Social justice in Canadian nursing professional documents: A Foucauldian discourse analysis.

Social justice is widely advanced as a central nursing value, and yet conceptual understandings of social justice remain inconsistent and vague. Further, despite persistently articulated commitments to upholding social justice, the profession of nursing has been implicated in perpetuating inequities in health and health care. In this context, it is essential to establish both conceptual clarity and tangible guidance for nurses in enacting practices to advance social justice-particularly through regulatory, education and accreditation documents that shape the nursing profession. This Foucauldian discourse analysis examines how social justice is discursively positioned within nursing professional documents in Canada, and illustrates that social justice was largely discursively excluded from these texts. Where social justice discourses were invoked, we identified that four central discursive patterns obscured and de-centred this nursing value: (i) Vague language undermined professional commitments to social justice; (ii) Constructions of knowledge and awareness de-emphasized practice; (iii) Individualism discourses minimized institutional/professional responsibility; and (iv) Aspirational language obscured present action. Extending from this analysis, we contend that the nursing profession must re-examine how social justice is understood and articulated, and call for a re-conceptualization of social justice grounded in nursing practice toward remediating inequities in health and health care.

From Subversion to Hard-Wiring Equity: A Discourse Analysis of Nurses' Equity-Promoting Practices in Emergency Departments.

Nursing has articulated a shared commitment to equity in response to inequities in health and health care; however, understandings of how nurses enact equity are needed to uphold this professional mandate. This Foucauldian discourse analysis examined how nurses' equity-promoting practices are shaped by dominant discourses within the emergency department and illustrated that within this institutional context that constrained equity, nurses engaged in equity-promoting practices through subversion of discursive power. This study illustrates the need for embedding equity discourses within health care systems and ensuring meaningful supports for nurses in enacting equity-promoting practices within the emergency department setting.

Core components of an anti-racist approach among health professions educators: an integrative review.

Objectives: This integrative literature review aimed to identify the core elements of an anti-racist approach among health professions educators. Methods: We searched five databases CINAHL (EBSCOhost), ERIC (ProQuest Dissertations & Thesis Global), EMBASE (Ovid), MEDLINE (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded) in March 2021. The search strategy combined concepts related to anti-racist pedagogies in the context of health professions education by educators in any capacity. From 1,755 results, we selected 249 manuscripts published in English or French between 2008 and 2021 based on titles and abstracts. After reviewing the full texts, we selected the 48 most relevant sources. We extracted data regarding knowledge, skills, and attitudes in reference to anti-racist approaches or surrogate terms. Within each category, we grouped similar data using a conceptual map. Results: Analysis of the selected sources revealed that, for health professions educators, engaging in an anti-racist pedagogical approach requires more than incorporating racialized perspectives and content into the classroom. It rather rests on three interrelated components: developing a critical understanding of power relationships, moving toward a critical consciousness, and taking action at individual and organizational levels. Conclusions: This review sheds light on knowledge, attitudes and skills that educators must deploy to adopt an anti-racist approach competently. This approach is a learned, intentional, and strategic effort in which health professions educators incorporate anti-racism into their teaching and apply anti-racist values to their various spheres of influence. This ongoing process strives for institutional and structural changes and requires whole-system actions.

Integrating equity and social justice for indigenous peoples in undergraduate health professions education in Canada: a framework from a critical review of literature.

Understanding how to create structural change by actively counteracting racialized ways of interacting with Indigenous peoples at an individual and organizational level within health care systems and health professions education is essential for creating a more inclusive, equitable, and healthier society. In health professions education, the primary means of teaching about health inequities has been to frame them as stemming from culturally or ethnically based issues. While attention to culturally specific practices can be valuable to health and healing in some contexts, education that solely focuses on Indigenous cultures risks perpetuating cultural stereotypes and othering, rather than focusing on how Eurocentric systems continue to exert oppressive effects on Indigenous peoples. We present an organizational transformation framework grounded in equitable partnerships from a comprehensive critical review of the literature on the integration of equity and social justice in undergraduate health professions education with a focus on Indigenous health. We did a thematic analysis of the results and discussions presented in the 26 selected articles to identify promising practices and challenges associated with the integration of equity and social justice in undergraduate health professions education. The framework resulting from this analysis is composed of three interrelated components: 1) adopt critical pedagogical approaches that promote Indigenous epistemologies; 2) partner with Indigenous students, educators and communities; 3) engage educators in critical pedagogical approaches and health equity issues. This framework could guide the development of contextually tailored interventions that contribute to decolonizing health professions education.

Understanding the expanded nursing role in indigenous communities: A qualitative study.

AIM: By studying an extreme context, we aim to provide an in-depth understanding of the expanded nursing role in remote aboriginal communities, its dynamics and the main barriers to its full expansion. BACKGROUND: While it is recognized that nurses play a major role in remote or rural areas, little is known about the dynamics of the expanded role and the nurses' daily practice and routines. METHODS: We conducted 49 in-depth interviews with nurses and key informants and more than 14 days of observation: two days of pre-departure training and 12 days in dispensaries and a hospital in Hudson Bay, Québec, Canada. RESULTS: We identified four sub-roles within the nurses' expanded role: administrative, nursing, medical and community sub-roles. This typology allowed us to document the evolving and dynamic nature of the role as well as the individual, organisational and community barriers that limit its expansion. CONCLUSION: This typology represents the first attempt to gain an in-depth understanding of the enlarged nursing role in northern Québec and of the complexity of the daily nursing routines and dynamics. We believe it to be relevant for other contexts, such as rural areas, even if nurses there do not always take on all four sub-roles during their nursing experience. IMPLICATIONS FOR NURSING MANAGEMENT: Our paper has significant practical implications for different stakeholders-educators, directors of nursing, recruiters, regulators and policymakers-as it may help with identifying the education and training requirements for developing specific sub-roles, overcoming obstacles to widening the expanded role or better allocating the resources needed based on the predominant sub-role in different contexts. More broadly, this study shows that, when properly regulated, extending professional nursing boundaries does not put the patient at risk and enables professionals to develop their practice. It represents a textbook case for rethinking our contemporary health care systems.

[Recommendations to Nursing Practice with Sexual and Gender Diversity Older Adults : A Scoping Review] / Une revue de la portée sur la pratique infirmière auprès des personnes âgées issues de la diversité sexuelle et de genre.

Context : The elder population is growing up and sexual and gender diversity older adults (SGDOA) live discrimination from healthcare professionals. In this context, this scoping review sought to describe the extent of knowledge about nursing practice among SGDOA and to synthesize the implications for clinical nursing practice. Method : The scoping review method according to the framework of Peters et al. of the Joanna Briggs Institute has been adopted. Results : The recommendations were grouped into five axes : raising awareness of the existence of SGDOA, their historical context and their health problems ; refrain from heterocissexist and heterocisnormative assumptions by adopting an inclusive language and an open attitude ; support SGDOA and their caregivers or their family of choice ; create a safe and confidential environment ; and promote the inclusion of SGDOA in the health care system. Conclusion : The results could be used by nurses and other health professionals to optimize the quality of care for SGDOA and to promote their inclusion.

Une revue de la portée sur la pratique infirmière auprès des personnes âgées issues de la diversité sexuelle et de genre.

Context : The elder population is growing up and sexual and gender diversity older adults (SGDOA) live discrimination from healthcare professionals. In this context, this scoping review sought to describe the extent of knowledge about nursing practice among SGDOA and to synthesize the implications for clinical nursing practice.Method : The scoping review method according to the framework of Peters et al. of the Joanna Briggs Institute has been adopted.Results : The recommendations were grouped into five axes : raising awareness of the existence of SGDOA, their historical context and their health problems ; refrain from heterocissexist and heterocisnormative assumptions by adopting an inclusive language and an open attitude ; support SGDOA and their caregivers or their family of choice ; create a safe and confidential environment ; and promote the inclusion of SGDOA in the health care system.Conclusion : The results could be used by nurses and other health professionals to optimize the quality of care for SGDOA and to promote their inclusion.

EQUIP Emergency: study protocol for an organizational intervention to promote equity in health care.

BACKGROUND: Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities. METHODS: EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis. DISCUSSION: This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs. TRIAL REGISTRATION: Clinical Trials.gov # NCT03369678 (registration date November 18, 2017).

Understanding competing discourses as a basis for promoting equity in primary health care.

BACKGROUND: Globally, health inequities persist with effects on whole populations and the most profound effects on populations marginalized by poverty, discrimination and other forms of disadvantage. In the current neoliberal political-economic context, health inequities are produced and sustained by the inequitable distribution of social determinants of health and structural inequities such as discrimination and institutional racism. Even in the context of healthcare organizations with an explicit commitment to health equity, multiple intersecting discourses, such as ongoing efficiency discourses, and culturalist and racialized discourses, are in constant interaction with healthcare practices at the point of care and the organizational level, limiting providers' and organizations' capacities to address structural inequities. Attention to discourses that sustain inequities in health care is required to mitigate health inequities and related power differentials. In this paper, we present findings from a critical analysis of the relations among multiple discourses and healthcare practices within four Canadian primary health care clinics that have an explicit commitment to health equity. METHODS: Informed by critical theoretical perspectives and critical discourse analysis principles, we conducted an analysis of 31 in-depth interviews with clinic staff members. The analysis focused on the relations among discourses and healthcare practices, the ways in which competing discourses influence, reinforce, and challenge current practices, and how understanding these dynamics can be enlisted to promote health equity. RESULTS: We articulate the findings through three interrelated themes: equity-mandated organizations are positioned as the "other" in the health care system; discourses align with structures and policies to position equity at the margins of health care; staff and organizations navigate competing discourses through hybrid approaches to care. CONCLUSIONS: This study points to the ways in which multiple discourses interact with healthcare organizations' and providers' practices and highlights the importance of structural changes at the systemic level to foster health equity at the point of care.

Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics.

BACKGROUND: The health care sector has a significant role to play in fostering equity in the context of widening global social and health inequities. The purpose of this paper is to illustrate the process and impacts of implementing an organizational-level health equity intervention aimed at enhancing capacity to provide equity-oriented health care. METHODS: The theoretically-informed and evidence-based intervention known as 'EQUIP' included educational components for staff, and the integration of three key dimensions of equity-oriented care: cultural safety, trauma- and violence-informed care, and tailoring to context. The intervention was implemented at four Canadian primary health care clinics committed to serving marginalized populations including people living in poverty, those facing homelessness, and people living with high levels of trauma, including Indigenous peoples, recent immigrants and refugees. A mixed methods design was used to examine the impacts of the intervention on the clinics' organizational processes and priorities, and on staff. RESULTS: Engagement with the EQUIP intervention prompted increased awareness and confidence related to equity-oriented health care among staff. Importantly, the EQUIP intervention surfaced tensions that mirrored those in the wider community, including those related to racism, the impacts of violence and trauma, and substance use issues. Surfacing these tensions was disruptive but led to focused organizational strategies, for example: working to address structural and interpersonal racism; improving waiting room environments; and changing organizational policies and practices to support harm reduction. The impact of the intervention was enhanced by involving staff from all job categories, developing narratives about the socio-historical context of the communities and populations served, and feeding data back to the clinics about key health issues in the patient population (e.g., levels of depression, trauma symptoms, and chronic pain). However, in line with critiques of complex interventions, EQUIP may not have been maximally disruptive. Organizational characteristics (e.g., funding and leadership) and characteristics of intervention delivery (e.g., timeframe and who delivered the intervention components) shaped the process and impact. CONCLUSIONS: This analysis suggests that organizations should anticipate and plan for various types of disruptions, while maximizing opportunities for ownership of the intervention by those within the organization. Our findings further suggest that equity-oriented interventions be paced for intense delivery over a relatively short time frame, be evaluated, particularly with data that can be made available on an ongoing basis, and explicitly include a harm reduction lens.

Applying cultural safety beyond Indigenous contexts: Insights from health research with Amish and Low German Mennonites.

People who identify as members of religious communities, such as the Amish and Low German Mennonites, face challenges obtaining quality health care and engagement in research due in part to stereotypes that are conveyed through media and popular discourses. There is also a growing concern that even when these groups are engaged in research, the guiding frameworks of the research fail to consider the sociocultural or historical relations of power, further skewing power imbalances inherent in the research relationship. This paper aims at discussing the uses of cultural safety in the context of health research and knowledge translation with groups of people that are associated with a specific religion. Research with the Amish and Low German Mennonites is provided as examples to illustrate the use of cultural safety in this context. From these examples, we discuss how the use of cultural safety, grounded in critical theoretical perspectives, offers new insight into health research with populations that are traditionally labeled as minority, vulnerable, or marginalized, especially when a dominant characteristic is a unique religious perspective.

Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing.

Although nursing has a unique contribution to advancing social justice in health care practices and education, and although social justice has been claimed as a core value of nursing, there is little guidance regarding how to enact social justice in nursing practice and education. In this paper, we propose a critical antidiscriminatory pedagogy (CADP) for nursing as a promising path in this direction. We argue that because discrimination is inherent to the production and maintenance of inequities and injustices, adopting a CADP offers opportunities for students and practicing nurses to develop their capacity to counteract racism and other forms of individual and systemic discrimination in health care, and thus promote social justice. The CADP we propose has the following features: it is grounded in a critical intersectional perspective of discrimination, it aims at fostering transformative learning, and it involves a praxis-oriented critical consciousness. A CADP challenges the liberal individualist paradigm that dominates much of western-based health care, and the culturalist and racializing processes prevalent in nursing education. It also situates nursing practice as responsive to health inequities. Thus, a CADP is a promising way to translate social justice into nursing practice and education through transformative learning.

[Cultural competence development: The perspectives of nursing students on their learning environment during an international clinical placement]. / Développement de la compétence culturelle infirmière : perspective d'étudiantes de leur environnement d'apprentissage lors d'un stage clinique à l'international.

INTRODUCTION: In nursing education, the organization of international placements and the support offered to students is widely different from one program to another. CONTEXT: In relation to the perspective of nursing students, few research works explore the elements of the learning environment that interact with their ability to open up to the different realities of nursing practice in the context of an international placement. OBJECTIVE: Guided by a constructivist cultural competence development model, this qualitative case study explored the elements of the learning environment that interact with the development of nursing practice in culturally diverse contexts through an international clinical placement. METHOD: A qualitative case study has been conducted. Ten students who had recently been on an international placement participated in an individual in-depth interview. A thematic data analysis was done. RESULTS: The results of this study highlight three interrelated themes: getting support through multiple collaborations, finding one's place in the host environment, and perceiving a gap between the expectations of the students and the lived experience. These themes deepened our understanding of learning environments in students' cultural competence development, particularly regarding their ability to open up to the different realities of practice in a culturally diverse context. DISCUSSION: This study contributes to defining the learning environment by integrating support as a collaboration with multiple partners. CONCLUSION: This study is an addition to current knowledge regarding the interactions between the learning environment and the development of cultural competence in nursing.

Nurse-Environment Interactions in the Development of Cultural Competence.

Studies on the development of cultural competence among healthcare providers tend to focus on the clinical encounter, with little attention paid to the environment. In this paper, results from a grounded theory study conducted with nurses and students to understand cultural competence development are presented; with a focus on findings that call particular attention to nurse-environment interactions. Two concurrent processes, as students and nurses develop cultural competence through interactions with their environment, were identified: "dealing with structural constraints" and "mobilizing social resources". These dynamic interactions between healthcare providers and the larger structures of healthcare systems raise critical questions about the power of healthcare providers to influence the structures that shape their practice. The intersection of nursing theory with social and critical theories is essential to gain a comprehensive understanding of cultural competence development and to transform healthcare providers' education in the service of social justice and health equity.

Critical Reflection in Cultural Competence Development: A Framework for Undergraduate Nursing Education.

BACKGROUND: Nursing faculties are urged to adopt a curriculum that supports culturally competent care and to mentor students to provide care that promotes social justice, particularly for the marginalized members of society. This article describes the development of a framework for critical reflection in cultural competence development among undergraduate nursing students. METHOD: Following the Medical Research Council guidelines for developing complex interventions, empirical and theoretical literature was reviewed to define the framework rationale and its components. RESULTS: The resulting framework is grounded in Blanchet Garneau's constructivist model of cultural competence development and Mezirow's transformative learning theory. It clarifies the desired outcomes, the main steps to foster critical reflection among students, and the contextual conditions and prerequisites for teachers and learners. CONCLUSION: Education oriented toward critical reflective practice promotes a full reflection about Western social and clinical practices and points out the role of nurses in reducing health inequities.

A constructivist theoretical proposition of cultural competence development in nursing.

Cultural competence development in healthcare professions is considered an essential condition to promote quality and equity in healthcare. Even if cultural competence has been recognized as continuous, evolutionary, dynamic, and developmental by most researchers, current models of cultural competence fail to present developmental levels of this competence. These models have also been criticized for their essentialist perspective of culture and their limited application to competency-based approach programs. To our knowledge, there have been no published studies, from a constructivist perspective, of the processes involved in the development of cultural competence among nurses and undergraduate student nurses. The purpose of this study was to develop a theoretical proposition of cultural competence development in nursing from a constructivist perspective. We used a grounded theory design to study cultural competence development among nurses and student nurses in a healthcare center located in a culturally diverse urban area. Data collection involved participant observation and semi-structured interviews with 24 participants (13 nurses and 11 students) working in three community health settings. The core category, 'learning to bring the different realities together to provide effective care in a culturally diverse context', was constructed using inductive qualitative data analysis. This core category encompasses three dimensions of cultural competence: 'building a relationship with the other', 'working outside the usual practice framework', and 'reinventing practice in action.' The resulting model describes the concurrent evolution of these three dimensions at three different levels of cultural competence development. This study reveals that clinical experience and interactions between students or nurses and their environment both contribute significantly to cultural competence development. The resulting theoretical proposition of cultural competence development could be used not only to guide initial and continuing nursing education, but also to help redefine quality of care in a culturally diverse context.

Cultural competence: a constructivist definition.

In nursing education, most of the current teaching practices perpetuate an essentialist perspective of culture and make it imperative to refresh the concept of cultural competence in nursing. The purpose of this article is to propose a constructivist definition of cultural competence that stems from the conclusions of an extensive critical review of the literature on the concepts of culture, cultural competence, and cultural safety among nurses and other health professionals. The proposed constructivist definition is situated in the unitary-transformative paradigm in nursing as defined by Newman and colleagues. It makes the connection between the field of competency-based education and the nursing discipline. Cultural competence in a constructivist paradigm that is oriented toward critical, reflective practice can help us develop knowledge about the role of nurses in reducing health inequalities and lead to a comprehensive ethical reflection about the social mandate of health care professionals.

[Cultural safety: a concept analysis]. / La sécurité culturelle culturelle analyse du concept.

Cultural safety is a concept that is getting more attention in scientific literature related to the cultural dimension of care. Difficulty to grasp the meaning and implications for research, education and practice is frequently raised by the authors. A concept analysis inspired by the evolutionary method of Rodgers was performed to better understand its meaning and its utility to the various fields of nursing. A systematic review of the literature was conducted in the databases CINAHL, PsycINFO, MEDLINE, EMBASE, ERIC, and Sociological Abstracts to identify literature published between 1988 and 2012 and containing the expression "cultural safety". 68 documents were analyzed. Findings included attributes, antecedents and consequences of cultural safety. The evolution of cultural safety through the various sociocultural and political contexts and application domains is also addressed. Issues related to the definition and operationalization of the concept, as well as the ability to export it out of its context of emergence, are discussed. The concept of cultural safety needs further development and a theoretical integration before reaching a conceptual clarity and effective operationalization.