The Structures of Caring

Implications for Knowledge Translation

Our journal's 2023 focus on Redesigning Health Care has highlighted structures that support the health-care workforce (Issue 1) and called into question the continued relevance of the legacy structures and habits of thought through which we encounter those we serve (Issue 2). Now, Issue 3 examines these structures in more detail, building on our journal's previous contributions to this knowledge.

In 2016 (Creative Nursing Vol. 22), we published 49 articles in four issues addressing that year's overarching theme, Determinants of Health. The World Health Organization (WHO) defines social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems” (WHO, n.d.).

Social Determinants of Health

In Issue 1, Social Determinants, our Guest Editor, Nursing Professor Dorothy Powell, made a strong statement in her editorial, “Social Determinants of Health: Cultural Competence is not Enough”: “Targeting social determinants of health (SDH) may be a more persuasive and evidence-based strategy for eliminating health disparities than cultural competence or cultural congruence” (Powell, 2016, p. 6). Other articles in this issue included discussions of cultivating the next generation of minority nurse leaders committed to health equity; overcoming challenges of finding clinical placements for advanced practice nursing students by teaching physical assessment skills in the community setting; systematic babywearing, particularly for children with disabilities and special needs; supporting mothers of infants with neonatal abstinence syndrome using infant massage; addressing issues of consent for research on adolescents; and a review of the book Yellow Dirt: A Poisoned Land and the Betrayal of the Navajos.

Structural Determinants of Health

Issue 2, Structural Determinants, was about barriers—to equitable care, and to equitable nursing education. Guest Editor Donna Biederman and colleagues at Duke University profiled nursing leadership in facilitating transitional care after discharge from acute care settings for persons experiencing homelessness—one of the starkest barriers to effective health care for people who “frequently move between institutional and community settings” (Biederman et al., 2016, p. 76). The 25th anniversary of the Americans with Disabilities Act occasioned an article by Alison Eide showing how far we have come, and how far we still have to go: “Who is considered a contributor to society and who is considered a burden are social constructs that have led to a history of discrimination in education and employment of people with disabilities” (Edie, 2016, p. 135). Other topics addressing barriers of various kinds included nurse philanthropy to address needs of under-resourced communities; nurses’ involvement in planetary health; barriers to care for transgender people and to advance care planning among Latino/Latina patients; continuity of nursing care in the NICU; educational needs of in-patient nursing staff about palliative and hospice care; minority perspectives on leadership in nursing education; the role of Relationship-Based Care in addressing the Institute of Medicine's Core Competencies for health educators in addressing issues of quality of care; and support for advanced practice nurses as primary care providers via a case study of a nurse practitioner's management of a complex illness.

Caregiver Determinants of Health

In my editorial in Issue 3, Caregiver Determinants, I asked the question, “What if health care that could have created, maintained, or restored well-being is avoided because of me?” (Lewis-Hunstiger, 2016, p. 143). This issue explored ways in which health-care professionals can neglect or even subvert the best intentions and best practices of our science of caring: inappropriate management of patients’ procedural pain; racism in the disparate institutional support for patients with sickle cell disease; and implicit and explicit biases about what women experiencing homelessness really need and want. Guest Editor Brooke Cunningham, Professor in the Department of Family Medicine and Community Health at the University of Minnesota Medical School, pointed out that “our expectations about caring . . . reflect widely held social values about who is to care, for whom, and to what ends” (Cunningham, 2016, p. 147). Other articles were more hopeful about our better natures: teaching nursing students about servant leadership and emotional intelligence, and empowering them through intentional structuring of a clinical day; a review of a concept analysis of cultural humility; and a curriculum to build a Relationship-Based Care milieu.

Global Determinants of Health

Issue 4, Global Determinants, truly had a worldwide reach, beginning with “Identifying Indicators of Healthy Work Environments in Nursing as Determinants of Health in the 21st Century” by Guest Editor Helga Bragadóttir, Nursing Professor at the University of Iceland. She stated, “It is of major importance for clinical nurses, nurse leaders, and policymakers to address the issue of staff health, not only for the well-being of those individuals but also for the health and sustainability of future health care services” (Bragadóttir, 2016, p. 222). Other international articles included outcomes of implementation of Primary Nursing in Italy; a community health survey in Peru; Dengue/Zika interplay in Hawai’i; the path to nursing for a Somali refugee; supporting health and well-being for resettled refugee women; addressing climate change as a global determinant of health; and the challenges of conducting study-abroad programs in the digital age. Topics that transcend borders included promoting heart health for women in rural areas; hidden grief and lasting emotions in Emergency Department nurses; and communication with families with special needs as a determinant of health.

In this current issue of Creative Nursing, the systems and structures that support our caring are revealed from many angles, levels, and perspectives. Readers are challenged to recognize the potential, embedded in every system and structure, for disparities in the provision of our care.

Nurse Executive Leaders Coping With Massive Change

Our Guest Editor, Cyrus Batheja, National Vice President for Nursing at Optum Rx, writes about the power of resilience in helping nurse executive leaders working to effect change in structural determinants of health at direct care, interprofessional, organizational, and policy levels. He gathers research, literature, and personal experiences to outline techniques including self-care, building relationships, seeking support, maintaining a positive attitude, and practicing mindfulness, as critical for nursing leaders working to make redesign of health-care structures a reality (Batheja, 2023).

Interdisciplinary Professors Facilitating International Student Collaboration

Linda Sue Hammonds, Nursing Professor at the University of South Alabama in Mobile, and Sara Newman, Professor of English and Rhetoric in the Universidad San Francisco de Quito in Ecuador, created a Collaborative Online International Learning (COIL) experience for students in a psychiatric mental health nurse practitioner program in the US and an English course, Writing and Rhetoric, in Ecuador, to develop global perspectives and cultural competencies about diversity and inclusion in mental health. The objective of the COIL experience was to identify existing structures and discuss changes in thinking in four areas (eugenics and cultural bias, cultural bias in research, culture and mental illness, and institutional and care policies), motivating students to question their assumptions, challenge those they find lacking if not harmful, and adapt new thinking (Hammonds & Newman, 2023).

Technology Specialists Supporting Patients’ Digital Literacy

Professor Ryan Shaw from Duke University School of Nursing reports that access to and the skills to use technology provide the digital equity necessary for civic and cultural participation, employment, lifelong learning, and access to essential services. However, disparities in access and skills (“the digital divide”) risk exacerbating health-care inequalities. The COVID-19 pandemic accelerated the adoption of technology-driven health care, but also amplified the digital divide, often leaving disadvantaged groups further behind. Digital inclusion encompasses efforts to ensure universal access to and utilization of the structures of information and communication technologies by individuals and communities, especially those facing significant disadvantages. The costs associated with equipping individuals to use the internet are significantly lower than treating the health conditions that may have been prevented or mitigated with the use of this technology. Nurses play a vital role in promoting digital equity, serving as educators, advocates, and digital navigators, guiding patients through the complexities of the digital health landscape (Shaw, 2023).

Early Responders Helping Victims of Sexual Assault

Everyone involved in the care of persons who have experienced sexual assault needs to be cognizant of the psychological–physiological phenomena of trauma in order to provide sensitive, high-quality care to these individuals. The structure of trauma-informed care encompasses the need to acknowledge the impact of traumatic events such as sexual assault, and respond without retraumatizing the person, by focusing on validating the trauma experience, serving the person's needs, and empowering them to make decisions, by offering choices, along with safety, cultural awareness, trust, and collaboration. Women's Health Care Nurse Practitioner Phyllis Mathews and Associate Vice President for Health and Well-Being Kristina Blyer from James Madison University in Harrisonburg, Virginia developed a decision aid that states the decisions that need to be considered, provides information about the options (including benefits and harms), and helps patients recognize their personal values in relation to the options. Based on the understanding of the neurobiology of trauma, this decision aid (included as a supplemental file) provides education and information to prepare the person to make care/treatment decisions that are important to them (Mathews & Blyer, 2023).

Hospital Staff Members Caring for Vulnerable Patients During the Height of a Pandemic

Mind maps, often employed in nursing education, use lines, symbols, words, and images to transform text information into flow diagrams, helping nurses analyze and recall information by visually structuring their ideas, and can improve decision making by decreasing cognitive effort. This article by Xue Bai, Chief Nurse at Jingzhou First People's Hospital in Hubei, China, presents an innovative use of mind mapping to structure the nursing care of patients on an in-patient neurology unit during the COVID-19 pandemic. The patients on this unit, many older and/or with chronic illnesses, are particularly susceptible to SARS-CoV-2 infection and have more serious symptoms after infection. Mind mapping was used to streamline and systematize all the links involved in the care process, from admission to discharge, giving nurses increased clarity in accurately implementing quality and safety measures, including infection control. The article includes a report of outcomes, and the Mind Map is presented as a supplemental file, in Chinese and in English translation (Bai, 2023).

Nurse Educators Teaching Students About the Impact of Culture on Health

The Hispanic population is the largest and fastest-growing minority group in the US, and is disproportionally impacted by health problems, including heart disease, stroke, diabetes, obesity, cancer, and unintentional injuries. Factors contributing to these disparities include cultural practices, lack of access to health care, language barriers, and a lack of cultural competence by health-care providers. Nurses must be knowledgeable about the impact of culture on health to dismantle the structural biases leading to racial/ethnic health disparities and deliver equitable and high-quality care to individuals, families, and communities. Nursing Professor Mariana da Costa of Western Carolina University discusses some cultural beliefs and traditions prevalent in the Hispanic community that impact health, including familism, curanderismo, machismo and marianismo, and personalismo, as well as systemic factors such as the Hispanic health paradox, acculturation, idioms of distress, and language-concordant care (Da Costa, 2023).

Faculties and Allies of Historically Black Colleges and Universities

The authors of this article are Roberta Waite, Dean and Chief Nursing Officer at Georgetown University School of Nursing; Yolanda VanRiel, Nursing Department Chair at North Carolina Central University College of Health and Science; Nina McCune, Associate Dean 2 of Inclusive Teaching and Learning Environment, and Catherine Holton, Associate Dean of the College of Nursing, both at Walden University; Gina Brown, Dean of the College of Nursing and Allied Health Sciences at Howard University; and Katie Boston-Leary, Director of Nursing Programs at the American Nurses Association. These nursing leaders advocate for identifying and operationalizing authentic, sustainable partnerships led by Historically Black Colleges and Universities (HBCUs), as a means to diversify nursing leadership and to stem systemic and structural inequities in health care. In this work, the social determinants of health (SDOH) framework are important in highlighting the impact of nursing and nursing leadership on the health and economic mobility of Communities of Color. The article presents strategies grounded in the SDOH framework: Addressing university hiring and staffing, particularly the development of faculty members as mentors. Supporting sustainable partnerships, exemplified by nursing school accrediting bodies developing more transfer-friendly environments. And holistic admissions processes that expand the criteria for rating applicants, reducing systemic barriers to transferring credits among institutions. HBCU nursing faculty, students, and programs bring great promise to the nation's practice partners and communities through complementary coalitions and alliances that promote new strategies and ideas, expanding opportunity for all stakeholders (Waite et al., 2023).

Clinicians Supporting the Use of a Mobile App to Help Individuals Manage Their Type 1 Diabetes

Diabetes mellitus is a chronic disease that needs long-term management, including education and support in self-care management to help patients make decisions about treatment plans, perform self-care management activities, solve problems, and collaborate with health-care professionals to achieve better health outcomes and quality of life. Mobile apps can be an effective way to improve patients’ knowledge about their disease, and consequently their self-efficacy (SE) and self-care agency (SCA), and can encourage active participation in and adherence to self-management and treatment plans. In Amman, Jordan, Professors Arwa Masadeh of Applied Science Private University and Ali M. Saleh of the School of Nursing at The University of Jordan studied the effectiveness of a diabetes self-management mobile app among 128 patients with Type 1 Diabetes Mellitus, half receiving usual care and half also using the app. Results after 3 months showed improvement in SCA and significant improvement SE in the intervention group. The authors conclude that use of the app may help improve patients’ confidence in self-management; increase their knowledge of the disease, complications, and various aspects of self-management; and enhance commitment to and performance of self-care activities (Masadeh & Saleh, 2023).

Mental Health Professionals Using the Newman Systems Model to Help a Patient With Significant Depression Cope With COVID-19 Illness

The COVID-19 pandemic caused concern among the public as well as vulnerable groups such as caregivers, seniors, and those with underlying health issues; fear and anxiety about what could happen when everyone is suspected to be vulnerable can be overwhelming, particularly among patients with pre-existing mental health issues. Golnaz Azami and Boshra Ebrahimy of the Department of Emergency Medical Sciences at Kurdistan University of Medical Sciences in Sanandaj, Iran, and colleagues Aliashraf Mozafari of the Department of Epidemiology, Mohamadreza Kafashian of the Department of Physiology, and Sanaz Aazami of the Department of Nursing, all at Ilam University of Medical Sciences in Ilam, Iran, present a case study of the use of the Newman Systems Model to structure the care of a patient with pre-existing mental health conditions struggling to cope with depression and COVID-19 illness. The Newman Systems Model focuses on primary, secondary, and tertiary nursing prevention for retention, attainment, and maintenance of patient system wellness. Providing culturally coordinated care for patients with depression requires looking beyond symptoms to comprehensively evaluate the role of stress, vulnerability, and personal factors. The study design used interviews, nursing observations, and document analysis to evaluate the patient's environmental factors and intra-, inter-, and extra-personal stressors, in developing an outcome-oriented nursing care plan, included as a supplemental file (Azami et al., 2023).

Nursing Professors and Students Collaborating in Virtual Reality Simulation About Cultural Competence in the Community Health Setting

Clinical experiences in nursing education often focus on acute care settings, whereas experiences representing other specialties such as community health are limited. Virtual reality (VR) simulation in nursing education, especially about care in non-acute settings such as community health, is an emerging learning strategy. At Eastern Michigan University, Nursing Professors Jenni Hoffman and Tsu-Yin Wu of the College of Health and Human Services, and Professor Grigoris Argeros of the Department of Sociology, Anthropology and Criminology in the College of Arts and Sciences, evaluated the effectiveness of a community health nursing VR simulation on prelicensure students’ knowledge about SDOH and cultural competence, with a goal of enhancing their preparation for practice. The scenario, aiming to increase knowledge and understanding of culturally appropriate care and the impacts of SDOH, with a focus on the Asian-American community, involved a Bangladeshi man with a history of hypertension, depression, and anxiety, who attended a wellness and flu clinic at a local mosque. Students who volunteered to use the headset and hand controls obtained a brief health history, conducted various health screenings (blood pressure, height, weight, body mass index, blood cholesterol, and blood glucose), provided education, and determined the patient's eligibility for and then administered his influenza vaccine; the remaining participants observed the scenario. Pre- and posttests containing content questions adapted from community health nursing resources were used to assess learning, and the Simulation Effectiveness Tool-Modified was used to assess perceived effectiveness of the intervention. The majority of posttest scores were higher than pretest scores; participants reported on new knowledge/skills learned, material found most helpful, and benefit to their nursing practice (Hoffman et al., 2023).

Our remaining issue for Creative Nursing 2023 will continue the discussion of structural aspects of disparities in care: Understanding the Human and Financial Costs of Marginalization. Please join us for this ongoing scholarly conversation.