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Posts from the ‘Featured Articles’ Category

The Patient Experience

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

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

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

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

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

  • Comfort
  • Communication
  • Connection
  • Care

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


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

Maternal Role Attainment

The current ANS featured article is titled “The Evolution of Maternal Role Attainment: A Theory Analysis” authored by Bridget J. Frese, PhD, RN, CNM, CNL and My Hanh (Theresa) Nguyen, PhD, PMHNP-BC. This article is available to be downloaded at no cost while it is featured, and there are Continuing Education (Professional Development) units available if you complete the CE test! We also welcome your comments about this article here! The authors have provided the following background about their work, and a slide set presenting the main points of the article.

Brenda Frese
My Hanh (Theresa) Nguyen

I am a certified nurse-midwife and my co-author, My Hanh (Theresa) Nguyen, is a psychiatric mental health nurse practitioner.  Although in different nursing disciplines, our passion overlaps in supporting the mental health of new parents with a focus on maternal mental health.  Underlying this passion is the recognition and understanding of the joys and challenges that happen with the transition of becoming a mother.  Our article is a theory analysis of Reva Rubin’s theory of maternal role attainment (1967) which was updated by Ramona Mercer, who changed the name to the theory of becoming a mother (2004).  Using the theory analysis developed by Walker and Avant (2011), Dr. Nguyen and I highlight the strengths of this important theory as well as offer suggestions to update concepts and language that are inclusive of all people and families. In addition, we offer novel visualizations of Rubin’s and Mercer’s theories as they evolved over time.  The theory of maternal role attainment and becoming a mother is relevant to any nurse who works with patients or clients during this exciting time of growth, development, and transition for families.  This not only includes labor and delivery nurses and midwives, but also prenatal, postpartum, neonatal, pediatric, community health, and psychiatric nurses.  As we continue to learn more and grow our nursing profession, it is important to remember those nurses who have come before us, such as Rubin and Mercer, and continue to keep their work alive and relevant.

Caption: Mercer’s “Becoming a Mother”

  1. Pregnancy: commitment, attachment, and preparation
  2. Birth to 2-6 weeks postpartum: acquaintance, learning, and physical restoration
  3. 2 weeks to 4 months postpartum: moving toward a new normal
  4. Around 4 months: Achievement of the maternal identity
    The process of becoming a mother involves an initial four stages that overlap and move in a linear fashion. The four stages lay a foundation for the continual evolution that continues after the achievement of maternal identity. This process happens in the context of family and friends, who are situated in the larger community, which is situated in society.

Conceptual and methodological Issues in Symptom Cluster Research

The current ANS featured article is titled “Advances in Conceptual and Methodological Issues in
Symptom Cluster Research: A 20-Year Perspective
” authored by Carolyn S. Harris, BSN, RN; Marylin Dodd, PhD, RN; Kord M. Kober, PhD; Anand A. Dhruva, MD; Marilyn J. Hammer, PhD, RN; Yvette P. Conley, PhD; and Christine A. Miaskowski, PhD, RN. The article is available for free download here while it is featured, and we welcome you to read the article and share your comments here. Carolyn Harris shared this message about her work for ANS readers:

Carolyn Harris

My program of research is centered on the identification of phenotypic characteristics and molecular markers that place patients with cancer at increased risk for a higher symptom burden. This research is informed by several years of experience as an oncology nurse where I witnessed firsthand the complexity of effective symptom management. For example, while patients with cancer often report multiple, co-occurring symptoms, these symptoms are often assessed and treated one-by-one. In addition, the symptom experience of these patients is highly variable: with some patients reporting several severe and distressing symptoms and others reporting a lower number of symptoms with lower severity. As described in this paper, symptom cluster research has the potential to address these important clinical issues and improve the symptom experience of patients with a variety of chronic conditions. This paper provides conceptual clarity for the application of two analytical approaches to symptom cluster research and describes novel methods that have recently emerged to facilitate our understanding of symptom clusters.

Access to Care

The October – December 2022 issue of ANS (45:4) is just published! The first ANS featured article in this issue is titled “Access Denied: Nurses’ Perspectives of Access to Oncology Care Among Indigenous Peoples in Canada” authored by Tara C. Horrill, PhD, RN; Donna E. Martin, PhD, RN; Josée G. Lavoie, PhD; and Annette S. H. Schultz, PhD, RN. You can download and read this article at no cost while it is featured, and we welcome your comments about this work here! Dr. Horrill shared this information about this work for ANS readers:

Tara Horrill

My program of research centers on health and healthcare inequities in the cancer care sector. The research findings reported in “Access Denied…” represents one component of a multiple methods study that investigated issues of access to cancer care among Indigenous Peoples in Canada, and was the final component of my doctoral dissertation. My interest in issues of inequitable access to cancer care and Indigenous Peoples was born out of my experiences as a clinical oncology nurse, and repeatedly seeing Indigenous patients be diagnosed with advanced cancers, often cancers that we have the ability to detect early and treat. As I started to ask questions of clinicians around me as to why we were seeing these patterns, the responses I received often attributed these late diagnoses to “lifestyle” choices or increased cancer risk. Yet there seemed to be more to the picture that I wasn’t hearing, and I wondered about issues of accessibility, which formed the basis of my dissertation research. The findings reported in this article focus specifically on interviews with oncology nurses to understand their perspectives on the barriers to and facilitators of access to oncology care, which has not yet been explored in existing literature. We were particularly interested in nurses’ perspectives as they provide the bulk of clinical care, daily navigate the tensions between individual patient experiences of illness and suffering and the health system in which they work, and also have experiences of caring for Indigenous patients over time and various practice settings. Nurses provided important insights into many of the challenges surrounding access to oncology care and drew attention to the actual and potential work of oncology nurses in addressing these inequities. It seems the role of nurses is not often considered in relation to healthcare access, however these findings open space to not only see the valuable work being done by nurses, but to consider where and how we, as a profession, could better to confront inequities in access to oncology care for Indigenous Peoples by addressing healthcare access at all levels.

Rethinking Cheating on Written Exams

The current ANS featured article is titled “Redefining Cheating on Written Exams: A Shift Toward Authentic Assessment to Promote Universal Design for Learning in the Context of Critical Caring Pedagogy” authored by Laura A. Killam, MScN, RN; Marian Luctkar-Flude, PhD, RN, CCSNE; Sara Brune, MA, RN; and Pilar Camargo-Plazas, PhD, RN. Please visit the ANS website to download this article at no cost while it is featured, and share our comments about this article here! Laura Killam shared this message about their work:

Nurse educators have a responsibility to prepare students for ethical and safe client care, which is why significant efforts are put into preserving the academic integrity in assessments. We believe that authentic open-book take-home exams are a tool that can be structured and delivered in a way that minimizes cheating possibilities. This article explores how to enact Critical Caring Pedagogy by role modeling integrity during value-based dialogue. In addition we discuss why students may cheat and how educators can design their exams in a way that prevents cheating possibilities (see Figure). We hope that this discussion stimulates discussion and debate around how to create (nearly) cheat-proof authentic exams.

A Student-Centered Approach to Authentic Written Exams

“Sex” and “Gender” in Research Reports in Nursing Journals

The current featured ANS article is titled “An Analysis of the Use of the Terms Sex and Gender in
Research Reported in Nursing Journals
” authored by John R. Blakeman, PhD, RN, PCCN-K and Valentina M. Fillman, PhD, RN. This article is available to download at no cost while it is featured, and we welcome your discussion about the issues raised here on the blog! Dr. Blakeman shared the background related to this work here:

John Blakeman

I learned a tremendous amount of information during my PhD coursework. I can still remember sitting in my Theoretical Basis of Nursing Research course, discussing the importance of defining variables precisely and transparently. My classmates and I agreed that if variables were imprecisely defined, operationalized, or reported, trusting the findings of a particular study is more difficult and muddies the science. It was during this time that I began to think more carefully about the common variables used in research reports. Certain fundamental demographic variables, such as sex and gender, are among the most used variables in all research reports.

At the time, many questions circled my mind, including (but not limited to):

  • Do researchers carefully decide whether they will use sex, gender, or both as variables in their studies?
  • How precisely are sex and gender defined and operationalized in nursing research?
  • How much ambiguity exists in the way that sex and gender are described in research reports?
  • Do researchers understand the difference between sex and gender?

Simultaneously, I was beginning to think about my dissertation study – what variables I would include and how I would define and operationalize these variables. Notably, my dissertation work focused on women’s experience of prodromal myocardial infarction symptoms – those symptoms that occur in the days, weeks, and months before myocardial infarction. Thus, it was especially important for me to think about what I truly meant by women’s experiences… Did I mean biologically female (at least as assigned at birth, based on genitalia)? Did I mean woman, as in a person who identified as a woman, even if their sex assigned at birth was not female? Or did I mean something else?

As a first step in answering the many questions that I had about sex and gender, I undertook a comprehensive literature review, ultimately penning an article titled “Words Matter: Sex and Gender as Unique Variables in Research,” also published in Advances in Nursing Science. This initial paper helped me focus my thinking regarding these two variables, and upon completion of my PhD, I decided to more fully explore how sex and gender were used in the research published in nursing journals.

I collaborated with Dr. Valentina Fillman to conduct the present study. She and I had long discussions about what research questions to include and how best to capture what was “happening” in the nursing literature. Ultimately, we decided that we needed to start at a basic level, given that limited information has been published about how sex and gender are specifically used/reported in research published in nursing journals. We felt that this initial work could point us in new directions moving forward – highlighting areas requiring additional focus or attention.

While I will let the article speak for itself, so to speak, the bottom line is that we found a large amount of ambiguity in the way that sex and gender were defined, used, and reported across the articles included in our study. It is important to note that in some cases it was difficult to know how authors defined or used sex and/or gender, given that reporting was limited. However, even when sex and/or gender were more clearly reported, issues of ambiguity or imprecision were common. In some cases, sex and gender were used interchangeably, and it was difficult to know which of these variables the authors truly measured.

Ultimately, the findings of this study led me to the conclusion that all researchers need to decide with more care a) whether they will use sex, gender, or both as variables in their research, b) how they will define and operationalize these variables, and c) how they will clearly report these variables. As researchers, I think that we sometimes become so focused on defining and measuring outcome variables that we take the demographic or independent variables in a study for granted. Perhaps these demographic variables have become so familiar that we do not give them additional thought. However, I hope that this paper serves to remind us all of the importance of carefully measuring and reporting sex and gender in research.

Revisioning Obesity

The current ANS featured article is titled “Revisioning Obesity in Health Care Practice and Research: New Perspectives on the Role of Body Temperature” authored by Mary Madeline Rogge, PhD, RN, FNP, BC; and Bibha Gautam, PhD, RN, CNE. While it is featured you can download the article at no cost! Here is some background that Dr. Rogge shared for ANS readers:

Mary Madeline Rogge

Our area of interest is obesity, especially the problem of obesity recidivism.  Intensive efforts to promote healthy eating and higher physical activity, alone or in conjunction with pharmacologic agents or surgical interventions, have failed to quell obesity prevalence. Furthermore, decades of research have shown weight loss produced by a negative energy balance, or caloric intake below energy expenditure, is attended by a reduction in the basal metabolic rate that suppresses further weight loss and promotes fat recovery.  This annoying but consistent outcome suggests to us that obesity may serve a functional, protective function.  Furthermore, if excess fat serves a functional purpose, losing weight in obesity that does not resolve the underlying environmental stimulus may exacerbate the biological drive to gain more fat.  Based on this framework, we surveyed the literature in search of antecedents or precursors of weight gain, adipogenesis, or increased fat mass that could explain intractable obesity.

Our research revealed that a major function of adipose tissue is maintenance of core body temperature, and the body’s temperature regulation is highly integrated with body mass and energy expenditure.  White adipose tissue reduces heat loss through the skin, while brown adipose tissue dissipates or disperses heat.  Increasing body temperature activates temperature-sensitive hypothalamic receptors to reduce food intake and simultaneously stimulates brown adipose tissue energy dispersal.  Hypothalamic detection of cooler body temperature stimulates food consumption and lowers energy expenditure.

Other research shows normal body temperature in Americans has declined in men and women over the past century, which could explain the concomitant rise in the population’s adiposity.  Increased exposure to air-conditioning also corresponds to the acceleration of obesity rates during the same time frame.  We also found research that demonstrates exposure to whole-body warm ambient temperature is associated with fat loss in human subjects.

We conclude declining core body temperature and lower ambient temperature may be an important contributor to intractable obesity.  Revisioning clinical obesity as a problem of adaptation to pervasive low ambient temperature offers a new perspective for obesity research and management. 

Prenatal Primary Nursing Care in a Context of Vulnerability

Our current featured ANS article is titled “The Prenatal Primary Nursing Care Experience of Pregnant
Women in Contexts of Vulnerability: A Systematic Review With Thematic Synthesis
” authored by Émilie Hudon, MSc, RN; Catherine Hudon, MD, PhD; Maud-Christine Chouinard, PhD, RN; Sarah Lafontaine, PhD, RN; Louise Catherine de Jordy, MSc, RN; and Édith Ellefsen, PhD, RN. The article is “open access” and available to download on the ANS website. Émilie Hudon shares this background about her work:

Émilie Hudon

My research interests focus primarily on pregnant women in vulnerable contexts and prenatal nursing care. Soon, I will be submitting my doctoral dissertation, a descriptive and interpretative qualitative study aimed at better understanding the prenatal nursing care experience of pregnant women in vulnerable contexts. The experience of prenatal nursing follow-up has a significant influence on women’s use of health services. The nurse’s pregnancy follow-up can contribute to preventing health complications for both the mother and the fetus. In my doctoral project, I identified the factors influencing the experience of prenatal nursing care for these women, the way in which the relationship between the pregnant women and the nurse influences the experience of prenatal nursing care, as well as avenues for improving the prenatal nursing care experience of pregnant women in vulnerable contexts.

Living with HIV/AIDS & Diabetes during COVID-19

The current ANS featured article is titled “Self-management of the Dual Diagnosis of HIV/AIDS and Diabetes During COVID-19: A Qualitative Study” by Julie A. Zuñiga, PhD; Heather E. Cuevas, PhD; Kristian Jones, PhD; Kristine Adiele; Lauren Cebulske; Livia Frost; Siddhaparna Sannigrahi, BS; Alexandra A. García, PhD, RN, FAAN; and Elizabeth M. Heitkemper, PhD, RN. The article is free to download while it is featured and we welcome your comments and responses here! Dr. Zuñiga sent this message about her work for ANS readers:

Julie A. Zuñiga

My area of research is HIV self-management and HIV prevention in under-represented communities. I recently completed an NIH-funded mixed methods study of people with the dual diagnosis of HIV and diabetes to explore self-management barriers and facilitators for both conditions.  From the findings, we extrapolated that social determinants of health were more influential in this population than in people living with HIV only. In the context of Covid, it became easier for some people to engage in some diabetes management behaviors during the lock down period. With the stigma of blood and HIV, it can be uncomfortable for people with the dual diagnosis of HIV and diabetes to test blood sugar outside of their homes or around others. My current study continues the stigma and discrimination research umbrella with a focus on barriers, facilitators, and preferences for HIV prevention in the transgender and gender expansive community.

Coaching for Childbearing Health

The current ANS featured article is titled “Coaching for Childbearing Health: A Theory Synthesis” authored by Jennifer M. Ohlendorf, PhD, RN and Lisa Anders, PhD, RN, IBCLC. This article is available at no cost from the ANS website while it is featured! Here is a message from Dr. Ohlendorf about the importance of this work:

One of the highest priorities of nursing and advanced nursing practice is health promotion, specifically health behavior change.  Over the past 20 years, the science of health behavior change has developed into the science of self-management—because most of the actual “doing” of health promotion is comprised of daily choices made by people in the midst of their complicated lives.   What this means is that providers must find effective ways to use the limited time they have with patients to influence health behaviors people may engage in in their daily lives.

In my work, I am interested in patient-centric approaches to making physical activity and nourishing eating behaviors part of the perinatal transition.   Transitions are periods of disorganization, followed by a process of engagement in the life change, and then a period of reorganization.  The way the transition unfolds results in a person having achieved a new identity.  Nursing interventions aimed at key timepoints–taking into account the context of the person’s life–to promote positive self-management can result in the person having incorporated health behaviors as part of this new identity. 

This article presents a model that can be used during perinatal care visits to engage in goal setting and planning with pregnant people to promote physical activity and nourishing eating behaviors.   The Coaching for Childbearing Health (CoaCH) Model incorporates salient concepts from Ryan and Sawin’s Individual and Family Self Management Theory (2009) and from Meleis’s Transitions Theory (2000), along with qualitative data women shared as part of a goal-setting intervention during pregnancy.  The qualitative data was keyThe resulting model can be used to design context-appropriate interventions nurses could use in prenatal practice to promote healthy behaviors across the perinatal transition.

This model has already been used to design a coaching intervention and feasibility testing is complete for the intervention. Next steps are to work with our clinical partners to begin a full-scale trial so that, in the future, this coaching can be implemented by nurses in perinatal practice to partner with people who are pregnant or postpartum to develop sustainable, healthy behaviors.

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