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Posts from the ‘Featured Articles’ Category

Transforming Health Interviews

The first featured article in ANS Volume 41:4 discusses ways to move interviews to approaches that more clearly reflect the context and experience of health challenges.  The article is titled “Creating Emancipatory Dialogues About Identity and Health by Modernizing Interviews,” authored by Doris M. Boutain, PhD, RN, PHNA-BC; Robin Evans-Agnew, PhD, RN; Fuqin Liu, PhD, RN; and Marie-Anne S. Rosemberg, PhD, RN. The article will be available to download at no cost while it is featured, and we invite you to read it and join a discussion in this blog!  The authors sent this message about this work for ANS blog readers:

Imagine the following scenario: it is the afternoon of a school day and a health

Doris M. Boutain

researcher, the recruited youth, and parents meet for the first time. The place is a quiet corner of a public café selected by the parents who will give their consent for research participation. The researcher explains the study using consent forms previously distributed to the family to read. The parents ask a few questions and then sign the consent form. The youth also signs the assent form. Then the researcher conducts a short interview asking the youth some pre-selected, close-ended questions about demographics and establishes a follow-up meeting time. What is the value of the information collected in this encounter, and who owns this value? How does this

Robin Evans-Agnew

encounter set up the power-relations for the development of knowledge for the remainder of the research study? What did the researcher miss that might have been important concerning the identity and health of the youth.

We developed this article to share another way to design an interview. Dr. Boutain was first introduced to the need to transform the interview in her dissertation research on hypertension management with African Americans in rural South Louisiana in 1999. In her dissertation, she describes a story of how she developed her interview questions using the advice from two neighborhood groups who both instructed her to modify the interview question “How much money do you earn in a year?”, by phrasing it differently and having a different target

Fuqin Liu

of inquiry. Namely, they suggested the two questions, “Are you doing okay making your ends meet?” together with “How does making ends meet affect your blood pressure?” The neighborhood groups’ suggestions led Dr. Boutain to consider a genesis of power in the interviewer-interviewee relationship. Namely, two questions became apropos: Who decides which questions to ask in the interview?, and Which interview questions are most meaningful for research participants?. The neighborhood groups taught Dr. Boutain to ask about the relationship between identity and health, and to care about the research participants’ way of relating their identity to their health in the process of the interview. The neighborhood groups provided a public service to Dr. Boutain and created the emergence of the Identity-Research-and Health

Marie-Anne S. Rosemberg

Dialogic-Open-ended interview (I-REH-DO).

As former graduate students and current colleagues working with Dr. Boutain we identified ourselves in a participatory scholarship group called “Scholars Ready”. Drs. Evans-Agnew, Liu, and Rosemberg, applied the I-ReH-DO interview in their own research beginning in 2010. Our article is an opportunity to provide new insights into the application of the I-ReH-DO interview across diverse, and critically situated, research interests. Our work involves community-based inquiry and health interview environments similar to the scenario above. Dr. Rosemberg’s interests lie in transnationalism and immigrant worker health, including people working in hotels and nail salons. Dr. Liu conducts inquiry about global maternal child health, especially in preconception and interconception care policy in China. Dr. Evans-Agnew focuses on childhood asthma inequities, citizen science, and environmental justice with Latina and African American groups. Dr. Boutain, as the John and Marguerite Walker Corbally Professor in Public Service at the University of Washington, has deepened her interests in systems research to promote knowledge about how to sustain health equity policies and practices with community-based organizations, faith-based organizations, and public health programs and services.

As scholars ready to advance emancipatory research methodologies, we are excited to publish the use of the I-ReH-DO interview. We regard the I-ReH-DO interview as an important visioning tool for new and experienced researchers to elicit novel ways of knowing about identity and health. The I-ReH-DO interview will facilitate research encounters which advance the power of participants to define their identity and health in a way that is significant and relevant for them. Thus, we as researchers will support the emergence of emancipatory research generation. We envision that the use of the I-ReH-DO will: (1) facilitate knowledge generation from participants who define themselves for themselves; (2) extend the close-ended facet of demographic surveys to result in rich contextual data; (3) inform sustainable programs/interventions that are applicable to individuals’ identity; and (4) foster changes in structural/systemic forces that participants identify as drivers of their health.

Doris M. Boutain
Robin Evans-Agnew
Fuqin Liu
Marie-Anne S. Rosemberg


Structuring Nursing Knowledge

The current ANS featured article presents a new way of structuring nursing knowledge.  It is title “The Nursing Knowledge Pyramid: A Theory of the Structure of Nursing Knowledge” by Veronica B. Decker, DNP, PMHCNS-BC, MBA and Roger M. Hamilton, PhD.  This article is available to download at no cost while it is featured, and I join the authors in inviting you to post your comments here, and to join in a discussion of their work!  Dr. Decker shared this message about the evolution of this work:

Veronica Decker

The idea for the Nursing Knowledge Pyramid started in the fall of 2012 when I was in my first semester of a Doctor of Nursing Practice (DNP) program at Wayne State University. I was going to school full time and working full time. I was (and still am) living in Orlando Florida and I attended my courses synchronously on-line. The internal visual I maintain from this time includes seeing my cohort in their classroom seats in downtown Detroit, while I was in front of my lap top video cam in the den of my home, in sunny Florida. Most of the time, my fellow classmates would instant message me that they were a little jealous of the weather.

I was taking a course on foundations in nursing from doctors Nancy George and Rosalyn Peters when my work on knowledge development started. I was trying to get my head around integrating philosophical and theoretical perspectives of nursing to create a solid foundation for nursing practice and meet the requirements of an assignment for the course, which included a very detailed rubric. The paper I submitted to my professors was titled Toward a Theory of Cancer Coping. I titled it after Imogene King’s 1971 – Toward a Theory for Nursing: General Concepts of Human Behavior in mind. It made sense to me because I realized my ideas weren’t fully established yet, but I had made a solid start. This first document included a concept map that aligned King’s conceptual system with my own nursing system model, which included the Nursing Knowledge Pyramid. Over the next two years, nearly every assignment even remotely asking for use of theory, I would continue to enhance and better define this work.

As many of you know, DNPs are required to complete projects rather than the traditional PhD dissertation. To meet the requirements of my program, I completed two projects. A clinical performance improvement project (Decker, Howard, G.S., Holdread, H., Decker, B.D., Hamilton, R.M. 2016). and a theoretical application by developing a practice theory called Substructing a Cancer Coping Rule-base, which included the Nursing Knowledge Pyramid.

The Nursing Knowledge Pyramid (NKP) is a practical approach to support nursing practice. In my DNP program I was able to use the pyramid as a means of bridging the gap between theory and practice. As an experienced psychiatric mental health advanced practice nurse (APRN), I could operationalize the research project by methodically going from abstract knowledge (bottom of the NKP) to the concrete knowledge (top). The abstract level of the project was my knowledge as an APRN developed over my 30 years of experience. The middle tiers indicate the theoretical underpinnings and evidence-based practice. The most concrete knowledge at the top of the pyramid was the rule-base used to offer my patients coping strategies to handle their distress. Most recently we utilized the NKP to help develop the key conceptual relationships and theoretical foundation for a case study where the patient had an unrealistic fall risk appraisal. The patient was treated with a feedback strategy to reframe her perception of risk of falling. I’m interested in feedback from others who are considering using the NKP in their research.


Decker, V.B., Howard, G.S., Holdread, H., Decker, B.D., Hamilton, R.M. (2016). Effects of an Automated Distress Management Program in an Oncology Practice. Clinical Journal of Oncology Nursing, 20(1), e9-15.

King, I.M. (1971). Toward a Theory for Nursing: General Concepts of Human Behavior. New York, NY: Wiley.

Theory Development Strategies for Middle Range Theories

The current featured article in ANS provides an analysis of methods used for development of middle-range theories over the past decade, titled “Theory Development Strategies for Middle-Range Theories” by Eun-Ok Im, PhD, MPH, RN, CNS, FAAN. Download the article at no cost while it is featured!  Here Dr. Im describes the background of this work:

First of all, I want to say that it is my great honor to have another paper published in Advances in Nursing Science.  Advances in Nursing Science has

Eun-Ok Im

been my number one journal in learning, developing, and disseminating my theoretical works throughout my career. I really appreciate all the works in Advances in Nursing Science that have been the insights for all my theoretical works.

This summer, I was in Australia, “the land down under.” They were having a winter while it was an obvious hot summer in North Carolina where my home was (please enjoy the below pictures from Australia; Koala was sleeping while showing only their back, and the winter beach had lots of rain and winds). Their cars were driven on the opposite direction; drivers were sitting on the right side and cars were going on the opposite lanes. So, I needed to think from the opposite side even when crossing the streets. Likewise, this paper started from the opposite side of a meta-theorist (that I personally identify myself); what students would want to know about middle range theories.

This paper was initiated because of my PhD students who asked me about theory development strategies that had been used in development of middle range theories.  I had a class on middle range theories versus situation specific theories. Unlike situation specific theories whose development methods were clearly proposed in the literature, the theory development methods used for middle range theories were not clear in the literature, and the students were asking what had been recently used in development of middle range theories and how they could develop their own middle range theories. Unfortunately, I could not articulate a clear answer for their questions although I knew about several strategies that had been proposed and used to develop middle range theories in the literature. I didn’t have any idea on how middle range theories have been developed in recent years. That was the start point of this paper. From a student’s perspective, I myself wanted to know how middle range theories had been developed during the past 10 years.

Although the task of conducting a systematic integrated literature review was extensive, I need to admit that this literature review did not include the middle range theories that had been developed before 10 years ago. Thus, many of the famous and widely used middle ranges theories are missing in this review. I just wanted to see the currently used theory development strategies in the past 10 years so that I could see the current trends and provide directions for future development. Another point that I need to admit was: there was no in-depth investigations on the philosophical and methodological aspects of the middle range theories in this paper because many of the articles on middle range theories that were reviewed did not specify their philosophical and methodological bases of theory development; many of them were confused even on the types of theories that they developed.

Despite these limitations, it was obvious that middle range theories became an essential part of theoretical bases in nursing, and I can see their steady and continuous development during the past decade. At the same time, I can see the necessity of further development of middle range theories in their philosophical and methodological bases. Hope this article could give an understanding on what is happening in development of middle range theories and hope this could give some insights to future theorists as I got my insights from the theoretical works that have been published in Advances in Nursing Science.

Best luck to all of us during this hot summer~  Or, cold winter (for many of us)~

From Eun-Ok Im, in Summer, 2018 in the U.S.




Nursing Health Assessment Using Storytelling

The current ANS featured article reports a project that demonstrates how storytellng as a means of assessment has the potential to expose the complexities of health experiences that are not readily uncovered using standard assessment approaches.  The article is titled “Narrative Inquiry Into Shelter-Seeking by Women With a History of Repeated Incarceration: Research and Nursing Practice Implications,” authored by by Amanda Marie Emerson, PhD (English), PhD (Nursing), RN.  Dr. Emerson shared this information about her work:

I had the enormous good fortune during my PhD program in nursing (2017,

“The Sexual Health Empowerment (SHE) for Cervical Health Literacy and Cancer Prevention study team, December 2017: (Back row) Katherine Gwynn, Amanda Emerson, Molly Allison, Brynne Musser. (Front row) Joi Wickliffe, Megha Ramaswamy (PI), Shelby Webb. Used by permission.

University of Missouri-Kansas City) to become part of an interprofessional team (RNs, public health professionals, health educators, medical residents, social workers, a sociologist, and even a historian!) doing cervical cancer prevention research led by Dr. Megha Ramaswamy (PI) at the University of Kansas Medical Center, and my mentor Dr. Patricia Kelly (Co-I) (UMKC). The Sexual Health Empowerment (SHE) study, funded by the National Cancer Institute, sought to learn whether a interactive, trauma-informed, small-group intervention centered on cervical health literacy and feminist principles would increase up-to-date Pap screenings among women detained in county jails. We implemented the program with successive cohorts of women over 2 years beginning in 2014 and have been following up for 3 years. In addition to my role in the intervention itself, I took part in an ethnographic sub-team that conducted interviews and participant observation with a group of volunteers in the community after their release.

The Advances in Nursing Science article reports on a series of particular interviews I conducted with those women. We were initially impressed by the variety of strategies women used in highly challenging circumstances (i.e., poverty, physical and emotional abuse, child separation, even during incarceration) to get and give social support to one another. In my analysis of the interviews—a course of coding, reiterative reading for themes, memoing, discussion with team members—a particular set of stories coalesced. Almost to a woman, the participants in our follow-up research struggled to find secure housing when they returned to the community. This basic need drove many of the stories they told, organizing how they perceived and interacted with others and impacted how they understood choices related to their health and safety. It bears noting that I have a background in literature as well (PhD, 2004) where I learned to recognize the power of stories to give form to versions of self and other, to shape feeling and motivate behavior. The stories about shelter-seeking told by women with histories of repeated incarcerations in this study were not long, but they were rich in implications for the women’s health. The analysis I present in this narrative inquiry maps a couple key trajectories the stories about shelter seeking take and serves as a call to nurses who work with women in the community who may have backgrounds involving incarceration. I urge nurses to listen up, to make stories part of the assessment. As my analysis illustrates, those narratives can carry otherwise unavailable information about threats to health and safety and open up valuable opportunities for nurse-led education and advocacy.


Testing a nurse developed, patient-centered health tracking app

The current featured article in ANS is titled “The Usability and Acceptability of a Patient-Centered Mobile Health Tracking App Among a Sample of Adult Radiation Oncology Patients,” authored by Susan D. Birkhoff, PhD, RN; Mary Ann Cantrell, PhD, RN, CNE, FAAN; Helene Moriarty, PhD, RN, FAAN; and Robert Lustig, MD, FACR. The article is available at no cost while it is featured on the website!

In speaking about this work, Dr. Birkhoff emphasized how important it is for nurses to be involved in designing, creating, and evaluating digital tools. Nurses, she believes, have a rich perspective on what patients need, arising from their close relationship with patients.  Her work reported in this article arises from her realization that existing digital tools lack the perspectives that nurses bring to healthcare. In this video, she speaks to her experience conducting this study, and why it is important.

Caring in the Margins: An Approach to Transcultural Nursing

Our current featured article presents the use of a nursing model in practice.  It is titled “Caring in the Margins: A Scholarship of Accompaniment for Advanced Transcultural Nursing Practice,” authored by Ruth C. Enestvedt, PhD, RN; Kathleen M. Clark, DNP, RN; Kaija Freborg, DNP, RN; Joyce P. Miller, DNP, RN; Cheryl J. Leuning, PhD, RN; Deborah K. Schuhmacher, DNP, RN; Kristin M. McHale, DNP, RN; Katherine A. Baumgartner, DNP, RN and Susan L. Loushin, DNP, RN.  We welcome you to download this article at no cost while it is featured, and share your comments here!  Dr. Enestvedt shared this message giving background to this work for ANS readers, followed by several photographs from the project reported in the article (used by permission):

Point of view shapes interpretation.  How can professionals shift their point of view in encounters with people in unfamiliar cultural settings?  In social margins? 

Ruth C. Enestvedt

Professionals are often in their own familiar settings, or they can structure a setting to fit their context of explanation.  Formal assessment procedures are quite efficient in this process. Field work for a PhD in Critical Medical Anthropology gave me insight into how low income elderly women resist professional control in health care encounters.  These “strategies of resistance”  are frequently troubling to professionals and considered to be e.g. “manipulative behavior” or “non-compliance” or “knowledge deficits” (1). I came to see them from the perspective of the poor elderly women as attempts to assert autonomy in these meetings. I also learned how critical social/cultural context is to understanding the meaning of behavior.  During my field work I had more than a decade in the the low-income public housing complex to gain some appreciation for the context of living in this social margin. In order to begin to understand the complex dynamics of such an unfamiliar setting, it was clear that I had to “de-professionalize” my interactions.

To do so, I developed the following “Rules of Thumb” for my interactions:

  • Acknowledge your ignorance (at least to yourself)
  • Have conversations NOT interviews (you don’t know what questions to ask and people will tend to give answers they think you want)
  • Listen for understanding
  • Beware questions that direct conversation
  • Respond to affirm (honor the complexity in the circumstance, the strength in the response)
  • Give direct answers
  • Assume there’s always more to it.

These insights were developed further in the care model that is central to this article.  They are foundational for Advanced Transcultural Nursing.

1 Scott, J.C.  (1990) Domination and the Arts of Resistance: Hidden Transcripts. New Haven: Yale University Press.


Graduating DNP Class of 2011. From top left to bottom right: Kristin M. McHale*, Susan L. Loushin*, Mary Ann Kinney, Kaija Freborg*, Joyce P. Miller*, Katherine A. Baumgartner*, Jean Gunderson, Deb K. Schuhmacher* (*author)

Kathleen M. Clark visiting with a guest at the Augsburg Central Health Commons (used by permission)

Nursing faculty and a volunteer providing outreach on the streets of Minneapolis

Predicting Birth Stress of Adolescent Mothers

We are currently featuring the ANS article titled “A Model to Predict Birth Stress in Adolescents Within 72 Hours of Childbirth” by Cheryl A. Anderson, PhD, RN, CNS and John P. Connolly, PhD, MLS, MBA, BEng. The article is available at no cost while it is featured.  Dr. Anderson sent this message for ANS readers  about her work:

Nearly a decade ago I attended a psychiatric nursing convention where the keynote speaker addressed the issue of birth trauma among adults in New Zealand. Her research findings greatly impressed me and I wondered how childbearing American women might differ, or be the same.  After exploring the literature I was surprised to see how few studies were conducted in America describing birth trauma, and virtually no studies on childbearing adolescents. As a maternal-child health nurse, I have seen many births among adolescents ages 10-20, and many were scared, depressed, and out of control.  I immediately reset my research goals to look into this area of interest within the potentially vulnerable population of childbearing adolescents 13 to 19 years of age.

Just recently we closed the data collection phase of this longitudinal study with 303 adolescents. I received help via many student research assistants along the way and together we published several articles on various aspects of the study. Currently a paper describing risk factor prevalence and racial/ethnic differences among the White, Black, and Hispanic adolescent child bearer is being written. In collaboration with Dr. John Connolly (statistician) another article is currently under review describing the pattern of depression and posttraumatic stress (PTS) across nine months postpartum.  Our last published article, “A Model to Predict Birth Stress in Adolescents within 72 Hours of Childbirth” in Advances in Nursing Science, is currently being featured.

With an evolving program of research a move was made recently from a population of adolescents to adults over 18 giving birth to preterm infants admitted into neonatal intensive care. As another vulnerable  population to experience depression and PTS, Phase 1 of this current study focuses on exploring the prevalence of depression and PTS and  mother –infant bonding over 18 months. At Phase 2, a random selection of mother-infant dyads will receive a novel, home-based intervention aimed at reducing infant developmental delays and improving maternal mental health and bonding.

A Scoping Review: Transitions, Stress & Adaptation among Emerging Adults

The first featured article for ANS 41:3 is titled “A Scoping Review of Transitions, Stress, and Adaptation Among Emerging Adults” by Kathleen M. Hanna, PhD, RN; Katherine Laux Kaiser, PhD, RN; Sara G. Brown, EdD, RN; Christie Campbell-Grossman, PhD, RN; Alissa Fial, MA, MLIS; Amy Ford, DNP, ARPN-NP, WHNP-BCS; Diane B. Hudson, PhD, RN; Rebecca Keating-Lefler, PhD, RN; Heidi Keeler, PhD, RN; Tiffany A. Moore, PhD, RN; Audrey E. Nelson, PhD, RN; Peggy Pelish, PhD, ARNP-NP and Susan Wilhelm, PhD, RNC.  The article is available at no cost on the ANS website while it is featured!  Here is a message from Dr. Hanna about their work:

This manuscript was the result of a project conducted by the College of Nursing Parent-Child Scholarship Group at the University of Nebraska Medical Center. These practice, education and

Kathleen Hanna

research scholars chose transitions as a focus for several reasons.

As articulated by Dr. Afaf Meleis and colleagues, transitions, important to the nursing discipline, are stressful, require adaptation and have consequences for health and well-being of those experiencing them. Those in the specialty of parent-child nursing have long addressed transitions. One has only to read the pioneering works of Reva Rubin and Ramona Mercer around the transition to motherhood to see an example.

When parent-child nurses work with infants, children, adolescents, emerging adults and parents, they incorporate developmental transitions as they address health/illness transitions such as diabetes, cystic fibrosis or cerebral palsy, to name a few. The focus on transitions was also congruent with the expertise of the co-leader and myself as leader. Dr. Kaiser, the co-leader, has expertise in transitions, developed from practice in public and community health nursing and research with high risk families with young children. Her most recent research focus has been with the transition of becoming a mother and risk. I have worked with adolescents and emerging adults throughout most of my career.

Most recently, I conducted research among emerging adults with type 1 diabetes. These youth are at risk as it is a period of multiple, co-occurring transitions such as the newly named developmental period of “emerging adulthood;” the health/illness one of type 1 diabetes; and situational ones of moving out of parental homes, graduating high school and/or entering the work force.  Thus, the first project for this Parent-child Scholarship Group was a scoping review of transitions, stress, and adaptation among emerging adults who are in this newly recognized developmental period and at high risk.

The findings of this review highlight the many common transitions these youth are experiencing as well as the variety of health outcomes such as management of a health/illness condition, typical-youth-related behaviors and/or developmental achievements.  We suggest further theoretical development and research among emerging adults experiencing multiple and sometimes co-occurring transitions.

Professional Governance

The current featured article in ANS is titled “Professional Governance Scale: Instrument Development and Content Validity Testing” by Marla J. Weston, PhD, RN, FAAN; Joyce A. Verran, PhD, RN, FAAN; Joanne T. Clavelle, DNP, RN, NEA-BC, FACHE and Tim Porter-O’Grady, DM, EdD, APRN, NEA-BC, FAAN. The article is available at no cost from the ANS website while it is featured.  Dr. Weston shared this message for ANS readers about this work:

The Professional Governance Scale research team began meeting over four years ago with the goal of developing and refining a new instrument to measure shared governance that could be used by aspiring and current Magnet® organizations. After more than thirty years of experience and maturation with shared governance, the team recognized that the context and concept had evolved and so there was a need to examine the concept with a fresh, contemporary perspective. One of the most insightful observations was that the term shared governance was originally selected in order to limit management resistance to legitimate nurse power over their practice and that it often created more confusion than clarity by leaving the content of what was shared in governance undefined. With deep analysis of excellence in nursing practice, the term professional governance was recognized as more accurately describing the practice of legitimate autonomy and control over the structures and processes of nursing care.

A concept analysis enabled the clarification of attributes and characteristics of professional governance, and subsequently guided item development. The second most interesting discovery of this work was during content validity testing of the instrument. Two groups of subject matter experts were used – those with expertise in instrument development and those with expertise in professional governance. Unexpectedly, relevancy ratings differed between the two groups of subject matter experts indicating that the unique perspective and expertise offered by each set of experts provided valuable input into the items and instrument development. This finding reinforces the importance of thoughtfully selecting content validity experts.

Upon reflection, this discovery also highlights one advantage of the composition of the research team. The combination of expertise in both instrument development and content on shared/professional governance facilitated a rich analysis and contribution to understanding an important facet of the professional practice of nursing.


Nursing Intervention for People Living with Parkinson’s Disease

The currently featured ANS article is  “It Is Hard Work, But It Is Worth It” – Patients and Spouses’ Experiences of a Nursing Intervention to Promote Adjustment to Deep Brain Stimulation for Parkinson’s Disease—A Feasibility Study by  Anita Haahr, PhD, MScN, RN; Karen Østergaard,

Anita Haahr

DrMSc, MD and Marit Kirkevold, DrEd, RN. We invite you to download this article (no cost) while it is featured, and share your comments here.  As leader of the Denmark/Norway team of researchers, Dr. Haahr shared this background about her interest in working with people living with Parkinson’s disease:

Parkinson’s disease has been my research focus for more than a decade. My interest in and passion for caring for persons living with Parkinson’s disease and their spouses, began when I was a nursing student. My passion developed further during my work as a neurological nurse. As a nurse researcher I have had a specific interest in exploring everyday living and coping with Parkinson’s disease when receiving deep brain stimulation. This focus has developed over time, focusing on how nurses and other health care professionals can support persons living with the disease and their spouses when coping with and adjusting to the unpredictability of living with the disease in the advanced stage, whether they are being treated with Deep brain stimulation, or in a general rehabilitation setting.
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