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Posts from the ‘Featured Articles’ Category

An Exemplar of Middle-Range Theory Revision: Self-Care of Chronic Illness


The current featured ANS article is an open access article, which means it is permanently available for all readers.  The article is titled “Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness” authored by Barbara Riegel, PhD, RN, FAAN; Tiny Jaarsma, PhD, RN, FAAN; Christopher S. Lee, PhD, RN, FAAN; and Anna Stromberg, PhD, RN, FAAN. Their article provides insight into this specific middle-range theory, but also serves as an exemplar of theory development and revision. We are eager to know your comments and responses to their work!  Here is a message from Dr. Riegel about their work:

Barbara Riegel

The purpose of our theoretical refinement was to disambiguate relationships between symptoms and the behaviors of self-care maintenance, monitoring and management within Middle-Range Theory of Self-Care of Chronic Illness. Since the Middle-Range theory was first published in 2012, our group has received a lot of positive feedback and the theory has been used extensively. We also have had external requests from investigators and even federal institutions about how to harmonize insights from theories focused on self-care with those focused on symptoms. Moreover, and as part of the theory-data process of theoretical refinement, we also had internal motivation to provide clarity on aspects of the theory related to symptoms.

Salient new themes explicated in this theoretical revision include that symptoms can be viewed as being part of self-care (e.g. the appraisal, detection and interpretation of bodily

Tiny Jaarsma

changes as symptoms are essential to self-care monitoring), as barriers or facilitators of self-care (e.g. motivate or blunt self-care behaviors), as outcomes of self-care (e.g. optimal symptom control), or in interaction with self-care of (e.g. moderation) depending on the research question being posed. Further, the interpretation of bodily changes as symptoms is complex and prone to heterogeneity such that multiple clinical phenotypes likely exist in how patients can engage in self-care monitoring and management.

We learned a great deal from one another and from the work of several other self-care and symptom scientists in this process, and are excited to see how the revised theory will be used to help guide innovative research. Please follow us at: http://www.selfcareresearch.org

 

Christopher S. Lee

Anna Stromberg

Reconceptualizing the Electronic Health Record for a new decade: A Caring Technology?


Our first featured article in ANS 42:3 is titled “Reconceptualizing the Electronic Health Record for a New Decade: A Caring Technology?” authored by Catherine Robichaux, PhD, RN; Mari Tietze, PhD, RN-BC, FHIMSS; Felicia Stokes, JD,MA, RN; and Susan McBride, PhD, RN-BC, CPHIMS, FAAN. This article examines and critiques a 2009 article published exactly 10 years ago in ANS that focused on the electronic health record and propose a virtue ethics framework for the future (see Dilemmas, Tetralemmas, Reimagining the Electronic Health Record). It is available for free download while it is featured, and we welcome your comments related to this important topic!  Here is a message from Dr. Robichaux about this work:

L to R – Felicia (Liz) Stokes, Mari Tietze, Catherine Robichaux

We are very happy to have this article published in the Critique and Innovation issue of ANS. This is our second collaborative publication and we each bring different experiences and perspectives to the complicated issues inherent in the development and use of the electronic health record (EHR). Susan and Mari are nurse informaticists, researchers and educators, Catherine’s background is ethics and education, and Liz (Felicia) is a nurse ethicist, policy expert and attorney. As with our first article, this manuscript evolved from Susan and Mari’s research exploring nurses’ experiences with the EHR in which the participants described a wide range of advantages and disadvantages.  Recognizing that it had been ten years since passage of the HITECH act in 2009, we were interested in whether some of the problems

Susan McBride

described in their research were identified ten years ago. Through our literature review, we discovered the article by Petrovskaya, McIntyre, and McDonald, Dilemmas, tetralemmas, reimagining the electronic health record.  This article beautifully analyzes advanced technologies with the ethical and philosophical constructs of caring in nursing.  Rather than viewing the use of technology and caring practice as an either/or dilemma, they suggested application of the tetralemma, a Buddhist approach which expands the range of choices.

Although positive aspects of the EHR have been realized since 2009, many problems identified by Petrovskya et al. continue. We discuss these ongoing challenges to patient safety and nursing practice and suggest integration of polarity thinking with the tetralemma as a viable approach to resolution.  Petrovskya et al. also addressed the potential negative impact of the EHR on ethical nursing practice and we explore the relevance of virtue ethics and technomoral wisdom in revisioning the EHR as a caring technology.

We believe that the roles of nursing leadership, education, research and organizational accountability are all critical in addressing the issues identified in this article.  We hope this discussion is helpful to readers and we look forward to your comments.

 

 

Creating Authentic Caring Relationships with Children Who are Technology-Dependent


In our current featured article the authors explore ways to create authentic caring relationships based on Watson’s Caring Science.  The article is titled “Caring for Children Who Are Technology-Dependent and Their Families The Application of Watson’s Caring Science to Guide Nursing Practice” authored by Sydney Breneol, BScN; Lisa Goldberg, PhD and Jean Watson, PhD. This article is accredited for Continuing Education, and you can download this article at no charge while it is featured on the ANS website. We would be delighted to hear from you in response to the ideas in this article!

Here is a message from the lead author, Sydney Breneol, about this work:

Sydney Breneol

This article was developed during my nursing theories and philosophy course in my first year of doctoral studies. We were encouraged to philosophically explore a topic that had meaning to us. At a young age, I was diagnosed with a chronic illness. Throughout my hospitalization, I developed strong relationships with many of the nurses who cared for me and was personally impacted by the positive effect nurses could have on their patients’ outcomes. These nurses displayed compassion and care and were integral to my recovery. These experiences have largely influenced my career as a registered nurse and doctoral student. My doctoral work focuses on improving health care for children with medical complexity and their families. This article focuses on those children requiring medical technology to sustain or optimize life. These children often experience frequent admissions to hospital. It is critical that nurses work to develop and foster a caring relationship with children who are technology-dependent and their families. This critical review examined the experiences and unmet care needs of children who are technology-dependent and their families. Findings from this review of the literature were analyzed using Watson’s Caring Science to explore how nurses can create an authentic caring relationship and environment for these children and their families within the hospital setting.

Breastfeeding in Disaster Relief Camps


Our current featured article addresses a health challenge that has become far too common in our era of climate change. The article is titled Breastfeeding in Disaster Relief Camps: An Integrative Review of Literature by Shela Akbar Ali Hirani, BScN, MScN, IBCLC, RN; Solina Richter, RN, DCur; Bukola Oladunni Salami, MN, PhD, RN; and Helen Vallianatos, PhD.  We invite you to download this article at no charge while it is featured, and return here to share your thoughts for discussion.  Shela Hirani prepared this information about her work for ANS blog readers:

Shela Hirani

Protecting breastfeeding practices of women is essential to reduce the number of child deaths and illnesses during emergency response. Disaster relief camps are one of the most vulnerable settings for mothers and young children where women are exposed to the risk of discontinuing their breastfeeding practices. In low middle-income countries like Pakistan where infant and child mortality is high, disasters and internal displacements result in a further increase in infant mortality and morbidity rates caused by suboptimal breastfeeding practices and subsequent rise of childhood malnutrition. To examine the factors that affect breastfeeding practices of displaced mothers in disaster relief camps, an integrative review of the literature was undertaken.

The review suggests that the breastfeeding experiences, behaviors, and practices of displaced mothers are shaped by a combination of gender-based, sociocultural, economic, and geopolitical factors. The literature review revealed gaps in knowledge on facilitators and barriers that shape the breastfeeding practices of displaced mothers residing in disaster relief in Pakistan. In view of the vulnerability of displaced mothers and rising child mortality rates in disaster relief camps in Pakistan, this review suggests a pressing need to explore a wide range of factors affecting breastfeeding practices of internally displaced mothers in the disaster relief camps in Pakistan. Research in this area is essential to design and execute context-specific and need-based programs, policies, and practices to protect, promote, and support breastfeeding practices of internally displaced mothers in disaster relief camps in Pakistan.

A thorough understanding of wide range of factors affecting breastfeeding practices of displaced mothers will develop nursing knowledge, guide future research by nurses involve in care of mothers and young children in disaster relief camps, and facilitate key stakeholders (health care professionals, policy makers and relief agencies) to develop context-specific supportive interventions, improve breastfeeding practices in relief camps, and potentially decrease deaths of young children.

In the year 2018, I travelled to the Northern region in Pakistan (Chitral) where thousands of families affected by natural disasters are residing in a variety of temporary settlements (disaster relief camps), mainly tents, transitional shelter and huts built out of mud and brick. I undertook a critical ethnographic study to examine the facilitators and barriers to breastfeeding practices of internally displaced mothers residing in disaster relief camps in Pakistan.

 

 

Unveiling Co-cultural Communicative Practices


We are now featuring the article by Cassie Wardlaw, PhD, MSW, PMHNP-BC; Donna Shambley-Ebron, PhD, RN, CTN-As titled “Co-cultural Communicative Practices of African American Women Seeking Depression Care.” In this article, the author’s report the outcome of their study, and in addition offer a model using two critical theories that can inform future research. Please share your comments and ideas related to the issues addressed in this article. Here is a message Dr. Wardlaw sent for ANS readers about this work:

Dr. Donna Shambley-Ebron hooding Dr. Cassie Wardlaw during graduation in April 2018

We are so honored to have our research study, “Co-cultural Communicative Practices of African American Women Seeking Depression Care” published in the current ANS issue featuring the topic of Culture, Race and Discrimination. This publication emanated from my PhD dissertation at the University of Cincinnati where I was a Substance Abuse and Mental Health Services Administration (SAMHSA) Minority Fellow. I had the privilege of presenting the preliminary findings of this study at the Transcultural Nursing Society annual meeting in 2017.  Moreover, for my dissertation work, I received the Outstanding PhD Student Award from the UC College of Nursing.

As a Psychiatric-Mental Health Nurse Practitioner, I was aware of data which indicate higher depression symptom severity and chronicity among African Americans.  I also understood that women of color face many challenges when seeking health care.  This led me to want to discover more about their experiences in the mental health care system, in order to improve care delivery for this population.  Moreover, I recognized that communication is a key factor in navigating within systems of care when attempting to achieve desired outcomes.  Dr. Mark Orbe’s theory, Co-Cultural Theory of Communication, explains the practices that people from traditionally marginalized groups use when communicating in dominant societal structures, which includes the health care system. This theory, in addition to Collins’ seminal work on Black Feminist Thought provided the theoretical underpinnings to support this study.

Dr. Wardlaw discussing the use of the frameworks used in the study at the University of Cincinnati

Dr. Donna Shambley-Ebron, my dissertation chair, mentor and co-author on this publication, is a certified Advanced Transcultural Nurse and a Transcultural Scholar. Her background in studying health issues facing African American women in addition to her experience in conducting ethnographies helped ensure the quality and integrity of this study.

African American women face unique challenges when seeking care, often related to past experiences with racism and subsequent distrust of providers. From the findings of this study which included interviews of 19 women who were receiving care for depression in community mental health agencies, we were able to develop a beginning theory about the influences that impact their communication practices. They were: intersectionality, system and structural impact, establishing trust, preserving self, and practice selection.  These findings demonstrated that African American women did indeed alter their communication in the mental health care setting. This was consistent with Orbe’s work. The implications of this study point to the need for nursing to move beyond basic assessment related to culture and examine the greater overarching issues related to power and dominant societal structures. Overall, we realize that the communicative practices of African American women who seek care for depression are complex and cannot be fully explained by the findings of this study. However, we believe that this study is an essential starting point in theory development regarding how African American women navigate the mental health care system.

 

 

Resisting Racism in Nursing


The current featured article in ANS offers critical insight into the dynamics of racism in nursing using narrative analysis. The article is by Nancy Clark, PhD, RN and Nasrin Saleh, RN, MPH, titled “Applying Critical Race Feminism and Intersectionality to Narrative Inquiry A Point of Resistance for Muslim Nurses Donning a Hijab”.  We invite you to download this article while it is featured, and share your comments and insights related to this important issue.  Here is a message sent by the authors for ANS readers:

Nancy Clark

Our article is based on the doctoral work of the second author who is a practicing Muslim nurse wearing a hijab. The article begins with a powerful quote by Nasrin Saleh stemming from her daily experiences and an encounter with one of her patients who accused her of being a terrorist based on her hijab. The article proposes a methodological approach that employs narrative inquiry framed within critical race feminism and the lens of intersectionality as a point of resistance for Muslim nurses donning to stand against their racialization.

We are very pleased to have our article published in ANS and in this special issue. Our article is timely and powerful, considering the dramatic and recent rise of islamophobia in the US, Canada, Europe and globally, and the current political climate, the heightened attention placed on Muslims by the media, the hypervisibility of Muslim women and nurses donning hijab, and the lack of knowledge on the experiences of Muslim nurses donning a hijab. Therefore, in our view, a main contribution of the article is in advocating for a collective antiracist social action in nursing by proposing a methodological approach to bring the voices of Muslim nurses donning hijab to the collective discourse

Nasrin Saleh

on racism in nursing, and to recognize and speak against the racialization of Muslim women/nurses. The article introduces religion as an axis of difference and the need for examining its intersections with gender and race in shaping the experiences of Muslim nurses donning hijab. This article is also a step forward in speaking against racism in nursing and to advance social justice.  

Promoting Culturally Safe Prenatal Care


The current featured article from ANS 42:2 is titled “Understanding Mi’kmaq Women‘s Experiences Accessing Prenatal Care in Rural Nova Scotia” authored by Laura Burns, BScN, RN; Joanne Whitty-Rogers, PhD, RN; and Cathy MacDonald, PhD, RN. Based on their study of Mi’kmaq women’s experiences accessing prenatal care, the authors reveal steps that are needed to improve culturally safe prenatal care for women at risk.  Here is a message providing the interesting background of this work from lead author Laura Burns:

Laura Burns being presented with the University Gold Medal in Nursing Award for the highest average in the final three years of study by StFX President, Dr. Kent MacDonald, and former StFX Chancellor, Dr. Susan Crocker.

I am so pleased to have this research study published in the ANS current issue: Culture, Race & Discrimination. I began this study as an undergraduate honours nursing student at St. Francis Xavier University. With the support and guidance of my previous supervisor, Dr. Joanne Whitty-Rogers, and second reader, Dr. Cathy MacDonald, I continued this work following graduation in 2017. I had the opportunity to attend the 44th Annual Conference of the Transcultural Nursing Society in San Antonio, Texas as a presenter. This international conference included over 260 participants from 48 cultures and more than 14 countries. Speakers and attendees included a diverse and global array of transcultural nursing and healthcare experts. The conference was an incredible experience for a novice researcher, as I engaged directly with theorists and providers from administrative, educational, practice, and research settings in a variety of panel discussions and breakout sessions.

Indigenous women experience a higher incidence of maternal complications compared with non-Indigenous women. Despite this, little is known about access to prenatal care for Mi’kmaq women in Nova Scotia. The purpose of this research study was to better understand the experiences of Mi’kmaq women accessing prenatal care in rural Nova Scotia. This was achieved using a Two-Eyed Seeing approach, by incorporating Indigenous and Participatory Action Research (PAR) principles to conduct research in a Mi’kmaq community. By using a feminist lens, Mi’kmaq women’s lived experiences were captured in a respectful manner, so as to legitimate their voices as sources of knowledge. Their experiences with access to prenatal care were used as a basis for building knowledge.

My early education of the Mi’kmaq people of Nova Scotia was essentially through the lens of Caucasian, Euro-Canadian perspectives. The importance of gaining an understanding of Mi’kmaq people’s experiences from their own perspectives became important to me during my first year of nursing school, when I was introduced to the concept of cultural safety. I recognized that nurses have the responsibility to continuously learn, and by listening to the stories of Mi’kmaq women’s experiences I developed an understanding of what it is like to navigate the Canadian health care system from a perspective that is much different from my own.  I remained aware of potential perceived power imbalances, as a non-Indigenous undergraduate student, I asked participants to share details of their personal maternal experiences.  The participants’ willingness and eagerness to share their experiences and offer suggestions to combat issues with access to prenatal care confirmed the importance of establishing partnerships with Mi’kmaq women, as they know what they need to improve their own health and the health of their community.

The findings from this study highlight key implications for nursing practice such as promoting the nurse’s role in supporting and advocating for Mi’kmaq women’s health and for providing culturally safe care. Throughout this study, it was evident that mothers, sisters, grandmothers, and aunties are significantly relied on for support, especially in regard to seeking reassurance and information. Colonization did much to destroy women’s ways of knowing about motherhood, however, many of these traditions still carry on, highlighting Indigenous mother’s strength and resiliency over time. This research will highlight that access to prenatal care is a complex issue for some women. Through this research process, it became evident that inequities in the social determinants of health impact women in accessing adequate prenatal care. Although barriers were identified, it is important to mention that all the participants in this study felt that they received the best prenatal care possible and were pleased with the care they received. This was especially true for the care and education the women received from the Health Centre in their community.

In an otherwise affluent society, Canada’s Indigenous women experience a disproportionate burden of maternal complications due to negative social determinants of health. Nurses have the responsibility to recognize these health inequities in practice, and advocate for clients and families. Nurses must play a key role in recognizing and addressing power imbalances within the health care system, so that equitable care may be achieved for all Canadians.

Laura Burns presenting her research study titled “Understanding Mi’kmaq Women’s Experiences Accessing Prenatal Care in Rural Nova Scotia” at the 44th Annual Conference of the Transcultural Nursing Society in San Antonio, Texas, October 2018.

 

 

Health Care Experiences of Transgender Adults


We are now featuring the article titled “Health Care Experiences of Transgender Adults: An Integrated Mixed Research Literature Review” authored by Ethan C. Cicero, PhD, RN; Sari L. Reisner, ScD; Susan G. Silva, PhD; Elizabeth I. Merwin, PhD, RN, FAAN; and Janice C. Humphreys, PhD, RN, FAAN.  This review, guided by a gender-affirmation framework, reveals many barriers to healthcare access that could be eliminated.  The article is available for no-cost download while it is featured, and we welcome your comments here!  This is the message the Dr. Cicero provided about this work:

© 2019 Ethan Cicero

Throughout the United States there has been a rise in public discourse about transgender people and transgender issues. Much of this attention stems from past and proposed anti-transgender legislation and governmental policies. Within healthcare, the Trump administration halted enforcement of the Affordable Care Act’s nondiscrimination protections for transgender people and most recently, a rule was issued that would allow healthcare institutions and clinical providers to deny healthcare to transgender individuals based on religious or moral reasons. These discriminatory and unjust actions oppose the medical guidelines of most professional medical and nursing associations, including the American Academy of Nursing, American Nurses Association, National Association of Pediatric Nurse Practitioners, and the National Association of School Nurses. Consequently, the decisions of this administration and the prejudice, stigma, and discrimination transgender people endure where they live, learn, work, and seek healthcare may contribute to the adverse health outcomes, social inequities, and barriers to equitable healthcare experienced by transgender individuals.

The transgender population is comprised of heterogeneous communities of individuals illustrating diversity of genders and gender expressions. In the United States, the transgender population is comprised of an estimated 1.4 million adults, which is more than the number of children and adults with type 1 diabetes. Transgender is an adjective used to describe individuals whose sex assigned at birth differs from their current gender or gender expression. This definition suggests a comprehensive approach to inclusion, but there are communities and individuals meeting its criteria who do not self-identify with the term (e.g., nonbinary, genderqueer, man or woman, gender expansive, etc.). In contrast, cisgender individuals have a gender that aligns with their sex assigned at birth.

With our integrated mixed research literature review, we described the scope of literature pertaining to the experiences of transgender adults accessing and utilizing healthcare in the United States. Evidence from the 23 articles synthesized indicated that transgender adults experience numerous obstacles accessing healthcare, discrimination from healthcare professionals and clinicians, and barriers to medically necessary care, such as gender-affirming (cross-sex) hormones, as well as primary and preventative healthcare. In light of our findings, the impact from the current administration on health outcomes and healthcare access is yet to be determined. However, the knowledge gained from this review can help nurses provide the best care for the transgender population. In order to promote health and well-being for transgender individuals, improvements to healthcare access, healthcare environments, and the clinical care provided are paramount.

Nurses play a key role in creating a care environment that is welcoming and affirming where all transgender people can thrive. It has been my experience that nurses do want to help, but many might be uncomfortable or lack an understanding in how to deliver gender-affirming care to transgender people, especially given the dearth of nursing curriculums designed to address caring for transgender communities. Although this may be true, there are plenty of evidence-based resources, including top-notch research in nursing and academic journals (Advances in Nursing Science!), and free online CEU/CMEs dedicated to improving the knowledge base of nurses. (Be sure to check out the Fenway Institute’s National LGBT Health Education Center)

Nurses can also join professional organizations, such as the World Professional Association for Transgender Health and the Association for Transgender Health Nurses, as well as attend professional continuing education conferences dedicated to transgender health. This September in Washington, DC, the United States Professional Association for Transgender Health (USPATH) will host their biannual conference, which will feature the first USPATH Nursing pre-course (see registration and pre-course details here). I’ve had the privilege and honor to partner with other nurse leaders in transgender health to establish and design this evidence-based course that aims to empower nurses to advocate for inclusive and equitable healthcare policies and clinical environments as well as ways to deliver gender-affirming care to transgender people across the lifespan.

As nurses, we can become change champions to improve and facilitate the delivery of gender-affirming healthcare. As outlined by the Nursing Code of Ethics, we have an ethical responsibility to maintain a safe and healthy environment for all patients. In order to improve the health and well-being of the transgender population, the time is now for us to focus our collective power in transforming and improving the healthcare experiences and care provided to all transgender individuals.

 

© 2019 Ethan Cicero

Queer Phenomenology, the Disruption of Heteronormativity, and Structurally Responsive Care


Our current featured article is authored by Jennifer Searle, BSc, BScN, RN, titled “Queer Phenomenology, the Disruption of Heteronormativity, and Structurally Responsive Care.” In this article, the author reveals heteronormativity as a prevalent, but largely unacknowledged, source of structural harms for LGBTQ patients and discusses the importance of gaining an awareness of ongoing structural harms that are disproportionately experienced by vulnerable patient populations. She shared this background about her work for ANS readers, and we invite you to download the article while it is available for download and share your comments and insights related to this work:

Jennifer Searle

I wrote this prior to being accepted into the doctoral program early, while I was completing the coursework for the Master of Nursing program. The paper was a major writing assignment that was supposed to explore a practice issue or experience. We were directed to use a theoretical lens to develop a manuscript for publication. Queer phenomenology was the methodology I had planned on using as a graduate student, but I have since switched to grounded theory for a number of reasons. The decision to leave queer phenomenology behind was largely informed by a realization that I no longer wanted to use an interpretive framework that sought to understand how heteronormativity is experienced within health care because this routinely caused me to re-engage with my own experiences of heteronormative-related harm.

As a lesbian, I experience harms that have been historically underrepresented, particularly in nursing literature. I often have to disclose personal experiences to illuminate the harms that heteronormative practices cause. I have found that those who do not experience such harms in their everyday realities often find it difficult to understand the risks of normativity to those who do not conform accordingly. This article does just that. I have taken an experience I had as a patient and used queer phenomenology to explain how being-in-the-world with heteronormativity causes harm to those who do not conform with the expectation of heterosexuality. I wanted to show both sides of a practice issue for this assignment and bring visibility to the intersection of my existence as both patient and healthcare provider. The systemic inequities that I experience are not unique to me as a lesbian or as a member of a historically marginalized group and like many others, I have come to anticipate being harmed. This informs my practice in ways that means I provide a level of care as a nurse that I have yet to receive as a patient. The risk of harm I was experiencing within my role as a graduate student became overwhelming and unsustainable. I felt as if I was always trying to convince others of the harm that characterizes my existence, which resulted in continued re-exposure to the trauma I experience in relation to discriminatory social structures. Some were easier to convince and I experienced most to be well-intended, but I came to realize that I must create distance between my harm and my work if I would be successful in finishing my graduate studies.

I believe this article reveals the necessity to provide care that has its intended impact and might even convey important insights into harm that resonates with members of dominant groups who have yet to gain an appreciation for the implications of professional education and training that inadvertently reinforces heteronormative assumptions. My understanding of harm has been expanded by queer phenomenology and it has provided me with a lens to make sense of a world that discriminates against me, but I did not feel as if my appreciation for how I might promote change within health care to address lesbian, gay, bisexual, transgender, and queer (LGBTQ) health disparities was furthered. Instead, I kept falling into a cycle of harm that has hindered my ability to focus on the purpose of my research. I want to know more about the process by which health services are delivered to LGBTQ patients by healthcare professionals who have received training that remains informed by a legacy of discrimination that once legitimized the stigmatization of non-heterosexuality via the pathologization of homosexuality. I no longer want to explore the ways in which people like me are harmed by a society that normalizes heterosexuality at our expense.

I believe the overall health system might be strengthened by narrowing the gap between health services provided by healthcare providers and those which are required to better meet the health needs of LGBTQ patients. Queer phenomenology will always shape my interpretation of the world around me and will likely inform the direction I take as a doctoral student, but its role in my work will be limited as such moving forward. Harm pulls focus on my ability to see a broader context and while I recognize that structural approaches can be overly deterministic and thus risk undermining the agentic possibilities available to individuals, this article reveals to me that agency will always be relative to structure. Those who are marginalized within broader society are likely to be constrained in their ability to re-act when they are re-exposed to structural harms. My experience as a patient as described in this article, demonstrates the role that healthcare professionals can take in understanding how a lack of reflexivity during the process of care delivery places patients at risk of being re-exposed to a lifetime of harmful assumptions, biases, and stereotypes. These subtler forms of harm often connect to personal, collective, and intergenerational traumas that are caused by social structures that discriminate, exclude, and marginalize individuals based on characteristics that they have no control over. As such, those who access health services are at an increased risk of being re-exposed to structurally-based forms of trauma.

As an educator, I recognize the ongoing gaps in nursing education in terms of perpetuating an assumption that marginalizing characteristics are visible and thus recognizable. I believe this sort of approach does us all a disservice. Members of equity seeking groups are not always recognizable; characteristics that relegate us to the margins are not always visible. Even if a person is visibly different, this does not mean that we, as healthcare professionals, can assume we know how a person’s lived reality is constructed alongside dominant cultures and normative expectations. Such an approach would surely reinforce stereotypes about groups rather than promote a layered understanding of individual circumstances in relation to structural conditions. This article is therefore offered as a means to explain that we, as healthcare professionals, must gain an appreciation for broader contexts of structural harm to situate individuals, understand their lived realities in safe and meaningful ways, provide what I describe as structurally responsive care, and minimize the risk of re-exposing patients to the traumas that characterize their existence.

Confronting Institutionalized Racism


Our first featured article in ANS 42:2 is titled “Words Matter: An Integrative Review of Institutionalized Racism in Nursing Literature” authored by Whitney Thurman, PhD, RN; Karen Johnson, PhD, RN, FSAHM; and Danica F. Sumpter, PhD, RN. This article, which provides insights that can guide dismantling racism in nursing, is available for download on the ANS website while it is featured.  Dr. Thurman shared this background about this work:

(l-r) Karen Johnson, Danica Sumpter, and Whitney Thurman

In 1999, the Institute of Medicine released the groundbreaking report, “To Err is Human.” One of the main conclusions of this report was that the majority of medical errors do not result from individual recklessness. Instead, errors are more commonly caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. Within this integrative review of the nursing literature, we hope our readers can see a parallel between focusing on institutionalized racism as a combination of systems and structures created in a culture that privileges whiteness and therefore requires systems-level solutions, just as medication errors require systems-level solutions. To be sure, similar to individual medication errors, individual acts of racism exist and must be quickly addressed. However, our purpose in conducting this review was to move the conversation past racism as merely interpersonal in order to challenge the nursing profession to understand and accept that racism is woven into the very fabric of this country and all of its institutions, including healthcare. After all, when it was written and signed, the Constitution of the United States did not consider African Americans to be fully human, and the ramifications of centuries of legalized discrimination and segregation did not vanish with the signing of the Civil Rights Act.

As nurses, we pride ourselves in serving our patient populations without judgement. The reality is, however, that all of us hold biases that have been formed– often without our awareness– by the larger culture and systems in which we operate. Similarly, patients bring with them a lifetime of experiences that influence their health beliefs and behaviors as well as their opportunities to be healthy and productive. As nurses with collective expertise and experience in public health, NICU, and pediatric nursing across teaching, research, and practice settings, we suggest that it is time for the nursing profession to reconsider our commitment to non-judgment. We challenge our readers to recognize and confront the systems that perpetuate health inequities, provider-level implicit biases, and individual-level overt and microaggressions. However, the challenge must be done in without re-centering the conversation on individual-level definitions and solutions to addressing racism. With greater intention to institutionalized racism across educational, research, and practice settings, nurses will be better equipped to dismantle systems and structures that perpetuate racial inequities in health.

Our hope with this integrated review is three-fold. First, this is a call to action to our nursing colleagues and students across practice, education, and research settings to engage in continuous self-reflection and dialogue about racism. Second, we challenge our peers to join us in owning our collective responsibility to recognize and challenge institutional policies that perpetuate racism and health inequities. Finally, we hope to amplify the voices– particularly those from communities of color who have been doing this work for ages– calling for us to address racism in our ongoing dialogue about health inequities. Specifically, we hope that the organizations and road maps that guide decision making for nursing and healthcare overall, such as the upcoming Healthy People 2030 and the Future of Nursing 2030 reports, will heed the recommendations of organizations such as the Black Mamas Matter Alliance and provide strong, evidence-based recommendations for nursing’s role in dismantling systems that have perpetuated racial inequities in favor of more equitable systems.

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