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.
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.
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.”
The current featured ANS article is titled “Information Security in Nursing: A Concept Analysis” authored by Jiwon Kang, PhD, RN and GyeongAe Seomun, PhD, RN — free to download while it is featured. This work resulted in a model that the authors project can guide the identification of physical, technical, and administrative attributes and definitions of information security in nursing. Dr. Seomun provided this description of their work:
Information security in nursing requires technical, physical, and administrative security, which comprise an essential information security aspect. Physical security includes disaster prevention measures to protect information processing facilities, where information systems are located, from natural disasters and insider threats, as well as methods for protecting information systems from invasion and destruction. Technical security includes information data protection. The most basic countermeasures are to control access to the information system or to use software with enhanced security is a macro-based security measure that establishes the law, the safety and reliability of information systems.
We performed the task of compiling and analyzing the essential attributes of the information security in nursing derived from the review of the literature in the theoretical phase and the attributes of the concepts identified in the fieldwork phase. In the theoretical phase, 7 attributes (facility stability, external access and intrusion control, technical access control, use of functions, establishing a system, management of human resources, and responsibility for information security) were derived. Seven attributes (facility stability, environmental control, access to information, practical use of security systems, stability, persistence, and professional responsibility) were analyzed in the fieldwork phase. In summary, the attributes of information security in nursing were derived from 7 attributes (facility stability, environmental control, information accessibility, take advantage of features, systematicity of of education, and professional responsibility) in 3 domains [See Figure].
Nurses can review the environmental controls of the workplace and the stability of the facility. They can understand and use the accessibility of health information and the functions of the security program. They can follow the system of the work, recognize the patient information security-related matters through education, and evaluate and maintain medical information security with professional responsibility.
The security of patient information in the nursing field is a sensitive situation, and understanding the information security of the nurse is necessary. Nurses’ information security is an important concept, it is necessary to develop scale suitable for the current situation. Nurses’ Information Security Scale assesses aspects of physical, technical, and administrative security based on conceptual analysis. Nurses can develop a systematic method of performance to enhance the security of medical information with this scale. This study is useful for educators interested in strengthening nurses’ information security
The first featured article for ANS 44:1 is titled “Advancing Nursing Policy Advocacy Knowledge: A Theoretical Exploration” authored by Patrick Chiu, RN, MPH. This article is available to download at no cost while it is featured, and we invite you to add your comments below to advance this discussion! Here is the background that Mr. Chiu provided for ANS readers:
Advocacy is a concept that all nurses are familiar with. It’s introduced to students right at the beginning of nursing education and is constantly promoted by nursing organizations as a key nursing role. Similarly, nurses are increasingly called on to engage in political discourse and to influence policy at all levels. While this enthusiasm has been generated by nursing leaders, organizations, and global campaigns, much of the discussion has focused on the idea of ‘getting a seat at the table’, with little emphasis on the knowledge and skills required to effectively influence policy.
Throughout my years in clinical practice, government, professional associations, and nursing regulation, I have had many discussions with novice and seasoned nurses at the local, national, and global level. Conversations related to patient, health system, or policy issues have always generated similar responses – that there is a need to galvanize more nurses to influence policy. Despite this eagerness, I’ve always wondered why in many jurisdictions across the globe, this remained an aspirational statement rather than a reality. A close look at the literature suggests that perhaps the discipline has not fully explored the areas that require further knowledge and skill development to fully realize this engagement.
Although I had worked in policy advocacy for a few years, it wasn’t until my experience participating in the International Council of Nurse’s (ICN) Global Nursing Policy Leadership Institute in 2017, where I began to understand the gap. While nurses are phenomenal at bringing forward content expertise on a range of health and public policy issues, little attention is placed on developing the knowledge and skills required to navigate political contexts, actors, and policy processes – all of which are integral to policy change.
I began writing this article for a theory development class in my PhD program in hopes of advancing the theoretical basis of policy advocacy knowledge within the discipline. By combining ideas from the extant literature and my professional experiences, my goal was to explore how current conc
epts within nursing could be extended from a micro to macro level; and to integrate concepts from the field of policy studies to provide a framework for nurses seeking to engage in policy advocacy to advance social justice. Recent events have once again exposed the high levels of racial injustice and health inequities that continue to exist within our society. While the ideas presented in this article are open to critique, I hope it serves as a useful reference for nurses across all domains wishing to strategically influence health systems and policy.
Our current featured article is titled “School Discipline Experiences Among Youth With Disabilities From the Perspective of School Nurses” authored by Hannah E. Fraley, PhD, RN, CNE, CPH; Gordon Capp, PhD, LCSW; and Teri Aronowitz, PhD, APRN, FNP-BC, FAAN. Download this article at no cost while it is featured — we welcome you comments below. Here is a message from Dr. Fraley about this work:
As an early career scientist and scholar, I have been building the science surrounding prevention of
youth violence, particularly trafficking, among youth attending schools in the U.S. A large focus of my work has been on evaluating and building awareness among school nurses regarding how youth experiencing violence and trafficking present in schools so that school nurses can identify and prevent trafficking, given survivors of trafficking consistently report that they are often misperceived in care interactions as “trouble” and “behavioral”. In these foundational studies, we have identified another common theme brought forward by school nurses- youth with disabilities are particularly misunderstood in schools and it is known in literature that they are a population of youth most at risk for violence. This led my colleagues and I to further explore our qualitative data through secondary analysis exploring the perspectives school nurses have regarding discipline practices in school among youth with disabilities using the Peace and Power Conceptual Model.
Our findings highlight youth with disabilities can experience unjust, harsh disciplinary practices because they are misunderstood and mislabeled, fueled by lack of awareness, and understanding among school faculty. These attitudes shape the power-over dynamics in schools, perpetuating the unjust experiences of youth with disabilities, our most vulnerable youth. Particularly, school nurses in our study have shed light on minority youth with disabilities disproportionately experiencing harsh discipline, including unjust, unwarranted restraints and seclusion, kicked out of classrooms and schools, and sent to residential placements, placing them at higher risk for exposure to violence and the juvenile justice system. School nurses’ perspectives of these youth also often conflicted with other colleagues, creating power-over dynamics, such as being left out of planning teams for youth with disabilities and their input disregarded. Bringing to light the disparate discipline experiences of youth with disabilities in our schools is critical to work towards rebuilding emancipatory school systems that promote social-emotional school-wide programs and restorative justice practices, consistent with peace-power dynamics. Findings from this secondary qualitative data analysis have set the stage for my future study with adults with disabilities exploring their past school discipline experiences. Because people with disabilities are often understudied, hearing directly from people with disabilities themselves about their school discipline experiences will not only serve to inform my future work with school faculty, but will serve to bring their voices and experiences forward.
Our current featured ANS article is titled “Social Cohesion in Health: A Concept Analysis” authored by Hailey N. Miller, PhD, RN; Clifton P. Thornton, MSN, CPNP; Tamar Rodney, PhD, PMHNP-BC; Roland J. Thorpe Jr, PhD and Jerilyn Allen, ScD, RN. We invite you to download this article at no cost while it is featured, and share your thoughts here! Dr. Miller shared this background about this work:
Early on in my PhD program, I grew an interest in understanding the social determinants of health, specifically as they relate to cardiometabolic diseases. While conducting a literature review to narrow my dissertation research question, I identified a gap in the literature surrounding the relationship between social cohesion and obesity. At the same time, I noticed the heterogeneity in how dimensions of the social environment, specifically social cohesion, were conceptualized and operationalized in literature. This made using the findings to draw conclusions and inform my dissertation work difficult. As a result, my colleagues and I decided to conduct a concept analysis on social cohesion. The findings from this concept analysis were integral to the development of my dissertation and the interpretation of my findings. It is my hope that readers find this article useful in informing their future work, as well.
As a nurse in a busy Neonatal Intensive Care Unit (NICU) you quickly become accustomed to the ‘revolving door’ nature of admissions, transfers and discharges – as one infant leaves the unit, they are swiftly replaced by another. During my 13 years as an RN in the NICU, I found admissions very fulfilling; the whole team would spring into action, working together to stabilize a critically ill infant or prepare newborns and their families for urgent surgery. Discharges and transfers were somewhat less satisfying. Being well enough to be discharged from intensive care was always something to be celebrated, however I often found myself wondering how infants and families fared post discharge; hoping someone in the community would notice, and tie up any loose ends that may have gone overlooked on account of the complexity and acuity of the NICU patient population and environment. These feelings of uneasiness at discharge – in particular with the more vulnerable adolescent mother/baby dyads in the NICU – served as the impetus to explore the NICU-to-home experience further.
The importance of successful care transitions and the need for novel patient- and family-centered care approaches to ensure safety in the hospital-to-home process is becoming a recognized priority within healthcare. However, while exploring the existing literature on NICU-to-home transitions, what I found striking was the primary and often exclusive focus on the discharge event. Very little attention was given to the fact that, according to Meleis’ Transitions Theory, at the time of discharge from NICU adolescent mothers are experiencing at least 4 transitions: (i) a health-illness transition—NICU admission; caring for an infant with increased risk of developmental-delay/complex health needs; (ii) a developmental transition—becoming a mother; (iii) a situational transition—discharge home from the NICU and notably, these 3 transitions occur within the context of a fourth transition; (iv) the developmental transition of the adolescent mother to adulthood.
This paper applies Meleis’ Transitions Theory to the example of hospital-to-home transitions for adolescent mothers and their infants and argues for and increased recognition of the importance of overlapping and intersecting transitions and an overall more holistic, theory-informed approach to understanding hospital to home care transitions.
Our current featured ANS article is titled “A Nursing Perspective on Infant Bed-Sharing: Using Multidisciplinary Theory Integration” authored by Marissa G. Bunch, MSN, RN, CPNP and Sadie P. Hutson, PhD, RN, WHNP, BC. Download this article at no cost while it is featured to learn more about the topic of bed-sharing, as well as the authors’ approach to theory integration. Here is a message provided by Marissa Bunch (now Dr. Bunch!) about this work:
After over a decade of work with families as a pediatric nurse practitioner, I recognized that philosophies of parenting and infant care advice often conflicted with what families were actually practicing in their homes. When it came to bed-sharing, there was a glaring mismatch between what I was telling caregivers and what many of them were actually doing; many were afraid to disclose that they were sleeping alongside their infant, despite the high prevalence of families who have shared a bed across cultures and throughout history.
While there is a large push to encourage caregivers to eliminate bed-sharing due to an association with infant death, there is also a surprising lack of clear evidence that an unimpaired caregiver poses an inherent danger to their child during sleep. The evidence that is available varies depending on which theoretical viewpoint the researcher adopts. This article calls for nurses to acknowledge the various theories guiding this research and how those paradigms frame research results. The knowledge I gained from immersing myself in the theory behind infant bed-sharing informed my dissertation research with caregivers from Appalachia who shared a bed with their infants. I wanted to give my patients a voice and bring into the open what I was hearing behind the clinic doors. This article is part of the foundation for that work.
The title of the current ANS featured article is “I Cannot Afford Off-loading Boots: Perceptions of Socioeconomic Factors Influencing Engagement in Self-management of Diabetic Foot Ulcer” authored by Idevania G. Costa, PhD, RN, NSWOC; Deborah Tregunno, PhD, RN and Pilar Camargo-Plazas, PhD, RN. The article is available to download at no cost while it is featured! Here is a message from Dr. Costa about this work:
During my experience providing care for individuals with chronic conditions for almost two decades and delivering wound care for marginalized people (e.g., low-income and minority groups) in society, I witnessed patients facing several struggles to achieve the desired outcomes, being oppressed and prevented from being actively involved in decision-making about their own care. They were victims of a biomedical model that often places individuals as passive subject in their own care and prevents them from taken on a more active role in order to achieve better outcomes. Because biomedical model is also paternalistic and focus on disease rather than on a person as whole, individuals are often prevented from understanding their roles and acquiring the abilities needed to manage their chronic conditions.
Thus, when I embarked on the journey of writing my doctoral thesis, I wanted to approach the topic by challenging the status quo of a biomedical model and therefore giving voices to research subjects. I wanted to provide them with the opportunity to help us to understand their needs, motivations and struggles of having a chronic wound while navigating in a social world. I also wanted to consider questions, such as how do healthcare providers might better meet the needs of individuals with chronic wounds (e.g. diabetic foot ulcer) if they looked beyond just the illness itself? I believed that to address my goals I needed to use a methodological approach that would view individuals in society as active subjects working collectively and sharing experiences to re-construct their world and realities. I was fortunate enough to have had two amazing co-supervisors (Drs. Tregunno and Camargo Plazas) who guided me through this process of learning about a variety of methodologies and choosing one that would be the best fit to my research questions and philosophical assumptions. With their guidance I embarked on the journey of writing a grounded theory (GT) study. They provided me directions and allowed me to make a decision about which version of GT to use in my study.
After reading and learning about the main versions of grounded theory and doing a literature review, I noticed sparse studies focusing on individuals’ needs, motivations and struggles to manage their chronic wounds. There was no published study showing a theoretical model depicting the factors that influence individual’s engagement in self-management of a multifaceted chronic wounds such as diabetic foot ulcer (DFU). In response to this research gap, and to contribute knowledge on how to improve self-management and health outcomes of DFU from patients’ unique experience, I decided to use constructivist grounded theory to understand the processes of engagement in self-management described by individuals with active DFU, and develop a theoretical model depicting the factors that influence their ability to actively engage in their own care (Figure).
Ultimately, I want to invite healthcare providers, particularly, wound care professionals and policy makers, to take a look in this paper as it uniquely uncovers inadequacies in diabetes knowledge and inequalities in access to wound care services and resources for individuals living with DFU. These findings provide a foundation to guide clinicians and policy makers in improving diabetes care in order to reduce the risk of developing DFU in the first place, and ultimately, to improve self-management of diabetes and DFU. Finally, these findings also highlight the need to ensure the necessary self-management education program, services, and resources to facilitate individuals’ engagement in self-management of a multifaceted condition are in place.
In my own undergraduate nursing program at the University of Hawaii, we heard an often-repeated phrase reminding us that we were being prepared to be “change agents.” Throughout my career I have often reflected on this “charge” and the reality that so little changes – particularly when we consider the challenges that nurses face in putting many of the ideals of nursing into practice. In our current featured article title “Constraints, Normative Ideal, and Actions to Foster Change in the Practice of Nursing: A Qualitative Study” the authors Patrick Martin, PhD and Louise Bouchard, PhD, address this long-standing tension. They conclude that what is needed is a radical renewal of democracy in hospitals. Dr. Martin provided this background information about their work:
The aim of this study on which we had a great time working together was to explore the lived experiences of politically engaged staff nurses working in a hospital centre; to portray the social order that exists there; to describe the way in which the nurses would ideally like to practise; and to record their ideas and the action they have taken individually and collectively for fostering change in the social order and the practice of nursing. Epistemologically, this qualitative study was based on a view of reality as complex, mutable, and dependent on individual perception, which suggests a comprehensive, contextualized approach to human action and politics and, hence, to the consideration of the political views of the participating nurses.
The linkage between lived experience, normative ideals and political action has been explored from a dialectical, praxeological, postmodernist perspective which constitutes a reflection not only on what is but also on what ought to be. Such a reflection may, under certain conditions, lead to transformative action. We cannot say that the results of this study have contributed to the current changes, however these have been widely published in the mass media and we can now see a small revolution taking place in the nursing field in Quebec (Canada).
These results indicate a gradual deprofessionalization and increasing technicization of nursing. Our findings point, too, to an intensifying drift towards authoritarianism in hospitals with the adoption of the semantic register of the market economy along with the notions of efficiency, performance and optimization. Viewed as little more than high-performance robots, staff nurses find themselves excluded from decision-making processes. They have thus been deprived of the freedom to express opinions about or criticize decisions taken by the top ranks of the hospital power hierarchy (rather than by the nurses themselves) regarding the way nursing is practised. Disciplinary power in hospitals, exerted through technological policies such as constant surveillance, reprisals and fear, the technicization of care, and mandatory overtime contribute to the staff nurses’ subjectivation. Their clinical judgment has been devalued, their group solidarity undermined, and their union organization brought to heel. They have thus been diverted from demanding the realization of their rights and their ideals of emancipation and been reduced to the role of subordinates.
Accordingly, although the nurse participants want to take action in the hospital to humanize care and achieve professional self-determination, the practical purpose of much of the action we recorded was, rather, their own protection and survival in a dehumanizing hospital system. There are, nonetheless, staff nurses who raise conscientious objections, resort to individual or collective non-cooperation or engage in acts of civil disobedience with the aim of establishing a new power relationship, one that must necessarily be put in place for their demands, which would otherwise be ignored in this system of hospital governance, to be taken seriously.
Unless the antagonistic exercise of power in this system of hospital governance is thwarted by the exercise of equal or greater power on the part of nurses working collectively, they will continue to be subjected to its political philosophy and objectives. It emerges from their discourse that nurses collective action must focus on the radical renewal of hospital democracy, which, as a new power relationship, will enable staff nurses to fully participate in discussions of the orientation of their practice.
About the authors:
Patrick Martin is a nurse activist and an associate professor at the Laval University’s Faculty of Nursing. He is also a researcher at the Quebec Heart and Lung Institute. His research interests include the organization of work, social relations and power structures in which nurses’ experiences are rooted and strategies for nonviolent action. The central axis of his research program proposes to examine the system of constraints inherent in the social world in which nurses and nurse managers operate, as well as the effects of this system on their health and workplace safety. He investigates these elements by focusing on their relationship to politics, allowing them to envisage individual and collective courses of action to reduce these constraints in a perspective of sustainable health at work.
Louise Bouchard is a retired professor from the Faculty of Nursing at the University of Montreal, after teaching for over 30 years. She campaigned for many years on feminist committees, both in the local union and in the Fédération québécoise des professeures et professeurs d’Université. Her political commitment is continuing to recognize nurses’ freedom of conscience, particularly in the ideological context of medicalization and biopower.
The essential purposes of ANS are to advance the development of nursing knowledge and to promote the integration of nursing philosophies, theories and research with practice. We expect high scholarly merit and encourage innovative, cutting edge ideas that challenge prior assumptions and that present new, intellectually challenging perspectives. We seek works that speak to global sustainability and that take an intersectional approach, recognizing class, color, sexual and gender identity, and other dimensions of human experience related to health.
This journal is a member of, and subscribes to the principles of, the Committee on Publication Ethics (COPE) www.publicationethics.org
The ANS Blog provides a forum for discussion of issues raised in the articles published in Advances in Nursing Science. We welcome all authors and readers to post your comments and ideas on the blog! If you would like to be an author on this blog, let us know!
The journal Editor is Peggy L. Chinn, RN, PhD, FAAN. Dr Chinn founded the journal in 1978.
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A wonderful serenity has taken possession of my entire soul, like these sweet mornings of spring which I enjoy with my whole heart. I am alone, and feel the charm of existence in this spot, which was created for the bliss of souls like mine. I am so happy, my dear friend, so absorbed in the exquisite sense of mere tranquil existence, that I neglect my talents. I should be incapable of drawing a single stroke at the present moment; and yet I feel that I never was a greater artist than now.