Abstract
Following one’s passion can lead nursing educators and scientists to develop nursing knowledge. Influenced by her and her family’s experiences with healthcare, Dr. Shannon Avery-Desmarais, a nurse practitioner, nurse educator, and scientist, has developed a theoretical framework with her colleagues to promote minority PhD and DNP student success in nursing education. In addition, she and other colleagues are looking at stigma in nursing students and how nursing education can decrease stigma toward patients with opioid use disorder (OUD). In this column, Dr. Avery-Desmarais shares her influences on nursing knowledge and discusses her early contributions to nursing.
For this issue of Nursing Science Quarterly’s (NSQ’s) Scholarly Dialogue column, I chose to dialogue with a tenure-track nurse scientist who has already contributed to nursing knowledge. Dr. Shannon Avery-Desmarais from the University of Massachusetts Dartmouth (UMassD) and her colleagues, Drs. Susan M. Hunter Revell and Mary K. McCurry, have developed a theoretical framework to promote minority PhD and Doctorate in Nursing Practice (DNP) students’ success in nursing education. Dr. Avery-Desmarais is also an adult gerontology primary care nurse practitioner working in palliative care and serves as chair-elect for the national organization GLMA Nursing: Nurses Advancing LGBTQ Equality (formerly known as the Gay-Lesbian Medical Association) committed to ensuring health equity for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities and equality for LGBTQ+ health professionals in their work and learning environment.
Dr. Avery-Desmarais, thank you for taking the time to converse with me today. I believe our readers are interested in hearing about nurse educators and scientists who are early in their academic career and are contributing to nursing knowledge. I am also interested in your journey since some in the discipline of nursing question the use of theory in research and practice. I am curious how you came to develop a theoretical framework. To start, please tell me a little about yourself and what influenced your nursing knowledge.
Thank you for the invitation. I am actually a second-career nurse. My first degree was a bachelor of science (BS) in biology, and I was unfulfilled in my job in pharmaceutical sales so I went back to nursing school at the ripe old age of 28. Since I already had a BS and wanted to start working, I went back for an associate degree in nursing (ADN). I became a critical care nurse and then, realizing I loved what nurse practitioners (NPs) do, I went back for my master’s degree and became an NP. Along the way, I discovered I loved teaching and research. That concept of being able to generate evidence was exciting to me, so I went back for my PhD.
I am a tenure-track assistant professor of nursing and DNP program director at UMassD, while still practicing as an NP in palliative care. As an assistant professor, I teach NP students and do research. My research focus is on lesbian, gay, bisexual, transgender, and queer (LGBTQ) health; specifically, I look at minority stress and how that impacts LGBTQ folks. I have broadened that focus to include how stigma in general affects people who are considered other. Minority stress is a fancy way of saying stigma: stigma that is related to being part of a minority population such as a LGBTQ population.
As far as what has influenced my nursing knowledge, because I am a second-career nurse, because I have had a variety of diverse experiences throughout my life and my career, such as collaborating with different people, different types of populations, doing different work, I am a lifelong learner. I focus on trying to learn from my patients, my fellow nurses and nurse scientists by constantly listening.
Part of my doctoral dissertation involved the concept of cultural humility. My colleagues and I (Avery-Desmarais et al., 2021) defined cultural humility [based on Foronda et al.’s (2016) concept analysis] as “an interpersonal interaction in which the participants are self-aware, open, egoless, willing to reflect on personal biases and critically evaluate their role in the interaction” (p. 1150). We cannot fully understand what it is like to be in another person’s shoes, but if we listen to them and we hear their stories and look at them as being teacher for us, then we can learn so much. We can develop really important, strong relationships with our patients, our students, and our colleagues. I think that is what is a big part of what influences my nursing knowledge and what it is to be a nurse.
Another influence would be my own experiences in the healthcare system. I am the aunt of a nephew who is a cancer survivor and who is also transgender. Because of the personal experiences I have had and seen, it has allowed me to look at how important it is for me to be affirming of a patient; to look at the patient and the family as a group who are moving through this health crisis. I am also a member of the LGBTQ community, so I have firsthand knowledge of what it is like to have good experiences in healthcare and not-so-good experiences in healthcare.
Shannon, did you use a nursing theory or frameworks to underpin your dissertation?
I actually used a psychology theory. The reason being, I did not feel like there was truly an LGBTQ-appropriate nursing theory that I could wrap my mind around. So, I used the theory of minority stress by Ilan Meyer (2003), a psychologist. Meyer’s work has since been used in the majority of LGBTQ research. Specifically, in my dissertation (Avery-Desmarais et al., 2020), I looked at the impact of minority stress on problematic substance use in nurses who identify as LGBTQ.
Do you use nursing theory to underpin your nurse-patient relationships (practice) or teacher-student (teaching-learning) relationships?
You know I was one of those people in my master’s program who did not give much credence to the use of nursing theory in practice early on. Now as faculty, I place so much value in nursing theory. As I work with my DNP students on their projects in nursing practice, I ensure that they have a nursing theory to support their projects.
I have encouraged my DNP students to use nursing theory to underpin their interventions; however, it is not a requirement at my nursing program. How do your DNP students use nursing theory for their projects?
Actually, this is a requirement in our program. It has been a part of our program’s culture prior to my start as faculty. They must choose a theory as soon as they have a PICO (Patient/Problem-Intervention-Comparison-Outcome) question. Then, whenever they have a question like, “should I be doing this in the intervention” or if they have barriers, I have them go back to the theory and say, “what does the theory say . . . or suggest on how to interact with the patient?”
What changed your interest in nursing theory?
I had this wonderful theory professor in my master’s program, Dr. Katherine Gramling. She is now retired, but she had a wonderful passion for nursing theory. Then, in my PhD program, I had another professor who was also passionate about nursing theory, now one of my co-authors on my MDSS framework, Dr. Susan Hunter Revell. I think these professors introduced nursing theory in a way that allowed me to envision that you really could bring it to practice. For one of my projects in my master’s theory class, we had to choose a theory—I chose Watson’s caring theory (2018), and then implemented the theory into an average practice day. We also had a patient exemplar assignment, and we wrote about how that theory could guide that practice experience. I was at Massachusetts General working in the cardiac critical care unit at that time and had a very sick patient on extracorporeal membrane oxygenation (ECMO). There were two nurses assigned to the patient along with the ECMO technologist. The care was very technical, but then I took that theory, and I was able to look at how it applied to the things I did for my patient that day, or the way I cared for the patient or his family, and suddenly the light bulb went off. I thought there is something to using nursing theory to underpin my practice. So now when I see patients in palliative care as a nurse practitioner, I have a lot of deep conversations with these folks. We talk about decision-making, about difficult family situations, how they feel supported or not supported in their healthcare journey. I really do call upon theories like Watson’s (2018) to support me as I support them in their decision-making and symptom management and what not.
So now, what would you say your contributions to nursing knowledge have been?
What I have done is looked at the LGBTQ nurses. When I did my dissertation, I found that not many folks have done research on LGBTQ nurses. What was there was qualitative, so I quantified the impact of minority stress on specifically LGBTQ nurses. As nurses experiencing stress, we think we are stronger than that, we got this, we are resilient, or should be more resilient, but it is not always the case. So I worked on quantifying the impact of stress on problematic substance use in nurses and, now in my most recent study, I am looking at anxiety and depression. Then there is my work with Drs. Monica Shuler, Mary McCurry, Jennifer Viveiros, and Mirinda Tyo on our NO STIGMA Foundation of Opioid Response Efforts (FORE) grant. We are looking at stigma in nursing students and how we can decrease stigma towards patients with opioid use disorder (OUD). The work I am doing now sheds light on stigma and minority stress and how those external and internal forces impact us. There is minority stress that comes from the outside and the inside, such as internalized negative feelings about yourself because of what society tells you, or expectations that you are going to be rejected because of who you are. All of these stressors impact our patients and impact us. So I think that my work has shed a light on all of this.
And I should tell you about my theory as well. The theoretical framework I helped develop with my colleagues, Dr. Susan Hunter Revell and Dr. Mary McCurry, is called the minority doctoral student success framework (MDSS). So again, I pulled that concept of minority stress into the picture. If you look at the theory synthesis we published, you see that students have financial difficulties, interactions with their faculty, with their fellow students, all of the normal things/challenges of a doctoral student, but they also have this minority stress. And people that do not have minority stress do not always recognize that. It is like when you are able-bodied and do not recognize what it is like to be in a wheelchair and that it is very difficult to be a differently-abled person in our society. So, I think it is important to shine a light on that so we can understand the stress that folks might be going through, in addition to all the regular stress. The model that we developed provides insight into the complexity of what a minority doctoral student experiences. We cannot just think if we recruit them, they will be successful; there is so much more into promoting someone’s success.
That is an important point. One of our minority DNP students has written a book about being a black queer nurse (Daniels, 2023). She was a master’s student when she wrote it, but I suspect she addresses some of the minority stress you are talking about. Our DNP program is an online program, and we realized recently that all the students need more interaction and connections with faculty and students to be successful. We have since started a monthly Zoom meeting we call Teatime. All DNP faculty and students are invited and with our DNP student advisor and director of the program co-facilitate the Zoom. We have gotten a lot of positive feedback on this intervention.
What is in the future for your framework? And do you know of anyone using it?
I would like to evaluate it. I would like to implement an intervention based upon the framework and get some good data. I would think it would need to be a collaborative or a multi-site pilot because there is not a large number of minority doctoral students in our program. I have seen our framework cited, but I have not seen it used in any research. There is a hospital group in California that requested permission to use it in a presentation they were giving to support healthcare students that are minorities. I was excited because this was a perfect use of the framework, and I look forward to people using it in the future.
It is interesting that you could not find a nursing theory that was useful for your dissertation, so you developed your own. That is remarkable. Now what are you most proud of?
I am most proud of being willing to research something that sometimes makes folks uncomfortable. Also, whether or not I am presenting, or in class, or having a conversation with my fellow colleagues, I am willing to speak up or say important things out loud that may make others uncomfortable. I think that if we are going to make change for the better in nursing education and in our United States’ (U.S.) healthcare system, so that folks that are minorities have better experiences in those systems, I think we need to be willing to be able to talk about the tough things, like systemic racism, systemic homophobia, transphobia, etc.
Can you give me an example of systemic racism you have seen in nursing education?
It can be as simple as our high-fidelity simulation manikins being all white, our case studies being only about heterosexual families, and our policies. Some policy examples include the lack of flexibility in our assignment due dates policies and bursar policies for signing up for classes. These policies tend to have a negative impact on students that have more socioeconomic challenges, many of whom are sometimes minorities. There are a lot of things that we (Caucasian persons of middle-class background) do not think of or consider that our students may be going through. For example, a student might have to work in order to eat, and they might have to go in for a shift that necessitates them being late for an assignment. There are lots of little subtleties like that that we do not always consider.
Ah yes, our college of nursing has purchased black and brown manikins now, and some of my colleagues allow all their students to be late once or twice during the course. It is harder for faculty to keep track of the assignments, but I can see now why they do that. Plus, allowing all the students to be late once or twice, it is fair to all the students in the course.
Some faculty say if you allow students to do that, they may take advantage of the situation and question if it is fair to the other students. But all of our students have different challenges. I think there is a way to be flexible and supportive for our students while still providing structure. Covid-19 has reminded us that challenges come up in life and that the need to be flexible to support a student’s success is an important concept.
What are you working on now?
I am working on our NO STIGMA FORE grant, which is developing high-fidelity simulations to reduce stigma in both undergraduate and graduate nursing students; to reduce stigma in patients with OUD. That has been an exciting collaboration with my colleagues. It has been humbling as well because the students have responded in a way that demonstrated the trauma that they have been through in their growing up in this age of problematic opioid use. In the way they have responded to the simulations, we discovered they have a lot of anxiety; they have personal experience with OUD. It reminded me that, as nurses, you bring to your patients a whole history of your life experiences. So, whether it is my experience of my nephew going through cancer at the ripe old age of 2.5 years or experience with a family member going through OUD, these types of experiences influence how we care for our patients. This has been a reminder to me to reflect on my own experiences and my own biases as I do not want them to come into play with my own patient or student interactions. Also I have a seed grant to use micro-mindfulness interventions to try to reduce stigma in nurses towards patients that are seen as other, whether it be persons of color, persons that are LGBTQ, etc.
When you talk about stigma, have you seen anything in the literature regarding stigmas related to patients that frequent the emergency room, are considered non-compliant with the plan of care, the elderly, or persons considered obese? It has been my experience that nurses sometimes label or stigmatize the persons we work with in health care, not always realizing that there might be other things going on in their lives we do not know or understand.
We have not included those types of patients in our studies. I have not seen a lot of evidence that there is a stigma of persons that are older. Definitely there is stigma in people with chronic obstructive pulmonary disease (COPD), lung cancer, substance abuse disorder, minorities, and LGBTQ persons. And yes there is so much more to our patient’s story. Always more to the story . . .
The NSQ issue this article will be in is about art. Do you or your colleagues use art in your work?
I have not used art per se in my research. I am not an artist, but I am a singer. I have been singing since I was a very young child, and I still sing in my church choir. For me, music and making music has been very therapeutic, and I have always tried to use music in my practice. When I was a critical care nurse if I had a patient that was anxious or was challenged, or we were challenged to help them breathe with the ventilator instead of against the ventilator, I would frequently try to use music with them, and it helped. It is interesting that you bring up this topic. As we are developing this micro-mindfulness intervention, I can see myself perhaps incorporating some music as a form of art.
What advice do you have to our readers and nurses interested in becoming nurse educators and scientists?
Follow your heart and your passion in your pursuits of nursing science and nursing education. Follow your passions even if someone says, “That passion is going to be harder to publish, or that passion may not be funded well.” You can make it happen; you may have to do it a bit differently, but follow your passion because if you do not, you miss out on some of the beauty that is being a nurse scientist.
Thank you for that and for spending time with me today. I wish you well in all your future endeavors.
Thank you. I enjoyed our conversation.
