Does Informed Consent Exist for Black Patients?

Contributor: Harriet Omondi MSN, APRN, FNP

Systemic racism and racial inequality are two concepts that are deeply ingrained in American history. These two issues come up in every single presidential election where candidates compete for the minority vote by promising reparations for black people and an end to systemic racism. Research has repeatedly revealed that minorities lag in the majority of health-related outcomes and this is often directly linked to racial inequity. In a recent blog post by Dr. Chinn titled, ‘Nursing and Racism: Are We Part of the Problem, Part of the Solution or Perhaps Both’, she eloquently addressed how we as nurses can be a part of the solution in ending racism. This can be achieved by educating ourselves on race relations, teaching our children by example by respecting people that may look different, and being empathetic to black people under our care. Patients trust nurses and easily share their fears and worries and nurses are often tasked with the burden of explaining procedures or give informed consent. Black people have been used in research studies over the years without consent or at times treated without full disclosure. How did this begin and how can nurses help resolve this problem?.

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The idea of informed consent began in the early 20th century and thus laid the foundation for the assertion of patient autonomy (Bazzano et al., 2021). Four landmark cases Mohr v Williams, Pratt v Davis, Rolater v Strain, and Schloendorff v Society of New York Hospital set a precedent for patient autonomy and formed the idea of the need for informed consent in medicine and research (Bazzano et al., 2021). In Mohr vs Williams, the patient had agreed to surgery on the right ear but during surgery, the surgeon decided that the left ear was worse off than the right ear and performed surgery on the left ear instead of the right ear (Bazzano et al., 2021, p. 80). The plaintiffs hearing thereafter worsened and she sued the surgeon for battery and assault for performing surgery on the left ear instead of the right as she had previously agreed (p. 82). Mrs. Mohr won the case as the court agreed that the surgeon was wrong for performing surgery on the left ear without her consent (p. 82). I have chosen to discuss informed consent because as much as research is important for the advancement of medicine and technology it is equally important to allow subjects to comprehend what they are signing up for and the potential risks or benefits of research. Participants need to also be aware that if they need to withdraw from a research study they can do so freely without fear of retaliation.

The issue of informed consent is a touchy subject when it comes to minorities especially the black population. This stems from the notion that historically blacks were seen as property and therefore the master did not need permission to do with them as they please. It is well documented that Dr.Marion Sims who is seen as “the father of gynecology” for pioneering successful gynecological surgeries, performed experiments on powerless black slaves without consent. The Tuskegee experiment is another well-known example of racial injustice where young black men some of whom were infected with syphilis were recruited for a research study on syphilis. Informed consent was not obtained for this study and when Penicillin became available to treat the disease the men were not treated. In addition, the men in the study were initially told the study would last six months but it went on for 40 long years where these men suffered the debilitating effects of syphilis without treatment. Fast forward to the 21st century while advances have been made in terms of how black people are treated more is yet to be done.

Working as a primary care nurse practitioner I have encountered countless black patients who distrust the medical system so much so that they would rather forgo medical treatment and seek alternative therapies. This distrust is deeply rooted in medical apartheid that they have witnessed or experienced over the years and it is up to us as nurses and frontline health care workers to empower these patients and provide culturally competent care to ease their doubt. Due to a lack of trust in the healthcare system rooted in racist practices, the black community continues to lag in nearly all aspects of healthcare. This issue has been at the forefront in the past year where we have seen black communities fair much worse on Covid-19 related outcomes, in addition, the vaccination rate among the black community is far less compared to the other races. When I ask my black patients why the hesitancy, the most common answer is, “can’t trust what they’re putting in my body”. One recent example that comes to mind is one of my black female patients was recently diagnosed with breast cancer and advised by her oncologists that she needed radiation after chemotherapy to eradicate cancer. The patient told the oncology team that she did not want radiation because she had a near-death experience during chemotherapy and did not want any more treatment. The oncologist kept pressing the idea of radiation on the patient and per the patient, a “black nurse was brought in to convince me to get radiation.” Ultimately the patient vehemently declined and radiation was not done. This is a classic example of how black patient`s requests are mostly ignored or dismissed with the assumption that they do not know any better.

Therefore, as nurses, we must take into account the complicated history of black people with medicine while providing care. We have to be empathetic to the needs of our black patients keeping in mind that they may have fear of not only the physical ailment but of the providers and the healthcare system as a whole and may need a safer environment. Jean Watson who is one of my favorite theorists once said. “Maybe this one moment, with this one person, is the very reason we’re here on earth at this time.” If we approach each patient with this in mind you never know if you might be the one person who changes their view on the distrust of the medical establishment.

References

Bazzano, L. A., Durant, J., & Brantley, P. (2021). A modern history of informed consent and the role of key information. Ochsner Journal, 21(1), 81–85. https://doi.org/10.31486/toj.19.0105

About Harriet Omondi

I have been a nurse practitioner for the past seven years, I graduated from Texas Woman`s University in 2014 and immediately started working in a Federally Qualified Health Center (FQHC) where I oversaw a clinic for patients with a dual diagnosis of mental health. When I started at the FQHC the clinic was new and only had five patients and after a year I had a panel of 100 new patients. Currently, I work for UT Health in Houston and care for patients in a primary care clinic. Prior to that, I worked as a nurse for six years with adult medical-surgical patients, pediatrics, and home- health caring for medically fragile children. In the Fall of 2020, I took the bold step of enrolling at Texas Woman`s University to pursue a doctorate in nursing where I have completed two semesters. My primary areas of research interest are obesity, women’s health, and preventative medicine with an emphasis on health promotion.

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Theorizing as Emancipatory Action; Emancipatory Action as Theorizing

Over the past year those of us managing the Nursology.net website have experienced two unintended consequences – growing awareness of the importance of fundamental nursing/ public health knowledge and action, and the imperative to examine the structural and interpersonal dynamics of racism. As the web manager of this Nursology.net site as well as the NurseManifest.com website, the home of “Overdue Reckoning on Racism in Nursing,” I have had a front-row seat from which to witness and participate in these two complimentary processes.

From the NurseManifest sphere, we have addressed (explicitly and implicitly) questions such as: “How does our activism contribute to our discipline?” “What are the fault-lines in nursing created by our failure to address racism in nursing?” “How can we engage in authentic reckoning with racism in nursing?” “How can this reckoning shift nursing to more fully engage in facilitation of humanization for those who have historically been harmed by racism?” “How can nursing knowledge be decolonized to fully embrace the knowledge and wisdom of Black, Indigenous, Latina/x, and other nurses of color?”

From the Nursology.net sphere, we have addressed (explicitly and implicitly) questions such as: “What does decolonization of nursing knowledge mean?” “What dynamics have persisted to bring us to this point in history where the scholarship and theorizing of Black, Indigenous, Latina/x and other nurses of color are strikingly absent from our historical record?” “How can we move away from performative action, to fully abandon white privilege in nursing, and to welcome nurse scholars of color to the center of our discourse?”

I do not have direct answers to any of these questions. In fact I believe there are no specific “action” prescriptions that can provide “answers.” The response to all of these questions is what I believe to be critical emancipatory process — a process that begins with a recognition of the fundamental realities of racism and dedication to the hard work of deepened awareness and action for change. In the first chapter of the text “Philosophies and Practices of Emancipatory Nursing,”(1) Kagan, Smith and Chinn identified the following characteristics of emancipatory knowledge and critical theory that informs emancipatory action, as revealed by the chapter authors who contributed to the text:

What is “critical’ –

  • Unpacking hegemonies
  • Upstream thinking
  • Interrogating historical/social context
  • Framing/anticipating transformative action

What is “emancipatory”

  • Facilitating humanization
  • Disrupting structural inequities
  • Self-reflection
  • Engaging communities

Taken together, these characteristics point to a deep understanding of what it might mean to bring knowledge and action together as one – the process and understanding that emerges from “knowing what we do, and doing what we know.” In my experience growing up and becoming an “elder” as a fully colonized white woman, I know all too well the experience of separation of mind and body, of understanding and experience. But there is a glimmer of recognition when I encounter instances – my own and those revealed to me in stories others recount – when experience and understanding come together as one – when we recognize the importance of personal knowing and doing. And, recognize when that unified experience reveals new knowledge, new understanding. This process of action/reflection is theorizing at its best. African American scholar Anthony James Williams described this process of theorizing that he observed in his mother and grandmother:

Everyday black women theorists are often forgotten, undervalued and rarely considered theorists due to their lack of formal training and scholarly publications. But for my maternal lineage, the social patterns they observed became lessons. Those lessons then became theories about the social world they incorporated into their daily lives. Keen observation on their part lead to mental maps of where it would be safe to walk as black women, raise their children and avoid white violence. As the wife of a man in the military, my grandmother inevitably had her own theory of residential redlining based on her lived experience well before any academics published on the topic. (2)

Now is the time to engage in the critical emancipatory act of centering the voices of nurses of color who have been undervalued and discounted, only rarely recognized as theorists. The privileged white gaze from which nursing scholarship views the world recognizes only that which appears consistent with white experience, white culture. To face the realities surrounding white complicity that perpetuates racism is a possibility that is either far too frightening, or simply not comprehensible. But comprehend we must if we are to ever move to a reality where all experience is celebrated as valid and valuable, where skin color is not a determinant of whether you live or die.

The time has now come for all in our discipline – nursologists, nurses, students, educators, administrators, policy-makers – to make a strong and unequivocal turn away from all words and actions that render advantage for those whose skin is “white” and that disadvantage all of those with dark skin. It is time to abandon performative words and actions that claim to care for all, and turn instead to dismantle dehumanizing forces of racism and restore full humanization for all. For those who have white skin, it is time to reckon with your own complicity, unveiling the fault-lines (rifts, splits) created by the persistence of racism, and engage in the healing that must be done. For those who have dark skin, it is time to gather the courage to speak your truth, calling on your keen capabilities to discern injustice. For all of us together, it is time to form strong bonds of connection and support for this difficult path. It is a difficult path, but it is the path that will lead us to mental maps – to theorizing the healing that must take place. As we have experienced in our “Overdue Reckoning on Racism in Nursing” journey, it is also a path that is lined with moments of pure joy!

Sources:

  1. Kagan, P. N., Smith, M. C., & Chinn, P. L. (2014). Introduction. In P. N. Kagan, M. C. Smith, & P. L. Chinn (Eds.), Philosophies And Practices Of Emancipatory Nursing: Social Justice As Praxis (pp. 1–20). Routledge Taylor & Francis Group.
  2. Williams, A. J. (2018, June 15). Who Teaches Academics to Theorize? Inside Higher Ed. https://www.insidehighered.com/advice/2018/06/15/theorizing-black-scholars-differs-white-western-academic-standards-no-less-valid

Guest post: The privilege of agency: The political shortcomings of nursing theory

Contributor: Mike Taylor

The four metaparadigm concepts of nursing knowledge have been human beings, environment, health and nursing process; with the state of the person at the center of the definition and achievement of health goals. The idea that an individual has the wherewithal, not only in name but also but also in action, to determine what health means for them as an individual and is able to work to accomplish those same goals is the concept of agency. Among nursing’s most referenced conceptual models and theories — Orem, Parse, Newman and Roy — keep the focus of nursing’s work on the individual before us, and much less of a consideration is on the environment the person inhabits. Newman (1979) for example states that the goal of nursing “is to assist people to utilize the power that is within them as they evolve toward higher levels of consciousness” (p. 67)  The concept of individual agency is central even in theories about the praxis of nursing such as Watson’s theory of human caring where the nurse/patient dyad “is influenced by the caring consciousness and intentionality of the nurse as she or he enters into the life space … of another person. It implies a focus on the uniqueness of self and other…” (https://www.watsoncaringscience.org/jean-bio/caring-science-theory/)

Sourcehttps://www.coe.int/en/web/interculturalcities/systemic-discrimination

Agency is not something that is naturally given to a person but emerges from the process of human development. That process is frequently affected  by poor schools, environmental pollution, and the other mediators of institutional racism and poverty. The chances of an individual reaching full agency, meaning the ability to identify and actualize individual health goals,  in adulthood are much more likely when those limiting factors are not present due to privilege. Even when an individual is able to overcome early life challenges, the social environment where agency can be exercised, there are limits on who can participate based on class, race, and gender. These limitations on the exercise of agency extend to persons who either want to or are actively practicing the profession of nursing. Even when a person can overcome the intersecting influence of race, poverty and gender to become a nurse; the same barriers remain in the practice environment often limiting choice of practice arena and opportunities for advancement to leadership roles.

Nursing theory is right to place individual agency at the center of the health improvement process, but it does not address the uneven distribution of that agency and the effect that has on health. Agency is only possible where it is allowed and when individuals in disadvantaged communities  do not have the inability to develop or exercise agency, the disparities in health outcomes we see today are the result. For nursing theory to meet these health challenges it must develop beyond a focus on individual agency to an emphasis on the social and environmental conditions that limit health improvement which means challenging institutional racism and poverty among others.

To develop the concept of agency in nursing and challenge existing social barriers, I believe that it would be instructive to align the development and exercise of agency with concepts of intersectionality. An important question might be can any correlation be found between the intersectionality and the degree of effective agency as reflected in an individual’s agency and the available social environments where that agency can be exercised. My anticipation is that it would be an inverse correlation with effective agency decreasing as the number of overlapping disadvantages increase. 

Sources

Newman, M., (1979). Theory development in nursing. F.A. Davis. https://openlibrary.org/books/OL4409082M/Theory_development_in_nursing 

Caring Science & Human Caring Theory, Transpersonal Caring and the Caring Moment Defined https://www.watsoncaringscience.org/jean-bio/caring-science-theory/

About William (Mike) Taylor

Mike Taylor is an independent nursing theorist specializing in the application of complexity science to health and compassion. His Unified Theory of Meaning Emergence takes a major stride in connecting the mathematics of complexity with self-transcendence and compassion. He has spoken at international, national and regional conferences on complexity in nursing, health, and business. He is a member of the board of the Plexus Institute where he is the lead designer of the Commons Project, a web based platform for rapid social evolution in climate change.

Guest Post: Allies and Advocates – Transforming Cultural Competence

Contributors: Jennifer Weitzel, Jeneile Luebke,
Linda Wesp, Maria Del Carmen Graf, Ashley Ruiz,
Anne Dressel, & Lucy Mkandawire-Valhmu

The murder of George Floyd and Breonna Taylor has prompted a wake-up call to reflect on the pervasive issue of structural racism.  As a nation created through histories of colonization and slavery, these murders—among countless others—have acted as a catalyst for American society to recognize and act to disrupt continued legacies of racism embedded into the fabric of American society1.  As nurses, as a part of this society (and thus a reflection of society) it is incumbent upon the nursing profession to take a stark look at the ways in which the legacy of structural racism has continued to inform nursing practice, education, and research.  Doing so speaks towards the nursing professions commitment towards supporting best health outcomes for everyone.  As the most trusted profession, and largest healthcare profession, such allyship not only recognizes this issue, but acts to decolonize discourses, and provides explicit attention to the impact that racism holds on health outcomes.  Such measures call to realize the reality that racism is a health issue, that must no longer remain on the periphery of nursing education, research, and practice in the U.S. (see https://nursology.net/2020/01/14/decolonizing-nursing/ ) .

Source

Nursing as a science, has historically been constructed from a positivist and Eurocentric framework that serves to sustain the domination of “whiteness as a form of disciplinary power.”2(p.196)  Cultural competence is often the primary concept used to guide the nursing profession in addressing the needs of diverse populations locally and globally.3 The principles of cultural competence are heavily influenced by the social and political history of the U.S.4 Practicing with cultural competence is tainted with the effects of racial bias, as this concept fails to recognize how perceived “cultural differences” are code for modern-day racist ideologies dating back to colonialism.6 Therefore, what is often believed to be cultural knowledge is rooted in White, European worldviews and codified into healthcare practices based on faulty interpretations and observations of “Othering”. 

Calls have been put forth for nursing transform these harmful approaches to cultural competency using emancipatory knowledge development and critical theory. Although nursing has been heavily impacted by the hegemonic ideologies of the biomedical model, we have also pioneered ways of knowing that disrupt oppressive knowledge paradigms.   The very institutionalization of competence within the medical field was one way for healthcare providers to establish a standard of expertise. This was key to the professionalization of many disciplines informed by the biomedical model, which focuses primarily on biological factors of health and excludes psychological, environmental, and social influences.Because of the societal value placed on our education and our expertise (cultural competence), nurses enjoy a position of power in Western models of health care. Operating blindly within the hierarchies of power existent in the Western, biomedical model of health leads to running the risk of de-contextualizing the care we provide. For example, Ilowite, Cronin, Kang, and Mack found that parents of children with cancer, regardless of race and ethnicity, wanted detailed information regarding their child’s prognosis.7 However, the researchers also found that physicians provided less information to Black and Hispanic parents than to White parents. This is an example of how healthcare providers exert power by deciding what information to share with patients based on perceived cultural norms and implicit bias.

Most individuals entering the healthcare field espouse a belief that they need to deliver care with impartiality.  However, without a sufficient understanding of the machinations of racism in everyday society, the ways in which racism are perpetuated in the healthcare system will remain a blind spot.6 In attempting to provide care regardless of race or ethnic background, we might overcompensate (“I don’t see color”) and subsequently fail to see how social determinants of health, including racism, affect our patient’s opportunities to achieve and maintain optimal health. 6

Practicing with cultural competence is predicated on the nurse’s ability to learn and understand cultures other than their own  to predict health behaviors and ultimately health outcomes.7 When these predictions drive how care is delivered, the complexities of how individuals, families, and communities make decisions about life, illness, and death become reduced to single narratives and stereotypes.9 By many of our textbooks and NCLEX review materials still provide content based on assumptions and broad categorizations. These assumptions often boil down to ideas such as the belief that because of their race or ethnicity, people share static traits, values, and beliefs, racial categories are legitimized as objective truths, when in reality, these categories are social constructions shaped by history and politics.

It is fundamentally impossible for nurses to provide culturally competent care under the premise that knowledge is based on these singular narratives, beliefs, and stereotypes. We must be open to the use of new frameworks that underpin the delivery of nursing care to meet the needs of diverse populations.  These frameworks derive from epistemologies that challenge Western hegemonic knowledge, how it is produced and who produces it.  For example, cultural safety is a concept originating from indigenous Maori New Zealanders that calls on nurses to engage in ongoing self-reflection about issues of power and privilege. Intersectionality theory, rooted in Black feminist thought, requires an understanding that people identify in a myriad of ways that are fluid and interactive.  These identities, some of which are self-ascribed, and others are socially ascribed, form matrices that confer or deny power. Legal scholars introduced Critical Race Theory (CRT) drawing from critical legal and civil rights scholarship.  CRT is underpinned by the following assumptions:

1.  Race is a social construct with no basis in science.

2. White supremacy does not exist on the fringes of society but is embedded in the everyday order of U.S. life.

3.  The voices of those experiencing racism are essential to knowledge development.

4.  The notion of ‘colorblindness’ is a detour that allows White people to absolve themselves of racial biases and deny the oppressive realities of structural racism.

These are a few of the concepts and frameworks that could inform nursing science and ultimately our practice. Why are we interested in theories from other disciplines? How might we develop nursology discipline specific knowledge that addresses the issues?  In the midst of the world witnessing the murder of George Floyd by police officers, the COVID-19 pandemic continues unabated with its current epicenter in the U.S.  In urban metropolitan areas, we have watched how centuries of disinvestment in Black and Brown communities and systematic oppression has led to health disparities that are also manifesting clearly in this pandemic in disproportionate morbidity and mortality of Black and Brown peoples.  Ethnic minority populations are at greater risk for contracting Covid-19, or experiencing severe COVID related illnesses.10  According to the CDC’s report on COVID-19 in the Racial and Ethnic Minority Groups, cases of COVID-19 are highest among American Indian persons, and hospitalization rates for COVID-19 related illness are highest among Latinos, American Indians, followed by Black persons.10  Since Covid-19 was first reported on the Navajo Nation in mid-March, infection rates per capita have soared to the highest in the country compared with any individual state.11   The COVID-19 pandemic thus only exacerbates the challenges that ethnic minority communities already face, particularly American Indians who already experience disproportionate disparities in health outcomes.

The time for nurses to act is now, not just in the care of people and communities that are most marginalized, but to address the very root of marginalization and oppression through a practice of critical reflection on our own profession: which of our theories need to be contested because they are rooted in colonist and white supremacist ideologies?  How can we embrace of innovative ways of theorizing, through meaningful and intentional care that results from a critical and reflective analysis of the realities going on around us and our role as a profession in fostering lasting change? We leave you with these questions and call upon you as fellow allies and advocates on the path towards health equity and social justice.  When we discuss racism, should we not include all races and ethnicities?

Sources

  1. Paradies Y. Colonisation, racism and indigenous health. J.Popul. Res. 2016; 33(1):83-96.
  2. Puzan E. The unbearable whiteness of being (in nursing). Nurs Inq. 2003; 10(3):193-200.
  3. Rajaram SS. Bockrath S. Cultural competence: New conceptual insights into its limits and potential for addressing health disparities. J Health Dispar Res Prac. 2014; 7(5):82-89.
  4. Kirmayer LJ. Rethinking cultural competence. Transcult Psychiatry. 2012; 49(2). 149-164. doi.org/10.1177/1363461512444673
  5. Wesp, L. M., Scheer, V., Ruiz, A., Walker, K., Weitzel, J., Shaw, L., . . . Mkandawire-Valhmu, L. An Emancipatory Approach to Cultural Competency: The Application of Critical Race, Postcolonial, and Intersectionality Theories. Advances in Nursing Science, ePub Ahead of Print. 2018.  doi:10.1097/ans.0000000000000230
  6. Hester, RJ. The promise and paradox of cultural competence. HEC forum. 2012;24(4):279-291. doi.org/10.1007/s10730-012-9200-2.
  7. Ilowite MF. Cronin AM. Kang TI. & Mack JW. Disparities in prognosis communication among parents of children with cancer: The impact of race and ethnicity. Cancer. 2017; 123(20): 3995-4003.
  8. Brascoupé S. Waters C. Cultural safety: Exploring the applicability of the concept of cultural safety to Aboriginal health and community wellness. Int J Indig Health; 2009; 5(2):6-41.
  9. Carter C. Lapum J. Lavallée L. Schindel ML & Restoule JP (2017). Urban First Nations Men: Narratives of Positive Identity and Implications for Culturally Safe Care. J Transcult Nurs. 2017; 28(5):445-454.
  10. Centers for Disease Control (CDC).  COVID-19 Racial and Ethnic Health Disparities. 10 December 20.  Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/increased-risk-illness.html
  11. Cheetham, J. Navajo Nation: The people battling America’s worst coronavirus outbreak.  BBC News.  15 June 2020.  Retrieved from: https://www.bbc.com/news/world-us-canada-52941984

Note: this post is based on the ANS article published in the spring of 2020 – Weitzel, J., Luebke, J., Wesp, L., Graf, M. D. C., Ruiz, A., Dressel, A., & Mkandawire-Valhmu, L. (2020). The Role of Nurses as Allies Against Racism and Discrimination: An Analysis of Key Resistance Movements of Our Time. ANS. Advances in Nursing Science, 43(2), 102–113. https://doi.org/10.1097/ANS.0000000000000290

L-R: Jennifer Weitzel, Jeneile Luebke, Linda Wesp, Maria Del Carmen Graf, Ashley Ruiz, Anne Dressel, Lucy Mkandawire-Valhmu

Jennifer Weitzel, MS, RN is a doctoral student and public health nurse with Public Health Madison & Dane County. Her research examines the use of cultural safety in the delivery of humanitarian nursing in Haiti

Jeneile Luebke, PhD, RN is a post-doctoral nurse research fellow at University of Wisconsin-Madison. Her area of research and expertise include violence in the lives of American Indian women and girls, and utilization and application of postcolonial and indigenous feminist methodologies.

Linda Wesp, PhD, FNP, APNP, RN is a Clinical Assistant Professor at University of Wisconsin-Milwaukee in the College of Nursing and Zilber School of Public Health, with a focus on health equity, participatory research, and critical theories. She also works as a family nurse practitioner and HIV Specialist at Health Connections, Inc. in Glendale, WI

Maria del Carmen Graf, MSN, RN, CTN-A, is a PhD candidate at UW-Milwaukee. Her research area includes studying the mental health needs within vulnerable populations with an emphasis on the Latina population and women of color in the US using a Postcolonial Feminist approach.

Ashley Ruiz RN, BSN, is a doctoral nursing student and clinical instructor at the University of Wisconsin-Milwaukee, as well as a Sexual Assault Nurse Examiner (SANE). Her current work focuses on advancing feminist theory in nursing science for the purposes of providing a theoretical foundation for addressing the problem of violence against women. Such advances inform Ashley’s research, which seeks to identify and develop nursing interventions that are tailored towards the unique needs of Black women that disclose sexual assault and seek healthcare services

Anne Dressel, PhD, CFPH, MLIS, MA, is an Assistant Professor in the College of Nursing at the University of Wisconsin-Milwaukee, where she also serves as Director of the Center for Global Health Equity

Lucy Mkandawire-Valhmu, PhD, RN is Associate Professor in the College of Nursing at University of Wisconsin-Milwaukee (UWM). Her research focuses on violence in the lives of Black and American Indian women. As a feminist scholar, she seeks to creatively identify interdisciplinary interventions and to inform policy that centers the voices of women in addressing gender-based violence. Dr. Mkandawire-Valhmu also seeks to contribute to the development of feminist theory that would help to advance nursing science.

Guest Post – Nursing’s call to action to address the social determinants of health

Guest contributors:
Kelli DePriest, PhD, RN
Paul Kuehnert, DNP, RN, FAAN 
Teddie Potter, PhD, RN, FAAN

Recently, several Expert Panels of the American Academy of Nursing collaborated to draft a new conceptual framework and consensus statement related to social determinants of health. The year-long endeavor integrated the thoughts and expertise of 15 nursing leaders. The outcome of our work directs nursing actions toward health policies supporting actions at multiple levels (i.e., upstream, midstream, and downstream) to promote equity in planetary health-related quality of life. We propose that planetary health-related quality of life, individual and population factors, and environments are the overarching societal contexts in which population health concerns arise. These population health concerns are articulated by stakeholders who, in turn, are the catalyst for population-focused nursing actions.

These population-focused nursing actions occur at multiple levels, in a variety of settings with a variety of persons and groups, and shape health policies, systems and services. Over time, the actions and interactions depicted by the cycle change the societal contexts and may lead to enhanced planetary health-related quality of life. We underscore the crucial need to eliminate systemic and structural racism if equity in planetary health-related quality of life is to be attained. We presented our findings and implications for action during a policy dialogue at the American Academy of Nursing Policy Conference in October 2020. Collaboration on this project inspired the following call-to-action.

Call to Action

Nurses are consistently ranked the most trusted profession by the American people. This trust is earned by the demonstration of care for people, day in and day out, in a wide variety of settings. It is time for all nurses do something to address the social determinants of health. We propose three concrete approaches.

The first two approaches can be summarized as praxis. According to Paulo Freire in Pedagogy of the Oppressed (1972), praxis is reflection and action on the world  to transform it.  

Reflection, the first approach, is often overlooked in calls for action. Yet we need to take a moment to reflect on what we mean by social determinants of health and what nursing actions in this space will help us achieve health equity. The consensus makes clear that equity cannot be achieved at any level (local, national, or global) until all forms of structural racism are eliminated. Eliminating structural racism should be a shared goal for all nurses.

We have work to do around structural racism in nursing. Nursologists are starting this type of reflection and discussion through nursology.net. (see https://nursology.net/about/nursology-management-team-statement-on-racism/). These conversations need to occur wherever we live and work, in the classroom, in the community, on social media, and with colleagues inside and outside of nursing. The consensus paper can be used to spark reflection and prompt discussions to support action.

Take action on social determinants to create transformative change is the second recommended approach. Action differs depending on our role. The consensus paper draws on the conceptual framework to provide several examples of population-focused nursologists’ actions to address policy issues. The common themes from the examples are that nursologists need to have a seat at the table when all policies are developed, using a Health in All Policies approach, which  includes policymaking across sectors, not only  those policies directly related to health, and nursologists need to advocate for policies that have been shown to effectively advance health equity.

Black, Indigenous, and Hispanic people in this country are experiencing disproportionately high rates of illness and death from the COVID-19 pandemic. To address this syndemic (Poteat, Millett, Nelson, & Beyrer, 2020), we need to address the structural racism at the root cause of these disparities. Who better to forge the path forward, than this group of nursology  leaders? It is time to move to action.

Inspire action on the environment and social determinants of health is the third approach. Another population-focused nursologists’ action from the conceptual framework posits that nursologists must build coalitions to be successful in this work. Others need to be inspired to join the effort. If nursologists are unsure of how to inspire, or lack inspiration themselves, they can read a few blog posts on nursology.net or nursesdrawdown.org for examples. Nursologists can also go to #nursetwitter where there are conversations about nursologists addressing the social determinants of health along with reflection and discussion on how to dismantle structural racism within nursology. Nursologists  can also be inspired by leaders who advocate for nursology by serving on boards, writing op-eds, acting as expert sources for the media, reaching out to legislators, and/or running for office themselves. Inspiration comes in many forms. There is an energy and passion required to do this work and if you have the capacity, please help inspire others to join the movement.

We leave you with the call-to-action to reflect, act, and inspire. We look forward to continuing this conversation.

References

Freire, P. (1972). Pedagogy of the oppressed. Herder and Herder.

Poteat, T., Millett, G. A., Nelson, L. E., & Beyrer, C. (2020). Understanding COVID-19 risks and vulnerabilities among black communities in America: the lethal force of syndemics. Annals of Epidemiology47, 1–3. https://doi.org/10.1016/j.annepidem.2020.05.004

About the contributors;

The authors are writing as nursology colleagues who have worked together through the Environmental and Public Health Expert Panel at the American Academy of Nursing (AAN). Paul and Teddie are the past and current chair of the expert panel and fellows of AAN and Kelli worked with the expert panel through the AAN Jonas Policy Scholars Fellowship program.

Kelli DePriest, PhD, RN

Dr. DePriest is a health policy and research fellow at the Institute for Medicaid Innovation and adjunct faculty at the Johns Hopkins University School of Nursing. Her research mission is to investigate strategies to leverage innovation in the Medicaid program to improve and/or inform the development of interventions and policies designed to achieve health equity for children and families living in poverty. Twitter: @kellidepriest

Paul Kuehnert, DNP, RN, FAAN

Dr. Paul Kuehnert is President and CEO of the Public Health Accreditation Board, the national non-profit organization that sets standards for and accredits governmental public health departments in the United States. Dr. Kuehnert’s career spans nearly 30 years of providing executive leadership to private and governmental organizations to build and improve systems to address complex community health needs. Dr. Kuehnert is a pediatric nurse practitioner and holds the Doctor of Nursing Practice in executive leadership as well as the Master of Science in public health nursing degrees from University of Illinois at Chicago. He was named a Robert Wood Johnson Foundation Executive Nurse Fellow in 2004, a Fellow in the National Academies of Practice in 2010, and a Fellow in the American Academy of Nursing in 2015. Twitter: @PaulKuehnert

Teddie Potter PhD, RN, FAAN

Saintelmophotography.com

Dr. Potter is Clinical Professor, specialty coordinator of the Doctor of Nursing Practice in Health Innovation and Leadership, and Director of Planetary Health for the University of Minnesota School of Nursing.

Guest post: The Role of Nurses and Women’s Health Advocates in Advancing a Social Justice Agenda in the Current Climate: The Case of Wisconsin

Contributors (see bios below)
Lucy Mkandawire-Valhmu, PhD, RN; Jeneile Luebke, PhD, RN;
Carolyn Eichner, PhD; Kaboni Gondwe, PhD, RN;
Diane Schadewald, DNP, RN; Peninnah Kako, PhD, RN;
Jacqueline Callari-Robinson, BSN, RN; Brittany Ochoa-Nordstrum;
Nicole Weiss; Jacqueline Campbell, PhD, RN, FAAN

As nursing professionals and women’s health advocates, we have watched in disbelief events unfolding in Barron County, Wisconsin. Embrace, a shelter serving survivors of sexual assault and domestic violence in Barron County, is facing backlash for displaying a Black Lives Matter (BLM) sign. Reacting to the sign, local officials stripped the organization of funding worth $25,000 and law enforcement are unwilling to continue collaborating with Embrace.

Source

Embrace, located in Northern Wisconsin, serves a predominantly White populace, but also has a significant population of migrant farmworkers and Somali refugees. Migrant farmworker women face difficulties in accessing help following an experience of violence due to transportation and language barriers. Many refugee women also often have a history of sexual violence and trauma. Black women make up less than 2% of the population in Baron County yet constitute 10% of the population accessing help at Embrace’s shelter. Part of the St. Croix Chippewa tribe is also located in Embrace’s service area. Black women and American Indian (AI) women are disproportionately impacted by violence, but do not ordinarily seek help despite the potential for severe negative impacts such as injury or even loss of life.

The National Intimate Partner and Sexual Violence Survey (NISVS) report shows that 84.3% of AI women have experienced lifetime violence (Rosay, 2016). The NISVS shows 41% of Black women have experienced physical IPV in their lifetime with homicide being one of the leading causes of death for women aged 44 and younger. It is in this context that Embrace seeks to serve the most vulnerable populations of women in a four-county area where they are the only available domestic violence shelter.

 We are in unprecedented times with an ongoing COVID-19 pandemic that not only disproportionately affects the lives of Black and Brown women and their communities, but also increases their risk of violence and homicide. A recent US study showed a surge in the incidence of severe intimate partner violence (IPV) during the Covid-19 pandemic compared to the previous 3 years, and a decrease in the number of people seeking hospital care (Gosangi et al., 2020). It is important to be clear that this supports the idea that the stressors of Covid-19 including the economic fallout may exacerbate existing IPV but probably does not start IPV that has not existed before.  Consistent with what has been seen in some other countries, IPV and sexual assault advocates across the state began to report an increase in self and police referrals to their agencies after the pandemic began (Luthern, 2020).

Domestic violence related homicides have been on the increase in Wisconsin even before the pandemic.  According to End Abuse Wisconsin’s Domestic Violence Homicide Report (2020), there were 47 domestic violence related homicide deaths in 2018, and 72 in 2019.  And frighteningly, as of September 29, 2020, domestic violence homicide has taken 69 Wisconsin lives this year.   If that pattern continues, it is estimated that 93 lives will be lost this year. Also concerning is that 22% of the victims, so far in 2020, were age 18 or under. 

Black communities in urban metropolitan areas like Milwaukee are disproportionately impacted by violence in general while also experiencing tensions with law enforcement. Recent acts of police brutality captured on video and circulated widely on social media have implications for community relations with law enforcement. The fear that community members have about police officers potentially using excessive and unjustified force in the policing of Black bodies (Frazer, Mitchell, Nesbitt, et al., 2018) can impact women’s help-seeking following an experience of violence. Black women may want to call the police if they feel like they are in danger from their partner’s abuse but they do not want that partner to be harmed and they usually do not want him to go to jail.  They, like most abused women, just want the violence to stop.  At the same time, there needs to be a non-racist police response available to abused women who are in fear for their and their children’s lives.  There needs to be carefully informed triage (a concept well known to nursing) for 911 calls for IPV so that police are not brought in when not needed but can be brought to homes where there is a high risk for homicide.  

Our state has also been the site of civil unrest in the past few months. In Kenosha, the police shooting of Jacob Blake in August resulted in protests requiring the declaration of a state of emergency. Clashes have also ensued between law enforcement and community members in Wauwatosa in the last few weeks as a result of protests for the February, 2020 shooting and killing of Alvin Cole by a police officer. Apart from these incidents that have created not only unrest but also continued mistrust between Black and Brown communities and law enforcement, there have also been concerns about the prevalence of the trafficking and sexual violation of young Black and Brown women. In Kenosha, Chrystul Kizer, a 19-year-old African American woman, was released this year after being charged for killing a man who sexually abused her as a child in what her defense team argued was self-defense (Fortin, 2020).  Her defense team spoke of how the criminal justice system fails to protect Black and Brown women and girls and yet also holds them disproportionately ‘accountable’ for crimes that would not be charged in cases of White women and girls. This is eloquently detailed by Beth Richie in Arrested Justice

Within the past few months, Wisconsin has had a number of Indigenous women murdered and missing.  Kozee Medicinetop Decorah (Ho-Chunk Nation) was found deceased on May 16, 2020, a victim of domestic violence related homicide (Volpenheln, 2020).  Stephanie Greenspon was found deceased on August 19, 2020. It is suspected that she was also a victim of violence related homicide. Her case is still being investigated by the FBI (Menominee Nation, 2020).  Kaitlyn Kelly has been missing since June 17th (Conklin, 2020). There has been little mention of the missing and murdered Indigenous women in local or national media, particularly taking into account the extent of national and even global media attention drawn to the missing of Jamie Closs;  Closs went missing in the area where Embrace is located, but she was eventually located.

Given all this, dialogue from law enforcement and local officials indicating willingness and commitment to community safety and wellbeing would be helpful. Instead, the response of law enforcement to Embrace’s display of a Black Lives Matter sign intensifies tensions and mistrust between the police and the communities they serve. It also seriously undermines the vital work of the only shelter in a four-county area, further endangering the most vulnerable populations Embrace serves.

 Employing relevant theories to our practice as nurses and liaising with our colleagues across disciplines has now become urgent. Together with colleagues across disciplines, nurses need to support and advocate for survivors of violence. Screening and identification of resources for women is of utmost importance, and shelters like Embrace both ensure the provision of shelter and connect women with urgently needed health and social services. As nurse scholars, we wrote this blog post in collaboration with our colleagues at Women’s and Gender Studies at University of Wisconsin-Milwaukee as part of building coalitions. But we also did so for the purposes of deepening our understanding of the urgent healthcare challenges experienced by the most vulnerable across our state, in the context of the rising tensions and mistrust among various institutions and agencies that exist to enhance the health, wellbeing and safety of all Wisconsin communities.

Violence is central and even essential to the sustaining of social hierarchies that inform the oppression of some groups while enhancing the privilege of others (Collins, 2017). Patricia Hill Collins (2017) points out how without human agency and resistance, institutions can engage in bureaucracies that replicate power dynamics, and even perpetuate normalized violence that maintains dominance and inequities. Law enforcement is one institution, and healthcare, of which nurses are a part, is another.

Robin Walter’s theory of Emancipatory Nursing Praxis comes to mind as one that guides us towards allyship in advancing a social justice agenda in pursuit of health equity, which is central to ensuring the health and wellbeing of the most marginalized in our communities during this time. In order to advance a social justice agenda, there is need for nursing as a profession to partner closely with domestic violence advocates and shelters like Embrace as well as law enforcement officers, who play an important role in enhancing the safety and wellbeing of our communities. We must engage in research and dialogue that would help us reimagine a criminal justice response that acknowledges the context of racism in which Black and Brown women experience violence.

As professionals, we need to respond and to meet their urgent needs for health and safety. It has never been more urgent to engage in the learning processes that Walter outlines, critically reflecting on our social location in relation to those we serve, shifting our worldview and experiencing transformation by expanding our consciousness (Walter, 2017).

References

Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, … & Laughon, K. (2003). Risk factors for femicide in abusive relationships: results from a multisite case control study. American journal of public health, 93(7), 1089–1097. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447915/

Collins, P. H. (2017). On violence, intersectionality and transversal politics. Ethnic and Racial Studies, 40(9), 1460-1473. https://www.fbi.gov/news/stories/operation-cross-country/operation-cross-country

Conklin, M. (July 28, 2020). Searching for Katelyn Kelley: The 22-year-old Menominee woman is part of a crisis of missing Indigenous people that Wisconsin is just beginning to confront. Wisconsin Examiner.  https://wisconsinexaminer.com/2020/07/28/searching-for-katelyn-kelley/

Fortini, J.  (June 23, 2020). Chrystul Kizer, teen charged with killing abuser, is released on bond. The New York Times. https://www.nytimes.com/2020/06/23/us/chrystul-kizer-free-bond.html

Frazer, Eva et al. “The Violence Epidemic in the African American Community: A Call by the National Medical Association for Comprehensive Reform.” Journal of the National Medical Association vol. 110,1 (2018): 4-15. doi:10.1016/j.jnma.2017.08.009 https://pubmed.ncbi.nlm.nih.gov/29510842/

Gosangi B., Park H., Thomas R., Gujrathi R., Bay C. P., Raja A. S., …  Khurana, B. (2020). Exacerbation of Physical Intimate Partner Violence during COVID-19 Lockdown. Radiology, 202866, Epub ahead of print. https://pubs.rsna.org/doi/10.1148/radiol.2020202866

Luthern, A. (May 18, 2020). Milwaukee is seeing a spike in homicides, and nearly half of them are related to domestic or family violence. Milwaukee Journal Sentinel. https://www.jsonline.com/story/news/crime/2020/05/18/milwaukee-homicides-nearly-half-linked-domestic-family-violence/3121220001/

Menominee Nation (October 22, 2020).  Press Release: Vehicle Arson and Discovery of Human Remains on Menominee Indian Reservation. Menominee Indian Tribal Newshttps://www.menominee-nsn.gov/NewsPages/NewsItem.aspx?NewsID=Vehicle%20Arson%20and%20Discovery%20of%20Human%20Remains%20on|10/22/2020

Richie, B. (2012).  Arrested Justice: Black women, violence and the America’s prison nation. NY: NYU Press.

Rosay, A. (2016). Violence Against American Indian and Alaska Native Women and Men. NIJ Journal, 277, 38-45.  Retrieved from:  http://nij.gov/journals/277/pages/violence-against-indians-alaska-natives.aspx

U.S. Department of Health and Human Services, Health Resources and Services Administration, & National Center for Health Workforce Analysis (2017). Sex, Race, and Ethnic Diversity of U.S, Health Occupations (2011-2015), Rockville, Maryland.

Volpenheln, S. (June 29, 2020).  Wisconsin family calls for harsher charges in ‘heinous’ killing of Ho-Chunk woman.  Milwaukee Journal Sentinel. https://www.jsonline.com/story/news/2020/06/29/wisconsin-family-calls-harsher-charges-homicide-ho-chunk-woman/3239543001/

Walter, R. (2017). Emancipatory nursing praxis. A theory of social justice in nursing. Advances in Nursing Science, 40(3), 225-243. Also see Walter’s Theory on Nursology.net

Acknowledgement:

We are grateful for the support and input of the following colleagues from Women’s and Gender Studies: Anna Mansson McGinty, PhD, Xin Huang, PhD, Kristin Pitt, PhD, Gwynne Kennedy, PhD, Melinda Brennan, PhD, & Jeremiah Favarah, PhD

About the contributors

Lucy Mkandawire-Valhmu, PhD, RN is Associate Professor in the College of Nursing at University of Wisconsin-Milwaukee (UWM). Her research focuses on violence in the lives of Black and American Indian women. As a feminist scholar, she seeks to creatively identify interdisciplinary interventions and to inform policy that centers the voices of women in addressing gender-based violence. Dr. Mkandawire-Valhmu also seeks to contribute to the development of feminist theory that would help to advance nursing science.

Jeneile Luebke, PhD, RN is a post-doctoral nurse research associate at University of Wisconsin-Madison. She in an enrolled member of Bad River Band of Lake Superior Chippewa Indians. She received her early nursing degrees (LPN and ADN) in Bemidji, MN, and her BS and MS Nursing from the University of Wisconsin- Madison, and her PhD at UW-Milwaukee. Her area of research and expertise include intimate partner violence in the lives of American Indian women, community health nursing and utilization and application of postcolonial and indigenous feminist methodologies. She is a survivor of intimate partner violence and is passionate about sharing her knowledge and personal experiences to help to support and empower other women to transition to survivorhood.

Carolyn J. Eichner is Associate Professor of History and Women’s & Gender Studies at the University of Wisconsin, Milwaukee. She was a Member at the Institute for Advanced Study in Princeton, New Jersey, in 2015-2016. Eichner is the author of Surmounting the Barricades: Women in the Paris Commune (Indiana University Press); published in French as Franchir les barricades: les femmes dans la Commune de Paris (Editions de la Sorbonne). She has two forthcoming books: Feminism’s Empire, which traces the roots of nineteenth-century French anti-imperialism in the race, gender, and class politics of the era’s first French feminists to engage with empire; and A Brief History of the Paris Commune for the 2021 sesquicentennial of the 1871 revolution (Rutgers University Press). Eichner he is currently writing The Name: Legitimacy, Identity, and Gendered Citizenship. She has published in journals including Feminist Studies, Signs: Journal of Women in Culture & Society, French Historical Studies, and Journal of Women’s History

Kaboni Gondwe, PhD, RN is an assistant professor at University of Wisconsin-Milwaukee College of Nursing. Her research interests are on maternal and child health and she is focused on studying effects on how chronic life stressors moderates the effects of perinatal stress on preterm biomarkers in African American /Black mothers and Malawian Black mothers. She completed her PhD in Nursing from Duke University in 2018 where her research focused on relationship between preterm birth with postpartum stress and mother-infant relationship. She received her undergraduate degree and midwifery training from University of Malawi, Kamuzu College of Nursing and her Master in Nursing Education and Nursing Administration from Ohio University. 

Diane Schadewald, DNP, MSN, RNC, WHNP-BC, FNP-BC joined the faculty of the University of Wisconsin-Milwaukee, College of Nursing in 2013 and is currently a Clinical Professor. I have been certified as a Family Nurse Practitioner and a Women’s Health Nurse Practitioner since 1993. As a board-certified Women’s Health Nurse Practitioner, I have experience providing care for Black women as well as AI women who are at risk for or who have experienced IPV. Since working in academia, I have practiced in primary care and am currently working for an online nurse practitioner service. Prior to working in academia, I practiced in an OB/GYN clinic setting. I’m a co-author of Women’s Health: A Primary Care Clinical Guide which is in its 5th edition. I have also lectured on care of women who have experienced female genital cutting and IPV. I’m currently working on an educational research project about female genital cutting.

Peninnah Kako, PhD, RN, FNP-BC, APNP is an Associate Professor at the University of Wisconsin-Milwaukee (UWM) College of Nursing. Dr. Kako’s research focus includes improving health care access for underserved populations, issues affecting women living with HIV in sub-Saharan Africa. Her research also focuses on violence in the lives of women. Her research aims to contribute to efforts that meet primary and secondary HIV prevention needs in sub-Saharan Africa; and build sustainable, timely, and effective interventions to assist African women and their families in accessing treatment and managing chronic HIV illness. Clinically, Dr, Kako has served in underserved populations including corrections as a family nurse practitioner.

Jacqueline Callari-Robinson, BSN, RN is a Doctoral student at the University of Wisconsin, Milwaukee, School of Nursing, Research Assistant for Tracking our Truth, and an on-call SANE Nurse for United Concierge TELESAFE Program. Previously, Jacqueline was the Director of Sexual Assault Prevention and Statewide SANE Coordinator for the Wisconsin Coalition Against Sexual Assault and the Wisconsin Department of Justice. In that role, she developed the Wisconsin adult, adolescent, and pediatric SANE training courses. Jacqueline was also instrumental in the facilitation and creation of the Wisconsin Attorney General Sexual Assault Response Team (SART). Working collaboratively with SANE programs, law enforcement communities, and the Wisconsin Crime Lab, the AG SART addressed patient access to advocacy driven medical forensic care and the composition, handling, and processing of sexual assault kits. 

Brittany Ochoa-Nordstrum is set to graduate with a Bachelor’s degree in Sociology in the spring of 2021. As a recipient of a SURF (support for undergraduate research fellow) award, Brittany is working under the mentorship of Dr. Lucy Mkandawire-Valhmu on various projects pertaining to advocacy for marginalized communities of color. Brittany’s area of study is medical racism and its impacts on maternal mortality amongst African American women in Milwaukee. She is applying to Ph.D. programs across the country in Sociology and African Diaspora studies. As a third generation Mexican American, her life experiences often inform her passion for these areas of study. When Brittany is not researching, she is often involved in planning and organizing community grassroots demonstrations and fundraisers to benefit marginalized groups around the city of Milwaukee.

Nicole Weiss is a current graduate student at the University of Wisconsin-Milwaukee pursing a Masters of Sustainable Peacebuilding. Nicole is the project coordinator for the Department of Justice funded project: Tracking our Truth, Providing Access to Advocacy Driven Medical Forensic Care. She received her BA in International Studies at the University of Wisconsin-Milwaukee. Her areas of focus include undertaking a holistic, systems approach to complex issues within our community through facilitation and conflict resolution strategies.

Jacqueline Campbell, PhD, RN, FAAN is a national leader in research and advocacy in the field of domestic and intimate partner violence (IPV). She has authored or co-authored more than 230 publications and seven books on violence and health outcomes. Her studies paved the way for a growing body of interdisciplinary investigations by researchers in the disciplines of nursing, medicine, and public health. Her expertise is frequently sought by national and international policy makers in exploring IPV and its health effects on families and communities.

Letter to the ANA

On September 26, 2020, the Nursology.net management team sent the following letter to the American Nursses Association, urging the organization to take a stand on the U.S. Presidential election candidates. We believe that given the dual pandemic of COVID-19 and racism, nursing’s strong voice of advocacy for the health of the nation must be heard. Here is the letter in its entirety:

September 26, 2020
Dr. Loressa Cole, ANA Enterprise CEO
Dr. Ernest J. Grant, President, ANA President
Dr. Debbie Hatmaker, Chief Nursing Officer, ANA Enterprise
American Nurses Association

Dear Drs. Cole, Grant and Hatmaker:


The Management Team of Nursology.net is writing to urge the American Nurses Association (ANA) to reverse its position against endorsing any candidate for President/Vice President in the 2020 election. We understand that the ANA reversed its previous policy to endorse presidential candidates based on the desire to “engage nurses in the voting process through providing accurate information and data and promoting nursing’s political advocacy role without alienating an entire contingency…acknowledging the reality of political polarization in this country” (ANA 2019 Membership Assembly Consideration of ANA’s Presidential Endorsement Process).

The recent draft of the document, Nursing’s Scope and Standards (2020), specifies nursing’s social contract with the public. The document includes nursing’s commitment to reject racism and promote equity and social justice for all. In addition, the document points to nursing’s accountability and responsibility to promote the health of all populations and to advocate for social and environmental justice, and access to high quality and equitable health care.

The proposed ANA Scope and Standards contradicts the ANA position against endorsing a presidential candidate if a particular candidate is a threat to equity, social justice, equitable healthcare and health for the population. While we respect that the Board made their decision thoughtfully, the current situation calls for a reconsideration based on the positions of the current administration that threaten public health. Scientific American, a journal who has never endorsed a candidate for president, has broken with their policy because of the dangerous anti-science views of the President

Today, the country needs to hear nursing’s voice related to this election from the ANA. We find ourselves in the midst of a perfect storm fueled by the mismanagement of a global pandemic, a health and environmental crisis from rampant fires, storms and floods attributed by scientists to climate change, and the public health crisis of systemic racism.

Many have referred to this election as the most consequential in recent history, certainly in our lifetimes. This is not the time for the nursing profession to sit out and fail to exercise our unified voice and moral authority. As the discipline focused on caring for the health and well-being of the people with an understanding of how the physical, social, political and economic environment influences health and well-being, and as the most trusted profession, the ANA must speak out against the policies of the current administration and endorse Joe Biden and Kamala Harris for President and Vice President. Please reconsider your position based on the actions taken by President Trump after your vote in 2019.

Here are a few reasons why we urge the ANA to reconsider and endorse the presidential ticket that is aligned with nursing values and actions and protects the public health:

  • The current administration’s lack of leadership to enact policies to stem the rising incidence of COVID-19 infections, including the President’s lack of providing timely information to the public that could have prevented thousands of infections and death
  • The current administration’s policies that have threatened accessibility to healthcare for millions of Americans by working to overturn the advances made through the ACA
  • The current administration’s position that denies human contributions to climate change and fails to support policies to abate its dangers.
  • The current administration’s lack of acknowledgement of the racial injustices experienced by people of color, especially Black people, at the hands of law enforcement.
  • The current administration’s policies of family separation at the border resulting in hundreds of children being placed in inhumane and dangerous conditions to their health and well-being.
  • The current administration’s lack of meaningful responsiveness to address the public health crisis of gun violence.

While the recommendations of the ANA’s Presidential Endorsement Process (2019) advocate for individual nurses to participate in election activities at the local, state and national levels and take advantage of educational opportunities to learn about the candidates that will inform their voting, nurses will look to the ANA for leadership, especially now. The ANA is the voice of the profession, and this is not the time for that voice to be silent. Without a unified position, the nursing profession is invisible, and the public trust in nursing’s commitment to protecting public health is compromised. Individual nurses can always vote their choice, but the unified voice of our profession is critical at this time in our history.

Please reverse your position and endorse the candidates that will advance policies that protect the health of the public. We cannot be silent. To be silent is to be complicit.

Thank you for your serious consideration of this request.

Respectfully,

Peggy L. Chinn, RN, PhD, DSc(Hon), FAAN peggychinn@gmail.com

Jessica Dillard-Wright, MA, MSN, CNM, RN jdillardwright@gmail.com

Rosemary William Eustace, PhD, RN, PHNA-BC

Jacqueline Fawcett, RN, PhD, ScD(hon), FAAN, ANEF

Jane Flanagan, PhD, RN, ANP-BC, AHN-BC, FNAP, FNI, FAAN

Dorothy Jones, RN, PhD, FAAN

Deborah Lindell, DNP, MSN, RN, CNE, ANEF, FAAN, Deborah.Lindell@gmail.com

Chloe Olivia Rose Littzen, MSN, RN, AE-C

Leslie H. Nicoll, PhD, RN, FAAN leslie@medesk.com

Adeline Falk-Rafael, PhD, RN, FAAN afalk-rafael@rogers.com

Marlaine C. Smith, RN, PhD, AHN-BC, HWNC-BC, FAAN

Marian Turkel, RN, PhD, NEA-BC, FAAN

Danny Willis, DNS, RN, PMHCNS-BC, FAAN

COVID-19 – What would Margaret Newman say?

Dorothy Jones and Jane Flanagan
See also Newman’s Theory of Health
as Expanded Consciousness

Although not the only global challenge we face, COVID-19 has the world’s attention while disrupting so many familiar routines. For those so fortunate, there is the new normal of working from home and countless conference calls that seem to blur one day into the next, almost erasing the confines of time while confining us to a physical space.  When things get back to “normal” what will that look like?

For those in service industries, there is the chaos of being the person in the midst of unsafe places whether the grocery store, a bus or as an employee in a hospital.  Making connections while fearing, am I safe? Do I have what I need to protect myself/ my family? And, sometimes knowing you do not have what you need, and in that moment, your awareness of the disparity of those who have and those who do not is heightened.  What will it be like when things get back to “normal?

 Then there are those who in a whirlwind, may have lost their job.  Now they are struggling to pay bills, perhaps visiting food banks for the first time mixed in with home schooling young children or a full house of grown children now back to the safety of their childhood home.  When and what will be that return to “normal”?  For every scenario, there is opportunity, freedom and new ways of being. There is also potential binding or unraveling.  But no matter the reality, there are the chants to “get back to normal”

Dr. Margaret Newman

This idea of “getting back to normal” raises the question; “What would Margaret say?” We think the answer is …actually, not very much.  She would smile gently and acknowledge each person who spoke and told his or her personal story. She would be present and authentically listen.  Her silence would spur more stories until in the sheer dizziness of it all, the cacophony would stop and everyone would look to her and wonder what she is thinking. Again, silence and this time the room would go quiet.  Finally, she would speak: “I’m just curious about people wanting to go back to normal, what do people think of that?”  Then she would sit and wait for us to react…and we would.  We would discuss how we cannot “go back” and about the opportunity in the chaos. What went well in nursing practice during COVID – 19 that was reflective of nursing and what did not?  She would smile, as we would envision a new future that informed by COVID-19, and the inequities of an illness, linked to an environmental crisis and manifested in our most vulnerable. An illness that has stuck down older adults, minorities and is on a path to literally destroying second and third world countries.  Go back?  No, we would not be going back we would be envisioning a new future, one with boundaryless opportunities.

There is for some, an increased awareness, that the inequities of COVID-19 along with the murder of George Floyd and other racial incidences has heightened the issue of structural racism that has always been simmering under the surface. Go back?  Oh no, we will not go back. Not to complacency, not to a world where nurses today are lauded for their actions during a crisis, but who will return to being a hidden entity, part of the bed charge.  No, we are now in a world that recognizes, yes there were many deaths, but because of nursing care, because of nursing’s commitment to meeting the person where they were at, commitment to delving into knowing other, upward of 85% of those who had COVID and were hospitalized were successfully discharged.  Yes, nursing care! It was the authentic presence of nurses who connected with patients in new ways and journeyed with them on a path of discovery, nurses learning to recognize the pattern of the critically ill when the normal mode of communication was no longer possible, and nurses who transformed the care environment. It was not a cure or a vaccine that made the difference; it was “the difference nursing makes” that made the difference.

The COVID-19 virus made visible a pattern of turbulence and disruption within the global whole.  Lack of awareness to growing social challenges, loss of freedom creation of boundaries and isolation confounded the environment within which the virus emerged. Within this context, the virus took on new meaning and yielded variety of responses. Using the theoretical lens of Health as Expanding Consciousness, Margaret would reflectively and carefully suggest that being exposed to the global and dramatic changes of the day has already begun to reshape/repattern us. She would envision the voice of nurses advocating on behalf of patients, on behalf of the myth of curing rather than healing, on behalf of older adults, racial and ethnic minorities.  Margaret would not support “going back”; instead, she would reflect on the meaning of the unfolding pattern emerging before us …within the context of an illness.

The event COVID-19 has served to make visible the invisible for society as a whole.  Recognition that we are all connected and interrelated. The actions and behaviors of one individual directly affecting the very life of another. Response to the virus has revealed a complex, dynamic human pattern of the whole within a dynamic and changing environment. As the illness experience is unfolding, individual responses shaped by factors including  vulnerability,  gender, age and the older adults, race, ethnicity, compromised health status, poverty, lack of insurance, homelessness, exposure to environmental stressors and population density, and personal responses to life challenges have been made visible. Compromised relationships, sustained loneliness and disconnection challenged human becoming and threatened choices about health and wellness. Rather than creating new problems, COVID-19 has manifested not only a serious disease but made visible longstanding global societal challenges that have gone unnoticed or suppressed.

Margaret would caution that “fixing” the illness (i.e. treating to cure) without addressing the whole person/environment interaction that include people and events surrounding the individual experience, could lead to a reoccurring manifestation of the underlying pattern in new ways (e.g. inequities and disparities in care). She would stress the importance of collaborating with individuals and groups in dialogue, she would identify what is meaningful, to acknowledge the collective increased awareness, and seek to uncover an underlying pattern of the whole. COVID-19 then becomes a stimulus for active discussion, identifying barriers that compromise moving forward as individuals and as a society. The insights gained through information and connecting with another create opportunities for new insights, actions and freedom to participate knowingly in actions that promote transformative change.

The importance of relationship is core to advancing the process of discovery. Partnerships that are open and evolving allow pattern to emerge and potentially increase the realization that we are all interdependent and connected within and across environments. Recognizing that what affects one-person or community can have a reciprocal impact on another. Within the discovery process there is freedom to hold on to what gives new meaning to one’s being and what binds and threatens our freedom  to become and engage in sustainable holistic healing. No, Margaret we are not going back. And she would smile, knowing we are with new heightened awareness and renewed energy, accelerating toward new potentials and  transformation.

Additional References

Newman, M. A. (2008). Transforming presence: The difference that Nursing makes. Philadelphia: F. A. Davis.

Newman, M. A., Smith, M. C., Pharris, M. D., & Jones, D. (2008). The focus of the discipline of nursing revisited. Advances in Nursing Science, 31(1), E16-E27. https://doi.org/10.1097/01.ANS.0000311533.65941.f1

Smith, M. C. (2011). Integrative Review of Research Related to Margaret Newman’s Theory of Health as Expanding Consciousness. In Nursing Science Quarterly (Vol. 24, Issue 3, pp. 256–272). https://doi.org/10.1177/0894318411409421

Nursing and Racism: Are We Part of the Problem, Part of the Solution, or Perhaps Both?

One of the first “lessons” in my now-long-ago nursing education was “the nursing process.” This was in the early 1960s, almost a decade before anyone spoke of nursing theory, but the University of Hawaii (my alma mater) had modeled the curriculum on that of the University of California at Los Angeles (UCLA) which was designed around the ideas of Dorothy Johnson. These ideas would ultimately become known as Dorothy Johnson’s Behavioral Systems Model (See also the history of the UCLA School of Nursing, pgs 43-48).

Of course this same problem-solving process is widely used in many walks of life, and many see it as a mere pragmatic outline for making good decisions and forming appropriate action – a necessary process but several degrees removed from developing foundational knowledge of the discipline. In reflecting on the situation in which we find ourselves today I fear that as a discipline we have not adequately faced the realities before us as a discipline and as a society – both as a problem, and as a health experience. As I wrote in my January 20th post titled “Decolonizing Nursing”

Despite the fact that race and racism so repeatedly rise to the surface with a clear intent to address this issue, there is typically little or no substantive discussion that begins to reach deep down into explanations or understanding of what is really going on (see https://nursology.net/2020/01/14/decolonizing-nursing/)

I know that I am not alone in recognizing this challenge, but I continue to wonder — when and how will this begin to change? This is not merely a “political” matter — it is a matter of life and death, of health and sickness. It is a pandemic of proportions far beyond the COVID-19 pandemic, and it has been infecting our lives for decades. In recent weeks we have witnessed the public killing of George Floyd by a Minneapolis police officer, of Ahmaud Arbery shot down while jogging in February, and Breonna Tayler, an EMT with plans of becoming a nurse, killed by police in her own home in March. Then just a few days before this post published, the killing in Atlanta of 27-year-old Rayshard Brookes, shot in the back several times by police after indicating that he was able and willing to walk home to his sister’s house.

These tragic murders in plain sight, coupled with widespread recognition of the over-proportioned number of Black and Brown people suffering from COVID-19 – give us a glimmer of opportunity to finally act. The calls for change are so pervasive and so sustained, that those of us ready and willing to make change have a real opportunity to do so. And so I return to my earliest nursing education and the foundational ideas that have been baked into my very fabric – the processes of active listening and observation that are vital to assessing and “diagnosing” a problem(1).

One of the notable signs that appears in all of the protests says “I see you, I hear you.” For me, this is a key to meeting the challenge before us. It starts with our interactions among our own colleagues. Throughout my nursing career I have seen many Black nurse colleagues come and go, and every single one of the nursing faculty I have served with have repeatedly decried how “difficult” it is to recruit and retain Black nurse faculty. Yet all too rarely have I witnessed concerted, deliberate efforts by the predominantly White(2) faculty to stop, step away from our privilege, seek the authentic stories of our Black colleagues, and actively hear (understand) their experience. Equally egregious is the fact that there are myriads of situations that, viewed through a lens of anti-racist awareness, could be instantly recognized as potentially harmful to a Black person, even dangerous. But over and over again we turn a blind eye, and fail to act. I have all too often been just as complicit in all of this as anyone else – we have all been caught up, and participate in a systemic web of injustice. And I suspect that this pattern is not unique to academics – that it runs deep in every setting where nursing is practiced.

Further, there is the all-too often deflection of the problem by the insistence that the “problem” is not unique to Black people – that all lives matter. Of course all lives matter and Black people are not the only ones who suffer injustice and discrimination. But this sentiment turns the lens away from the specific voices, experiences, and challenges faced Black people. We can listen to all people – but until we listen to, and sincerely seek to understand, Black people and recognize the experiences of trauma and harm that Black people uniquely suffer, and how we participate, we will not be able to truly understand the problem.

It is undeniable that the prejudice and hate toward Black Americans, and people of African descent in many other countries is profound and amplified by the historical trauma of slavery and in the United States, the fall-out of the civil war fought to end slavery in the United States. I hear many White nurses in my circle expressing true outrage about this situation and we are all sincere in our desire to see it change, yet the problem persists. Until we White nurses face the reality of our privilege and the injustices that flow from this, until we learn ways to step away from our privilege and engage in serious anti-racism work, until we create spaces in which we can authentically engage with our Black colleagues to understand the problem, the injustices in our own house will remain.

We can all shift in the direction of being part of the solution. There are signals that point us in the direction of actions we can all take – particularly those of us who are White – to seize this moment, start to address the scourge of racism in our own house, and make real change. The circumstance of the COVID-19 shift to virtual reality offers ample opportunities for all of us to engage in antiracism work! Here are a few examples that I can personally recommend – if you start searching, you will find many many others!

  • Nurse Caroline Ortiz organized a “platica” (Spanish for discussion) held on March 9th over Zoom. Caroline recorded the session, which you can access here: https://vimeo.com/397047962. You can organize similar discussions – we are all now expert Zoom organizers!
  • African-American activist Nanette Massey holds a weekly discussion with White people from all walks of life to discuss the ideas in Robin DiAngelo’s book “White Fragility: Why It Is So Hard for White People to Talk About Race.” I have participated in many of these informative, interesting and affirming Sunday discussions. Learn more here.
  • The “Everyday Feminism” website has pages and pages of content on ethnicity and racism – https://everydayfeminism.com/tag/race-ethnicity/. Just browsing titles is a rich experience! Their 2014 post of 10 Simple Ways White People Can Step Up to Fight Everyday Racism is precisely relevant today!
  • Invest 1.5 hours into Everyday Feminism’s founder, Sandra Kim’s excellent session on “Why Healing from Internalized Whiteness is a Missing Link in White People’s Anti-Racism Work.” White nurses can benefit especially, but knowing that White people are facing this challenge, and how this can happen, can be helpful for everyone.
  • Practice generosity of spirit toward your nursing colleagues – each of us are being challenged in this moment to examine our own attitudes, actions and words. Many of us are just starting on this journey. This demands kindness and understanding toward one another as we work together, often in uncomfortable situations, to make meaningful change. Let us call forth the best we can be, and support one another with compassion and understanding when we mis-step.
  • Consider how application of many tenets of our own nursing theories can be activated in the quest to address racism. Consider Peplau’s approach to meaningful interpersonal relationships, the very important insights from Margaret Newman “Health as Expanded Consciousness,” and any one of several theories of caring such as Watson’s Theory of Human Caring, or Boykin and Schoenhofer’s Theory of Nursing as Caring, While these and other nursing theories were not created specifically to address racism and social injustice, we certainly can draw on their wisdom to bring nursing perspectives to the center in our anti-racism work.
  • Follow the opportunities provided by the Nursology Theory Collective to join discussions focused on creating equity in nursing
  • Find, read and cite nursing literature authored by nurses of color. Learn the names of these authors, and seek out their work. If you teach, make sure you include this literature in your syllabi(3).
  • Explore the work of scholars in other disciplines who are also committed to anti-racism work. The “Scholarly Kitchen” blog posts regularly on matters of racism and discrimination – see their June 15, 2020 post titled Educating Ourselves: Ten Quotes from Researchers Exploring Issues Around Race
  • Make your own video, as a nurse, speaking to these issues and how your values, ideas, nursing perspectives inform your actions to fight racism! Post it on YouTube or Vimeo .. and then share it with us – we can consider posting on Nursology.net or another nursing website. See this wonderful video (below) by de-cluttering expert Mel Robertson for inspiration!
Notes
  1. Ultimately the concept of active listening formed a basis for the essential processes of “critical reflection” and “conflict transformation” in my heuristic theory of Peace and Power.
  2. See this excellent article from the Center for the Study of Social Policy on the capitalization of the terms “Black” and “White,” which I consulted in refining this post: Nguyễn, A. T., & Pendleton, M. (2020, March 23). Recognizing Race in Language: Why We Capitalize “Black” and “White” | Center for the Study of Social Policy. Center for the Study of Social Policy. https://cssp.org/2020/03/recognizing-race-in-language-why-we-capitalize-black-and-white/
  3. See Kagan, P. N., Smith, M. C., & Chinn, P. L. (Eds.). (2014). Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis. Routledge. This collection includes many of the leading authors, including many nurse scholars of color, whose work focuses on social justice.

Black Lives Matter: Building an Antiracist Nursing Future

Register for June 12th Webinar

“Our lives begin to end the day we become silent about things that matter.” Martin Luther King, Jr.

We, the Nursology Theory Collective, in light of the current events surrounding the murders of George Floyd, Breonna Taylor, and Tony McDade, cannot be silent.

Image created by NTC member Jessica Dillard-Wright

In partial answer to this, we have included our anti-racism position statement below, and invite you, as nurses and nursologists, to join us this Friday, June 12th from 4:00 – 5:00 PM EST to discuss the future of nursing theory and its interrelationship with diversity, equity, inclusion, and justice. We understand that many of us don’t know where to start, but it is in times like these that as the most trusted profession in the United States we must use our privilege to create a more equitable and just world and do something. It’s time we actively listen, learn, unlearn, discuss, and take a stand for those who have been oppressed for hundreds of years, raise their voices, and be better together.

To join this event, please register here in advance to save your seat. 

  • We support the protests in the names of George Floyd, Breonna Taylor, and Tony McDeade, recognizing that their murders are some of the innumerable instances of anti-Black violence that corrode our collective consciousness 
  • We condemn police brutality, a state-sanctioned violence, and recognize its deleterious and disproportionate impact on the lives of Black people
  • We recognize the collusion of white supremacy, capitalism, and patriarchy as the root cause of the ongoing violence that is experienced by Black people
  • Structural racism and white supremacy are public health crises, socially-constructed, legally-entrenched systems of power that benefit and privilege white people
  • We will act to dismantle the structural racism that has characterized the status quo in the United States for over 400 years as a critical, urgent, and essential nursing intervention
  • We recognize our disciplinary complicity with white supremacy, capitalism, and patriarchy, which has shaped modern nursing from its beginnings
  • We collectively commit to do the work: to continue reading and promoting anti-racist work, donate to funds and support initiatives that advance antiracist work, divest from groups that promote hate, promote Black leadership and cite Black scholars, speak out against racism in all its forms, hold space to support and center this essential work while acknowledging this as a forever initiative
  • We commit to uphold anti-racism and anti-oppression, and acknowledge that this commitment must be an ongoing and eternal process

The statement above is a collaborative project, commenced on June 1, 2020. We invite you to join us in this initiative, continue the dialogue, create a better world, amplify Black voices, and show that #BlackLivesMatter.

To join us and sign your name to acknowledge support for the NTC formal position statement, please follow this link: https://forms.gle/NpYWRHtsKe7WZmrD9

In solidarity,
The Nursology Theory Collective

The Nursology Theory Collective is a group of scholars and students that formed after the landmark conference, “Nursing Theory: A 50 Year Perspective Past and Future”, on March 21-22, 2019 at Case Western Reserve University. The mission of the Nursology Theory Collective is to advance the discipline of nursing/nursology through equitable and rigorous knowledge development using innovative nursing theory in all settings of practice, education, research, and policy.

To join the Nursology Theory Collective, and be added to our email list, please send us an email at nursingtheorycollective@gmail.com.