes in women choosing to go flat after mastectomy through an integrative review. Satisfaction outcomes addressed in this literature review included: chest wall appearance/aesthetic satisfaction, decision satisfaction, healthcare clinician interaction/care satisfaction, and factors affecting satisfaction. Most studies compared outcomes among different surgical options: breast-conserving surgery, mastectomy without reconstruction, and mastectomy with implant or autologous flap reconstruction. Only two qualitative studies specifically addressed women who “chose” to go flat. Overall, decision satisfaction was good, but there were mixed results on aesthetic satisfaction. Studies looking at satisfaction with healthcare clinician interactions were quite illuminating, revealing issues of paternalism, implicit and explicit biases regarding societal femininity and breasts, and a lack of educational resources available for these women. The strongest factors impacting satisfaction were body image, body mass index, radiation therapy, and access to information and resources.

This literature review found a significant paucity in the literature on satisfaction outcomes in women choosing mastectomy with aesthetic flat closure. We have only scratched the surface on understanding patient-reported satisfaction outcomes in this population. Future research needs are limitless. As nurses, we can play a pivotal role in improving patient satisfaction and health outcomes for women “choosing to go flat.”

National Cancer Institute (2020). Aesthetic flat closure.


Guidance on Concept Analysis

Beth Rodgers

For the current issue of ANS, I invited Beth Rodgers, PhD, RN, FAAN, to share her thoughts and guidance for nurse scholars embarking on this important work! Dr Rodgers is Professor Emeritus, University of Wisconsin Milwaukee, Nursing Alumni Endowed Professor, Department of Adult Health and Nursing Systems. Her work defining quality in concept analysis work as enabling conceptually sound research to improve clinical care was recently explicated in the Journal of Nursing Scholarship.1 In this Guest Editorial, Dr Rodgers further explains the importance of this necessary intellectual challenge for the discipline. Access her Guest Editorial “Confronting Conceptual Challenges in Nursing Scholarship” and share your comments and responses here!

  1. Rodgers BL, Jacelon CS, Knafl KA. Concept analysis and the advance of nursing knowledge: state of the science. J Nurs Scholarsh. 2018;50(4):451–459. doi:10.1111/jnu.12386.
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