ETHICS AND THE DNP-PREPARED NURSE

Note: Author and primary contact: Linda S. Johanson, EdD, MS, RN, Core Nursing Faculty MSN program, College of

Nursing, Walden University, 100 Washington Ave S. Suite 900, Minneapolis, MN 55401. Email:

[email protected]; Secondary Authors: Patti P. Urso, PhD, APRN, ANP-BC, FNP, CNE Specialization

Coordinator, Nurse Educator Track, Walden University, College of Nursing, 100 Washington Ave. S. Suite 900,

Minneapolis, MN 55401. Email: [email protected] and Kimberly Priode, Ph.D., RN, CNE, CCRN, Nursing

instructor, James Madison University College of Nursing, Health and Behavioral Sciences Building (HBS), Burruss 204B,

235 Martin Luther King Jr. Way, Harrisonburg, Virginia 22807. Email: [email protected] (work)

Conflicts of Interest and Source of Funding: The author of this manuscript have no conflicts to report. No external

funding was solicited in the composition of this work.

Journal of Excellence in Nursing and Healthcare Practice

2022, Volume 4, Issue 1, Pages 1–10 DOI: 10.5590/JENHP.2022.4.1.01

© The Author(s)

Original Research

Factors Influencing the Development of Social Change Involvement

Linda Johanson, EdD Walden University, Minneapolis, Minnesota, United States

Patti P. Urso, PhD Walden University, Minneapolis, Minnesota, United States

Kimberly Priode, PhD James Madison University, Harrisonburg, Virginia, United States

Contact: [email protected]

Abstract

How to cultivate and encourage the motivation to become an agent of positive social change has not been

studied to a great degree. For example, what kind of factors influence the development and growth in nurses

toward a desire to be involved in changing society for the better? Knowledge of these factors could help

educators and nurse leaders provide and encourage those growth opportunities. The purpose of this research

was to interview nurses known to be deeply involved in various types of positive social change and discover

what factors influenced this development. Three overall themes emerged as influencing factors for

involvement in positive social change including emerging perspectives; experiences and encounters; and

consideration of the successful effects of social change attempts.

Keywords: social change, motivation, nursing

Date Submitted: January 19, 2022 | Date Published: October 8, 2022

Recommended Citation

Johanson, L., Urso, P. P., & Priode, K. (2022). Factors influencing the development of social change involvement. Journal

of Excellence in Nursing and Healthcare Practice, 4, 1-10. https://doi.org/10.5590/JENHP.2022.4.1.01

Introduction

Nursing is consistently recognized as a caring profession. Many who enter the profession do so out of a desire

to simply help others. Many nursing students believe that the most important characteristic nurses possess is

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 2

the ability to provide compassionate care (Rhodes et al., 2011). Caring behaviors, such as showing respect,

attention, and valuing the person, have healing elements but also provide personal meaning to the caregiver

(Karlsson & Pennbrant, 2020). These caring behaviors make nurses a logical group of people to initiate

positive changes in society. Whether that be through political voices to change health-care processes and

practices, advances in health through research, or in the many ways nurses volunteer their skills to change the

lives of communities, nurses constitute a powerful force.

How to cultivate and encourage the motivation to become an agent of positive social change has not been

studied to a great degree. It is important to understand the factors that may influence the development and

growth of nurses toward a desire to be involved in changing society for the better. Knowledge of these factors

may help educators and nurse leaders provide and encourage growth opportunities. The purpose of this

research was to discover what factors influenced this development by interviewing nurses known to be deeply

involved in various types of positive social change.

Literature Review

There is little specific research on nurse knowledge and ability to effect positive social change. While little was

found in the literature regarding the specific topic of developing attitudes oriented toward changing society,

some studies were tangentially related to this concept. For example, Chi (2018) found that foundational faith-

inspired concepts are instrumental in both social work and as a lifestyle framework. Shim and Park (2019)

concluded that, among Korean government employees, the style of servant leadership was related to

motivating individuals toward public service motivation. Public service motivation was also studied by Evans

and Evans (2019), who concluded that, while adverse childhood experiences correlated negatively with

motivation, extremely negative childhood experiences correlated positively with engagement in public service.

These are some examples of the minimal exploration of nursing and its impact in the positive social change

arena.

On a smaller scale, there has been more research conducted with respect to working in a specific organization

and motivation within that organization. Lin et al. (2019) investigated the concept of helping behaviors among

employees, which have been linked to higher performance in organizations. Lin et al. (2019) found that if

motivations for helping others were voluntary (as opposed to mandated as a part of the job), the effect of the

motivation was more positive, and they tended to help others more frequently in the future. In addition, Kim

& McGill (2018) also studied helping behaviors in organizations and determined that helping other persons in

need is enhanced by self-affirmation. What we do see documented in the literature here is a sense that there is

a personal reward in helping others in the workplace when it is not forced.

Some research related to the role of nursing education in the development of nursing values and caring

behaviors was found. Role models in nursing school, as well as learning correct methods for nursing skills,

support this development (Culha & Acaroglu, 2019). Finally, a position paper by Mumby (2020) discusses the

thesis: coaching that focuses on the positive qualities of groups disadvantaged by society could work better to

effect social change than focusing on the negative. Thus, working social change into the job can also be

effective and motivating.

Methods

Ethics

The university Institutional Review Board (IRB) granted approval for this study to proceed (prior to data

collection) on September 20, 2021. As part of the IRB process, an informed consent form was created and

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 3

utilized. CITI Research, Ethics, and Compliance training was current for all of the co-researchers. The

informed consent form reviewed the purpose of the study. This was also provided at the start of each

interview, as well. Identities of the participants were known to the researchers; however, these identities were

not divulged in the reporting of research findings. An interview script was used to interview participants so

that answers were not coached or pressed.

Study Design

A qualitative approach was used to pursue the research inquiry. The researchers perceived that this approach

would generate deeper insights into the reasons participants became involved in social change initiatives.

Participants

Participants were individual nurses who participated in activities to promote social change. A purposive

sampling method was used to ensure a sample diverse in age, gender, and academic preparation. Twenty-six

individual nurses who were known to the researchers as being involved in social change activities (either by

reputation or previous professional encounters) were initially invited by email or phone to participate in the

study. Seven who were contacted did not respond to the initial contact and request, and three declined to

participate for various reasons. This left a sample of 16 individuals who agreed to be interviewed. Once data

collection and analysis were complete, we determined that data saturation had been achieved with this group

of 16, and no more participants were recruited for the sample.

The age composition of the sample ranged from age 23 to 80 with an average age of 56. The largest proportion

of participants was educated at the doctoral level (n = 7); however, there were also nurses in the sample whose

highest degree was an MSN, BSN, ADN, or diploma. Most nurses in the sample were female (n = 13), but three

were male. Years in nursing ranged from 6 months to 52 years. Current roles in nursing included educators (n

= 7), and the remainder was distributed among nurse midwives, nurse practitioners, and nurses working in

pediatrics, administration, ex-military, and retired nurses. The geographic distribution covered nine states.

Data Collection

Sample participants were selected and initially contacted by phone or email with a broad introduction to the

study and a request to be interviewed. Participation was voluntary. Potential participants could ignore the

initial contact or could decline to participate. If interest was expressed in a response, details were shared, and

the consent form was sent to individuals who officially agreed to participate. Finally, mutually convenient

times were established for the interviews. Two broad statements guided the interview encounters:

• Talk about the activities in which you currently participate that promote social change.

• Discuss factors in your life that encouraged your interest and participation in social change activity.

The telephone interviews were audio recorded, and interviews lasted between 12 and 45 minutes, averaging

24.5 minutes. The audio recordings were then transcribed and analyzed for themes.

Data Analysis

The data analysis from this research included the interpretation from expert researchers about the agreed-

upon concepts from the verbatim transcripts. A general qualitative approach guided this inquiry.

The credibility or rigor of a qualitative inquiry is just as important as the credibility of a quantitative inquiry.

Credibility is achieved by applying structured assessment and evaluation to the interpretation of the findings,

which defines trustworthiness (Creswell & Poth, 2018). In this inquiry, a coding table was developed to

provide a structured process for the analysis of the transcripts (see Denzin & Lincoln, 2018). The coding table

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 4

was offered by an expert qualitative researcher (part of the research team) and reviewed by the primary

investigators, creating a comparative analysis. The coding table was divided into axial concepts, meanings,

and themes by applying the interpretation of the concepts that were realized by the investigators.

Saturation of the data, with respect to interpretation of the findings, is also important and provides credibility

to a qualitative inquiry (Denzin & Lincoln, 2018). In this research, saturation was obvious as each participant

commented on common feelings and understandings in the interviews. We highlighted these common

threads, and then each investigator verified the common themes in an additional review. As common themes

were then agreed upon, the investigators provided supporting evidence by including verbatim participant

comments from the interviews.

Results

The first statement directed participants to discuss the types of social change activities in which they have

engaged. These activities are sectioned into five broader categories, including volunteerism, research, politics,

career, and faith-based projects.

Volunteerism

Several of the participants described how they engaged in volunteer efforts, both community and abroad, to

change society in positive ways. Several participants mentioned regular medical mission work to

impoverished third-world countries to teach health practices and provide medical care. Others were active in

communities helping in food distributions, a senior center, local non-profit organizations, a guardian ad litem

program to advocate for abused children, and as a liaison to the Board of Health to promote local health

issues, such as reduction of health care costs. Community action for older adults was another area of

volunteerism, helping this group with health promotion, social security issues, and support for chronic health

issues.

Research Endeavors

In particular, two participants discussed their research endeavors and how they promoted social change. One

participant, P1, had expertise in the area of end-of-life care and the resulting research has promoted change in

hospice policies for the dying. Another, P6, had a research agenda in resilience-building, which has

contributed to positive ways to embrace change. P6 stated, “you can’t have change unless you are willing to

build a safe environment.”

Politics

Several of the study participants were involved in political action and advocacy to promote better health.

Some were involved in nurse’s associations, such as their state nurse foundation, Oncology Nurse’s

Association, Holistic Nurse’s Association, and American Cannabis Nurse’s Association. Two were involved in

community advisory committees working on advocacy for minority groups and vaccine access and

distribution, respectively. One nurse was an elected city councilor and involved in advocacy of programs for

poverty, noise reduction, and dust reduction.

Career

Some of the nurses interviewed had careers in nursing education and perceived that their roles in academia

contributed to positive social change. Examples mentioned included mentoring students to be involved in

community activism, identifying gaps in education for minorities and eliminating barriers in education for

these groups through activities. Also mentioned was specifically teaching the topics of social change,

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 5

economics, finance, and evidence-based practice as ways to equip students with tools for positive social

change. Two participants were nurse practitioners who worked with clients enduring the challenges of

poverty. These nurses discussed the efforts of their work to change conditions for the poor with respect to

health teaching, promotion, and care.

Projects

Finally, several in the cohort of participants discussed social change in view of the spiritual condition through

faith-based endeavors. Two nurses were involved in evangelistic outreach programs. The nurses who

participated in medical missions mentioned these programs also had a component involving spiritual support.

One church hosted a food distribution program with prayer available for recipients, in which the nurse in the

sample participated.

Major Themes

The second part of this study was to uncover the perceptions of participants regarding what they thought had

influenced their interest in becoming agents of positive social change. The analysis resulted in the emergence

of three major themes that were categorized as emerging perspectives, experiences and encounters, and

effects of endeavors. Each theme is highlighted under the respective heading.

Theme 1: Emerging Perspectives

In the theme of emerging perspectives, participants discussed influences toward social change in their lives

when growing up. Several discussed having been a member of a family with inclinations toward social justice

or strong faith-based beliefs, for example. One, P5, stated, “I come from a large family, and my parents were

very active in the church and with social justice, and so we started working with them before we even knew

what we were doing.” Another, P1, had even been in a convent as a young adult for a number of years and

stated, “so I know my Christian background (was influential), as I was in a convent for five years, and since I

was in the eighth grade my main ambition was to be a missionary in Africa. That has always been my goal. It

started that early on.” Some told stories of how their parents were very involved in social issues. One, P10,

discussed, for example, how her mother was especially involved in the formation of nursing unionization,

stating, “weekends… she’d drop my brother and I off at the movies or bowling alley, or whatever, and she

would go out and work on trying to get people to accept the union, and it did happen!” In these individuals,

there was a natural development in the interest in involvement in social change, as it was a vibrant and

consistent part of their upbringing.

Theme 2: Experiences and Encounters

This second theme surrounds particular experiences or encounters that study participants perceived to have

influenced their interest in becoming agents of positive social change. Some of these experiences were

regarded as positive; however, another group of experiences was the opposite. Both types of experiences

seemed to have influenced the development of interest in impacting social issues.

Subtheme A: Positive Experiences

Many of the participants in the study recounted experiences where the need for social change was apparent.

Participants indicated that they were affected by seeing poverty on a mission trip or studying abroad in school,

children of parents involved in drug abuse who were abandoned, hearing the struggles of immigrant friends,

or even in their roles as registered nurses encountering particular situations with patients who were struggling

with the health-care system. Almost all participants could relate a particular story that was influential to them.

Some of the commentaries included the following:

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 6

• P2, “I have a friend who is Guatemalan, and she has lived here for about 25 years, but she has shared

a lot with me about her life growing up and how hard it has been to raise her kids here. I see things

in their lives that need change, to make their lives better in a way.”

• P4, “The medical mission trip was a major factor in stimulating my interest in getting involved in

social change. It was on my heart to make life better for people with low access to care and poverty.”

• P3, “I got involved because of a friend of mine, had actually been guardian ad litem with twin girls,

they were probably only about 2 years old. They had been abandoned. Their parents had been

involved in drugs.”

Also relevant to this category, several of the participants discussed environmental or social issues that

influenced a desire to become involved in social change. One mentioned the impact that the civil rights

movement had on her desire to advocate for racial equality. This person, P14, commented, “I think the things

(that were influential) were things happening in the ’60s in terms of the civil rights movement. We didn't

know what we did not have until someone would call it to our attention in terms of, say, the right to vote, the

right to sit in the front of the bus instead of the back of the bus.”

Another, P16, described a natural environmental disaster as being influential. The participant conveyed the

notion of living through the destruction from a major hurricane that quickly and completely obliterated their

community. This loss of a sense of security encouraged the participant to desire to build community relations

as ways to support and help out neighbors through adversity.

Several of the participants had been active in military service and indicated that this particular experience had

been instrumental in building the skills needed to make positive social change. One, P6, stated, “I never did

the same job in the military in 27 years. Each time I took a new job, it was an opportunity to learn something

new. For me, that energizes me. That discovery is just wonderful.” Another, P1, indicated the military ignited a

passion for a particular change in society. She stated, “As an Army nurse I was thrust into the environment

where many died. That became my passion in the Army to do something to get better care for those who were

sick and dying.” This nurse went on to publish research on end-of-life care and advocate for the expanded role

of nurse practitioners in hospice care.

Many participants in the study commented on the role of mentors, nurse leaders, faculty members, and

friends throughout their experiences as students or as working registered nurses. In these experiences, others

saw a quality or characteristic in the participant, brought it to their attention, and encouraged them to become

involved in social change behavior. One relevant example was a retired nurse who never perceived herself as

being politically active. A group of friends suggested that, with her background in conducting research and

teaching nursing, she would be an amazing city councilor, and they encouraged her to run. She did so, won the

election, and has since developed a network related to food sustainability and distribution, helped formulate a

vaccination incentive program, and conducted participatory action working in communities with a focus on

health and slumlords and noise decrease ordinances. She initiated action to deactivate 175 wells that were

associated with arsenic.

Subtheme B: Negative Experiences

Although positive experiences and encounters in one’s life were perceived by all participants as something

that stimulated interest in becoming agents for social change, some also shared events described as extremely

difficult for the participants to endure. These negative situations tended to precipitate a similar motivation for

desiring change. Participants with negative stories were challenged to change societal circumstances so that

others could be spared the experience of devastation.

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 7

Several of the nurses described situations that occurred in nursing school when an instructor treated them

unfairly or unkindly, and this motivated them to become involved in nursing education and make changes in

academia. One participant, P8, described the following:

“It was an instructor who just belittled people. She was like a witch, terrible. She was not that much

older than me. That is why I became an educator. Through that bad situation I wanted to create a change

in nursing education for other people so that they don’t have that kind of situation.”

Another described a faculty member who lacked empathy:

In college, I had a really negative experience in nursing school. I had one faculty, and it was a horrible

experience with her. It stands out in my mind so distinct. But I can remember sitting in her office and

thinking that if I ever did this (teach) I would not be you. She was my oncology clinical instructor, and

my dad’s best friend had been diagnosed. My dad had some rare form of cancer they were trying to do

testing on. And I was just struggling. It was just hard for me. And I just needed someone to talk with

me, and she told me I had just better suck it up. And I remember thinking, “That wasn’t what I

needed. I needed something different than that. I was young and didn’t know what I really needed but

that wasn’t it.” (P9)

This nurse went on to become an associate professor with tenure at a state university and has conducted

research, presented papers, and published in the research agenda of improving nursing education. She taught

graduate courses in nursing education and perceived herself as a positive role model for future nurse

educators.

Some of the participants described personal, negative situations as being influential in encouraging the desire

for change. One expressed a previous episode with severe depression, even to the degree where suicide was

attempted, and hospitalization for a near-death experience. She had a faith conversion and is now involved in

evangelical efforts to change the spiritual conditions of those who feel lost. Another described the role of her

personal failures as being influential. She (P6) stated:

A lot of my drive to become a change agent emerged from learning from failure (in home life,

elementary school, and in the military for example), learning how to turn that around. From

incidences of negativity, learning to say, “it has to be different. I had to rewrite the narrative.”

Theme 3: Effects of Endeavors

The final of the three themes that emerged from the study interviews related to the ways in which participants

were encouraged by seeing the results of efforts toward social change. Some talked about legislation that had

been developed that motivated them to continue trying to produce more. Some discussed the results of

research that produced change, which motivated them to continue a research agenda in that arena. Others

discussed activities of students they had taught skills for social change, as well as the resulting work of these

students in impacting change, which motivated them to continue their educational endeavors. Some of the

comments of participants follow:

• P15, “And there were nine different pieces of legislation that were out there that were all health care

related, and we were able to get these groups united. We got all nine pieces of legislation passed,

anything from making CPR a graduation requirement for high school, APRN consensus model for

independent practice, oral chemotherapy agents covered by insurance. We helped the Oncology Nurses

Association get that one through.

• P6, “If we are going to create people who are innovative and on the edge (of change in society), we need

to take risks. Number one, we have to enjoy our differences. You have to have that psychological safety

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 8

where you are in an environment where you can take those risks. And you can pick yourself up again.

Leadership makes a huge difference. Integrity makes a huge difference. And relationships make a huge

difference. I think all of those are involved in facilitating that innovation.

• P5, “My research skills also came into play in encouraging involvement in social change. All the analysis

of things, like why people are vaccine resistant. A couple of others on my committee were professors.

We would pull research and then summarize it for the entire committee, so we didn’t put effort into

something that wasn’t going to pay off. We involved Latino and Native American organizations from

the university, and they began to work in their populations. It turned out successful.”

Limitations

To secure the sample for this study, we contacted individuals who were known to be involved in efforts to

positively change different aspects of society. Potential participants were known to the researchers either by

reputation or professional encounters. The consent forms used assured participants that they were free to

decline, and no coercion was used to acquire a sample. Efforts were made to engage individuals who had

diverse interests, were of diverse ages and genders, were involved in different nursing careers, and lived in

different parts of the country. That said, because the sample group was known to us, there could have been a

bias related to the particular types of acquaintances the researchers have. Having two distinctly different

researchers who know different people and who have known one another only 1.5 years was helpful to

minimize this potential bias.

Discussion/Implications for Theory and Practice

This study is important in providing insight into the types of situations that can motivate nurses to become

agents of positive social change. Knowing this can help educators and nurse leaders to provide structured

opportunities to that end. Although past experiences cannot be changed, nurses can be encouraged to

consider the potential positive impact of past experiences, which had been regarded as negative, and view

them with the purpose of making change. Activities, such as studying abroad, and the provision of positive

mentors and role models can be structured. Exposure to skills that will help develop change initiatives, such

as political advocacy, leadership, research, cultural sensitivity, and resilience training, can be components of

nursing curricula or continuing education programming. Nurses are already recognized as care agents. This

foundation is a natural launch for the development of advocacy for positive social change.

Conclusion

This qualitative study involved analysis of the interviews of selected participants who are involved in social

change efforts to discover which types of social change activities they engage in and what motivated their

involvement. An array of social change endeavors was reported from volunteerism, research, political action,

career endeavors, and faith-based projects. Three overall themes emerged as influencing factors for

involvement in positive social change, including emerging perspectives; experiences and encounters; and

consideration of the successful effects of social change attempts.

Johanson et al., 2022

Journal of Excellence in Nursing and Healthcare Practice 9

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Practice welcomes manuscripts focusing on topics such as national

and international workforce issues, quality improvement projects,

evidence-based practice initiatives, nursing research studies, interprofessional practice, educational issues,

telehealth, improvements in technology, and the impact of social change in society.