Philanthropic Foundations' Discourse and Nursing's Future: Part I: History and Agency.

In this article, we examine external agents' effect on nursing's professional evolution and the consequences for the discipline's collective agency, social contract, and self-regulation. Situated within Foucault's theories of power, we review how the power of organizations reaches into the fabric of everyday life and explore how philanthropic foundations have influenced a diverse array of disciplines, including nursing. Through a genealogic lens, we examine nursing history and professionalization and conclude with concerns surrounding nursing's exercise of its collective agency during one of the most significant, discipline-shaping activities of modern times-Robert Wood Johnson Foundation's Future of Nursing initiatives.

Philanthropic Foundations' Discourse and Nursing's Future: Part II: A Critical Discourse Analysis of RWJF Future of Nursing Initiatives.

Critical social scholarship highlights the power philanthropic foundations wield on the collective agency of groups, yet analyses specific to nursing are absent in the literature. In this second of a 2-part series, we employed critical discourse analysis to examine how control of enunciative privilege in Robert Wood Johnson Foundation's (RWJF) 2010 and 2020-2030 Future of Nursing (FON) initiatives challenge nursing's ability to enact its collective agency, particularly through professional nursing organizations. Findings are discussed within the context of nursing's self-regulatory privileges, history, and agentic obligations that are bestowed on the discipline by the greater public for the public good.

A Sisyphean task: Developing and revising public health nursing competencies.

BACKGROUND: Competencies are intended to enhance the public health workforce's skills. Competencies used to evaluate public health nursing (PHN) practice and education have been promoted by several nursing organizations. Having multiple sets of competencies raises questions about redundancies and their usefulness in evaluating PHN, as well as the central question about the value of the competencies themselves. METHODS: A literature review of psychometric evaluation research of the competencies was performed. Qualitative content analyses were conducted of seven documents: Association of Community Health Nursing Educators', 2000 and 2010 essentials; Quad Council Coalition's 2004, 2011, and 2018 competencies; and the American Nurses Association's, 2013 and the 2021 draft of PHN scope and standards of practice with respect to competency definition, conceptual basis, and use of an established taxonomy. RESULTS: No psychometric evaluations of the competency sets were found. Textual content analysis revealed inconsistent and or missing competency definitions and theoretical frameworks with competencies proliferating over time. Taxonomy analysis identified minimal competencies at higher complexity levels according to Bloom's revised taxonomy. CONCLUSIONS: Analyzed competencies lack reliability and validity testing, making assessment difficult for PHN educators and practitioners. Multiple and competing competencies further erode PHN's visibility, even among public health nurses. With unending revisions of PHN competencies and lack of supporting evidence regarding their effect and their integration into education or practice, recommendations for future efforts are offered.

RWJF's future of nursing's campaign for action: A content analysis of social determinants of health activities.

The RWJF-sponsored 2010 report, The Future of Nursing: Leading Change, Advancing Health (FoN), fostered creation of the Campaign for Action (Campaign) as a mechanism to monitor and enact the FoN report's recommendations. Influenced by RWJF's Culture of Health initiative, Campaign efforts refocused to include the social determinants of health (SDOH), with an additional action area entitled "Building Healthier Communities" (BHC). This study describes nursing activities in the BHC action area relative to the six initial FoN core action areas and assesses the extent to which nursing actions in the BHC action area align with public health conceptions of the SDOH. A content analysis was conducted of the RWJF's Campaign issue blog posts on 51 state Action Coalition websites from January 2011 to August 2018. Results demonstrate a decline in blog posts among the six FoN action areas over time compared to an increase in the BHC action area. BHC blog posts of nursing activities included predominantly stories and events, with few interventions. Although the Campaign's definition of the SDOH aligns with definitions from public health, posted actions do not. Re-evaluation of the Campaign' tagging process is needed so system-level conceptualizations can be integrated into the Campaign's next iteration for categorizing SDOH-driven interventions.

Being a real nurse: A secondary qualitative analysis of how public health nurses rework their work identities.

Many Western nations are emphasizing the importance of population health across health care delivery organizations and education systems. Despite significant momentum to integrate population health into nursing practice, a parallel effort to examine how these efforts impact practicing nurses' views of their professional role and work identity has not occurred. This secondary qualitative analysis, employing an abductive approach, explored processes public health nurses use in creating and maintaining their work identity through three organizing themes: narrative self-identity, mandated identity, and identity as struggle. The analysis was based on interview data collected from 30 US public health nurses residing in 17 states. 'Being a real nurse' describes public health nurses' efforts to balance a contradictory work identity where at times they are expected to focus on populations and at other times, on individuals. The identity work revealed through this study should be further explicated and specific strategies developed for stabilizing a work identity for public health nurses, as well as for any nurse charged with a population health role.

Public health nurses' graduate education decision making processes.

INTRODUCTION: A well-educated public health workforce is needed to improve population health. Although nurses constitute the largest number of U.S. public health professionals, those holding graduate degrees remain low. This study describes public health nurses' (PHNs) perspectives on graduate school decision-making processes. METHODS: Using a qualitative descriptive design, semi-structured, qualitative telephone interviews with PHNs (n=30) were conducted June 2014-January 2015. Study participants included PHNs from 17 states employed in a variety of positions within government health agencies, academe, and business. Interview transcripts were coded and thematically analyzed. RESULTS: PHNs' pursuit of a graduate degree varied, often depending on work setting and/or availability of degree programs. Many study participants were unaware of the public health nursing graduate degree option, with only 9 of 26 participants obtaining an advanced degree in public health nursing. The MPH degree however, was well-known and particularly valued. CONCLUSION: Opportunities for graduate public health nursing are limited; as such, marketing of existing programs need to be nationally coordinated and new collaborative efforts between schools of nursing and schools of public health developed. These efforts are required if graduate-prepared public health nurses are to be part of the future workforce, prepared to tackle increasingly complex population health issues.

Trends in Health Disparities, Health Inequity, and Social Determinants of Health Research: A 17-Year Analysis of NINR, NCI, NHLBI, and NIMHD Funding.

BACKGROUND: The theoretical landscape of health disparities research now emphasizes health inequities and the role that social determinants of health (SDOH) play in creating and perpetuating them. Whether National Institutes of Health (NIH) funding patterns reflect this theoretical shift is unknown. OBJECTIVES: The aim of this study was to examine the National Institute of Nursing Research's (NINR) funding for research focused on health disparities, health inequities, and SDOH, relative to other key NIH institutes. METHODS: Data on 32,968 projects funded by NINR, the National Cancer Institute, the National Heart, Lung, and Blood Institute, and the National Institute of Minority Health and Health Disparities (NIMHD) during the years 2000 through 2016 were downloaded from NIH RePORTER; those with health disparities, health inequity, or SDOH terms used in the abstract were identified. Descriptive statistics and a general linear model approach were used to assess differences in cumulative project counts and funding proportions, and funding trends over time. RESULTS: Overall, funding for health disparities projects was 14-19 times greater than for health inequity and SDOH projects and was more concentrated in centers and institutional training than in individual research projects. NINR's proportion of funding for disparities projects was consistently greater than that of the National Cancer Institute and the National Heart, Lung, and Blood Institute, but not for inequities and SDOH projects. NIMHD's proportion of funding for disparities, and inequities and SDOH projects (combined) was 2-30 times greater than that of other institutes. Over the 16-year period, funding for disparities, inequity, and SDOH projects each increased (all ps < .05); however, growth in inequities and SDOH funding was not evident in more recent years. DISCUSSION: Funding for projects focused on health equities and the SDOH lag behind theoretical shifts in the broader health disparities research arena. With the exception of NIMHD, there is a disconnect between funding for projects with a disparities orientation in institutional training and center projects relative to individual research projects. These trends have implications for nurse scientists seeking NIH funding to support health equity-oriented research.

Culture Shifts: From Cultural to Structural Theorizing in Nursing.

BACKGROUND: As a discipline, nursing emphasizes the importance of culture to care. Cultural competence is seen in nursing practice, education, and research as essential for addressing health disparities-particularly racial and ethnic disparities. There now is broad consensus that the causes for health disparities lie beyond the individual and are found in the structures of society. Current cultural competency theories and conceptual models, however, focus on the individual and do little to address the social/structural determinants of health. APPROACH: Reviewing the literature on cultural competency, current theorizing on culture and healthcare in nursing, and critiques of this theorizing is summarized. Emerging models that highlight the structural features of society influencing health are described. KEY POINTS: Cultural competency theorizing has been embraced in nursing, but its effectiveness in reducing health disparities has yet to be demonstrated. A shift in how the discipline addresses health disparities is needed. New theoretical approaches, such as fundamental causes theory, the health impact pyramid, ecological models, and structural competency, emphasize larger social determinants of health and should be more fully utilized in nursing. IMPLICATIONS: Nurse theorists need to clarify the usefulness of the emerging theories to the discipline, nurse educators should incorporate structural theories and concepts into curricula, practicing nurses will want to include structural screening assessment tools in their provision of care, and nurse researchers will need to develop skills in conducting and measuring the impacts of structural interventions.

Community/public health nursing: is there a future for the specialty?

Graduate nursing education in the United States has undergone significant changes over the last decade with institution of the doctorate in nursing practice (2006) and the revised Essentials of Master's Education in Nursing (2011). An overview of the status of community/public health nursing (C/PHN) education and practice during the past 100 years provides a historic context for understanding the current situation of the specialty. An analysis of U.S. graduate nursing programs in C/PHN is used to foreground a discussion of the factors that may significantly affect community/public health nurses' interest in graduate education and the ability to sustain a master's-prepared C/PHN workforce. Questions are raised about how the potential loss of this particular specialty may influence the practice of C/PHN and the role of nursing in general in ensuring the public's health. Recommendations are offered for strengthening the specialty long-term, with a particular focus on C/PHN education and practice.

Nurses' knowledge and attitudes toward pain in the emergency department.

INTRODUCTION: The purpose of this study was to investigate emergency nurses' knowledge and attitudes about pain. METHODS: A descriptive design was used for this study. A validated tool, the Knowledge and Attitudes Survey Regarding Pain (KASRP), was administered to nurses working in 5 U.S. emergency departments. Demographic data also were collected from each participant. RESULTS: Ninety-one emergency nurses completed the survey. The mean total KASRP score was 76%. No significant differences were found in mean total scores by age, education level, years of nursing experience, or years of ED experience. Eight questions were answered incorrectly by more than 50% of participants. Five of these questions were related to opioid pharmacology and dosage, 2 concerned understanding of addiction and dependence, and one was linked to nurse assessment and patient report of pain level. Analysis of these 8 questions revealed that higher education levels had a weak positive association with correct answers. DISCUSSION: Participants taking the survey scored comparably or better than participants in other reported studies using the KASRP. Years of nursing experience was not correlated with correct responses. Findings from this study underscore the Institute of Medicine's Pain in America recommendation to increase pain management education for all providers.

Injustice, suffering, difference: how can community health nursing address the suffering of others?

Social justice brings to life the purpose of public health-improving a population's overall health and well-being. Critiques of the concept demonstrate that social justice is inconsistently defined and rarely is acted upon, and continuation of these injustices constitutes a form of suffering. Seeing one's self as disconnected from others makes their suffering normal. Viewing others from an ethical, moral, and human rights perspective helps one understand that the well-being of the self and the individual rests on the well-being of the collective other; this obligates each person to ameliorate and, if possible, prevent the suffering of others.

Transitions, decisions, and regret: order in chaos after a cancer diagnosis.

Receiving a cancer diagnosis marks a life transition that evokes feelings of chaos. Additional transitions occur when patients with relapsed cancer must decide to pursue conventional care or participate in experimental clinical trials. Individuals with hematologic malignancies (n = 25) and their caregivers (n = 20) were interviewed about their decisions to have an experimental stem cell transplant. Noting that they had "no other choice," participants expressed no regret posttransplant. "Doing something" perhaps helped address the chaos of cancer. This aggressive response to advanced cancer also represented a social imperative that negated the options of living with the cancer or entering palliative care.

"I had already made up my mind": patients and caregivers' perspectives on making the decision to participate in research at a US cancer referral center.

BACKGROUND: Hematopoietic cell transplants (HCTs) are associated with high morbidity and mortality, which complicate the decision-making process for people considering HCT clinical trials. There is a lack of research examining longitudinally how patients make clinical trial participation decisions in US cancer referral centers. OBJECTIVE: A qualitative study was conducted to examine how patients and their family caregivers decide to participate in HCT research at a US cancer referral center. METHODS: Semistructured interviews were conducted with 25 patients enrolled in early-stage phase 2 HCT research studies and with 20 family caregivers. Interviews were conducted before HCT and approximately days 80 and 365 after HCT. RESULTS: Most patients (92%) and their caregivers (75%) decided to participate in research well before consent conferences at the cancer referral center. Patients' reasons for deciding to participate included having "no other option," seeking a cure, and following their home oncologists' recommendations. CONCLUSION: Currently, US researchers are primarily guided by Federal regulations that view the decision-making process as a cognitive one. Findings confirmed cognition was a part of consent; however, most patients made the decision to participate in high-risk clinical trials long before they had been apprised of the specific information about the study and before the consent conference. IMPLICATIONS FOR PRACTICE: The high risk of death from the disease and/or the HCT underscored the emotional component of decision making and affirmed that researchers need to acknowledge this emotional component to meet the ethical imperative of providing "informed consent."

Of goldfish tanks and moonlight tricks: can cultural competency ameliorate health disparities?

Within nursing, cultural competency is seen as an important mechanism for reducing racial and ethnic health disparities; however, after years of attempted implementation of "cultural competence," minimal evidence exists demonstrating a relationship between culturally competent interventions and improved health outcomes or reduced disparities. We examine how cultural competency as an intervention for tackling health disparities is undertheorized and misguided, and deflects attention and efforts needed to address broader social determinants of health. We provide a historical overview of cultural competency, critiques of the concept, and recommendations for moving beyond cultural competency as a means of diminishing health disparities.