A Critical Discourse Analysis of AACN's Tool Kit of Resources for Cultural Competent Education for Baccalaureate Nurses.

American institutions of nursing education have integrated cultural competence as a pillar approach to addressing health disparities. The theoretical frameworks, priorities, and solutions that national organizations pursue and endorse have far-reaching implications. The American Association of Colleges of Nursing (AACN) is one such organization. The purpose of this project was to critically analyze the AACN's Tool Kit of Resources for Cultural Competent Education for Baccalaureate Nurses to excavate dynamics related to language, power, and inequality. Findings of this critical discourse analysis indicate: (1) the centrality of the AACN's assumed authority and lack of relationality with readers, (2) nursing insularity and narrow theorization of culture and power, and (3) the harm of whiteness and colonialism as pedagogy. Accountability and repair include transparency, taking note of resources and viewpoints available and endorsed on organization websites, and updating (or refuting) outdated and harmful approaches.

"I've Never Been to a Doctor": Health Care Access for the Marshallese in Washington State.

The Ri Majel (Marshallese) migrants of Washington State have endured health inequities and unique laws dictating their access to health care once they arrive to the United States. These health inequities can be seen to be a result of historical trauma and militarization of their islands. The research question was an inquiry regarding access to health care for the Ri Majel in Washington State. We first provide detailed historical data in the background to contextualize our research inquiry. We interviewed 12 people and using manifest content analysis found 2 main themes regarding the health of the Ri Majel: (1) health care access and inequity and (2) historical trauma and embodiment. Health care access was impeded by (1) ongoing effects of radiation, (2) repeated denial of services, (3) lack of health care and insurance, (4) lack of language interpretation during health care visits, and (5) poverty. Historical trauma and embodiment were evidenced by these findings: (1) illness and early mortality; (2) provider lack of knowledge and understanding of the Ri Majel; (3) structural discrimination; (4) feelings of sadness and despair; (5) shyness and humility; and (6) a sense of "cannot/will not" and fatalism. Our findings demonstrate the need to examine structural factors when assessing health inequities and a need to understand and mitigate the effects of historical trauma enacted by structural racism, violence, and colonialism. Strategies to mitigate the embodiment of historical trauma require further investigation.

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

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

Structural competency: A pilot study.

OBJECTIVE: The objective of this study is the use of structural competency (SC) as a tool to broaden the view of nursing students beyond individual, behavioral, biological, and cultural frameworks to encompass the structural determinants of health. DESIGN: This mixed-methods pilot study consists of a concurrent nested strategy in which close-ended, forced-choice questions are the drivers while open-ended questions are embedded therein. SAMPLE: The sample consists of second-year doctor of nursing practice students. MEASURES: The short-term impact is measured through the use of a survey tool. INTERVENTION: The 3-hr SC educational module focuses on six learning objectives: knowledge of structural terms, identifying SC effects on population and patient health; strategizing responses to these influences, student readiness to create change at the individual, organizational, and systems-level, identifying needed tools, and assessing empowerment and burnout. RESULTS: Students understand structural terms and are willing to create systemic change but lack necessary tools which may result in burnout. CONCLUSIONS: Careful thought about curricula incorporating SC and skills to offset the potential impact of burnout is needed.

Epistemic Injustice: A Philosophical Analysis of Women's Reproductive Health Care in a Somali-American Community.

Epistemology is the study of the grounds of knowledge. We illustrate through case studies how epistemic injustice is manifested in the delivery of reproductive health care services for women from Somalia, even though it may not be intended or recognized as injustice. Testimonial injustice occurs when women are not believed or are discredited in their aim to receive care. Hermeneutic injustice occurs when a significant area of one's social experience is obscured from understanding owing to flaws in group knowledge resources for understanding. For example, women from Somalia may not receive full disclosure about the diagnostic or treatment services that are recommended in the reproductive health care setting. We explore how the many intersections in a person's identity can give rise to epistemic injustice and we suggest more expansive ways of evaluating the validity of diverse epistemologies in patient-centered care. Structural competency is recommended as a way nurses and other health care providers can mitigate the social determinants of health, which contribute to epistemic injustice.

A pedagogy of social justice for resilient/vulnerable populations: Structural competency and bio-power.

BACKGROUND: Nursing schools frequently assert the importance of social justice curriculum, but little information is available about specifics for such a class. PURPOSE: The purpose of this article is to describe a class that builds a foundation for the understanding of social justice and the pedagogical frameworks on which it rests. METHODS: The authors develop a class grounded in bio-power and structural competency. DISCUSSION: Described are topics presented to students, the rationale for their selection along with class activities and implementation challenges. Highlighted is the use of praxis as students incorporate the components of structural competency and bio-power. The focus is on the potential for public health and advanced practice registered nurses to recognize and evaluate structural factors in patient and population-based care. CONCLUSION: Faculty meet substantive challenges in teaching social justice, including lack of recognition of societal forces which affect student's ability to provide care. Focused effort incorporating newer structural and philosophical frameworks in a social justice class may improve the provision of health services. The frameworks of structural competency and bio-power provide a critical paradigm salient in social justice pedagogy.

Administrator Perspectives of Patient-Centered and Culturally Appropriate Reproductive Health Care for Women From Somalia.

OBJECTIVE: To explore health care administrators' perspectives on (a) institutional values, practices, and policies on the provision of patient- and family-centered and culturally appropriate reproductive health care for women from Somalia; (b) limitations imposed by these institutional values, practices, and policies; and (c) strategies to address these limitations. DESIGN: An exploratory single case study with in-person interviews and institutional document analysis guided by critical theory. SETTING: A Level 4 academic medical center on the West Coast of the United States. PARTICIPANTS: Eleven health care administrators employed at the study site. METHODS: Administrators participated in semistructured interviews after reading a prototypical vignette to contextualize the clinical encounter of a Somali woman with health care providers. Data from interviews were analyzed using a deductive structural coding process. Institutional documents were analyzed to identify values, policies, and practices regarding patient- and family-centered and culturally appropriate care for women from Somalia. RESULTS: The overarching theme was Our institution respects diversity and patient- and family-centered care. The subthemes that emerged were Current practices are important but difficult to institute, Current institutional policies are good but too nonspecific to follow, and Engagement between the provider and woman is of value but difficult to enact. Recommendations to address these contrasts fell into two categories: pragmatic planning and changing the paradigm of care. CONCLUSION: Cultural barriers, limitations caused by structural factors, and competing provider-patient paradigms contribute to challenges for many providers when caring for Somali women in some U.S. health care systems. Specific policies and training to provide culturally appropriate reproductive care for Somali women are imperative.

Caring ethics and a Somali reproductive dilemma.

The use of traditional ethical methodologies is inadequate in addressing a constructed maternal-fetal rights conflict in a multicultural obstetrical setting. The use of caring ethics and a relational approach is better suited to address multicultural conceptualizations of autonomy and moral distress. The way power differentials, authoritative knowledge, and informed consent are intertwined in this dilemma will be illuminated by contrasting traditional bioethics and a caring ethics approach. Cultural safety is suggested as a way to develop a relational ontology. Using caring ethics and a relational approach can alleviate moral distress in health-care providers, while promoting collaboration and trust between providers and their patients and ultimately decreasing reproductive disparities. This article examines how a relational approach can be applied to a cross-cultural reproductive dilemma.