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Mar 2

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Modification of a Grounded Theory of Postpartum Depression


Appearing in the current issue of ANS is the article titled “Teetering on the Edge:
A Third Grounded Theory Modification of Postpartum Depression” authored by Cheryl Tatano Beck, DNSc, CNM, FAAN. Dr. Beck is widely known for her long research career that explores the challenges of postpartum depression using a variey of research methods and exploring conceptualizations and experiences in different cultural contexts. Her article is available to download at no cost while it is featured, and we welcome your comments here! Dr. Beck shared this message about her work for ANS readers:

Over 2 decades ago Glaser (2001) alerted grounded theorists that once their substantive theory was completed, their work should not end there. Glaser stressed that modification never stops for a grounded theory. A Glaserian grounded theory should be continually modified by constant comparison of new literature that has been published or new data the grounded theorist had collected. By continually modifying a grounded theory, the researcher can produce a theory with a higher level of theoretical completeness. Researchers can increase the scope of their grounded theory by choosing which groups to use for comparison.

My original grounded theory study of postpartum depression, Teetering on the Edge, was published in 1993. The photo I included in this blog is one of me interviewing a mother of twins regarding her experien:ces of postpartum depression. The sample for the original study included all Caucasian women. For 30 years I have been modifying my grounded theory to increase its transferability to other ethnic groups of women at risk for developing postpartum depression. Another reason for modifying Teetering on the Edge a third time was for educational purposes. I teach qualitative research methods to PhD students in nursing and other disciplines at the University of Connecticut. When it’s time in the semester to cover classic Glaserian grounded theory methods, I search databases for examples of modified grounded theories to share with my students but do not have much luck. More modified grounded theories need to be conducted and published to help educate our PhD students and qualitative researchers about this valuable option.

Feb 27

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Caring in the Context of Risk


The first article in the current issue of ANS is titled “Caring in the Context of Risk: Moving Beyond Duty” authored by Darcy Copeland, PhD, RN. The article is available to download at no cost while it is featured! Dr. Copeland shared this important message about her work investigating workplace violence!

Discussion of ethics or ethical frameworks is extremely rare in workplace violence literature. I have been investigating workplace violence for many years and view the phenomenon, in part, as an occupational hazard. When healthcare systems across the country were faced with a novel occupational hazard (coronavirus infection), there was swift and relatively agreed upon guidance regarding provider obligations and duties in the face of this risk. A duty-bound approach to decision making in the context of infectious disease seemed to work. I wondered if a duty-bound approach to decision making regarding the provision of care in the context of risk posed by patient violence would be similarly helpful.

I determined that a duty-based framework was insufficient to capture the contextual nuances and moral complexity of providing nursing care to hospitalized patients who exhibit violent behavior. I propose that examination of professional duties is one framework that can be used to guide our actions but might be insufficient if used in isolation of other frameworks. In the article I describe additional ethical frameworks and explore how they may also be used to guide decision making in the context of risk associated with violent patient behavior. These frameworks include virtue ethics, ethics of the everyday, and care ethics.

Nursing has a very long history of using virtue ethics to inform appropriate professional behavior. Virtues are characteristics that make one a “good” person/nurse and are not dependent on roles or duties. An internalization of nursing values results in a lack of distinction between being a good person and being a good nurse. Decision making utilizing this framework focuses our attention on what behaviors would maintain individual and disciplinary character in given situations.

Ethics of the everyday implores us to utilize our conceptions of “right” behavior in normal, everyday work to inform our behavior in circumstances that we deem as extraordinary, or at least out of the ordinary. This framework reminds us that we enact values as we live our ordinary lives, that everyday living is morally significant. How we conceptualize nursing and the provision of nursing care under “normal” circumstances can be used to inform decisions about the provision of care when “big” issues arise.

Finally, given the centrality of caring for others in nursing the inclusion of care ethics as a framework was obvious. This framework situates caring as occurring in the context of a relationship between two people – a caregiver and a care recipient. This perspective recognizes care as a complex site of power dynamics; it also draws attention to the humanity, needs, and vulnerability of both people. Attention to these aspects of care draw attention away from rules or duties that may be difficult to implement in complex situations.

Workplace violence is a major issue in nursing. It is also a complex issue that does not lend itself to standardized, algorithmic approaches. The more tools nurses and nurse leaders have in their tool box to determine how to respond to this issue the better.

Jan 17

Distant Reiki Intervention During the COVID-19 Pandemic


The current ANS featured article is titled “Experiences With a Distant Reiki Intervention During the
COVID-19 Pandemic Using the Science of Unitary Human Beings Framework” authored by Jennifer DiBenedetto, PhD, RN-BC. You can download this article at no cost while it is featured on the ANS website! Here is a message from the author about her research:

One of my research interests centers on mind-body therapies and its integration into conventional medicine to offer non-pharmacologic interventions to manage psychological and emotional distress in the community. A mind-body therapy I am especially interested in researching is Reiki therapy. Reiki therapy is a holistic healing modality that facilitates an exchange of life force energy to promote wellness in its recipient. As a Reiki Master and Registered Nurse, I enjoy integrating Reiki therapy into both my nursing practice and to clients in my local community.

When this study was designed and conducted, I was employed as a critical care nurse during the COVID-19 pandemic. I witnessed the way nurses cared for patients with COVID-19 and the effect it had on the emotional and mental health of patients, nurses, and the community. With stress and anxiety being especially high, along with my personal passion of engaging in self-care and practicing Reiki, it sparked my desire to research distant Reiki and its impact on perceived stress and anxiety using Rogers’ Science of Unitary Human Beings Framework. Distant Reiki was selected for this article due to its ability to offer healing in a socially distant way within the human-environmental field pattern.

This article stretches the lens of what is traditionally published in studies employing Rogers’ framework, particularly in its mixed method design and the interpretation of the qualitative and quantitative results. There is also novelty in the reconceptualization of the terms “stress” and “anxiety” by noting these patterns as perceptions of stress and anxiety. Further emphasis is given on the intentional presence of the nurse who is delivering the distant Reiki and how the openness allowed for the nurse and participant to engage in a mutual and dynamic process of generating new patterns. This pattern change is achieved through the promotion of participant awareness, self-reflection, self-discovery, and human choice. Verbal accounts from the participants, along with the instrument scores, support a transformative experience in fostering mental wellness, wellbecoming, and self-care. Future research into how nurses can use healing modalities into their practice, such as Reiki, to foster the nurse-patient relationship is needed.

Dec 13

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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.

References:

  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 https://news.aamc.org/patient-care/article/search-measures-matter-star-ratings-miss-mark/
  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/.cms.hhs.gov/HospitalQualityInits/downloads/Hospital3State_Pilot_Analysis_Final200512. pdf.

Nov 29

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.

Nov 15

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.

Nov 10

COP27 Climate Change Conference: Urgent action needed for Africa and the world


This Commentary is being published simultaneously in multiple journals.
See the full list of journals here.  

Wealthy nations must step up support for Africa and vulnerable countries in addressing past, present and future impacts of climate change

The 2022 report of the Intergovernmental Panel on Climate Change (IPCC) paints a dark picture of the future of life on earth, characterised by ecosystem collapse, species extinction, and climate hazards such as heatwaves and floods (1). These are all linked to physical and mental health problems, with direct and indirect consequences of increased morbidity and mortality. To avoid these catastrophic health effects across all regions of the globe, there is broad agreement—as 231 health journals argued together in 2021—that the rise in global temperature must be limited to less than 1.5oC compared with pre-industrial levels.

While the Paris Agreement of 2015 outlines a global action framework that incorporates providing climate finance to developing countries, this support has yet to materialise (2). COP27 is the fifth Conference of the Parties (COP) to be organised in Africa since its inception in 1995. Ahead of this meeting, we—as health journal editors from across the continent—call for urgent action to ensure it is the COP that finally delivers climate justice for Africa and vulnerable countries. This is essential not just for the health of those countries, but for the health of the whole world.

Africa has suffered disproportionately although it has done little to cause the crisis

The climate crisis has had an impact on the environmental and social determinants of health across Africa, leading to devastating health effects (3). Impacts on health can result directly from environmental shocks and indirectly through socially mediated effects (4). Climate change-related risks in Africa include flooding, drought, heatwaves, reduced food production, and reduced labour productivity (5). 

Droughts in sub-Saharan Africa have tripled between 1970-79 and 2010-2019 (6). In 2018, devastating cyclones impacted three million people in Malawi, Mozambique and Zimbabwe (6). In west and central Africa, severe flooding resulted in mortality and forced migration from loss of shelter, cultivated land, and livestock (7). Changes in vector ecology brought about by floods and damage to environmental hygiene have led to increases in diseases across sub-Saharan Africa, with rises in malaria, dengue fever, Lassa fever, Rift Valley fever, Lyme disease, Ebola virus, West Nile virus and other infections (8, 9). Rising sea levels reduce water quality, leading to water-borne diseases, including diarrhoeal diseases, a leading cause of mortality in Africa (8). Extreme weather damages water and food supply, increasing food insecurity and malnutrition, which causes 1.7 million deaths annually in Africa (10). According to the Food and Agriculture Organization of the United Nations, malnutrition has increased by almost 50% since 2012, owing to the central role agriculture plays in African economies (11). Environmental shocks and their knock-on effects also cause severe harm to mental health (12). In all, it is estimated that the climate crisis has destroyed a fifth of the gross domestic product (GDP) of the countries most vulnerable to climate shocks (13). 

The damage to Africa should be of supreme concern to all nations. This is partly for moral reasons. It is highly unjust that the most impacted nations have contributed the least to global cumulative emissions, which are driving the climate crisis and its increasingly severe effects. North America and Europe have contributed 62% of carbon dioxide emissions since the Industrial Revolution, whereas Africa has contributed only 3% (14). 

The fight against the climate crisis needs all hands on deck

Yet it is not just for moral reasons that all nations should be concerned for Africa. The acute and chronic impacts of the climate crisis create problems like poverty, infectious disease, forced migration, and conflict that spread through globalised systems (6, 15). These knock-on impacts affect all nations. COVID-19 served as a wake-up call to these global dynamics and it is no coincidence that health professionals have been active in identifying and responding to the consequences of growing systemic risks to health. But the lessons of the COVID-19 pandemic should not be limited to pandemic risk (16, 17). Instead, it is imperative that the suffering of frontline nations, including those in Africa, be the core consideration at COP27: in an interconnected world, leaving countries to the mercy of environmental shocks creates instability that has severe consequences for all nations. 

The primary focus of climate summits remains to rapidly reduce emissions so that global temperature rises are kept to below 1.5 °C. This will limit the harm. But, for Africa and other vulnerable regions, this harm is already severe. Achieving the promised target of providing $100bn of climate finance a year is now globally critical if we are to forestall the systemic risks of leaving societies in crisis. This can be done by ensuring these resources focus on increasing resilience to the existing and inevitable future impacts of the climate crisis, as well as on supporting vulnerable nations to reduce their greenhouse gas emissions: a parity of esteem between adaptation and mitigation. These resources should come through grants not loans, and be urgently scaled up before the current review period of 2025. They must put health system resilience at the forefront, as the compounding crises caused by the climate crisis often manifest in acute health problems. Financing adaptation will be more cost-effective than relying on disaster relief.

Some progress has been made on adaptation in Africa and around the world, including early warning systems and infrastructure to defend against extremes. But frontline nations are not compensated for impacts from a crisis they did not cause. This is not only unfair, but also drives the spiral of global destabilisation, as nations pour money into responding to disasters, but can no longer afford to pay for greater resilience or to reduce the root problem through emissions reductions. A financing facility for loss and damage must now be introduced, providing additional resources beyond those given for mitigation and adaptation. This must go beyond the failures of COP26 where the suggestion of such a facility was downgraded to “a dialogue” (18). 

The climate crisis is a product of global inaction, and comes at great cost not only to disproportionately impacted African countries, but to the whole world. Africa is united with other frontline regions in urging wealthy nations to finally step up, if for no other reason than that the crises in Africa will sooner rather than later spread and engulf all corners of the globe, by which time it may be too late to effectively respond. If so far they have failed to be persuaded by moral arguments, then hopefully their self-interest will now prevail.

Lukoye Atwoli, Editor-in-Chief, East African Medical Journal; Gregory E. Erhabor, Editor-in-Chief, West African Journal of Medicine; Aiah A. Gbakima, Editor-in-Chief, Sierra Leone Journal of Biomedical Research; Abraham Haileamlak, Editor-in-Chief, Ethiopian Journal of Health Sciences; Jean-Marie Kayembe Ntumba, Chief Editor, Annales Africaines de Medecine ; James Kigera, Editor-in-Chief, Annals of African Surgery; Laurie Laybourn-Langton, University of Exeter; Bob Mash, Editor-in-Chief, African Journal of Primary Health Care & Family Medicine; Joy Muhia, London School of Medicine and Tropical Hygiene; Fhumulani Mavis Mulaudzi, Editor-in-Chief, Curationis; David Ofori-Adjei, Editor-in-Chief, Ghana Medical Journal; Friday Okonofua, Editor-in-Chief, African Journal of Reproductive Health; Arash Rashidian, Executive Editor, and Maha El-Adawy, Director of Health Promotion, Eastern Mediterranean Health Journal; Siaka Sidibé, Director of Publication, Mali Médical; Abdelmadjid Snouber, Managing Editor, Journal de la Faculté de Médecine d’Oran; James Tumwine, Editor-in-Chief, African Health Sciences; Mohammad Sahar Yassien, Editor-in-Chief, Evidence-Based Nursing Research; Paul Yonga, Managing Editor, East African Medical Journal; Lilia Zakhama, Editor-in-Chief, La Tunisie Médicale; Chris Zielinski, University of Winchester.

Correspondence: chris.zielinski@ukhealthalliance.org

References

  1. IPCC. Climate Change 2022: Impacts, Adaptation and Vulnerability. Working Group II Contribution to the IPCC Sixth Assessment Report; 2022.
  2. UN. The Paris Agreement: United Nations; 2022 [Available from: https://www.un.org/en/climatechange/paris-agreement (accessed 12/9/2022)].
  3. Climate change and Health in Sub-saharan Africa: The Case of Uganda. Climate Investment Funds; 2020.
  4. WHO. Strengthening Health Resilience to Climate Change 2016.
  5. Trisos CH, I.O. Adelekan, E. Totin, A. Ayanlade, J. Efitre, A. Gemeda, et al. Africa. In: Climate Change 2022: Impacts, Adaptation, and Vulnerability. 2022 [Available from: https://www.ipcc.ch/report/ar6/wg2/  (accessed 26/9/2022)].
  6. Climate Change Adaptation and Economic Transformation in Sub-Saharan Africa. World Bank; 2021.
  7. Opoku SK, Leal Filho W, Hubert F, Adejumo O. Climate Change and Health Preparedness in Africa: Analysing Trends in Six African Countries. Int J Environ Res Public Health. 2021;18(9):4672.
  8. Evans M, Munslow B. Climate change, health, and conflict in Africa’s arc of instability. Perspectives in Public Health. 2021;141(6):338-41.
  9. S. P. Stawicki, T. J. Papadimos, S. C. Galwankar, A. C. Miller, Firstenberg MS. Reflections on Climate Change and Public Health in Africa in an Era of Global Pandemic.  Contemporary Developments and Perspectives in International Health Security. 2: Intechopen; 2021.
  10. Climate change and Health in Africa: Issues and Options: African Climate Policy Centre 2013 [Available from: https://archive.uneca.org/sites/default/files/PublicationFiles/policy_brief_12_climate_change_and_health_in_africa_issues_and_options.pdf (accessed 12/9/2022)].
  11. Climate change is an increasing threat to Africa2020. Available from: https://unfccc.int/news/climate-change-is-an-increasing-threat-to-africa (accessed 12/9/2022).
  12. Atwoli L, Muhia J, Merali Z. Mental health and climate change in Africa. BJPsych International. 2022:1-4 https://www.cambridge.org/core/journals/bjpsych-international/article/mental-health-and-climate-change-in-africa/65A414598BA1D620F4208A9177EED94B (accessed 26/9/22022).
  13. Climate Vulnerable Economies Loss report. Switzerland: Vulnerable twenty group; 2020.
  14. Ritchie H. Who has contributed most to global CO2 emissions? Our World in Data. https://ourworldindata.org/contributed-most-global-co2 (accessed 12/9/2022).
  15. Bilotta N, Botti F. Paving the Way for Greener Central Banks. Current Trends and Future Developments around the Globe. Rome: Edizioni Nuova Cultura for Istituto Affari Internazionali (IAI); 2022.
  16. WHO. COP26 special report on climate change and health: the health argument for climate action. . Geneva: World Health Organization; 2021.
  17. Al-Mandhari A; Al-Yousfi A; Malkawi M; El-Adawy M. “Our planet, our health”: saving lives, promoting health and attaining well-being by protecting the planet – the Eastern Mediterranean perspectives. East Mediterr Health J. 2022;28(4):247−248. https://doi.org/10.26719/2022.28.4.247 (accessed 26/9/2022)
  18. Simon Evans, Josh Gabbatiss, Robert McSweeney, Aruna Chandrasekhar, Ayesha Tandon, Giuliana Viglione, et al. COP26: Key outcomes agreed at the UN climate talks in Glasgow. Carbon Brief [Internet]. 2021. Available from: https://www.carbonbrief.org/cop26-key-outcomes-agreed-at-the-un-climate-talks-in-glasgow/ (accessed 12/9/2022).

Oct 31

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.

Oct 20

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

Oct 12

1 Comment

“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.

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