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Confronting Institutionalized Racism

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

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

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

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

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

Health Care Experiences of Lesbian Women

Our current ANS featured article is titled Health Care Experiences of Lesbian Women: A Metasynthesis authored by Marianne Snyder PhD, MSN, RN. Her metasynthesis offers insights that can assist nurses in providing sensitive and appropriate care for lesbian women.  This article is also our current continuing education offering, providing nurses in all area of practice an opportunity to explore the important issues raised here, and demonstrate understanding of these issues.

Dr. Snyder provided this message for ANS readers about her work:

Marianne Snyder ’17 Ph.D. on May 10, 2018. (Peter Morenus/UConn Photo)

Despite the increasing awareness about the health disparities among lesbian women, many in this population continue to  encounter discrimination in healthcare settings. We know from the literature that many lesbian women delay seeking preventative healthcare service based on previous negative encounters with a healthcare provider. This metasynthesis addresses the healthcare experiences of lesbian women as explicated across 14 qualitative studies. This study resulted in four overarching themes about lesbian women’s perceptions that emerge during a healthcare encounter. Lesbians cautiously navigate a healthcare visit by listening to the provider for statements based on heteronormative assumptions, responses to the women who voluntarily disclose their sexual orientation or have a partner who accompanies them to the visit.  A broader understanding of the factors that contribute to positive and negative experiences among these women can benefit current and future healthcare providers who strive to provide more culturally sensitive and affirming care. Lesbian women perceive providers who demonstrate a welcoming and affirming presence when communicating and caring more positively.

Realizing the focus of the discipline of nursing

The final featured article for this important issue of ANS (Vol 42:1) relates the perspective of doctoral students who share the experience of discovering the vital importance of nursing’s underlying perspective as an underpinning for practice.  The title of the article is “Realizing the Focus of the Discipline: Facilitating Humanization in PhD Education A Student Exemplar Integrating Nature and Health” by Tara M. Tehan, MSN, MBA, RN; Amanda E. Cornine, MSN, RN; Rita K. Amoah, BEd, BSN, RN; Thin Zar Aung, BSN, RN; Danny G. Willis, DNS, RN, PMHCNS-BC, FAAN; Pamela J. Grace, PhD, RN, FAAN; Callista Roy, PhD, RN, FAAN; Kathleen A. Averka, BA; Donna J. Perry, PhD, RN. The four doctoral student authors of this article shared this description of their experience:

Our article, “Realizing the Focus of the Discipline: Facilitating Humanization in PhD Education” began as an assignment in our nursing theory class. When Dr. Perry asked our cohort of four to “apply a nursing theoretical lens to nature and health” never in our wildest dreams could we anticipate that the assignment would lead to this article. Each of us was still learning what it meant to be a doctoral student, all while balancing careers and families.

Dr. Perry encouraged us from the onset to be creative and to consider untraditional products for this assignment. This license to think beyond the boundaries of papers and presentations spurred reflection and thought from the beginning and allowed us the opportunity to integrate the various roles we lived. In hindsight a children’s book seemed an obvious choice. Our classmate, Rita, recently reflected on what this assignment meant to her as a mother:

 Being in a graduate school as a wife and a mother of three young children is very challenging and stressful in all possible senses – physically, emotionally, and psychologically. The guilt of not being there for my children and countless occasions of delegating parent conferences and my kids’ games and performances to my husband become overwhelming sometimes. Studies evince a significant negative relationship between work-family conflict and life satisfaction, work satisfaction, and family satisfaction. As interpersonal support from family increases, perceived stress in graduate education decreases as noted by Iniki (2018).

This scholarly work undertaken with my colleagues that yielded this publication brought the assertions above into reality for me as a beneficiary with my first-grade daughter as the supporting agent to mitigate stress. The choice of including my child in this project was pricelessly meaningful to both of us. I remember how my daughter’s eyes widened with gleam and excitement the day I invited her to help my classmates and me do a project. Her anthem to siblings and friends through the week was, “I’m helping my mom and friends in their school project!” My personal interpretation of those words of hers is, “My mom’s schooling is not depriving me of her after all; I could still have fun with her even when she’s doing schoolwork!” To this day, Yiedie and I still reminisce on our experience on the trip to take pictures for this project. The lovely memories of the day are etched in our hearts.

As we worked together creating the book, we realized how transformative this assignment had been. By applying nursing theory in general, and the unifying focus specifically, we came to understand nursing theory and knowledge not as a static framework but as a reciprocal guide that is generated from experience and in turn guides practice. More importantly, we experienced humanization and improved quality of life. It is quite possible the renewal that came from this assignment carried us through the remainder of the year!

We hope this article spurs faculty and students to consider ways to apply nursing theory in a way that is meaningful to them.  We truly believe that theory guided practice comes from knowing and embracing theory in a practical and personally relevant way. Finally, we applied the principles of the unifying focus to public health. In the future we plan to further disseminate the  book to encourage children to enjoy the wonders of nature.  We hope that nurses in all role groups and settings can consider how they can apply the concepts of humanization, meaning, choice, quality of life and health to their practices; for it is through these concepts that we differentiate our practice from those of other health disciplines.

Thin Zar Aung, BSN, RN
Rita K. Amoah, BSN, RN
Amanda E. Cornine, MSN, RN
Tara M. Tehan, MSN, MBA, RN


Iniki, F. 2018),”My Life’s in Shambles: Examining Interpersonal Relationships as a Moderating Factor in Reducing Post-Graduate Stress” (Electronic Theses & Dissertations Collection for Atlanta University & Clark Atlanta University. 131.

Willis DG, Grace PK, Roy, C. A central unifying focus for the discipline: facilitating humanization, meaning, choice, quality of life, and healing in living and dying. ANS Advances in Nursing Science. 2008; 31 (1) :E28-E40. Doi:10.1097/01.ANS.000311534.0459.d9

Spiritual Knowing

Danny G. Willis

The current featured article from the current issue of ANS is titled “Spiritual Knowing Another Pattern of Knowing in the Discipline” by Danny G. Willis, DNS, RN, PMHCNS-BC, FAAN; Danielle M. Leone-Sheehan, MS, RN. In this article, the authors call for “stunning clarity” about the focus of the discipline. We are featuring this article during the time that a large number of nursing scholars will be gathered at Case Western Reserve University (Cleveland, Ohio, USA) toe.  examine the focus of the discipline, and chart the course forward in the development of nursing knowledge.  This article, and the other articles in this issue of ANS focusing on this topic, will be available on the ANS website at no cost for the next few weeks.  Dr. Willis sent this background about the work on which this article is based:

When Danielle Leone-Sheehan and I wrote this paper, it came from our collaborative engagement in living nursing theory and caring. Our experiences as n: urses and human beings compelled us to write about that which was special to us within the unitary field. As nurses grounded in nursing disciplinary knowledge and deeply appreciative of the view of life’s unfoldment afforded from within nursing’s unitary-transformative paradigm, we felt it important to explicate spiritual knowing as another pattern of knowing in nursing.  In a sense, we wanted to act as ‘illuminators of spiritual knowing’ drawing upon wisdom deep within ourselves that reflected our experiences as healers and teachers oriented towards all that is good, wholesome, and healing in being human. In our collective experiences across multiple dimensions of our lives as private citizens as well as in our nursing research, clinical nursing experiences, and teaching-learning-mentoring work with students, we’ve experienced the value of being the recipient of and holding-for-others this expanded spiritual consciousness  of compassion, peace, patience, kindness, and gentleness. We’ve known the power of spiritual knowing when discerning meaning or finding strength within difficult situations. We’ve felt compelled to claim and lift up that which is spiritual and central in the work of healing, caring, and humanization in its fullest sense.

This journey into the land of spiritual knowing has been inspiring. We look forward to the evolution of our expanded unitary spiritual knowing as the years unfold ahead. As we were planning this paper, our common insight was that spiritual knowing is real; yet, spiritual knowing has not been named, lifted up, privileged, and talked about within the wide world of nursing. This insight energized us to change this unfortunate reality. We named spiritual knowing as a unitary-transformative pattern of knowing the world. And, as we often reflect, once you’ve experienced spiritual knowing there’s nothing quite like it. There is a feeling of  alignment with a universal world of goodness without boundaries. Spiritual knowing is pan-dimensional and healing. It uplifts one’s consciousness into a more expansive unitary thought model than is possible without it. Spiritual knowing is important to human wellbeing such that nurses need to engage in further research/study about this pattern of knowing particularly with relevance to how nursing and caring grounded in spiritual consciousness influences nursing-sensitive caring outcomes and human wellbeing.

We wrote this paper to strongly advocate for spiritual knowing and to  intentionally focus our work as caring healers on spiritual qualities that uplift humankind. It has been our experience that human beings typically do well with lovingkindness, compassion, forgiveness, peacefulness, and experiencing self-other and living-dying within a larger framework of meaning and purpose. We are pleased that we have named and claimed spiritual knowing as a pattern of knowing for the discipline and profession of nursing on behalf of those we serve. We hope other nurses will find our writings valuable contributions to the ongoing evolution of nursing. Opening and Welcoming All – Come walk with us on this inspiring and expanding unitary-transformative journey.

Exploring the Knowledge Base of Nursing

The current featured article is authored by Mary Jane Smith, PhD, RN, FAAN and Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, titled “Perspectives on the Unitary Transformative PersonEnvironment-Health Process for the Knowledge Base of Nursing” . This article, along with others in the current ANS issue, will form a basis for discussion at a conference to be held March 20-21st at Case Western Reserve University Frances Payne Bolton School of Nursing.  The conference will be focused on exploring the knowledge base for nursing, and will commemorate the first nursing theory conferences held in 1967, 68 and 69.  The theme of the conference is “Nursing Theory: A 50 Year Perspective, Past and Future”  At the conference, participants will be doing exactly what the title of this post calls for – exploring the knowledge base of nursing. In this current featured article, the authors focus on a unitary-transformative perspective – one of a number of perspectives that contribute to the development of knowledge that informs and shapes nursing practice.  Download your copy of this article while it is featured – and come back here to share your comments and reflections!

The Future of Nursing

The current ANS featured article is titled “Nursing Knowledge in the 21st Century: Domain-Derived and Basic Science Practice-Shaped” authored by one of nursing’s best known scholars – Callista Roy, PhD, RN, FAAN. In this article Dr. Roy proposes a path forward for nursing that is clear, well-defined and vital to the future of nursing and healthcare. We invite you to download this article while it is featured and share your comments here – let us know your vision for the future!  Dr. Roy sent this message for ANS readers about her work:

Callista Roy

As I look back on the last 50 years of progress in nursing knowledge (Roy, 2018) I feel a great sense of pride in accomplishments of setting a firm foundation for the discipline of nursing and the practice of nursing as a profession.  Still, I feel challenged by a call to nurses to move forward in building on the advances in defining nursing to create a structure for knowledge for practice that accounts for our developments and those of all the sciences. This structure gives a central place to all levels of nursing theory. In this article, I present a full picture of nursing knowledge development as domain-derived and practice shaped. The figure (Figure 1 below) includes philosophical beliefs and values and has at the center, the goal of nursing. I really feel, as did Dorothy Johnson 50 years ago (Johnson, 1968) that a clear goal for nursing is the basis for developing knowledge. I selected the goals of facilitating humanization, meaning, choice, quality of Life, healing in living and dying from a publication on a central unifying focus for the discipline (Willis, et al. 2008) that has received attention in the literature in the years since. The right side of the figure proposes that nurses use all other scientific developments, including genomics by shaping them for practice. Nurses will contribute to this knowledge in other disciplines by asking practice relevant questions. However, the major efforts of nurse scholars will be to focus on domain-derived knowledge using all forms of inquiry.

In my view, the contribution of this article is the domain-nursing knowledge tree (see Figure 2 below). I am proposing that based on the over-all goals of nursing, each nursing grand theory has a way of contributing to these goals.  Each grand theory then is the basis for a number of model range theories that give rise to practice theories. This approach is open to controversy. I ask PhD students to consider the advantages of all theories aimed at common goals of nursing. Secondly, what do they think might be barriers to all theories aimed at common goals?  Every reader will have opinions on these and other questions. Still at this stage of my work, I feel called to put forth this possibility. I would love to see how this approach might turn out. I will also enjoy whatever happens by just putting the ideas forward.


Johnson, D. E. (1968). Theory in nursing: Borrowed and unique. Nursing Research, 17, 206-209.

Roy, S. C. (2018). Key issues in nursing theory: Historical developments and future directions. Nursing Research. Special Focus Issue on Theory and theorizing in nursing science. 67 (2). 81-92.

Willis, D., Grace, P., & Roy, C. (2008). A Central Unifying Focus for the Discipline: Facilitating Humanization, Meaning, Choice, Quality of Life and Healing in Living and Dying. Advances in Nursing Science. 31(1).  available online only:



Intermodernism and Nursing Theory Development

The current featured article in ANS 42:1 is by Pamela G. Reed, PhD, RN, FAAN title “Intermodernism: A Philosophical Perspective for Development of Scientific Nursing Theory.” This article will also serve as a focus of discussion at a conference that will convene at Case Western Reserve University March 21-22 in Cleveland, OH, celebrating the 50th year since the first conferences focused on the disciplinary perspective of nursing, and the structure of nursing knowledge. Dr. Reed’s article will serve as a focus for discussion and debate for years to come, prompting advances in nursing knowledge development in the years ahead.  Her aritcle is available to download at no cost while it is featured, and we welcome your comments here!  Dr. Reed sent this message about her work.

Pamela Reed

I am SO pleased to have this paper published in Advances in Nursing Science! It was in this same journal where in 1995 I published a treatise that introduced some initial ideas about a philosophy of nursing science, which I then labeled neomodernism.  This current paper is the outcome of my continued work (and passion) in philosophy of science as it relates to knowledge and theory development in our discipline. In developing this philosophical perspective, I was particularly interested in bringing together the foundational focuses of nursing knowledge with the creative and scholarly ways that nurses practice their profession and science. I drew from philosophical worldviews within and outside of nursing, and from philosophies of science more formally.

I also thought it important to provide (for readers and me!)  some historical perspective on philosophies of science and theory structure, as background for a philosophical view I am  proposing for nursing’s present and future.  Whereas I initially called this view neomodernism, I came to the decision that intermodernism better represented the post-postmodern philosophy that it is – one that incorporates both modern and postmodern ideas. I wanted to articulate a philosophical view that is meaningful to nursing and is also pluralist yet internally consistent.  Accomplishing all of this will likely involve continued work and dialogue!  In the meantime, I hope it can be useful among nursing students as they hone their research questions, and among nursing scholars and maybe also other health science scholars as they formulate new directions for research and practice.

Mostly I am hoping that this article generates discussion among nurses about the role of theory in building nursing knowledge – about new strategies for theory development that integrate practice and science more deliberately, and about expanding perspectives of our familiar ‘nursing theory’ to make it the central cog in the wheel of nursing inquiry into processes or mechanisms underlying human health and well-being.


Regenerating Nursing’s Disciplinary Perspective

Our first featured article for ANS 42:1 is titled “Regenerating Nursing’s Disciplinary Perspective” by Marlaine C. Smith, PhD, RN, AHN-BC, HWNC-BC, FAAN.  This article will also serve as a focus of discussion at a conference that will convene at Case Western Reserve University March 21-22 in Cleveland, OH.  The conference will be celebrating the 50th year since the first conferences focused on the disciplinary perspective of nursing, and the structure of nursing knowledge. Dr. Smith’s article is available for download while it is featured, and we invite you to contribute to the discussion of the important challenges that the article raises.  Here is a message from Dr. Smith, with some background about this work:

Marlaine Smith

This paper addresses a topic that has generated debate within the discipline of nursing for at least 50 years, just a little longer than I’ve been a nurse.  Even when I was younger, or newer in my career, I was in search of the answer to the questions, “What differentiates nursing from other disciplines?” “What is unique about what we study and what we offer to society?” “I’ve tackled that question and have answered it for myself, by stating that it is the study of human-environment health and healing through caring, and that through a caring relationship nurses promote health and healing of whole persons within their relevant environment (physical, social, political, economic)”.  Some may argue that this question is settled, but I disagree.  There are many troubling signs, “existential threats”, that tell me that these questions and answers are as important as they were 50 years ago. I’ve described some of them in this paper.

In my experience nurse researchers, scholars and practitioners are not at all clear about the nature of the focus of the discipline. I’ve taught undergraduate and graduate nursing students for over 40 years.  In many of my classes I introduced the question, “What is the focus of the discipline of nursing?” The responses are often related to what nurses do in practice, or that “we coordinate the activities of all the health professions”.  As we dug deeper they discover how defining nursing by what nurses do has left us vulnerable to others who have carved out a practice grounded in specialized knowledge related to their phenomena of concern. By defining nursing as a verb (what we do) without considering nursing as a noun (what we know and study) has strengthened the claims that registered and advanced practice nurses are assistants, coordinators, team members, and technicians.  I can’t tell you how many “A-Ha” moments I’ve witnessed after this discussion as students come to the epiphany that being clear about the focus of our discipline matters.

But, this isn’t about staking a claim for the discipline of nursing and defending it for our own sake.  It is about valuing nursing knowledge and the difference it makes to those we serve. Nursing knowledge is needed for the well-being of humankind.  When we conduct research contributing to the knowledge of medicine, psychology or sociology, or practice from the perspective of other disciplines, society suffers.  I do believe that nursing’s disciplinary perspective and the knowledge and practice that evolves from it is the “secret sauce” often missing in healthcare today. People need what we offer when nursing is studied and practiced from our disciplinary perspective.

I approached this article through analyzing the literature on the discipline of nursing to arrive at themes.  These themes could guide us in the differentiation of the professional discipline of nursing.  They might be a touchstone for those practitioners, educators and researchers as they ask, “How does my practice, curriculum or research align with the focus of the discipline of nursing?” I offer examples of areas of inquiry that would be aligned with the nursing knowledge.

I hope this article generates some lively discussion that regenerates the interest in and focus on nursing knowledge.  My hope is that while it may not be new, revisiting it may spark new understandings.  It reminds me of T.S. Eliot’s words, “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time”.





Caring Science Education to Promote Interprofessional Understanding

The current ANS featured article, available now to download at no cost, is titled

Kathleen Sitzman

Usefulness of Watson’s Caring Science for Online Educational Practices in Disciplines Outside of Nursing.” The authors, Kathleen Sitzman, PhD, RN, CNE, ANEF, FAAN and Dorothy H. Muller, PhD, report the results of a study to explore the perceptions of people from a wide range of disciplines of the usefulness of Watson’s Caring Science.  Here is a message from Dr.Sitzman about her ongoing work in this area:

I have been conducting research related to Watson’s Caring Science for many years. I teach online nursing courses and so a lot of my work explores caring in online settings. I also teach a Caring Science, Mindful Practice Massive Open Online Course where I regularly interact with people all over the world who are interested in learning about caring and sharing their own caring experiences. So far, almost 4000 people (and counting) have registered for this course, and about 25% of them are not in healthcare or (specifically) nursing. Despite not being nurses and knowing nothing about Watson’s Human Caring Theory when the signed up for the course, my non-nurse learners have responded with enthusiasm, wisdom, and deep understanding as they have progressed through the course. It became apparent to me that Watson’s Caring Science resonated with nurses and non-nurses alike, so I set out to conduct structured research to explore this more fully. This article is the result of my inquiry around this interesting observation.

Currently there is a paucity of research related to applicability of nursing theory outside of the nursing discipline. It is unknown from a formal, academic standpoint, whether Watson’s Caring Science would be considered applicable outside of the nursing discipline and I believe the results that appear in this article provide validation regarding applicability of caring science across disciplines. More research is certainly needed, but this is a good start.

This type of research is important because of the current focus in increasing interdisciplinarity in healthcare and beyond, and I believe that establishing/identifying a shared frame of reference (i.e. principles related to Caring Science) will help people create and maintain productive interdisciplinary collaborations and relationships. Exploration and recognition of basic shared core caring values (i.e. who we “are” as opposed to what we “do”), coupled with shared exploration of trim activities (i.e. varied tasks and job roles that all of us “do” every day), will create common ground upon which to build working relationships with a focus on caring rather than doing. And caring rather doing is a useful approach in nursing, healthcare, and beyond.

New Graduate Transition Programs: An Integrative Review

Our current featured article in ANS is titled “The Impact of New Graduate Nurse

Deborah E. Tyndall

Transition Programs on Competency Development and Patient Safety: An Integrative Review” by Deborah E. Tyndall, PhD, RN; Gina C. Firnhaber, PhD, RN, MLS, MPH and Elaine S. Scott, PhD, RN, NE-BC, FNAP. I had the pleasure of speaking with the authors about their work, and in the video below share our very interesting and informative conversation about how they came to do this work, insights about their method, and the implications of their work for future scholarship in this area.  Their article is available at no cost while it is featured – we welcome our comments and feedback below!

Dr.Tyndall sent this message about the background of her work:

My interest in New Graduate Nurse (NGN) transition stems from my experiences working with undergraduate nursing students and novice nurses in the first year of practice.  For many years, I taught professional development classes to NGN.  In one of these classes, Thriving in Your First Year of Nursing, I heard the successes and challenges that NGN face.  These stories deeply impacted my understanding of the many factors that influence NGN transition to practice.

After graduating with my PhD in 2016, I accepted a grant manager position to work

Elaine S. Scott

with a multidisciplinary team.  This team, led by Dr. Elaine Scott, was formed to advance nursing science by evaluating nurse’s contributions to: 1) patient safety, 2) organizational capacity-building, 3) organizational sustainability, and 4) economic benefit (POSE).  Dr. Scott had been my dissertation chair and I was familiar with her work related to NGN transition to practice.  Through her leadership, the team generated various grant projects.  This article features our scholarly work from of those projects.


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