Culture Shifts: From Cultural to Structural Theorizing in Nursing

An antiracism framework for educating nursing professionals

BACKGROUND

A conceptual, methodological, and theoretical framework is needed in Nursing Education to center racism, in the curriculum, as a root cause of health inequity.

PURPOSE

To provide Nursing and health professions' educators with a comprehensive unifying framework to fundamentally conceptualize and deliver a curriculum which positions racism's impact as a root cause of health inequities.

METHODS

Critical race theory is the underpinning for a historical analysis of racism and a critique of scientific racism, whiteness, and white supremacy ideologies that perpetuate harmful and lethal outcomes for racialized individuals and communities.

RESULTS

This framework conceptualizes learning, unlearning, relearning, and reflective practice as the fundamental process needed to transformative nursing education and advance health equity.

DISCUSSION

Methodological application is given for 1) unlearning harmful white supremacy ideology 2) learning that racism as it is embedded in every sector of American life and racial inequities are inherent in the health care system 3) relearning the importance of counternarratives and building structural competency and 4) engaging in reflective practice to challenge deficit paradigms assigned to racialized people and their communities.

CONCLUSION

The Antiracism Framework provides foundational principles, guiding steps, and rationale for curricula that acknowledges the critical role of racism as a barrier to achieving health equity.

Reflections of a white healthcare professional researching ethnicized and racialized minorities: Autoethnographically explored emotions revealing implicit advantages and consequences

Health research is often embedded in biomedicine in which the goal is to remove all bias. However, this is problematic in research on social issues such as social and health inequities. Therefore, there is growing criticism of health researchers' positions as neutral and invisible. I explore research-based advantages and consequences following my positionings within whiteness, nursing and healthcare professionality. Drawing on two ethnographic studies conducted in Denmark, one among black Nigerian women working in the streets of Copenhagen, the other following patients, defined in Danish healthcare as 'ethnic minorities', in two hospitals in the greater Copenhagen area, I take the point of departure from autoethnographic emotions of 'doing good', 'discomfort' and 'denial'. As I analyse these emotions as a production in the contexts, I show the advantages and consequences of leaving my marked body unmarked. With an intersectional lens, I discuss how health researchers' risk (re)producing social inequalities in health based on for example, avoiding topics of skin colour and experiences of discrimination. Ultimately, what legitimized my access to the people in the field paradoxically also risked delegitimizing their experiences of racialized and ethnicized inequalities. This is not only consequential for the interlocutors but also for the knowledge production, since we as health researchers' risk implicitly avoiding important knowledge if we do not see our own research positionings as a racialized, ethnicized and culturalized matter. Therefore, the need for educational curriculum on racialization and anti-discrimination is imperative within the health professions and as health researchers regardless of profession or research area.

The work of race, culture, and ethnicity in nursing literature, 1970 to 1985

BACKGROUND

In our current attempts to address health inequities and injustices, it is crucial to critically examine the evidence base from which we are working. The concepts of "race," "ethnicity," and "culture" have been persistently under-examined in healthcare literature.

PURPOSE

Earlier reviews found that terms relating to race and ethnicity frequently go undefined, while euphemisms are used to avoid naming racism. This paper will elucidate the ways in which these concepts were put to work in nursing texts between 1970 and 1985.

METHODS

This critical narrative review utilizes critical discourse-historical analysis to illuminate mechanisms through which racism operates in nursing and healthcare more broadly.

DISCUSSION

Three operational categories, named for titles of representative works, are identified for concepts of racialized social difference during this time period: Working with others who are not like me, Biologic variation in health and illness, and When your patient is Black West Indian.

CONCLUSION

The wide lens provided by temporal distance, with the benefit of historical perspective, can help attune us to the function of these concepts in the present.

Overwork as a concept to understand health inequities for ethnicised patients in health care

Health inequities for ethnically minoritised patients are well-documented. In this ethnographic study, we follow thirteen patients categorised as 'ethnic minorities' in Danish health care during hospitalisation in three orthopaedic wards across two hospitals. The categorisation of 'ethnic minority patient' has been problematised for its Eurocentric origin and practices within Westernised health care. We use ethnicised to emphasise the process of becoming minoritised based on markers of physical appearance, religious symbols, language or names. Access to health care also rely on perceived legitimacy as health-care recipients which requires work by patients. We demonstrate the workings patients categorised as 'ethnic minorities' engage in by (re)producing othering ideas about non-Danishness, including distancing from other patients perceived as problematic. These were then (counter)produced by positioning oneself as the opposite, as deserving health-care receivers by displaying welfare reciprocity, supporting egalitarian ideas by discounting discriminatory experiences, showing gratitude and identifying staff with good vibes. We propose these doings as creating overwork. This theoretical approach enables a sensitivity towards subtle and covert workings for patients placed in the margins of health care. In this study, overwork is closely related to notions of Danishness and takes on specific forms within a modernised and universalised Danish health-care system.

Anti-oppression pedagogy in health professions: a scoping review

Health professional learners are increasingly called to learn about health inequity to reduce inequities and improve patient care and health outcomes. Anti-oppression pedagogy (AOP) addresses the need for health professional learners to understand multiple health inequities and the structures and systems that produce inequities. However, the inclusion of AOP in health professions education varies and there is a lack of clarity in its conceptualization and integration. A scoping review was conducted to address this gap and to understand how AOP is conceptualized and integrated in health professions education. Thirty-six articles met the inclusion criteria. The articles demonstrated that AOP is not commonly utilized terminology within health professions education. When AOP is integrated, it is not consistently conceptualized but is generally viewed as a broad concept that focuses on antiracism; decoloniality; intersectionality; and supporting learners to understand, critically reflect on, and act against structural and systemic forms of oppressions. In addition, there is variation in the integration of AOP in health professions education with the most common methods consisting of discussions, cases, reflection, learning through lived experiences, and the incorporation of humanities within a longitudinal curriculum. The results of this scoping review highlight the need for health professions education to develop one clear concept that educators use when teaching about anti-oppression, which may reduce working in silos and allow educators to better collaborate with each other in advancing this work. In addition, this review suggests that health professional programs should consider incorporating AOP in curricula with a broad and longitudinal approach utilizing the common methods of delivery. To better support programs in including AOP in curricula, further research is required to emphasize the benefits, provide clarity on its conceptualization, and determine the most effective methods of integration.

Using nursing science to advance policy and practice in the context of social and structural determinants of health

BACKGROUND

Social and structural determinants of health play a large role in health inequities.

PURPOSE

To highlight how nursing science can be used to advance policy and practice in the context of social and structural determinants of health.

METHODS

This paper reports on the author's keynote presentation from the 2022 State of The Science Conference on Social and Structural Determinants of Health presented by the Council for the Advancement of Nursing Science. Key concepts are overviewed and defined, followed by examples of two community-engaged research projects with findings that inform practice and policy. The author concludes with individual-, social- and structural-level recommendations as a clarion call for nurses to use research to eliminate health inequities and promote justice for all.

CONCLUSION

What we know is, in part, only as good as what we do with that knowledge. When lives are at stake, gone are the days of knowing something and failing to act on that knowledge.

Social justice in nursing education: A review of the literature

BACKGROUND

Social justice is a cornerstone of nursing because nurses have responsibilities for providing equal and fair care for people from all background. Social justice as nursing imperative is clearly recognised by some professional nursing organisations, but not so by others.

AIM AND OBJECTIVES

The aim of this review was to establish the current state of the literature on social justice and nursing education. The objectives included to understand the meaning of social justice for the nursing profession, assess the visibility of social justice learning in nursing education, and explore frameworks for integrating social justice learning in nursing education.

METHODS

The SPICE framework was applied to identify the phrases social justice and nursing education. Inclusion and exclusion criteria were used to search the EBSCOhost database, set email alerts on three databases, and search the grey literature. Eighteen literatures were identified for evaluation of predetermined themes on meaning of social justice, visibility of social justice learning, and frameworks for social justice nursing education.

FINDINGS

Firstly, the meaning of social justice relates to general theories rather than practical issues in nursing. Secondly, social justice is embraced as an imperative in nursing profession. Lastly, critical pedagogies can support social justice learning in nursing education.

DISCUSSION

There is consensus on need for social justice issues to be incorporated in nursing education. This would create paths for nurses to engage in actions that change health inequalities.

CONCLUSION

Nursing organisations embrace social justice as nursing imperative in different ways. It is important to explore how this imperative is upheld by nursing professional organisations and education institutions.

Racialised experiences of Black and Brown nurses and midwives in UK health education: A qualitative study

BACKGROUND

Institutional racism within the United Kingdom's (UK) Higher Education (HE) sector, particularly nurse and midwifery education, has lacked empirical research, critical scrutiny, and serious discussion. This paper focuses on the racialised experiences of nurses and midwives during their education in UK universities, including their practice placements. It explores the emotional, physical, and psychological impacts of these experiences.

METHODS

This paper draws on qualitative in-depth interviews with participants from the Nursing Narratives: Racism and the Pandemic project. Of the 45 healthcare workers who participated in the project, 28 participants obtained their primary nursing and midwifery education in UK universities. Interviews with these 28 participants were selected for the analysis reported in this paper. We aimed to employ concepts from Critical Race Theory (CRT) to analyse the interview data in order to deepen our understanding of the racialised experiences of Black and Brown nurses and midwives during their education.

FINDINGS

The interviews revealed that the healthcare workers' experiences coalesced around three themes: 1) Racism is an ordinary, everyday experience; 2) Racism is operationalised through power structures; and 3) Racism is maintained through denial and silencing. Experiences often touch on a series of issues, but we have highlighted stories within specific themes to elucidate each theme effectively. The findings underscore the importance of understanding racism as a pandemic that we must challenge in response to a post-pandemic society.

CONCLUSION

The study concludes that the endemic culture of racism in nurse and midwifery education is a fundamental factor that must be recognised and called out. The study argues that universities and health care trusts need to be accountable for preparing all students to challenge racism and provide equitable learning opportunities that cover the objectives to meet the Nursing and Midwifery Council (NMC) requirements to avoid significant experiences of exclusion and intimidation.

Testing the Assumptions in the Process of Cultural Competence in the Delivery of Healthcare Services Using Empirical Data, Focusing on Cultural Awareness

INTRODUCTION

Encounters with children of foreign origin call for school nurses' cultural competence during the health visits. This study aimed to investigate the statistical associations between the cultural constructs described by the Process of Cultural Competence in the Delivery of Healthcare Services (PCCDHS) model and whether school nurses' cultural encounters, cultural knowledge, and cultural skill could statistically predict their cultural awareness.

METHODOLOGY

Spearman correlation and hierarchical regression analyses were conducted using cross-sectional secondary data from 816 Swedish school nurses. The cultural constructs in the theoretical description of the PCCDHS model guided the selection and sorting of the items on cultural competence.

RESULTS

The constructs of cultural knowledge, cultural skill, cultural encounters, and cultural awareness were positively correlated with each other. However, becoming culturally aware was not statistically predicted by included cultural constructs (R² = 13.4, p = .06).

DISCUSSION

Despite the interrelations between the investigated cultural constructs of the PCCDHS model, understanding cultural awareness development requires further empirical testing.

Preparing Nurse Educators to Teach Social Determinants of Health Using Backward Design

BACKGROUND

Recent national recommendations have been developed to ensure nurse educators are prepared to teach about health equity and social determinants of health. Nurse educators may not have had formal or professional development in teaching these concepts, which may pose a barrier to implementing recommendations.

METHOD

This article outlines a graduate course focused on social determinants of health to prepare future nurse educators with the knowledge, skills, and ability to address these concepts in future teaching.

RESULTS

A backward design approach facilitated the alignment of learning outcomes, assessments, and activities that resulted in Quality Matters certification in this online graduate-level course. Topics include health equity and implicit bias, and learners evaluate educational resources and develop an educational presentation of health inequities in a selected population.

CONCLUSION

This course supports the development of nurse educators to increase their skill in understanding and teaching social determinants of health and health equity. [J Nurs Educ. 2022;61(9):511-515.].

A Concept Analysis of Structural Competency

Structural competency is a concept that offers a way to understand and respond to health inequities and work toward antiracism in health care. This article undertakes a concept analysis of structural competency using Rodgers' evolutionary method. Based on this analysis, structural competency refers to the ability to recognize and act on structural inequities, skill development, multidisciplinary collaboration, and the reproduction of inequity over time. The meanings and use of this concept differ among disciplines. Multidisciplinary applications of structural competency offer insight into how this concept can foster health equity and antiracism in nursing care, education, research, and health services delivery.

Structural competency in emergency medical education: A scoping review and operational framework

Objectives

Existing curricula and recommendations on the incorporation of structural competency and vulnerability into medical education have not provided clear guidance on how best to do so within emergency medicine (EM). The goal of this scoping review and consensus building process was to provide a comprehensive overview of structural competency, link structural competency to educational and patient care outcomes, and identify existing gaps in the literature to inform curricular implementation and future research in EM.

Methods

A scoping review focused on structural competency and vulnerability following Arksey and O'Malley's six-step framework was performed in concurrence with a multistep consensus process culminating in the 2021 SAEM Consensus Conference. Feedback was incorporated in developing a framework for a national structural competency curriculum in EM.

Results

A literature search identified 291 articles that underwent initial screening. Of these, 51 were determined to be relevant to EM education. The papers consistently conceptualized structural competency as an interdisciplinary framework that requires learners and educators to consider historical power and privilege to develop a professional commitment to justice. However, the papers varied in their operationalization, and no consensus existed on how to observe or measure the effects of structural competency on learners or patients. None of the studies examined the structural constraints of the learners studied.

Conclusions

Findings emphasize the need for training structurally competent physicians via national structural competency curricula focusing on standardized core competency proficiencies. Moreover, the findings highlight the need to assess the impact of such curricula on patient outcomes and learners' knowledge, attitudes, and clinical care delivery. The framework aims to standardize EM education while highlighting the need for further research in how structural competency interventions would translate to an ED setting and affect patient outcomes and experiences.

A Systematic Review of Global Health Assessment for Education in Healthcare Professions

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Structural competency curriculum in health sciences education: a scoping review protocol

OBJECTIVE

This scoping review aims to explore existing literature related to structural competency and how this concept is being implemented and evaluated in health sciences programs. Another aim is to examine and summarize any documented outcomes related to structural competency training.

INTRODUCTION

Structural competency is a concept that was introduced in 2014 to train pre-health and health professionals to understand the broader structures that influence health outcomes. Studies have shown structural competency training is beneficial to health science students. To address health outcomes at the population level, students should collaborate with other disciplines to address the larger structures that influence health.

INCLUSION CRITERIA

This scoping review will consider studies that include health science programs that implemented or evaluated structural competency training for undergraduate students, graduate students, and postgraduate trainees.

METHODS

The key databases to be searched include MEDLINE (PubMed), CINAHL (EBSCO), Scopus (Elsevier), Embase (Elsevier), Europe PubMed Central (European Bioinformation Institute), and PsycINFO (EBSCO). The search for unpublished studies will consist of ProQuest Dissertations and Theses (ProQuest), PapersFirst (WorldCat), and OpenGrey (www.opengrey.eu/). Studies conducted in English, in any year, setting, and geographical location will be included. Two independent reviewers will perform retrieval of full-text studies and data extraction. The results will be presented in diagrammatic or tabular format with a narrative summary.

Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American academy of nursing

BACKGROUND

The 2019-2020 American Academy of Nursing (Academy, 2019) policy priorities document states that "they have a clear and distinct focus on social determinants of health and uses this lens to advance policies and solutions within each of the three overarching priorities" PURPOSE: This consensus paper seeks to establish conceptual clarity and consensus for what social determinants of health mean for nursing, with emphasis on examples of health policies that advance planetary health equity and improve planetary health-related quality of life.

METHODS

Volunteers from five Expert Panels of the Academy met via videoconference to determine roles and refine the focus of the paper. After the initial discussion, the first draft of the conceptual framework was written by the first three authors of the paper and, after discussion via videoconference with all the co-authors, successive drafts were developed and circulated for feedback. Consensus was reached when all authors indicated acceptance of what became the final version of the conceptual framework.

DISCUSSION

A conceptual framework was developed that describes how the social determinants of health can be addressed through nursing roles and actions at the individual, family, and population levels with a particular focus on the role of health policy. The paper provides a specific health policy example for each of the six key areas of the social determinants of health to illustrate how nurses can act to improve population health.

CONCLUSION

Nursing actions can support timely health policy changes that focus on upstream factors in the six key areas of the social determinants of health and thus improve population health. The urgent need to eliminate systematic and structural racism must be central to such policy change if equity in planetary health-related quality of life is to be attained.

Ethnic minority patients in healthcare from a Scandinavian welfare perspective: The case of Denmark

The Scandinavian welfare states are known for their universal access to healthcare; however, health inequalities affecting ethnic minority patients are prevalent. Ethnic minority patients' encounters with healthcare systems are often portrayed as part of a system that represents objectivity and neutrality. However, the Danish healthcare sector is a political apparatus that is affected by policies and conceptualisations. Health policies towards ethnic minorities are analysed using Bacchi's policy analysis, to show how implicit problem representations are translated from political and societal discourses into the Danish healthcare system. Our analysis shows that health policies are based on different ideas of who ethnic minority patients are and what kinds of challenges they entail. Two main issues are raised: First, ethnic minorities are positioned as bearers of 'culture' and 'ethnicity'. These concepts of 'othering' become both explanations for and the cause of inappropriate healthcare behaviour. Second, the Scandinavian welfare states are known for their solidarity, collectivism, equality and tolerance, also grounded in a postracial, colour-blind and noncolonial past ideology that forms the societal self-image. Combined with the ethical and legal responsibility of healthcare professionals to treat all patients equally, our findings indicate little leeway for addressing the discrimination experienced by ethnic minority patients.

Upstream Factors in Population Health: A Concept Analysis to Advance Nursing Theory

The assessment of upstream factors is important in population-based nursing practice. The aim of this concept analysis is to enhance understanding of upstream factors and articulate a definition linked to the Conceptual Model for Nursing and Population Health. Upstream factors are thus defined as established conditions related to economic, social, and physical environments that occur outside the health care system, in the communities where people live, and contribute indirectly to the health outcomes for groups of individuals through multiple causal pathways. This concept analysis highlights the need for middle-range theory to guide nursing assessment and contributes to conceptual model evaluation.

"I Can't Breathe": Biopower in the Time of COVID-19: An Exploration of How Biopower Manifests in the Dual Pandemics of COVID and Racism

In this article, we apply Agamben's theory of biopower and other related concepts to the COVID-19 pandemic in the United States. We explore the similarities between the COVID-19 pandemic and the pandemic of racism. Concepts such as bios, zoe, homo sacer, and states of exception can be applied to understand inequities among marginalized communities in the COVID-19 pandemic. We recommend that nurses and health care workers use critical conscientization and structural competency to increase awareness and develop interventions to undo the injustices related to biopower faced by many in the COVID-19 pandemic.

Let's Talk About Racism: Strategies for Building Structural Competency in Nursing

A major goal of Healthy People 2020 is healthy equity, or the attainment of the highest level of health for all groups of people. Yet, disparities based on race remain the most persistent and difficult to address. Getting at the root causes of disparities, inequities, and injustices is essential for health equity to become a reality. The authors elucidate the urgent need for the nursing profession (and all health care professions) to push beyond cultural humility to structural competency and shift the focus from individuals to institutions, systems, practices, and policies to address racism, bias, and discrimination as root causes of disparities and inequities in health, health care delivery, and health care outcomes.Through a case study approach, the authors demonstrate the need for faculty to contextualize learning to help integrate the necessary historic and contemporary drivers of racism, bias, and discrimination into health care. They discuss strategies for faculty to develop the knowledge, skills, and attitudes to teach about the importance of addressing structural racism and discrimination in health care. Through a "no shame, no blame" approach, the authors encourage faculty to develop the courage to engage with students, colleagues, other health care professionals, and communities in conversations about racism, bias, and discrimination.

The evolution of cultural competence theories in American (United States) nursing curricula: An integrative review

INTRODUCTION

Baccalaureate nursing students develop cultural competence through curricula of theories and frameworks which evolve to reflect new knowledge, but their synthesis and impact upon health quality outcomes is not known.

METHODS

A cross-platform literature review was conducted to identify innovation and use of cultural competency theories and frameworks in nursing. Optimal literature included a formal theory, pedagogy, measures, and outcomes, which were then classified and evaluated. Additional perspectives and interventions were reviewed for potential influence on curricula and impact through the lens of integrative review.

RESULTS

A shift in theory from essentialism to constructivism has occurred in undergraduate curricula. Challenges to measuring outcomes have been noted. All studies reported positive outcomes but suffer from self-selection, unvalidated instruments, and little to no longitudinal data.

CONCLUSIONS

Nursing students are exposed to culturally competent care via several validated and canonical frameworks, but self-efficacy and long-term impact have not been assessed.

Thoughts About the Language of Equity for Population Health

This is the first of two essays addressing equity and social justice, which are interrelated concepts of considerable interest to members of the discipline of nursing. The purpose of this essay is to define equity and related terms, including inequity, inequality, and disparities, within the context of the intersection of nursing and population health science. An essay about social justice will appear in a subsequent issue of Nursing Science Quarterly.

"Spinning Their Wheels … "-Influences That Shape How Nurse Educators Teach Social Justice

Despite institutional claims that social justice is a core professional nursing value, efforts to fulfill this claim remain uneven. The purpose of this study was to examine the circumstances that shape nursing educators' approaches to social justice. In-depth semi-structured interviews with 28 educators teaching theory courses in baccalaureate nursing programs shed light upon the influences that shape how educators integrate social justice. These include formative experiences, institutional factors, and curricular opportunities. Formative experiences include upbringing, educational background, and preparation to teach. Institutional factors consist of the type of institution, geographic location, and the specter of retention, promotion, and tenure. Finally, curricular opportunities and fit include the positioning of Community Health Nursing, fragmentation and tension between "content and context," and the "driving force" of the National Council Licensure Examination for Registered Nurses (NCLEX). Findings indicate that the capacity to uphold the value of social justice is shaped by experiences across the lifespan, institutional policies, and practices related to faculty hiring, development, career advancement, as well as curricular vision. This study calls for a concerted effort to enact social justice nursing education.

An Emancipatory Approach to Cultural Competency: The Application of Critical Race, Postcolonial, and Intersectionality Theories

Nurses teach, work, and conduct research in an increasingly hostile sociopolitical climate where health inequities persist among marginalized communities. Current approaches to cultural competency do not adequately equip nurses to address these complex factors and risk perpetuating stereotypes and discrimination. A theory-driven emancipatory approach to cultural competency will instead lead to lasting change and uphold the core nursing value of commitment to social justice. This article explicates key tenets of critical race, postcolonial feminist, and intersectionality theories and then applies them, using an emancipatory approach to cultural competency that can reshape nursing education, research, and practice.

Philosophical and Contextual Issues in Nursing Theory Development Concerning Technological Competency as Caring in Nursing

Theory development in nursing has been contentious so that issues about theory as knowledge base and counterpart of practice, and theory as the foundation of nursing as a discipline of knowledge and practice profession have facilitated the seeming ambiguity hindering theoretical contributions integral to human health and well-being. Nursing science continues to generate discussions about its development particularly grounding its practice as a legitimate component of human health care. The aims of this paper are (a) to describe three contemporary issues regarding theory construction and development in nursing, and (b) to advance a theory of nursing that can reconcile these issues. Content analysis following a review of literature revealed ontological,epistemological, and contextual issues on nursing theory development and theory-based practice perspective. The middle-range theory of Technological Competency as Caring in Nursing is advanced as integral to pursuing the reconciliation of theory development and practice engagements within the Universal Technological Domain in nursing and the health sciences. J. Med. Invest. 66 : 8-11, February, 2019.