Running head: UPHOLDING SOCIAL JUSTICE IN NURSING UPHOLDING SOCIAL JUSTICE IN NURSING: THE VALUE OF EDUCATIONAL EXPERIENCES by FLAVIA CARLA BUGHIU B.Sc.N, Trinity Western University, 2014 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES We accept this thesis as conforming to the required standard Dr. Barbara Astle, Supervisor Dr. Sheryl Reimer-Kirkham, Second Reader Dr. Em Pijl, Third Reader TRINITY WESTERN UNIVERSITY September, 2017 © Flavia Carla Bughiu, 2017 1 UPHOLDING SOCIAL JUSTICE IN NURSING 2 Abstract Social justice is a fundamental tenet to the profession of nursing. Embedded within the notion of upholding social justice is that of addressing the social determinants of health (SDH). Yet, little is known about nursing students’ views of whether they feel competent, or confident, to address the SDH, after partaking in an educational experience offering exposure to the SDH. The purpose of this research was to explore the value of clinical educational experiences in expanding nursing students’ understanding of—and perceived ability to address—the SDH, and in so doing to uphold their social justice mandate. An integrated mixed research synthesis of 33 studies was conducted. Four themes arose from thematic analysis: cognitive learning, experiential learning, reflexive learning, and praxis learning. Implications are discussed for nursing education and research to foster praxis learning, as transformational learning, in order to promote nursing students’ perceived ability to address the SDH. UPHOLDING SOCIAL JUSTICE IN NURSING 3 Table of Contents Abstract ........................................................................................................................................... 2 Table of Contents ............................................................................................................................ 3 List of Tables .................................................................................................................................. 9 List of Figures ............................................................................................................................... 10 Acknowledgments......................................................................................................................... 11 Dedication ..................................................................................................................................... 13 Chapter 1: Introduction and Background ...................................................................................... 14 Background ............................................................................................................................... 15 Definitions of Terms ................................................................................................................. 18 Address ................................................................................................................................. 18 Clinical practice .................................................................................................................... 18 Competency .......................................................................................................................... 19 Educational experience ......................................................................................................... 19 Global .................................................................................................................................... 19 Health disparity ..................................................................................................................... 19 Health equity ......................................................................................................................... 20 Health inequality ................................................................................................................... 20 Health inequity ...................................................................................................................... 20 Mandate................................................................................................................................. 20 UPHOLDING SOCIAL JUSTICE IN NURSING 4 Nursing student ..................................................................................................................... 21 Service-learning .................................................................................................................... 21 Social determinants of health ................................................................................................ 21 Social justice ......................................................................................................................... 21 Structurally vulnerable .......................................................................................................... 22 Thesis Description .................................................................................................................... 22 Purpose and research questions ............................................................................................ 22 Thesis Method ........................................................................................................................... 23 Relevance and Significance ...................................................................................................... 24 Chapter 1 Summary .................................................................................................................. 25 Outline of Thesis ....................................................................................................................... 26 Chapter 2: Preliminary Literature Review .................................................................................... 27 Preliminary Search Strategy ..................................................................................................... 27 Results of Preliminary Literature Review................................................................................. 28 Nursing’s mandate for social justice ..................................................................................... 28 Educational experiences: Academic and action-oriented ..................................................... 30 Awareness and understanding of the SDH ........................................................................... 32 Addressing the SDH ............................................................................................................. 33 International experiences ...................................................................................................... 34 Cause to question: Conflicting findings ................................................................................ 35 UPHOLDING SOCIAL JUSTICE IN NURSING 5 Barriers to addressing the SDH............................................................................................. 36 Facilitators to addressing the SDH ....................................................................................... 37 Subtleties of language in “addressing the SDH” .................................................................. 37 Recent innovations: Online learning and simulation experiences ........................................ 38 Culture versus equity discourses ........................................................................................... 39 Gaps in the Research ................................................................................................................. 40 Future areas of research ........................................................................................................ 40 Lack of syntheses .................................................................................................................. 40 Chapter 2 Summary .................................................................................................................. 41 Chapter 3: Methodology ............................................................................................................... 43 Comprehensive Search Strategy ............................................................................................... 43 Retrieval Strategy: Inclusion and Exclusion Criteria................................................................ 46 Inclusion criteria ................................................................................................................... 48 Exclusion criteria .................................................................................................................. 50 Methodology ............................................................................................................................. 50 Sampling ............................................................................................................................... 50 Data appraisal........................................................................................................................ 64 Data extraction ...................................................................................................................... 66 Supplementary methods ........................................................................................................ 68 Mixed Research Synthesis (MRS) ........................................................................................ 69 UPHOLDING SOCIAL JUSTICE IN NURSING 6 Data analysis ......................................................................................................................... 71 Scientific rigour .................................................................................................................... 73 Ethical Considerations .............................................................................................................. 76 Limitations ................................................................................................................................ 76 Chapter 3 Summary .................................................................................................................. 76 Chapter 4: Findings ....................................................................................................................... 78 Theme One: Cognitive Learning .............................................................................................. 79 Subtheme one: Understanding that the SDH exist ................................................................ 79 Subtheme two: Understanding the realities of the SDH ....................................................... 83 Subtheme three: Understanding through comparisons ......................................................... 88 Subtheme four: Conceptual understanding of the SDH ........................................................ 90 Theme Two: Experiential Learning .......................................................................................... 94 Subtheme one: Contextual learning ...................................................................................... 94 Subtheme two: Barriers to learning ...................................................................................... 98 Subtheme three: Facilitators to learning ............................................................................. 102 Subtheme four: Firsthand learning...................................................................................... 109 Subtheme five: Seeing the other ......................................................................................... 114 Theme Three: Reflexive Learning .......................................................................................... 119 Subtheme one: Seeing the self ............................................................................................ 120 Subtheme two: Willingly reflecting .................................................................................... 123 UPHOLDING SOCIAL JUSTICE IN NURSING 7 Subtheme three: Unreadiness to act .................................................................................... 125 Subtheme four: Struggling with understanding injustice.................................................... 129 Theme Four: Praxis Learning ................................................................................................. 131 Subtheme one: Moving towards seeing their potential influence ....................................... 131 Subtheme two: Moving towards competence and confidence ............................................ 139 Chapter 4 Summary ................................................................................................................ 150 Chapter 5: Discussion ................................................................................................................. 155 Recalling Social Justice: Meaning and Expression in Synthesized Studies ........................... 155 Transformational Learning Theory ......................................................................................... 157 Comparison with transformative thinking model…………………………………………161 In context of thematic conceptualization ............................................................................ 170 Praxis Alignment with Transformational Learning Theory.................................................... 173 Potential Barriers to Transformative Learning ....................................................................... 177 Chapter 5 Summary ................................................................................................................ 182 Chapter 6: Conclusions and Recommendations ......................................................................... 184 Summary of Study .................................................................................................................. 184 Conclusions ............................................................................................................................. 185 Recommendations for Education ............................................................................................ 186 Recommendations for Research ............................................................................................. 189 Limitations of this Research ................................................................................................... 192 UPHOLDING SOCIAL JUSTICE IN NURSING 8 Chapter 6 Summary ................................................................................................................ 194 References ................................................................................................................................... 196 Appendix A ................................................................................................................................. 220 Appendix B ................................................................................................................................. 225 Appendix C ................................................................................................................................. 275 UPHOLDING SOCIAL JUSTICE IN NURSING 9 List of Tables Table 1 ………………………………………………………………………………………… 54 Table 2 ………………………………………………………………………………………… 62 Table 3 ………………………………………………………………………………………… 65 Table 4 ……………………………………………………………………………………….. 146 UPHOLDING SOCIAL JUSTICE IN NURSING 10 List of Figures Figure 1 ………………………………………………………………………………………… 52 Figure 2 ………………………………………………………………………………………… 68 Figure 3 ………………………………………………………………………………………… 79 Figure 4 ……………………………………………………………………………………….. 154 Figure 5 ……………………………………………………………………………………….. 161 UPHOLDING SOCIAL JUSTICE IN NURSING 11 Acknowledgments Words cannot express how grateful I am to my parents, Viorel and Camelia Bughiu, without whom this work would not have been possible. Amidst all my recurring doubts, your faith in me never wavered in the slightest. I will forever be grateful to you both. To my supervisor, Dr. Barbara Astle—I cannot thank you enough for your constant encouragement. You have made this thesis-writing process transformational in itself, by teaching me that completing a study is really only the beginning—it is one’s love of learning that one carries with them long after their work is completed. In short, you inspired me to start this thesis, you inspired me to finish it, and by your example you continually inspire me to—above all—work with passion. To Dr. Bill Astle, Barb’s husband, thank you for your moral support, and for sharing your wife with me so patiently, and on so many occasions! To my second reader, Dr. Sheryl Reimer-Kirkham—you were instrumental in shaping this thesis from inception to end! Your perceptive suggestions were invaluable in guiding me through the research process. You also challenged me to think more critically and creatively—to the great benefit of this work. In short, this thesis would not look the same without your wisdom. I am also indebted to Duncan Dixon, a Trinity Western University (TWU) academic librarian, who took the time to coach me one-on-one and provided me with detailed, constructive feedback on my early literature search strategy. Many thanks also go to the TWU library staff who managed, and always met in a timely manner, my requests for interlibrary loans. I would also like to recognize, and thank, faculty members in the TWU School of Nursing for allowing me to share my thoughts with them, and for broadening my thinking with their own. UPHOLDING SOCIAL JUSTICE IN NURSING 12 Finally, I am deeply grateful to the Canadian Institutes of Health Research for granting me the Frederick Banting and Charles Best Canada Graduate Scholarship–Master’s award, which was an invaluable asset to the completion of this research. UPHOLDING SOCIAL JUSTICE IN NURSING 13 Dedication I dedicate this thesis to my parents: my dad, Viorel, and my mom, Camelia. Thank you so much for your sacrifices, love, and for modeling an enduring spirit of courage and faith. I have been blessed to learn from you. UPHOLDING SOCIAL JUSTICE IN NURSING 14 Chapter 1: Introduction and Background The Canadian Nurses Association1 (CNA) (2017a) adamantly contends—in its Code of Ethics for Registered Nurses—that upholding social justice is nurses’ ethical mandate. Implicitly ingrained within the notion of upholding social justice, moreover, is that of addressing the social determinants of health (SDH)—that is, “the conditions in which people are born, grow, live, work, and age” (Commission on Social Determinants of Health [CDSH], 2008, p. 26). Broadly, such conditions include income and social status, education, and physical environments (Public Health Agency of Canada, 2015). Indeed, the SDH are singularly responsible for determining health (Reutter & Kushner, 2010). A commitment to social justice, then, inevitably entails a commitment to addressing the SDH (CNA, 2017a). Toward this end, the call to incorporate learning of the SDH and social justice in nursing education has become unmistakable, with research increasingly testifying to the utility of clinical, educational experiences to nursing students’ (NS) learning. However, examining how students best learn to address the SDH in clinical practice is not, on its own, sufficient; rather, students’ views of their own abilities to do so must be sought. Yet very little is known about whether students perceive themselves as competent, and confident, to address the SDH as a result of participating in an educational experience. As such, this study aims to comprehensively explore and concisely synthesize the literature describing NS’ understanding of—and their perceived ability to address—the SDH following their participation in a clinical educational experience in order to further inform the academic preparation of students to address the SDH in nursing practice. Please note that my use of the CNA’s statements on social justice is due to my familiarity with these statements and my personal interest and involvement in Canadian health care. Yet as is unanimous in the literature, a social justice mandate pertains to nurses globally and, as such, I intend to address a global nursing audience with my use of these statements, as well as in the writing of this thesis. 1 UPHOLDING SOCIAL JUSTICE IN NURSING 15 Background There is no shortage of research attesting to the alarming effects that the SDH have on health. One seminal, longitudinal study examining 17,530 individuals in London found that the lower one’s employment status, the higher their risk for mortality from coronary heart disease (CHD) (Marmot, Rose, Shipley, & Hamilton, 1978). In fact, those who were employed in lower positions evidenced 3-6 times higher mortality from CHD than more highly employed individuals (Marmot et al., 1978). Today, statistics worldwide are, overall, not any more promising; as Marmot (2015) stated, this social gradient in health is prevalent both within and between countries. With respect to the latter, “the unhealthiest country has a life expectancy nearly forty years shorter than the healthiest” (Marmot, 2015, p. 22). To blame are the “causes of the causes” (Marmot, 2006, p. 3)—that is, if individuals suffer from poor health caused by alcohol consumption, obesity, and inadequate diet, for instance, the causes of these causes are SDH such as the availability and affordability of foods (Marmot, 2006). It is clear, then, that these SDH must be addressed. Toward this end, the CNA (2013) has long recognized the urgency of addressing the SDH to nursing practice. Indeed, the CNA (2013) asserts that registered nurses’ (RNs’) responsibility to address the SDH is both professional and ethical, and that—notably— responding to the SDH necessitates particular attention in nursing education (CNA, 2013). However, nurses’ call to action is manifested unequivocally not solely by their national licensing organization—it is also widely and diversely promulgated by nursing scholars. Indeed, many such scholars appeal to religious, ethical, social, theoretical, political, philosophical, or otherwise ideological constructs to frame nurses’ social mandate from a unique nursing perspective. Smith (2007), for instance, appeals to nursing’s inherent capacity for caring in calling nursing “the UPHOLDING SOCIAL JUSTICE IN NURSING 16 health profession best suited for…. reducing disparities” (p. 286). Falk-Rafael and Betker (2012), in comparison, discuss the theory of critical caring—encompassing the ethics of both social justice and caring—as underpinning nursing action on the SDH. Reimer-Kirkham and Browne (2006), furthermore, espouse a postcolonial feminist reading of social justice encouraging consideration of how power relations may disadvantage certain individuals. Yet more specifically, academics are increasingly emphasizing the central role of nursing education in teaching students to address the SDH in practice. Numerous authors support the role of nursing education broadly: for instance, Mahony and Jones (2013) adamantly contend, “SDH should be introduced at the beginning of the educational journey and remain a significant priority in clinical experiences” (p. 282). Likewise, Reutter and Kushner (2010), Smith (2007), and Waite and Brooks (2014)—among many others—also advocate for increased pedagogical involvement. Consequently, certain educational modalities such as service-learning (SL)—a teaching methodology whereby students are encouraged to reflect critically on their clinical experiences—are gaining increasing attention in the nursing literature. Of note, there has been growing interest in innovative clinical placements (Reimer-Kirkham, Van Hofwegen, & Hoe Harwood, 2005; Reimer-Kirkham, Hoe Harwood, & Van Hofwegen, 2005), with corrections, parish, rural, Aboriginal, and international sites being some of the most common (ReimerKirkham, Hoe Harwood, & Van Hofwegen, 2005). In general, educational initiatives implemented by researchers occur in clinical settings and range from local experiences—such as that offered by Krumwiede, Van Gelderen, and Krumwiede (2014), where students engaged community stakeholders in a Community Health Needs Assessment—to international enterprises, such as that described by Curtin, Martins, Schwartz-Barcott, DiMaria, and Ogando (2013), where NS provided healthcare in rural areas of the Dominican Republic. Research UPHOLDING SOCIAL JUSTICE IN NURSING 17 exploring students’ learning from these varied educational experiences has, indeed, burgeoned in the last 15 years. While qualitative studies exploring educational experiences’ influence on students are plentiful, quantitative research too is expanding. As an example, acknowledging the comparatively greater amount of qualitative research, Groh, Stallwood, and Daniels (2011) conducted a study whereby their convenience sample of 306 nursing students completed the Service Learning Self-Evaluation Tool before and after a SL experience. Subsequent statistical analysis of t-tests revealed that students rated their level of leadership and social justice abilities as higher following their experience (Groh et al., 2011). However, while novel educational clinical experiences continue to be explored as a possible avenue for students’ learning, “research on the impact… on students…. is relatively new” (Sabo et al., 2015, p. S38). Sabo et al. (2015) found that there is little scrutiny of students’ own opinions of how—or whether—educational experiences have prepared them to address the SDH. Notably, there is little questioning of whether students feel competent, and confident, to address the SDH as a result of having participated in an educational experience. With such uncertainty as to whether NS feel they are able to address the SDH, educators cannot accurately gauge the success of educational experiences in preparing them to do so. Research highlighting the tremendous impact that social determinants have on health further underscores the urgent need for educators to prepare students to feel ready to act. This study addressed the gap in the literature that excludes students’ voices with the aim of encouraging nursing’s uptake of educational experiences that empower NS to feel competent to address the SDH. UPHOLDING SOCIAL JUSTICE IN NURSING 18 Definitions of Terms As Boutain (2005) so aptly puts it, “nurses lack a multidisciplinary vocabulary to discuss, critique, and strategize about injustice” (p. 405). The following definitions will define the terms used in this study. Address. As a verb, “address” is inherently an action-oriented word with the following meaning: “To direct one’s skill or energies to some task, goal, or purpose; to devote oneself” (Oxford University Press [OUP], 2015b, para. 38). In the context of this thesis, then, “address” entails taking initiative, of one’s own volition, to work toward ameliorating the SDH in one or more of various ways, such as by advocating for policy change, assisting patients to access community health resources, or participating in community outreach programs. Moreover, “to address” necessitates that an individual first feels ready to act; in other words, “address” entails a “state or quality of being prepared or ready to do something; [that is, having] adroitness, resourcefulness; ability, skill, dexterity” (OUP, 2015a, para. 16). As such, “addressing” in the context of this research will invoke notions of competence and confidence—characteristics that underscore a state of preparedness or readiness. Further, no assumptions will be made as to the nature, or extent, of action required for someone to have addressed the SDH. Clinical practice. Clinical practice refers to students’ practice of nursing both within the context of a post-secondary course in the various settings to which they are assigned (or, if the experience is not course-based, then the practice of nursing in the academic context of the educational experience), as well as in their individual workplaces after graduation. Clinical practice may broadly encompass the practice of acute nursing in hospital settings, nursing in community settings, as well as academic nursing activities such as the conduction of research. UPHOLDING SOCIAL JUSTICE IN NURSING 19 Also, clinical practice may take place in local, national, or international settings. Further, clinical practice will not be confined to a certain time period post-graduation. Competency. As described by Epstein and Hundert (2002), competency is to be understood as: “… the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” (p. 226). Educational experience. For the purpose of this study, an educational experience is defined as an experience that occurs within an academic context, ideally as part of a clinical course—or, whether or not it is course-based, the experience is otherwise part of an academic endeavour permitting the practice of nursing. Further, the educational experience accommodates students’ exposure to the SDH, thereby allowing them to learn about issues of social justice. Such an experience may occur within a setting in either a local, national, or international location. Global. “Global”—referring broadly to the settings in which educational experiences may take place—is well-construed by Bozorgmehr’s (2010) definition of globality. Namely, globality specifies “supraterritorial links between the social determinants of health located at points anywhere on earth” (p. 6). Hence, “global” understood thusly entails a connected world as a result of globalization (Bozorgmehr, 2010), and, as such, permits the addressing of SDH in local, national, and international settings. Health disparity. Healthy People 2020 (2015) systematically defines a health disparity as: A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people… UPHOLDING SOCIAL JUSTICE IN NURSING 20 based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. (para. 6) Health equity. Health equity may be understood as “the absence of systematic disparities in health (or its social determinants) between more and less advantaged social groups” (Braveman & Gruskin, 2003, p. 256). Moreover, as Braveman (2014) further explains, “health equity is social justice in health” (p. 367). That is, health equity reflects social justice in that to achieve health equity, one must address health disparities, which are themselves socially unjust because “they put an already economically/socially disadvantaged group at further disadvantage with respect to their health. [Thus, health disparities] … are particularly unjust because health is needed to overcome economic/social disadvantage” (Braveman, 2014, p. 367). Health inequality. A health inequality denotes “a systematic inequality in health (or in its social determinants) between more and less advantaged social groups, in other words, a health inequality that is unjust or unfair” (Braveman & Gruskin, 2003, p. 255). Health inequity. A health inequity is a “[difference] in health which [is] not only unnecessary and avoidable but, in addition, [is] considered unfair and unjust” (Whitehead, 2000, p. 7). As such, health inequities—in comparison to health disparities and health inequalities— more distinctly and inherently embody an element of morality and therefore of social justice (Reutter & Kushner, 2010). Mandate. A “mandate” signifies “a commission, or explicit statement of empowerment for a professionally qualified person to perform a designated service or fulfill a requirement” (A Dictionary of Public Health, 2007, as cited in Oxford Reference, n.d., para. 1). UPHOLDING SOCIAL JUSTICE IN NURSING 21 Nursing student. A nursing student is an individual of any gender and demographic background enrolled in a nursing program, often a baccalaureate program of a four-year duration. However, nursing students may also be enrolled in RN-to-baccalaureate (BSN), associate degree, and diploma programs. In addition, graduate nursing students—enrolled, for instance, in masters’, doctoral, or nurse practitioner programs—are also taken into account. Service-learning. Service-learning is “a method of teaching that combines classroom instruction with meaningful community service…. emphasiz[ing] critical thinking and personal reflection while encouraging a heightened sense of community, civic engagement, and personal responsibility” (Center for Community Engagement, n.d., para. 13). Social determinants of health. The social determinants of health “are the conditions in which people are born, grow, live, work and age” (CSDH, 2008, p. 1) largely responsible for health inequities (CSDH, 2008). Key SDH recognized by Mikkonen and Raphael (2010)—and widely corroborated in the literature—include “early life, education, employment and working conditions, health services, housing, income and income distribution, and social safety net” (p. 9). Social justice. As the CNA (2010) asserts, social justice is: The fair distribution of society’s benefits, responsibilities and their consequences. It focuses on the relative position of one social group in relationship to others in society as well as on the root causes of disparities and what can be done to eliminate them. (p. 10) UPHOLDING SOCIAL JUSTICE IN NURSING 22 Structurally vulnerable2. As Bourgois, Holmes, Sue, and Quesada (2017) relate, structural vulnerability is: An individual’s or a population group’s condition of being at risk for negative health outcomes through their interface with socioeconomic, political, and cultural/normative hierarchies. Patients are structurally vulnerable when their location in their society’s multiple overlapping and mutually reinforcing power hierarchies (e.g., socioeconomic, racial, cultural) and institutional and policy-level statuses (e.g., immigration status, labor force participation) constrain their ability to access health care and pursue healthy lifestyles. (p. 2) A person who is structurally vulnerable, then, satisfies the conditions of—and suffers from the effects of—structural vulnerability. While definitions are not all, as Boutain (2005) observes, “static” (p. 405)—instead varying “across disciplines and over time” (p. 405)—endeavouring to understand the meaning of such terms nevertheless sets the foundation for grasping their relevance to the profession of nursing. Thesis Description Purpose and research questions. The purpose of this research is to explore the value of clinical educational experiences in expanding NS’ understanding of—and perceived ability to As Browne and Reimer-Kirkham (2014) caution, the term “vulnerable”—along with other descriptors such as “oppressed” and “marginalized”—has the potential to perpetuate an us-them, “oppressed/oppressor” (p. 26) dichotomy, where the oppressed are victims that can only be helped by those who are more socially advantaged, or more superior. In line with growing concern of portraying the disadvantaged in such a helpless state (Browne & Reimer-Kirkham, 2014; de Chesnay, 2016), “structurally vulnerable” will be used instead of “vulnerable”, or other descriptors such as “oppressed” and “marginalized”, to refer to those persons who are made structurally vulnerable by the SDH. 2 UPHOLDING SOCIAL JUSTICE IN NURSING 23 address—the SDH, and in so doing to uphold their social justice mandate. In attaining this purpose, the following research questions will be addressed: 1. How has participation in a clinical, practice-based educational experience contributed to NS’ understanding of the SDH? 2. How prepared do NS feel to respond to the SDH in their practice as a result of their educational experience? 3. What are major facilitators of students’ understanding of, and perceived ability to address, the SDH? 4. What are major barriers to students’ understanding of, and perceived ability to address, the SDH? and 5. How are students taught about the SDH? The purpose and research questions invoke the ideas of competence and of confidence through both students’ increased knowledge (i.e., competence) and perceived ability to address (i.e., confidence) the SDH. For, as Ballou (2000) so elegantly remarks, nursing education seeks to prepare NS to embark on sociopolitical action by helping them “to be able to identify social needs [increased knowledge] and develop individual capacities for meeting those needs [increased competence and confidence]” (p. 182). Thesis Method In order to address the purpose and to answer these research questions, a two-pronged approach was used: first, the literature was systematically reviewed, an integrated Mixed Research Synthesis (MRS) (Sandelowski, Voils, and Barroso, 2006) of 33 relevant qualitative, quantitative, and mixed-methods studies was included, and second, a thematic analysis in UPHOLDING SOCIAL JUSTICE IN NURSING 24 keeping with the Interpretive Description (Thorne, 2016a; Thorne, 2016b) provided a more substantive grounding of the emerging findings. Relevance and Significance While this research will indeed serve to fill a gap in the literature, other reasons, too, justify its necessity. First, it is incontrovertible that social disadvantage “leads to diminished health and well-being” (CNA, 2017a, p. 19)—Brunner and Marmot (2006) and Braveman (2014), for instance, speak about the physiological toll that arises from chronic stress (resulting from social disadvantage) alone. Truly, “[n]urses of the 21st century face global health care issues not even imagined in the most recent past” (Levine, 2009, p. 156). Nurses, however, must come to understand the profound extent to which social forces convene to engender that disadvantage. In recognizing the influence of social forces such as the SDH, then, nurses must decide how they—as members of society which in turn shapes the SDH—will respond. Further, in deciding, nurses must take into account that as professionals, they bear a professional, ethical responsibility to uphold social justice. Certainly, nurses’ Code of Ethics (CNA, 2017a) is clear: advocating for social justice is part of ethical nursing practice. Finally, nurses would do well to also bear in mind that they possess the requisite abilities—that is, the knowledge and skills (CNA, 2009; Gillis & Mac Lellan, 2013)—to address the SDH. In fact, as the largest health professional group in Canada (CNA, 2009), they are ideally suited to do so. Thus, if nurses are both responsible and able to address the SDH, it therefore follows that they must strive toward this end. As future practitioners, furthermore, NS must be taught about the ethical standards to which they will be held as independent professionals. If they do not grasp the consequence of their responsibility—and of their potential—to address the SDH as students, they may not do so UPHOLDING SOCIAL JUSTICE IN NURSING 25 as practicing nurses. This risk already prevails among nurses today; as Gillis and Mac Lellan (2013) comment, “[d]espite the inclusion of social justice statements in the CNA Code of Ethics (2008), many nurses have limited familiarity with the concept of social justice and no clear vision of its relevance to their practice” (p. 63). Consequently, helping nurses to understand their social justice mandate as students is not only necessary, but critical. As Snyder (2014) remarks, “[NS] who learn to embrace and value emancipatory knowing during their educational program may likely continue this praxis after they graduate” (p. 65). As those entrusted with teaching and mentoring students, nurse educators, in turn, bear an academic duty to teach social justice (Fahrenwald, Taylor, Kneipp, & Canales, 2007). What is more, “teaching social justice demands action beyond classroom pedagogy” (Fahrenwald, 2003, p. 222). Yet as Mohammed, Cooke, Ezeonwu, and Stevens (2014) comment, NS are not always sufficiently taught about social justice. While this issue leads to “the inability of students—who are the leaders of the future—to articulate a substantive nursing perspective related to social justice” (Chinn, 2014, p. 487), it simultaneously opens a “door of opportunity” (Chinn, 2014, p. 487). Chapter 1 Summary Conditions of daily life, such as income and education, have long been known to have an ineludible impact on health. It has also long been known that nursing—an intrinsically othercentered profession—is ideally suited to redress inequities in health; indeed, nurses are ethically and professionally obliged to do so. However, very little is known about whether NS feel competent, and confident, to address the SDH. To address this gap in knowledge, this thesis aims to further knowledge on the value of educational experiences in expanding NS’ understanding of—and perceived ability to address—the SDH. In so doing, it is hoped that UPHOLDING SOCIAL JUSTICE IN NURSING 26 educators will learn more about how to create educational experiences that profoundly deepen students’ understanding of, and heighten their perceived ability to act on, the SDH, so that as future nurses they feel able to uphold their social justice mandate. Outline of Thesis This thesis is structured in six chapters. This first, introductory chapter has provided background information on the need for addressing the SDH and nursing’s unique role in doing so, and has also introduced the purpose and research questions for the study. Chapter 2 will next present the results of comprehensive literature reviews conducted in six databases to reveal the current state of nursing research, focusing on pivotal ideas dominating the literature. In Chapter 3, the process followed to arrive at a body of key studies for synthesis will be outlined, followed by a discussion of the methodological techniques employed to arrive at findings. The findings, then, will be presented in Chapter 4, focusing on detailed descriptions of themes as the ultimate units of analysis. These findings will be critically examined in the context of existing research and scholarship in Chapter 5, and, finally, Chapter 6 will provide concluding thoughts centered on recommendations for nursing education and research, in addition to a review of the limitations of this study. UPHOLDING SOCIAL JUSTICE IN NURSING 27 Chapter 2: Preliminary Literature Review In order to contextualize the need for nursing to address the SDH, this Chapter will present the current state of research linking nursing’s mandate of upholding social justice with educational experiences. As such, the Chapter first outlines the Preliminary Search Strategy conducted to review current literature, and then presents the results of this Preliminary Literature Review divided into headings of major ideas dominating the literature. A summary of this literature review then concludes the Chapter. Preliminary Search Strategy The strategy incorporated to search the literature was two-pronged: at the same time that the literature was searched for studies relevant for synthesis, primary research and non-primary articles (such as editorials, policy briefs, and review articles) were reviewed in depth to gain a sense of discussions dominating the literature as well as potential gaps in research—that is, a “preliminary literature review” was conducted. With respect to this latter, preliminary literature review, the search strategy is briefly discussed here as a “preliminary search strategy.” A detailed account of the search strategy is, however, provided in Chapter 3 (specifically, see the section titled “Comprehensive Search Strategy”) as the complete, methodological strategy employed to arrive at the studies chosen for synthesis. First, six databases were searched in conducting a preliminary review of the literature to facilitate a comprehensive overview of existing knowledge: CINAHL Complete, PubMed, PsycINFO, ScienceDirect, ProQuest Dissertations and Theses Global, and EMBASE. All searches conducted were guided by the following PICOT-format (Melnyk & Fineout-Overholt, 2015) research question: How do NS come to understand, and perceive their ability to address, the SDH following an educational experience? Specific techniques employed to search each UPHOLDING SOCIAL JUSTICE IN NURSING 28 database (explained in Chapter 3) were, as this question suggests, structured in three overall concept areas—that of population (NS), the issue of interest (NS’ participation in an educational experience), and outcome (NS’ subsequent understanding, and perceived ability to address, the SDH) (Melnyk & Fineout-Overholt, 2015). Finally, limiters employed included a date of publication between January 2000 and December 2015; the English language; and that articles were peer reviewed/scholarly. The results of the preliminary literature review are, therefore, as follows. Results of Preliminary Literature Review A review of the literature reveals that scholars have written extensively on nursing’s mandate for social justice in addition to the value of educational experiences in teaching students about the SDH. As well, existing primary research is mostly qualitative and depicts NS’ experiences in rich and vivid tones. Overall, many studies are conducted in North American settings, yet studies have also been conducted in international settings such as Guatemala (Evanson & Zust, 2006), Australia (Hunt et al., 2015), and Brazil (Zanchetta, Schwind, Aksenchuk, Gorospe, & Santiago, 2013). As the subsequent sections demonstrate, nursing’s engagement with issues related to social justice and learning of the SDH is broad, with educational experiences being particularly diverse. Nursing’s mandate for social justice. Upholding social justice in nursing is not merely an ideal—it is a moral imperative (Falk-Rafael, 2005). After all, as a helping profession, nursing is intrinsically moral (Ballou, 2000). In calling nurses to embrace their mandate, scholars often appeal to nursing’s historical legacy (Falk-Rafael, 2005, p. 213; Lathrop, 2013, p. 42; Reutter & Kushner, 2010, p. 273) of addressing society’s social needs, frequently discussing the contributions of Florence Nightingale as a particularly influential pioneer in this regard. Yet, as UPHOLDING SOCIAL JUSTICE IN NURSING 29 academics also point out, nursing’s involvement in social justice has abated in recent years (Buettner-Schmidt & Lobo, 2012). Indeed, Falk-Rafael (2005) poignantly asks, “when did sociopolitical activism slip outside of nursing’s social mandate?” (p. 214). This declining zeal, Boutain (2005) explains, has resulted from a shift in nurses’ view of health as being a social mandate to health as being individual responsibility, occasioning a lack of knowledge of how to pursue social justice to redress health inequities. However, in constructing nurses’ social justice role, scholars underline not only moral obligation and tradition, but also highlight nursing’s position in the context of society, thereby re-directing nurses’ attention to social justice as social mandate. For instance, in her exploration of nursing’s relationship with society, Fowler (2015) explores the multiple facets of social contract, an “unwritten understanding” (p. 2) between nursing and society containing enforceable conditions for both. While nursing bears certain expectations of society within the contract, society’s expectations of nursing include advocacy for individuals, communities, and populations, such as addressing health disparities (Fowler, 2015). Ballou (2000), too, reminds readers that nursing care is given within a “social, economic, cultural, and political context” (p. 172-173)—a context that includes society. Moreover, justice is a principal moral obligation of nursing’s social contract with society, and should, therefore, be the outcome (Ballou, 2000). In short, these and other authors call for a renewal of nurses’ commitment to their social justice mandate. Yet some evidence reveals that nurses do indeed view social justice as important to their practice (Falk-Rafael & Betker, 2012)—even if they do not always consciously pursue it. For instance, nurses in Falk-Rafael and Betker’s (2012) study unanimously viewed pursuing social justice as the “epitome of nursing” (p. 106) and as the “imperative of our discipline” (p. 107). UPHOLDING SOCIAL JUSTICE IN NURSING 30 However, common reasons nurses did not uphold social justice—expanding upon Boutain’s (2005) claim of a lack of knowledge mentioned above—included an inability to reference an ethical framework on which to base their practice, as well as feeling powerless (Falk-Rafael & Betker, 2012). Hence, the renewed, unmistakable interest in social justice currently permeating nursing literature—indeed, the ethical responsibility itself of “[p]romoting justice” (CNA, 2017a, p. 15) that unifies all nurses—appropriately necessitate increased attention to the manner in which social justice is taught. If eliminating health disparities is to be nursing’s chief concern in the twenty-first century (Villeneuve, 2008), then nurses must be assisted to overcome the barriers—such as lack of knowledge and ability—that deter them from meeting the social needs they perceive. Educational experiences: Academic and action-oriented. Educational clinical experiences, therefore, have been viewed as an optimal means by which nurses may be assisted to address the SDH and, in so doing, to uphold social justice. In order for NS to benefit fully from educational experiences, these experiences must be inherently both academic and actionoriented. First, there is growing consensus among researchers regarding the potential influence of academic experiences. Boutain’s (2005) comments effectively capture scholars’ sentiments: For nurses to…. promote equality, they must first be educated on how unequal relationships are created and sustained…. [t]eaching nursing students about social justice will also enable them to…. be both agents for social change and citizens of the world. (p. 404) Toward this end, educational experiences typically incorporate an element of reflection for NS to critically contemplate what they have seen and learned in practice. As an example, in the study by Ezeonwu, Berkowitz, and Vlasses (2014), opportunities for reflection were balanced UPHOLDING SOCIAL JUSTICE IN NURSING 31 between classroom, online, and clinical settings. In the classroom, students engaged in face-toface discussions; discussions were continued online through students’ weekly reflective posts; and five weeks of community activities then followed with continued reflection through assignments (Ezeonwu et al., 2014). In this study, students reflected particularly on “the intersection of public health issues and policy” (Ezeonwu et al., 2014, p. 275). Other researchers incorporated similar learning opportunities: students who worked with structurally vulnerable mothers in DeLashmutt’s (2007) study capitalized on every clinical day by completing and discussing readings in postclinical sessions, reflecting on such concepts as “homelessness, the feminization of poverty, and self-actualization” (p. 185) through the distinct lenses of “spirituality and nursing” (p. 185). Written assignments especially served to enrich NS’ understanding of the value of nursing presence as well as of their social responsibility (DeLashmutt, 2007). Indeed, participation in clinical postconferences is an especially prevalent practice to facilitate reflection (D’Lugoff & McCarter, 2005; Gillis & Mac Lellan, 2013; Pennington, Coast, & Kroh, 2010). However, educational experiences notably impact students when integrating action with learning. For example, NS in numerous studies are enrolled in a community health nursing course, and as such are required to perform, analyze, and act upon community assessments. To illustrate, NS in August-Brady and Adamshick’s (2013) study prepared and delivered a presentation to the volunteer staff of a homeless shelter covering topics specific to their unique learning needs. These topics diversely included communication techniques, mental health first aid, and strategies to cope with violence, suicidal persons, and substance or alcohol intoxication and withdrawal (August-Brady & Adamshick, 2013). Indeed, the ways in which students act to better the lives of the structurally vulnerable individuals they encounter are as diverse as their UPHOLDING SOCIAL JUSTICE IN NURSING 32 respective experiences. Therefore, given the unique ability of educational experiences to offer opportunities for learning both through critical reflection as well as through hands-on activity, such experiences ultimately assist NS “to identify, challenge, and bridge the gap between education and practice” (Hart, 2015, p. 77). Awareness and understanding of the SDH. Scholars discussing the implementation of educational experiences, furthermore, do so with differing purposes. For instance, certain books are theoretical in nature, such as that edited by Bailey, Carpenter, and Harrington (1999) offering practical guidance on how to incorporate SL experiences into nursing curriculum. The majority of studies, however, describe how students are impacted by their educational experiences; in particular, scholars often report on the newfound awareness and understanding that students gain. For instance, Bentley and Ellison (2005) and DeLashmutt and Rankin (2005), among others, comment on students’ increased understanding of their preconceived biases. Bell and Buelow (2014), furthermore, found that students’ understanding of the complexity of poverty greatly improved—for instance, students commented that they had not realized before their SL experience how difficult it is for some individuals to escape poverty. Similarly, ReimerKirkham, Van Hofwegen, and Hoe Harwood (2005) discovered that students in their study— assigned to clinical experiences in parish, corrections, rural, Aboriginal, and international sites— gained critical awareness of inequities, poverty, and marginalization. In another study, students learned of both the intricacies of poverty as well as their own biases, such that these “[s]hifts in view” (Reimer-Kirkham, Hoe Harwood, & Van Hofwegen, 2005, p. 266) became “‘lifechanging’” (p. 266), ultimately leaving students with “insight into the [SDH] and heightened awareness of social justice” (p. 265). Indeed, these findings are widely corroborated: for example, a student in a different study commented, “‘statistics… become faces of people I UPHOLDING SOCIAL JUSTICE IN NURSING 33 know’” (Reimer-Kirkham, Van Hofwegen, & Pankratz, 2009, p. 6). Gillis and Mac Lellan (2013)—in discussing the learning of students who participated in a cardiac screening clinic for a structurally vulnerable population—note that the understanding students gained of the “root causes of health and social inequities” (p. 69) was especially profound. Another student quote saliently exemplifies this: “If nothing more comes from this, I have made a real connection of theory to practice, and I see a different role for nurses in health care” (Gillis & Mac Lellan, 2013, p. 70). Addressing the SDH. In addition to gaining newfound awareness and understanding of the SDH, students across studies unanimously identify how their educational experiences taught them to act to address the SDH. For instance, in Zanchetta et al.’s (2013) study, students reported feeling highly confident to tailor health teaching strategies to patients’ knowledge, age, level of education, and cultural affiliations. Indeed, students in this study continued to evidence initiative by seeking feedback from both patients and supervisors to further refine their teaching skills (Zanchetta et al., 2013). In essence, then, the belief expressed by students in Bentley and Ellison’s (2005) study—namely, “that they could make a difference in the community” (p. 289)—echoes the sentiment apparent in the comments of students in Zanchetta et al.’s (2013) study, as well as of those in countless others (Curtin et al., 2013; DeLashmutt & Rankin, 2005; Jarrell et al., 2014; Rooks & Rael, 2013, Vogt, Chavez, & Schaffner, 2011). Moreover, the activities undertaken by students in Wros, Mathews, Voss, and Bookman’s (2015) study effectively represent the breadth of action of students across studies. These activities include: educating patients on—and assisting them with—medication administration; liaising with other health care professionals (e.g., to assist patients to obtain housing); assisting patients with UPHOLDING SOCIAL JUSTICE IN NURSING 34 paperwork; and assisting patients to access primary care and other health resources (e.g., helping them secure insurance) (Wros et al., 2015). More specifically, scholars have found that educational experiences enhance students’ abilities to address the SDH in two distinct ways. First, scholars have observed students to engage in political activity, often for the first time. NS in DeLashmutt and Rankin’s (2005) study, for example, interacted “with federal and state program representatives” (p. 144), and they identified relevant policy actions such as advocating for affordable housing, increasing access to programs, and developing more opportunities for employment. Similarly, NS in Krumwiede et al.’s (2014) study developed, according to the authors, skills in the public health nursing core competency of “[p]olicy development/program planning” (p. 365) by recommending “a healthy snack policy” (p. 365) for nearby elementary schools. Second, students have been found to be better prepared to address the needs of communities by conducting research. As Reising et al. (2008) report, NS who partook in their unique SL research endeavour evaluated health promotion programs that they themselves developed by collecting data through a pre- and posttest method, and then analyzing and presenting it. As well, by collecting and analyzing survey data, students in Ezeonwu et al.’s (2014) study found that 50% of individuals were unfamiliar with the health risks associated with using cosmetics, and that 90% voiced a desire to alter their buying customs following students’ teaching. International experiences. Also noteworthy is the learning that occurs from international educational experiences. As most clinical placements described in the literature are located within areas that are readily geographically accessible (i.e., sites are located within a distance from the student’s home or school that accommodates the experience in a day), they are usually local. However, the existing research reveals outcomes that result from the often unique UPHOLDING SOCIAL JUSTICE IN NURSING 35 nature of opportunities offered in international settings. In Curtin et al.’s (2013) study, for instance, students who travelled to the Dominican Republic felt more confident in speaking Spanish as well as in assessing health issues, and also developed greater cultural awareness. Comparatively, Kent-Wilkinson et al. (2010) demonstrate—in reporting on students’ learning from an exchange trip to Australia—that students gained acute care skills in a small rural hospital that they would not likely otherwise have obtained at home. For instance, students saw the benefit of performing phlebotomy procedures at patients’ bedsides, such as assessing blood levels of troponins—a practice which the students viewed as potentially beneficial to their rural practice back home in Saskatchewan, Canada (Kent-Wilkinson et al., 2010). Were they to advocate for its adoption in Canadian rural settings, students could use this learning to the eventual benefit of structurally vulnerable locals. Finally, Reimer-Kirkham et al. (2009) describe how students were impacted after returning home from an international experience in Guatemala. Such an international experience may—the authors found—excellently facilitate the acquisition of social consciousness necessary for “critiquing processes of oppression and power relations and enacting moral agency by selecting key actions such as resistance and activism” (ReimerKirkham et al., 2009, p. 11). Cause to question: Conflicting findings. It is, however, also important to recognize that several studies present conflicting findings with respect to the potential benefits of educational experiences. For instance, when considering the studies just mentioned, Curtin et al. (2013) also report on the difficulty NS experienced in adapting to their physical environment, as well as describe students’ feelings of frustration in their inability to fully meet patients’ needs. Similarly, Reimer-Kirkham et al. (2009) explain how, following their overseas experience, students struggled in the long-term with how to maintain social consciousness in their home UPHOLDING SOCIAL JUSTICE IN NURSING 36 environments. As such, the authors maintain that “appraisal of the longer-term benefits” (Reimer-Kirkham et al., 2009, p. 10) of international experiences is warranted. Other researchers’ findings suggest that local SL as well may not, in fact, be particularly beneficial; for example, Nokes, Nickitas, Keida, and Neville (2005) found that students scored lower on critical thinking and cultural competence post-experience. In comparison, students in Evanson and Zust’s (2006) study experienced “[u]nsettled [f]eelings” (p. 416) in that they struggled with such questions as “‘Did we/can we help?’” and “‘Why do we have so much [compared to] others?’” (p. 416). Finally, Afriyie Asenso, Reimer-Kirkham, and Astle (2013) found that students’ expectations of Africa as being riddled with poverty, disease and famine—as shaped by media influences—caused them to view their role as one of “helping”, and also that students did not ask critical questions reflective of global citizenship, such as how colonialism and socioeconomic factors favour persons living in the West. Therefore, carefully taking into account such results— especially how they might impact students’ perceived ability to address the SDH—is necessary to forming an informed opinion on the value of educational experiences. Barriers to addressing the SDH. On a related note, students across studies specifically identify barriers to their learning of, and ability to address, the SDH. Several notable examples of such barriers are presented in Zanchetta et al.’s (2013) study alone. Briefly, they include: a language barrier, little time for health-teaching, and inadequate support from supervisors (Zanchetta et al., 2013). Still more barriers are noted by educators in Cohen and Gregory’s (2009) study, including the lack of student appreciation for non-traditional placements; student difficulty remaining self-motivated when they must work independently in settings lacking a preceptor; and challenges in selecting clinical sites, as well as experienced RN-preceptors, who will best facilitate learning. Additional barriers to students’ learning resulting from UPHOLDING SOCIAL JUSTICE IN NURSING 37 interdisciplinary collaboration include “territorial issues that often stemmed from a lack of understanding of other disciplines” (Gupta, 2006, p. 59). Facilitators to addressing the SDH. However, students also readily identify facilitators to their ability to understand, as well as uphold, social justice. For instance, faculty and preceptor support of students is generally recognized as a major facilitator (Afriyie Asenso et al., 2013; Cohen & Gregory, 2009; Connolly et al., 2004; Knecht & Fischer, 2015). While faculty in Gupta’s (2006) study assisted students in many ways, they did so notably by “providing the right level of challenge…. emotional support, and guided reflection” (p. 58)—as did mentors in many other studies. Further facilitators of NS’ learning include students’ active engagement in experiences as well as the opportunity to critically reflect on issues of justice (Afriyie Asenso et al., 2013). Also, since some scholars do not expressly describe barriers and facilitators as such, I carefully interpreted possible barriers and facilitators in consultation with my supervisory committee. Subtleties of language in “addressing the SDH”. As has been mentioned, authors do not consistently—and do not always overtly—frame outcomes in terms of the impact on students’ perceived ability to address the SDH. Nevertheless, students’ widespread discussion of the various, tangible ways in which they have learned to assist populations variably described as persons facing structural vulnerabilities—as well as of their newfound understandings of social justice issues—may reasonably be viewed as exemplifying their perceptions of their ability to address the SDH. In other words, from increased understanding of the nature of health inequities, and from opportunities to practice mitigating them, a heightened sense of ability to address social injustice follows (unless barriers to either of these conditions are explained). Hence, for those studies that do not discuss outright improved ability to address the SDH in these UPHOLDING SOCIAL JUSTICE IN NURSING 38 or similar terms, such an improved ability has been (following discussion with my supervisory committee) appropriately inferred from the findings. As an example, Groh et al. (2011) discuss enhanced leadership skills and greater awareness of social justice; it is then feasible to deduce that, as a result, NS’ ability to address the SDH may have also improved. I have, in interpreting such results, made no assumptions as to the extent to which students’ ability may have improved, or which specific SDH the improvement concerned, when this information was not clearly specified. Rather, I have stated (following discussion with my supervisory committee) that an appreciable improvement to students’ abilities to address the SDH may have occurred in tandem with other discussed benefits of educational experiences. Recent innovations: Online learning and simulation experiences. It is, in addition, interesting to note that studies increasingly describe learning from educational experiences that do not necessarily occur at physical clinical locations. For instance, many studies describe online experiences with virtual communities (Breen & Jones, 2015; Levett-Jones, Bowen, & Morris, 2015), as well as simulation experiments that either occur online (Breen & Jones, 2015; Menzel, Willson, & Doolen, 2014) or in-person (Mawji & Lind, 2013; Patterson & Hulton, 2012). For example, students in Levett-Jones et al.’s (2015) study engaged with a virtual Australian community called “Wiimali”, which is presented in the form of an interactive map containing digital stories which are based on curricular learning outcomes and exemplify the SDH. In contrast, other students who do receive face-to-face interaction may in fact interact with a simulation manikin, such as the female manikin “Imogene”—appearing as a homeless, sex trade worker—that facilitated case study scenarios whereby students conducted physical assessments and discussed her life story in the context of concepts such as social justice (Mawji & Lind, 2013). UPHOLDING SOCIAL JUSTICE IN NURSING 39 My focus, however, nevertheless remains on direct care offered in clinical settings due to the unique hands-on learning such experiences afford. As Jarrell et al. (2014) put it, “[c]linical settings provide an ideal environment for students to examine the effects of poverty on health” (p. 299). The benefits of face-to-face experiences are indeed expressed emphatically by students: “You can read about poverty” one student remarked, “but you don’t feel the emotion of it or the impact of it like when you see it firsthand” (Hunt, 2007, p. 278). Another commented, “This experience has truly changed me.... [s]eeing how the people in the communities were happy and grateful for the little they have has made me change” (Curtin et al., 2013, p. 554). In fact, such feelings of “transformation” are commonly reported by students as a result of their engagement in on-site experiences with structurally vulnerable persons. Culture versus equity discourses. Noting also the proliferation of studies related to culture, a search was conducted on cultural diversity, cultural sensitivity, and cultural competence as they pertain to nursing education (see Appendix A) and found that discourses of culture are indeed prevalent in nursing education research. To illustrate, current studies bear such titles as “Conceptualizations of Culture and Cultural Care Among Undergraduate Nursing Students: An Exploration and Critique of Cultural Education” by Vandenberg and Kalischuk (2014); “Influence of International Service-Learning on Nursing Student Self-Efficacy Toward Cultural Competence” by Long (2014); and “Cultural Competence and Cultural Safety in Canadian Schools of Nursing: A Mixed Methods Study” by Rowan et al. (2013). However, in order to better ascertain when discourses of equity diversified when compared to those of culture (upon the recommendation of S. Reimer-Kirkham, personal communication, October 14, 2015), I combined an equity-centered literature search with a culture-centered search. Results indicate that, although culture-centered and equity-centered studies persist to comparable degrees in the UPHOLDING SOCIAL JUSTICE IN NURSING 40 early 2000’s and recently (from approximately 2013-2015), research exemplifying equity discourses proliferated in 2009. Gaps in the Research Future areas of research. Finally, areas for needed future research also become evident, and are often acknowledged by scholars themselves. For example, researchers recognize the need to study “the outcomes [emphasis added] of the service delivery at the community level” (Norbeck, Connolly, & Koerner, 2008, p. 2). That is, asking how students impact the community—rather than only how the community experience impacted students—is also significant. Additionally, the query posed by Cohen and Gregory (2009) exemplifies numerous others’: “‘What is the best method of developing students’ ability to apply a social justice/equity ‘lens’ in their clinical practice?’” (p. 12). As academics, authors therefore frequently acknowledge that the curriculum itself must be revisited if it is to optimize students’ learning of social justice. In surveying current research, areas for future study were identified: for example, what are the effects of educational experiences on graduated nurses who have considerably more experience in clinical practice? Lack of syntheses. As the discussion until now reveals, the existing literature exploring how social justice-oriented educational experiences affect NS is growing and quickly diversifying. During early scoping searches, it was noted that the majority of articles on these various local, national, and international experiences are quite recent, appearing mostly in the last 15 years. These studies appeared to offer potentially promising means through which nursing may work to address the paucity of research on how students may be assisted to feel ready to uphold their professional social justice mandate. Indeed, little primary research has, on the whole, been conducted with the explicit aim of assessing students’ perceived ability to UPHOLDING SOCIAL JUSTICE IN NURSING 41 address the SDH, and there are even fewer syntheses of such literature. In fact, no syntheses were identified with the specific purpose of synthesizing knowledge on students’ perceived understanding of, and ability to act on, the SDH. Noteworthy syntheses that do exist, however, include the study by Gillis and Mac Lellan (2010) which examines students’ experiences of SL, the skills and knowledge they gained, and barriers as well as enablers to students’ learning across 25 studies. Likewise, while no theses/dissertations with the same purpose as mine were identified, more theses are appearing that address issues of social justice and nursing education. A recently published thesis by Cellini (2015), for example, documents the author’s thematic findings of how RN to BSN graduates’ SL experiences as students influenced their professional practice. Chapter 2 Summary Even though researchers are increasingly attempting—as a thorough review of the literature reveals—to promote NS’ learning of social justice through educational experiences, a problem arises: that little is known about how prepared students actually feel to uphold social justice. There is little evidence of research with the explicit aim of exploring NS’ understanding of and perceived ability to address the SDH. Moreover, this review of the literature has not uncovered any attempts to synthesize such information when it does arise, often in response to scholars’ research questions that are either quite different from, or somewhat similar to, those of this project. Therefore, based on current evidence alone, we cannot say with certainty whether NS in general believe they understand, and feel capable of addressing, the SDH. While a synthesis of the literature capturing students’ reflections in several studies will not speak authoritatively on the beliefs of NS everywhere, it will serve as a pivotal, initial step in furthering our understanding of students’ perceptions. If we are to assist NS to uphold social justice by UPHOLDING SOCIAL JUSTICE IN NURSING 42 ameliorating the SDH, we must first understand what they think in regard to whether or not they are ready to act. Chapter 3 will discuss the methodology used in this study. UPHOLDING SOCIAL JUSTICE IN NURSING 43 Chapter 3: Methodology As the gaps in research presented in the previous chapter reveal, there is a significant need for synthesizing the evidence that does exist in relation to students’ perceived ability to address the SDH. Toward this end, this chapter begins by describing the Comprehensive Search Strategy employed to search for relevant research studies, followed by the Retrieval Strategy (i.e., detailed inclusion and exclusion criteria) enacted. The methodology is then explained more specifically with respect to processes of sampling, data appraisal, data extraction, and supplementary methods enacted to arrive at, and collect data from, the 33 studies, as well as from the perspectives of Mixed Research Synthesis and data analysis approaches undergone to generate findings. Discussions of scientific rigour, ethical considerations, and limitations— followed by a chapter summary—then conclude this chapter. Comprehensive Search Strategy Given the focus of this work on synthesizing relevant literature, the process of reviewing the literature was methodical and comprehensive. To begin with, the databases of CINAHL Complete, PubMed, PsycINFO, and ScienceDirect, as well as ProQuest Dissertations and Theses Global, and EMBASE, were searched. As a database containing articles from nursing and allied health disciplines that may be difficult to access in other databases (Melnyk & Fineout-Overholt, 2015), CINAHL was invaluable. In comparison, PubMed—a particularly extensive database with “biomedical literature from MEDLINE, life science journals, and online books” (National Center for Biotechnology Information, n.d., para. 1)—was also viewed as indispensable due to its comprehensiveness. PsycINFO—as recommended by an academic librarian—is a database focusing on “psychological aspects” (TWU, 2015, para. 9) of literature in nursing (TWU, 2015), and also consists of scholarly literature from psychology, the behavioral sciences, and mental UPHOLDING SOCIAL JUSTICE IN NURSING 44 health (Melnyk & Fineout-Overholt, 2015). PsycINFO was therefore included to ensure that literature from these related fields was accounted for. Moreover, because many relevant articles were identified in ScienceDirect during early scoping searches, literature searches were also conducted in this database. In addition, theses and dissertations were searched for automatically as part of searches conducted in databases such as CINAHL and PsycINFO, as well as searched for more systematically in ProQuest. Finally, as a very large European database with the potential to return results especially pertinent to the international scope of this research (D. Dixon, personal communication, October 26, 2015), EMBASE—once more upon the advice of an academic librarian—was included in the larger search strategy. The search strategy, furthermore, was comprised of three general search areas, or “concepts”: population, the issue of interest, and outcome (Melnyk & Fineout-Overholt, 2015). The following question guided the search strategy: How do NS (population) come to understand, and perceive their ability to address, the SDH (outcome) following an educational experience (intervention)? Given that this is a mostly unexplored area of research, I chose not to specify a “Time” concept—that is, I sought to understand students’ learning and perceived ability on both short-term (while still partaking in the experience or directly after the experience) and long-term (a significant period of time following the experience) bases. “Nurs*” or “nurs* educat*” were most frequently searched to indicate population as searches even more specific—such as “nurs* student*”—tended to yield irrelevant articles. Originally, searching students’ understanding as part of the outcome with keywords such as “understand*”, “knowledge”, and “aware*” similarly reduced relevant articles. Also, the outcome was sought through searches with words such as “perceiv* competed*/confidence”, “address*”, and “ameliorat*” to signify NS’ perceived ability to act on the SDH; however, these searches yielded high numbers of unrelated articles. As such, UPHOLDING SOCIAL JUSTICE IN NURSING 45 students’ understanding and perceived ability to address the SDH were largely inferred from reading of abstracts and further reading of studies. Likewise, although keywords such as “social change”, “social problem*”, “social discriminat*”, and “social marginaliz*” were originally searched to specify outcome (that is, the achievement of social improvement and/or eradication of social injustice), these words were more often effective when searched as controlled vocabulary terms. Hence, keywords such as “social justice”, “equit*”, and “social determinant*” were searched in their place and found to be more effective. Lastly, limiters applied to all searches included a date of publication between January 2000 and December 2015 (to reflect the evolving of research involving social justice and the SDH in this time period); the English language (with the exception of ScienceDirect, which did not offer this option); and that articles were peer reviewed/scholarly (with the exception of ScienceDirect, PubMed, and EMBASE, which did not offer this option). (Articles retrieved from databases that did not provide a “peer reviewed/scholarly” limiter were, if considered for inclusion, screened for this quality indicator by myself and my immediate supervisor). In conjunction with these literature searches on the topic of interest, two additional, related searches in PubMed were conducted to serve as background searches providing further context to the study. Given the abundance of literature on topics of culture and nursing—such as integrating cultural competency and cultural safety in nursing education—a separate search on concepts of culture and nursing education combined with a search on concepts of equity and nursing education were conducted, in order to ascertain when discourses of culture diverged from those of equity. Additionally, background searches on SL in nursing were conducted in order to better compare the nature and outcomes of SL initiatives—which scholars are UPHOLDING SOCIAL JUSTICE IN NURSING 46 increasingly discussing—to different educational experiences. See Appendix A for a table outlining in detail literature search strategies applied across all databases and their results. Moreover, recognizing the need to include “supplementary efforts” (Polit & Beck, 2017, p. 667) to ensure representativeness, additional search methods were a key component of my review of the literature. For instance, I searched the reference lists of the relevant studies chosen for synthesis (for example, searching the reference lists of seminal articles such as Gillis and Mac Lellan’s [2010]), as well as conducted ancestry and descendancy searches (Polit & Beck, 2017) of these studies. Further, I stayed abreast of the literature through ongoing searches as well as through the use of database alerts (created for most databases). Finally, I placed interlibrary loans as necessary (doing so, for instance, for the Knecht and Fischer [2015] study). The overall, step-by-step process, then, undertaken for searching the literature was as follows: an initial review comprised of the conduction of scoping searches to become familiar with existing research (particularly with the language employed to describe concepts); detailed reviews consisting of database-specific search strategies (see Appendix A); and ongoing reviews involving reviews of studies provided by database alerts. Retrieval Strategy: Inclusion and Exclusion Criteria In addition to seeking studies meeting the study purpose and research questions, specific inclusion and exclusion criteria were created. Prior to reviewing specific inclusion criteria (and, correspondingly, exclusion criteria), certain considerations must first be outlined. As mentioned previously, study samples largely consist of undergraduate students. Some studies, however, include graduate students, such as Sabo et al.’s (2015) inclusion of masters’ and doctoral students, and Rasmor, Kooienga, Brown, and Probst’s (2014) study of nurse practitioner students’ willingness to work with structurally vulnerable patients. These studies included NS UPHOLDING SOCIAL JUSTICE IN NURSING 47 since NS at every level of education share the same social mandate. In addition, while the samples of most studies involve only NS, several studies include students from multidisciplinary professions (Bell & Buelow, 2014; De Los Santos, McFarlin, & Martin, 2014; Gupta, 2006; McNeil, Guirguis-Younger, Dilley, Turnbull, & Hwang, 2013; Wros et al., 2015). These studies, too, have been included, given the potential insight to be gleaned from the learning of NS that is described within them. Finally, given the exploratory nature of my research, studies surveying both short-term as well as long-term effects of educational experiences (e.g., Evanson and Zust’s [2006] inquiry two years later) were also included, not taking into consideration how students were impacted by time. Further, while studies generally describe students’ learning experiences in diverse ways, they often nevertheless describe similar experiences with similar learning outcomes. As an example, Van Hofwegen, Kirkham, and Harwood’s (2005) curriculum did not employ “service learning” per se; yet, as Amerson (2010) says of this study, “[a]lthough the curriculum did not specifically use the term service-learning, the findings supported the development of partnerships to build civic responsibility and provide service to the community” (p. 19). Hence, many studies described as SL experiences, or whose experiences are not explicitly labeled, were deemed equally relevant. Other authors describe their educational experiences as “an international experience” (Evanson & Zust, 2006, p. 418), a “Global Health Nursing Education Experience” (Wagner & Christensen, 2015, p. 295), and “experiential learning” (Breen & Jones, 2015, p. 27). Recognizing the collective relevance of this research, studies with such assorted interventions were included as long as they met the overall inclusion criteria (an exception was studies incorporating “online”, “virtual”, or “simulation” experiences where direct student contact with structurally vulnerable persons did not occur). UPHOLDING SOCIAL JUSTICE IN NURSING 48 By the same token, articles assessing learning of a culture-related variable were not discounted. As Lonneman (2015) suggests, cultural awareness should encompass awareness of the SDH. Indeed, some studies that mention students’ improvement in cultural awareness, competence, or an associated concept do so in reference to the SDH (Evanson & Zust, 2006), while others that seemingly focus on culture-specific topics also incorporate learning of the SDH (Hunt & Swiggum, 2007). Therefore, the inclusion criteria stipulate that studies describe the impact that any kind of clinically-based educational experience had on NS’ (either undergraduate or graduate) understanding of, and perceived ability to address, the SDH. As a final consideration, primary studies were largely sought—that is, “original research investigations” (Polit & Beck, 2017, p. 647)—because non-research reports do not provide evidence on the problem of interest (Polit & Beck, 2017). Nevertheless, secondary sources—descriptions of research written by individuals other than the original authors (Polit & Beck, 2017)—were also considered for inclusion. An example of such a source is the literature review by Gillis and Mac Lellan (2010); literature reviews such as this are valuable in that they offer a broad review of a topic while also providing useful references (Polit & Beck, 2017). Yet because literature reviews seldom provide significant detail about studies and are not always objective (Polit & Beck, 2017), a larger sample of primary studies for synthesis were sought. Inclusion criteria. In addition to the considerations discussed above, my specific inclusion criteria for studies, therefore, are as follows: 1. Nursing students are a primary or significant part of the sample. 2. Undergraduate, Second-Degree (RN-BSN), Associate-Degree, or Graduate NS comprise the sample. UPHOLDING SOCIAL JUSTICE IN NURSING 49 3. Students’ experiences are ideally described in their own words; however, their experiences may also be related through the words of others—such as educators—on their behalf. 4. Adherence to delimitation criteria (namely, a publication date between 2000 and 2015; written in the English language; and peer-reviewed/scholarly). 5. Regardless of how the educational experience is labeled (for instance, as a SL intervention), learning with respect to the SDH and/or social justice is described. 6. Educational experiences are ideally part of a clinical course (or, if they are not coursebased, experiences are academic and practice-based in nature). Specifically, involves the practice of nursing during and/or after the educational experience. 7. Students’ learning of the SDH and their perceived ability to address the SDH—or either of these two concepts—is described, as assessed not by length, but by consensus among myself and my supervisory committee. 8. Students’ learning of and/or their perceived ability to address the SDH is explicitly or implicitly discussed. (Implications related to implicit discussion will be examined as a potential limitation, and such studies only included upon consultation with my supervisory committee). For instance, where articles do not use the exact term “social determinants of health”, students’ exposure to such conditions will be understood from descriptors of the populations they work with such as “vulnerable”, “disadvantaged”, and “marginalized”. Similarly, where students do not directly state that they felt or believed themselves to be, as a result of their experience, more capable of addressing the SDH, this outcome will be deduced from statements that otherwise support this conclusion UPHOLDING SOCIAL JUSTICE IN NURSING 50 (such as a student commenting that he or she feels prepared to advocate for the structurally vulnerable upon returning to his or her home country [Levine, 2009]). Exclusion criteria. In turn, my exclusion criteria specify that studies are to be excluded if: 1. The above inclusion criteria are not met, such as with description of learning of culturerelated concepts but not of students’ ability to address the SDH (as, for example, in Amerson, 2010; Fleming, Thomas, Burnham, Charles, & Shaw, 2015). 2. The primary learning modalities comprise online, virtual, or simulation learning activities. 3. Grey literature was not included. Methodology Because multiple methods were used to implement the steps necessary to carry out this work, these methods together constitute this study’s methodology. In essence, this mixed methods synthesis was conducted in keeping with the systematic process promoted by the Joanna Briggs Institute (JBI) (2014) of (a) carefully reviewing the literature and applying inclusion/exclusion criteria; (b) appraising; (c) extracting; and (d) synthesizing data. While strategies for reviewing the literature and retrieval through application of inclusion/exclusion criteria have been discussed, the subsequent section delineates their practical application as part of overall sampling. In addition, the application of appraisal, extraction, supplementary methods, MRS, data analysis, and scientific rigour techniques is discussed in the remaining sections as final components of the overarching methodology. Sampling. Sampling for this study was purposive; in particular, criterion sampling was implemented, whereby articles that met “predetermined criter[ia] of importance” (Polit & Beck, UPHOLDING SOCIAL JUSTICE IN NURSING 51 2017, p. 495)—that is, the limitation as well as inclusion and exclusion criteria delineated earlier—were selected. Once articles passing these criteria were initially selected, they were then subjected to appraisal. In particular, studies that addressed all or as many of the research questions as possible, as well as those that contained sufficient commentary from students (or others on their behalf) to gauge students’ perceptions, were included. However, because studies did not all comprehensively answer each of these questions—and because there is no general consensus as to the final article count in literature reviews (Polit & Beck, 2017)—a predetermined number of articles to review was not set, but instead the final number to include for synthesis was determined in consultation with my immediate supervisor. Overall, then, in choosing the articles to ultimately be analyzed, a general systematic process was followed of: (a) choosing relevant studies based on inclusion/exclusion criteria; (b) appraising studies and eliminating those not meeting quality appraisal criteria (with the appraisal process discussed below); and (c) finalizing the chosen studies based on their adherence to inclusion/exclusion, and appraisal, criteria. The outcomes of this general sampling process are documented in Figure 1, a PRISMA-style (Preferred Reporting Items for Systematic reviews and Meta-Analyses) (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009) flow diagram. UPHOLDING SOCIAL JUSTICE IN NURSING 52 Identification Records Identified Through * Database Searches (N = 5,585) Duplicates Removed (N = 249) Number of Records Left After Duplicates Removed (N = 5,336) Screening** Records Screened (N = 5,336) Eligibility Full-Text Articles Assessed for Eligibility (N = 44) Records Excluded (did not meet purpose of study as well as inclusion and exclusion criteria) (N = 5,292) Full-Text Articles Excluded, with Reasons*** (N = 11) Inclusion Included Studies Meeting Purpose, Inclusion and Exclusion Criteria, and Passing Appraisal Criteria (N = 33) Qualitative (N =27) Quantitative (N = 2) Mixed-Methods (N = 4) Figure 1. Flow diagram of the study sampling process. This figure was adapted from the PRISMA flow diagram espoused by Moher et al. (2009). While the steps presented are sequential, representing the overall process for systematically reviewing the literature, the actual process conducted was iterative; for instance, screening was often revisited in the determination of full-text articles to assess for eligibility. (cont.) UPHOLDING SOCIAL JUSTICE IN NURSING 53 Figure 1, cont. * Regarding identification: While additional studies were identified through ancillary sources (such as reviewing the reference lists of relevant studies), because all relevant records found through such sources were also found through database searches, this figure displays only database searches for the sake of simplicity. **During screening, titles, abstracts, and full-texts were reviewed in this order (that is, abstracts were read when insufficient information was obtained from titles, and full-texts read when insufficient information was obtained from abstracts) before determining which records to exclude. *** Regarding the heading “Full-Text Articles Excluded, with Reasons,” eight full-text articles were excluded for, upon careful re-reading, not meeting inclusion criteria, leaving 36 articles; the remaining three articles were then excluded for not meeting appraisal criteria (resulting in a total of 11 articles excluded at this stage). Table 1 lists the 33 studies chosen for synthesis following the sampling process illustrated in the PRISMA-style diagram above, along with their corresponding record numbers (assigned to organize studies during appraisal and extraction processes): UPHOLDING SOCIAL JUSTICE IN NURSING 54 Table 1 Chosen Studies for Synthesis and their Corresponding Record Numbers Record Number Study Title, Authors, and Year "'Bittersweet Knowledge': The Long-Term Effects of an International Experience" by 1 Evanson and Zust (2006) "Capturing a Vision for Nursing: Undergraduate Nursing Students in Alternative Clinical Settings" by Reimer2 Kirkham, Hoe Harwood, and Van Hofwegen (2005) "Community Health Clinical Education in Canada: Part 2 - Developing Competencies to Address Social Justice, Equity, and the Social 3 Determinants of Health" by Cohen and Gregory (2009) "In Real Time: Exploring Nursing Students’ Learning during an International Experience" 4 by Afriyie Asenso, Reimer-Kirkham, and Astle (2013) UPHOLDING SOCIAL JUSTICE IN NURSING 55 "An international internship on social development led by Canadian nursing students: Empowering learning" by 5 Zanchetta, Schwind, Aksenchuk, Gorospe, IV, and Santiago (2013) "Development and Evaluation of an International Service Learning Program for Nursing Students" by Curtin, Martins, 6 Schwartz-Barcott, DiMaria, and Ogando (2013) "The Meaning of Participation in an International Service Experience Among 7 Baccalaureate Nursing Students" by Evanson and Zust (2004) “‘I Saw it in a Different Light’: International Learning Experiences in Baccalaureate 8 Nursing Education” by Walsh and DeJoseph (2003) UPHOLDING SOCIAL JUSTICE IN NURSING 56 “International Cultural Immersion: En Vivo Reflections in Cultural Competence” by 9 Larson, Ott, and Miles (2010) “Nursing Students’ Experiences of Health Care in Swaziland: Transformational 10 Processes in Developing Cultural Understanding” by Murray (2015) “New Ways of Seeing: Nursing Students’ Experiences of a Pilot Service Learning 11 Program in Australia” by Townsend, Gray and Forber (2015) "Keeping the Vision: Sustaining Social Consciousness with Nursing Students following International Learning 12 Experiences" by Reimer Kirkham, Van Hofwegen, and Pankratz (2009) “Narratives of Social Justice: Learning in 13 Innovative Clinical Settings” by Reimer- UPHOLDING SOCIAL JUSTICE IN NURSING 57 Kirkham, Van Hofwegen, and Hoe Harwood (2005) “Reclaiming the Essence of Nursing: The Meaning of an Immersion Experience in Honduras for RN to Bachelor of Science 14 Students” by Adamshick and August-Brady (2012) “Service-Learning: An Eye-Opening Experience that Provokes Emotion and 15 Challenges Stereotypes” by Hunt (2007) “The Strength of Rural Nursing: Implications for Undergraduate Nursing Education” by 16 Van Hofwegen, Kirkham, and Harwood (2005) "Transforming Experiences: Nursing 17 Education and International Immersion Programs" by Levine (2009) "Undergraduate nursing students integrating 18 health literacy in clinical settings" by UPHOLDING SOCIAL JUSTICE IN NURSING 58 Zanchetta, Taher, Fredericks, Waddell, Fine, and Sales (2013) "Undergraduate Nursing Students’ Experience of Service-Learning: A 19 Phenomenological Study" by Knecht and Fischer (2015) "Capturing Student Transformation From a Global Service-Learning Experience: The Efficacy of Photo-Elicitation as a Qualitative 20 Research Method" by Kronk, Weideman, Cunningham, and Resick (2015) “Reflexive Photography: An Alternative Method for Documenting the Learning 21 Process of Cultural Competence” by Amerson and Livingston (2014) "Long-Term Learning in a Short-Term Study Abroad Program: 'Are We Really Truly 22 Helping the Community?'" by Caldwell and Purtzer (2014) UPHOLDING SOCIAL JUSTICE IN NURSING 59 “Academic-Hospital Partnership: Conducting a Community Health Needs Assessment as a 23 Service Learning Project” by Krumwiede, Van Gelderen, and Krumwiede (2014) “Seeing With New Eyes: The Meaning of an Immersion Experience in Bangladesh for 24 Undergraduate Senior Nursing Students” by Maltby and Abrams (2009) “‘Leaving the Comfort of the Familiar’: Fostering Workplace Cultural Awareness Through Short-Term Global Experiences” by 25 Smith-Miller, Leak, Harlan, Dieckmann, and Sherwood (2010) "Short of Transformation: American ADN Students’ Thoughts, Feelings, and Experiences of Studying Abroad in a Low26 Income Country” by Foronda and Belknap (2012) UPHOLDING SOCIAL JUSTICE IN NURSING 60 “Opening our hearts and minds: The meaning of international clinical nursing electives in 27 the personal and professional lives of nurses” by Clark Callister and Harmer Cox (2006) "Constructing the foundations for compassionate care: How service-learning 28 affects nursing students’ attitudes towards the poor" by Jarrell et al. (2014) “Service-Learning in Nursing Education: Its Impact on Leadership and Social Justice” by 29 Groh, Stallwood, and Daniels (2011) “A Mixed Methods Evaluation of an International Service Learning Program in the 30 Dominican Republic” Curtin, Martins, and Schwartz-Barcott (2014) “Learning and Helping: Benefits of International Nurse Practitioner Student 31 Experiences” by Smit, Delpier, Giordana, and Tremethick (2012) UPHOLDING SOCIAL JUSTICE IN NURSING 61 “Second-Degree Bachelor of Science in Nursing Students’ Preconceived Attitudes 32 Toward the Homeless and Poor: A Pilot Study” by Boylston and O’Rourke (2013) "A Community Engagement Initiative: Service-Learning in Graduate Nursing 33 Education" by Narsavage, Lindell, Chen, Savrin, and Duffy (2002) Finally, Table 2 provides key descriptive information for these 33 studies: UPHOLDING SOCIAL JUSTICE IN NURSING 62 Table 2 Description of Relevant Studies Study Method Qualitative Country Where Educational Experience Took Place Canada Number Country Where Study Was Published Number 3 Canada 2 13 3 16 4 18 5 12 13 16 18 1, 2, 7, 8, 9, 12, Guatemala U.S.A. 1 21, 25 Guyana 2 6 Zambia 4 7 Brazil 5 8 6 9 Swaziland 10 10 Australia 11 11 Honduras 14, 22 14 Dominican Republic UPHOLDING SOCIAL JUSTICE IN NURSING 63 U.S.A. 15, 19, 23 15 Nicaragua 20 17 Bangladesh 24 19 Ecuador 26 20 Multiple 17, 27 21 22 23 24 25 26 27 Quantitative U.S.A. 28 U.S.A. 29 Mixed-Methods 28 29 Dominican 30 U.S.A. 30 Republic Honduras 31 31 U.S.A. 32, 33 32 33 Note. “Multiple” under the heading “Country Where Educational Experience Took Place” for study number 17 (Levine, 2009) refers to countries in Central America, Southeast Asia, and Eastern Europe. For study number 27, “multiple” refers to Argentina, Guatemala, and Jordan. UPHOLDING SOCIAL JUSTICE IN NURSING 64 Data appraisal. More specifically, initial qualitative studies chosen were appraised with the JBI evidence-based practice assessment checklist entitled “JBI QARI Critical Appraisal Checklist for Interpretive & Critical Research” (JBI, 2011b). Similarly, the evidence-based practice assessment checklist entitled “JBI Critical Appraisal Checklist for Descriptive/Case Series” was used to appraise initially-chosen quantitative studies (JBI, 2011a). Furthermore, initially-chosen mixed-methods primary research articles were appraised according to the guidelines provided in Table 12.5—“Integrative Framework for Inference Quality”—on page 301 of Teddlie and Tashakkori (2009). Finally, the single literature review chosen was appraised using criteria outlined in Box 29.1—“Guidelines for Critiquing Systematic Reviews”—on page 667 of Polit and Beck (2017). Both my immediate supervisor and I independently appraised all qualitative, quantitative, mixed-methods, and literature review studies. No gross discrepancies were noted during later comparison of these appraisals. Finally, as per JBI, Levels of Evidence (LOE) rank the evidence of primary research based on quality, and, as such, were also assigned in consultation with my immediate supervisor to further specify quality. Overall, 3 studies were eliminated from synthesis based on insufficient adherence to appraisal criteria, as Table 3 shows. UPHOLDING SOCIAL JUSTICE IN NURSING 65 Table 3 Summary of Appraisals Record Number Appraisal Decision JBI Level of Evidence* 1 Include 3 2 Include 3 3 Include 3 4 Include 3 5 Include 3 6 Include 3 7 Include 3 8 Include 3 9 Include 3 10 Include 3 11 Include 3 12 Include 3 13 Include 3 14 Include 3 15 Include 3 16 Include 3 17 Include 3 18 Include 3 19 Include 3 20 Include 3 UPHOLDING SOCIAL JUSTICE IN NURSING 66 21 Include 3 22 Include 3 23 Include 3 24 Include 3 25 Include 3 26 Include 3 27 Include 3 28 Include 2.d 29 Include 3.e 30 Include 2 31 Include 2 32 Include 2 33 Include 2 34 Exclude 2 35 Exclude 3 36 Exclude 3 Note. Given that consensus has not yet been established for the assignment of LOE to mixed-methods (MM) research, MM studies were given a LOE of 2 under the “Levels of Evidence for Meaningfulness” (“New JBI Levels of Evidence”, 2014, p. 6) category. Also, as per JBI (M. Peters, personal communication, November 22, 2016), there is no JBI MM appraisal form in existence, thereby necessitating the evaluation of MM studies via alternate means (Teddlie & Tashakkori, 2009). Data extraction. In order to guide later analysis, data from the studies passing inclusion/exclusion and appraisal criteria were extracted methodically. To guide this process, the following eight extraction questions were created, in consultation with my supervisory UPHOLDING SOCIAL JUSTICE IN NURSING 67 committee: (a) What have students learned in general about the SDH? (b) What have students learned specifically about the SDH? (c) In general, what indications are given that students feel better prepared to address the SDH? (d) Specifically, what indications are given that students feel better prepared to address the SDH? (e) What indications are given that students do not feel better prepared to address the SDH? (f) What is said about facilitators to students’ ability to address the SDH? (g) What is said about barriers to students’ ability to address the SDH? (h) How are students taught about the SDH? Data were extracted within a Microsoft ® Excel ® 2016 workbook to allow for the collection of a vast quantity of data; specifically, illustrations for each study were entered into individual cells, and these illustrations organized beneath category and sub-category column headings for each question. Reading of data thus contained within columns across relevant studies listed in rows facilitated the generation of themes. Polit and Beck (2017), in fact, contend that a literature review has as its focus the identification of themes, and that reading the columns of a matrix is particularly beneficial in the discernment of patterns. Figure 2 presents a snapshot of the extraction matrix, revealing data extracted for the first of 33 studies: UPHOLDING SOCIAL JUSTICE IN NURSING 68 Figure 2. Data extraction matrix. Cells coloured green represent UE quotations (i.e., illustrations); those coloured yellow represent C illustrations. The blue numbers following each extraction question (in red at the top), and each category and subcategory (beneath the red extraction questions in this respective order), represent the number of findings (that is, illustrations) supporting each category and subcategory. Supplementary methods. In addition to extracting data for ultimate analysis, the data was abstracted (Garrard, 2017) (that is, detailed notes on each article were taken) in a review matrix, a method whereby documents are strategically summarized in chronological order in a table format (Garrard, 2017). All 33 articles listed in Appendix B are abstracted according to column topics that provide key descriptive information about each study, providing an at-aglance view of the state of this body of evidence. Moreover, the general principles presented by the matrix method—including the creation of folders similar to Garrard’s (2017) “Master”, “Paper Trail”, “Documents”, “Review Matrix”, and “Synthesis” (p. 226) folders—were followed, in order to structure and organize the review. Lastly, the features of EndNoteTM Web (Thomson Reuters, 2015)—such as the “Find Duplicates” option—were used to aid the management and referencing of articles. UPHOLDING SOCIAL JUSTICE IN NURSING 69 Mixed Research Synthesis (MRS). Since the focus of this research is in synthesizing research on a topic that relatively little is known about in nursing—and due to the concomitant qualitative and quantitative aspects of this research—the chosen synthesis method is mixed research synthesis as espoused by Sandelowski, Voils, and Barroso [Sandelowski et al., 2006] (2006; also called mixed-methods research by Sandelowski, Voils, Leeman, & Crandell, 2012). While most included studies are qualitative, with significantly less quantitative in addition to those that are themselves based on mixed-methods approaches (as is reflective of the current literature), studies with both qualitative and quantitative elements were nevertheless chosen. According to Sandelowski, Voils, and Barroso (2006), their versatile method is a “type of systematic review aimed at the integration of results from both qualitative and quantitative studies in a shared domain of empirical research” (p. 1). More precisely, Sandelowski, Voils, and Barroso (2006) introduce three different approaches to conducting MRS: segregated, integrated, and contingent. The segregated approach involves separate synthesis and analysis of quantitative and qualitative research (hereby called “mixed” research or data), while the contingent approach is an iterative process where several syntheses—segregated and/or integrated—are performed based on results from the previous synthesis until the researcher’s questions are answered (Sandelowski, Voils, & Barroso, 2006). In comparison, the integrated design—whereby data from mixed research are directly combined into a single synthesis without the preliminary synthesis of each data-set separately— was found to be most suited to the purpose. A central reason for this is that the integrated design permits the transformation of quantitative data into themes. Yet in order for this to occur, the data must meet a principal condition: namely, that mixed data are sufficiently similar to allow for combination into a single synthesis. As such, a central assumption underlying this approach is UPHOLDING SOCIAL JUSTICE IN NURSING 70 that “any differences between qualitative and quantitative studies that do exist do not warrant separate analyses and syntheses of their findings” (Sandelowski, Voils, & Barroso, 2006, p. 8). Consequently, the processes of assimilation or aggregation—rather than configuration of findings—is emphasized. Since the findings within the mixed data were found to indeed be sufficiently similar, they therefore did not warrant separate syntheses (considering also the comparatively less quantitative research). As such, an integrated MRS approach was found to accommodate this data. As Sandelowski, Voils, and Barroso (2006) further explicate, when data across a data-set address “different aspects of a target phenomenon” (p. 7)—that is, when they do not necessarily answer the same research questions—they only complement as opposed to confirm or refute each other. Configuration—as occurs in the segregated design—is therefore “the arrangement of complementary findings into a line of argument” (Sandelowski, Voils, & Barroso, 2006, p. 7). However, the data across the quantitative and qualitative studies discovered do indeed answer many of the same questions and bear similar research purposes—for instance, discovering what NS learned about structurally vulnerable populations after a clinical experience, examining NS’ attitudes toward such populations, and/or examining NS’ perceived ability to assist them. Hence, in accounting for such similarities, the underlying process maintained by an integrated MRS is confirmation, a method which essentially leads to convergent validation (triangulation) of data (Sandelowski, Voils, & Barroso, 2006), and—considering the similar aims among the mixed research—underlied this integrated MRS as well. Therefore, assimilation—or the transformation of data into each other (Sandelowski, Voils, & Barroso, 2006)—ultimately occurs. An integrated approach bears the potential to provide a truly unique conceptualization of findings. In essence, this style—as intimated above—is based on “the repetition of the same UPHOLDING SOCIAL JUSTICE IN NURSING 71 relationship among findings (i.e., the confirmation of them) across primary studies regardless of their methodological pedigree” (Sandelowski, Voils, Leeman, & Crandell, 2012, p. 8). Such repetition of findings, not only aims—evident in the articles abstracted in Appendix B—is indeed apparent across the chosen studies. Most quantitative studies are of a pre-post test design and address the same, or very similar, questions as the qualitative studies, often doing so through survey questions instead. For instance, one study’s instrument is titled, “Attitude Toward Poverty–Short Form” (Vliem, 2015, p. 308) where students’ attitudes are measured on stigma, among other items. Yet another study’s instrument is said to have “tapped perceptions” (Rasmor et al., 2014, p. 593), and still another used by Reising et al. (2008) reported a mean score for professional and civic responsibility as 4.5/5 (which other qualitative studies instead describe). Thus, since many quantitative findings confirm qualitative results merely in their own distinct ways, an integrated mixed-methods synthesis indeed appeared appropriate for the data. The results of the completed integrated MRS, then, are the codes generated during creation of the codebook for data extraction (see Appendix C), which was completed in close consultation with my immediate supervisor. Several revisions were made to the codebook during data extraction and throughout the MRS process, reflecting ongoing conversations about the wording of codes between myself and my supervisory committee. That is, the process of synthesis undertaken to synthesize data from across all 33 studies was inherent to the creation of—and is therefore represented by—these codes, which are, in essence, the categories and subcategories illustrated in Figure 2. Data analysis. While Sandelowski, Voils, and Barroso (2006) do not espouse any particular method of analysis, they do recognize that in an integrated approach, “syntheses of both qualitative and quantitative findings can be produced from methods developed for UPHOLDING SOCIAL JUSTICE IN NURSING 72 qualitative…. findings” (p. 8). Given the largely qualitative aspects of findings across the studies—as often becomes evident in authors’ prolific usage of student quotations—findings were therefore analyzed through the conduction of a thematic analysis (also recognized as valid to a mixed approach by Pope, Mays, and Popay [2007]). Thematic analysis was completed in keeping with Thorne’s (2016b) interpretive description approach, a method that moves beyond description to answer the “so what” question of applicability to practice. During analysis, the principles espoused by Thorne (2016a; 2016b) were followed with all authenticity and rigour, in order to “see beyond the obvious” (Thorne, 2016a, p. 156) and to offer a meaningful and compelling representation of findings. Moreover, ongoing discussions with my supervisory committee proved essential in preventing “premature closure” (Thorne, 2016b, p. 194) to ensure the achievement of such a representation, thereby achieving trustworthiness. In presenting themes and corresponding subthemes, a “rich description” (Thorne, 2016a, p. 169) of these findings was ultimately sought. In considering the process of thematic analysis more specifically, moreover, it is relevant to note that thematic analysis was conducted within a Microsoft ® Excel ® data extraction workbook (or extraction matrix) due to the high volume of data there was to work with. As such, the extraction workbook (see Figure 2) served as a codebook in that illustrations were entered— or “coded”—directly beneath categories and subcategories (that is, the codes themselves) rather than assigned a numbered or lettered label representing each category and subcategory within the original research reports. Moreover, the eight extraction questions (discussed earlier) were used to guide the creation of categories and subcategories (see Figure 2 for a visual representation of this extraction matrix question, category/subcategory, illustrations framework) (see Appendix C for the codebook and accompanying extraction questions). Coding in such a manner served two UPHOLDING SOCIAL JUSTICE IN NURSING 73 critical purposes: first, it allowed for the collection of a great amount of data within a single document, facilitating later analysis; and second, since the majority of illustrations were in participants’ own voices, it allowed me to more distinctly emphasize their words such that my subsequent analysis of data was based not only on the reading and re-reading of categories, but on iterative reading of the words of participants themselves—whose voices I ultimately aimed to capture in generating themes. As such, the actual process of thematic analysis began with the early creation of extraction questions, grounded in the research questions, to facilitate the collection of data within this extraction matrix. As data were coded, then, the analytic process continued concurrently; namely, my supervisory committee and I repeatedly immersed ourselves in the data of the matrix—using the interpretive descriptive method—and engaged in numerous, ongoing discussions to compare emerging ideas. A preliminary thematic framework was developed early in this analytic process, and, once data were completely extracted and following continuing immersion, interpretive inductive thinking, and intensive discussion, initial impressions were refined and a final thematic framework was reached. Furthermore, this thematic analytic process was also facilitated by the iterative creation of a “thematic representation” table (see Table 4 in Chapter 4); namely, as analysis was underway, emerging themes were entered alongside choice illustrative quotations. As analysis progressed, these themes were then finalized along with their most salient, descriptive quotations. As such, creation of this table served as an adjunct to the interpretive, analytic process as it necessitated critical reading and re-reading of data to achieve a veracious, and compelling, representation of the final thematic framework. Scientific rigour. As Evans (2002) cautions, when no clear procedure is in place to guide synthesis, “the validity of findings is threatened because of the many subjective decisions UPHOLDING SOCIAL JUSTICE IN NURSING 74 made while generating the narrative” (p. 23). Thus, to guard against the influence of my own biases, scientific rigour was regularly sought throughout the research process by, for instance, maintaining an audit trail (Polit & Beck, 2017) to document significant decisions made in consultation with my supervisory committee. Moreover, I explored in detail theoretical and analytic questions during analysis in a document entitled “Analytic Memos”, and continued to make analytic memos as “comments” in both the extraction matrix workbook as well as word processed document containing the thematic analysis write-up. This ongoing analysis of my “interpretive thoughts, questions, and hunches” (Thorne, 2016a, p. 167) were indeed instrumental in the ultimate formation of “more fully developed conceptual understandings that [became] … study findings” (Thorne, 2016a, p. 168). In addition, I maintained a reflexive journal (Polit & Beck, 2017) in which I especially focused on critiquing my own a priori assumptions, values, beliefs, and biases, in order to prevent “[o]verinscription of self” (Thorne, 2016b, p. 196). Furthermore, decisions to enhance scientific quality were made at every stage of the research process. For instance, as I performed literature searches, I especially strove to achieve data triangulation (Polit & Beck, 2017), and, before choosing studies for inclusion my immediate supervisor and I carefully appraised them based on predetermined criteria (JBI, 2011a; JBI, 2011b). Also noteworthy is that during analysis, I regularly sought out opportunities to achieve a robust analysis. For example, I often challenged my own understanding of the codes, and later, themes, generated during analysis, reflecting “on all possible ‘solutions’” (Thorne, 2016b, p. 194) to consider which coding and analytic structures most truly captured the meaning within the data. In additionally aiming to achieve thick description in my presentation of findings, I ultimately sought—through these various means—to enhance credibility (Polit & Beck, 2017). UPHOLDING SOCIAL JUSTICE IN NURSING 75 Moreover, to enhance auditability, I assigned descriptors that alluded to the quality of my data as described by JBI (2014). For instance, I drew upon the principles of the levels of credibility of either Unequivocal, Credible, or Unsupported, as espoused by JBI (2014), in assigning these labels to each extracted finding (noted in the extraction matrix next to the finding as well as through a colour scheme; see Figure 2) according to how congruent the finding was with the category or subcategory that it was coded beneath. Finally, I appointed a grade of recommendation of either A or B to each of the recommendations I discussed in the “Recommendations” sections of Chapter 6 (which were discussed with my supervisor if questions arose). The opinions of knowledgeable and experienced researchers—in particular, Drs. Barbara Astle and Sheryl Reimer-Kirkham who comprised my supervisory committee—proved especially invaluable; as such, investigator triangulation (Polit & Beck, 2017) was consistently sought. Further, in continued recognition of my novice research abilities, I also tested data saturation by extracting data from an additional study near the end of the research process in order to see whether any new information emerged (Polit & Beck, 2017). Finally, I acknowledged the limitations of my research (see Chapter 6), noting how, for instance, I focused mainly on awareness and increased sense of ability to act as outcomes as opposed to other possibilities (such as “tolerance, humanity, innovativeness, creativity, [and] risk taking” [Levine, 2009, p. 156]). Likewise, I discussed the implications of “qualitizing” (Sandelowski, Voils, & Barroso, 2006, p. 8) quantitative data as a possible limitation to my methodology. UPHOLDING SOCIAL JUSTICE IN NURSING 76 Ethical Considerations Since this research did not necessitate direct involvement with human participants, means associated with the protection of humans—such as attaining Research Ethics Board (REB) approval—were unnecessary. Limitations While the methodology employed in this research was systematic and comprehensive, limitations also needed to be acknowledged when considering the findings. For instance, studies were limited to those that were written in the English language. In addition, online learning and simulation experiences, and studies post-2015 were not included. While grey literature may have offered other relevant studies, it was not feasible within the scope of this synthesis to include this literature. Furthermore, learning with respect to the SDH and/or social justice, and students’ perceived ability to act on the SDH, is not always explicitly described by authors, so that such learning and perceived ability had, at times, to be appropriately inferred in consultation with my supervisory committee. Chapter 3 Summary A comprehensive search strategy—as well as detailed inclusion/exclusion criteria constituting a retrieval strategy—allowed for the initial identification and choosing of 44 studies for synthesis. Following closer analysis of full-texts, eight articles were excluded for not meeting inclusion criteria, and following rigorous appraisal of the remaining 36, three articles were excluded for not meeting appraisal criteria. The varied methodology employed consisted of this sampling process, as well as data appraisal and data extraction processes, supplementary methods (e.g., creation of a review matrix), MRS (Sandelowski et al., 2006) as a synthesis method, thematic analysis following an interpretive description approach (Thorne, 2016a; UPHOLDING SOCIAL JUSTICE IN NURSING 77 Thorne, 2016b) as a data analysis method, and finally, various techniques to achieve scientific rigour. Ethical considerations were, furthermore, consistently taken into account. Altogether, rigorous implementation of these diverse methods allowed for the conception of cogent themes and subthemes—the findings of this research—will be discussed in detail in Chapter 4. UPHOLDING SOCIAL JUSTICE IN NURSING 78 Chapter 4: Findings The purpose of this research was to explore the value of clinical educational experiences in expanding NS’ understanding of—and perceived ability to address—the SDH, and in so doing to uphold their social justice mandate. This Chapter describes the findings that emerged from the rigorous conduction of MRS and interpretive description processes with the 33 studies. During the data analysis, four main themes were derived from the data: Cognitive Learning, Experiential Learning, Reflexive Learning, and Praxis Learning. See Figure 3 for a thematic framework portraying the themes and subthemes. Theme One, Cognitive Learning, described students’ emerging awareness of the SDH, such as: Understanding that the SDH Exist, Understanding the Realities of the SDH, Understanding through Comparisons, and Conceptual Understanding of the SDH. Theme Two, Experiential Learning, addressed the experience of learning with the accompanying subthemes: Contextual Learning, Barriers to Learning, Facilitators to Learning, Firsthand Learning and Seeing the Other. Theme Three, Reflexive Learning, described the students’ reflection on the experience, as captured in the following subthemes: Seeing the Self, Willingly Reflecting, Unreadiness to Act, and Struggling with Understanding Injustice. The final theme, Theme Four, Praxis Learning, revealed students’ emerging readiness to act, as seen in the subthemes: Moving Towards Seeing their Potential Influence, and Moving Towards Competence and Confidence. This chapter will be organized into a discussion of the four themes: Cognitive Learning, Experiential Learning, Reflexive Learning, and Praxis Learning. A summary of the findings will end the chapter. UPHOLDING SOCIAL JUSTICE IN NURSING Theme 1: Cognitive Learning Theme 2: Experiential Learning Theme 3: Reflexive Learning Theme 4: Praxis Learning 79 • Subtheme (ST) 1: Understanding that the SDH Exist • ST 2: Understanding the Realities of the SDH • ST 3: Understanding Through Comparisons • ST 4: Conceptual Understanding of the SDH • ST 1: Contextual Learning • ST 2: Barriers to Learning • ST 3: Facilitators to Learning • ST 4: Firsthand Learning • ST 5: Seeing the Other • ST 1: Seeing the Self • ST 2: Willingly Reflecting • ST 3: Unreadiness to Act • ST 4: Struggling with Understanding Injustice • ST 1: Moving Towards Seeing their Potential Influence • ST 2: Moving Towards Competence and Confidence Figure 3. Thematic Framework of Findings Theme One: Cognitive Learning This first theme, “Cognitive Learning”, captures the idea that students did gain an understanding of principles related to the SDH—that is, their experiences were, first and foremost, characterized by “learning about” the SDH. While this chapter presents quotations illustrating the discussion, other, particularly salient quotations are given in Table 4, to more succinctly demonstrate the meaning of subthemes within their respective themes. Subtheme one: Understanding that the SDH exist. All of the studies addressed the immediate instance of understanding of SDH—that is, of social conditions. Such newfound awareness is often voiced clearly in students’ comments, or in instructors’ comments of students’ experiences. For instance, some authors described students’ cognitive learning quite explicitly; Evanson and Zust (2004), for example, commented that living among the people allowed students specifically to “observe how physical, social, political, and cultural environments are UPHOLDING SOCIAL JUSTICE IN NURSING 80 major determinants of health” (p. 9). Maltby and Abrams (2009), similar to Walsh and DeJoseph (2003), noted that the majority of participants realized the state of poverty surrounding them; however, they further illustrated the “‘difference’” (p. 6) that students “were confronted with” (p. 6) with the image of “small children dressed only in a pair of shorts [who] came begging for food and money” (p. 6). One student’s response to this event powerfully captures his (or her) previous unawareness of the existence of such social conditions in the Bangladeshi villages: “‘I was very taken aback when children came up to me begging for money’” (p. 6). The fact that such accounts are given that more indirectly speak of students’ gained cognitive knowledge of the SDH reveals the extent of their learning: that is, whether or not authors recognize and label these witnessed conditions as SDH, they nevertheless still often indicated that these conditions were witnessed. In particular, students evidenced awareness of the existence of the SDH on a global scale. Such awareness was expressed variably by authors: for instance, “awareness of the global community” (Walsh & DeJoseph, 2003, p. 271); “… new understanding of issues of social justice and a global society” (Evanson & Zust, 2004, p. 11); and finally, the realization among students that the injustices they had seen were “indeed global injustices” (Afriyie Asenso et al., 2013, p. 6). One student in Adamshick and August-Brady’s (2012) study summarized recognition of the global occurrence of health inequities forthrightly: “‘[w]hat an eye opening journey”, the student remarked, “[o]nce again I am reminded of my ignorance of global poverty’” (p. 194). Reimer-Kirkham et al. (2009) referred to this awareness as “social consciousness”; in their words, “[s]tudents’ initial responses to the international experience were marked by reports of new ways of viewing the world, often characterized by heightened social consciousness” (p. 5). Clark Callister and Harmer Cox (2006) expressed students’ newfound UPHOLDING SOCIAL JUSTICE IN NURSING 81 global awareness somewhat differently, as “increasing understanding of global sociopolitical and health issues…” (p. 95). Evanson and Zust (2006), in comparison, voiced students’ awareness more explicitly; they commented that witnessing the effects of poverty led participants to better understand the global impact of “scarcity and abundance, resourcefulness and waste” (p. 414). Indeed, “[p]articipants became aware of “how many people in the world need help” (Evanson & Zust, 2006, p. 417). In Reimer-Kirkham et al. (2009), global awareness was framed through the understanding that people worldwide are exposed to the same conditions, implying a view of the structurally vulnerable as “fellow” human beings; that is, “[u]nderstanding universal human experience was reflected by the student comment, ‘People are the same everywhere’” (p. 6). One student in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood’s (2005) work, moreover, demonstrated how global awareness of the SDH provoked his or her thinking of how the SDH manifested at home; in his or her words: We often hear things about First Nations or Indo Canadians but when you’re in Guatemala it’s very easy to start from scratch and appreciate the culture. You step back and think “oh my, why is it any different from the cultures in my home community?” It was a real eye opener that way. (p. 8) As this quotation shows, global awareness included awareness of the SDH in the student’s own community at home, in addition to her current placement in Guatemala. This emphasis on home as part of a larger, global community was shared by a student in Afriyie Asenso et al.’s (2013) study, who noted: From talking with the Zambians and seeing the hospital, they don’t have resources. There is all this need. But we have those needs at home, it just looks different. I don’t need to travel to Africa to help the needy when they are right in my backyard. (p. 6) UPHOLDING SOCIAL JUSTICE IN NURSING 82 Truly, this student’s comment is a poignant depiction of the realization that health inequities are universal. Further, awareness of the SDH on a global scale also meant that students realized how actions undertaken in their home community could, in fact, affect others in the world. This was succinctly summated by Zanchetta, Schwind, et al. (2013), who observed that students came to see “[u]nexpected reciprocity between global health and urban health” (p. 761). More specifically, as Evanson and Zust (2006) found, nurses learned how the political actions of their government affected people worldwide. Likewise, in Larson, Ott, and Miles’s (2010) study, students came to understand how U.S. policies influenced poverty: In some cases, students faced uncomfortable connections between U.S. policy and developing countries. This theme is depicted in this student's comment: ...I learned how the US influenced the [civil] war [in Guatemala]. It was odd. To be standing in a place (church) where my country had a bad influence over was weird. Coming on this trip has helped me realize how the US can have a major influence over other countries. (p. 48) Another notable example from this study was students’ realization of how employability in the US facilitated Guatemalans’ livelihood. As the authors explained: “[s]ome students lived with families who had family members working in the US. They learned how employment in the US can provide economic assistance to families in Guatemala and viewed immigration from a broader perspective” (Larson et al., 2010, p. 49). The value, then, of students’ across-the-board realization that people worldwide are connected in their experience of SDH—that the SDH are global, not merely local—was captured powerfully by one student in Caldwell and Purtzer’s (2014) work: When we see how others are living, the better able we are to become global citizens. This is critical because if the world is going to thrive, we must recognize and validate the UPHOLDING SOCIAL JUSTICE IN NURSING 83 unique differences and wonderful contributions that all societies can bring to the mix. (p. 580) Students in Curtin, Martins, and Schwartz-Barcott (2014) seemed to share this enthusiasm for global awareness; as the authors reported, “[i]n terms of international perspectives, the highest mean (M = 6.45) obtained related to the level to which the program influenced one’s discussion of international and transcultural issues with other people” (p. 63). Subtheme two: Understanding the realities of the SDH. Moreover, cognitive learning of the realities of the SDH (that is, learning of their extent and impact) was expressed in the majority of the studies and also became unmistakable within certain student accounts. Students’ understanding of the SDH, in this subtheme, was focused more on the toll that such conditions exacted on the lives of persons who are structurally vulnerable. Narsavage, Lindell, Chen, Savrin, and Duffy (2002) illustrated this compellingly—they found an increase from 3.26 to 3.76 on the item, “[u]nderstand the effect of socioeconomic status on health and illness”—a “92.9% above moderate change” (p. 460). Moreover, the authors offered an explicit example of such understanding: in their words, “[t]he students reported they gained a better understanding of how difficult it is for clients with diabetes to rely on community meals and food banks to follow a diabetic diet” (Narsavage et al., 2002, p. 459). Furthermore, Jarrell et al. (2014) discussed how students came to understand the effects of lack of income and resources; for example: Multiple students noted that clients’ inability to comply with their treatment plans was not due to a lack of knowledge, as they originally believed, but rather due to a lack of resources. It became evident to the students that people who are poor may be financially unable to maintain a healthy lifestyle. (p. 302) UPHOLDING SOCIAL JUSTICE IN NURSING 84 Indeed, awareness of how such social determinants of health were important determining factors of health was clearly articulated across studies. One student in Smith-Miller, Leak, Harlan, Dieckmann, and Sherwood (2010) explained, “I saw a weariness and, at times, even desperation . . . children were already involved in the family struggle to survive” (p. 23). In noting children’s early implication in the fight for survival—a factor that doubtlessly influenced, starting at this young age, their ability to pursue health—this comment operationalized the idea expressed by Jarrell et al. (2014) that SDH may be solely responsible for individuals’ ability to maintain their health. Foronda and Belknap (2012) similarly highlighted how SDH convened to elicit the tragic consequence of child labor. As one student remarked, The one thing that really surprised me was that children work…young children. They could be less than ten years old. I was rather shocked to see the children that were begging in the street trying to sell pieces of candy…for money. (p. 8) Finally, as one student in Afriyie Asenso et al. (2013) observed, the dynamics of family lifestyle were upended in ways she had not previously considered: To have the opportunity to interact with the widows and hear their stories was really powerful… It made me realize how hard they work, how far they have to walk to get things done, and the other side of AIDS and what the people who are left behind have to go through. (p. 4) Further, comments by students across studies especially evinced notions of shock at the social conditions witnessed, and the subsequent impact they had on the structurally vulnerable; notably, one student in Maltby and Abrams (2009) conceded: “‘I was in shock as we travelled around to the different villages to see how they live. It truly is unbelievable…daily life here appears as a fight for survival’” (p. 6), and “‘[t]he poverty here is unimaginable’” (p. 6). UPHOLDING SOCIAL JUSTICE IN NURSING 85 Zanchetta, Schwind, et al. (2013) similarly noted “the moral shock of seeing overt deprivation of the basic necessities” (p. 762) experienced by students. In particular, the account of one student in Curtin et al. (2014) vividly detailed her experience in coming to terms with conditions witnessed: I found it difficult to even comprehend the lack of resources in this community. Many of the people that came to see us that day were dirty. Most of the children did not have shoes, some not even clothes. They had a layer of filth on them and a lack of water means no way to clean up. Many . . . told us they were hungry. It broke my heart when elderly woman after elderly woman came in saying they hadn’t eaten in days. (p. 63-64) More pointedly, Knecht and Fischer (2015) shared students’ realization that less-thanideal social conditions could impart a significant physiological impact. As one student submitted: I learned a lot about factors I had not considered before. This gentleman had come in for the first time, from prison, he had been incarcerated a few days before... He had high BP [blood pressure], and no medication was given to him. His BP was 220/120. (p. 381) Such an impact on health was also recognized by students in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005), who stated, “[i]n an emotional re-telling, another student reflected on her visit to a hospital in an international setting where she spent time with a teenaged girl who was developmentally delayed, physically disabled, and malnourished” (p. 6). After recounting the SDH that figured prominently in one village, a student in Curtin et al. (2014) remarked, “[t]hese people were starving, dehydrated, sick and exhausted” (p. 63), and another student recounted how the most she or he and his or her peers could do for a pregnant teenage girl was to give her a month’s supply of prenatal vitamins (Curtin et al., 2014). Finally, UPHOLDING SOCIAL JUSTICE IN NURSING 86 Jarrell et al. (2014) noted how even when the structurally vulnerable did receive medical attention, other factors might still have precluded their uptake of medical care: “[a] homeless client stated after being seen in the emergency department for a fractured tibia he was told to ‘go home, elevate his leg, and apply ice,’ none of which he could possibly do” (p. 302). Explicit examples of learning of the complexities of the SDH also occurred in numerous studies. As one student in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005) remarked, You think it’s like what you’ve seen on TV…like Little House on the Prairie. You get there and ask “what’s your main health issue” and its drugs and alcohol abuse. That’s not at all what I would have expected. So you think “It’s a smaller community...easier to get everyone to know about it and to fix it.” But then you have the issue of ‘it’s a secret’ because everyone knows each other and you can’t go get help because your parents are friends with the counselor. (p. 6) Here, the student learned of the delicate complexities of the SDH—namely, the fact that drug and alcohol usage could, in the first place, themselves constitute SDH, and that working to address such issues was made all the more complicated by their taboo nature. Quite often, students’ learning was framed as learning of the complexities involved. One student in ReimerKirkham, Hoe Harwood, and Van Hofwegen (2005), for example, noted: “‘health problems are complex. It is not just that there are economic problems but also social factors and what people believe’” (p. 265); further, in understanding complexities, students saw the “bigger picture” (p. 265) of community health nursing, as was explicated by one student: It developed my sense of the broader community. I saw families coming to visit their husband or dad and then I saw a parole board hearing where the victims were represented UPHOLDING SOCIAL JUSTICE IN NURSING 87 and I saw the inmates.... they’re all different communities that need so much help. (p. 265) In recognizing all the different people affected by the SDH, this student saw the underlying complexities that shaped how the SDH impacted persons in a prison setting. Similarly, Van Hofwegen et al. (2005) related how students became aware of how policies and budget cuts determined “resource allotment and accessibility. [Namely] [t]he threat of possible closure or reduction of the emergency care and hospital services in the community gave students insight into the complexities of health policy and resource allocation” (p. 7). In Zanchetta, Schwind et al. (2013), furthermore, student-interns became frustrated when they realized “… the limits and struggles of communities to overcome the structural roots of social inequities” (p. 762). Awareness of such varying complicated factors, then, contributed significantly to the realities that students began to see as encompassing the SDH. In comparison, Zanchetta, Taher, et al. (2013) told of how students were surprised by the realization that relatively simple factors—such as the abilities to understand health teaching and to speak English—could strongly impact patients’ decision-making. As they recounted, one student said: I had to consider basically what their cultural background was first of all. Sometimes they had a language barrier, and they had a history of Alzheimer's.…and I found that they base their knowledge on whatever they’ve been told. I found that they rely on other health professionals for what they knew. (Zanchetta, Taher, et al., 2013, p. 1029) This realization of the impact of health illiteracy on health was shared by one student in Murray (2015), who noted, “[s]tudents recognized that physician usage is infrequent…. due to the lack of providers. Many people still turn to traditional healers, and the nursing students saw harmful evidence of this” (p. S70). UPHOLDING SOCIAL JUSTICE IN NURSING 88 Further, Levine’s (2009) account of the understanding that students gained of realities echoed sentiments expressed by Maltby and Abrams (2009) and Evanson and Zust (2006). She wrote: Interviewees focused on the disparities: Those who could pay fees for services fared much better than did those who could not, people who were perceived to be of minority status were treated differently than the mainstream patient, the powerlessness of many patients and their families, and the overall physical state of the hospitals. (p. 166) Overall, coming to understand the realities of the SDH meant that students had to come to terms with the toll that such realities exerted on persons that were structurally vulnerable and the complexities of the SDH. However, students often came to terms with the existence, and realities, of the SDH in other ways: by making comparisons. Subtheme three: Understanding through comparisons. Notably, this awareness of the existence, and realities, of the SDH was often expressed in the context of comparisons. For example, Evanson and Zust (2004) stated simply but profoundly that students “compared their own lives to those of people in a developing country” (p. 6). Indeed, students across studies frequently did so. In Knecht and Fischer (2015), for instance, one student remarked, “[y]ou meet people who are nowhere close to where you are… They are going through so much, and when you put your issues next to their issues, you think to yourself, ‘I am stressed over this?’” (p. 381). Other students compared living conditions more explicitly—for example, one student in Kronk, Weideman, Cunningham, and Resick (2015), said: Seeing the barrio [home] helped me understand the extent of the poverty...I knew it would probably be different from what I've experienced in socioeconomically depressed UPHOLDING SOCIAL JUSTICE IN NURSING 89 neighbourhoods in the United States, but I was shocked to see the extreme differences. (p. S101) Frequently, however, students compared their home health care system to that of the country they were visiting. In many cases, direct comparisons allowed students to understand the dire circumstances afflicting host country health care systems. For example, in Adamshick and August-Brady (2012), one student observed: “‘[t]he hospital had wards which did not give the patients any privacy. There were no curtains between the beds, there were no bassinets for the babies. Obviously, that does not meet the American standard’” (p. 194). Concerns related to privacy were also expressed by students in Foronda and Belknap (2012). Further comparisons were made by students in Smith-Miller et al. (2010), who described the Guatemalan health care system as dated, especially with respect to equipment, and unsafe in terms of nurse-to-patient ratios. In Murray (2015), students especially noted how the lack of patient education affected care. Yet in some instances, students saw, in comparing health systems, that they could learn from the health practices of their host country. Another student in Evanson and Zust (2006) disclosed: We can drag on death. We’ve had patients on our floor for 2-3 months, and we’re just prolonging their [suffering].… We keep doing all this invasive stuff that you wouldn’t do in a third world country… I think they have a different concept of death and just how you go about things. I think a lot of them are more spiritual or religious in a sense, and they put more value in that than actual medicine… And I think a lot about the way Western medicine is and the way we’re treating people. They develop a problem, we give them the pill, they get another side effect from the pill, and we give them another UPHOLDING SOCIAL JUSTICE IN NURSING 90 pill. And I just think, you know, they don’t have that availability of all those different medications in those countries, and really, I wonder if we’re really better off. (p. 417) Similarly, in Larson et al. (2010): One student characterized the hospital environment as healthy for patients. She wrote, ‘I liked it better than in our hospitals, in some aspects. I like the way the hospital is open to the world—children can get fresh air and be outside [during hospitalization]’” (p. 48). Likewise, despite having noted disadvantages to the Guatemalan health care system, students in Smith-Miller et al. (2010) also saw certain benefits in Guatemalan health system practices, such as how “‘. . . the health department helped train lay midwives . . . to give competent health care to those in very rural areas’” (p. 24). In all, comparisons—especially of health care systems between countries—helped to tangibly contextualize students’ learning of the SDH. Subtheme four: Conceptual understanding of the SDH. Finally, students’ cognitive learning was also shaped by their education. Curricular integration, for instance, encompassed various concepts integrated in students’ curriculum. Early curricula incorporated concepts of, for instance, “transcultural nursing theory” (Evanson & Zust, 2004; Evanson & Zust, 2006) as well as concepts of SL (Hunt, 2007; Narsavage et al., 2002). In comparison, as the 2000’s progressed, curricular concepts undergirding students’ learning focused more on community health nursing—such in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005) where “[t]he majority of… placements were associated with a senior level community health course” (p. 3)—on health promotion (Narsavage et al., 2002), and on rural health (Van Hofwegen et al., 2005). Toward the late 2000’s, early curricular ideas largely fell out of use, with ideas from the mid-2000’s persisting; moreover, novel concepts such as public health (Caldwell & Purtzer, UPHOLDING SOCIAL JUSTICE IN NURSING 91 2014; Krumwiede et al., 2014; Maltby & Abrams, 2009) emerged to substantiate previous concepts such as community health. It is, however, noteworthy that explicit mention of the SDH—or of social justice or equity—was not clearly articulated in the articles from the early 2000’s to 2009 in this study. As Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005) commented, “…. the objectives for the courses in which these clinical placements occurred did not include explicit references to social justice” (p. 9). In the late 2000’s, however, mention of such equity-based concepts emerged, such as in Reimer-Kirkham et al.’s (2009) study where emphasis was placed on “… curricular themes related to social consciousness; course expectations to integrate learning re: social justice themes” (p. 9-10). In Zanchetta, Schwind, et al. (2013), students were exposed to “…. critical social theory, social development and social justice, and social determinants of health” (p. 760) in their curriculum. Cohen and Gregory (2009), moreover, noted the importance of regular integration of such concepts: “[a] curriculum that promotes the values of social justice/equity and which focuses on the social determinants of health throughout the program was viewed as the ideal” (p. 5), having also noted that such curricular integration was perhaps the most important method of addressing barriers collectively (p. 12). Zanchetta, Taher, et al. (2013) supported this idea of ongoing curricular integration of social justice-based concepts, which formed the “philosophical underpinning of [their] nursing curriculum” (p. 1031), noting that students had become more sensitive to social justice issues as a result. Moreover, as the years progressed (particularly from the mid 2000’s onward), scholars increasingly experimented with innovative placements—which, as Reimer-Kirkham, Hoe Harwood, and Van Hofwegen (2005) wrote, most commonly comprise corrections, parish, rural, Aboriginal, and international sites. Indeed, much of students’ learning—including cognitive UPHOLDING SOCIAL JUSTICE IN NURSING 92 learning as encompassed by this theme, as well as different kinds of learning as will be captured by the themes that follow—occurred in these more unconventional placements. In particular, international sites were extensively used. In addition, additional curricular lessons to bolster students’ learning of international host communities was not explicitly emphasized until 2010; in Larson et al. (2010), for instance, students received intensive preparation in Spanish beforehand, learned about Guatemalans’ health and health care delivery, as well as of the “role of international agencies in Central America” (p. 46). Having provided similar preparation, students in Curtin et al. (2013) were also taught about “… Dominican history, [and] politics” (p. 550). Reflective activities were also incorporated into educational experiences throughout the 2000-2015 time period, and while they varied, journaling was especially common, in some cases continuing until after the educational experience (Evanson & Zust, 2004; Levine, 2009; Curtin et al., 2014). However, other activities, such as paper-writing (Larson et al., 2010; Smith-Miller et al., 2010), a photo journal (Reimer-Kirkham et al., 2009), and group discussions (Narsavage et al., 2002; Evanson & Zust, 2004; Reimer-Kirkham, Van Hofwegen, & Hoe Harwood, 2005) were also implemented. Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005) found that journaling in particular helped students “make sense of their experiences” (p. 9-10) as students reflected on such ideas as “… the concept of ‘upstream thinking’ or ‘community empowerment’ as seen in the clinical practice setting” (p. 7). Student attestations to the benefit of reflection were palpable, as in the words of one student in Hunt (2007): [b]eing forced to put my thoughts on paper [enabled me] to go to the next step. To be able to think, OK, this goes on here, what about this? How come this is like this? It builds doors in my mind” (p. 279). UPHOLDING SOCIAL JUSTICE IN NURSING 93 It is also interesting to note that learning about the SDH appeared to have been framed from a number of different theoretical lenses, including: an individual, family, community, or population lens (found in 19/33 studies); a culture-related lens (e.g., cultural diversity, cultural competence, cultural sensitivity, or cultural awareness, etc.) (25/33 studies); a health equity, or disparity, lens (16/33 studies); a global health (i.e., global citizenship, and/or globalization) lens (16/33 studies); and a social justice lens (17/33 studies). While these lenses were not referred to as such by authors, authors’ descriptions of their curricula and educational experiences indicated that they had, in fact, structured learning from the perspective of such lenses. For instance, in Groh, Stallwood, and Daniels’ (2011) study, one of the only two constructs measured by the Service-Learning Self-Evaluation Tool was “social justice” (p. 400), which was reflective of the researchers’ purpose of first identifying social justice as a nursing value, and then comparing “the impact of a service-learning experience on senior nursing students’ self-rated leadership and social justice interest” (p. 401). This purpose—alongside the authors’ accompanying discussion on SL, leadership, and social justice—indicated that the authors indeed intended for students to learn about social justice following participation in their SL experience. In addition, it is also worthwhile to note that even when several lenses seemed to have been incorporated in framing students’ learning, one or two lenses usually predominated. In Zanchetta, Taher, et al. (2013), for example, the culture and health equity lenses dominated, and in Curtin et al. (2014), the culture and global health lenses dominated. Finally, authors did not always explicitly state the desired outcomes of their implemented educational experiences. Where they did, explicitly stated outcomes included, for instance, Smith-Miller et al.’s (2010) statement that the goal of their immersion program was “… to facilitate the development of cultural competence in the workplace, improve Spanish language UPHOLDING SOCIAL JUSTICE IN NURSING 94 skills, and increase awareness of global health issues” (p. 20). More infrequently, outcomes included reference to social justice or the SDH; as examples, Townsend, Gray, and Forber (2015) stated that they aspired for their SL program to “… support experiential learning about the social determinants of health” (p. 1), and in Cohen and Gregory (2009), twelve different course leaders variously described learning outcomes in reference to students’ development of knowledge and skills related to addressing social justice, equity, and the SDH. In comparison, learning of and/or ability to operationalize a culture-related variable, such as cultural competence, was a commonly stated outcome (implicit or explicit). Theme One, therefore, has shown that learning about the SDH occurred by students’ gaining understanding of their existence, gaining understanding of their realities, and gaining further understanding through making comparisons. Students’ cognitive learning was, moreover, heavily influenced by their conceptual preparation, as occurred notably through exposure to concepts in their nursing curriculum, through reflective activities, through different theoretical lenses, and according to specific learning outcomes. Theme Two: Experiential Learning While students learned cognitively by assimilating information, they also learned through experiencing. The acts of being in their respective clinical settings and partaking in the associated activities gave rise to rich and varied learning. Subtheme one: Contextual learning. Such “learning by doing”, as captured by this second theme of “Experiential Learning”, was, first and foremost, shaped across all studies by the contexts of students’ learning. The studies described the nature of students’ experiences from the perspectives of type of setting (local, national, or international settings), type of experience UPHOLDING SOCIAL JUSTICE IN NURSING 95 (health or non-health sector), and, in some cases, length of experience. Context, then, influenced students’ learning through each of these factors. To begin with, with respect to type of setting, experiences unique to local placements became readily evident; in Jarrell et al.’s (2014) study, for instance, clinical experiences occurred in “a homeless shelter and a low-income independent housing setting” (p. 300). Similarly, in Narsavage et al. (2002), students addressed “[t]he health care needs of Cleveland’s inner-city community…” (p. 457)—needs that were likely unique to this community. Notably, ReimerKirkham, Hoe Harwood, and Van Hofwegen (2005) described different local/international settings such as: parish (encompassing different faith communities), rural (a 3-hour distance from an urban setting), corrections (maximum and medium security prisons), Aboriginal (a reserve more than 60 km from urban setting), and international settings in either Guyana or Guatemala, in which students had a combination of urban and rural experiences. It is interesting to note, moreover, that Reimer-Kirkham, Hoe Harwood, and Van Hofwegen (2005) referred to local (in addition to international) locations as innovative sites. The merits of local placements were especially seen in the observation by Cohen and Gregory (2009) that—although the educators interviewed had experience with international practicums—“[o]f interest, none of the participants mentioned international student exchanges, whereby students can learn about and experience social justice issues in the global community” (p. 11-12). Some students, furthermore, lived in the communities in which their local experiences took place. For example, in Van Hofwegen et al. (2005)—where experiences took place partly in “[t]he local public health unit” (p. 4)—“[s]tudents lived in the community during the 2-week placement” (p. 4). Further, 21 out of 33 studies occurred in various international settings (as Table 2 reveals), which—as settings differing greatly from local placements—offered unique learning UPHOLDING SOCIAL JUSTICE IN NURSING 96 opportunities. Whereas international experiences usually occurred in one country, this was not always the case, as in Levine (2009) where each international program took place “in 1 or 2 of 10 countries” (p. 157). Most international experiences took place in Central America (see Table 2). In Clark Callister and Harmer Cox’s (2006) study, for example, students had “… international opportunities in Argentina, Guatemala, Jordan, or with the Ute and/or Navajo Nations (Native Americans)” (p. 96). Similarly, Levine (2009) noted that in students’ international settings, “[a]ll the communities were extremely remote” (p. 157). Indeed, rural experiences were spoken of often in tandem with international settings (Afriyie Asenso et al., 2013; Caldwell & Purtzer, 2014; Curtin et al., 2014; Curtin et al., 2013; Reimer-Kirkham, Hoe Harwood, & Van Hofwegen, 2005; Smit, Delpier, Giordana, & Tremethick, 2012). For example, in Zambia, students in Afriyie Asenso et al. (2013) visited rural places such as “the mission’s hospital, an outpatient AIDS clinic, and a traveling health unit” (p. 3). The contexts that shaped learning were also defined by the type of experience offered as occurring in either the health or non-health sector. Various health-care sector experiences included: settings described as clinics such as village clinics and a local government-operated clinic in Evanson and Zust (2004), hospitals or other settings described as acute (Afriyie Asenso et al., 2013; Adamshick & August-Brady, 2012; Clark Callister & Harmer Cox, 2006; Curtin et al., 2013; Evanson & Zust, 2006; Foronda & Belknap, 2012; Larson et al., 2010; Levine, 2009; Maltby & Abrams, 2009; Murray, 2015; Narsavage et al., 2002; Reimer-Kirkham, Van Hofwegen, and Hoe Harwood, 2005; Smith-Miller et al., 2010; Zanchetta, Taher, et al., 2013); and various settings described as community or public health settings (Clark Callister & Harmer Cox, 2006; Cohen & Gregory, 2009; Levine, 2009; Murray, 2015; Reimer-Kirkham, Van Hofwegen, & Hoe Harwood, 2005; Zanchetta, Schwind, et al., 2013; Zanchetta, Taher, et al., UPHOLDING SOCIAL JUSTICE IN NURSING 97 2013). Unique among these were “…. the Malta House of Care, a mobile van providing primary health care to the uninsured” (Knecht & Fischer, 2015, p. 378), “a faith-based long-term care facility serving adults and children with severe disability” (Smith-Miller et al., 2010, p. 20), and “a home for children and adults living with human immunodeficiency virus/acquired immunodeficiency syndrome…" (Smith-Miller et al., 2010, p. 20-21). Experiences outside of the health-care sector were also, however, notable. These included non-health-related community sites (Adamshick & August-Brady, 2012; Amerson & Livingston, 2014; Boylston & O’Rourke, 2013; Caldwell & Purtzer, 2014; Cohen & Gregory, 2009; Curtin et al., 2014; Jarrell et al., 2014; Knecht & Fischer, 2015; Levine, 2009; Maltby & Abrams, 2009; Smit et al., 2012; Townsend et al., 2015; Walsh & DeJoseph, 2003; Zanchetta, Taher, et al., 2013) such as “a homeless shelter” (Hunt, 2007, p. 278), village schools and an agricultural site (Evanson & Zust, 2004), as well as alternative settings described in ReimerKirkham, Van Hofwegen, and Hoe Harwood (2005) such as corrections and parish sites. Notably, as Groh et al. (2011) related, “students [had] the opportunity to serve at a number of community locations that provide family-focused services, including… soup kitchens, church “resting” centers, shelters for abused women and children, and/or community outreach programs for run-away teens” (p. 401). Moreover, in Evanson and Zust (2006), non-health sector experiences included informal hands-on care provided through home visits—similar to Kronk et al. (2015), Levine (2009), Maltby and Abrams (2009), and Zanchetta, Schwind, et al. (2013). In particular, it is interesting to note that with respect to the unique non-health sites of “prisons and half-way houses and different places like that, they tend to ‘get it’ better. They see health as rooted in social structures” (Cohen & Gregory, 2009, p. 6). UPHOLDING SOCIAL JUSTICE IN NURSING 98 Finally, the length of the educational experience also bore precedence in consideration of the many contexts of learning. In general, experiences were two or three weeks in length (Curtin et al., 2013; Curtin et al., 2014; Larson et al., 2010; Maltby & Abrams, 2009; Van Hofwegen et al., 2005; Walsh & DeJoseph, 2003), although occasionally they were longer, such as in ReimerKirkham et al. (2009) where the experience was three to four weeks long, in Townsend et al. (2015) where it was four weeks, in Krumwiede et al. (2014) were it lasted seven weeks, and in Clark Callister and Harmer Cox (2006) where “[i]nternational experiences ranged from weeks to a semester in length” (p. 96). In contrast, some experiences were comparatively much shorter, such as the “week-long placement” (p. 191) in Adamshick and August-Brady (2012) or 10-day experiences in Caldwell and Purtzer (2014) and Kronk et al. (2015). In fact, in Groh et al.’s (2011) study, “SL experiences [were] a minimum of 10 hours” (p. 401), and in Boylston and O’Rourke (2013), the clinical experience was merely eight hours in length. Subtheme two: Barriers to learning. Students’ experiential learning was, however, also impacted by several factors that arose as barriers to learning. To begin with, factors relating to the clinical experience itself often deterred students’ learning. Notably, many authors spoke of the inability to assure that capable mentors could be found to guide students through their educational experiences. Reimer-Kirkham, Hoe Harwood, and Van Hofwegen (2005) found that a lack of supportive clinical instructors who were passionate about teaching resulted in students having to take greater initiative for their learning, and that, consequently, experiences were not as positive. This concern became tangible in Zanchetta, Taher, et al. (2013) in the following student comment: Some supervisors were uninterested in health teaching, thus students saw them as ineffective models for the role of nurse as health educator. ‘She [the supervisor] didn't UPHOLDING SOCIAL JUSTICE IN NURSING 99 have time for me. It was all move, move, move.... I didn't get the support I would have needed’. (p. 1030) Cohen and Gregory (2009) echoed the concern of ineffective role models by commenting on students’ being driven to independent work (and, in some cases, feelings of isolation) in settings lacking a nurse preceptor, and added that the extent of instructors’ knowledge was an important determining factor of students’ learning. Specifically, one educator in Cohen and Gregory’s (2009) study commented: It’s difficult to find role models in the community, particularly in the health care sector, who understand and use the community development process, which would include social justice and equity and the social determinants of health, in their assessment and implementation. We still tend to have a downstream approach, an individually-focused, family-focused approach to delivering health care, rather than communityfocused [sic]. I find that there are many times when there are agencies within the non-health care sector that are more aware of community development. So that is a barrier, finding community health professionals who are aware of and practice that approach. (p. 9) In the same vein, planning and preparing for experiences was also burdensome— international experiences, for instance, required a preparatory trip in advance in ReimerKirkham, Hoe Harwood, and Van Hofwegen (2005), similar to the preparatory work they required in Smit et al. (2012), where planning began six months before the experience. Rural experiences required particular effort to procure in Van Hofwegen et al. (2005), as did innovative sites in Cohen and Gregory (2009). Moreover, the number of details to account for when planning international experiences in particular became evident in Smit et al.’s (2012) comment that: UPHOLDING SOCIAL JUSTICE IN NURSING 100 Planning by faculty included how best to integrate the clinic within the Honduran health care system and determining the most beneficial experiences for students…. Logistical aspects of programming such as housing, meals, transportation, and interpreters were arranged through the Honduran network previously developed by undergraduate programming in Honduras. (p. 20) Another recognized barrier was the lack of sufficient time to assimilate and implement knowledge (Afriyie Asenso et al., 2013; Cohen & Gregory, 2009; Zanchetta, Taher, et al., 2013). Lack of time was discussed at length by Zanchetta, Taher, et al. (2013), who offered a cogent example of how this barrier impacted students’ ability to address the SDH: “[f]ast-paced healthcare environments of facilities allowed very few opportunities for assessing clients’ health literacy or readiness to learn. In these settings, more value was placed on timely completion of tasks rather than health education...” (p. 1029). Also, as one educator in Cohen and Gregory (2009) related, When you’re getting to promoting social justice and equity, the application of the theory and the implementation of any type of strategies that would promote social justice and equity, I find that difficult in the short clinical time that we have… (p. 10) In addition to the inability to apply theory in promoting social justice and equity, another, potentially related downfall resulting from a lack of time arose: namely, the inability to engage in critical thinking in relation to how the SDH came about. Afriyie Asenso et al. (2013), on commenting about students’ lack of recognition of how global structures influenced those in Zambia, stated “[t]hus, if the students had spent a longer time in the setting they may have developed a critical understanding [emphasis added] of social justice” (p. 8). Clearly, the lack UPHOLDING SOCIAL JUSTICE IN NURSING 101 of capable clinical instructors and lack of time spent involved in the educational experience bore the potential to affect students’ experiential learning. Whether or not students’ learning was affected by ineffective clinical instructors, the work required to prepare experiences, or a lack of time, other factors—such as students’ unpreparedness—were detriments to their learning. Unpreparedness arose in Narsavage et al. (2002) as lack of familiarity with the structurally vulnerable population encountered; as the authors explained: Faculty involved were somewhat surprised at the students’ lack of familiarity with individuals from very low and no income populations. It was apparent from faculty's conversations with them that students had spent the majority of their nursing careers in hospital settings and suburban offices where there were few very low-income clients. For example, although students understood the pathophysiology of diabetes and its effect on individuals, they had little understanding of how to help clients with diabetes in the real world. (p. 459) Moreover, lack of previous travel experience to underserved locations was noted by several authors (Foronda & Belknap, 2012; Levine, 2009; Maltby & Abrams, 2009; Murray, 2015; Smith-Miller et al., 2010). Curtin et al. (2014), for instance, noted that 80% of participants had not travelled to an international destination for a SL experience. Levine (2009) noted the possible disadvantage of this by explaining that for one student, the “‘clean little bubble’” (p. 161) she had lived in her entire life in the U.S. “gave her a false sense of reality” (p. 161). In addition to not having physically encountered the structurally vulnerable, a lack of experience of merely thinking about issues related to social justice, and their potential role, may have proved detrimental; as is explained by one educator, UPHOLDING SOCIAL JUSTICE IN NURSING 102 The students have a lot of difficulty understanding these concepts… Some of the difficulty that I think they have is…that in a community development setting, their critical reflection and critical thinking skills come through even more so because it’s not written anywhere…They have to take their assessment and think about what they know about this particular organization or population, and with that population support community development principles by helping them [the clients] to help themselves…They find it very difficult and need a lot of help from the clinical instructors… (Cohen & Gregory, 2009, p. 9-10) Similarly, Boylston and O’Rourke (2013) added: “… the students did not fully understand the actual role of the nurse in such a setting. They did not know how to approach the clients and were unsure about their role, especially with immigrants…” (p. 314). It is evident, then, that in not considering issues of injustice and how they would act to address them beforehand, students found it difficult to act on these complex issues when encountering them for the first time. Several facilitators, however, served to redress the impact of such barriers. Subtheme three: Facilitators to learning. However, facilitators to students’ experiential learning also arose prominently in the various author accounts. To begin with, preparation beforehand proved to be key to students’ understanding. Students were often engaged in practical learning activities before the experience, such as in Amerson and Livingston (2014) where “they were required to attend a 1-hour briefing… to learn about the principles of reflexive photographs, what questions their photographs needed to answer… how to take photographs and use a camera, and how to document their perceptions of the photographs” (p. 204); in Evanson and Zust (2004) where students and faculty met weekly for eight weeks beforehand, during which time students learned about Guatemalan “local political history, UPHOLDING SOCIAL JUSTICE IN NURSING 103 culture, and health issues” (p. 4); and in Van Hofwegen et al. (2005) where students “received intensive theoretical preparation in community health and development principles….” (p. 10). In Smit et al. (2012) where NP students read articles and blogs, among other activities, to prepare, Students valued many of the pre-clinic activities and felt these activities were important in building knowledge, skills, and confidence. Preparation ahead of time in terms of identifying expected health care issues and developing protocols to treat common illnesses made the actual clinic experiences more productive. Discussions with local health care providers and faculty who had traveled to Honduras were identified as especially helpful in preparation. (p. 24) Educators in Cohen and Gregory (2009) in particular espoused early introduction to concepts of social justice, equity, and the SDH and consistent integration of these concepts throughout the curriculum. As one educator reflected, … if you are in a school where the whole evidence-based decision-making is really strong and students get inculcated into that way of thinking about health care and where community-related or social justice-related concepts aren’t as strong, then when they arrive at the community course, you’ve kind of got an uphill battle to fight…. You can do so much more with a community health course if students arrive in the course thinking this is really important. (p. 5) In comparison, in Curtin et al. (2014), students were exposed, in pre-experience seminars, to “… Riner’s (2011) ‘global health core content’ with a major focus on country specific knowledge, service learning, and social consciousness” (p. 60-61). Indeed, the importance of such theoretical preparation was confirmed by Zanchetta, Schwind, et al. (2013), who noted that students in their study felt well-prepared to apply “such tenets of their nursing curriculum as UPHOLDING SOCIAL JUSTICE IN NURSING 104 critical social theory, social development and social justice, and social determinants of health” (p. 760). Thus, students’ pre-learning was customized to the unique contexts of the locations they were visiting, as well as to the concepts defining their academic coursework. Receiving support from both the host community as well as instructors arose as a significant extension to the notion of preparatory work. Partnership between the host community and the postsecondary institution was commonly mentioned and identified as a central factor in achieving the objectives of the educational experience. Together, community members and students collaborated on, and achieved, healthcare goals for the community: in Krumwiede et al. (2014), for instance, Educators, students, hospital personnel, key stakeholders… and community members formed the Madelia Community Based Collaborative (MCBC) to identify family and community health concerns and to prioritize actions to improve health outcomes. MCBC developed a mission and vision statement to guide the direction toward community health and well-being. (p. 362) Similarly, following conversations over a one-year period, the University of Saint Joseph and the Franciscan Center for Urban Ministry partnered to establish a Wellness Center that facilitated student SL experiences (Knecht & Fischer, 2015). Indeed, community members were instrumental in facilitating students’ integration into the host community. For instance, in Evanson and Zust (2004), Catholic mission representatives were key in facilitating a successful experience for students and faculty—they helped to arrange travel, accommodation, and supplies; connected students and faculty with nurses; and when students could no longer accompany midwives, they “… worked with faculty to plan other nursing activities for students” (p. 5). In Walsh and DeJoseph (2003) close collaboration was especially evident as “… an UPHOLDING SOCIAL JUSTICE IN NURSING 105 American Roman Catholic priest who had lived in San Lucas Toliman for more than 30 years… was instrumental in helping participants understand the culture, as well as the role of women in society” (p. 271). Moreover, scholars frequently drew attention to the fact that the trust established between students and the community served as an important element in the receipt of community support. The formation of trust was wonderfully illustrated by Amerson and Livingston (2014): A photograph of the students walking down the road holding hands with local children demonstrated how students bonded with the children who came to the school each day, sometimes shortly after sunrise and stayed until dark. The children came to play with the American students. They played games, learned new language skills, and shared snacks. In a community where the indigenous people are leery of strangers, the relationships that were initiated here provided the groundwork to become a trusted friend. (p. 205) The establishment of such trust, therefore, allowed support to be given in the context of relationships. This emphasis revealed that collaboration, or partnership, did not facilitate positive experiences in isolation, but that the formation of relationships—as evidenced through the establishment of trust—often contributed to what was achieved in partnership. Further benefit to support given in the context of relationships was expressed by a student in Walsh and DeJoseph (2003): We went to the fincas [coffee plantations] every day. We earned the [comadronas’] trust, and they turned their patients over to us. We were partners with them. We let them draw conclusions and stay in charge… After a while we were just all women together. (p. 270) UPHOLDING SOCIAL JUSTICE IN NURSING 106 In this account, trust facilitated students’ provision of healthcare to patients in the community, in that because of the trust the community established with students, “they turned their patients over to us” (Walsh & DeJoseph, 2003, p. 270). Further, in Afriyie Asenso et al. (2013), the formation of relationships allowed participants themselves to feel more comfortable working with the underserved; as the authors explained, The sense of community and trust demonstrated to the participants by the Zambians allowed the North American students to let their guard down and connect with them. Over the three weeks, participants came to the conclusion that this generosity was integral to their learning. (p. 4) Finally, as Caldwell and Purtzer (2014) disclosed, the rapport that formed between students and community members “speaks to longterm commitment and sustainability” (p. 577). Relationships between community members and students, then, not only enriched students’ experiences while they worked with host communities, but facilitated students’ provision of healthcare to the community and potentiated a possibility of long-term partnership. Along these lines, support provided by instructors—whether faculty members or nonfaculty clinical instructors—was invaluable to students’ learning. Instructors supported students in numerous ways; for example, instructor support was frequently cited as being inspirational to students, who “… reflect the level of commitment they see in faculty” (Narsavage et al., 2002, p. 458). In Van Hofwegen et al. (2005), students were encouraged when “[t]he nurse mentors provided direction, encouraged students to access resources, and empowered students to take on a community project” (p. 8). Indeed, instructors’ outlook on the experience was readily apparent to, and significantly impacted, students: one student in Clark Callister and Harmer Cox (2006) even commented: UPHOLDING SOCIAL JUSTICE IN NURSING 107 The attitude of the faculty I was with really had an impact on the students’ attitudes. Both of the professors who were with me were very eager to learn, interactive with people, excited about clinical sites, and helped us take advantage of our opportunities. (p. 98) Notably, instructors had the potential to “promote values of social justice/equity” (Cohen & Gregory, 2009, p. 12). As Cohen and Gregory (2009) found, non-RN agency contacts provided optimum experiences because they possessed a “holistic understanding of social determinants of health and social justice/equity issues” (p. 6). A core strength of faculty support, as Reimer-Kirkham et al. (2009) added, was its potential to promote sustained social consciousness in students: “[s]pending time with students reflecting on newly gained insights and strategizing actions that would address social injustices was a central strength of this project in sustaining social consciousness” (p. 12). Students’ perspectives confirmed that support given by faculty particularly inspired them: Sometimes you don’t know who or how to ask but when the nursing instructor came in, it helped light a fire under me to say, ‘okay, I can ask questions and learn from that’. It pushed me into engaging with the patients and the staff instead of being a bystander. (Afriyie Asenso et al., 2013, p. 5) In this study, instructors’ encouragement of students to think critically was instrumental in, for instance, helping students “… to begin thinking as global citizens” (Afriyie Asenso et al., 2013, p. 8), just as it promoted sustained social consciousness in Reimer-Kirkham et al. (2009). Challenge—contrary to initial impression—also arose as a key facilitator of students’ learning. As Van Hofwegen et al. (2005), for example, noted: UPHOLDING SOCIAL JUSTICE IN NURSING 108 Factors that might be barriers to learning were instead often constructed as positive. For example, the location of the community required students to live there in an immersion experience. While the related logistics of lodging, transportation, and expense were raised, living in the community was reported as enhancing understanding of the community and rural health nursing. (p. 9) The scholars continued, maintaining that isolation, too, proved beneficial: Similarly, the isolation of the community with lack of access to health resources was seen as a challenge for rural health in general but also served to provide the catalyst for the independent nursing practice identified as rewarding by both students and nurses. (Van Hofwegen et al., 2005, p. 9) In Clark Callister and Harmer Cox (2006), one student underscored lack of access to technology in particular, sharing: We had to depend on our assessment skills. I would think, ‘I don’t know what their blood pressure is, but they have pulses everywhere, they have good capillary refill, they are warm.’ I would think, ‘Are they retracting? Do they have nasal flaring? What is their color?’ While technology provides a lot of information, gaining assessment skills is so important. (p. 101) As such, these narratives revealed that such challenges as living on-site, being isolated as part of the experience, and lacking access to technology actually provided students with unique learning opportunities. Students in Levine’s (2009) study were, moreover, challenged in myriad ways. Levine (2009) notably observed that these many challenges “… stretched students' understanding, tolerance, humanity, innovativeness, creativity, risk taking, confidence, and competence” (p. 156). She furthermore noted that challenges facilitated students’ practice of UPHOLDING SOCIAL JUSTICE IN NURSING 109 nursing following their experiences, such that as professional nurses students were “…. basking in anticipated challenge when working with individuals and families with different value systems” (Levine, 2009, p. 167). Similarly, Zanchetta, Schwind, et al. (2013) described how students in their study were also challenged on multiple levels, and consequently grew in multiple ways. Challenges for these students included: “… having the opportunity to problem solve, practice conflict resolution, implement a health promotion project, and associate with a different culture” (Zanchetta, Schwind, et al., 2013, p. 760) as well as applying for a grant and practicing leadership, and resulting benefits included the development of professionalism, learning to collaborate with others including stakeholders, and learning to be creative in the face of limited resources. Finally, although the challenge of working in an unfamiliar environment was widely recognized, the experience of students in Amerson and Livingston (2014) epitomized that of many: namely, the students “felt that having to adapt their language, nursing skills, and teaching strategies to the needs of the Mayan women was highly beneficial to increase their selfconfidence in working with people of different cultures” (p. 207). Subtheme four: Firsthand learning. Not only did knowledge facilitate students’ learning, but knowledge gained firsthand—or firsthand learning—was consistently highlighted as a distinct facilitator. To begin with, firsthand learning allowed students across studies to “… observe firsthand the health care issues facing those who live in poverty” (Hunt, 2007, p. 277). Students themselves claimed many benefits of such firsthand learning; as one student in Evanson and Zust (2006) contended, “when you see things firsthand, I think it makes that much more of a difference. It makes a bigger impact” (p. 415). In Larson et al. (2010), students also noted a more pronounced impact of firsthand learning when compared to more traditional pedagogical techniques; namely, “[t]hey reported that visualizing these scenes made more of an impact than UPHOLDING SOCIAL JUSTICE IN NURSING 110 if they had read about them in a book or heard about them in seminar” (p. 48). Notably, seeing illnesses common to underdeveloped nations firsthand put into context students’ learning of them at home in Afriyie Asenso et al. (2013). As one student explained, “[i]t’s so real here. When we [sic] learning about HIV or TB in Canada, we are removed from it, so we don’t have the emotional aspect as much and don’t have all our senses engaged. It’s much more powerful here” (Afriyie Asenso et al., 2013, p. 5). In addition, other authors corroborated how firsthand learning afforded students the opportunity to learn about concepts taught in the classroom, such as health inequities. As Reimer-Kirkham et al. (2009) noted: “[s]tudents repeatedly remarked how seeing first hand [sic] the lived realities of poverty, lack of housing, and malnutrition, brought home to them the social determinants of health as much more than a theoretical concept” (p. 6). The following student comment markedly demonstrated this: “statistics… become faces of people I know” (p. 6). Finally, Reimer-Kirkham et al. (2009) also drew attention to the potential of firsthand learning to promote critical thinking, as “… being witness to poverty and health disparities first hand resulted in critical reflection and profound moral questioning for many students” (p. 7). In Smit et al. (2012), critical thinking also arose as NP students had to make “… decisions about what medications to prescribe when the first line drug choice was not available” (p. 25), requiring “collaboration and thinking through the needs of the patient” (p. 25). Clearly, then, firsthand learning brought to life students’ classroom learning by facilitating, for instance, the formation of relationships and the learning of course concepts such as the SDH, as well as by promoting critical thinking. Experiencing the host culture in context—where immersion in another culture greatly facilitated learning of that culture—was, furthermore, a unique aspect of students’ firsthand UPHOLDING SOCIAL JUSTICE IN NURSING 111 learning. As Evanson and Zust (2006) reported, “… the continued impetus to grow in terms of cultural care could not have been taught in a classroom” (Evanson & Zust, 2006, p. 418). Maltby and Abrams (2009) agreed about the benefits of firsthand learning of culture, noting, “[t]hese are difficult concepts to teach in the classroom without commensurate exposure to the realities of other cultures” (p. 10-11). Indeed, the collective account of several students in Maltby and Abrams (2009) reinforced the benefits of being immersed in another culture: We would encourage any future and current nurses to take opportunities to travel abroad. Our experience in Bangladesh has made us more culturally competent and opened our eyes to health needs outside of the USA. It was immeasurably vital to our development both as individuals and as nurses interacting with people of many cultures. (p. 11-12) More specifically, students in Walsh and DeJoseph (2003) learned much about the Guatemalan culture during their two weeks of immersion—for example, they learned about the cultural value of children, and learned how to appreciate the comparatively unstructured Guatemalan lifestyle. In Amerson and Livingston (2014), students also learned much about Guatemalan culture, specifically observing a midwife discuss the use of herbs during childbirth, as well as “… the common use of a temazcal (steam bath) during days immediately following childbirth” (p. 205). Such lessons were, the authors claimed, important because “[p]articipants’ resulting appreciation for a culture different from their own increases their ability as nurses to be open to the various beliefs and values found in diverse communities” (Walsh & DeJoseph, 2003, p. 272). One student’s comment in Larson et al.’s (2010) study saliently demonstrated this: … I was open-minded and learned a lot and found it very interesting. It (the time spent with traditional healer) was a good activity because it really informs us about their culture UPHOLDING SOCIAL JUSTICE IN NURSING 112 and beliefs regarding health care that could help us in the future to care for Latino patients. (p. 48) Moreover, the finding by Smit et al. (2012) of a score of 4.8/5 on the question, “I believe I am more sensitive to cultural diversity after participating in this course” (p. 22), also affirms this observation, as does a comment by a student in Clark Callister and Harmer Cox (2006): “I also understand better how to incorporate beliefs and practises into client care” (p. 101). In Reimer-Kirkham, Hoe Harwood, and Van Hofwegen (2005), students were exposed to the beliefs and traditions of an Aboriginal community. Likewise, in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005), one student recounted: We were invited our second week to go bark stripping. We spent a day—not in the office at all. We were out in the forest stripping bark from trees; the women taught us how to shear it with the knife. They invited us to join them for the sacrifice…. We participated in the ceremony. That may not look like nursing, but we were getting to know the people, and understanding their culture. (p. 5) Thus, by directly partaking in the culture’s traditions, these students truly experienced the culture in context. Moreover, in commenting that participation in the ceremony was, in fact, nursing, the student who partook in the bark stripping ceremony notably highlighted that experiencing culture in context was, significantly, a form of practicing nursing. Further, another student in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005) pointed out that lack of engagement in the host culture may result in deficient knowledge of predominant health needs important for a practicing nurse to address: “[t]he student reflected that as she interacted with the community, members would ‘start talking about their drug use, or high death rates around UPHOLDING SOCIAL JUSTICE IN NURSING 113 suicides, and you are able to learn about the health needs through talking about their culture’” (p. 5). Similarly, a student narrative in Clark Callister and Harmer Cox (2006) engagingly related the value of experiencing culture in context: I came to appreciate a different culture and see another way of viewing life: political, spiritual, religious, and social. I celebrated the first day of Ramadan with Hiba and several of her friends. I had fasted as they had. At dusk, we went to eat the first meal after prayer. I remember standing at the window, overlooking the white buildings of Amman, as the call to prayer floated over the hills. As we ate, they taught me about Islam. It was a very joyful and moving experience in a way a textbook cannot offer. (p. 100) Also in Clark Callister and Harmer Cox (2006), a student shared how gaining familiarity with the host culture resulted in “real growth” (p. 101), and went on to describe how his or her knowledge of the Guatemalan culture now endeared patients to him or her in the workplace: I became more aware, more patient, and understanding. This has had an impact on the way I provide care to women in labor who are from different cultures. I have more understanding of immigrants. When I tell a Guatemalan mother I have been to Guatemala, her face lights up. We have something to share. (p. 101) In addition to previously mentioned benefits of experiencing culture in context such as openness to and respect for patients’ beliefs, values, and traditions; practicing nursing in an unconventional but real way; and firsthand knowledge of culture-specific health needs, this most recent quotation reveals the potential of such past experience with culture to facilitate the establishment of rapport with patients. Finally, living with host families allowed students in UPHOLDING SOCIAL JUSTICE IN NURSING 114 certain studies an exclusive glimpse into culture and thereby excellent firsthand learning opportunities—as one student in Smith-Miller et al. (2010) remarked, “‘[l]iving with a local family . . . we were able to learn so much more about the way of life in Guatemala than we would have staying in a hotel’” (p. 22). Experiencing culture in context, then, proved to be an integral component of firsthand learning. Subtheme five: Seeing the other. A particularly interesting phenomenon arose during students’ experiential learning—that of students’ learning to fully see the other, or the structurally vulnerable persons they encountered. To begin with, this subtheme of “Seeing the Other” included the developed ability to look at these persons broadly in considering many aspects of their lives in relation to the SDH. At times, “Seeing the Other” meant coming to terms with the factors that caused the other to be other, or different. For instance, in Hunt (2007), students saw that “[t]he majority of people were from different ethnic backgrounds, socioeconomic status, [and] completely different life situations” (p. 279). This realization seemed to even be disconcerting for some, such as for one student who commented, “[f]rom the time that I first entered the shelter, I felt I was entering a different world. Here there were people who had such a different lifestyle from mine. Our paths never crossed, except here” (Hunt, 2007, p. 279). However, “Seeing the Other” also meant that students became more aware of their unique needs, or, as Levine (2009) put it, more aware of “… each client as an individual with his or her unique set of needs, each of whom deserved absolute respect and understanding” (p. 166). In Evanson and Zust (2004), this was simply yet profoundly described as “learning to appreciate the whole person in their care” (p. 10). Indeed, this language of “wholeness” was also used by other scholars, such as Reimer-Kirkham, Hoe Harwood, and Van Hofwegen (2005), who stated that participants practiced nursing holistically in parish and corrections settings in the UPHOLDING SOCIAL JUSTICE IN NURSING 115 sense that “… they responded to the ‘whole person’ composed of spiritual, emotional, and social needs as well as physical needs. Notably, students envisioned nursing as inclusive of a range of relational, social, and community-based activities” (p. 265). Students actively questioned the circumstances involved in creating and sustaining the conditions characterizing the lives of the structurally vulnerable, such as one student in Hunt (2007) who—upon seeing homeless women with children—was “… kind of wondering about their past and what brought them to that point” (p. 278). One student in Clark Callister and Harmer Cox (2006), moreover, illustrated the kinds of questions implicit to the ability to see the other as the fully unique individual they were. With respect to the international experiences she (or he) had, the student commented: When I see a Hispanic family with five little children, I think, ‘May be [sic] that person is from Guatemala or Mexico or Brazil or Argentina. I wonder what their needs are? I wonder if they’re doing okay? Does this family have enough support?’ Such awareness influences my clinical practice. (p. 100) At times, “Seeing the Other” manifested in seeing the other as happy—evidencing that students only began to truly see the other. One student in Walsh and DeJoseph (2003), for example, reflected: “I was very struck by the happiness of the children. Yes, they were dirty, but they were obviously well loved—all were dressed and played with the abandon of happy children everywhere” (p. 271). Views of the other as happy also arose in accounts given by students in Maltby and Abrams (2009) of Bangladeshis; for example, students said “[i]t seems as though the people are happy because they know nothing else (but poverty)” (Maltby & Abrams, 2009, p. 7), and “[a]t the end of the day, the people appear to be hopeful, happy people despite … extreme poverty” (Maltby & Abrams, 2009, p. 7). Certainly, similar comments were made by UPHOLDING SOCIAL JUSTICE IN NURSING 116 students in Adamshick and August-Brady (2012)—one in particular reiterated the illustration of children playing given by Walsh and DeJoseph (2003) earlier: “[i]t appears as if the quality of their life isn’t so good, but the value of their life is. As poor as they are, and as little as they have, they seem happy. The children played nicely. They shared” (p. 194). Finally, as one student in Foronda and Belknap (2012) offered: I was very sad but I also understood that it’s kind of like it was during the Great Depression here, that theirs is just all the time there, but they accept it…at first it was a big cultural shock and you just want to go out and buy all these shoes, but then, after the third or fourth day, you decided that they are happy so we need to be happy for them. (p. 9) In line with viewing the structurally vulnerable as happy, one student in Caldwell and Purtzer (2014) suggested that they were actually “rich” by other standards: “[t]he people of Honduras appeared poor . . . by Western standards but I also see how rich they are in other aspects” (p. 580). Finally, in learning to see the other, some students felt more connected to them, realizing that “the other”—structurally vulnerable persons—were not very different from themselves. As a student in Townsend et al. (2015) said, “‘[i]n this sort of setting they were equal to you. Do you know what I mean? Everyone is on the same level. They can talk to you. You can talk to them’” (p. 3). Also, in Clark Callister and Harmer Cox (2006), one student commented, I have images of the Guatemalan people. I see their faces, expressions, tears, joys, sadness, love, struggles, determination. I am overwhelmed by their strength and courage. Although I did not speak their language, I came to love these people. The greatest insight UPHOLDING SOCIAL JUSTICE IN NURSING 117 I gained from working with these people is the great human connexion [sic] that we have with all people. We are all brothers and sisters. (p. 101) This sense of connection—or “recognizing the humanity in all of us via identifying our human similarities” (p. 166), as Levine (2009) put it—notably became evident in the stories told by students in Hunt’s (2007) study. Namely, Hunt (2007) told of how students realized that “families who are homeless are both different from and similar to families who have housing” (p. 277). As Hunt (2007) further related: “[d]uring the semester, students discovered that like all families, families who are homeless have hopes, dreams, and goals” (p. 279). Likewise, in Larson et al. (2010), this understanding of a connection was seen in one student’s comment that “[i]t is a different culture but only in degrees. The homes are comfortable and centered around the kitchen… Life here is similar to my own, but simpler and less fancy” (p. 48). Interestingly, a feeling of connection arose specifically because students themselves gained a sense of what it meant to be “other”. As explained by Reimer-Kirkham et al. (2009), “[t]he dissonance of ‘being other’ stimulated examination of previously held suppositions” (p. 67). In Smith-Miller et al.’s (2010) study, students’ difficult adjustment to life in Guatemala led them to appreciate the difficult adjustment of immigrants in the US; as one student remarked, “I do understand the fear, uncertainty, and even shame that they felt at times when trying to navigate through the US system and make their needs known, understood, and respected” (p. 24). In particular, students in this study who struggled with speaking Spanish while in Guatemala came to understand the similar difficulty of immigrants in the US. One student recounted: Being in a land where no one speaks your language is especially miserable so I can now understand why they all create their own culture and community and manage to continue UPHOLDING SOCIAL JUSTICE IN NURSING 118 living in the United States without being fluent in English or submitting to the dominant American culture. (Smith-Miller et al., 2010, p. 24-25) In addition to learning to see the other broadly in considering many aspects—such as their culture, happiness, and connection to oneself—students also saw the resilience of those who were made structurally vulnerable. This was clearly evident in various assertions that the structurally vulnerable, across studies, were “… making the best of their situations” (Narsavage et al., 2002, p. 459), such as, for instance, “doing the best with what they have” (Smith-Miller et al., 2010, p. 23) in terms of resources. Kronk et al. (2015) demonstrated resilience explicitly when noting that “[w]hen discussing a photograph of a man selling mangos, one student stated, ‘They have a 'keep at it' attitude and persistence; Nicaraguans are so resilient’ (p. S101). Indeed, in Caldwell and Purtzer (2014), “[s]tudents were awed and perplexed at the possibility of living so simply and yet still being content without most basic needs” (p. 580). Specific manifestations of resilience were indeed numerous in student accounts; for instance, one student observed that “[f]amilies are there for each other” (Walsh & DeJoseph, 2003, p. 271)—a realization repeated in Kronk et al. (2015)—and “… the humanity, generosity, and strength displayed by the Zambians also surprised the participants” (p. 7) in Afriyie Asenso et al.’s (2013) study. A particularly interesting story told by a student in Curtin et al. (2013) demonstrated resilience well: After a student treated a malnourished 53-year-old man and provided him with granola bars and crackers, she stated ‘… as he left, I watched him out the window. I watched him share his food we had given him with some children…It made me look at myself and how I would act in his situation and also how I act now. He made me want to be less selfish and share what I have with others who are less fortunate’. (p. 554) UPHOLDING SOCIAL JUSTICE IN NURSING 119 Kronk et al. (2015) used words such as “strength, enduring spirit, creativity, and… beauty” (p. S101) to describe the Nicaraguan people. Both Kronk et al. (2015), and Murray (2015), in fact, spoke to the creativity seen in the structurally vulnerable in making the most of the few resources they had. Finally, one student in Knecht and Fischer (2015) reiterated seeing characteristics such as graciousness and kindness—as also evident in the preceding accounts—in the structurally vulnerable; in his or her words, [t]hey are struggling, yet they are so happy for us. I don't know how to describe it. They are so proud of us, they are not jealous. They are selfless. They have nothing and they are happy for us. It is heartwarming. (p. 382) Ultimately, then, “Seeing the Other”—which involved seeing the structurally vulnerable as individuals, or as a “full person” (Adamshick & August-Brady, 2012, p. 195)—was summarized well by a student in Townsend et al. (2015): “[y]ou are looking at people more as people than patients. You’re not looking at them as a medical problem. You’re looking at them as themselves” (p. 3). These varied factors affecting experiential learning, then—from the contexts in which experiences took place, to barriers and facilitators of learning, to firsthand learning, and finally to the beginning developed ability of “seeing the other”—all attested to how students’ “learning by doing” was in itself enough to engender rich learning. Theme Three: Reflexive Learning While experiential learning proved to be a robust avenue to learning, another distinct, and more understated, kind of learning also arose—that of “Reflexive Learning”, or “contextualizing learning through oneself.” Whether or not students were aware that they inscribed their own UPHOLDING SOCIAL JUSTICE IN NURSING 120 selves into much of their learning, it was evident that they did in fact learn with such a reflexive mindset, as the following subthemes revealed. Subtheme one: Seeing the self. Perhaps the most fundamental examples of reflexive learning arose within the first subtheme of “Seeing the Self”. Student and author comments often revealed learning of one’s worldview (Evanson & Zust, 2004; Caldwell & Purtzer, 2014; Levine, 2009; Reimer-Kirkham, Van Hofwegen, & Hoe Harwood, 2005; Walsh & DeJoseph, 2003). Specifically, Evanson and Zust (2004) remarked that students expanded their worldview “… based upon a new understanding of issues of social justice and a global society” (p. 10-11). One student in Walsh and DeJoseph’s (2003) work poignantly captured the sentiments of students in general in the following comment in which she reflected on changed worldview: It’s like when you close your eyes when you’re looking at the sun. Then you look away, and when you open your eyes, everything seems brighter. When I got home and looked around, everything was the same, only I saw it in a different light. (p. 271) Other students described gaining a better understanding of who they were as individuals. Indeed, students’ learning about themselves was incredibly broad and nuanced; comments ranged from one student’s in Maltby and Abrams (2009), who admitted, “‘[o]ne of the main things that I have learned here is how little I know’” (p. 10), to Levine’s (2009) assertion that students “also learned about their own specific culture, who they were, and what they brought to client interactions” (p. 159), and finally to Zanchetta, Schwind, et al.’s (2013) notation that students obtained “confirmation of their religious and philosophical values” (p. 761). Furthermore, certain comments revealed undertones of social justice, such as Levine’s (2009) statement that students came to see themselves “as persons of privilege” (166-167)—a notion shared by Amerson and Livingston (2014), who noted that students “…. acknowledged their own UPHOLDING SOCIAL JUSTICE IN NURSING 121 privileges in life” (p. 207)—and Zanchetta, Schwind, et al.’s (2013) observation of students’ becoming “knowledge experts on their own social situation” (p. 758). In addition to gaining a general understanding about themselves, students specifically came to see their biases and stereotypes. In most cases, students themselves acknowledged their biases, making remarks such as, “‘[t]his has been an amazing experience to be more introspective and reflective on how I perceive them and all the biases I’ve had’” (ReimerKirkham, Hoe Harwood, & Van Hofwegen, 2005, p. 266). Biases manifested in different ways; for instance, students were, at times, biased toward culture. For instance, in Walsh and DeJoseph (2003), students recognized that because they knew so little about the Guatemalan culture, they made false, ethnocentric assumptions about it; one student openly admitted: How do we help change [practice] and still fully respect their culture and beliefs? An example I found interesting today was that they suspected twins because the woman was having pains while working the previous day. The rationale threw me off, and I chuckled about it… I don’t understand the indigenous beliefs, and since they are far off from what we are taught in the U.S., I automatically thought it [their beliefs] were worse. (p. 270) Similarly, in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005), students realized that they, too, were biased—even if unwittingly—toward the Aboriginal culture. Once students had been able to watch the Native community work through the aftermath of colonizing practices such as residential schools, their opinions changed. As one student explained: “‘[g]rowing up in a nonnative neighborhood, you have assumptions. Unless you know the people, you don’t really understand their needs, or what the experience would be like to be native. This has been an amazing experience….’” (p. 5). UPHOLDING SOCIAL JUSTICE IN NURSING 122 Biases toward the structurally vulnerable were not, however, related to culture alone. Some biases occurred with respect to lifestyle, such as in Hunt (2007), where one student said: “[m]y assumptions about homeless people have changed now. I learned what these people have gone through and the challenges that they may always face. I have changed my attitude towards homeless people” (p. 279). Moreover, comments on lifestyle frequently evinced surprise at the living conditions of the structurally vulnerable; for example, in Boylston and O’Rourke (2013), students were surprised to see that the homeless looked the same as volunteers. Another student expressed: “‘I was shocked that an affluent community had a shelter and clinic. I did not think that they had homeless people’” (Boylston & O’Rourke, 2013, p. 315). Forming relationships with the homeless was, furthermore, key to recognizing bias. Indeed, spending one-on-one time connecting with the structurally vulnerable was recognized by Larson et al. (2010) as an important part of students’ becoming less biased toward Guatemalans who immigrated to the U.S. Biases about immigrants changed in other studies as well, such as in Smith-Miller et al. (2010), and in Knecht and Fischer (2015). Further, Levine (2009) referred to recognitions of biases as “transforming experiences” (p. 162), and illustrated this phenomenon poignantly with the following student quote: Stereotyping is so common by race, religion, or color and with preconceived ideas about behaviors and a certain way of life. Today, I go into a situation totally accepting the patient. I grew up in the American south, a very biased part of the United States, and when I returned from the immersion program, I really felt that I had made significant life changes. It was almost like a spiritual awakening about the reality of life and how people are. It was a great experience. You just look into the eyes and soul of your patient and UPHOLDING SOCIAL JUSTICE IN NURSING 123 communicate with them. We’re all people, and if we can just break the chain of bias and racism, it sure would be a better place. (p. 162) Thus, recognizing one’s own prejudices had, Levine (2009) averred, “… profound longterm transformative effects” (p. 162), as seen in another student’s comment that, “‘[w]hen we become aware of our limitations and stereotyping, we can do something to change them’” (Levine, 2009, p. 162). Clearly, then, learning to see the self proved to be an integral part of students’ reflexive learning. However, students’ learning progressed beyond awareness of self to the rich learning gained upon willingly reflecting on issues of social justice. Subtheme two: Willingly reflecting. Students also ventured to initiate reflection on situations they encountered in practice—that is, to willingly reflect. The subject matter of students’ reflection was diverse, revealing students’ own individuality. At times, reflection centered on the meaning of the experience for students, coupled with a desire to act. In Walsh and DeJoseph (2003), for instance, one student mused, “‘… I’ve been spending more time thinking about community, how much personal power we have, we have time and we have what we need. So now I need to do something’” (p. 271). Another student in Evanson and Zust (2004) expressed a desire to share the meaning of the experience with others: When people say, ‘Do you have pictures?’ I say, ‘Yeah, but I won’t show them unless you sit and listen to the stories that go with them.’ It takes about an hour to go through my photographs and I’ve shown them to many people. I think you have to find a way to hook them into listening to what these people’s lives are like, and what it was like to be living among them. It’s hard to find a way to give others a message that conveys what the experience meant for you personally. (p. 10) UPHOLDING SOCIAL JUSTICE IN NURSING 124 Similarly, in Evanson and Zust (2006), nurses sought opportunities to share the meaning of their experiences by displaying objects in their homes to serve as reminders, such as photographs of children and handmade materials. While willful reflection most often occurred in isolation, students did, at times, find it beneficial to reflect with others, such as in Evanson and Zust (2004) where “[students] found it important to talk with each other about their collective experience and its shared meaning” (p. 10). In Levine (2009), group discussion was valuable because it “… generated… intense discussion, and interpretation that in turn created a new appreciation of and new knowledge of life in its many variants” (p. 159). The profoundness of students’ reflection was evident in reflections that their experiences had changed them, as well as in moral questioning. With respect to the former, while students revealed their individuality in what they chose to reflect on, the experiences themselves first shaped them as individuals. To begin with, one student in Evanson and Zust (2004) spoke of how the experience was a part of him or herself: Sometimes I think that this stuff will bubble up 20 years from now in ways that I haven’t anticipated. I think that in time, the experiences will just keep coming up. You can’t take this experience away from you. It’s in you and it’s part of you. Who knows what will happen with it?" (p. 10) Another student in Clark Callister and Harmer Cox (2006) commented more explicitly on feeling changed: “[y]ou can’t have a profound life experience like I’ve had and not have it change you. It changed how I practice my profession. It changed my life” (p. 98). Along with these realizations that their experience had changed them, students voiced that, consequently, they would continue to reflect on their experiences throughout life—as in the previous comment UPHOLDING SOCIAL JUSTICE IN NURSING 125 that “[s]ometimes I think that this stuff will bubble up 20 years from now… You can’t take this experience away from you. It’s in you and it’s part of you” (Evanson & Zust, 2004, p. 10). Moral questioning, moreover, was explicit in the study by Reimer-Kirkham et al. (2009). Their questioning also extended to global, and personal, domains. With respect to the former, “[p]articipants raised soul-searching questions regarding profound historical and current realities of global power differentials” (p. 13), and with respect to the latter: “[s]tudents turned a critical lens inward examining their own positioning, motivations for being in the international setting, and the impact on their Guatemalan hosts” (p. 7). Finally, critical reflection was also evidenced by students in Levine’s (2009) study, who discussed such varied topics as “cultural differences, women’s roles… access to health care, and the overwhelming impact of poverty” (p. 159). As these examples revealed, students across many studies began to willfully reflect on issues of social justice. Indeed, in Afriyie Asenso et al. (2013), students began to reflect specifically on social justice as they learned to advocate. Likewise, in Zanchetta, Schwind et al. (2013), reflection potentiated self-confidence in taking action: “motivation to learn…. within an emancipating perspective allowed the student-interns to reconsider their knowledge, values, beliefs, experiences, and deeds and realize their enormous potential” (p. 762). Moreover, dissonance—as seen particularly in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005)—triggered much critical reflection. Indeed, dissonance arose prominently in students’ reflections, as the following subthemes reveal. Subtheme three: Unreadiness to act. Notably, students expressed unreadiness to act on the SDH. Such unreadiness was evident, at times, in students’ disconnecting from what they were witnessing—that is, students’ outlooks on their experiences frequently evinced a sense of disconnect and, therefore, of unreadiness to act. For example, in Jarrell et al. (2014), Just World UPHOLDING SOCIAL JUSTICE IN NURSING 126 Scores (JWS) for the control group, and for all students overall, slightly increased; if students generally felt more strongly that the world “is always just and fair” (p. 302) after the experience, it was also possible that they felt the structurally vulnerable deserve poverty. Comparatively, in Reimer-Kirkham et al. (2009), students allowed their worldviews “of…. coming from an advanced Western country to ‘help’ those in ‘underdeveloped’ Guatemala” (p. 10-11) to characterize their experiences—a view very similar to those of students in Afriyie Asenso et al. (2013) “that… Africans, are incapable of improving themselves and will always require help” (p. 7). Finally, in Cohen and Gregory (2009), students’ view toward non-traditional sites were negative in that not all students were able to “… readily see the value of non-traditional placements and they do not always appreciate the potential benefit of working with a non-nurse agency mentor. Instead, these placements are sometimes viewed as being ‘second rate’” (p. 9). In each of these examples, then, of potentially viewing conditions of poverty as just, viewing the structurally vulnerable as being reliant on them for help, and not valuing their non-traditional sites, students distanced themselves from becoming fully invested in—and from fully appreciating—the learning from their experiences. Furthermore, the lack of any mention of students’ attempts to contend with the emotion that often arose also demonstrated—if only indirectly—an attitude of disconnect. Levine (2009), for instance, explained that “[t]he atmosphere at times became charged, was palpable, and was fraught with grief and… feelings of powerlessness….” (p. 160), giving no indication of students’ attempts to make sense of these emotions (or, for that matter, of instructors’ recognition of and attempts to help students make sense of them). Jarrell et al. (2014) made a very similar observation, noting “[o]thers expressed that it was depressing to see how poor people struggle on a daily basis” (p. 303). In fact, as Maltby and Abrams (2009) disclosed, “[i]t was… too UPHOLDING SOCIAL JUSTICE IN NURSING 127 disturbing for some of the students, one of whom stated that ‘I learned to ignore the beggars; it was more relaxing that way’” (p. 9). As this student openly admitted, rather than work on processing and making sense of feeling disturbed, he or she instead chose to ignore this emotion. Additionally, in Adamshick and August-Brady (2012), a sense of guilt arose in one student’s words: “‘I feel bad and piggish for the culture I live in, having all that I have and not giving as much as I could…’” (p. 193). Furthermore, fear characterized many student accounts; Smit et al. (2012), for instance, found a score of 3.2/5 to the statement, “I had fears about traveling out of the country to participate in this course” (p. 22), and in Foronda and Belknap (2012), students were afraid for their safety, afraid of rainforest animals and insects, and afraid of touring hospitals. In all of these instances, then, the lack of attempt to cope with the emotion felt evidenced a disconnection from the experience, and, as such, an unreadiness to act. Moreover, Foronda and Belknap (2012) described how one student “… referred to the elderly being ‘herded’ to the showers” (p. 10), and went on to comment that: [t]his metaphor may have been an attempt to describe the drastic differences in showering routines, yet the language projects a disconnect from this human experience. An animal metaphor indicates seeing the elders as something other than as human beings similar to herself. (p. 10) Other students in Foronda and Belknap (2012) “disconnected” in a similar manner—for example, “[a]fter discussing a neonatal death from lack of resources, Kam responded, ‘I guess that’s just the way the cookie crumbles sometimes’” (p. 10). In choosing to disregard the inherent sadness of these situations of communal showering and neonatal death, these students therefore disconnected from what they were seeing. Similarly, certain students in Foronda and Belknap (2012) not only disregarded, but apparently attempted to reframe, such sadness in a UPHOLDING SOCIAL JUSTICE IN NURSING 128 positive light in adopting a “vacation mindset” (p. 11) by which they thought of their experiences—in the words of one student—as “fun” and “an adventure” (p. 11). Students’ unreadiness to act also became evident in their doubting of the extent of their influence. One student’s account in Evanson and Zust (2006) fittingly illustrated this doubt: “I had a problem with going on this service trip and feeling like when I came back that only I gained from it and not the people. I felt that I really just didn’t do anything for these people” (p. 416). Similarly, another student narrated: I don’t know how well we touched their lives. When I was working in the hospital and brushing the old guy’s rotten teeth... I think it did more to slow me down and open my eyes, which is kind of sad when you leave thinking, did we really even help? (Evanson & Zust, 2006, p. 416) For many students, doubting the extent of their influence became clear in expressions to the effect that they wished they would have done more for persons who were structurally vulnerable. In Curtin et al. (2013), students’ discouragement at feeling they had not done enough—and that they could not do more—became palpable. One student voiced his or her frustration in saying “‘[w]e all talked about how we were kind of hitting our breaking points” (Curtin et al., 2013, p. 553). Indeed, the story told by a student in Murray (2015) eloquently captured this sense of feeling the need to do more: I'll never forget that family that had five kids, the five orphans, and their grandmother's taking care of them and all the kids are complaining of a stomachache… I'm trying to ask all these questions to understand what's causing the stomach-ache, and I realize it's because they're hungry. They're asking me for food and the only thing I have is an apple. UPHOLDING SOCIAL JUSTICE IN NURSING 129 I mean, I gave them the apple, but I don't know what to do.... That was a hard, hard thing to deal with. (p. S69) In disconnecting from their experiences, and in doubting the extent of their influence, then, students demonstrated an unreadiness to act. In addition to such displays of unreadiness, students also struggled with questions of injustice, as the following subtheme reveals. Subtheme four: Struggling with understanding injustice. Among these varied indications of unreadiness, another, distinct struggle emerged in student accounts: namely, a struggle with understanding injustice. Here—as opposed to disconnecting from, and doubting the worth of, the experience—students moved toward more critical questioning of whether certain situations were, indeed, instances of injustice. To illustrate this, students in Afriyie Asenso et al. (2013) reflected on their roles, namely in thinking “‘critically about the global distribution of wealth, beginning with themselves, and their positions of relative privilege’” (p. 8). As well, one student in Evanson and Zust (2004) questioned his or her lifestyle: Does me having ten pairs of shoes indirectly contribute to others having none? ... I have to ask the question, ‘Is the lifestyle that I’m living, directly or indirectly affecting their lifestyle?’ Does the fact that coffee companies, in order to produce coffee at a high profit, keep the people of Guatemala in poverty and poor living conditions—does my lifestyle of drinking coffee everyday, does that directly affect other people? I think it’s very direct, and we saw that connection. So for me, it’s become pretty obvious how my lifestyle affects others and how my ignorance contributes to others’ poverty. (p. 7) These powerful words disclosed this student’s underlying struggle of trying to come to terms with the meaning of injustice—that is, with whether his or her lifestyle was, in itself, unjust. Likewise, another student remarked: UPHOLDING SOCIAL JUSTICE IN NURSING 130 I went down there and realized how my lifestyle affects other people. I remember the feeling coming back and going into the cafeteria and seeing everybody who had lived in their little bubble world all of their lives. I was so frustrated that they had no idea that there’s so many people that had no running water in their house, couldn’t drink the water, and had so little. We have so much and took it for granted. We are a very rich nation and don’t understand how rich we are. (Evanson & Zust, 2004, p. 7) Other students—in comparing their home health care system to that of their host country as discussed earlier—instead questioned whether their own health care system was unjust. As one student reflected: In the U.S., you have money, and if you have health insurance you can get into any care that you need. I think I question if that’s right. In the U.S., we put the emphasis on the individual instead of the greatest good for the greatest number... I look at just one person with all of that technology and equipment, and if that same energy and money could be applied, it could help a whole community in Guatemala. (Evanson & Zust, 2004, p. 7-8) This same student later remarked, “…but then I have to step back and say, ‘What if this were my mother and she would be withheld that care?’ I just don’t know” (Evanson & Zust, 2004, p. 7-8). Students in Smith-Miller et al. (2010) also questioned the comparatively higherquality care given in the U.S. Further, in Evanson and Zust (2006), one student pondered the high-quality care that infants and pregnant women received in the U.S., and went on to also question U.S. health care practices with respect to resources: I also think about how many times a day we empty the garbage at work. How much plastic do we use that never gets recycled? How much do people waste? The American dream. Somehow we got it in our head that we deserve all of this.… There’s a nurse that UPHOLDING SOCIAL JUSTICE IN NURSING 131 I work with that is in Haiti right now. She [brought down] boxes of things that weren’t used or expired things. And, I think about all the expired equipment that we brought.… And it’s like, why is it not good enough for us to use, but it’s good enough for them? Why is expired tubing and catheters good enough for them? Why do we think that people in our country deserve better? (p. 416) Whether in relation to lifestyle or health care system practices, guilt was often described as occurring alongside such internal struggles. As one student in Reimer-Kirkham et al. (2009), for instance, commented, “…I think about how it changed me when I came home… I felt uncomfortable buying things” (p. 8). In Caldwell and Purtzer (2014), for instance, students struggled “… with feelings of guilt. One student said, ‘... I… felt ashamed of some of my guilty pleasures’” (p. 580). Overall, reflexive learning as a whole—as seen in expressions of seeing the self, willingly reflecting, unreadiness to act, and struggling with understanding injustice—was summarized well by the comment of one student in Caldwell and Purtzer (2014)—namely: “‘[t]he way I perceive the world and myself within has changed. Since returning I have placed increased importance on self-reflection and evaluating the effect my actions may have on others’” (p. 580). Theme Four: Praxis Learning Ultimately, cognitive, experiential, and reflexive learning progressed toward the final, most action-oriented theme: “Praxis Learning”. Subtheme one: Moving towards seeing their potential influence. Several unanimous indications of students’ readiness to act emerged. Although notions of readiness—as opposed to decisive statements of readiness—these indications were nevertheless compelling. First, in contrast to comments previously discussed under “Reflexive Learning” evincing students’ UPHOLDING SOCIAL JUSTICE IN NURSING 132 feelings of “unreadiness” about their experiences and their potential influence, students embraced positive thinking. Such positive thinking was readily apparent in certain comments about the experience; as one student in Walsh and DeJoseph (2003) enthusiastically remarked, “I was looking forward to getting home, then I wished I was back there. Everyday I learned something new. It was the best experience I’ve ever had” (p. 271). In addition, Levine (2009) related how students learned “… recognition and acceptance of ‘differentness’” (p. 157). Zanchetta, Schwind, et al. (2013) expounded on this idea by stating, in the first place, that students gained “open-mindedness to others’ world perspectives, native knowledge, and life philosophies” (p. 762), and that this then “allowed the student-interns to become more understanding and socially responsive to marginalized populations” (p. 762). Townsend et al. (2015), moreover, described this acceptance of difference as the lack of judgement: “[s]tudents identified coming away from the clinical placement… making fewer judgements around community members and circumstances…” (p. 4). Yet often, a sense of positive thinking became palpable not only in the acceptance of difference, but in students’ ability to sympathize and empathize with the structurally vulnerable. With respect to the former, Levine (2009) commented that “[t]he students… learned…. compassion” (p. 157), a sentiment echoed by Murray (2015) in her observation that students “[d]eveloped more compassion and understanding for people” (p. S69). Also, Foronda and Belknap (2012) noted that “[s]ympathy carried across the narratives as participants expressed sadness for the Ecuadorians” (p. 7). With respect to the latter quality of empathy, then, Hunt (2007) offered: “… a sense of empathy developed in students as the needs or despair of another were encountered….” (p. 280). UPHOLDING SOCIAL JUSTICE IN NURSING 133 In Smith-Miller et al. (2010), gaining such perspective affected students quite strongly, eliciting within them “a new compassion for” (p. 23) the structurally vulnerable. As the scholars disclosed: Beholding this profound poverty has led some to a new compassion for… the families who appear to abandon their relatives in orphanages and long-term care facilities because of permanent disabilities, mental illness, or human immunodeficiency virus status. [One student stated:] ‘I can understand . . . how incredibly difficult it is for some families simply to survive, much less care for a completely dependent family member,’ as ‘[t]hese families simply do not have the resources to take care of family members’. (p. 23) In addition to such affirmations of positive thinking, another emotion arose prominently in the data—that of hope. Namely, in contrast to students’ doubting the extent of their influence as discussed in “Reflexive Learning”, comments revealed that students were hopeful in seeing the educational experience, and their role, as impactful. With respect to the former, Narsavage et al. (2002) portrayed the sense of feeling hopeful about the experience in general with their finding that: “[e]ighty-six percent of students described the service goal as providing a needed education and health service to the community” (p. 459). Another student in Zanchetta, Schwind, et al. (2013) said candidly: “I hadn’t thought all that much about the importance of international nursing movements … that they could actually make such a difference…” (p. 761). Further, hope about one’s individual role also became evident. One student in Clark Callister and Harmer Cox (2006) echoed the sense of hope in impacting the community described in Narsavage et al. (2002): “[t]here are traces of our footsteps in Jordan”, the student remarked, “and I am hopeful that positive prints are being left…” (p. 101). In this comment, hope was construed as more personal in the student’s language of “our footsteps” (p. 101; UPHOLDING SOCIAL JUSTICE IN NURSING 134 emphasis added), a notion confirmed by one student in Levine (2009) who said, “it makes you understand how you can become part of a community and make a difference too” (p. 160), where the potential for individual influence as a member of a community is highlighted. Notably, in Adamshick and August-Brady (2012), one student realized that even seemingly simple actions could be significant; she remarked, “[a]t that point I realized my nursing skills can be used in so many ways, I don't have to be handing out medication or cleaning a wound, I can help put a cement floor so the little girls are not living in mud and getting parasites” (p. 194). Truly, hope in personal ability was unmistakable in Zanchetta, Schwind, et al.’s (2013) statement that “they realized how much power they had” (p. 762). Indeed, several scholars shared students’ realizations that they, personally, specifically possessed the requisite abilities and skills necessary to address the SDH (Adamshick & August-Brady, 2012; Krumwiede et al., 2014; Reimer-Kirkham, Hoe Harwood, & Van Hofwegen, 2005; Smit et al., 2012). As one student in Krumwiede et al. (2014) related, “I think the most enjoyable part will be when the hospital takes into consideration the recommendations that we identified for the community and implements changes to better the community as a whole” (p. 364). Hence, as these collective examples revealed, hope arose among students not just in the realization that the experience as a whole had the potential to engender impact, but that by partaking in the experience, students themselves could engender impact. Along these lines, hope was a universal emotion in Reimer-Kirkham et al.’s (2009) study, and was, notably, applied to the future; as the authors related: “[s]tudents and faculty-researchers alike emphasized how valuable the project was in re-attuning them to their learning and offering ideas about how to translate this learning to different settings” (p. 9). In this study, then, it is clear that hope occurred not only with respect to impact in the community during the educational UPHOLDING SOCIAL JUSTICE IN NURSING 135 experience, but regarding potential future influence. Indeed, this notion of hope translated to the future was palpable in the words of one student in Adamshick and August-Brady’s (2012) study, who discussed his or her experience of transitioning back into the work environment following the educational experience in Honduras: I feel differently going to work. I dread it to some degree, but I'm also excited to be there, because I feel like I do make a change, I do make a difference, and so I feel renewed and refreshed in that because I felt it. It had been so long, and I felt it in Honduras. (p. 193) In Zanchetta, Schwind, et al. (2013), translation of hope to the future occurred in the context of furthering knowledge; as the authors explained, students realized “…. their enormous potential to participate in reshaping the vision and contribution of nursing knowledge to improve the health of global populations” (p. 762). Specifically, students “[r]ealized the value of their personal contribution to stimulate change in … knowledge exchange in their home country as well as in developing countries” (p. 758). Finally, students saw that they could contribute to knowledge by disclosing inequity: “[t]hey became aware of their capacity to promote change by revealing the dynamics of inequity…” (p. 763). Also, feeling grateful arose as an indication of students’ moving towards seeing their potential influence. This feeling of gratefulness was embodied in an account of appreciating one’s clothes, for example, when “… there are people who would be so gracious just to have clothes” (Evanson & Zust, 2006, p. 417). Similarly, students in Foronda and Belknap (2012) and in Smit et al. (2012) alike gained new appreciation for the resources and living conditions they had in the U.S. Also, students in Maltby and Abrams (2009) who “… saw, perhaps for the first time, that they had a great many advantages” (p. 8), proceeded to act on this realization; one UPHOLDING SOCIAL JUSTICE IN NURSING 136 student, for example, immediately donated several personal belongings upon arriving home. Indeed, in expressing their gratefulness students also often related how they intended to act on their gratefulness. As an example, one student in Curtin et al. (2014) reflected: … not enough Americans realize how great we have it… I know because of this day, this experience, I will not only be aware of how lucky I am for the care I receive, but will also be keen to make sure I give the best care I can, wherever I am. I will give all my clients the same care, compassion and support because that is what every human deserves. (p. 64) Likewise, one student in Kronk et al. (2015) resolved to be more resourceful, saying, [n]ow when I am in the hospital, I need to think before I use anything... do I realy [sic] need this disposable item? Will it be useful? I even think about not wasting things at home... You see how little they [Nicaraguans] have, and it makes you not want to waste anything. (p. S101) Furthermore, students moved towards seeing their potential influence when they linked action with their professional identity as nurses. In Clark Callister and Harmer Cox (2006), for instance, one student described reconnecting with, and recommitting to, nursing: “[w]hen I went [abroad]”, the student explained, “I felt I was able to fulfill my ideals that caused me to choose nursing as a career. I reflected on why I went into nursing. It created in me a long-term commitment to provide humanitarian service” (p. 100). In realizing that the actions taken during the educational experience fundamentally embodied actions the student initially associated with nursing when choosing it as a career, the student essentially linked these actions of addressing the SDH with his or her identity as a nurse. In turn, this fostered a desire to continue providing humanitarian aid. Indeed, reconnecting with why they went into nursing in the first place helped UPHOLDING SOCIAL JUSTICE IN NURSING 137 students in Adamshick and August-Brady (2012) in particular to understand the values intrinsic to nursing—which, in one participant’s words, were “the caring, the compassion, [and] the people” (p. 194). Moreover, actions taken during their experiences helped students understand their future professional nursing roles. In Evanson and Zust (2004), for instance, students’ experiences influenced their future vocational goals: in the words of one student, “[b]efore leaving for the trip, I wasn’t sure which area of nursing to pursue. Pediatrics? Cardiology? Med-surg? After being in Guatemala, I have found the area that I want to pursue is pediatrics” (p. 6). Another student in Knecht and Fischer (2015), also looking to the future, described how the lessons he or she learned would impact his or her future nursing care: “[m]y experiences there have caused me to reflect on my practice as a nurse. At times… I find myself thinking ‘… How can I better myself so that I am able to provide the care that these clients need?’” (p. 382). Indeed, students saw how the skills they had learned during their experiences could be translated directly into their future practice as nurses; for instance, Students reported that this experience helped them to sharpen their critical thinking skills. They used language such as ‘...thinking on our feet.’ Students were able to relate this back to the nursing process of assessment, planning, implementation, and evaluation. One student said, ‘One thing I noticed... at the start of nursing school was trying to put together the whole picture, and this trip definitely helped with that’. (Murray, 2015, p. S71) In addition to understanding how skills such as critical thinking could be translated to their future practice, students also understood how knowledge of more conceptual subjects— such as the SDH—could also translate. As Townsend et al. (2015) related, students commented UPHOLDING SOCIAL JUSTICE IN NURSING 138 “…. that they now understand how the social determinants of health relates and impacts on their nursing practice” (p. 4-5). Finally, for some students, such as those in Hunt (2007), their understanding of the role of the nurse grew, for instance, “beyond focusing on the individual to concern for the well-being of groups, communities, and populations” (p. 280). In this sense, students came to understand that their professional roles as nurses were broader than they had previously thought, and that they could therefore act as nurses in more ways than they had thought. Lastly, students moved towards seeing their potential influence when they engaged in interprofessional collaboration. For instance, in Evanson and Zust (2004), students worked with staff nurses at the mission hospital, a physician in remote villages, and with volunteer medical students. To compare, in Larson et al. (2010), students worked with a “lay midwife/partera” (p. 47) and a “natural healer/curandero” (p. 47). Collaboration did not, however, occur only with healthcare professionals. In Smit et al. (2012), for example, meeting with community leaders was key in deciding on future steps for the Yojoa International Medical Center (YIMC) hospital as well as on clinic activities. Finally, in addition to the professionals already mentioned, students in Zanchetta, Schwind, et al. (2013) had opportunities to collaborate with social workers, elementary school teachers, government representatives, dentists, and CHAs (community health agents). In Zanchetta, Taher, et al. (2013), benefits of interprofessional collaboration were readily evident in that “[s]tudents felt less like outsiders and more like valuable members of interdisciplinary teams” (p. 1031). In fact, one student remarked, “‘I'm working closely with the different interdisciplinary teams…and have been networking and they're approachable…very encouraging and empowering’” (Zanchetta, Taher, et al., 2013, p. 1031). UPHOLDING SOCIAL JUSTICE IN NURSING 139 Hence, students’ moving toward seeing their potential influence to act was captured by notions of positive thinking, feelings of hope and gratefulness, linking of action with professional identity, and interprofessional collaboration. More direct indications of readiness to act, however, became apparent in the ensuing subtheme. Subtheme two: Moving towards competence and confidence. Beyond notions of readiness, students more decidedly moved toward competence and confidence in acting on the SDH. Expressions of competence and confidence often occurred in tandem, with confidence usually following competence. However, competence in particular was especially emphasized in students’ realization that they were, in fact, sufficiently knowledgeable to act on the SDH. As one student in Van Hofwegen et al. (2005) related, We saw so many instances where you are the only person in that situation and you need to deal with crisis situations just with the experience you have…This has been the experience where all of a sudden I know I can do it…And I see this is totally possible, and can be done, and I can help the community. (p. 8) This student felt that he or she was competent; as a result, confidence also became evident in his or her words that “… all of a sudden I know I can do it” (Van Hofwegen et al., 2005, p. 8). In Narsavage et al. (2002), students’ learning of community resources available to them, of their community’s health care needs, and of the roles of other health care providers similarly engendered a feeling of competence. Likewise, in Knecht and Fischer (2015), “… students recognized the difference in roles between an acute care and community care provider. They developed an appreciation for the work of those who practice in the community setting and stated that their acute care work was informed by their community experience” (p. 381). In UPHOLDING SOCIAL JUSTICE IN NURSING 140 understanding the role of community care providers and themselves gaining community care experience, students came to feel more competent in their overall practice. Notions of competence and confidence also often arose with respect to students feeling able to perform hands-on skills. This was evident in Walsh and DeJoseph (2003), and in Narsavage et al. (2002), most students came to feel competent performing skills such as assessments and education with the structurally vulnerable. Similarly, in Reimer-Kirkham, Hoe Harwood, and Van Hofwegen (2005), one student in an international setting who expected to teach a small group of secondary school students ended up teaching an entire group of around 750; this empowered her immensely, such that she said: “[i]f I can do this, I can do anything” (p. 265). Having also provided health teaching, students in Zanchetta, Taher, et al. (2013) felt confident when they saw that “clients understood the health information they provided” (p. 1031), and when they received empowering feedback from supervisors and faculty. Further, in Smit et al. (2012), one FNP student described her experience of assessing over 500 individuals in four days as instilling confidence specifically because it made her “‘… rely on basic assessment to diagnose without x-rays and lab data’” (p. 24). Indeed, students’ excitement at their discovery that they were skilled to act was often palpable in their remarks across studies, such as “‘[i]t’s up to me!’” (Reimer-Kirkham, Hoe Harwood, & Van Hofwegen, 2005, p. 265), and “‘I’ve never been so surprised at my abilities and so proud of myself’” (Walsh & DeJoseph, 2003, p. 270). Moreover, students’ sense of competence—and increasingly, of confidence—became especially palpable in their feeling responsible to act. One student in Maltby and Abrams (2009) cogently summarized the sentiments of many with the assertion: “‘… after having lived and breathed in Bangladesh for 3 weeks, I am no longer able to look away. I feel compelled to help’” (p. 8). Along with a sense of responsibility, students developed a sense of leadership, UPHOLDING SOCIAL JUSTICE IN NURSING 141 through which their knowledge and skills were again operationalized. As Groh et al. (2011) found, for example, “[a]ll but one item on the self-perception of leadership skills …. showed a significant change in a positive direction after the SL experience” (p. 402). In keeping with the emphasis on action characteristic of this subtheme, the various actions students undertook in initiating interaction with the structurally vulnerable during, and after, their educational experiences clearly evidenced their moving toward confidence in particular in addressing health inequities. In Van Hofwegen et al. (2005), for example, students helped to develop a community health fair, helped implement a drug awareness program, and participated in influenza clinics—all activities involving direct interaction with the structurally vulnerable. Similarly, in Larson et al. (2010), students performed a myriad of actions that put them in direct contact with the structurally vulnerable; one noteworthy example was: Four to five students formed a group to work on a specific community service learning project identified by the host agency and the local communities. They created games and songs in Spanish and delivered the projects to school-age children in three rural Mayan communities. These projects targeted oral health, nutrition, and sanitation issues. (p. 46) In response to this experience, one student’s increased confidence in interacting with the structurally vulnerable became clear: We were able to teach the children how to brush their teeth and then we painted the walls of the school. The children were so excited to see us and it was so worthwhile. This type of thing is why I decided to come on this trip. (p. 48) Similarly, actions undertaken by students in Afriyie Asenso et al. (2013) when hosting a tea for women who had lost their husbands to AIDS—namely, providing tea, pedicures, and manicures—especially evidenced a sense of feeling comfortable in interacting with the UPHOLDING SOCIAL JUSTICE IN NURSING 142 structurally vulnerable. Indeed, GNP students in Narsavage et al. (2002) also appeared to feel comfortable in working with structurally vulnerable persons when they creatively developed “a game … [where] [q]uestions were asked, and when they answered correctly, residents were able to unwrap a gift” (p. 460). Furthermore, in Clark Callister and Harmer Cox (2006), one student evidenced feeling comfortable in her interaction with a structurally vulnerable woman when she was willing to be vulnerable in sharing the woman’s pain: I had one experience where a mother had ridden in a bus for 18 hours to bring her child to get care. Her child had so many birth defects and was so small. We weren’t able to help him. We cried together and [the mother] shared with me. I told her she had a beautiful, wonderful child that she’d kept hidden under a blanket so no one could see. What creates the bond is that you’re there to help, even though sometimes it is only by your presence. (p. 101) Likewise, a student in Evanson and Zust (2004) formed a relationship with a structurally vulnerable woman simply by taking the time to talk to her in broken Spanish, saying “we somehow had a conversation and we learned a great deal about each other and our families” (p. 8). Indeed, some students recognized that merely spending time with—that is listening to, and conversing with, individuals—was, in itself, an important action: Students listen to the stories of patients being turned away from care and it brings reality to social injustice. One student commented: ‘They need a friend and it is more of a peer relationship. They need someone to confide in… You need to fulfill that first level of need, the relationship, before you can move on to further issues of their health’. (Knecht & Fischer, 2015, p. 382) UPHOLDING SOCIAL JUSTICE IN NURSING 143 Perhaps an even more tangible indicator of confidence in particular was the spirit of advocacy that was apparent in certain students’ comments. As a student in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005) commented, [the experience] gave me a renewed passion to use my skills for relief work, or in areas where its [sic] really needed. Where people might not have enough money to get competent health care. It focused my vision and taught me a lot in the area of charity... (p. 6) Also, in Smit et al. (2012) where students advocated for the building of a local hospital, a score of 5/5 to a statement of building the community’s capacity to meet their own health needs, as well as of 4.8/5 to a statement of being an advocate of the proposed hospital, clearly revealed students’ readiness to address the SDH in their advocacy. This powerful notion of advocating for the structurally vulnerable was indeed clear in the language of countless other students. Interestingly, students in Evanson and Zust (2006) advocated for the structurally vulnerable indirectly through telling stories; for instance, participants shared “… stories about the Guatemalan people with other nurses” (p. 418) at home. Further, beginning notions of political advocacy were especially evident in Evanson and Zust (2006) and other studies, as in the comment of one student: I think it has added to my liberalness maybe. Like my humanitarian part of my beliefs and you know, politically being liberal…. I think it just added to my...wanting to be a humanitarian and do stuff with our tax money that’s going to help people. I just see it kind of fueling that flame. (p. 417) As another student in Hunt (2007) further emphasized: UPHOLDING SOCIAL JUSTICE IN NURSING 144 I need to educate myself more and get more politically involved. I have never been involved in politics. You always hear people say ‘You have a voice,’ but I never felt it more than I do now. If I have that voice and I don’t use it, nothing is going to get done. (p. 280) In Maltby and Abrams (2009), students felt a strong desire to advocate for Bangladeshis by donating money and supplies, and especially felt that the American and Bangladeshi governments should focus on doing the same. Students in Reimer-Kirkham et al. (2009) felt likewise and fundraised for the Guatemalan hospital. Finally, perhaps the most telling indicator of students’ competence, and confidence, in addressing the SDH was their continued effort to do so after their educational experience. In Clark Callister and Harmer Cox (2006), students engaged in very practical activities upon their arrival home; for example, “[f]ive study participants served faith-based missions in Central America or Spain” (p. 96); “[a]nother study participant works in a busy emergency department serving a large population of Hispanics” (p. 96); and “[t]hree have continued to actively participate in humanitarian health missions to Mexico and Guatemala” (p. 96). Smit et al. (2012), furthermore, found there was a score of 4.4/5 to the question, “[s]ince my return to the United States, I have applied the knowledge gained in Honduras in clinical situations” (p. 22), as well as a score of 4.2/5 to the statement, “I plan to return to Honduras to provide health care services at some time in the future” (p. 22). Evanson and Zust (2006), moreover, described how students tried to provide “culturally sensitive” (p. 418) care to patients at home by “trying to speak Spanish with immigrant patients in the hospital to make the patients feel welcome” (p. 418), taking time to explain procedures to immigrants and encouraging other nurses to do likewise. Also in Evanson and Zust (2006), nurses tried to write to families in Spanish and sent UPHOLDING SOCIAL JUSTICE IN NURSING 145 them pictures. A desire to “make a difference” was notably expressed by students in Caldwell and Purtzer (2014), some of whom moved to a structurally vulnerable country, and others of whom chose to build their knowledge by obtaining Masters’ degrees in public health as well as in advanced practice nursing. Thus, feeling knowledgeable, gaining hands-on skills, feeling responsible, initiating interaction with the structurally vulnerable, advocating, and continuing to act after the experience all characterized students’ moving towards competence and confidence. While both competence and confidence were evident in these examples, competence was perhaps more evident in feeling knowledgeable and gaining hands-on skills, whereas confidence more evident in feeling responsible, initiating interaction with the structurally vulnerable, advocating, and continuing to act. To illustrate the meaning within each of the themes and corresponding subthemes heretofore discussed, therefore, Table 4 displays particularly notable quotations: UPHOLDING SOCIAL JUSTICE IN NURSING 146 Table 4 Thematic Representation of the Value of Clinical Educational Experiences in Expanding Nursing Students’ Understanding of, and Perceived Ability to Address, the SDH Themes with Citations Theme 1: Cognitive Learning Illustrative Quotation Theme 1, Subtheme 1: Understanding that the SDH Exist [1, 2, 4–22, 24–33] “‘I went into the homes of the women, to see their situations—they were so poor. Dirt floors, rats running around. Going into their actual world, seeing what they have to work with. It is one thing to just spout it off and say you should have a crib [teaching infant care] but they don’t have these things…’” [13]. Theme 1, Subtheme 2: Understanding the Realities of the SDH [1, 2, 4, 5, 7, 8, 10–22, 24–26, 28–30, 32, 33] "We had an interesting case today. There was a lady who had a 4 year old, a 17 month old, and a 4-day-old infant… We were told that she [the mother] had a fever, and that’s all they [the community nurses] knew. Upon entrance to her house, we could tell she [the woman] as extremely poor, poorer than previous families. Her house was one room, with flies all over. She could barely sit up when we came [because] she was too tired and weak. We wanted her to go to the clinic for IV [intravenous] antibiotics, but she said she couldn’t because her husband works long days, and nobody would be there to take care of the kids… It’s pretty sobering to realize that without treatment, she [the woman] could have very well died, leaving three small kids and a husband who pushes a…cart in the streets from 7 a.m. to 7 p.m.’" [8]. Theme 1, Subtheme 3: Understanding through "When touring hospitals, all of the Comparisons [1, 4–6, 9, 10, 17, 21, 25, 26] participants made comparisons regarding the differences in health care practices. Participants were surprised to see many patients in one large room. Dawn stated, ‘They had fifty women in one room…the women were either all pregnant…or just given birth or who had miscarried…they just UPHOLDING SOCIAL JUSTICE IN NURSING 147 have them all in the same room. This is something here in the States we never would do. We would never put a woman who just lost her baby right next to someone who is celebrating the birth of her baby’" [26]. “The first 2-hr seminar was scheduled for 2 weeks post trip to give students a chance to acclimate to the United States and to reflect on their experience. Faculty facilitated the discussion to assist students in processing their emotions, evaluation, and reflection on the experience” [6]. Theme 1, Subtheme 4: Conceptual Understanding of the SDH [1–33] “Rural, parish, corrections, Aboriginal, and international sites…” [2]. Theme 2: Experiential Learning Theme 2, Subtheme 1: Contextual Learning [1–33] Participants did not "base their interpretations of the injustices they witnessed on global economic systems, but turned instead to the explanation that God was in some way in control" [4]. Theme 2, Subtheme 2: Barriers to Learning [2–6, 8–10, 12, 17, 18, 24, 25, 28, 30, 32, 33] Theme 2, Subtheme 3: Facilitators to Learning [2–17, 19, 21– 23, 27, 29–31, 33] "We find that the advisor at the clinical setting gives them [students] the context…. It’s the clinical nursing teacher that threads the nursing content through. “OK. What does this mean for practice? How is this a social determinant of health? What does this have to do with peace? How is this just or unjust and why and where does it come from? What now? How can consciousness raising help a client’s self-worth?” So we find that the clinical teachers are sort of “weavers” and the advisors give the fabric" [3]. Theme 2, Subtheme 4: Firsthand Learning [1, 2, 4–15, 17, 18, 20, 21, 23–27, 30–33] “It’s so real here. When we [sic] learning about HIV or TB in Canada, we are removed from it, so we don’t have the emotional aspect as much and don’t have all our senses engaged. It’s much more powerful here” [4]. UPHOLDING SOCIAL JUSTICE IN NURSING Theme 2, Subtheme 5: Seeing the Other [2, 4–20, 22, 24–27, 30, 31, 33] 148 “‘Looking at some of the older women, they just have this look of sadness in their eyes. It kind of makes me think what really has this woman gone through, how many children has she…how does she manage to get food on her table every night and things like that. And sometimes you come up to a face [in the U.S.] and you might see that same look of sadness, and it makes you think of what has this woman gone through instead of just having her as some kind of patient… Now I’m looking into the people, instead of just through them’” [7]. Theme 3: Reflexive Learning Theme 3, Subtheme 1: Seeing the Self [2, 4, 5, 7–10, 12–15, 17–22, 24–27, 29–32] “Transforming experiences also dealt with the issue of recognizing prejudice and its existence in both blatant and subtle forms. Participants discussed their realizations about themselves and others having preconceived notions about people. They discussed their own discriminatory beliefs and biased feelings that they did not realize they held. This enabled them to change. As Jasmine said, ‘When we become aware of our limitations and stereotyping, we can do something to change them’” [17]. Theme 3, Subtheme 2: Willingly Reflecting [1–8, 10–15, 17–19, 21, 24, 26, 27] "Once in a while everyone has [an] incredible experience. I had the opportunity to experience such a moment in Argentina while working at a public maternity hospital. I learned to go beyond what I had learned in nursing school, and discovered something that cannot be taught. Seemingly forgotten, theses [sic] babies in the “abandoned” section [of the nursery] will live in my memory forever. Three month old Ivan had hydrocephalus. He loved being held, as if he had been starved for human contact. As I held Ivan, I had plenty of time to think and reflect. I wondered what the future held for UPHOLDING SOCIAL JUSTICE IN NURSING 149 him. I watched as he lay complacently in my arms and wondered what kind of perfect spirit was inside his imperfect body. I loved that I had the opportunity to help ease his great pain, if only for a day. I know of no greater profession wherein lies the opportunity to help heal others, both physically and spiritually. My heart and mind go back to that place often. I want to learn the Healer’s Art, and my journey has just begun" [27]. Theme 3, Subtheme 3: Unreadiness to Act [1, 3–6, 8, 10, 12–15, 17–19, 22, 24, 26–29, 31, 32] "The most compelling example of emotional disconnect was provided by Erin in her description of photographing a dying man in the emergency room. ‘There was a man that was 24 or 25…he was not in very good condition at all…he was shaking... I diverted my attention to him and later we found out that his complete intestines were laying top of his abdomen…that was pretty interesting. Showing that picture to people back here, they were just ‘oh my gosh!’…That’s not something you see everyday…I’m glad I’m not in his shoes’" [26]. Theme 3, Subtheme 4: Struggling with Understanding Injustice [1, 4, 6, 7, 12–14, 17, 22, 24–26] "‘I went from being in Guyana to being on a cruise ship which I called the ‘Ship of Gluttony.’ I just came from a country where people are dying, people are in pain because they don’t have pain medication …they don’t do heart surgery. People are dying! I didn’t want to ease back in and forget. At the same time, this is my reality, my life. How can I incorporate these principles into how I live here?’ This narrative captures the disjuncture between this student’s two realities, the moral distress engendered, and her need to make sense of conflicting experiences to move forward with her life" [13]. Theme 4: Praxis Learning Theme 4, Subtheme 1: Moving Towards Seeing their Potential Influence [1–33] "As a nurse, I felt very small. I was only one person. What could I do to meet the crying needs of the suffering around the world? I think sometimes what is easily forgotten is the UPHOLDING SOCIAL JUSTICE IN NURSING 150 incomprehensible impact we can have on others. Someone eloquently said, ‘What you say and do will carry hope and give direction to people far beyond your natural abilities and your own understanding.’ I need to understand that the potential I have to lift others is far greater than I think" [27]. Theme 4, Subtheme 2: Moving Towards Competence and Confidence [2, 4–6, 8, 11, 16–20, 22, 25, 27–31, 33] "‘Our nation spends money on useless items and events where the money could be put towards feeding the millions of people who go days without eating food or drinking clean water. I think our government needs to reconsider our expenditures and put the money towards more important matters and towards other, less developed nations in need of assistance’" [24]. Note. The numbers in brackets coincide with the article record numbers, as presented in Table 1. Chapter 4 Summary Four themes arose following analysis of the rich, nuanced data set obtained from careful coding of 33 qualitative, quantitative, and mixed-methods studies to answer the research question, “How do NS come to understand, and perceive their ability to address, the SDH following an educational experience?” The first theme—Cognitive Learning—captured, in essence, students’ “learning about” the SDH. First and foremost, students gained understanding of the existence of the SDH. This understanding was not confined to their current experiences, but extended to a global scale. Students then evidenced a more involved understanding in coming to understand the realities of the SDH—that is, they came to see the extent and impact of, or toll exacted by, the SDH. In coming to see realities, students witnessed how the SDH impacted health as well as witnessed complexities involving the SDH, and expressed shock alongside their awareness of these realities. Interestingly, students also gained understanding by making comparisons; namely, they compared living conditions between their lives and those of UPHOLDING SOCIAL JUSTICE IN NURSING 151 the structurally vulnerable, and compared both benefits and disadvantages of the health care systems of their home and host countries. Finally, students’ conceptual understanding of the SDH was formed especially through their nursing curriculum, through reflective activities, through different theoretical lenses, and according to specific learning outcomes. Although students, in mentally processing witnessed truths about the SDH, had in so doing learned about them intellectually, they also learned by experiencing circumstances shaped by the SDH. The second theme—Experiential Learning—captured this “learning by doing” that occurred from such on-site, in-person exposure. To begin with, students’ learning was greatly influenced by the respective contexts shaping their experiences. Contexts included setting (that is, either local, national or international); type of experience as occurring in either the health or non-health sector; and length of the experience. It became readily evident, however, that barriers also defined students’ experiences. Many barriers to students’ learning were factors directly relating to the educational experience, such as unsupportive instructors, planning and preparatory work required beforehand, and a lack of time. Yet students’ own unpreparedness also served to stymie their learning; for example, students were unfamiliar with the structurally vulnerable population encountered, they lacked travel experience to underdeveloped countries, and they had also not previously thought about social justice issues or their potential role in addressing them. Nevertheless, facilitators to students’ learning also clearly arose and—like some of the barriers mentioned—were academic in nature. For instance, instructive preparation beforehand was an important facilitator, as was support received internally (from the host community) and externally (from instructors). Challenge—constituting such circumstances as locations requiring students to live on-site—was, notably, another facilitator. Moreover, firsthand learning arose as a particularly defining influencer of students’ Experiential Learning. UPHOLDING SOCIAL JUSTICE IN NURSING 152 Students’ accounts wholly attested that hands-on opportunities yielded far richer learning than that offered by traditional pedagogical methods—for instance, firsthand learning afforded students the opportunity to experience culture in context. Lastly, “learning by doing” allowed students to truly see the other—that is, to see the structurally vulnerable as different; as uniquely individual; as happy; as not that different from oneself; and finally, as resilient. Students’ learning was, furthermore, largely shaped by students’ inscription of their own unique selves into their experiences, as captured by the third theme of Reflexive Learning, or “contextualizing learning through oneself.” First, students came to see themselves much more clearly (including their biases and stereotypes), and they also willingly reflected on many issues related to the SDH (such as on the meaning of their experiences and how to share that meaning). Students’ accounts also, however, revealed that they felt unready to act, as seen in students’ disconnecting from their experiences (often emotionally), and in their doubting the extent of their influence. Particularly striking was students’ struggling with understanding injustice, which focused primarily on questions of lifestyle, and on questions surrounding their home health care system. As the fourth and final theme, Praxis Learning—“learning by emancipatory action”— pivotally demonstrated students’ movement towards integrating their learning into practice. Beginning indications of students’ readiness for praxis emerged in students’ moving toward seeing their potential influence, as evidenced through positive thinking, a sense of hope as well as of gratefulness, students’ linking action with their professional identity as nurses, and through students’ interprofessional collaboration. In comparison, more explicit indications of readiness for praxis were seen in students’ moving towards competence and confidence. Indeed, competence and confidence were apparent in varying degrees in students’ expressions of feeling UPHOLDING SOCIAL JUSTICE IN NURSING 153 knowledgeable, in their gaining of hands-on skills and initiating interaction with the structurally vulnerable, in a spirit of advocacy, and in their continual action after their experiences. While each of these four themes is distinct, the first three contribute to the final, fourth theme of Praxis Learning. As Figure 4 below shows, Cognitive, Experiential, and Reflexive learning individually intersected with Praxis Learning, so that each of these kinds of learning uniquely informed Praxis Learning. That is, the findings suggested that Praxis Learning—where students felt competent and confident to translate their learning into practice to address the SDH—did not occur apart from these other kinds of learning. Rather, for Praxis Learning to occur, nursing students had to first “learn about” the SDH (i.e., Cognitive Learning), “learn by doing” (i.e., Experiential Learning), and “contextualize learning through themselves” (i.e., Reflexive Learning). In achieving Cognitive, Experiential, and Reflexive learning, students were therefore poised for Praxis Learning. Also, as Figure 4 reveals, Praxis Learning is encompassed entirely within the first three themes, emphasizing that, in this study, Cognitive, Experiential, and Reflexive learning alone contributed entirely to Praxis Learning. Moreover, the numbered themes of Figure 4 also demonstrate a hierarchical progression toward praxis; that is, the findings also suggested that the first three themes contributed to the final theme of praxis learning progressively—that an understanding of the SDH (Cognitive Learning) was first gained; that this understanding was further shaped by students’ direct experiencing of the SDH (Experiential Learning); that students’ reflexivity then built critically upon this cognitive and experiential learning (Reflexive Learning); and finally, that students’ cognitive, experiential, and reflexive learning altogether culminated in their ultimate ability to take action, as reflected by Praxis Learning. UPHOLDING SOCIAL JUSTICE IN NURSING 154 However, these findings raise the question as to how students fully enacted praxis learning, as will be further discussed in Chapter 5. Chapter 5 will next present a discussion of these findings. 1. Cognitive Learning 4. 2. 3. Praxis Learning Experiential Reflexive Learning Learning Figure 4. Conceptualization of Students’ Learning about the SDH to Uphold the Social Justice Mandate UPHOLDING SOCIAL JUSTICE IN NURSING 155 Chapter 5: Discussion As the previous chapter revealed, students gained understanding of—and began to perceive themselves as capable of addressing—the SDH in “learning about” the SDH (Cognitive Learning), “learning by doing” (Experiential Learning), “contextualizing learning through oneself” (Reflexive Learning), and “learning by emancipatory acting” (Praxis Learning). As a whole, then, these findings support the value of educational experiences in helping nursing students (NS) to uphold their social justice mandate. Careful consideration of these findings, however, revealed three overriding, noteworthy concepts: (1) a chronological progression toward praxis—that is, toward upholding social justice—in the chosen studies (both in how social justice was taught and learned); (2) close and significant alignment with major theoretical principles in the literature, most notably Transformational Learning Theory (TLT) as initially described by Mezirow (1991) and further refined in Mezirow (2009); and (3) potential barriers to transformative learning. Throughout discussion of these main concept areas, the findings of Cognitive, Experiential, Reflexive, and Praxis learning will be critically examined. In so doing, these findings will be re-contextualized such that their meaning may be extended and their applicability for nursing education made transparent. Recalling Social Justice: Meaning and Expression in Synthesized Studies As introduced in the Chapter 1, social justice is: The fair distribution of society’s benefits, responsibilities and their consequences. It focuses on the relative position of one social group in relationship to others in society as well as on the root causes of disparities and what can be done to eliminate them. (CNA, 2010, p. 10) UPHOLDING SOCIAL JUSTICE IN NURSING 156 Health equity, then, fundamentally reflects social justice because to achieve equity, health disparities must be addressed, which are themselves unjust since—to re-present the definition provided in Chapter 1—“they put an already economically/socially disadvantaged group at further disadvantage with respect to their health. [Thus, health disparities] … are particularly unjust because health is needed to overcome economic/social disadvantage” (Braveman, 2014, p. 367). In essence, then, achieving equity in health means achieving social justice; as such, due to the interrelated nature of these concepts, use of the term “social justice” will henceforth imply the achievement of health equity. In consideration of these principles, NS’ upholding of their social justice mandate may be understood as their seeking to achieve health equity. Further, NS achieve health equity when addressing the SDH—“the conditions in which people are born, grow, live, work and age” (CSDH, 2008, p. 1). Moreover, the 33 studies synthesized and thematically analyzed in this work did not, as a whole, express the encompassing view of social justice and equity—neither in how social justice was taught or learned. Prior to 2009, concepts such as SL and transculturalist nursing care were heavily emphasized; in particular, a focus on culturalist thinking persisted among the synthesized studies (Clark Callister & Harmer Cox, 2006; Evanson & Zust, 2006; Hunt, 2007; Walsh & DeJoseph, 2003). These findings are substantiated by other research at the time, as well as by current research, where scholars still focus on such concepts as cultural competence and cultural sensitivity, such as in the study by Ulvund and Mordal (2017), who sought to understand how a clinical placement in Ethiopia impacted Norwegian nursing students’ “development of cultural competency” (p. 96). Yet, as Valderama-Wallace (2017) notes, this emphasis on culture “… deters the collective nursing gaze from the role of systems and social structures” (p. 366), with UPHOLDING SOCIAL JUSTICE IN NURSING 157 the result of “… distracting from differences created by injustice” (p. 368)—thereby perpetuating health inequities. As Subtheme Four under Theme One—Conceptual Understanding of the SDH— explicitly revealed, educators did not appear to explicitly incorporate social justice principles in nursing curricula until the latter 2000’s. At this time, there appeared to be a notable increase in the mention of social justice, notably in the studies by Reimer-Kirkham et al. (2009), and Cohen and Gregory (2009). Reviewing the literature for past and current research confirms this finding. Further, increasing attention on social justice coincided with Canadian publications such as CNA’s release of various documents, including position statements, highlighting social justice around the year 2009 (CNA, 2008; CNA, 2009a; CNA, 2009b; CNA, 2010), in addition to the writings of several scholars emphasizing the importance of nursing’s uptake of social justice from various perspectives (e.g., Boutain [2008] on educating undergraduate students for social justice). Owing to the distinct benefits noted by students and educators in the findings of this study of incorporating a focus on social justice in nursing curricula—as is currently espoused in the literature, such as by Thurman and Pfitzinger-Lippe (2017) and the CNA (2017a)—a move toward social justice in nursing education should be an essential part of nursing education in our globalized world (as will be explored more thoroughly in Chapter 6). The next section describes how the findings of this study compared with Transformational Learning Theory (TLT) (Mezirow, 2009). Transformational Learning Theory According to Mezirow (2009), a prolific and respected writer on TLT, TLT aims to describe how adults learn and is meant to primarily engage adult educators in this process. In Mezirow and Associates’ 1990 book, the authors outlined how transformational learning can be UPHOLDING SOCIAL JUSTICE IN NURSING 158 fostered in such contexts as the workplace, classroom, and informal group discussions. This book serves as a resource to educators and other professionals to guide program development. Transformational learning, along with its application in such practice-based settings, was then further developed in ensuing editions by Mezirow (1991), Mezirow and Associates (2000), and finally in Mezirow, Taylor, and Associates’ (2009) work. Mezirow and his associates describe ten phases that adult learners go through which shape their attitudes and worldviews. These ten phases are: (1) The occurrence of a disorientating dilemma; (2) Self-examination accompanied by feelings of shame or guilt, at times turning to religion for support; (3) Critically assessing cultural, professional, or personal assumptions; (4) Recognizing that the processes of discontentment and transformation may be shared, and acknowledging that others have handled similar changes; (5) Searching for, and committing to, new behaviors, relationships, and roles; (6) Planning a strategy to take action on commitment; (7) Gaining skills and knowledge for implementing strategies for action; (8) Trying and evaluating new behaviours and roles; (9) Developing personal confidence and skill in new relationships and roles; and (10) Integrating behavioural change[s] into one’s life according to the new perspectives (Morris & Faulk, 2012, p. 5). In essence, Mezirow stated that an adult will experience what he labels as “disorienting dilemmas”, a phenomenon where one experiences initial disorientation which then leads to an endpoint of reintegration forming a new perspective, until the process repeats. Following many years of using TLT to plan lessons for baccalaureate nursing students, Morris and Faulk (2012) adapted Mezirow’s (1991) model to a “professional role transformation model” (p. 10), with the most recent model released in 2010. This “transformative thinking model” (p. 11) is therefore uniquely applicable to nursing, and in particular to nurse educators, as UPHOLDING SOCIAL JUSTICE IN NURSING 159 it specifically relates “… how planned transformative learning approaches could be used in nursing curricula to promote learner lifelong transformation for professional role identity” (p. 11). Similar to Mezirow (1991), the transformative thinking model (TTM) illustrates the process an adult undergoes in experiencing transformational learning. Accordingly, the first component of the TTM is labeled “adult learner” (p. 11). The second component, “points of view” (p. 11), represents the “habits of mind and frames of reference” (p. 11) that adults bring with them. Perspective transformation is then triggered when adults are exposed to “planned triggering events” (p. 11)—such as occurs during “learning activities/opportunities” (p. 11)—or “happenstance triggering events” (p. 11)—represented by the third component of the model. Such exposure leads to “disorienting dilemmas” (p. 11), the fourth component, which triggers “[c]ritical reflection/self-reflection” (p. 11) and “[c]ritical dialogue” (p. 11), both of which involve the questioning of “assumptions, values, beliefs, [and] points of view” (p. 11); altogether, reflection and dialogue constitute the fifth component. This critical engagement leads to the penultimate, sixth component of “[e]mancipatory [l]earning” (p. 11), characterized by the “[f]reedom to assume professional and personal values and roles” (p. 11), and also by the making of choices to “integrate new thoughts or release or revise prior points of view” (p. 12). Emancipatory learning then culminates in the seventh and final component of “[t]ransformative [t]hinking” (p. 11) characterized by “[c]ommitment reflected in decisions/behaviors” (p. 11). From the perspective of nursing education, this model is particularly salient because of its encouragement to “… plan learning activities or seize situations that cause critical reflection and/or dialogue” (Morris & Faulk, 2012, p. 12; emphasis added). Also, following transformative thinking, the cycle may repeat, such that “motivation for continual reflection and lifelong learning” (Morris & Faulk, 2012, p. 12) may be fostered in students. Finally, as Morris UPHOLDING SOCIAL JUSTICE IN NURSING 160 and Faulk (2012) recognize that the model may be used for purposes “broader” (p. 11) than for promoting professional role identity, use of the model to contextualize this study’s results suggests that emancipatory learning may occur with respect to students’ acting on the SDH (for instance, as students choose to value social justice and see their role as promoters of it). This commitment is then evident (as part of transformative thinking), in students’ behaviour of acting to address the SDH. Hence, nursing educators may use the TTM as a framework when developing curricula and planning practice experiences to assist nursing students to undergo a transformation in feeling more competent and confident to address the SDH. To illustrate how cognitive, experiential, reflexive, and praxis learning may be key elements of such an ultimate transformation—and therefore potentially key factors to consider in the development of curricula and practice experiences—Figure 5 demonstrates how the thematic findings of this study progressed linearly in line with components of the TTM: UPHOLDING SOCIAL JUSTICE IN NURSING Transformative Thinking 161 Study Findings Model Theme 1: Cognitive Learning Theme 2: Experiential Learning Theme 3: Reflexive Learning Theme 3: Reflexive Learning Theme 4: Praxis Learning Theme 4: Praxis Learning Figure 5. Alignment of study findings with Morris and Faulk’s (2012) transformative thinking model (p. 11). Comparison with transformative thinking model. Theme One, Cognitive Learning, aligned with the first stage of “Points of view” (Morris & Faulk, 2012, p. 11)—which in turn aligned with Mezirow’s “frames of reference”. In this study, students’ cognitive learning— whether in relation to a more outward understanding of the mere existence of the SDH, or a deeper understanding of the realities of the SDH (both of which occurred at times in the context of comparisons)—signified that the points of view they previously held in relation to the SDH UPHOLDING SOCIAL JUSTICE IN NURSING 162 were significantly altered. At times, this became evident through subtleties of language, such as Maltby and Abrams’ (2009) mention that students were confronted with “‘difference’” (p. 6), suggesting that their points of view did not previously accommodate the state of poverty currently before them. At other times, students’ points of view were more readily apparent; for example, comments of students’ realization of the occurrence of SDH on a global scale revealed that students had not realized how widespread the SDH were, or how far-reaching their consequences. Reimer-Kirkham et al. (2009) also saw “social consciousness”; that is, “… new ways of viewing the world, [were] often characterized by heightened social consciousness” (p. 5), based on the work of Giddings (2005). However, students’ points of view were seen perhaps most explicitly in expressions of shock at the living conditions of the structurally vulnerable, and at the impact such conditions had on their health. Statements such as “It truly is unbelievable” (Maltby & Abrams, 2009, p. 6), “I found it difficult to even comprehend the lack of resources…” (Curtin et al., 2014, p. 63), and “… factors I had not considered before” (Knecht & Fischer, 2015, p. 381) throughout students’ accounts strongly demonstrated changed points of view (and, correspondingly, the experience of a disorienting dilemma). Because encountering the “unexpected” (Morris & Faulk, 2012, p. 4) material depravity characterizing the lives of the structurally vulnerable—which, in many cases, was quite severe—led students to make such statements, this suggests that students had not previously gained sufficient knowledge of these realities, so that, consequently, their points of view were greatly expanded to accommodate this newfound awareness. Moreover, making comparisons seemed to especially expose students’ points of view; one notable example was students’ realization that health care systems of their host countries were not, in every case, of lesser quality, and that some of their practices were in fact novel and beneficial. The degree to UPHOLDING SOCIAL JUSTICE IN NURSING 163 which students were able to glean these insights related to the extent to which the SDH were framed in a critical way (Andreotti, 2006), however, was questionable—such that the underlying structures of race, White privilege, colonial histories, globalization, neoliberalism, and market economies, which are directly linked to the lived realities of the impact of the SDH, were not (as will be discussed later) entirely acknowledged. Finally, students’ points of view appeared to change suddenly, as opposed to over time (Morris & Faulk, 2012). Moreover, students’ academic preparation considerably shaped their points of view. Indeed, the cognitive knowledge they gained through their curricular and on-site education often prompted students to think about SDH, thereby preparing them for their experiences. Morris and Faulk (2012) acknowledge the role of education to this end; they write, “[a] learning activity… can stimulate learners to question prior habits of mind and points of view, leading to the assumptions that may be driving their view of the self and the world” (p. 7). Notably, curricular inclusion of social justice—as opposed to other concepts such as transcultural nursing theory or SL—was spoken of explicitly as having helped students to address social justice issues. As opposed to the “happenstance triggering events” (Morris & Faulk, 2012, p. 11) that occurred with students’ in-the-moment, on-site exposure to the social conditions witnessed, this academic preparation resembled “[e]xposure to… planned triggering events (learning activities/opportunities)” (Morris & Faulk, 2012, p. 11) that served to challenge students’ points of view. Just as the theme of Cognitive Learning aligned well with the second component of the TTM, the ensuing theme of Experiential Learning aligned particularly well with the third component of exposure to “planned triggering events” (Morris & Faulk, 2012, p. 11)—which may occur during “learning activities/opportunities” (Morris & Faulk, 2012, p. 11)—or UPHOLDING SOCIAL JUSTICE IN NURSING 164 “happenstance triggering events” (Morris & Faulk, 2012, p. 11) (see Figure 5). Stated differently, the exposure to events corresponded with students’ experiencing. Before expressly considering the “events” that triggered learning, the contexts encompassing these events are essential to consider. In this study, students’ contextual learning was shaped by whether they occurred in local, national, or international settings, the type of experience (health or non-health sector), and, in some cases, the length of the experience. While each of these factors uniquely influenced learning, international settings in particular appeared to offer a variety of learning opportunities, such as the ability to visit a traveling health unit, AIDS clinic, and mission hospital in Afriyie Asenso et al. (2013). As students’ experiential learning occurred mostly in the context of experiences directly associated with their learning, planned triggering events usually prompted this learning. Barriers, moreover, often hampered these planned educational events. Often, factors more directly related to the educational experience such as the work required to prepare for international experiences, a lack of time, or inadequate instructor support served as barriers that significantly impacted students’ experiences of the triggering events necessary to prompt transformational learning. For instance, a lack of time notably precluded students’ critical reflection on their experiences. On the other hand, facilitators enhanced students’ experiences of these triggering events; academic-related facilitators such as preparing students beforehand, and supporting students as instructors, appeared to greatly assist students in being able to make the most of the experiences that eventually led to their transformational learning. Interestingly, challenge arose, in addition to these, as a rather unexpected, unique facilitator; indeed, challenging events were in themselves a kind of triggering event. Whether planned—such as the need to work in an unfamiliar setting, in an unfamiliar language—or unplanned—such as having UPHOLDING SOCIAL JUSTICE IN NURSING 165 to problem solve and manage conflict—challenge allowed students to practice collaboration, leadership, professionalism, and creativity, among other unforeseen benefits. While contexts, barriers and facilitators were indeed important elements defining students’ experiential learning—and, correspondingly, the triggering events resulting in their eventual transformation—these elements mostly defined such events, rather than constituting triggering events themselves. In comparison, two additional elements—firsthand learning and seeing the other—were, notably, directly triggering events. Firsthand learning arose as a strong promoter of students’ ability to put into real context events and scenes they had not previously seen, and many firsthand opportunities arose as a result of happenstance triggering events. While these happenstance events occurred throughout the data, their occurrence in the context of firsthand learning was telling; for instance, unplanned opportunities for problem-solving—that arguably could have only arisen on-site and in-the-moment—allowed NP students in Smit et al. (2012) to think critically about medication prescriptions and patient care. Also, firsthand learning, in affording students hands-on interaction with the structurally vulnerable, uniquely provided students with a more direct avenue to their eventual praxis learning—such as with the student in Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005) who commented that experiencing culture in context was, in fact, a form of practicing nursing. While the benefits of firsthand learning were, as this study has revealed, numerous, Langham and Schutt (2012) notably observe that “[d]eliberate staging of service learning opportunities in areas that expose students to unfamiliar populations or diverse cultures allows for a disorienting dilemma” (p. 122). As such, firsthand learning may have provided a direct means of progression to the next stage of the TTM: disorienting dilemmas. UPHOLDING SOCIAL JUSTICE IN NURSING 166 In lieu of considering this next component of the model, the phenomenon of seeing the other first warrants special consideration. In short, the ability to “[look] into the people, instead of just through them” (Evanson & Zust, 2004, p. 9)—that is, learning to look at the structurally vulnerable holistically in considering all of their needs during educational experiences— prompted considerable reflection. For instance, students reflected on the conditions convening to elicit the material need of the structurally vulnerable, and they also reflected that structurally vulnerable persons were not very different from themselves, and that, as a result, a sense of connection had even arisen between them. Such early reflections in the data, then, provide a segue to the consideration of disorienting dilemmas—the fourth component of the TTM—and their correspondence with the theme of Reflexive Learning. Indeed, it is perhaps best to first make explicit that, at times, certain points of “overlap” occurred between the themes of this study and the components of the TTM. For instance, as with the example just given where students reflected while seeing the other—that is, they reflected during their experiential learning so that overlap occurred between Themes Two and Three—some overlap also occurred in other cases. For instance, students’ experience of the dissonance, or disorienting dilemma, of feeling that they themselves were “other” enhanced their ability to see the other. Disorienting dilemmas, however, were, by and large, more prominent among students’ overall reflexive learning. In particular, disorienting dilemmas were tangibly evident in students’ emotionally disconnecting from their experiences. Upon witnessing the grave conditions of depravity characterizing the lives of the structurally vulnerable—that is, upon experiencing a disorienting dilemma—some students felt powerful emotions such as grief, powerlessness, guilt, and fear, and did not contend with them. Other signs of disconnection upon witnessing the struggles of UPHOLDING SOCIAL JUSTICE IN NURSING 167 the structurally vulnerable included ignoring the sadness of the situation before them, and even attempting to reframe it in a positive light. Such disconnection is not, as Mezirow and Associates (1990) offer, entirely unexpected: “[w]hen experience is too strange or threatening to the way we think or learn”, they write, “we tend to block it out or resort to psychological defense mechanisms to provide a more compatible interpretation” (p. 4). Such “blocking” was seen in the student in Maltby and Abrams (2009) who was so disturbed that she chose to “ignore the beggars” (p. 9), and such “psychological defense mechanisms” (p. 4) perhaps seen in the reframing of experiences as positive, for instance in adopting a “vacation mindset” (Foronda & Belknap, 2012, p. 11). Finally, students experienced disorienting dilemmas particularly strongly upon realizing that they had witnessed potential injustice and in then struggling with understanding that injustice. In addition, the fifth component of the TTM—“[c]ritical reflection/self-reflection” (p. 11) and “[c]ritical dialogue” (p. 11)—also aligned well with reflexive learning. As Taylor (2009) notes, critical reflection is often triggered by a recognition of conflicting feelings, thoughts, and actions. This was observed in this study, as critical reflection often immediately followed feelings of dissonance—that is, disorienting dilemmas that challenged students’ frames of reference. In other words, through critical reflection, students critically engaged with, and attempted to make meaning of (Mezirow & Associates, 1990), the struggles they encountered as a result of experiencing dilemmas and changed frames of reference while learning to address the SDH (such struggles were notably seen in expressions of doubting the extent of their influence in feeling unready to act, and in their struggling with understanding injustice). Through such gradual advancement from disorienting dilemma/changed frame of reference, to critical reflection of, for example, situations that constituted injustice, students directly followed a UPHOLDING SOCIAL JUSTICE IN NURSING 168 progression to praxis. Other research confirms the value of critical reflection to students’ transformation. Bass, Fenwick, and Sidebotham (2017), for instance, found that the “Model of Holistic Reflection” (p. 227)—based, in part, on TLT—that they implemented in their Australian Bachelor of Midwifery Program supported the reflexivity necessary “… to facilitate transformative learning” (p. 227), and was therefore effective as an educational tool. Moreover, critical reflection—“[t]he process an individual uses to learn”, and that “[i]nvolves pondering new concepts” (Faulk & Morris, 2012, p. 17), became especially evident as students willingly reflected on matters directly related to their educational experiences. Namely, in this study, it was found that students reflected on such ideas as the meaning of their experiences, how they felt changed by their experiences, and moral questioning on various levels. The asking of moral questions in particular—for instance, in regard to their motivations and the impact of their participation on their hosts in Reimer-Kirkham et al. (2009)—evidenced this deeper, critical engagement with their experiences. Critical self-reflection—or “[t]he process of questioning personal values, beliefs, and assumptions” (Faulk & Morris, 2012, p. 17)—was, moreover, also particularly evident in students’ seeing the self. Of note, students admitted, more than once, their astonishment at realizing how biased they were; questioning their biases and stereotypes indeed led several students to comment on how this had incited them to think differently, with Levine (2009) even commenting that recognitions of biases were “transforming experiences” (p. 162). Moreover, critical dialogue—defined as “[t]he process whereby an individual considers new concepts, how this concept fits within the personal point of view, and what revisions to personal assumptions, beliefs, or values may be indicated compared to the other points of view” (Faulk & Morris, 2012, p. 17)—also occurred. In this study, researchers often noted that students found it helpful to reflect alongside each other, with group UPHOLDING SOCIAL JUSTICE IN NURSING 169 discussions frequently being mentioned as helping students to gain new perspectives. Indeed, Morris and Faulk (2012), recognizing the value of critical reflection and dialogue as, stated elsewhere by them, “[c]ore transformative learning approaches” (Faulk & Morris, 2012, p. 17), emphasize the promotion of critical reflection and dialogue when planning educational activities. Finally, the theme of Praxis Learning found in this study aligned well with “[e]mancipatory [l]earning (Morris & Faulk, 2012, p. 11), the sixth component of the TTM (see Figure 5). In the authors’ words, emancipatory learning means, in essence, the “[f]reedom to assume professional and personal values and roles” (Morris & Faulk, 2012, p. 11), emphasizing that autonomous decisions are made. More specifically, emancipatory learning entails commitment to new ways of thinking (which are, as the subsequent component of the TTM reveals, then acted upon) (Morris & Faulk, 2012). In autonomously choosing, or committing to, values/new ways of thinking, the individual essentially chooses whether “… the content will become a part of his or her character” (Morris & Faulk, 2012, p. 7). Such decision and commitment became particularly palpable in the subtheme of moving towards seeing their potential influence. In this subtheme, beginning indications of students’ readiness to act on the SDH were evident through their positive thinking, feelings of hope and gratefulness, linking of action with their professional identity as nurses, and engagement in interprofessional collaboration. In deciding to think positively about their experiences, students directly reflected the autonomous choosing of, and commitment to, new ways of thinking about the SDH and their experiences, as well as the structurally vulnerable. This was also seen in feelings of hope and gratefulness. If the choosing of, and commitment to, new ways of thinking about their experiences is also thought of as the valuing of their potential ability to act on the SDH, then, in the linking of action with their professional identity as nurses, students had more clearly adopted UPHOLDING SOCIAL JUSTICE IN NURSING 170 this as a professional value, seeing their ability to act on the SDH as part of their nursing role (Morris & Faulk, 2012). Likewise, the choosing of, and commitment to, new ways of thinking was operationalized as a professional value in students’ engagement in interprofessional collaboration. Praxis Learning, however, also aligned well with the seventh component of the TTM— namely, that of “[t]ransformative [t]hinking” (Morris & Faulk, 2012, p. 11). Transformative thinking more strongly reflects commitment as it occurs in “decisions/behaviors” (Morris & Faulk, 2012, p. 11). As opposed to emancipatory learning, the focus of this final stage of the model is on action; that is, “… commitment to the new ways of thinking is reflected in behaviors” (Morris & Faulk, 2012, p. 12). As such, the subtheme of moving towards competence and confidence—which itself emphasized action—in particular, evinced transformative thinking. Specifically, students’ feeling competent with hands-on skills, their feeling responsible to act, and the various actions that students undertook themselves in initiating interaction with the structurally vulnerable, as well as an overarching spirit of advocacy and students’ continued efforts to address the SDH after their educational experience, all demonstrated how students’ commitment to new ways of thinking about the SDH translated into action. In particular, because initiating interaction with the structurally vulnerable, as a behaviour, resulted from students’ own decision-making, this especially reflected their transformative thinking (this direct decision-behaviour correlation likely also applied to students’ advocacy, and continued efforts to address the SDH). In context of thematic conceptualization. Thus, having considered how each of the thematic findings of this study aligned with the different components of the TTM—revealing, quite compellingly, that students in this study were indeed transformed in coming to feel more UPHOLDING SOCIAL JUSTICE IN NURSING 171 competent, and confident, in addressing the SDH—it is also important to note a further intricacy of this thematic/TTM association. While each theme largely corresponded to a single component of the model, there were—as has been briefly mentioned—certain points of overlap between individual themes and different model components. Moreover, there were also points of overlap between individual subthemes. While it is beyond the scope of this discussion to taken into consideration every one of these points of overlap, particularly salient points of overlap will be discussed in order to illustrate the intricate complexity of the transformative process. In addition to examples already discussed (such as with students reflecting while seeing the other such that there was overlap between Themes Two and Three, or “[e]xposure to… planned triggering events” and “critical reflection” [Morris & Faulk, 2012, p. 11] of the model), other examples are worth noting. For example, Themes One (Cognitive Learning) and Two (Experiential Learning) overlapped when students realized that actions they had not previously thought of as nursing could, in fact, constitute nursing (as when students realized that experiencing a new culture by participating in a bark stripping ceremony was nursing in ReimerKirkham, Van Hofwegen, and Hoe Harwood [2005]). This overlap, in consideration of corresponding TTM components, occurred between “[p]oints of view” (Morris & Faulk, 2012, p. 11) and “[e]xposure to… planned triggering events” (Morris & Faulk, 2012, p. 11). Such overlap also occurred prominently when students’ points of view were altered, as a result of having been exposed to the planned and happenstance triggering events of their experiences, in coming to see the other. Indeed, overlap occurred quite frequently with respect to points of view, as well as with respect to disorienting dilemmas. For instance, students’ experiencing of the dissonance, or disorienting dilemma, of feeling that they themselves were “other” enhanced their ability to see UPHOLDING SOCIAL JUSTICE IN NURSING 172 the other, such that overlap again occurred between Themes Two and Three (or between the planned/happenstance triggering events and disorienting dilemmas model components). Also, in understanding the realities of the SDH, often expressed in feelings of shock—and in understanding their realities also through comparisons—students experienced disorienting dilemmas, so that overlap occurred between Themes One and Three (or the points of view and disorienting dilemmas TTM components). Finally, because students’ points of view changed considerably as they moved toward seeing their potential influence, overlap occurred also between Themes One and Four, or the points of view and emancipatory learning TTM components. While not exhaustive, these especially pertinent examples serve to illustrate how the different ways of learning intersect with each other, in addition to interesting with praxis learning. While Figure 4 in Chapter 4, and the discussion surrounding it, emphasized that each theme individually intersected with Praxis Learning—so that the findings appeared to immediately indicate the relevance of cognitive, experiential, and reflexive learning to praxis learning—the current discussion serves to illustrate how each of these three themes also intersected with each other. See Figure 4 for an illustration of this complex interplay among themes. As the discussion of Figure 4 in Chapter 4 entailed, and as has been mentioned earlier in this chapter, consideration of how each of the ways of learning contributes to praxis learning (or transformation) is key from a nursing education standpoint. The current discussion suggests that it would also benefit nurse educators to be aware of the complexities of how these ways of learning intersect with each other, in order to appreciate that the progression toward praxis is not a purely hierarchical, stepwise process, but rather an iterative process whereby elements defining UPHOLDING SOCIAL JUSTICE IN NURSING 173 one type of learning may occur, at any moment, along elements that define another. In considering students’ ultimate praxis/transformation, then, it is particularly expedient to examine the meaning of praxis, and its alignment with transformation, more explicitly. Praxis Alignment with Transformational Learning Theory An understanding of how this study’s findings compare with the TTM, then, sets a critical foundation for the understanding of the practical application of TLT in nursing practice— that is, how TLT aligns with praxis—the ultimate end of transformation as found in this study. That is, having seen how students in this study epitomized key TLT principles such as points of view and disorienting dilemmas—and having seen traces of transformation in such experiences—it is particularly noteworthy to next consider how students’ transformation more distinctly engendered their ultimate praxis. In so doing, consideration of different types of knowledge, or learning—which have, until now, been shown to contribute to praxis—is first warranted. Indeed, it has long been recognized, in nursing literature, that nursing is defined by different types of knowledge. For instance, Cranton, a transformative learning author and educator, has discussed roles of a transformative educator specifically from the context of three kinds of knowledge: technical, communicative, and emancipatory (Faulk & Morris, 2012). Indeed, Faulk and Morris (2012) comment that consideration of different types of knowledge often accompanies discussions of transformational learning. Given the centrality of different types of knowledge to transformational learning recognized in the literature, then, the following discussion critically compares the thematic findings of this study to the literature, emphasizing praxis as the end of transformation. UPHOLDING SOCIAL JUSTICE IN NURSING 174 The kinds of learning found in this study—cognitive, experiential, reflexive, and praxis— both differ from, and are similar to, other kinds of learning recognized in research. Nursing literature richly describes various ways of knowing. Since “knowing is [an]… elusive concept” (Chinn & Kramer, 2015, p. 3) shaped by a variety of influencing factors such as what one was taught, what one has read, one’s own thinking, the subconscious uptake of societal messages, and multiple additional sources (Chinn & Kramer, 2015), it cannot be said with certainty that students in this study experienced cognitive, experiential, reflexive, and praxis knowing, but rather that the data obtained provided enough information for findings to clearly support their learning on these various fronts. However, because ways of knowing, as opposed to ways of learning, are spoken of more often by academics, where “knowing” is used in the current discussion and at any point hereafter, it is used with the understanding that learning may not necessarily equate to knowing. Glimpses of different ways of knowing acknowledged in the literature can be seen in the findings of this study. For instance, personal knowing as described by Chinn and Kramer (2015) may be equated with elements of seeing the self in reflexive learning. To look at knowledge foundational to transformational learning, technical knowledge allowing for the “manipulation and control of one’s environment” (Morris & Faulk, 2012, p. 6) may be aligned with the gaining of hands-on skills as seen in praxis learning. Afriyie Asenso et al. (2013), furthermore, recognized relational, embodied, and experiential learning. Notably, glimpses of embodied learning—which “… prompts students to examine their reactions (including somatic and emotional reactions) and to learn from that reflection” (Afriyie Asenso et al., 2013, p. 7)—were seen at times in the data, such as in the account of a student in Clark Callister and Harmer Cox UPHOLDING SOCIAL JUSTICE IN NURSING 175 (2006) who described the engagement of her senses as she learned about the host culture through her fasting, sharing of a meal, admiration of architecture, and listening to a call for prayer. However, many scholars recognize emancipatory knowing as distinct in its social justice orientation. Chinn and Kramer’s (2015) conceptualization of emancipatory knowing is particularly expedient in the context of this research. As the authors explain, emancipatory knowing is: … the human capacity to be aware of and critically reflect on the social, cultural, and political status quo and to determine how and why it came to be that way. Emancipatory knowing calls forth action in ways that reduce or eliminate inequality and injustice. (p. 5) As this definition reveals, emancipatory knowing is inherently social justice-oriented as it focuses on “… an awareness of social problems and taking action to create social change” (Chinn & Kramer, 2015, p. 2). Given that praxis learning aligned with emancipatory learning of the TTM, then, it may reasonably be understood that students in this study gained emancipatory knowledge—as defined by Chinn and Kramer (2015)—prior to, or alongside, their praxis. Praxis, at the core of emancipatory knowing, is “[t]he integrated expression of emancipatory knowing” (Chinn & Kramer, 2015, p. 6); moreover, praxis is “reflection and action” (Chinn & Kramer, 2015, p. 2). Indeed, Kagan, Smith, and Chinn’s (2014) use of the term “[s]ocial justice nursing” (p. 12) denotes that emancipation is achieved through praxis: that is, social justice nursing is “nursing practice that is emancipatory and rests on the principle of praxis, which is practice aimed at attaining social justice goals and outcomes that improve health experiences and conditions of individuals, their communities, and society” (Philosophies and Practices of Emancipatory Nursing, para. 1). In particular, the thematic finding of this study of praxis UPHOLDING SOCIAL JUSTICE IN NURSING 176 learning embodied these descriptions of praxis because reflection, or reflexivity, was especially essential to students’ movement toward seeing their potential influence, as well as their movement toward competence and confidence, in acting to uphold their social justice mandate by addressing the SDH. As Chinn and Kramer (2015) further explain, the term “integrated” in the definition of praxis reflects that emancipatory knowing comprises all patterns of knowing. In other words, knowledge is an “integrated whole” (p. 16). The findings of this study support such integration—as discussed in Chapter 4, and as depicted in Figure 4—where each of the first three themes intersected with praxis learning, revealing that they each uniquely informed praxis learning, and that apart from any of these other kinds of learning, praxis learning could not occur. Further, Chinn and Kramer (2015) note that there are “interrelationships” (p. 11) among the patterns of knowing, and, moreover, that these connections are iterative—they are nonlinear, without a single starting point (Chinn & Kramer, 2015). Findings from this study also supported an iterative relationship among the kinds of learning, in that overlap occurred among the themes. Indeed, Morris and Faulk (2012) claim that within a transformative learning approach, “[p]erspective transformation is a process of change that is not always linear” (p. 7). Thus, transformation was found to align with praxis in this study, where praxis learning was the reflective, action-oriented, integrated, and iterative expression of emancipatory knowledge, and where praxis may be understood as the end of students’ transformation. Interestingly, there is, moreover, an overall association of transformation and social justice in the literature, such as in Langham and Schutt (2012), where SL activities are described as promoting “… not only professional and personal transformation, but social transformation as well” (p. 119). As such, the uptake of TLT in nursing education—particularly following the TTM or a UPHOLDING SOCIAL JUSTICE IN NURSING 177 similar framework to contextualize TLT to nursing practice—therefore bears the potential to practically assist students in upholding social justice by fostering such a pattern of progressive learning to praxis. Potential Barriers to Transformative Learning However, despite evidence of some transformative learning among the findings of this study, several potential barriers to students’ transformative learning also became evident. For instance, there was under-theorizing of the underlying, structural forces, such as racialization, social gradients of power (advantage and disadvantage), market economies and political economies, migrant labour, colonialism and neoliberalism, as well as globalization. Afriyie Asenso et al. (2013) made explicit note of this when they commented that, “… there was silence in regard to the global structures, such as economic and sociopolitical factors, that affected people in Africa as well as in Canada” (p. 6), and, “… there was a lack of reflection on how colonization and globalization shaped poverty and inequalities in Zambia” (p. 6). While some evidence arose that educators may have attempted to foster learning of such concepts as revealed by the use of apparent lenses to frame learning about the SDH—such as the social justice and global health lenses—clear evidence of teaching of these underlying structures, or of students’ learning of them, did not arise. Notably, direct references to racism arose only in Levine’s (2009) study, such as with the student comment presented in Chapter 4 that “… if we can just break the chain of bias and racism, it sure would be a better place” (p. 162). Similarly, recognition of social gradients of power occurred in only a few instances; again, Levine (2009) noted that students became aware of “… the wealth of the overdeveloped nations versus those of the developing world….” (p. 165), or—as she stated elsewhere—that students recognized differences between the “have and UPHOLDING SOCIAL JUSTICE IN NURSING 178 have-nots” (p. 164). Power relations were furthermore mentioned in Reimer-Kirkham et al. (2009), who stated that “[s]tudents gained awareness of international relations, with the power relations reflected in current north:south, rich:poor gradients” (p. 7), and specifically commented that students felt dissonance in noticing the private hospital care obtained by the wealthy, while the poor lacked even basic resources. Finally, Zanchetta, Schwind, et al. (2013) took note of how students realized their potential positions of power—as well as that of the healthcare system in general—over the patients they looked after. In particular, there was no explicit mention of the awareness of market economies or political economies. Likewise, migrant labour was rarely hinted at, with the closest references usually occurring with respect to students’ increased awareness of the realities of immigrants’ lives in the U.S. (Walsh & DeJoseph, 2003). Further, mentions of colonialism and neoliberalism were subtle and only markedly more frequent; reference to the latter, for example, was briefly made in the previous comment of Reimer-Kirkham et al. (2009) on care received in private hospitals. Covert references to an attitude of colonialism, in comparison, were made by one student in Levine (2009), who commented on the culturally imperialistic attitude of the U.S. in believing that American healthcare was superior because it relied on scientific evidence, as well as by students in Caldwell and Purtzer (2014), who questioned whether their presence caused “more harm than good” (p. 581), with one student notably asking “[a]re we indirectly changing the culture, and if yes, is it a good thing?” (p. 581). Moreover, while there was some recognition among students across studies as a whole of their privileged positions in being able to lead Western lifestyles, this did not occur to a significant extent. Finally, awareness of globalization appeared to have also occurred superficially among the studies, with clear UPHOLDING SOCIAL JUSTICE IN NURSING 179 examples arising in students’ questioning of how their actions—such as buying shoes and coffee (Evanson & Zust, 2004)—affected structurally vulnerable individuals around the world. As this discussion entails, students’ lack of engagement with such causes of causes evidenced soft, as opposed to critical, global citizenship (Andreotti, 2006). Andreotti (2006) characterizes critical global citizenship as the desire to address underlying causes of causes in order to achieve social justice. While evidence of critical global citizenship surfaced at times— as these limited examples of students’ recognition of underlying structures has revealed, in addition to certain instances of students’ reflexivity (for example, their struggling to understand injustice)—the current discussion notably highlights the gap in the findings of such a lack of critical engagement. Indeed, while awareness of these various underlying structures was, as these examples have revealed, acknowledged, it was not discussed at length, nor was it discussed in a critical way. As such, it may be argued that soft global citizenship—characterized by a less critical, humanitarian/moral desire for action on poverty—characterized the learning of the majority of students across all studies. As such, while the findings of this study ultimately suggest that transformation occurred in the sense that students evidenced praxis, in revealing students’ lack of critical engagement with such underlying forces, the findings also introduce question as to the extent to which transformation occurred. While students experienced the disorienting dilemmas, critical reflection, and changed points of view that ultimately led to transformative thinking, the question nevertheless arises: Were students truly transformed if they were not sufficiently taught, and did not evidence sufficient critical understanding of, the underlying forces eliciting the SDH? Because such learning cannot be shown conclusively from the findings of this study, it is then feasible to suggest that students experienced transformation to a limited extent—that is, only to UPHOLDING SOCIAL JUSTICE IN NURSING 180 the extent that they evidenced competence, and confidence, in acting on the SDH, or that they achieved praxis. Such an interpretation also reflects just how difficult it can be to address macro-level, structural forces, particularly for nurses who are entering the profession. The implications of these potential gaps in learning are important to acknowledge for nurse educators. For instance, Mikkonen and Raphael (2010) highlight the stark disparity in income and health outcomes between individuals of different races, noting, for example, that non-European immigrants have a significantly higher relative risk for poor health than European immigrants or the Canadian-born population. In further consideration of racialization, the Truth and Reconciliation Commission of Canada (2015) notes that health educators have a particularly important role in educating students on racism toward the Aboriginal population, so that students are better informed as future health practitioners. Nurse educators may, therefore, play a crucial role in helping student nurses to critically reflect on underlying causes of causes such as racialization. For, as Burgess, Reimer-Kirkham, and Astle (2014) note, just as Giddings’ (2005) “Theoretical Model of Social Consciousness”, with its three domains of social consciousness, says that a nurse can be located in either domain at one time and shift between domains following experiential learning, one can move toward critical global citizenship following greater experience with, and reflection on, social justice. As such, instances of soft global citizenship— such as those that occurred in this study—“should not be viewed negatively but as a starting place for increased global awareness and engagement” (Burgess et al., 2014, p. 7). Nurse educators should, therefore, view the occurrence of such soft global citizenship—or limited transformation—among students positively, as states of learning that can be built upon. In line with this discussion, another potential barrier to transformative learning may have been students’ equity fatigue—that is, “paralysis at the scale of addressing health inequities or UPHOLDING SOCIAL JUSTICE IN NURSING 181 guilt about one’s complicities in inequitable social relations” (Browne & Reimer-Kirkham, 2014, p. 21-22). Indeed, students in this study evidenced such paralysis specifically in doubting the extent of their influence, where expressions of powerlessness were especially palpable. Specifically, students questioned whether their actions were enough to truly help the structurally vulnerable with whom they interacted. Although a lack of being able to see “a clear pathway for how to respond” (Browne & Reimer-Kirkham, 2014, p. 31) was not a notable finding in this study—as it was, for instance, for students in Reimer Kirkham et al. (2009) who found it difficult to sustain their social consciousness upon their arrival home—these expressions of doubt nevertheless signaled equity fatigue. Further, while statements reflective of guilt occurred less frequently, they did nevertheless arise, and therefore serve to further illustrate a sense of paralysis. A final potential barrier to transformative learning became evident in the given ethnicities of participants across studies. As Appendix B reveals, when ethnicity was mentioned, the majority of students were described as Caucasian. As Browne and Reimer-Kirkham (2014) discuss, two problematics in social justice discourses are that of emphasizing difference in calling the structurally vulnerable “other”, and the imposition of Western values. With respect to the former, a focus on framing the structurally vulnerable as “other” identifies them as being vulnerable, or oppressed. As 16 of the 33 studies which discussed students’ ethnicity (see Appendix B) revealed that students were overwhelmingly Caucasian, it is possible, then, that the ethnicity of the majority of students in this study (possibly including those students among studies not discussing ethnicity) may have influenced their “[o]thering” (Browne & ReimerKirkham, 2014, p. 26). That is, students’ participation in othering may have been influenced by their implicit adoption of a colonial, “white”, ethnocentric lens, as was evident in findings related UPHOLDING SOCIAL JUSTICE IN NURSING 182 to seeing the other. For instance, students’ seeing the other as happy may have been shaped by implicit Western tendencies of overlooking the suffering of the structurally vulnerable in favour of the belief that life for such individuals is not very different from that of those in the Western world. Similarly, students viewed themselves as coming to help the other in findings expressing disconnection from their experiences—again revealing a Western lens of seeing the other as being reliant upon Western, Caucasian persons such as themselves. However, if nurse educators are aware of the potential of a colonial, ethnocentric lens, they may help students to also become aware of, critically reflect on, and redress this potential barrier. Chapter 5 Summary In consideration of nursing’s social justice mandate, the definition of social justice was revisited and found to inherently reflect health equity. Consideration of the studies synthesized, however, revealed that most did not discuss the upholding of social justice directly, but rather still tended to emphasize variables such as, for instance, are related to culture. Moreover, transformational learning theory was found to describe students’ progression toward praxis as revealed by this study’s findings; in particular, components of the transformative thinking model (Morris & Faulk, 2012) were found to align well with this study’s themes. While overlap did occur between certain components of the model and certain themes, this evidenced that the transformative process was not only hierarchical—where each theme contributed to praxis learning alone in a progressive manner—but that all ways of learning intersected with each other and that the transformative process was iterative and complex. Upon closer consideration of different ways of knowing, then, it was found that praxis learning most closely embodied the social justice principles espoused by emancipatory knowing, and that, furthermore, students’ achievement of praxis in this study was found to align with their transformation. Yet potential UPHOLDING SOCIAL JUSTICE IN NURSING 183 barriers to transformative learning were also noted in students’ lack of critical engagement with causes of causes, such as racialization, social gradients of power (advantage and disadvantage), market economies and political economies, migrant labour, colonialism and neoliberalism, as well as globalization, where students evidenced soft, as opposed to critical, global citizenship, and therefore experienced potentially limited transformation. Similarly, equity fatigue and students’ othering as influenced by a colonial, ethnocentric lens may have served as barriers to transformation. Nurse educators, however, may still build upon potentially limited transformation to encourage critical global citizenship among students, and they may similarly help students become aware of, and redress, equity fatigue and the influence of an ethnocentric lens. As Chapter 6 next reveals, the implications of this discussion—especially as they relate to the fostering of praxis and transformational learning—are particularly salient for nursing education. UPHOLDING SOCIAL JUSTICE IN NURSING 184 Chapter 6: Conclusions and Recommendations “Tell me & I’ll listen. Show me & I’ll understand. Involve me & I’ll learn. –Teton Lakota Indian Proverb” (Langham & Schutt, 2012, p. 119) Nursing’s mandate to uphold social justice endures just as powerfully today as it has throughout nursing’s history. While the current literature discloses a growing recognition that educators must teach nursing students (NS) to uphold social justice, it remains comparatively silent on students’ own views of their ability to do so. The purpose of this research, then, was to explore the value of clinical educational experiences in expanding NS’ understanding of—and perceived ability to address—the SDH, and in so doing to uphold their social justice mandate. Summary of Study In order to capture and compellingly present existing knowledge on NS’ understanding of—and perceived ability to address—the SDH, the literature was searched thoroughly and studies meeting detailed inclusion criteria chosen carefully for ultimate synthesis. Specifically, 33 qualitative, quantitative, and mixed-methods studies were chosen, rigorously appraised for quality criteria, and extracted according to eight extraction questions that were created in line with the study’s research questions. An integrated mixed research synthesis (MRS) was then conducted of the extracted data, and ultimately enabled the assimilation of both qualitative and quantitative data into themes. Finally, an interpretive thematic analysis allowed for the inductive generation of themes; namely, four themes arose: Cognitive Learning, Experiential Learning, Reflexive Learning, and Praxis Learning. Implications for nursing education are especially UPHOLDING SOCIAL JUSTICE IN NURSING 185 palpable. Therefore, this chapter begins with salient study conclusions, followed by pertinent recommendations for nursing education and research, before considering overall study limitations. Conclusions Four conclusions were derived from this study, as follows: 1. Different ways of learning—such as cognitive, experiential, reflexive, and praxis learning as found in this study—must all be present in order for transformative learning to occur (since each may contribute to praxis learning, or transformation, and because transformation may follow a pattern of cognitive, to experiential, to reflexive, to praxis learning). Nurse educators who are involved in global opportunities with their nursing students should strive to promote that their educational experiences include elements such as these for transformational learning to occur (therefore, they should adopt the tenets of different ways of learning alongside principles of TLT [or, more directly, a TLT-based model such as Morris and Faulk’s (2012) TTM]). 2. Reflection (as seen in students’ journaling, in dialogue, and especially in their selfinitiated reflection of seeing the self and willingly reflecting) prompted much of students’ learning. Notably, reflection led to students’ critical engagement with, and efforts to make sense of, struggles (often occurring as a result of changed points of view and disorienting dilemmas) as they learned to address the SDH, such as was seen in expressions of feeling unready to act (e.g., doubting the extent of their influence), and in their struggling with understanding injustice. Because reflection—recognized as a core concept of TLT (Taylor, 2009)—thereby served as the fulcrum, or critical turning point, UPHOLDING SOCIAL JUSTICE IN NURSING 186 allowing students to progress toward praxis, educators should especially focus on fostering critical reflection. 3. Although there has been increasing emphasis on social justice in recent years in national nursing documents as well as in primary research—and while social justice was deemed important by authors of studies in this research—it was either poorly defined, or not explicitly addressed in many of the studies. 4. Nurse educators can assume a very important role in assisting students to better understand what is occurring in situations that they are unsure or uncomfortable with (such as with changed points of view and disorienting dilemmas as presented in this study). The following recommendations, therefore, follow these conclusions. Recommendations for Education The Canadian Association of Schools of Nursing (CASN) (2015) already acknowledges, as a core expectation for baccalaureate nursing programs, that baccalaureate-prepared students should be able to demonstrate knowledge of, and leadership in, social justice. Notably, CASN (2015) states that students should have “[k]nowledge of primary health care in relation to health disparities, vulnerable populations, and the determinants of health” (p. 11); “[k]nowledge of social justice, population health, environment and global health issues” (p. 11); and that students demonstrate “[t]he ability to advocate for change to address issues of social justice, health equity, and other disparities affecting the health of clients” (p. 17). This focus on knowledge and action, then, directly corresponds to the purpose of this study of learning about students’ understanding of, and perceived ability to address, the SDH. The recommendations that follow therefore fall in UPHOLDING SOCIAL JUSTICE IN NURSING 187 line with CASN’s (2015) current expectations of nursing education, yet also reflect the conclusions of this study. Furthermore, each recommendation is assigned a grade of either A or B, as per JBI, where grade A denotes a “‘strong’ recommendation”—or, in the context of this study, a recommendation “where there is evidence of sufficient quality supporting its use” (JBI, 2014, p. 14)—and grade B a “‘weak’ recommendation” (JBI, 2014, p. 14), or a recommendation “where there is evidence supporting its use, although this may not be of high quality” (p. 14). Specifically, recommendations for education are as follows: 1. Grade A: Educators to adopt a praxis/TLT approach in all nursing courses. Specifically, educators could center teaching around ways of learning such as cognitive, experiential, reflexive, and praxis, trying to incorporate as many as possible, with the ultimate aim of achieving praxis. In so doing, educators should recognize that these ways of learning may be inherent to achieving transformational learning (where they all contribute to transformational learning, and may do so hierarchically). Thus, educators could adopt TLT as an overarching framework. 2. Grade A: Educators to teach skills of advocacy as intended skills for praxis, such as skills for understanding and contributing to health policy. 3. Grade A: Educators to promote critical thinking by fostering critical reflection through reflective practices such as journaling—a technique implemented widely and found to be useful by the majority of study authors in this research—and critical dialogue (Morris & Faulk, 2012). In particular, educators should promote critical thinking of the underlying forces precipitating SDH, such as globalization, colonialism, and racism. UPHOLDING SOCIAL JUSTICE IN NURSING 188 4. Grade A: Educators to ensure that the concept of social justice is explicit in curricula (e.g., in desired outcomes of education, in teaching, in assignments, in documents [purpose, mission, vision of SON]), since it is already a professional value and professional nursing competency. Nurse educators may take as an example the “Social Determinants of Health e-Learning Course” offered by the CNA (2017b)—or may even use this course—with its four modules on: (1) What SDH are; (2) Health equity and social justice; (3) How understanding the SDH enhances nursing practice; and (4) Putting into action knowledge about the SDH. Similarly, educators may find the SDH supporting resources offered by the CNA (2017c)—such as a number of documents, videos, webinars, and websites—to also be helpful when structuring curricula. 5. Grade B: Educators to consider implementing social justice in courses throughout nursing school. As Langham and Schutt (2012) state, the “[s]trategic placement of community-based service learning activities throughout the nursing curriculum helps to meet… transformative learning” (p. 121). 6. Grade B: Educators to continue experimenting with innovative clinical experiences. 7. Grade B: Educators to consider making educational experiences longer. 8. Grade A: Educators’ presence and support to be a key facilitator to students’ learning (as was found to be key in this study). Such support may especially help in dealing with disorienting dilemmas and changing points of view. 9. Grade A: Educators to adopt a praxis/TLT approach, as per the first recommendation, with the ultimate aim of promoting global citizenship among students. Toward this end, educators may find it helpful to refer to the CUGH Global Health Education Competency UPHOLDING SOCIAL JUSTICE IN NURSING 189 Tool-kit, which defines competencies for global citizens (Consortium of Universities for Global Health, 2017). Recommendations for Research Recommendations for research, in comparison, are as follows: 1. Grade A: Future research to be conducted exploring what elements constitute transformative learning, from the perspective of upholding a social justice mandate. For instance, is students’ competence, and confidence, in addressing the SDH—or their praxis—enough to suggest that they have been transformed, or must recognition of underlying causes of the SDH, such as globalization, colonialism, and racism, be in place for transformation to occur? The concept of transformation as it occurs specifically in the context of upholding social justice requires further exploration. 2. Grade A: Further research to be done on the praxis/TLT approach suggested by this study (specifically, the usefulness of using the thematic conceptualization suggested, and the TTM to guide the uptake of TLT). For example, are the ways of learning found by this study truly the most expedient to guide curricular formation in helping students to achieve praxis/transformation in addressing the SDH? Also, is the theory of TLT as a guiding principle sufficient? As Morris and Faulk (2012) comment: “[t]he use of TLT as a framework for thinking about nursing curricula and development of teaching and learning strategies that foster perspective transformation is underresearched” (p. 8). 3. Grade B: Further research should also be done on how nurse educators can implement TLT in the teaching of their curriculum. 4. Grade B: Future research that is completed on educational experiences incorporating learning of social justice—such as with the studies synthesized in this research—should UPHOLDING SOCIAL JUSTICE IN NURSING 190 be published more often, and “social justice” used as a key term (Canales & Drevdahl, 2014). 5. Grade A: Further research to be done incorporating a variety of clinical experiences where students work with those who are made structurally vulnerable by the SDH, and exploring accompanying concepts of racism, neoliberalism, market economies, etc. (e.g., in innovative sites such as prisons). Specifically, further research should be done on the benefit of online and simulation experiences where students may be required to uphold social justice in scenarios. 6. Grade B: Further research to be done on the benefits of short- versus long-term experiences (including defining both). 7. Grade A: More systematic reviews should be completed in relation to students’ ability to address the SDH. These systematic reviews could adopt other perspectives; for example, are the educational frameworks increasingly being used—such as the Community-Based Collaborative Action Research (CBCAR) framework in Krumwiede et al.’s (2014) study—effective? Also, a systematic review with the same purpose, research questions, and methodology as this study could be conducted on articles incorporating online and simulation experiences. 8. Grade A: In addition, more primary research to be done answering the questions of this study. Primary studies could, moreover, assess the value of educational experiences for undergraduate and graduate students separately, noting whether there is any difference in outcomes for these population groups. Primary research could also be conducted with practicing nurses as opposed to students. As the vast majority of studies found through the literature reviews conducted for this research were qualitative, more primary UPHOLDING SOCIAL JUSTICE IN NURSING 191 quantitative and mixed-methods studies could be completed. Primary research should also continue to experiment with creative research methodologies, such as with Amerson and Livingston’s (2014) use of reflexive photography, or photovoice (Cooper, Sorensen, & Yarbrough, 2017). Further, new quantitative assessment tools such as surveys and questionnaires could perhaps be developed (given that tools such as the “Attitudes about Poverty and Poor People Scale” [Jarrell et al., 2014, p. 301], and the International Education Survey [IES] [Curtin et al., 2014], are particularly common). As an example, the structural vulnerability assessment tool discussed by Bourgois et al. (2017) presents a list of nine questions that clinicians may ask—even in resource- and time-limited settings—to determine patients’ need of additional health and social support. 9. Grade B: Further research to be done on the benefits of the different contexts in which educational experiences take place. For example, with the current focus on international experiences in the literature, do these international settings offer unique learning compared to other settings? 10. Grade A: While the focus in the literature seems to be on examining the benefits of educational experiences exposing students to SDH from perspectives of culture-related variables, as well as personal and professional transformation, further research could consider other factors to examine, such as competence and confidence as evaluated in this study. Langham and Schutt (2012), for instance, discuss that SL activities should promote “… not only professional and personal transformation, but social transformation as well” (p. 119). UPHOLDING SOCIAL JUSTICE IN NURSING 192 Limitations of this Research While limitations were presented in Chapter 3 in reference to the study methodology, limitations for the study as a whole are summarized here to ensure that all limitations are accounted for. 1. As mentioned in Chapter 3, because some of the student and author quotes were vague when describing learning with respect to the SDH and/or social justice, as well as students’ perceived ability to act on the SDH, such learning and perceived ability had, at times, to be appropriately inferred alongside my supervisory committee. The implication of authors’ implicit commentary is that this called into question how well data “fit” the thematic findings, so that data gathered in support of students’ learning and/or perceived ability may not have accurately reflected their learning of, and perceived ability to address, the SDH. Therefore, this implication served as a limitation in this study, and studies with such implicit commentary were only included upon consultation with my supervisory committee. 2. In line with the first limitation above, it was difficult to count how many students across studies were transformed. This was because authors did not always present their results in terms of the principles of transformational learning, such as those suggested by this study (e.g., not all authors spoke on students’ reflexive learning). Further, when presenting their themes, authors often presented the learning of different students under each theme, and did not always specify which participants offered supporting quotations, such that it was unclear whether the findings applied to all students consistently. It was, therefore, difficult to say how many students, in each study, actually achieved praxis learning or were transformed. As such, it was difficult to say if negative cases occurred. UPHOLDING SOCIAL JUSTICE IN NURSING 193 The achievement of praxis learning or transformation was, rather, deduced from a broad reading of the findings from all the studies as a whole, which altogether variably presented evidence in support of cognitive, experiential, reflexive, and praxis learning. Because all the studies presented some evidence of praxis learning, transformative learning was, ultimately, inferred alongside my supervisory committee as having occurred for the majority of students across the studies. 3. It was not feasible, within the scope of this research, to synthesize all relevant literature, such as additional potentially relevant studies that may have been found outside of those that were discovered through the search strategies implemented for this study. 4. The focus on students’ understanding of, and increased sense of ability to act on, the SDH as outcomes—as opposed to other possibilities such as “tolerance, humanity, innovativeness, creativity, [and] risk taking” (Levine, 2009, p. 156)—may have limited the understanding of students’ ability to act on the SDH presented by this study. 5. Implications surrounding the “qualitizing” (Sandelowski, Voils, & Barroso, 2006, p. 8) of quantitative data—or “… converting quantitative findings into qualitative form so that they can be combined with other qualitative data and subjected to qualitative analysis” (p. 8)—also presented a limitation. 6. Study authors did not always specify demographic variables for their participants; for example, ethnicity was mentioned in only 16 of 33 studies, so that it was overall unclear whether NS were Caucasian or of other ethnic backgrounds. Thus, it was difficult to ascertain how students’ ethnic lens may have influenced their learning. 7. The extraction questions may have been unspecific for certain concepts; for example, they were unspecific for concepts such as globalization, market economies, migrant UPHOLDING SOCIAL JUSTICE IN NURSING 194 labour, political economy, or neoliberalism. As such, these concepts—either authors’ explicit teaching of them, or students’ explicit mention of having learned them—may not have been sufficiently captured in the findings of this study. Chapter 6 Summary This research has examined the extent to which NS feel competent, and confident, to uphold their social justice mandate by looking specifically at their understanding of, and perceived ability to address, the SDH. The value of educational experiences toward this end was ultimately sought, in recognition of the growing body of research describing educational experiences exposing students to principles of social justice and the SDH. As rich data was gathered on students’ understanding of, and perceived ability to address, the SDH, educational experiences were indeed found to be very valuable in preparing students to address the SDH. The four conclusions of this study, then, ultimately support the continued development of such educational experiences so that NS may be prepared as well as possible to address the SDH in practice. The first conclusion on the need to adopt the tenets of different ways of learning, as well as of TLT, in curricula and educational experiences is a direct consequence of the finding of this study of the significance of different ways of learning, and of transformation, to students’ ultimate ability to act. Likewise, the second conclusion on the need to incorporate reflective activities in educational experiences stems from the central role that reflection was found to play in students’ progression to praxis. Furthermore, the third conclusion emphasizing the need to adequately define, and explicitly address, social justice in primary research reflects the overall paucity of either of these principles among the 33 articles synthesized. Finally, the fourth conclusion on the importance of nurse educator support of students experiencing, for instance, UPHOLDING SOCIAL JUSTICE IN NURSING 195 unsureness or discomfort (such as with changed points of view or disorienting dilemmas) is based on the notable occurrence of such feelings of dissonance of students in this study. The nine recommendations for nursing education and ten recommendations for nursing research were, in turn, based on these conclusions. Significantly, recommendations for both of these fields of nursing draw attention to: further critical consideration of the cognitiveexperiential-reflexive-praxis learning conceptualization presented in this study to implement in aiming to achieve praxis/transformation; more deliberate incorporation of the concept of social justice; and the design of educational experiences with respect to, for instance, length and the usage of innovative placements. Finally, the seven limitations presented extended those offered in Chapter 3 for added credibility. Health is a universal human right; health inequities, however, are also universally rampant. Because nurses have an ethical obligation to address social injustice, nurses must act to ameliorate the SDH. Yet, if nurses are to do so, it is without doubt that they must be exposed to educational experiences as nursing students that—as this study has shown—critically shape their ability to act. This research, then—in giving voice to students who have already spoken on their experiences—ultimately serves to encourage the profession of nursing to continue to design educational experiences that assist students to uphold social justice. UPHOLDING SOCIAL JUSTICE IN NURSING 196 References Adamshick, P., & August-Brady, M. (2012). Reclaiming the essence of nursing: The meaning of an immersion experience in Honduras for RN to bachelor of science students. Journal of Professional Nursing, 28(3), 190-198. doi:10.1016/j.profnurs.2011.11.011 Afriyie Asenso, B., Reimer-Kirkham, S., & Astle, B. (2013). In real time: Exploring nursing students' learning during an international experience. International Journal of Nursing Education Scholarship, 10(1), 227-236. doi:10.1515/ijnes-2012-0045 Amerson, R. (2010). The impact of service-learning on cultural competence. Nursing Education Perspectives, 31(1), 18-22. doi:10.1016/j.teln.2011.11.002 Amerson, R., & Livingston, W. G. (2014). Reflexive photography: An alternative method for documenting the learning process of cultural competence. Journal of Transcultural Nursing, 25(2), 202-210. doi:10.1177/1043659613515719 Andreotti, V. (2006). Soft versus critical global citizenship education. Policy & Practice – A Development Education Review, 3, 40-51. Retrieved from https://www.developmenteducationreview.com/sites/default/files/article-pdfs/andreotti %20focus%204.pdf August-Brady, M., & Adamshick, P. (2013). Oh, the things you will learn: Taking undergraduate research to the homeless shelter. Journal of Nursing Education, 52(6), 342-345. doi:10.3928/01484834-20130515-02 Bailey, P. A., Carpenter, D. R., & Harrington, P. A. (Eds.). (1999). Integrating community service into nursing education: A guide to service-learning. New York, NY: Springer Publishing Company. Retrieved from https://books.google.ca/books?hl=en&lr=&id =lqGpVPkTfJIC&oi=fnd&pg=PR7&dq=Integrating+community+service+into+nursing+ UPHOLDING SOCIAL JUSTICE IN NURSING 197 education:+A+guide+to+service-learning&ots=Fx2HBNYXVN&sig =qsR0y7s3cMzTJ3Bf78KOUG2oAqI#v=onepage&q=Integrating%20community%20ser vice%20into%20nursing%20education%3A%20A%20guide%20to%20servicelearning&f=false Ballou, K. A. (2000). A historical-philosophical analysis of the professional nurse obligation to participate in sociopolitical activities. Policy, Politics & Nursing Practice, 1(3), 172-184. doi:10.1177/152715440000100303 Bass, J., Fenwick, J., & Sidebotham, M. (2017). Development of a model of holistic reflection to facilitate transformative learning in student midwives. Women & Birth, 30(3), 227235. doi:10.1016/j.wombi.2017.02.010 Bell, M. L., & Buelow, J. R. (2014). Teaching students to work with vulnerable populations through a patient advocacy course. Nurse Educator, 39(5), 236-240. doi:10.1097/NNE.0000000000000063 Bentley, R., & Ellison, K. J. (2005). Impact of a service-learning project on nursing students. Nursing Education Perspectives, 26(5), 287-290. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?sid=583c1d42-6d6e-4ecc833c-ad3151c3d95d%40sessionmgr120&vid=182&hid=105 Bourgois, P., Holmes, S. M., Sue, K., & Quesada, J. (2017). Structural vulnerability: Operationalizing the concept to address health disparities in clinical care. Academic Medicine, 92(3), 299-307. doi:10.1097/ACM.0000000000001294 Boutain, D. M. (2005). Social justice as a framework for professional nursing. Journal of Nursing Education, 44(9), 404-408. Retrieved from http://ezproxy.student.twu.ca:4434 /ehost/pdfviewer/pdfviewer?sid=583c1d42-6d6e-4ecc-833c-ad3151c3d95d UPHOLDING SOCIAL JUSTICE IN NURSING 198 %40sessionmgr120&vid=16&hid=105 Boutain, D. M. (2008). Social justice as a framework for undergraduate community health clinical experiences in the United States. International Journal of Nursing Education Scholarship, 5(1), 1-12. Retrieved from https://digital.lib.washington.edu/researchworks /bitstream/handle/1773/15520/Boutain1.pdf?sequence=1 Boylston, M. T., & O'Rourke, R. (2013). Second-degree bachelor of science in nursing students' preconceived attitudes toward the homeless and poor: A pilot study. Journal of Professional Nursing, 29(5), 309-317. doi:10.1016/j.profnurs.2012.05.009 Bozorgmehr, K. (2010). Rethinking the ‘global’ in global health: A dialectic approach. Globalization and Health, 6:19. doi:10.1186/1744-8603-6-19 Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health, 57(4), 254-258. doi:10.1136/jech.57.4.254 Braveman, P. (2014). What is health equity and how does a life-course approach take us further toward it? Maternal Child Health Journal, 18(2), 366-372. doi:10.1007/s10995-013-1226-9 Breen, H., & Jones, M. (2015). Experiential learning: Using virtual simulation in an online RNto-BSN program. Journal of Continuing Education in Nursing, 46(1), 27-33. doi:10.3928/00220124-20141120-02 Browne, A. J., & Reimer-Kirkham, S. (2014). Problematizing social justice discourses in nursing. In P. N. Kagan, M. C. Smith, & P. L. Chinn (Eds.), Philosophies and practices of emancipatory nursing: Social justice as praxis (pp. 21-38). New York, NY: Routledge. Retrieved from http://ezproxy.student.twu.ca:2152/ehost/ebookviewer/ebook /bmxlYmtfXzgxNTA1MF9fQU41?sid=9a74d0e0-1a85-4aaa-8b14-de093451a66b UPHOLDING SOCIAL JUSTICE IN NURSING 199 @sessionmgr4009&vid=0&format=EB&rid=1 Brunner, E., & Marmot, M. (2006). Chapter 2: Social organization, stress, and health. In M. Marmot & R.G. Wilkinson (Eds.), Social determinants of health (2nd ed.) (pp. 6-30). Oxford, NY: Oxford University Press. Buettner-Schmidt, K., & Lobo, M. L. (2012). Social justice: A concept analysis. Journal of Advanced Nursing, 68(4), 948-958. doi:10.1111/j.1365-2648.2011.05856.x Burgess, C. A., Reimer-Kirkham, S., & Astle, B. (2014). Motivation and international clinical placements: Shifting nursing students to a global citizenship perspective. International Journal of Nursing Education Scholarship, 11(1), 1-8. doi:10.1515/ijnes-2013-0056 Caldwell, P., & Purtzer, M. A. (2014). Long-term learning in a short-term study abroad program: "Are we really truly helping the community?". Public Health Nursing, 32(5), 577–583. doi: 10.1111/phn.12168 Canadian Association of Schools of Nursing/Association Canadienne des Écoles de Sciences Infirmières [CASN/ACESI]. (2015). National nursing education framework: Final report. Ottawa, ON: Author. [PDF]. Retrieved from: http://www.casn.ca/wp-content/ uploads/2014/12/Framwork-FINAL-SB-Nov-30-20151.pdf Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author. [PDF]. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdfen/ps95_code_of_ethics_2008_e.pdf?la=en Canadian Nurses Association. (2009a). Ethics in practice for registered nurses: Social justice in practice. [PDF]. Retrieved from http://cna-aiic.ca/~/media/cna/page-content/pdfen/ethics_in_practice_april_2009_e.pdf UPHOLDING SOCIAL JUSTICE IN NURSING 200 Canadian Nurses Association. (2009b). Position statement: Determinants of health (PS-109). Ottawa, ON: Author. Canadian Nurses Association. (2010). Social justice: A means to an end, an end in itself. Ottawa, ON: Author. [PDF]. Retrieved from http://cna-aiic.ca/~/media/cna/pagecontent/pdf-en/social_justice_2010_e.pdf Canadian Nurses Association. (2013). Position statement: Social determinants of health (PS124). Ottawa, ON: Author. [PDF]. Retrieved from http://cna-aiic.ca/~/media/cna /files/en/ps124_social_determinants_of_health_e.pdf Canadian Nurses Association. (2017a). Code of ethics for registered nurses. Ottawa, ON: Author. Canadian Nurses Association. (2017b). Social determinants of health e-learning course [Elearning course]. Retrieved from https://cna-aiic.ca/en/on-the-issues/better-health/socialdeterminants-of-health/social-determinants-of-health-e-learning-course Canadian Nurses Association. (2017c). Supporting resources. Retrieved from https://cnaaiic.ca/en/on-the-issues/better-health/social-determinants-of-health/supporting-resources Canales, M. K., & Drevdahl, D. J. (2014). Social justice: From educational mandate to transformative core value. In P. N. Kagan, M. C. Smith, & P. L. Chinn (Eds.), Philosophies and practices of emancipatory nursing: Social justice as praxis (pp. 153174). New York, NY: Routledge. Retrieved from http://ezproxy.student.twu.ca:2097 /ehost/ebookviewer/ebook/bmxlYmtfXzgxNTA1MF9fQU41?sid=e618b80c-b78b-48789db2-f18230a5a747@sessionmgr103&vid=0&format=EB&rid=1 Cellini, K. E. (2015). The impact of service learning experiences on the professional practice of RN to BSN graduates (Doctoral dissertation). Retrieved from ProQuest Dissertations and UPHOLDING SOCIAL JUSTICE IN NURSING 201 Theses Global. (No. 3723040) Center for Community Engagement. (n.d.). Center for community engagement. Retrieved from http://web.csulb.edu/divisions/aa/personnel/cce/ Chinn, P. L. (2014). Educating for social justice. Journal of Nursing Education, 53(9), 487. doi:10.3928/01484834-20140821-10 Chinn, P. L., & Kramer, M. K. (2015). Chapter 1: Nursing’s fundamental patterns of knowing. In Knowledge development in nursing: Theory and process (9th ed.) (pp. 1-23). St. Louis, MO: Elsevier. Clark Callister, L., & Harmer Cox, A. (2006). Opening our hearts and minds: The meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing and Health Sciences, 8(2), 95–102. doi:10.1111/j.1442-2018.2006.00259.x Cohen, B. E., & Gregory, D. (2009). Community health clinical education in Canada: Part 2– Developing competencies to address social justice, equity, and the social determinants of health. International Journal of Nursing Education Scholarship, 6(1), 1-15. doi:10.2202/1548-923X.1638 Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the commission on social determinants of health. Geneva, Switzerland: World Health Organization. [PDF]. Retrieved from http://whqlibdoc.who.int/publications/2008 /9789241563703_eng.pdf?ua=1 Connolly, C., Wilson, D., Missett, R., Dooley, W. C., Avent, P. A., & Wright, R. (2004). Academic practice exemplars. Associate degree nursing in a community-based health center network: Lessons in collaboration. Journal of Nursing Education, 43(2), 78-80. UPHOLDING SOCIAL JUSTICE IN NURSING 202 Retrieved from http://ezproxy.student.twu.ca:4437/ehost/pdfviewer/pdfviewer?sid =41e7c0f7-502d-4187-9769-842baa9af89d%40sessionmgr4001&vid=9&hid=4206 Consortium of Universities for Global Health. (2017). CUGH global health education competencies tool kit. Retrieved from http://cugh.org/resources/2063 Cumulative Index of Nursing and Allied Health Literature. (2016). Database: CINAHL complete. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/mesh?sid=414c20a6dd61-43d5-873a-a58b0d5aaf1c%40sessionmgr112&vid=10&hid=125 Curtin, A. J., Martins, D. C., & Schwartz-Barcott, D. (2014). A mixed methods evaluation of an international service learning program in the Dominican Republic. Public Health Nursing, 32(1), 58-67. doi:10.1111/phn.12117 Curtin, A. J., Martins, D. C., Schwartz-Barcott, D., DiMaria, L., & Ogando, B. M. S. (2013). Development and evaluation of an international service learning program for nursing students. Public Health Nursing, 30(6), 548-556. doi:10.1111/phn.12040 de Chesnay, M. (2016). Chapter 1: Vulnerable populations: Vulnerable people. In M. de Chesnay & B. A. Anderson (Eds.), Caring for the vulnerable: Perspectives in nursing theory, practice, and research (4th ed.). (pp. 3–18). Burlington, MA: Jones & Bartlett Learning. DeLashmutt, M. B. (2007). Students' experience of nursing presence with poor mothers. Journal of Obstetric, Gynecologic & Neonatal Nursing, 36(2), 183-189. doi:10.1111/j.1552-6909.2007.00135.x DeLashmutt, M. B., & Rankin, E. A. (2005). A different kind of clinical experience: Poverty up close and personal. Nurse Educator, 30(4), 143-149. Retrieved from http://ezproxy .student.twu.ca:4434/ehost/detail/detail?vid=48&sid=583c1d42-6d6e-4ecc-833c- UPHOLDING SOCIAL JUSTICE IN NURSING 203 ad3151c3d95d%40sessionmgr120&hid=105&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d %3d#AN=106518873&db=ccm De Los Santos, M., McFarlin, C. D., & Martin, L. (2014). Interprofessional education and service learning: A model for the future of health professions education. Journal of Interprofessional Care, 28(4), 374-375. doi:10.3109/13561820.2014.889102 D'Lugoff, M. I., & McCarter, J. (2005). Learning from experience: Three community health population-based outreach projects for graduate and undergraduate students. International Journal of Nursing Education Scholarship, 2(1), 1-11. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?sid=d73cb955-90f8-4ac28e72-3eb6edd68e9c%40sessionmgr114&vid=15&hid=106 Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. Journal of the American Medical Association, 287(2), 226-235. Retrieved from doi:10.1001/jama.287.2.226 Evans, D. (2002). Systematic reviews of interpretive research: Interpretive data synthesis of processed data. Australian Journal of Advanced Nursing, 20(2), 22-26. Evanson, T. A., & Zust, B. L. (2004). The meaning of participation in an international service experience among baccalaureate nursing students. International Journal of Nursing Education Scholarship, 1(1), 1-14. doi:10.2202/1548-923x.1070 Evanson, T. A., & Zust, B. L. (2006). 'Bittersweet knowledge': The long-term effects of an international experience. Journal of Nursing Education, 45(10), 412-419. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?vid=61&sid =583c1d42-6d6e-4ecc-833c-ad3151c3d95d%40sessionmgr120&hid=105 Ezeonwu, M., Berkowitz, B., & Vlasses, F. R. (2014). Using an academic-community UPHOLDING SOCIAL JUSTICE IN NURSING 204 partnership model and blended learning to advance community health nursing pedagogy. Public Health Nursing, 31(3), 272-280. doi:10.1111/phn.12060 Fahrenwald, N. L. (2003). Teaching social justice. Nurse Educator, 28(5), 222-226. Retrieved from http://ezproxy.student.twu.ca:2087/sp-3.18.0b/ovidweb.cgi?QS2 =434f4e1a73d37e8cb6441ef9cf4b76cb51706ffb2f374669d73d8ff3933bcb15c1b91614c1 7c9b3cea747dd1715e95208ec3035c93a29a82ab4902e3e61d45be4c0c4976b5fc1c081f7c c48f8bb39341afbe2594537055631f68bc379d24a3738eff298ae6e1778bc1456d8570c025 240368c9020e3e796002b7266e51be79417e3f65f04de59035bdde3a5ae28018858320f2ab 736da380336086404673f7df193871723f6fca76ef38f1392bb1c73906ecac982aae8d71bf4 0b4f10094b21a522c0f0422d50da09e70f8c6a69a139d Fahrenwald, N. L., Taylor, J. Y., Kneipp, S. M., & Canales, M. K. (2007). Academic freedom and academic duty to teach social justice: A perspective and pedagogy for public health nursing faculty. Public Health Nursing, 24(2), 190-197. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?sid=9fd33430-09d4-49da9cf6-d68c3c334a63%40sessionmgr198&vid=11&hid=106 Falk-Rafael, A. (2005). Speaking truth to power: Nursing's legacy and moral imperative. Advances in Nursing Science, 28(3), 212-223. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?vid=23&sid=583c1d426d6e-4ecc-833c-ad3151c3d95d%40sessionmgr120&hid=105 Falk-Rafael, A., & Betker, C. (2012). Witnessing social injustice downstream and advocating for health equity upstream: "The trombone slide" of nursing. Advances in Nursing Science, 35(2), 98-112. doi:10.1097/ANS.0b013e31824fe70f Faulk, D. R., & Morris, A. H. (2012). Transformative learning environments: Teacher and UPHOLDING SOCIAL JUSTICE IN NURSING 205 learner perspectives. In A. H. Morris & D. R. Faulk (Eds.), Transformative learning in nursing: A guide for nurse educators (pp. 15-26). New York, NY: Springer Publishing Company. Retrieved from http://ezproxy.student.twu.ca:2152/ehost/ebookviewer/ebook /bmxlYmtfXzQ0NDM2N19fQU41?sid=9cea5f96-c954-4221-8132-b551ed4ace11 @sessionmgr4006&vid=0&format=EB&rid=1 Fleming, B. D., Thomas, S. E., Burnham, W. S., Charles, L. T., & Shaw, D. (2015). Improving ethnocultural empathy in healthcare students through a targeted intervention. Journal of Cultural Diversity, 22(2), 59-63. Retrieved from http://ezproxy.student.twu.ca:4434 /ehost/pdfviewer/pdfviewer?vid=152&sid=583c1d42-6d6e-4ecc-833c-ad3151c3d95d %40sessionmgr120&hid=105 Foronda, C. L., & Belknap, R. A. (2012). Short of transformation: American ADN students' thoughts, feelings, and experiences of studying abroad in a low-income country. International Journal of Nursing Education Scholarship, 9(1), 1-16. doi:10.1515/1548-923X.2411 Fowler, M. D. M. (2015). Guide to nursing’s social policy statement: Understanding the profession from social contract to social covenant. Silver Spring, MD: American Nurses Association. Garrard, J. (2017). Health sciences literature review made easy: The matrix method (5th ed.). Burlington, MA: Jones & Bartlett Learning. Giddings, L. S. (2005). A theoretical model of social consciousness. Advances in Nursing Science, 28(3), 224-239. Retrieved from http://ezproxy.student.twu.ca:2152/ehost /pdfviewer/pdfviewer?vid=6&sid=01c63527-88d9-4091-a69b-2d25e6730945 %40sessionmgr4009 UPHOLDING SOCIAL JUSTICE IN NURSING 206 Gillis, A., & Mac Lellan, M. (2010). Service learning with vulnerable populations: Review of the literature. International Journal of Nursing Education Scholarship, 7(1), 1-27. doi:10.2202/1548-923X.2041 Gillis, A., & Mac Lellan, M. A. (2013). Critical service learning in community health nursing: Enhancing access to cardiac health screening. International Journal of Nursing Education Scholarship, 10(1), 63-71. doi:10.1515/ijnes-2012-0031 Groh, C. J., Stallwood, L. G., & Daniels, J. J. (2011). Service-learning in nursing education: Its impact on leadership and social justice. Nursing Education Perspectives, 32(6), 400-405. doi:10.5480/1536-5026-32.6.400 Gupta, J. (2006). A model for interdisciplinary service-learning experience for social change. Journal of Physical Therapy Education, 20(3), 55-60. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?vid=99&sid=583c1d426d6e-4ecc-833c-ad3151c3d95d%40sessionmgr120&hid=105 Hart, S. (2015). Engaging the learner: The ABC's of service–learning. Teaching & Learning in Nursing, 10(2), 76-79. doi:10.1016/j.teln.2015.01.001 Healthy People 2020. (2015, December 23). Disparities. Retrieved from http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities Hunt, L., Ramjan, L., McDonald, G., Koch, J., Baird, D., & Salamonson, Y. (2015). Nursing students' perspectives of the health and healthcare issues of Australian indigenous people. Nurse Education Today, 35(3), 461-467. doi:10.1016/j.nedt.2014.11.019 Hunt, R. (2007). Service-learning: An eye-opening experience that provokes emotion and challenges stereotypes. Journal of Nursing Education, 46(6), 277-281. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?vid=2&sid=eb76c751- UPHOLDING SOCIAL JUSTICE IN NURSING 207 0fb5-4aae-9092-bd3d1a905fcc%40sessionmgr115&hid=115 Hunt, R. J., & Swiggum, P. (2007). Being in another world: Transcultural student experiences using service learning with families who are homeless. Journal of Transcultural Nursing, 18(2), 167-174. doi: 10.1177/1043659606298614 Jarrell, K., Ozymy, J., Gallagher, J., Hagler, D., Corral, C., & Hagler, A. (2014). Constructing the foundations for compassionate care: How service-learning affects nursing students' attitudes towards the poor. Nurse Education in Practice, 14(3), 299-303. doi:10.1016/j.nepr.2013.11.004 Joanna Briggs Institute. (2011a). Meta analysis of statistics assessment and review instrument. Retrieved from http://www.jbiconnect.org/sumari/mastari/common/login.cfm Joanna Briggs Institute. (2011b). Qualitative appraisal and review instrument. Retrieved from http://www.jbiconnect.org/sumari/qari/common/login.cfm Joanna Briggs Institute. (2014). Joanna Briggs Institute Reviewers’ Manual: 2014 Edition. Australia: Author. 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. 1-17). New York, NY: Routledge. Retrieved from http://ezproxy.student.twu.ca:2097/ehost/ebookviewer/ebook/bmxlYmtfXzgxNTA1MF9f QU41?sid=e618b80c-b78b-4878-9db2f18230a5a747@sessionmgr103&vid=0&format =EB&rid=1 Kent-Wilkinson, A., Starr, L., Dumanski, S., Fleck, J., LeFebvre, A., & Child, A. (2010). International nursing student exchange: Rural and remote clinical experiences in Australia. Journal of Agromedicine, 15(1), 58-65. doi:10.1080/10599240903389672 UPHOLDING SOCIAL JUSTICE IN NURSING 208 Knecht, J. G., & Fischer, B. (2015). Undergraduate nursing students' experience of servicelearning: A phenomenological study. Journal of Nursing Education, 54(7), 378-384. doi:10.3928/01484834-20150617-04 Kronk, R., Weideman, Y., Cunningham, L., & Resick, L. (2015). Capturing student transformation from a global service-learning experience: The efficacy of photoelicitation as a qualitative research method. Journal of Nursing Education, 54(9), S99S102. doi:10.3928/01484834-20150814-18 Krumwiede, K. A., Van Gelderen, S. A., & Krumwiede, N. K. (2014). Academic-hospital partnership: Conducting a community health needs assessment as a service learning project. Public Health Nursing, 32(4), 359-367. doi:10.1111/phn.12159 Langham, G., & Schutt, M. A. (2012). Service learning to promote social transformation in nursing students. In A. H. Morris & D. R. Faulk (Eds.), Transformative learning in nursing: A guide for nurse educators (pp. 119-128). New York, NY: Springer Publishing Company. Retrieved from http://ezproxy.student.twu.ca:2152/ehost/ebookviewer/ebook /bmxlYmtfXzQ0NDM2N19fQU41?sid=002d0c31-1278-4aa7-a9e1-355697b56209 @sessionmgr4010&vid=0&format=EB&rid=1 Larson, K. L., Ott, M., & Miles, J. M. (2010). International cultural immersion: En vivo reflections in cultural competence. Journal of Cultural Diversity, 17(2), 44-50. Retrieved from http://ezproxy.student.twu.ca:2097/ehost/pdfviewer/pdfviewer?vid=2 &sid=6719cca7-dd8c-401a-bc35-b457d433973a%40sessionmgr101 Lathrop, B. (2013). Nursing leadership in addressing the social determinants of health. Policy, Politics, & Nursing Practice, 14(1), 41-47. doi:10.1177/1527154413489887 Levett-Jones, T., Bowen, L., & Morris, A. (2015). Enhancing nursing students' understanding of UPHOLDING SOCIAL JUSTICE IN NURSING 209 threshold concepts through the use of digital stories and a virtual community called ‘Wiimali’. Nurse Education in Practice, 15(2), 91-96. doi:10.1016/j.nepr.2014.11.014 Levine, M. (2009). Transforming experiences: Nursing education and international immersion programs. Journal of Professional Nursing, 25(3), 156-169. doi:10.1016/j.profnurs.2009.01.001 Long, T. (2014). Influence of international service-learning on nursing student self-efficacy toward cultural competence. Journal of Nursing Education, 53(8), 474-478. doi:10.3928/01484834-20140725-02 Lonneman, W. (2015). Teaching strategies to increase cultural awareness in nursing students. Nurse Educator, 40(6), 285-288. doi:10.1097/NNE.0000000000000175 Mahony, D., & Jones, E. J. (2013). Social determinants of health in nursing education, research, and health policy. Nursing Science Quarterly, 26(3), 280-284. doi:10.1177/0894318413489186 Maltby, H. J., & Abrams, S. (2009). Seeing with new eyes: The meaning of an immersion experience in Bangladesh for undergraduate senior nursing students. International Journal of Nursing Education Scholarship, 6(1), 1-15. doi: 10.2202/1548-923X.1858 Marmot, M. G., Rose, G., Shipley, M., & Hamilton, P. J. S. (1978). Employment grade and coronary heart disease in British civil servants. Journal of Epidemiology and Community Health, 32(4), 244–249. doi: 10.1136/jech.32.4.244 Marmot, M. (2006). Chapter 1: Introduction. In M. Marmot & R. G. Wilkinson (Eds.), Social determinants of health (2nd ed.) (pp. 1-5). Oxford, NY: Oxford University Press. Marmot, M. (2015). The organization of misery. In The health gap: The challenge of an unequal world (pp. 22-48). London, UK: Bloomsbury Publishing Plc. UPHOLDING SOCIAL JUSTICE IN NURSING 210 Mawji, A., & Lind, C. (2013). Imogene: A simulation innovation to teach community health nursing. Clinical Simulation in Nursing, 9(11), e513-e519. doi:10.1016/j.ecns.2013.03.004 McNeil, R., Guirguis-Younger, M., Dilley, L. B., Turnbull, J., & Hwang, S. W. (2013). Learning to account for the social determinants of health affecting homeless persons. Medical Education, 47(5), 485-494. doi:10.1111/medu.12132 Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice. (3rd ed.). Philadelphia, PA: Wolters Kluwer Health. Menzel, N., Willson, L. H., & Doolen, J. (2014). Effectiveness of a poverty simulation in Second Life ®: Changing nursing student attitudes toward poor people. International Journal of Nursing Education Scholarship, 11(1), 39-45. doi:10.1515/ijnes-2013-0076 Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA: JosseyBass. Mezirow, J. (2009). Chapter two: Transformative learning theory. In Transformative learning in practice: Insights from community, workplace, and higher education (1st ed.) (pp. 1832). San Francisco, CA: Jossey-Bass. Retrieved from https://books.google.ca/books?id =OcVhvLDB22MC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepa ge&q&f=falsehttps://books.google.ca/books?id=OcVhvLDB22MC&printsec=frontcover &source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false Mezirow, J., & Associates. (1990). Fostering critical reflection in adulthood: A guide to transformative and emancipatory learning. San Francisco, CA: Jossey-Bass. Mezirow, J., & Associates. (2000). Learning as transformation: Critical perspectives on a theory in progress. San Francisco, CA: Jossey-Bass. UPHOLDING SOCIAL JUSTICE IN NURSING 211 Mezirow, J., Taylor, E. W., & Associates. (2009). Transformative learning in practice: Insights from community, workplace, and higher education. San Francisco, CA: Jossey-Bass. Mikkonen, J., & Raphael, D. (2010). Social determinants of health: The Canadian facts. Toronto, ON: York University School of Health Policy and Management. [PDF]. Retrieved from http://www.thecanadianfacts.org/The_Canadian_Facts.pdf Mohammed, S. A., Cooke, C. L., Ezeonwu, M., & Stevens, C. A. (2014). Sowing the seeds of change: Social justice as praxis in undergraduate nursing education. Journal of Nursing Education, 53(9), 488-493. doi:10.3928/01484834-20140805-03 Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Journal of Clinical Epidemiology, 62, 1006-1012. doi:10.1016/j.jclinepi.2009.06.005 Morris, A. H., & Faulk, D. R. (2012). Transformative learning as an innovative pedagogy for nursing education. In A. H. Morris & D. R. Faulk (Eds.), Transformative learning in nursing: A guide for nurse educators (pp. 3-14). New York, NY: Springer Publishing Company. Retrieved from http://ezproxy.student.twu.ca:2152/ehost/ebookviewer /ebook/bmxlYmtfXzQ0NDM2N19fQU41?sid=4c9af8f5-f2da-4076-9d01-b80848f37a55 @sessionmgr4007&vid=0&format=EB&rid=1 Murray, B. A. (2015). Nursing students' experiences of health care in Swaziland: Transformational processes in developing cultural understanding. Journal of Nursing Education, 54(9), S65-S73. doi:10.3928/01484834-20150814-13 Narsavage, G. L., Lindell, D., Chen, Y. J., Savrin, C., & Duffy, E. (2002). A community engagement initiative: Service-learning in graduate nursing education. Journal of Nursing Education, 41(10), 457-461. Retrieved from http://ezproxy.student.twu.ca:2152 UPHOLDING SOCIAL JUSTICE IN NURSING 212 /ehost/pdfviewer/pdfviewer?vid=3&sid=ef605be1-cf54-4095-8235-bc05050bb2f9 %40sessionmgr4008 National Center for Biotechnology Information. (n.d.). PubMed. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/ Nokes, K. M., Nickitas, D. M., Keida, R., & Neville, S. (2005). Does service-learning increase cultural competency, critical thinking, and civic engagement? Journal of Nursing Education, 44(2), 65-70. Retrieved from http://ezproxy.student.twu.ca:4434/ehost /pdfviewer/pdfviewer?sid=583c1d42-6d6e-4ecc-833c-ad3151c3d95d%40sessionmgr120 &vid=258&hid=105 Norbeck, J. S., Connolly, C., & Koerner, J. (2008). Introduction. In J. S. Norbeck, C. Connolly, & J. Koerner (Eds.), Caring and community: Concepts and models for service-learning in nursing (pp. 1–6). Sterling, VA: Stylus Publishing, LLC. Retrieved from https://books.google.ca/books?id=48WrGsW3cfAC&pg=PA2&lpg=PA2&dq=%22the+o utcomes+of+the+service+delivery+at+the+community+level%22+(Koerner)&source=bl &ots=x_Mjwh6wFC&sig=Hq5N2nvL4R5U2xeLJLWAxFd2L78&hl=en&sa=X&ved=0a hUKEwi70dWWmvvJAhWJ2T4KHb_lBJYQ6AEIGzAA#v=onepage&q=%22the%20ou tcomes%20of%20the%20service%20delivery%20at%20the%20community%20level%22 %20(Koerner)&f=false Oxford Reference. (n.d.). Mandate. Retrieved from http://ezproxy.student.twu.ca:2223/view/10 .1093/acref/9780195160901.001.0001/acref-9780195160901-e-2691?rskey=QdMtie &result=10 UPHOLDING SOCIAL JUSTICE IN NURSING 213 Oxford University Press. (2015a). Address, n. Retrieved from http://ezproxy.student.twu.ca :2237/view/Entry/2208?rskey=fCQk0s&result=1&isAdvanced=false#eidhttp://ezproxy.st udent.twu.ca:2237/view/Entry/2208?rskey=fCQk0s&result=1&isAdvanced=false#eid Oxford University Press. (2015b). Address, v. Retrieved from http://ezproxy.student.twu.ca :2237/view/Entry/2209?rskey=fCQk0s&result=2&isAdvanced=false#eid Patterson, N., & Hulton, L. J. (2012). Enhancing nursing students' understanding of poverty through simulation. Public Health Nursing, 29(2), 143-151. doi:10.1111/j.1525-1446.2011.00999.x Pennington, K., Coast, M. J., & Kroh, M. (2010). Health care for the homeless: A partnership between a city and a school of nursing. Journal of Nursing Education, 49(12), 700-703. doi:10.3928/01484834-20100930-02 Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Pope, C., Mays, N., & Popay, J. (2007). Synthesizing qualitative and quantitative health evidence: A guide to methods. Retrieved from http://ezproxy.student.twu.ca:4437/ehost /ebookviewer/ebook/bmxlYmtfXzIzNDI0Ml9fQU41?sid=54143d8c-e9de-4fe3-bfe7c00c3f61bcea@sessionmgr4004&vid=1&format=EB&rid=1 Public Health Agency of Canada. (2015, July 28). Social Determinants of Health. Retrieved from http://cbpp-pcpe.phac-aspc.gc.ca/public-health-topics/social-determinants-of-health/ Rasmor, M., Kooienga, S., Brown, C., & Probst, T. M. (2014). United States nurse practitioner students' attitudes, perceptions, and beliefs working with the uninsured. Nurse Education in Practice, 14(6), 591-597. doi:10.1016/j.nepr.2014.05.011 UPHOLDING SOCIAL JUSTICE IN NURSING 214 Reimer-Kirkham, S., & Browne, A. J. (2006). Toward a critical theoretical interpretation of social justice discourses in nursing. Advances in Nursing Science, 29(4), 324-339. Retrieved from http://ezproxy.student.twu.ca:2087/sp-3.15.1b/ovidweb.cgi?&S =BMCPFPOOIGDDGIOPNCKKOHIBJFEGAA00&Link+Set=S.sh.22.23.27.31|6|sl_10 Reimer-Kirkham, S., Hoe Harwood, C., & Van Hofwegen, L. (2005). Capturing a vision for nursing: Undergraduate nursing students in alternative clinical settings. Nurse Educator, 30(6), 263-270. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/detail/detail ?vid=201&sid=583c1d42-6d6e-4ecc-833c-ad3151c3d95d%40sessionmgr120&hid =105&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#AN=106394042&db=ccm Reimer-Kirkham, S., Van Hofwegen, L., & Hoe Harwood, C. (2005). Narratives of social justice: Learning in innovative clinical settings. International Journal of Nursing Education Scholarship, 2(1), 1-14. doi:10.2202/1548-923X.1166 Reimer-Kirkham, S., Van Hofwegen, L., & Pankratz, D. (2009). Keeping the vision: Sustaining social consciousness with nursing students following international learning experiences. International Journal of Nursing Education Scholarship, 6(1), 1-16. doi:10.2202/1548-923X.1635 Reising, D. L., Shea, R. A., Allen, P. N., Laux, M. M., Hensel, D., & Watts, P. A. (2008). Using service-learning to develop health promotion and research skills in nursing students. International Journal of Nursing Education Scholarship, 5(1), 1-15. Retrieved from http://ezproxy.student.twu.ca:4434/ehost/pdfviewer/pdfviewer?sid=583c1d42-6d6e-4ecc833c-ad3151c3d95d%40sessionmgr120&vid=241&hid=105 UPHOLDING SOCIAL JUSTICE IN NURSING 215 Reutter, L., & Kushner, K. E. (2010). ‘Health equity through action on the social determinants of health’: Taking up the challenge in nursing. Nursing Inquiry, 17(3), 269-280. doi:10.1111/j.1440-1800.2010.00500.x Rooks, R. N., & Rael, C. T. (2013). Enhancing curriculum through service learning in the social determinants of health course. Journal of the Scholarship of Teaching and Learning, 13(2), 84-100. Retrieved from http://josotl.indiana.edu/article/view/3147/3392 Rowan, M. S., Rukholm, E., Bourque-Bearskin, L., Baker, C., Voyageur, E., & Robitaille, A. (2013). Cultural competence and cultural safety in Canadian schools of nursing: A mixed methods study. International Journal of Nursing Education Scholarship, 10(1), 1-10. doi:10.1515/ijnes-2012-0043 Sabo, S., de Zapien, J., Teufel-Shone, N., Rosales, C., Bergsma, L., & Taren, D. (2015). Service learning: A vehicle for building health equity and eliminating health disparities. American Journal of Public Health, 105, S38-43. doi:10.2105/AJPH.2014.302364 Sandelowski, M., Voils, C. I., & Barroso, J. (2006). Defining and designing mixed research synthesis studies. Research in the Schools, 13(1), 29. Retrieved from http://ezproxy.student.twu.ca:5115/pmc/articles/PMC2809982/pdf/nihms151622.pdf Sandelowski, M., Voils, C. I., Leeman, J., & Crandell, J. L. (2012). Mapping the mixed methods–mixed research synthesis terrain. Journal of Mixed Methods Research, 6(4), 317-331. doi:10.1177/1558689811427913 Smit, E. M., Delpier, T., Giordana, S. L., & Tremethick, M. J. (2012). Learning and helping: Benefits of international nurse practitioner student experiences. Online Journal of Cultural Competence in Nursing & Healthcare, 2(1), 18-28. Retrieved from https://www.researchgate.net/profile/Terry_Delpier/publication/272760884_Learning_an UPHOLDING SOCIAL JUSTICE IN NURSING 216 d_Helping_Benefits_of_International_Nurse_Practitioner_Student_Experiences/links/573 d11ff08ae9f741b2ec6e3/Learning-and-Helping-Benefits-of-International-NursePractitioner-Student-Experiences.pdf Smith, G. R. (2007). Health disparities: What can nursing do? Policy, Politics, & Nursing Practice, 8(4), 285-291. doi:10.1177/1527154408314600 Smith-Miller, C. A., Leak, A., Harlan, C. A., Dieckmann, J., & Sherwood, G. (2010). "Leaving the comfort of the familiar": Fostering workplace cultural awareness through short-term global experiences. Nursing Forum, 45(1), 18-28. Retrieved from http://ezproxy.student.twu.ca:2195/doi/10.1111/j.1744-6198.2009.00163.x/epdf Snyder, M. (2014). Emancipatory knowing: Empowering nursing students toward reflection and action. Journal of Nursing Education, 53(2), 65-69. doi:10.3928/01484834-20140107-01 Taylor, E. W. (2009). Chapter one: Fostering transformative learning. In Transformative learning in practice: Insights from community, workplace, and higher education (1st ed.) (pp. 3-17). San Francisco, CA: Jossey-Bass. Retrieved from https://books.google.ca /books?id=OcVhvLDB22MC&printsec=frontcover&source=gbs_ge_summary_r&cad=0 #v=onepage&q&f=false Teddlie, C., & Tashakkori, A. (2009). Foundations of mixed methods research: Integrating quantitative and qualitative approaches in the social and behavioral sciences. Thousand Oaks, CA: SAGE Publications. Retrieved from https://books.google.ca/books?id =c3uojOS7pK0C&pg=PT6&dq=Foundations+of+mixed+methods+research:+Integrating +quantitative+and+qualitative+approaches+in+the+social+and+behavioral+sciences&hl= en&sa=X&redir_esc=y#v=onepage&q=Foundations%20of%20mixed%20methods%20re UPHOLDING SOCIAL JUSTICE IN NURSING 217 search%3A%20Integrating%20quantitative%20and%20qualitative%20approaches%20in %20the%20social%20and%20behavioral%20sciences&f=false The Truth and Reconciliation Commission of Canada. (2015). Honouring the truth, reconciling for the future: Summary of the final report of the truth and reconciliation commission of Canada. [PDF]. Retrieved from http://www.myrobust.com/websites/trcinstitution/File /Reports/Executive_Summary_English_Web.pdf Thomson Reuters. (2015). EndNote. Retrieved from https://www.myendnoteweb.com /EndNoteWeb.html Thorne, S. (2016a). Chapter eight: Working data. In Interpretive description: Qualitative research for applied practice (2nd ed.) (pp. 155-171). New York, NY: Routledge. Thorne, S. (2016b). Chapter nine: Transforming data. In Interpretive description: Qualitative research for applied practice (2nd ed.) (pp. 173-197). New York, NY: Routledge. Thurman, W., & Pfitzinger-Lippe, M. (2017). Returning to the profession's roots: Social justice in nursing education for the 21st century. Advances in Nursing Science, 40(2), 184-193. doi:10.1097/ANS.0000000000000140 Townsend, L., Gray, J., & Forber, J. (2015; in press). New ways of seeing: Nursing students' experiences of a pilot service learning program in Australia. Nurse Education in Practice, 1-6. Retrieved from http://ezproxy.student.twu.ca:2147/S1471595315001328 /1-s2.0-S1471595315001328-main.pdf?_tid=52631500-799b-11e7-8268-00000aacb35d &acdnat=1501909547_98ee48e55a2478dd9fe08f3116f98ac5 Trinity Western University. (2015, September 8). PsycINFO (EBSCOhost). Retrieved from http://www.twu.ca/library/PsycINFO.htm Ulvund, I., & Mordal, E. (2017). The impact of short term clinical placement in a developing UPHOLDING SOCIAL JUSTICE IN NURSING 218 country on nursing students: A qualitative descriptive study. Nurse Education Today, 55, 96-100. doi:10.1016/j.nedt.2017.05.013 Valderama-Wallace, C. P. (2017). Critical discourse analysis of social justice in nursing's foundational documents. Public Health Nursing, 34(4), 363-369. doi:10.1111/phn.12327 Vandenberg, H., & Kalischuk, R. G. (2014). Conceptualizations of culture and cultural care among undergraduate nursing students: An exploration and critique of cultural education. Journal of Cultural Diversity, 21(3), 99-107. Retrieved from http://ezproxy.student.twu.ca:2211/openview/241d34ca93cba9467cafaa537fc57d9f/1?pqorigsite=gscholar Van Hofwegen, L., Kirkham, S., & Harwood, C. (2005). The strength of rural nursing: Implications for undergraduate nursing education. International Journal of Nursing Education Scholarship, 2(1), 1-13. doi:10.2202/1548-923X.1142 Villeneuve, M. J. (2008). Yes we can! Eliminating health disparities as part of the core business of nursing on a global level. Policy, Politics, & Nursing Practice, 9(4), 334-341. doi:10.1177/1527154408328661 Vliem, S. (2015). Nursing students' attitudes toward poverty: Does experiential learning make a difference? Nurse Educator, 40(6), 308-312. doi:10.1097/NNE.0000000000000168 Vogt, M. A., Chavez, R., & Schaffner, B. (2011). Baccalaureate nursing student experiences at a camp for children with diabetes: The impact of a service-learning model. Pediatric Nursing, 37(2), 69-73. Retrieved from http://ezproxy.student.twu.ca:4434/ehost /pdfviewer/pdfviewer?vid=235&sid=583c1d42-6d6e-4ecc-833c-ad3151c3d95d %40sessionmgr120&hid=105 Wagner, L. D., & Christensen, S. E. (2015). Establishment of a short-term global health nursing UPHOLDING SOCIAL JUSTICE IN NURSING 219 education experience: Impact on students' ways of knowing. Journal of Nursing Education, 54(5), 295-299. doi:10.3928/01484834-20150417-09 Waite, R., & Brooks, S. (2014). Cultivating social justice learning & leadership skills: A timely endeavor for undergraduate student nurses. Nurse Education Today, 34(6), 890-893. doi:10.1016/j.nedt.2014.02.009 Walsh, L. V., & DeJoseph, J. (2003). “I saw it in a different light”: International learning experiences in baccalaureate nursing education. Journal of Nursing Education, 42(6), 266-272. Retrieved from http://ezproxy.student.twu.ca:2152/ehost/pdfviewer /pdfviewer?vid=8&sid=ef605be1-cf54-4095-8235-bc05050bb2f9%40sessionmgr4008 Whitehead, M. (2000). The concepts and principles of equity and health. Copenhagen: World Health Organization. [PDF]. Retrieved from http://salud.ciee.flacso.org.ar/flacso /optativas/equity_and_health.pdf Wros, P., Mathews, L. R., Voss, H., & Bookman, N. (2015). An academic-practice model to improve the health of underserved neighborhoods. Family & Community Health, 38(2), 195-203. doi:10.1097/FCH.0000000000000065 Zanchetta, M., Schwind, J., Aksenchuk, K., Gorospe, F. F., & Santiago, L. (2013). An international internship on social development led by Canadian nursing students: Empowering learning. Nurse Education Today, 33(7), 757-764. doi:10.1016/j.nedt.2013.04.019 Zanchetta, M., Taher, Y., Fredericks, S., Waddell, J., Fine, C., & Sales, R. (2013). Undergraduate nursing students integrating health literacy in clinical settings. Nurse Education Today, 33(9), 1026-1033. doi:10.1016/j.nedt.2012.05.008 UPHOLDING SOCIAL JUSTICE IN NURSING 220 Appendix A FOCUSED DATABASE SEARCH STRATEGIES FOR REVIEWING THE LITERATURE* Database Searched PubMed CINAHL Search Search 1*: (("nurs* educat*") AND ("social justice" OR "social determinant*")) Limits and Database-Specific Strategies Applied - Limits: Publication date: 2000-01-01 to 2015-12-31; English language. - Searched in “All Fields”. - Limits: Publication date from 2000/01/01 to 2015/12/31; English language. Search 2: ("Education, Nursing"[Mesh]) AND ("Social Justice"[Mesh] OR "Social Determinants of Health"[Mesh]) Search 3: Culture vs. Equity discourses: Part 1: (("nursing education") AND ("cultur* diversi*" OR "cultur* sensitivit*" OR "cultur* competenc*")) Search 4: Culture vs. Equity discourses: Part 2: ((nurs*) AND ("cultur* diversi*" OR "cultur* sensitivit*" OR "cultur* competenc*")) AND ((nurs*) AND (social justice OR social determinant* of health)) Search 1: ("nursing education") AND (justice OR "social determinants of health") Search 2: ("nurs* - Articles screened educat*") AND (justice with limiters in OR "social determinant*") mind (due to small number of results). Results 212 87 1,790 117 97 120 UPHOLDING SOCIAL JUSTICE IN NURSING Search 3: "nursing education" AND "service learning" Search 4: (MH "Social Determinants of Health") OR (MH "Health Status Disparities") OR (MH "Social Justice") AND (MM "Education, Nursing, Diploma Programs") OR (MM "Education, Nursing, Associate") OR (MM "Education, Nursing, Practical") OR (MM "Education, Nursing, Masters") OR (MM "Education, Nursing, Doctoral") OR (MM "Education, Nurse Anesthesia") OR (MM "Education, Nursing, Theory-Based") OR (MM "Education, Nursing, Research-Based") OR (MM "Education, Nursing, Post-Doctoral") OR (MM "Education, Nursing, Graduate+") OR (MM "Education, Nursing, Continuing") OR (MM "Education, Nursing, Baccalaureate+") OR (MM "Education, Nursing+") OR (MH "Education, Diploma Programs+") OR (MM "Education, Post-RN") OR (MM "Students, Nursing, Male") OR (MM "Students, Nursing, Graduate+") OR (MM "Students, Nursing, Doctoral") OR (MM "Students, Nursing, Associate") OR (MM 221 136 - Limits: English Language; Published Date: January 2000 – December 2015; Peer reviewed. - Did not choose any subheadings for greater inclusivity. Searched with both “explode” and “major concept” functions. - Search mode: Find all my search terms. - Apply related words. 79 UPHOLDING SOCIAL JUSTICE IN NURSING "Students, Nursing, Masters") OR (MM "Students, Nursing, Diploma Programs") OR (MM "Students, Nursing, Baccalaureate+") OR (MM "Students, Nursing+") OR (MM "New Graduate Nurses") Search 1: (nurs* educat*) AND (social n5 determinant* OR "social just*" OR equit* OR inequit*) PsycINFO Search 2: Heading Search: (S3) AND (S4 OR S5 OR S2 OR S1 OR S6 OR S7 OR S8) where: S8: MM "Socioeconomic Status" OR MM "Family Socioeconomic Level" OR MM "Income Level" OR MM "Lower Class" OR MM "Social Class" S7: MM "Social Change" S6: MM "Social Deprivation" OR MM "Social Isolation" S5: MM "Disadvantaged" S4: MM "Social Issues" OR MM "Crime" OR MM "Homeless" OR MM "Human Rights" OR MM "Paternalism" OR MM 222 - Limits: Peer Reviewed/Refereed (Scholarly); Date Published 2000 (January) – 2015 (December); English language. - Searched with “Apply related words” as an expander. - Searched with “Find all my search terms”. - Searched under “All Results” for Source Types. - No limits applied due to small number of results. 336 31 UPHOLDING SOCIAL JUSTICE IN NURSING 223 "Peace" OR MM "Poverty" OR MM "Social Discrimination" OR MM "Social Equality" OR MM "Social Integration" OR MM "Unemployment" OR MM "War" S3: (MM "Nursing Education" OR MM "Nursing Students") S2: MM "Social Justice" S1: MM "Equity (Social)" ScienceDirect ProQuest Dissertations and Theses Global Search 1: ("nursing education") AND ("social justice" OR "social determinants of health") Search 1: ("nurs* educat*") AND ("social justice" OR "social NEAR/5 determinant*") Search 2: ("nurs* educat*") AND ("social justice" OR social NEAR/5 determinant*) - Limit: from 2000 to Present. - Searched under ALL tab, including all types of publications. 295 1,694 - Limits: Peer reviewed, scholarly journals; English language; Date range: 2000, January, any day, to 2015, December, any day. - Searched in all fields. - Searched under “Command Line Search” option of “Advanced Search”. - 32 databases searched, including “ProQuest Dissertations & Theses Global”. These automatically searched 48 UPHOLDING SOCIAL JUSTICE IN NURSING EMBASE Search 1: (nurs* educat* AND (social adj5 determinant* OR just* OR equit*) Search 2: "nurs* educat*".sh,hw,ec,fs; "just*".sh,hw,ec,fs. 224 for/generated by ProQuest system. - Limits: English language and 2000 to 2015. - Searched in All Fields. - Searched in “heading-related” fields of: Heading word (hw), Subject headings (sh), Embase Section Headings (ec), and Floating Subheading (fs). 569 125 Search 3: ("nursing education" and "social 281 determinants of health") Note. * Searches are at times abbreviated as “S” followed by the corresponding search number. Headings were not available to be searched for ScienceDirect. Several scoping searches were conducted in addition to these more focused, database searches. For example, an initial search was conducted in CINAHL—nurs* AND (educat* OR clinical OR learn*) AND (social n5 determinant* OR social OR just*)—yielding 15,061 articles, all of which were reviewed. Further, scoping searches were at times conducted in GoogleScholar, another database that I had known to contain quality nursing research from previous experience. Moreover, other search strategies specific to databases were utilized when possible (e.g. the “find relevant articles” function). Retrieved articles are relevant articles and potential options for synthesis. Please note: These numbers add up to 6,017 and represent articles prior to the removal of duplicates (as, once results from each database search are combined into one “group” in EndNote to remove duplicates, one cannot tell which database articles originally came from). “Headings” refers to the controlled vocabulary used by each database; specifically, CINAHL’S “CINAHL Headings”, PubMed’s “Medical Subject Headings (MeSH)”, PsycINFO’s “Thesaurus”, ProQuest’s “Thesaurus”, and EMBASE’s “Emtree”. Running head: UPHOLDING SOCIAL JUSTICE IN NURSING 225 Appendix B REVIEW MATRIX DISPLAYING SYNTHESIZED STUDIES Authors, Year, Study Narsavage, Lindell, Chen, Savrin, and Duffy (2002). A Community Engagement Initiative: ServiceLearning in Graduate Nursing Education. Journal of Nursing Education. Purpose The CETSL (community engagement through servicelearning) project was meant to provide graduate NS “with an opportunity to link nursing theory and clinical experience with the social environment (i.e., to serve and learn in the “real world”). The health care needs of Cleveland’s innercity community were the primary focus of service” (p. 457). Method (Design, Data Collection, Intervention) Design: Mixedmethods: “[b]oth qualitative and quantitative tools for formative (e.g., journaling, midcourse focus groups) and summative (e.g., surveys, focus groups) methods were used” (p. 459). Data Collection: - “… pretest questionnaires … and, after the service-learning activities, completed two posttests… ” (p. 459). Participants - 79 participants - “Master's of science in nursing students (N = 79)” (p. 458). - “70 female (88.6%) and 9 (11.4%) male students” (p. 459). - “The average ages were 34 for female students and 31 for male students” (p. 459). - “Most respondents were White (73.4%), although 9 were international Data Analysis - “… themes of [SL] in graduate education were identified through analysis of transcripts of focus groups and reflection responses from a Web-based educational discussion board” (p. 459). - “Demographic and survey data from students were analyzed using the Statistical Package for the Social Sciences 11.1 for Windows…. paired t tests compared the relationship of the students’ responses Study Results - “Most students agreed they had learned new skills (e.g., assessment), especially with individuals who were underprivileged and minimally educated, and how to deliver needed health care or information to these populations” (p. 459). - Students valued their experiences overall: “… 75% of all students reported learning as much or more than they did with the ‘usual methods’” (p. 459). Study Recommendations “… to continually assess the benefits of interventions not only to students but also the community agencies and the constituents served” (p. 460). UPHOLDING SOCIAL JUSTICE IN NURSING - Pre- and post-tests measured “expected outcomes of the CETSL program” (p. 458). 226 students from Asian and African countries” (p. 459). before and after the CETSL projects. Significance level was set at p < .05” (p. 459). - Learning: “The statistical analysis of the pretest and posttest quantitative evaluation demonstrates significant learning after the CETSL activities (p < .0001)” (p. 460). Specifically, on learning: “Student means (1 = low to 5 = high) attested to a higher level of understanding of their role as community resources in providing health service in the community” (p. 460). Overall, students learned about the “needs and barriers” (p. 460) of populations and how they could act as resources for the community. - 9 participants Two independent researchers reviewed interview transcripts and journals—following a process of “analytic induction” - Three themes were ultimately identified: being “other,” “I was already a nurse,” and expanding my worldview (p. 266). Intervention (Description of educational experience): Students developed educational materials and programs (e.g., for diabetic clients); performed practical activities such as obtaining “cholesterol levels and blood glucose levels” (p. 458); and developed numerous creative projects, such as a "‘Who Wants to Be a Millionaire’ game [to] be used by staff to assess participants' cognitive function and reaction time" (p. 458). Walsh and DeJoseph (2003). “I Saw it in a Different Light”: International Learning Experiences in “This study explored the experiences of nursing students and faculty mentors who participated in Design: “exploratory descriptive study” (p. 267). Data Collection: - “For this study, a - “Two participants were faculty members, two were recent graduates of the baccalaureate “Further research will help nurse educators understand which components of immersion experiences are UPHOLDING SOCIAL JUSTICE IN NURSING Baccalaureate Nursing Education. Journal of Nursing Education. a short-term immersion learning project in Central America to identify conceptual themes that may contribute to development of cultural competence” (p. 267). demographic data sheet was developed to obtain information about participants’ ages, ethnicities, and birthplaces, as well as languages they spoke and their previous international experiences” (p. 268). - Interviews of students and faculty. - “Other data sources included students’ applications; journals kept by all participants during the 2-week immersion experience…; a 2hour postimmersion focus group interview; and a written evaluation of the experience” (p. 268). Intervention (Description of educational experience): E.g., visiting "… the comadona’s clients… the students 227 program, and five were upper division undergraduate students” (p. 269). - Participants were from “… a Jesuit and Roman Catholic university in the western United States” (p. 267). - All participants were women. - “The median age of the 9 participants was 28.4, with a range of 21 to 52 (mode = 24)” (p. 269). - “Most (n = 7) had been born in the United States. Five participants identified themselves as European American, 3 were Latina, and 1 selected ‘other’” (p. 269). - “Most participants (n = 6) spoke both English and Spanish, and the remainder spoke (p. 268)—and prepared an initial thematic analysis. They then met to compare themes. 1). Being “Other”: Participants felt like the minority, due in part to a language barrier. 2). “I Was Already a Nurse”: Students realized they did have the knowledge and skills to intervene, came to better understand the role of the nurse and felt more like professional nurses. 3). Expanding my Worldview: Expanded worldviews included increased understanding of the Guatemalan culture, developing relationships with Guatemalans, and comparing poverty between Guatemala and the U.S. most associated with participants’ personal and professional growth and whether there is a long-term effect on their practice” (p. 272). UPHOLDING SOCIAL JUSTICE IN NURSING Evanson and Zust (2004). The Meaning of Participation in an International Service Experience Among Baccalaureate Nursing Students. International Journal of Nursing Education Scholarship. “… to explore the meaning assigned by baccalaureate nursing students to their participation in a short- term international service experience” (p. 3), and, “to describe the findings from the research study” (p. 1). 228 and faculty assessed the clients using tools not readily available to comadronas (e.g., stethoscope, sphygmomanometer , fetoscope)" (p. 268). English only” (p. 269). Design: Qualitative. - 9 participants - Content analysis. Data Collection: - Data collected through “reflection journals, evening group conversations in Guatemala, written narratives, and a postexperience focus group interview” (“Abstract”). - “self-selection process of participants” (p. 12). - Two researchers independently reviewed the data, identified emerging themes, and compared these for similarities and differences. - “participant observation” (p. 6). - Focus group interview took place 2 weeks after return to U.S. with all 9 students. Intervention (Description of educational experience): - Students partook in varied activities, such as working at - all baccalaureatenursing students, from a Midwest liberal arts college. - 8 students seniors; 1 a junior. - “Their ages ranged from 21 to 27 years” (p. 5). - “Two were fluent in Spanish” (p. 5). - Together the 2 researchers identified major themes. Six themes: 1). Clarification of career path or goals 2). Improved understanding of social justice and globalization issues 3). Motivation to continue service work 4). Discovering the reciprocity of relationships with others 5). Appreciation for the whole person 6). Finding a way to respect the sacredness of the experience “Further research is needed to understand what impact a meaningful international experience has upon later personal and professional life” (p. 12). UPHOLDING SOCIAL JUSTICE IN NURSING 229 the mission’s hospital, providing prenatal assessments, and assessing children. - Students especially valued the learning from informal activities, such as conversing and playing with children (p. 5). Reimer-Kirkham, Hoe Harwood, and Van Hofwegen (2005). Capturing a Vision for Nursing: Undergraduate Nursing Students in Alternative Clinical Settings. Nurse Educator. To explore students’ learning of population nursing care in alternative clinical sites, including corrections, rural, parish, Aboriginal, and international sites. Design: Qualitative. - 65 participants Data Collection: - Separate focus groups ran for nurses, instructors, and students. - Convenience sample of students (in 3rd or 4th year of baccalaureate [BSN]) nursing program) placed in one of five alternative community settings. - Interviews held when focus groups not feasible. Intervention (Description of educational experience): Often students’ experiences included a debriefing process when students could reflect on their learning. In international settings, students went as a group - Most students enrolled in a community health course (e.g. completing preceptorships or clinical practicums). - Clinical instructors and RNs supervising students also comprised sample. - Repeated immersions. - Code book developed (joint coding of about 30% of transcripts). - Thematic analysis (used Interpretive descriptive method as outlined by Thorne et al.). - Qualitative data analysis software employed. Three themes: 1). Envisioning possibilities (content of learning): Students felt empowered as they perceived the many opportunities for nursing in community settings, and grasped that they did in fact have sufficient skills to address community needs. 1). Understanding realities (content of learning): - In international settings, students gained awareness of how economic factors and determinants of health contributed Nurse educators must carefully consider organization of experiences, creation of partnerships with host sites, and proper preparation and screening of students. UPHOLDING SOCIAL JUSTICE IN NURSING with 2 instructors and experienced urban and rural opportunities. In the rural setting, one student went to work with a midwife independently. 230 to complexities of health. - Aboriginal setting (social, cultural, & historical context) also facilitated understanding of social justice. - Gained greater recognition of nurses’ professional role. - Students gained greater awareness of how “economics, history, and politics…. produce…. disparities” (p. 269). - Overall, students’ “confidence and abilities grew” (p. 265). 2). Engaging in learning (process of learning): - Includes critical reflection (on views and biases), student initiative and autonomy, and service. UPHOLDING SOCIAL JUSTICE IN NURSING 231 - Many students commented their international experiences changed their practice upon return to Canada. - Students evidenced great energy and enthusiasm in willingly going over and beyond clinical expectations of them. 3). Creating transformative learning environments (structuring the learning) Reimer-Kirkham, Van Hofwegen, and Hoe Harwood (2005). Narratives of Social Justice: Learning in Innovative Clinical Settings. International Journal of Nursing Education Scholarship. “Specifically, “The aims of the study were to: a) describe the learning experiences of nursing students in [innovative] settings; b) elicit the perspectives of… nursing instructors … c) describe the experiences of [RNs]… d) evaluate innovative… settings for attainment of Design: Qualitative. - 65 participants Data Collection: - “focus groups and interviews over a 2year data collection period” (p. 3). - “… 65 undergraduate nursing students, clinical instructors, and RN mentors” (Abstract). - “Separate focus groups were held for students, instructors, and nurses” (p. 4). Intervention (Description of - “Students were in the third and fourth years of a four-year baccalaureate nursing Program” (p. 3). - Data analysis started with repeated immersions, then progressed to codebook development. - Roughly 30% of transcripts were jointly coded. - Thematic analysis then followed abiding by the - “The focus of this paper is on a particular aspect of the findings, namely, the ways in which discourses of social justice were taken up by participants” (p. 4). Critical Awareness: Being Witness: - To poverty, inequities, and marginalization. - “Substantive theory regarding social justice, resource allocation, health disparities, vulnerable populations, globalization, relations of power and so forth is needed in nursing curricula” (p. 11). - “Nurse educators committed to UPHOLDING SOCIAL JUSTICE IN NURSING student learning goals; e) examine the service component of innovative… placements; and f) examine ethical, legal, and academic issues associated with … these settings for the attainment of student learning goals” (p. 3). educational experience): Activities varied, including accompanying midwives during home visits, and joining members of an Aboriginal community in their activities. 232 - “Eight students in corrections were in the community component of a third year mental health course. Three students in Aboriginal communities were completing senior preceptorships” (p. 3). interpretivedescriptive method. - “Data management and analyses were facilitated by the QRS N-Vivo software V2.0.163” (p. 4). - Included learning about the Aboriginal culture through, for instance, participation in a bark-stripping tradition. Critical Engagement: Experiencing Dissonance and Engaging in Critical Reflection: Included descriptions of difficulty coming to terms with the poverty witnessed; physical difficulties such as using transportation; and feeling like a minority. fostering such transformation must question how we they [sic] model praxis. Are they ready to engage in social change as faculty, possibly requiring a move beyond the comfortable enclaves of academia?” (p. 12). - “More research is needed that evaluates the longterm effects of learning such as that which occurs in innovative clinical placements that heightens social consciousness…” (p. 12). Seeking Social Change: - A renewed commitment to social transformation. - More research is needed exploring “… what strategies best support civic engagement over time” (p. 12). - For example, in trying to “erase all those prejudices” (p. 8) about different cultures. - “Catalysts for transformative learning, the processes leading up to transformational change, and the UPHOLDING SOCIAL JUSTICE IN NURSING 233 dialectic between individual and social transformation have also been identified as areas for future research (Schugurensky, 2002)” (p. 12). Van Hofwegen, Kirkham, and Harwood (2005). The Strength of Rural Nursing: Implications for Undergraduate Nursing Education. International Journal of Nursing Education Scholarship. “… to examine student learning opportunities for community health nursing in a rural clinical placement… from the perspective of students, clinical instructors, and nurses” (p. 3). Design: Qualitative. - 14 participants Data Collection: “Three student focus groups, a joint interview of 2 RNs, and an interview of the clinical instructor were conducted” (p. 5). - Convenience sample. Intervention (Description of educational experience): Students participated in a community health fair, and created programs such as a “drug awareness program” (p. 8). Moreover, in working with clients, students “… saw a full spectrum of health needs including mental health, infectious disease, substance - “11 fourth-year undergraduate nursing students… 2 RNs who facilitated students’ clinical experience, and the universitybased clinical instructor” (p. 4). - “Students from three separate experiences in one rural setting over a three-year period were included” (p. 4). - Data analysis followed a process of: immersion, codebook creation, and thematic analysis. - 30% of transcripts were coded jointly. - “Data management and analysis were facilitated by the QRS N-Vivo software V2.0.163” (p. 5). - “interpretive descriptive method” (Abstract). - Analytic Framework was also used, consisting of “community health and development” (p. 3) and SL perspectives. Four themes: 1). “the nature of rural health communities and clinical learning” (p. 5), including: Relational nursing, Microcosmic view of community (allowing students to see the “‘big picture’ of community health” (p. 6)), and Learning from limited health resources (p. 5). Students also learned of “socioeconomic health determinants” (p. 7). 2). “the autonomous role of the rural health nurse mentor and its influence on students” (p. 5), including: - “Research is merited about means to sustain student commitment to rural nursing and subsequent rural nursing practice” (p. 9). - “We recommend that rural community health sites and nursing education programs form partnerships to expand resources for education, promote understanding of rural nursing, provide students with exceptional community health practica, and augment services to communities with limited resources” (p. 10). UPHOLDING SOCIAL JUSTICE IN NURSING abuse, and environmental health” (p. 6). 234 Independent decision-making, Expanded breadth of practice, and Interdisciplinary role (p. 5). Nurse mentors were models for students, and encouraged them to be autonomous practitioners themselves. 3). “opportunities for service learning” (p. 5), including: Provision of care, Student projects, Participation in health fair, and Encouragement to nurse mentors (i.e., mentors felt challenged, and encouraged to reflect critically, by students) (p. 5). 4). “practicalities of the placement” (p. 5), including: Placement distance, Increased work of placement development, and Increased expense (p. 5). UPHOLDING SOCIAL JUSTICE IN NURSING Clark Callister and Harmer Cox (2006). Opening our hearts and minds: The meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing and Health Sciences. “… to examine the personal and professional meaning of participating in international clinical nursing electives during their undergraduate nursing studies” (p. 95). Design: Qualitative (specifically, “phenomenological inquiry” (p. 97)). Data Collection: - Interviews. - “Some of the participants shared their clinical journal entries…” (p. 97). Intervention (Description of educational experience): Students, for instance, provided education on labour support, looked after postpartum mothers, and looked after newborns. 235 - 20 participants - “maximum variation sampling” (p. 96) was aimed for. - “20 former nursing students” (p. 95). - “The 20 study participants included graduates who had international opportunities in Argentina, Guatemala, Jordan, or with the Ute and/or Navajo Nations (Native Americans) between 1995 and 2004” (p. 96). - “Fifteen were baccalaureate prepared and five participants had Master’s degrees with advanced practise certification” (p. 96). - Participants “… from a large private western university” (p. 96). - “Van Manen’s (1984) method of phenomenological analysis was utilized for data analysis” (p. 97). - Both researchers contributed to the development of themes. “‘Opening our hearts and minds’ was described by the study’s participants, with the following themes…” (p. 95): “increasing understanding of other cultures and peoples” (p. 95); “increasing understanding of global sociopolitical and health issues” (p. 95); “increasing the commitment to make a difference” (p. 95); “experiencing personal and professional growth” (p. 95), including increased confidence performing handson skills and handling challenges; “contributing to professional development in the host country” (p. 95) (according to the authors, not previously found). This included: “Recommendations for research include prospective longitudinal studies, with the generation of both qualitative and quantitative data” (p. 98). - “Analyses of clinical journal entries of both faculty and students is also recommended” (p. 98). - APPENDIX X recommendations for faculty: “1. Demonstrate a positive attitude. 2. Demonstrate respect for cultures and peoples, including traditional cultural healing practises. 3. Provide clear objectives for international learning experiences. 4. Help students gain as much foundational knowledge as UPHOLDING SOCIAL JUSTICE IN NURSING 236 - “There were two males and 18 female participants” (p. 96). - “… ages ranging from 23–46 years of age, with a mean age of 27 years” (p. 96). - “Fifteen participants reported having linguistic skills beyond English, including Spanish (n = 13), Chinese, and Arabic as second languages” (p. 96). Evanson and Zust (2006). "Bittersweet Knowledge”: The Long-Term Effects of an International Experience. Journal of Nursing Education. To examine the impact of an international experience on students’ ensuing professional and personal lives (i.e., its dual impact). Design: A descriptive qualitative study. Data Collection: - Individual written narratives. - A focus group. - Students prompted to write reflectively in response to a question related to the study’s purpose prior to the focus group. - 6 participants - All participants were BSN NS who finished an international experience in Guatemala 2 years earlier. - At time of current study, all participants were practicing RNs (5 practicing for 2 years; 1 for 1 year). Each investigator read the data and identified initial themes. They then met to compare findings, and together reached the major themes. “1. Modeling evidence-based practise. 2. Demonstrating holistic nursing practise. 3. Participating in international nursing conferences” (p. 101); “making interpersonal connexions” (p. 95), and “developing cultural competence” (p. 95). possible prior to going to the host country” (p. 102). Major theme: participants developed “bittersweet knowledge”. Three sub-themes: Schools of nursing should aim to incorporate experiences of hands-on nursing care. 1). Coming to understand: Subthemes: (a). “Lasting Connections”. Participants tried to stay connected with families by writing letters to them. UPHOLDING SOCIAL JUSTICE IN NURSING - Purpose of focus group was to ascertain long-term effects of experience and thoroughly explore its dual impact. Intervention (Description of educational experience): - Students provided informal and formal care. - Students conducted home visits. 237 - “Five women and 1 man comprised the sample” (p. 413). - “their mean age was 24.8” (p. 413). (b). “Cultural Awareness”. (c). “Global Perspective”. The experience “opened their eyes” to the “poverty, oppression, and potential danger” (p. 415) in a developing country. 2). Unsettled feelings: - Uncomfortable feelings related to questions where answers are unclear or unknown. - 3 major questions: (a). “Did we/can we help?”, (b). “Why do we have so much when others have so little?” Participants expressed “frustration and a sense of hopelessness” (p. 416) when comparing available resources in the US to those in Guatemala. (c). “Are we better off?” Participants questioned whether or not they were UPHOLDING SOCIAL JUSTICE IN NURSING 238 better off materially, and whether their health care system at home was superior. 3). Advocating for change: - Ongoing response to experience. Greater understanding and unsettled feelings motivated participants toward action on personal, local, and global spheres. - All participants disclosed a desire to again participate in international trips in the future. - A desire to promote social justice through political means. - Increased cultural awareness served to sensitize participants to the needs of patients from other cultures at home. UPHOLDING SOCIAL JUSTICE IN NURSING 239 - Participants shared “what the Guatemalan people’s lives were like” (p. 417) with others at home. - Sense of responsibility in that participants felt a need to protect those in developing countries from exploitation by Americans. Hunt (2007). Service-Learning: An Eye-Opening Experience that Provokes Emotion and Challenges Stereotypes. Journal of Nursing Education. “… to explore the lived experience of nursing students in service-learning clinical placement working with families who are homeless” (p. 277). Design: Qualitative (“Descriptive phenomenology” (p. 277)). Data Collection: “in-depth interviews” (p. 278). Intervention (Description of educational experience): Activities not described in detail, although those mentioned included providing patient education, and talking to/spending time with patients. - 14 participants - “Fourteen students from two different service-learning courses involving a family homeless shelter ” (p. 277). - “Of the participants, 7 were enrolled in a basic baccalaureate (BSN) program and 7 in an RN-to-BSN program” (p. 278). - “… analyzed using a tripartite structure approach for descriptive phenomenology, as described by Dahlberg, Drew, and Nystrom (2001)” (p. 278). - First, an “overall structure of the phenomenon” (p. 278) was identified, and then “six themes” (p. 278). “Six constituent descriptions were identified from thematic analysis: eye-opening to realize the effects of homelessness on families; feeling intense emotions that are sometimes hard to express [e.g., at the poverty witnessed]; realizing families who are homeless are both different from and similar to families who have housing; challenging and transforming assumptions, perceptions, and stereotypes; the - “… the importance of preparing students for the emotional aspects of working in a multicultural community. The first encounter must be thoughtfully planned, taking into consideration any emotions and beliefs about social relations and social structure that students bring to the experience, as well as those at play within the agency or institution” (p. 280). - “Service-learning emerges as a UPHOLDING SOCIAL JUSTICE IN NURSING 240 importance of reflection; and discovering new and different aspects of the nursing role [e.g., the importance of presence, advocacy]” (p. 277). powerful vehicle to inspire concern for political action and civic responsibility, as well as a tool to develop advocacy skills. Numerous applications exist in nursing education that remain unexplored” (p. 280). - “Essentially nothing has been published about the cognitive, affective, or social processes experienced during service-learning. Nor are there studies investigating the relationship between servicelearning and emotional intelligence…” (p. 280). - “This study reveals the prominent role emotions play in both servicelearning and reflection, areas that are largely uncharted and fertile for UPHOLDING SOCIAL JUSTICE IN NURSING 241 investigation” (p. 280). - “Discovering how coming face to face with the ‘other’ inspires empathy and compassion and becomes a call to action would be a fascinating issue to understand more fully through research” (p. 280). Maltby and Abrams (2009). Seeing With New Eyes: The Meaning of an Immersion Experience in Bangladesh for Undergraduate Senior Nursing Students. International Journal of Nursing Education Scholarship. “The purpose of this study was to discover the meaning of a Bangladesh immersion experience for undergraduate nursing students as it was lived” (p. 1). Design: Qualitative. Specifically, “descriptive phenomenological design” (p. 4). - 17 participants Data Collection: - “The reflective journals completed by the students” (p. 1). - “17 senior undergraduate nursing students” (Abstract). - “Students were invited to participate in the study… approximately four weeks after returning home” (p. 5). Intervention (Description of educational experience): - Students “selfselected for this study” (p. 4). - “The student group comprised 94% females” (p. 4). - “… with an age range of 22 to 54 years and an average age of 24.5 years” (p. 4). “Journal entries were thematically analyzed using the steps outlined by Colaizzi (1978)” (p. 5). - Four themes were derived. “These themes combine into a framework that has been tentatively titled, Seeing Through New Eyes…” (Abstract): 1). “Beginning to See” (p. 6). Especially seeing “difference” with respect to poverty. 2). “Thinking about the Seen” (p. 6). For instance, in considering Bangladeshi history, in learning what “wealth” meant for Bangladeshis, and - With respect to the themes uncovered, “[t]hrough additional research, there should be exploration of how long these attitude changes will persist. Once students are re-acculturated into American life, it may be difficult for many of them to remember their initial transformation” (p. 11). - “With future research, investigation of cultural competencies of nursing students throughout their UPHOLDING SOCIAL JUSTICE IN NURSING 242 - “a three-week public health nursing immersion study abroad experience in Bangladesh” (p. 4). in judging Bangladeshis to be happy. 3). “Wanting to Change the Seen” (p. 6). In wanting to advocate, for instance by providing money and resources. Also, in wanting political intervention from both their and the Bangladeshi governments. - “The students interviewed 100 families in total... Quantitative data were collected including education level, income, health status... Qualitative data were gathered about gender health, environment, social cultural norms, social support services, and poverty issues” (p. 4). Reimer- Kirkham, Van Hofwegen, and Pankratz (2009). Keeping the Vision: Sustaining Social Consciousness with Nursing Students following International Learning Experiences. International Journal of Nursing “… to: (1) explore the nature of learning achieved by students regarding social justice… and (2) identify and facilitate strategies that support students in the integration of this learning into personal and professional 4). “Transformed by the Seen” (p. 6). Changed attitude with respect to their own possessions and lifestyle. Especially, feelings of gratefulness. Design: Qualitative (“participatory action study” (Abstract)). - 20 participants Data Collection: - “… over twelve months following their international experiences” (Abstract). - 17 undergraduate nursing students and 3 faculty members. - “focus groups (i.e. group reflection undergraduate program and for several years following graduation should take place. This would help to determine the impact of different cultural experiences on perceived competence, longterm effects, as well as uncover pertinent data to ground curricular innovation” (p. 11). - “convenience sample” (p. 3). - Each researcher independently developed a codebook; they then met to compare codes. - From codes and grouping of codes, themes derived. - “All research documents were entered into - For “Profound Learning but Difficult Translation and Sustainability” (p. 5), “two overarching themes” (p. 6): 1). “Acquiring Social Consciousness: Learning in International Settings” (p. 6): Recommendations captured in “A Preliminary Framework for International Learning Experiences” (p. 12), including: - “Guiding Principle #1: Maximizing Transformative Learning” (p. 12) with: “Intentionality” (p. UPHOLDING SOCIAL JUSTICE IN NURSING Education Scholarship. domains upon return to Canada” (p. 2). regarding the experience of returning home)” (p. 3) over one year. - “Data took the form of focus group transcripts, field notes from the various project initiatives, minutes from the research team meetings including methodological reflections on the PAR process, and participants’ journal entries” (p. 4). Intervention (Description of educational experience): 3-4 week immersion in Guatemala. Various activities, including: participating in health clinics, fairs, hands-on care at a children’s hospital, and several debriefing sessions. 243 NVivo™ software for qualitative data management, coded, and analyzed” (p. 4). Included learning of the SDH and activism. Firsthand learning of poverty was especially impactful. Also, “[e]xperiential, embodied immersion” (p. 6) proved important to learning. Embodied learning especially triggered “critical reflection and profound moral questioning” (p. 7). 2). “Sustaining Social Consciousness: Translating Learning to Home Settings” (p. 8): Students experienced dissonance reintegrating home, such as emotional difficulty, and found it difficult to deal with the degree of effort required to maintain social consciousness. Strategies that maintained social consciousness included: fundraising for a damaged hospital, 12), including spending time reflecting with students (for possibly longer than 12 months), “Meaning making in community” (p. 12), “Critical spaces” (p. 12), including moving beyond consideration of cultural competence alone, to other notions such as the SDH, and “Ongoing critical engagement with social justice initiatives” (p. 13). - “Guiding Principle #2: Equitable Partnerships: Tending to Power Relations” (p. 13). - “Guiding Principle #3: Organizing the Experience” (p. 13). - “Guiding Principle #4: Generating Knowledge” (p. 13). Specifically, “To prevent reinforcing colonial exploitation there is a need to know more about the UPHOLDING SOCIAL JUSTICE IN NURSING 244 individual journaling, and conversing with peers and faculty who had also gone overseas. long-term effects of these learning experiences on all stakeholders” (p. 14). - Notably, “[f]acilitating intentional reflection in the focus groups gave students opportunity to process the intense international experience in a safe setting over time and likewise provided support for [faculty’s] own experiences of translating and sustaining learning” (p. 10). Cohen and Gregory (2009). Community Health Clinical Education in Canada: Part 2 Developing Competencies to Address Social Justice, Equity, and the Social Determinants of Health. International To determine how Canadian nursing programs promote the development of skills and knowledge pertaining to the SDH and social justice. Design: Descriptive qualitative research. Data Collection: - Focus group interviews via teleconference with leaders of community health nursing (CHN) courses. - 12 participants - all participants course leaders Qualitative content analysis resulting in dominant themes. Two overarching themes: 1). Enabling factors for advancing the CHN role in upholding social justice, equity, and addressing SDH. - Exposure to concepts and socialization: Ongoing integration of equity-related - Staff of local public health units could be more involved in students’ education generally. - Future research should include views of students and agencies. UPHOLDING SOCIAL JUSTICE IN NURSING Journal of Nursing Education Scholarship. 245 - Three questions guided discussions. topics throughout nursing education. Intervention (Description of educational experience): Course leaders whose programs focused on nontraditional (typically nonhealth-care affiliated sites) were interviewed. - Contemporary, innovative settings: Such as non-health and untraditional community health sites that excellently illustrate the SDH and social justice. - Student supervision: Nonnurse preceptors often understand SDH well. - Facilitation of learning by clinical teachers. - Learning environment and student engagement in critical thinking. 2). Challenges to developing the CHN role. - Site selection: Difficulty securing ideal sites and experienced instructors. - Students’ concerns re: non-traditional sites: do not value site and mentors; difficulty working - Future research should investigate optimal methods of teaching students to uphold social justice; optimal means of developing facilitators’ ability to promote this; and process of securing non-traditional sites. UPHOLDING SOCIAL JUSTICE IN NURSING 246 independently; difficulty integrating theory. - Lack of RNpreceptors. - Lack of sufficient time to understand CHN role in addressing SDH. - Difficulty addressing public health competencies in non-traditional sites. Levine (2009). Transforming Experiences: Nursing Education and International Immersion Programs. Journal of Professional Nursing. To ascertain the full meaning of international health programs for BSN students. Design: Qualitative. Specifically, narrative tradition (heurism). Data Collection: - Participants interviewed 3-13 years following international experiences. Intervention (Description of educational experience): - Requirements: That nurses engage in 6-9 weeks of professional practice, complete daily journal entries - 10 participants - All participants U.S. BSN students, all of whom took part in one of several international programs in 1 or 2 of 10 countries which lasted between 6-9 weeks (summer experiences). Transcriptions thematically analyzed. - Students’ “worldview” (p. 159) shifted, affecting their professional, academic, and social lives. - Four major categories and corresponding themes: 1). “Having blind trust” (Welcome/Accepta nce; Building rapport; TeachingLearning; Open relationship with patient care; Camaraderie and rapport); - Increased teaching of social justice in nursing schools. - Future nursing research on social justice. UPHOLDING SOCIAL JUSTICE IN NURSING 247 on professional issues, engage in socialization, reflect on feelings, and submit a paper 4 weeks following their return home. 2). “Valuing others” (Relationships beyond language; Being a human being; Caring about and for others; Sharing lives); - Patients: Providing care to the mentally ill, and structurally vulnerable. 3). “Transforming experiences” (Taking risks; Assuming advocacy roles; Recognizing prejudice; Having life changes) (p. 160). - Activities: teaching (formal and casual), education projects, and patient care.  Formal: E.g., teaching on breast feeding.  Informal: Impromptu discussions with local people on their ailments. - Also, three dialectic/opposition al categories: “have and have-nots”, “being an insider and an outsider”, and “a world shrinking, a world expanding” (p. 164). - Increased awareness, e.g. of such different material conditions. - Participants became aware of their preexisting biases and discriminatory beliefs. UPHOLDING SOCIAL JUSTICE IN NURSING Larson, Ott, and Miles (2010). International Cultural Immersion: En Vivo Reflections in Cultural Competence. Journal of Cultural Diversity. To explore the impact of a cultural immersion experience on students’ cultural competency. Design: Qualitative descriptive study. Data Collection: Interviews (one preexperience, one post-experience, 4-6 months later, per student) and en vivo reflective journals. Intervention (Description of educational experience): - SL projects major. - 2 weeks in Guatemala. Time was divided on-site between language lessons (40 hours) and community health clinical experience (48 hours). E.g., students bought medicines, took health histories, provided education, and assisted with health assessments. 248 - 13 participants - all participants nursing students (junior and senior). - Only 7 participated in the pre-experience interviews. - “Most of the participants were of European-American heritage” (p. 47). - “All were women…” (p. 47). - “… their ages ranged from 21-45 years” (p. 47). - Interview data analyzed. - Also, en vivo reflective journals completed daily during the experience were collected and analyzed. Three themes: 1). Navigating daily life. - Difficulty adjusting to hardships such as physical exercise, illness and injury, homesickness, and limited sanitation facilities. - Adopted healthier practices such as healthier eating. 2). Broadening the lens. - Understood realities of the SDH (e.g., great poverty). Appreciated firsthand learning. - Understood impact of U.S. policies. 3). Making a difference. - In gaining knowledge of traditional healers. - In completing projects and collaborating. Participantobservation and reflective writing activities might help students heighten their self-awareness as well as enhance what they gain from a cultural immersion course. UPHOLDING SOCIAL JUSTICE IN NURSING Smith-Miller, Leak, Harlan, Dieckmann, and Sherwood (2010). “Leaving the Comfort of the Familiar”: Fostering Workplace Cultural Awareness Through Short-Term Global Experiences. Nursing Forum. To understand how experiences fostered culturally competent practice, “…and how participants may translate this experience into the workplace” (p. 19). Design: Qualitative. Data Collection: 15 reflection papers. Intervention (Description of educational experience): Students observed staff members in government health facilities and NGOs. 249 - 53 participants, although a “representative sample of 15 reflection papers” (p. 21) were chosen. - Baccalaureate and master’s degree students contributed papers. - Students were “male and female” (p. 21). - “aged 22–50 years old” (p. 21). - Students were “… of varied ethnic backgrounds” (p. 21). - “Spanish language abilities ranged from unfamiliarity to fluency” (p. 21). - Reflection papers analyzed. - Reviewer consensus following dialog and discussion unearthed themes. 6 themes: 1). Leaving the Comfort of the Familiar. Difficulty adjusting to a different culture. 2). Bridging Cultures. - Learning about the culture, especially by living with families. - Learning about SDH impacting families. 3). Witnessing the Impact of Poverty. Profound poverty was witnessed, and how SDH were involved was considered. 4). “Doing the Best With What They Have”. - The people were seen as resilient. - Students compared Guatemalan and US health care systems. - Some students struggled with Cultural competency may be sustained through efforts of staff development departments, such as hosting discussions on articles, books, and films, and asking nurses who have travelled internationally to coach others who have not. UPHOLDING SOCIAL JUSTICE IN NURSING 250 questions of injustice. 5). Giving a Face to Immigration. - Previous assumptions and beliefs about immigrants changed. - Their own experiences in Guatemala helped students empathize with immigrants. 6). “Understand . . . Patients Better”. Students wanted to take their learning into the workplace: e.g., educating colleagues working with Spanishspeaking patients. Groh, Stallwood, and Daniels (2011). Service-Learning in Nursing Education: Its Impact on Leadership and Social Justice. Nursing Education Perspectives. To ascertain whether a SL experience improves a nursing student’s rating of their competency in leadership abilities and heightens his or her interest in social justice matters. Design: Quantitative descriptive study. Data Collection: - Pre- and postservice-learning tests. - Instrument was the ServiceLearning SelfEvaluation Tool - 306 participants - all participants senior baccalaureate nursing students (RN-completion and pre-licensure) currently taking the course “Intervening with Families at Risk” (p. 402). - Paired-samples ttest to examine differences between pre- and post-test scores. - Bonferronicorrected p-value used to protect against Type 1 errors. - All items except for one on leadership and social justice subscales changed in a positive direction postexperience. - Only “healing” under leadership skills (caring for others and self) - Those in positions of nursing leadership should consider in which courses SL would be particularly appropriate. - Nurses should consider whether SL outcomes should be consistent across UPHOLDING SOCIAL JUSTICE IN NURSING (SLSET) with 17 items (10 on leadership; 7 on social justice). Intervention (Description of educational experience): - Setting: Detroit, Michigan, U.S. - Students selected their own SL sites, which were at either a church, homeless shelter, soup kitchen, community outreach program, or shelter for women and children. - Students experienced at least 10 hours of SL throughout the semester. 251 - “the vast majorities were female (range 89 percent to 93 percent)” (p. 402). - “the vast majorities were … white (range 65 percent to 71 percent)” (p. 402). - “… a mean age in the 30s (range 31 to 36 years)” (p. 402). - “The most frequent religious affiliation reported was Catholic (range 35 percent to 38 percent) followed by “other” (range 25 percent to 26 percent)” (p. 402). - Cronbach’s alphas used for internal consistency of subscales (social justice and leadership). - SPSS, version 16.0 used for all statistical analyses. - Significance level of p < .025. changed significantly in a negative direction. all nursing curricula. - Future research should compare freshman and senior students’ conceptualizations of outcomes. - Future research should compare outcomes between nursing and other health professions. - Specific course objectives should be connected to SL outcomes. - Analysis of qualitative data from reflective journals. - Assess the influence of SL on the organizations and populations being served. - A need for more rigorous studies, perhaps quasiexperiments with larger samples and numerous sites. UPHOLDING SOCIAL JUSTICE IN NURSING Adamshick and August-Brady (2012). Reclaiming the Essence of Nursing: The Meaning of an Immersion Experience in Honduras for RN to Bachelor of Science Students. Journal of Professional Nursing. “… to uncover the meaning of [the experience] for RN students… and its impact on their professional practice upon return from Honduras” (p. 190). 252 Design: Qualitative (descriptive, interpretive phenomenological). - 8 participants Data Collection: - From reflective journals, and focus groups (where focus groups were 3 weeks and 4 months later). - all participants RN students - “… seven participants attended the initial focus group, and four of those seven participated in the focus group 4 months later” (p. 192). Intervention (Description of educational experience): - A week-long immersion in Honduras. - Daily brigades to remote villages where health services provided. - Students also visited one hospital and one clinic in a - Convenience, purposive sampling. - “one male and seven females” (p. 192). - “two of Latin ethnicity and six White” (p. 192). - “… with an age range of 24 to 50 years” (p. 192). - Journal and focus group data analyzed. - Analysis followed principles of “hermeneutic phenomenological reflection” (p. 192). - Each researcher analyzed texts first, using “selective highlighting approach” (p. 192), then met to compare. After writing and rewriting, agreed on themes. - 6 participants agreed with themes. Four themes: Altogether, these themes formed “the essence of the meaning of the experience: reclaiming the essence of nursing” (p. 190). 1). From the outside looking in. - Difficulty fitting sights and experiences into their frames of reference. - Compared health care between countries. - Learned about Honduran culture; felt “other” as did so. - Saw people as happy; saw through a “… protective lens, seemingly to avoid the disturbing reality of poverty” (p. 194). 2). Struggling with dissonance. - Struggling in dealing with reality of poverty. - Educators should emphasize cultural immersion experiences in the curriculum of nursing students at all levels of education. - “Immersion experiences for undergraduate nursing students should focus on opportunities for developing valuebased nursing practice, in addition to the traditional goals for developing cultural sensitivity” (p. 197). - “Nursing leadership courses could be considered for immersion experiences, including an emphasis on nursing values, ethics, and compassion” (p. 197). - “This study could be replicated with a larger sample of nurses from diverse UPHOLDING SOCIAL JUSTICE IN NURSING 253 local urban environment. - Realized they could do much outside of “traditional” nursing tasks to help. - Angry with wasteful work practices at home. practice environments” (p. 197). - “Longitudinal studies are recommended to evaluate the longterm effects of transformative learning” (p. 197). 3). Searching for meaning. - “meaning making” (p. 194). - Reconnected with nursing values. - Grateful for what they had at home. - Found spiritual meaning in their experience. 4). From the inside looking out. At home, participants felt changed and wanted to live out that change – e.g., in living out their nursing values, and forming relationships with patients. Foronda and Belknap (2012). “… to describe the thoughts, feelings, Design: - 10 participants - “Data were analyzed using Three categories. - “Transformative learning is not a UPHOLDING SOCIAL JUSTICE IN NURSING Short of Transformation: American ADN Students’ Thoughts, Feelings, and Experiences of Studying Abroad in a Low-Income Country. International Journal of Nursing Education Scholarship. and experiences of… students who participated in a short study abroad course in a lowincome country” (Abstract). 254 “Qualitative, narrative method” (Abstract). - “A clustering approach” (p. 5) used. Data Collection: Phone interviews two to six weeks after return home. - all participants Associate degree nursing (ADN) students. Intervention (Description of educational experience): - Observational and patient care experiences in Ecuador. - All participants female - Participated in a “traditional yucca planting ceremony, a medicinal plant hike, and a shaman ceremony” (p. 4). - “Participants’ ages ranged from 20 to 49” (p. 5). - “One participant identified herself as a person of color and nine participants identified themselves as Caucasian American” (p. 5). categorical-content perspective developed by Lieblich, TuvalMashiach, & Zilber (1998)” (p. 4). 1). “Constant Comparisons”. - cultural beliefs, health care practices; - poverty. - Consensus reached between three nurse researchers on final categories. 2). “Emotional Journey”. - fear; - frustration; - shock/surprise (at social conditions witnessed); - sympathy (in all narratives; followed by acceptance). 3). “Learning”. - elaborating and/or learning new meaning schemes, as with one student who learned about family roles in caregiving. - transforming meaning schemes, or changed points of view. As in being more grateful for health care at home. - “Several potential blocks to perspective transformation were guaranteed result. Nurse educators must consider strategies to foster transformation including discussing global systemic oppressors, international relations, coping, connecting, and social action” (Abstract). - “This preparation must be didactic as well as experiential. Providing information is not enough” (p. 13). - “Debriefing sessions, reflection, and problem solving groups will foster coping skills and a capacity for empathy rather than emotional disconnect” (p. 13). UPHOLDING SOCIAL JUSTICE IN NURSING 255 identified: egocentrism/emotio nal disconnect, perceived powerlessness/bein g overwhelmed, and a vacation mindset” (Abstract). Smit, Delpier, Giordana, and Tremethick (2012). Learning and Helping: Benefits of International Nurse Practitioner Student Experiences. Online Journal of Cultural Competence in Nursing and Healthcare. To discuss “… the planning, implementation, and evaluation of an international clinical experience designed to promote cultural awareness and enhance the clinical skills of nurse practitioner students” (p. 18). Design: Mixedmethods. Data Collection: - Survey consisting of nine quantitative, and nine qualitative, questions. - Also, a focus group and journals. Intervention (Description of educational experience): - Rural Honduras. - Students developed physical exam documentation forms, and prepared teaching handouts on clean water in Spanish. - Students set up and participated in a clinic, conducting assessments and - 5 participants (five Family Nurse Practitioner [FNP] students completed the survey) - Quantitative data were “reviewed” (p. 24) – i.e., mean scores deduced. - Qualitative data were analyzed with QSR NVivo 9 software. Content analysis done to generate six themes. Six themes: 1). Increased knowledge, skills, and confidence in the delivery of health care Preparation beforehand especially helpful. 2). Appreciation of resources taken for granted in the United States 3). Unexpected non material wealth/joy of the Honduran families.. 4). Effective shortterm impact but uncertainty about long-term impact. 5). Importance of advocacy as having a potential “longterm impact on the community” (p. 25). - “The mental stress reported by the students may be alleviated by identifying community resources that the students can tap into prior to the immersion” (p. 2627). - “Community programming may be beneficial and alleviate stress related to childcare and transportation” (p. 27). - “The reported physical challenges can be addressed for future participants by better preparing them for the physical realities of Honduras” (p. 27). UPHOLDING SOCIAL JUSTICE IN NURSING 256 providing treatments. Afriyie Asenso, Reimer-Kirkham, and Astle (2013). In Real Time: Exploring Nursing Students’ Learning during an International Experience. International Journal of Nursing “… to explore how nursing students learn during the international experience” (p. 1). Design: Qualitative. - 8 participants - Thematic analysis. Data Collection: - Data collected in “real time” – “firsthand contemporaneous data collection” (p. 2). - all undergraduate nursing students - “Main themes generated from the data were synthesized into a framework that represented the whole” (p. 3). - all students were female - “rang[ed] in age from 19 to 24” (p. 3). 6). Personal challenges of international service learning. Physical, mental, and psychosocial difficulties. Three additional themes identified based on faculty reflections: Theme 1: Unique learning experience for FNP students. Theme 2: Personal/profession al impact of experience upon faculty. Theme 3: Importance of collaboration with the Honduran health care system. To prevent ethical issues of providing care in a developing country. - “Additional daily downtime during future immersions is also an important consideration” (p. 27). Three major themes: - That educators discuss with students “… what the media portrays as truth and to find balanced reports on the issues faced by the countries that host international learning experiences” (p. 7). 1). Expectations shaped students’ learning. - Expectation of coming to “help” Zambians. UPHOLDING SOCIAL JUSTICE IN NURSING Education Scholarship. - Students observed, and were interviewed three times. Intervention (Description of educational experience): - Three weeks in Zambia. - Students learned and interacted with patients in the mission’s hospital, an outpatient AIDS clinic, and a traveling health unit. 257 - “All the participants… selfidentified as practicing the Christian faith, and attended the same faith-based university” (p. 4). - Media shaped expectations. 2). Engagement facilitated learning. - About Zambian culture. - Generosity of Zambians facilitated engagement. - Students hosted widows’ tea. - Learned through peer relationships. - Instructor support facilitated engagement. - Firsthand learning important. 3). Critical reflection enhanced learning. - Reflected on social justice. - Struggled with questions of injustice. - Doubting the extent of their influence. - “… nurse educators need to be knowledgeable of the socioeconomic and political factors that propagate the portrayal of these countries in states of poverty” (p. 7). - “Educational curricula… need to include content about colonial histories, global trading patterns, global health inequities…” (p. 7). - “Future research into the effectiveness of partnerships between visiting and host nursing students is needed to increase our understanding of how contextualized transformational learning occurs” (p. 8). - “To foster global citizenship, nurse educators must commit to continue the discourse about UPHOLDING SOCIAL JUSTICE IN NURSING 258 social justice and global inequities when students return from these international experiences” (p. 8). - “Future research about the long-term effects of the learning in the setting, how students use what they learned in their communities back home, and how global citizenship might be promoted is needed” (p. 8). Boylston and O’Rourke (2013). Second-Degree Bachelor of Science in Nursing Students’ Preconceived Attitudes Toward the Homeless and Poor: A Pilot Study. Journal of Professional Nursing. “… to determine if… students possess preconceived attitudes toward the poor and the homeless and whether personal exposure to the populations in a clinically supervised setting can identify and perhaps alter the aforesaid attitudes” (p. 310). Design: Mixedmethods. Data Collection: - Interviews. - Survey on Social Issues. Intervention (Description of educational experience): - Students provided care in a suburban homeless day shelter. - 8-hour clinical experience with - 14 participants - Convenience sample. - All participants second-degree baccalaureate nursing students (senior-level community health students). - Participants were from a “Christian University” (p. 313). - Themes derived from interviews. - Focus group six months later to affirm study findings. Focus group data also analyzed. - “… there are subtle stereotyping and negative attitudes regarding the plight of overtly impoverished individuals before rendering care” (p. 309). - Before experience, 78.5% of the participants thought homeless responsible for their situation. - Before experience, “ All… suggested that the public is - “… building of class content with case studies and clinical exposure focusing on the unique needs of the poor begin the process of constructing a foundation of knowledge that may challenge preexisting attitudes toward any population in preparation for professional practice” (p. 315). UPHOLDING SOCIAL JUSTICE IN NURSING 259 structurally vulnerable. responsible to help the homeless…” (p. 314). - “After… clinical experience… attitudes toward the vulnerable slightly improved…” (p. 309). - Common themes: understood reality of poverty; unsure about role of nurse. Curtin, Martins, Schwartz-Barcott, DiMaria, and Ogando (2013). Development and Evaluation of an International Service Learning Program for Nursing Students. Public Health Nursing. To describe a shortterm, international service learning program to serve as a means of exploring the further development of optimal programs for students. Design: Qualitative descriptive study. Data Collection: Pre- and postexperience questionnaires. Intervention (Description of educational experience): - SL experience 2 weeks long, in rural southwestern region of the Dominican Republic (DR). - 10 participants - all participants Caucasian, senior baccalaureate nursing students. - All students were female. - Students aged 21 to 24 years. - “Sixty percent (N = 6/10) had ‘minimal to some’ Spanish language skills and one (10%) had Thematic analysis. Five themes: 1). Adapting physically. Difficult traveling conditions left students exhausted. 2). Encountering frustration in inability to fully meet needs. Frustration in a constrained nursing role, e.g. in addressing a lack of resources. - “Adding conversational Spanish as an elective, seminar, or workshop would be helpful in eliminating some of the… language barriers” (p. 316). - Future research should assess whether the “BSN program itself, rather than one 8hour clinical experience, can … impact students' preconceived attitudes…” (p. 316). Long-term implications of the experience on personal and professional roles of students should be studied. UPHOLDING SOCIAL JUSTICE IN NURSING - SL experiences included (Monday to Friday): hospital prenatal and well child clinics; day health program for adults; “head start” program; rural clinics. 260 proficient Spanish language skills” (p. 553). 3). Increasing confidence speaking Spanish and assessing health issues. 4). Increasing cultural awareness. - In regard to U.S. and DR health care systems. - In regard to culture of people in DR. - Activities included health teaching and assessments. 5). Shifting foci from self to other. Greater awareness of the selflessness of the people despite their state of poverty. Zanchetta, Schwind, Aksenchuk, Gorospe, IV, and Santiago (2013). An international internship on social development led by Canadian nursing students: Empowering learning. Nurse Education Today. To determine the short-term outcomes of an international internship of Canadian nursing students in Brazil. Design: Qualitative appraisal. Data Collection: Interviews. Intervention (Description of educational experience): - Setting: the cities of Birigui and Araçatuba, Brazil. - Project led by students, who - 4 participants - all participants Canadian BSN nursing students in the fourth year of their undergraduate program. - “Three of the student-interns were female and one male” (p. 759). - “their ages ranged from 22 to 28 years” (p. 759). Thematic analysis - “Eye-opening” experience to learn about Brazilian healthcare system. - Students felt they received confirmation of their career choice. Two analytical themes: 1). “Associations for evolution: personal transformation that resulted in - Future research should include perspectives of overseas partners. - Students with international experience could teach others how to respond to social injustice. They could also advocate for funding for such experiences in their universities. UPHOLDING SOCIAL JUSTICE IN NURSING worked closely with community health agents (CHAs). - Experience lasted from May to August, 2008. 261 - “Two were permanent residents of Canada, and two were born in Canada” (p. 759). establishing new connections” (p. 759). - Students developed personal empowerment. - Resulted from realizing that every effort counted, and from coming to terms with their personal and professional limitations. - Resulted from learning of different religions and cultures. - Resulted from leadership opportunities. - Students learned to work with others and to manage power. 2). “Dichotomizing realities: seeing the two sides of each situation and acknowledging the unexpected reciprocity between global and urban health” (p. 759). UPHOLDING SOCIAL JUSTICE IN NURSING 262 - Learned more about knowledge dissemination in creating partnerships between health professionals and communities. - This occurred because students became more respectful of another culture, more open to their perspectives, and more responsive to them. Zanchetta, Taher, Fredericks, Waddell, Fine, and Sales (2013). Undergraduate nursing students integrating health literacy in clinical settings. Nurse Education Today. To ascertain how students perceive health literacy, what barriers they perceive to their promotion of health literacy, what opportunities and challenges confront them regarding its promotion, and how teaching strategies supported its promotion. Design: Exploratory qualitative study. Data Collection: - 3 individual interviews; 3 focus groups. - Students’ academic portfolios. Intervention (Description of educational experience): - Setting: Toronto, Canada. - Experiences took place in community health and social - 14 participants - all participants fourth-year undergraduate nursing students taking the course “Integration of Professional Self into the Health Care System”. - “In the focus groups, 13 students identified themselves as Canadian born (n=2), of European descent (n=3), as visible minorities (n=7)…” (p. 1028). - Transcriptions coded with qualitative program ATLAS ti 6.0. - Increased understanding of issues related to health literacy. - Including healthteaching simulations in nursing courses. - Texts analyzed for themes: a thematic axis was defined, and a thematic tree visually illustrating connections among parts of thematic groups created. - Students reported competence and high confidence in their health teaching from having received ample teaching opportunities. - Students’ confidence increased when their health teaching was understood. - Encouraging students to engage in professional development and to update their knowledge by attending workshops and conferences and through reading. - Themes grouped and labeled. Two Themes: - Supervisors should model the professional role of health teaching and focus on UPHOLDING SOCIAL JUSTICE IN NURSING 263 centers, hospitals, shelters, and schools. 1). “Awareness of Challenges to Becoming Effective Health Educators” (p. 1031). Students realized importance of tailoring teaching according to clients’ life experiences. - Students provided health teaching to clients largely through verbal and written means. 2). “Students' Sensitivity to Understanding Health Literacy within a Critical Perspective” (p. 1031). Students helped clients to become autonomous learners. Amerson and Livingston (2014). Reflexive Photography: An Alternative Method for Documenting the Learning Process of Cultural Competence. Journal of Transcultural Nursing. “… to evaluate the learning process of cultural competence during an international service-learning project in Guatemala” (p. 202). Design: Qualitative descriptive study. - 10 participants Data Collection: - Reflexive photography (over 100 photographs). - All baccalaureate nursing students. - Interviews. - “Additional items for data collection included pretrip essays, end-ofcourse evaluations, researcher field notes, and one - Purposive sample. - All students were female. - All students Caucasian. - “The ages of the students ranged from 21 to 23 years” (p. 204). - Content analysis: “Transcripts from each interview, written explanations of photographs, pretrip essays, endof-course evaluations, photographs, and video were analyzed with NVivo 9 (QSR International, 2010) to identify the interpretative themes that emerged from the Five themes: 1). Cognitive Theme. Learned about cultural practices, religion, SDH. 2). Practical Theme. Students developed relationships, gained experience teaching. 3). Affective Theme. Students became aware about religious beliefs, gained respect for empowering students. - Managers should review the possibility for experiential learning of health education in practice environments. - Future research can examine how students’ nonacademic skills might facilitate health-teaching. - “Further research is needed to explore the relationship between selfperceived values of TSE and objective evidence of learning, especially in the affective dimension” (p. 209). - “Reflexive photography accommodates the learning preferences of visual learners for self-reflection UPHOLDING SOCIAL JUSTICE IN NURSING 264 student-generated video” (p. 205). students’ work” (p. 205). Intervention (Description of educational experience): - Guatemala. - Findings were confirmed through peer debriefing. - Students “… conducted family and community assessments, engaged in home visits, and provided health education” (p. 202). Caldwell and Purtzer (2014). Long-Term Learning in a ShortTerm Study Abroad Program: “Are We Really Truly Helping the Community?”. Public Health Nursing. “… to discover what contributes to, and sustains, longterm learning outcomes in a 10– 12 day short-term study abroad program through use of a qualitative approach” (p. 579). Design: Qualitative descriptive study. Data Collection: “… a written questionnaire completed one or more years postimmersion” (p. 577). Intervention (Description of educational experience): - 10-day immersion in remote Honduras. the Guatemalan culture, and were grateful for their privileges. 4). TSE Theme. Students’ TSE grew as they taught others and made home visits. and should therefore be considered as an alternative or a complement to written journals” (p. 209). 5). Reflexive Photography Theme. Reflexive photography more effective for reflection than journaling. - 41 participants - Purposive sampling. - All participants nursing students. - “There were 39 women and two men” (p. 579). - “At the time of their immersion, one participant was a prenursing student, 34 were seniors, four were family nurse practitioner (FNP) students, and two Qualitative descriptive analysis. Four themes: 1). Embracing Other. - Shocked at poverty surrounding Hondurans. - Saw Hondurans as resilient. - Saw Hondurans as happy. 2). Gaining Cultural Competencies. - Felt guilty at being privileged. - Saw themselves as similar to Hondurans. - There is a “strong need to re-examine the long-term benefits and/or harms short-term learning services may have on vulnerable populations…” (p. 582). - “… future research question: Would good communication skills without a language barrier along with a commitment to the host community avoid doing harm?” (p. 582). UPHOLDING SOCIAL JUSTICE IN NURSING - “Students worked directly with community members to identify health issues, implement educational workshops addressing those issues, and evaluate health outcomes” (p. 577). 265 were FNPs enrolled in a doctorate of nursing program” (p. 579). 3). Experiencing an Ethnocentric Shift. - Worldview grew. - Students more clearly saw health inequities. - “Ages ranged from 22 to 60 years” (p. 579). - Less judgmental of structurally vulnerable. - More reflective. - Students develop health promotion projects and perform home visits. Curtin, Martins, and Schwartz-Barcott (2014). A Mixed Methods Evaluation of an International Service Learning Program in the Dominican Republic. Public Health Nursing. “… to explore the impact of an ISL experience on global awareness, professional and personal growth” (p. 58). Design: Mixedmethods. Data Collection: - The International Education Survey (IES) was used as the quantitative measure. - Narratives from Critical reflective inquiry (CRI). Intervention (Description of educational experience): - “… public health nursing educators, as well as host communities… consider their individual and collective worldview or habits of mind as related to global health issues and health disparities” (p. 582). 4). Negotiating Ethical Dilemmas. Students questioned whether they did “more harm than good” (p. 581). - 11 participants - All baccalaureate nursing students. - All students were female. - All students Caucasian. - Students “aged 21–24 years” (p. 62). - “Seventy-two percentage (N = 8/11) had ‘minimal to some’ Spanish - Content analysis of CRI narratives. - Descriptive statistics (means, standard deviations). SPSS v21 was used for all analyses. - “Students reported a high overall impact (M = 5.9) using the IES with high means for the Professional Student Nurse Role (M = 6.10, SD: 0.74), Personal Development (M = 6.08, SD: 0.76), International Perspectives (M = 6.03, SD: 0.71), and a lower mean for Intellectual Development (M = 5.40, SD: 0.69)” (p. 58). - “Further exploration of the usefulness of various evaluation tools and methodological designs is warranted to understand this type of pedagogy and its impact on student learning outcomes short- and long-term” (p. 58). - “… enhancing the validity of the dimension on intellectual development. UPHOLDING SOCIAL JUSTICE IN NURSING - 2-week, on-site immersion experience in the Dominican Republic. - Students developed health education projects. 266 language skills, 18% (N = 2) with intermediate Spanish language skills, and one (9%) had proficient Spanish language skills” (p.62). - In terms of professional nurse development role: “… the highest means (M = 6.36) related to the program’s impact on one’s practice as a student nurse and relevancy to one’s nursing career” (p. 62). - Students participated in clinics and health programs, and worked in hospitals. - “CRI narratives revealed… increased empathy and ability to communicate effectively with patients from life situations very different from their own” (p. 58). - Students conducted assessments. Adding items on increasing social consciousness and global awareness might capture the student’s ability to respond to the challenges of globalization” (p. 66). - “… comparing IES scores of former graduates would provide further information on the usefulness of the quantitative instrument for measuring shortand long-term impact” (p. 66). - Narratives revealed awareness of reality of poverty. - Narratives revealed gratefulness. Jarrell et al. (2014). Constructing the foundations for compassionate care: How servicelearning affects nursing students’ To establish the overall impact of SL on students’ attitudes toward those in poverty. Design: Pre-post test quantitative design. Data Collection: - Just World Scale (JWS) and Attitudes Intervention Group: Two consecutive baccalaureate senior nursing student cohorts in a community health - Descriptive quantitative analysis. - Two independent t-tests. - JWS: both IG and CG experienced decreases at posttest; not statistically significant. Additional quantitative and mixed-methods research. UPHOLDING SOCIAL JUSTICE IN NURSING attitudes towards the poor. Nurse Education in Practice. about Poverty and Poor People Scale (APPPS). - Survey of student gender, age, and poverty experiences. - Minimal qualitative data collection from written pieces and verbal comments of students, and verbal comments of clients. Intervention (Description of educational experience): - Setting: a homeless shelter and apartment complex home to low-income elderly and/or disabled persons in a large southwestern U.S. urban setting. - Students worked in groups with the urban homeless and low-income elderly and/or disabled individuals during one day a week for 15 weeks. 267 clinical course (20 students per semester in each cohort; 40 students total), as well as a group of students who cared for patients in a homeless shelter and low-income housing center. Control Group: 130 students placed in community settings such as schools where they were paired with a nurse and did not exclusively serve structurally vulnerable persons. - Overall, 86.5% of students were female. - 69.3% (the majority) were aged 19-23. - Bivariate correlations between experiences with poverty variables and baseline scores on scales for IG and CG. - APPPS: IG had a small decrease counter to hypothesized direction, and CG had increase; not statistically significant. - two significant correlations with JWS: having a poor family member positively correlated with belief in a just world, and student work experiences with the poor were negatively correlated. - IG: views such as the poor “act differently”, and are “dirty”, were improved (although not statistically significant). - IG: students believed more strongly in society’s responsibility toward the poor, and lessened their blaming of the poor for their status (although not UPHOLDING SOCIAL JUSTICE IN NURSING 268 - Activities included health promotion, taking health histories, performing assessments, offering education, taking vital signs and screening for hypertension and diabetes. statistically significant). - IG had greater scores toward empathetic attitudes than CG (yet not statistically significant with small effect size). - IG had larger change toward perceived social difference; yet not significant with small effect size. - Students realized difficulty adhering to treatment plans due to lack of resources, not lack of knowledge. - Students expressed difficulty in seeing struggles of the poor. - Students felt that they were able to make a difference in vulnerable lives. Krumwiede, Van Gelderen, and Krumwiede (2014). Academic-Hospital Partnership: To pilot nursing students’ application of the Community-Based Collaborative Design: Qualitative (a public health nursing case study analysis employing - 15 participants - All baccalaureate senior nursing students Qualitative review used to conduct a thematic analysis of 15 students’ journal reflections. - Improved research skills: e.g., collecting data on health determinants. Educators must provide opportunities for students to identify barriers and SDH, UPHOLDING SOCIAL JUSTICE IN NURSING Conducting a Community Health Needs Assessment as a Service Learning Project. Public Health Nursing. Action Research (CBCAR) framework, and understand their experience as well as competencies met. the CBCAR framework). Data Collection: Data collected via processes of CBCAR framework. Intervention (Description of educational experience): - Experience lasted 7 weeks, in a rural city, Madelia, in south-central Minnesota. - Students collected data for the Community Health Needs Assessment (CHNA) on 7 key populations through questionnaires, foot and windshield surveys, observations, interviews, and field notes. - Students also presented recommended interventions, based on which the CHNA report was revised and made final. 269 - Students learned how to effect policy change by, e.g., recommending a healthy snack policy for elementary schools. - Students learned how to adapt interventions according to cultural preferences. Four themes: 1). Real-world solutions. Students felt they were of value to the community and that their work was meaningful. 2). Professional development. 3). Community collaboration. Students learned to collaborate with peers, teachers, interpreters, collaborative and community members. 4). Making a difference. Established new ways of engaging to prioritize primary prevention, and to apply resources to improve communities’ health. UPHOLDING SOCIAL JUSTICE IN NURSING 270 with populations and the public. Knecht and Fischer (2015). Undergraduate Nursing Students’ Experience of Service-Learning: A Phenomenological Study. Journal of Nursing Education. To determine the essence of SL for undergraduate baccalaureate nursing students. Design: Phenomenology (as per philosophy of Edmund Husserl). Data Collection: Unstructured interviews. Intervention (Description of educational experience): - Setting: the Wellness Centre in Connecticut, U.S… at a program for women in recovery, Catherine’s Place. - Therapeutic communication. - Students visited twice a week. - Blood glucose and pressure screenings. - Teaching. - 10 participants - Purposive sample. - All participants were undergraduate sophomore, junior, and senior nursing students enrolled in a baccalaureate program. - Eight were between the ages of 20-29. - All participants were women. - 9/10 participants were Caucasian. Method of Paul Colaizzi, which includes creation of themes as foundation of the “fundamental structure” (p. 380), and memberchecking. Five themes: 1). Shattering Stereotypes. Students’ assumptions and stereotypes challenged. 2). Overwhelmed with their need. Overwhelmed with diverse needs of patients, lack of resources, and limited services. 3). Transitioning to community caregiver. - Students learned to focus on communication. - Students learned about available resources. - Students came to appreciate nursepatient relationship. 4). Advocating. Students learned about the importance of listening to clients first. - Future research with methods allowing for a representative sample. - Consider an interdisciplinary team to guide students in SL endeavours. - Research on SL’s effect on cultural integrity and agility. UPHOLDING SOCIAL JUSTICE IN NURSING 271 5). Reciprocal benefits. 4/10 described experience as awesome. Kronk, Weideman, Cunningham, and Resick (2015). Capturing Student Transformation From a Global Service-Learning Experience: The Efficacy of PhotoElicitation as a Qualitative Research Method. Journal of Nursing Education. “… to demonstrate the use of photoelicitation as a qualitative research method that captured transformational outcomes of baccalaureate nursing students” (p. S99). Design: Qualitative. - 8 participants Data Collection: - Photo-elicitation. - All nursing students. - Interviews. - Six female students (undergraduates); two male students (second-degree). Intervention (Description of educational experience): - 10-day SL experience in Nicaragua. - Students delivered health care in rural and urban settings. - The six female students were aged 20-22; males were aged 26 and 59. - All students were Caucasian. - Students were all “of middle socioeconomic status” (p. S100). Inductive thematic analysis (first independently by each instructor, then compared). Three themes: 1). “Letting go”. Leaving behind what was familiar. 2). “Embracing reality”. Reality of poverty. 3). “Understanding”. - “… the strength, enduring spirit, creativity, and the beauty of [the] people” (p. S101). - Resilience of the people. - Overall, there was a process of “[c]ultural, [p]rofessional, and [p]ersonal transformation” (p. S101). Personal transformation included confidence, the desire to themselves be resilient, as well as to live simply. Further use of photo-elicitation, as it “… can be a usefuI qualitative research method to capture student outcomes in nursing education and research” (p. S102). UPHOLDING SOCIAL JUSTICE IN NURSING Murray (2015). Nursing Students’ Experiences of Health Care in Swaziland: Transformational Processes in Developing Cultural Understanding. Journal of Nursing Education. “… to explore the personal and professional growth reported by bachelor of science in nursing (BSN) students following an overseas servicelearning health care delivery program experience” (p. S66). Design: Qualitative. Data Collection: Interviews. 272 - 6 participants - Thematic analysis. - All were BSN students. - Analysis guided by a literature review. - All were women. Intervention (Description of educational experience): - Swaziland. - “Students worked in a hospital and implemented community health clinics” (p. S65). - All were “White” (p. S66). - All were “in their early 20s” (p. S66). Four themes: 1). Transitions. Personal hardships, emotional reactions (e.g., doubted extent of their influence), and language difficulties. 2). Perceptions. - Cultural dissonance… between the health care and nursing cultures of Swaziland and the U.S. - Swazi people made the best of what they had. - Saw poverty, lack of transportation as barriers to care. 3). Internalization. “[d]iscomfort and cultural dissonance activated coping mechanisms within students that generated a process of change in attitudes and beliefs” (p. S65). 4). Incorporation. - “[p]ersonal and - “[t]he challenge for nurse educators is to try and find ways to incorporate the same processes of cultural dissonance that will provoke activation of coping strategies without… financial barriers. This may be possible by assigning students to clinical placements that are outside of their comfort zone but are not as physically distant, for example, a disaster recovery zone, a rural health clinic, or an urban setting” (p. S72). - Further research on whether transformational experiences can occur in noninternational placements. UPHOLDING SOCIAL JUSTICE IN NURSING 273 professional growth were demonstrated with greater awareness, compassion, resourcefulness, and comfort with diversity” (p. S65). - Gratefulness for their lives at home. Townsend, Gray and Forber (2015)*. New Ways of Seeing: Nursing Students’ Experiences of a Pilot Service Learning Program in Australia. Nurse Education in Practice. “… to evaluate preregistration nursing students' experiences of a pilot program that placed them in community based non-government organisations for clinical placement as part of a core mental health subject” (p. 1). Design: Qualitative. - Nine second year nursing students. Data Collection: One focus group. - Ten NGOs. Intervention (Description of educational experience): - Sydney, Australia. - A “strong focus on direct consumer interactions in addition to tasks designated by NGO staff” (p. 2). - “… students were expected to participate in service activities including serving meals, going on community outings, talking with consumers and Thematic analysis of focus group data, using constant comparison methods. Overarching theme identified was “new ways of seeing”, with three subthemes: (a) ‘Learning outside the box’. - Outside of the hospital, students had greater exposure to mental health. - Students felt they could communicate more easily with patients outside of the hospital, and gained confidence in doing so. - Impromptu, unplanned learning. - More experiential, as opposed to taskbased, learning. - “In order to optimise the building of an aware and engaged nursing workforce, we propose it may be advantageous for educators and clinical partners to seek innovative contexts within which to implement Service Learning models for nursing students” (p. 5). - “… further research is warranted to investigate generalizability, and the impact of student involvement on NGO services” (p. 5). UPHOLDING SOCIAL JUSTICE IN NURSING joining in art and music groups” (p. 2). 274 (b) ‘Confronting the real world’. - Challenging experiences, including seeing realities of the SDH. - Students found support from staff very helpful in dealing with experiences. (c) ‘Transformative experiences’. “Subtle and overt changes to the way they saw the world, themselves and/or their nursing education” (p. 4). Note. Adapted from the principles espoused by Garrard (2017). * Also, note that the Townsend et al. (2015) article was in press at the time this research was conducted. Running head: UPHOLDING SOCIAL JUSTICE IN NURSING 275 Appendix C CODEBOOK FOR DATA EXTRACTION* Question 1: What Have Students Learned in General About the SDH? C 1: Awareness of the Existence of the SDH C 2: Comparing own Health Care System to that of a “Disadvantaged” Country C 3: Global Awareness C 4: Personal Awareness SC 1: About Themselves Generally SC 2: About Own Views, Biases and Stereotypes Question 2: What Have Students Learned Specifically About the SDH? C 1: About the SDH SC 1: How the SDH Impact Health SC 2: Realities of the SDH SC 3: Ethical Implications C 2: About the “Disadvantaged” SC 1: Realizing their Resilience SC 2: Learning to Look at “Disadvantaged” Populations Broadly in Considering Many Aspects of their Lives in Relation to the SDH Question 3: In General, What Indications Are Given That Students Feel Better Prepared to Address the SDH? C 1: Notions of Feeling Ready to Act SC 1: Embracing Positive Thinking SC 2: Being Hopeful: Seeing the Educational Experience, and their Role, as Impactful UPHOLDING SOCIAL JUSTICE IN NURSING 276 SC 3: Being Grateful C 2: Taking Initiative to Reflect on Issues Related to the SDH Question 4: Specifically, What Indications Are Given That Students Feel Better Prepared to Address the SDH? C 1: Feeling Competent, and More Confident, to Act C 2: Linking Action with Professional Identity C 3: “Spirit” of Advocacy C 4: Taking Action After the Experience C 5: Collaborating Interprofessionally C 6: Taking Initiative to Interact Directly With the “Disadvantaged” Population SC 1: As Part of Course Activity SC 2: Willingly Instigated Question 5: What Indications Are Given That Students Do Not Feel Better Prepared to Address the SDH? C 1: Negative Attitude C 2: Doubting the Extent of Their Influence Question 6: What is Said About Facilitators to Students’ Ability to Address the SDH? C 1: Being Challenged C 2: Knowledge SC 1: Knowledge Brought to Experience SC 2: Knowledge Gained During Experience C 3: “Internal” Support (From Host Community) SC 1: Being in Relationship with Community UPHOLDING SOCIAL JUSTICE IN NURSING SC 2: Partnership with Community C 4: “External” Support (From Outside Host Community) C 5: Firsthand Learning C 6: Culture in Context C 7: Internal Struggle Engendering a Questioning Attitude Related to Injustice Question 7: What is Said About Barriers to Students’ Ability to Address the SDH? C 1: Unpreparedness C 2: Issues Pertaining to the Clinical Experience C 3: Acclimating to Host Country Conditions Question 8: How Are Students Taught About the SDH? C 1: Methods by Which Education Addresses the SDH SC 1: Curricular Integration SC 2: Teaching Strategies to Facilitate Reflection SC 3: Activities to Facilitate Interaction with the “Disadvantaged” C 2: Nature of Experiences SC 1: Local, National, or International SC 2: In the Health Sector SC 3: In the Non-Health Sector SC 4: Length of Experience C 3: Through Which Lens is Learning About the SDH Framed? SC 1: Through an Individual, Family, Community, or Population Lens? SC 2: Through a Culture-Related Lens (e.g., cultural diversity, cultural competence, cultural sensitivity, cultural awareness, etc.)? 277 UPHOLDING SOCIAL JUSTICE IN NURSING 278 SC 3: Through a Health Equity, or Disparity, Lens? SC 4: Through a Global Health (global citizenship, and/or globalization) Lens? SC 5: Through a Social Justice Lens? C 4: What Are the Stated Outcomes of Education? SC 1: Explicitly Stated SC 2: Implicitly Stated * Note. C: Category; SC: Subcategory. Although this codebook uses the language of “disadvantaged” (e.g., the “disadvantaged”, “disadvantaged” country and “disadvantaged” population), the decision was made following later conversations between myself and my supervisory committee (during thematic analysis) to use the term “structurally vulnerable” instead of “disadvantaged” in the presentation of themes and throughout the thesis (see definition of “structurally vulnerable” in Chapter 1).