We Will Never Meaningfully Transform Research-focused Doctoral Education in Nursing Without Addressing Who Has Power Over Its Design and Implementation
Rachel (Rae) Walker, PhD, RN, FAAN (they/them)1
Jessica (Jess) Dillard-Wright, PhD, RN, MA, RN, CNM (she/them)2
Raeann (Raeann) LeBlanc, PhD, DNP, AGPCNP-BC, CHPN (they/them)1
Cory Ellen Gatrall, MFA, RN (she/her)1
1 Elaine Marieb College of Nursing, University of Massachusetts Amherst, Amherst, MA, United States
2 College of Nursing, Augusta University, Augusta, GA, United States
On October 15, 2021, the AACN released draft guidance on excellence in research-focused doctoral education in nursing and opened a two-week public comment period that, following multiple requests from AACN members, was eventually extended to November 17, 2021. This new guidance, available here on the AACN website, was drafted by a Task Force composed of accomplished nurse leaders from a variety of nursing school types, including large public research universities, private schools, schools in rural and urban settings, and at least one HBCU. The Task Force was initially convened and charged “to revise AACN’s 2010 position statement, The Research-Focused Doctoral Program in Nursing: Pathways to Excellence, with the goal of developing a vision for research-focused doctoral programs and graduates” (2021).
In the request for public comments, the Task Force requested responses to the following questions, using line numbers from the document as appropriate:
● What was captured well in the statement?
● What areas appear to be missing?
● What else does the task force need to consider?
The following essay responds to these questions, using a design justice framework. Design justice is a term that emerged from a multidisciplinary community of practice of design practitioners working with and for social movements and community-based organizations around the globe, including but not limited to clinicians, technologists, developers, journalists, artists, community organizers and activists (Costanza-Chock, 2020). The Design Justice Network is built upon conceptual foundations built by generations that preceded it, particularly within the realm of Black feminism such as Dr. Patricia Hill Collins’ landmark scholarship that described the matrix of domination wherein interlocking systems of oppression including but not limited to centered whiteness and white supremacy, settler colonialism, ableism, cisheteropatriarchy, and capitalism, mutually constitute each other and shape people’s lives (Collins, 1990). The Design Justice Network’s principles are a living document first drafted in 2015 at a workshop convened by Una Lee, Jenny Lee, Melissa Moore and facilitated by Una Lee and Wesley Taylor at the Allied Media Conference in Detroit, Michigan. Design justice work is guided by two core beliefs: “first, that those who are directly affected by issues a project aims to address must be at the center of the design process, and second, that absolutely anyone can participate meaningfully in design” (Costanza-Chock, 2020, p. 7).
Design justice invites us to consider how design decisions regarding research-focused doctoral education programs in nursing reproduce and/or challenge the matrix of domination, and how such decisions are impacted at the institutional level by factors such as strategic agendas, funding priorities, leadership hierarchies, institutional policies and practices.
What was captured well in the statement?
This statement captured the opinions of a group of doctorally-prepared nurse academics and representatives of funding agencies, such as the Robert Wood Johnson Foundation, who were also present during an initial by-invitation-only think tank hosted by the AACN task force. A number of accomplished nursing experts worked on the Task Force and their perspectives are appreciated. The Task Force also anonymously surveyed PhD students and deans of accredited nursing schools with research-focused doctoral programs located in the United States, using a structured closed-response electronic questionnaire, thereby foreclosing on input that might not be addressed by the questionnaire. Peer-reviewed literature in English pertaining to research-focused doctoral education in nursing and published between 2010–2020 was reviewed and synthesized, firmly situating recommendations in what is rather than what might be. While the task force held an informational meeting at the AACN PhD education pre-conference in January 2021, with a series of virtual breakout room listening sessions at the main Doctoral Nursing Education conference that followed, no record of notes from those sessions or attributions for opinions or ideas is present in the draft document, so it is impossible to say how much, if any, of the feedback shared in those sessions by other AACN conference attendees was incorporated. Attendees of the AACN Doctoral Nursing Education conference are typically nursing deans, department chairs, and doctoral program administrators, the overwhelming majority of which, as the report notes, remain doctorally-prepared white women academic nurses.
We believe some of the content captured by the statement resonates. We commend the Task Force for synthesizing these findings and recommendations. Table 1 below outlines particularly impactful sections, with their line numbers.
Table 1. Statements From Sections I-III That Resonate.
What areas appear to be missing?
From a design justice perspective, the process of developing new and revised guidance for research-focused doctoral education in nursing begins by asking who currently holds power over decision-making, who is benefiting from that power arrangement, and who is being harmed? We would then seek to center the voices and leadership of those impacted by PhD nursing education who have been harmed by or excluded from the design process.
While it is commendable that the task force surveyed current PhD students, we will never transform PhD nursing education without engaging those who’ve been kept out of it. Future redesign efforts might consider the perspectives of those who are most impacted by PhD education in nursing, not just nurses but patients, caregivers, communities and prospective students.
Overall, this document misses an opportunity to liberalize our understanding of knowledge production and nursing research.
By continuing to focus on “fundable science,” this guidance forecloses important avenues for knowledge production that do not meet federal funding priorities or aims of other funders. This has the net effect, in spite of good intentions, of reinforcing a very narrow, very white, very elitist status quo. This is further reinforced by the emphasis on postdoctoral fellowships, something that not even all nursing PhD graduates can secure, even those who will carry on research. Emphasizing this exceedingly narrow gate will further curtail the development and advancement of a PhD-prepared nursing workforce and nursing’s research. Other areas that are potentially missing include scholarly priorities and epistemics other than those of NIH’s research agenda (Rabelais & Walker, 2021), which are repeatedly (and unnecessarily) reflected in this document (Georges, 2003).
The emphasis on science as it is constructed precludes considerations of philosophy.
The document is predicated on a deeply positivist type of empiricism, also grounded in colonialism (Clayton, 2020; Hogarth, 2017; Ross, 1991). Scientific perspectives, such as those mentioned on page 4, line 162, are not the only schema that shape inquiry and research (Tuck & Yang, 2014; Boulton, Sandall & Sevdalis, 2020). A PhD in nursing should attend to the interdisciplinary ideas that come to bear on the discipline, from within and from without. Not all of these ideas are “scientific” in the narrowest sense — but that does not mean they are not central to formulating new knowledge for the discipline (McGibbon et al., 2014; Dillard-Wright, Walsh & Brown, 2020).
The draft guidance lacks much discussion regarding the evaluation of the impacts of research-focused doctoral education in nursing, beyond peer-reviewed publications, presentations and grants. Such “impacts”are just productivity metrics mostly grounded in the neoliberal audit culture and political economy of predominantly white institutions (PWIs) such as universities and the academy (Sparkes, 2021). Impacts are predominantly described as instrumental and devalue the intrinsic values of doctoral education. While such outputs remain deeply embedded within the political economies of scholarship, we are compelled to ask, what about impacts on communities we work with and for? How are we considering and assessing these outcomes, and who holds us (as scholars) accountable?
Nursing’s scholarship and doctoral training requires critical reflexivity about power: who is wielding it, how, and what those impacts are on nursing, the nursing profession, and those we work with and for.
While the AACN Task force has repeatedly insisted it does not intend to accredit nursing PhD programs, its recommendation that qualification for entry into a nursing PhD program should include completion of the AACN Essentials represents a narrow slippery slope. This guidance, if implemented, would tie nursing PhD programs to competencies and associated accreditation processes for prelicensure and advanced nursing practice clinical education programs, as they have now been named as the sole pipeline to PhD training. As nursing PhD programs represent one of the only areas of nursing education truly open to innovation and rapid change, why would the AACN seek to prescribe or dominate best practices in this space, including admission to PhD training?
What else does the task force need to consider?
Power in the context of the development and application of such guidance, including but not limited to the survey process, review of the literature, analysis and interpretation, etc. is an important space for the Task Force’s consideration. Many of us who participated in some of the listening sessions nonetheless felt voiceless or at very least, unclear on the extent to which our views influenced the draft guidance. There has been little transparency regarding the degrees to which our voices have been heard in terms of the citation politics of the draft guidance or provision of notes or recordings from the listening sessions that might provide more of an audit trail. Mid-October 2021 was the first opportunity many of us had to weigh in, directly in writing, on the actual language and substance of the statement — even as the version we are commenting on is the third draft of this guidance.
One of the hazards of even constructing a response like this is validating the power of an organization like AACN to lead transformation in nursing. It is not evident that AACN — or indeed any other current professional organization within nursing or from outside — is appropriate to lead for a future of nursing research that does anything other than consolidate power and reinforce the status quo.
While AACN, like many professional nursing organizations, can offer recommendations from the standpoint of a certain set of perspectives and positionalities within academic nursing, these views are not representative of all stakeholders and especially those who will be most impacted in the long run. We need new power arrangements, and new design processes that center those who continue to be left out of and, in some cases, harmed by past and current approaches to the development of recommendations and quality metrics for doctoral study. The Task Force undertook some steps towards engagement of a more expansive set of stakeholders , including receipt of public comments, but these steps fall short of what is needed to be a co-creative process to truly transform power over discourse and design decisions.
More of the same will not lead us anywhere new. We will never get to a transformed program of research-focused doctoral education in nursing without considering who has been excluded from these discussions from the start, including but not limited to nurses whose expertise has been repeatedly minimized or dismissed by this organization, such as LPNs and ADN-prepared nurses who do not hold a baccalaureate in nursing or other graduate nursing degrees. A feminist standpoint informs us that lived experience is expertise, and often far more critical than purely academic input to the development of truly transformational and sustainable policies.
AACN is an organization composed of (primarily white and cisgender) nursing deans and department chairs. The task force incorporated leaders whose views extend beyond these perspectives as well, and we appreciate their contributions and labor in this process. There is tremendous wisdom and expertise there, which we respect, but AACN cannot and should not speak for all of nursing and particularly, what might be needed to transform the future of research-focused doctoral education in nursing. The realm of who is impacted by research-focused doctoral education in nursing is so much broader than what AACN can represent, including the challenge to innovate beyond current models and networks of power.
From a design justice perspective, none of the current professional organizations who’ve dominated in publishing white papers and best practice documents are equipped to speak to the needs of those most impacted by (and frequently excluded from) decision-making processes in PhD nursing education: professional nursing organizations, from a business-model standpoint, are mostly invested in maintaining the status quo.
When considering stewardship of the discipline and its primacy, we must also consider the degree to which the peer-reviewed literature and research practices in U.S.-based nursing education to date have reflected a fairly homogenous and — at times — oppressive and exclusionary set of perspectives, grounded in whiteness, and particularly white feminism (Bell, 2020a; Bell, 2020b).
What aspects of this legacy should we steward, and which should be dismantled, transformed, abolished? It seems if nursing as a discipline is going to move beyond the status quo (wherein racism, cisheteropatriarchy and its attendant transmisogyny, ableism, capitalism, settler colonialism, and other systems of oppression, including deficit thinking, are actively maintained), abolition is the form of stewardship most urgently necessary.
Progression of the science and knowledge for nursing requires epistemic diversity, not dogma regarding the primacy of any particular paradigm or set of methods, such as the NIH’s current focus on omics, so-called artificial intelligence for health care, or data science. Further, portions of this statement that focus in on these areas of inquiry largely excludes whole realms of vital scholarship essential to their moral and ethical application, specifically, critical digital studies, and the work of community-driven organizations such as Data for Black Lives, Our Data Bodies, and the Algorithmic Justice League. Where such scholarship and activism is mentioned, it is not centered, even as these are the movements at the cutting edge of meaningful progress towards greater equity and institutional accountability in the realm of technology and data science.
Cultural competency is a harmful, elitist, and outdated concept (Beagan, 2018; Drevdahl, Canales & Dorcy, 2008) and even cultural humility misses the point of the need to have science and the future of health and safe health care driven by the perspectives of persons most-impacted by those studies and policies. Ideally, nursing science would progress to the point wherein diversity of positionalities was not only a product of cultural humility, but of the fact that those leading the development of the science also fully reflected membership in communities nursing works with and for.
Language regarding a focus on training “global populations” assumes primacy and dominance of our institutions here in the United States. We are not inherently better at nursing science or research, rather, we have much to learn from partners outside the United States and Global North. Any statement focusing on training “global populations” to adopt certain points of view about nursing’s scholarly priorities and best practices reflects colonizing histories of settler nurses that continue to erase and marginalize Indigenous knowledges and ways of knowing (Waite & Nardi, 2019).
While postdoctoral fellowships allow for extended immersion in research-focused activities, they are not realistic or accessible for all prospective PhD-prepared nurses.
Postdoctoral fellowships are frequently reserved for the privileged whose lives and economic security allow for their pursuit. Financial penalties of delayed income are real: asking nurses and other PhD graduates who are already “onlys” to postpone the higher income of Assistant Professor roles or other jobs to persist through a postdoc financially penalizes these individuals. Many postdocs come with a salary cap that is significantly below what PhD-prepared scholars could earn in other roles. While it is absolutely important to ensure that scholars who have been historically underrepresented and excluded are supported to pursue the types of training and career opportunities that will allow them to flourish, we cannot and should not assume or prescribe what the specific nature of those trajectories should be. Postdoctoral fellowships are not intrinsically bad or good. They might be an excellent choice for some scholars, and a terrible fit for others. The imperative for postdoctoral fellowships seems to flow more from the very specific model of scholarship adopted by Federal funding agencies like the NIH, which is not the only framework for scholars and scholarship to flourish. There are also numerous career development awards and opportunities PhD-prepared scholars can apply for later in their career trajectory, at such a time when the pursuit of new skills or forms of knowledge might be critical to their work, and a better fit for their life and circumstances.
Mentorship & succession planning are important, but the invisible labor of “onlys” has an impact on their ability to survive and thrive in nursing research. “Onlys”, as we refer to them here, are persons belonging to groups that are marginalized within or excluded by dominant cultures in institutions, as in, someone who is often the only person of a particular positionality or identity within a room. Onlys frequently shoulder tremendous invisible labor and service burdens, such as informal mentorship of students or colleagues who are similarly underrepresented in the system, or being asked to serve on every committee or search so as to increase “diversity” in those spaces. It is unclear the degree to which the surveys, literature search and Task Force process have prioritized the perspectives of “onlys”. Certainly well-established, externally-funded “senior” PhD scholars have access to resources, knowledge and wisdom that can provide important support for PhD students. But they are not the only persons who can mentor, and in fact, research on mentorship indicates new investigators benefit from networks of mentorship including mentorship from peers, early career scholars, and others whose positionality, lived experiences and expertise fill important gaps. PhD mentoring needs can be highly dynamic and individualized, and adequate mentorship often requires an interdisciplinary team.
Overall, the task force needs to deeply reflect on the assumptions, theories, values, and philosophy that undergird the proposed “Research-Focused Doctoral Program in Nursing: Pathways to Excellence.” The perspectives included are quite narrow and rely on an outdated and exclusionary approach to research doctoral education.
We offer the following specific areas for consideration:
Page 1, line 11 — jumping into postdoctoral study before even addressing doctoral study undermines the veracity of the claim that PhD is a terminal degree. We need to interrogate this — both from a legitimacy perspective and from an extractive perspective. Why is our doctorate insufficient to create the expertise necessary for our research? Why do we wish to manufacture added precarity and extract additional labor from junior researchers — who are often NOT junior in terms of their nursing experiences or life experience? This kind of emphasis ensures that the most highly-resourced folks will be the ones who continue to populate the ranks of nursing research.
Page 1, line 16 — “develop its science” should read “develop its knowledge” to embrace patterns of knowing and epistemology that do not adhere to a narrowly defined vision of science.
Page 1, line 18 — is the goal of nursing to improve health outcomes? Or is it to facilitate health and wellbeing? Outcomes are reductive, metric-driven, and defined from outside communities.
Page 1, footnote 2 — name the other disciplines. Otherwise this is effectively lip service and recenters a very particular arrangement of who nurses are supposed to collaborate with and thus what their research should look like.
Page 4, line 157 — “Develop the Science” should really be “Develop the Knowledge” — science is not the only path for research or knowledge creation. Consider who is excluded.
Page 4, line 173 — cultural humility is outdated — the reference is from 1998, and so much has happened in the world, in nursing, and in nursing’s research since that time. Further in this discussion, you point to the analytics of power and understanding the operation of racism and sexism in health and research — this could and perhaps in this COVIDicene era should draw on philosophy and theory like feminist thought, queer theory, critical race theory, abolition, and other tools. The reference to “cultural humility” follows the call that “holders of the PhD in nursing should possess the skills required to assume leadership in the conduct of culturally-competent research and scholarship. . . “ which specifically ignores one of cultural humility’s central tenets: that the practitioner must relinquish the role of “expert,” as the patient is a full partner in the therapeutic process (Tervalon & Murray-Garcia, 1998, p. 121).
Cultural rigor, as described by Scott, Bray and McLemore (2020) in the context of philanthropy’s work and agendas for reproductive equity and racial justice, provides an alternate and more just approach: “As a praxis, cultural rigor mandates the operationalization of Black feminism, reproductive justice, and research justice, along with participatory data and technology development and dissemination in health care services provision, research, quality improvement, and policy. Cultural rigor ultimately asserts that all white-governed institutions cannot serve as the benefactors, oppressors, and redeemers of Black women’s genius, and it reinforces an inconvenient truth: You have no answer that Black women don’t already possess.18 Cultural rigor requires funders to divest from the comfortable, convenient, common, and complacent practices of tokenism, decoration, manipulation, and exploitation, which reinforce a hierarchy of knowledge generators and systems disruptors.19”
We question whether “stewardship portfolios” documenting leadership in nursing’s professional organizations are necessary or good.
Page 5, line 198: Nursing’s professional organizations remain overwhelmingly elite, white, cisgender, settler-dominated and inaccessible (physically and financially) to many leaders already in the profession, not to speak of the degree to which so many are siloed from larger transformational movements in community organizing and abolitionist movements, policy, health and health care. For example, this document dedicates several pages to description of competencies in data science, and never once mentions community-directed leadership in this space, such as the organization Data for Black Lives, or the Algorithmic Justice League. So often throughout nursing’s history, stewardship of the discipline via many of these organizations has meant sustaining a violent and unacceptable status quo. We reject the recommendation that future scholars of nursing be forced to prove their competence through the accrual of a portfolio of leadership accomplishments in spaces that were never designed for many of us, and that purposefully continue to keep so many out (Bell, 2020).
We object to this draft guidance’s recommendations to exclude multidisciplinary scholars (referred to here in the document as “non-nurses”) from eligibility to pursue nursing PhD study.
Page 6, lines 265–274: While the document asserts nursing is a “practice discipline”, we seek to problematize the concept of ‘practice’: what constitutes ‘practice’ or proof of expertise or ‘competence’, and who decides? The draft guidance cites results of the AACN’s Dean’s survey indicating only 1.8% of schools currently allow multidisciplinary scholars who do not possess a nursing degree to enroll in their PhD programs, and suggests this relatively small proportion supports elimination of this possibility in the future. How can this be? We suggest there is another way to frame this empirical finding: that the few research-focused doctoral programs in nursing who currently admit multidisciplinary scholars are the ones on the cutting-edge, so much so, that scholars from spaces outside of nursing want to pursue and engage in the co-creation of this knowledge! We question why, after so many years of PhD-prepared leaders in nursing fighting for the legitimacy of our scholarship and research, we would seek to gatekeep this knowledge and training from persons with clinical or disciplinary backgrounds and lived experiences outside of nursing.
After all, how did we get here? Did nurses not pursue doctoral studies in disciplines such as education, social sciences, and anthropology, prior to widespread accessibility to the research-focused doctoral degree in nursing? Had those disciplines prevented nurses that did not possess their degrees or licenses from entering those programs, would the concept of a PhD in nursing even exist as it does today? We should be widening the pathway, not narrowing it.
Page 8, lines 341–344: There is no imperative to complete a PhD in nursing other than that which AACN or other bodies create. A case in point includes recommendations that PhD students engage full-time and exclusively doctoral study (as it is defined in these pages). Such expectations are often predicated on PhD students leaving or cutting down significantly on time spent in other roles, such as provision of direct care, that may also be an essential source of income not just for the student but for other household members, so as to move efficiently through their studies in 5 years or less. Many prospective and actual PhD students have been unnecessarily excluded and harmed by such expectations, developed by the academy as opposed to with and for those the academy serves.
Current models of PhD apprenticeship and training in the United States were originally developed by elite private universities and divinity schools for landed white male academics with privilege and financial security (Thurgood, Golliday & Hill, 2006).
Since that time there have been some innovations, however, the underlying model has not changed significantly and continues to reflect such structural biases. Rather than continue to morph PhD education in nursing to tighter and tighter timelines, would it not make sense to adjust models of education to better accommodate the diverse needs of scholars who wish to pursue it? Potential “delays in [the student’s] future career as a scientist” are not an adequate or even logical justification for expediting the training process, if by doing so PhD students are harmed either by overwhelming and unsustainable responsibilities, or, precluded from pursuing the PhD in the first place as there is no space for their lived reality in the timelines of doctoral programs.
Page 14, lines 586–588: While the concept of a “portfolio” to demonstrate scholarly progress presents an exciting and potentially more accessible and appropriate alternative to narrower, structured forms of assessment such as written comprehensive qualifying exams, we urge the AACN to resist calls to further quantization, metricization and ‘badge-ification’ of scholarship. We suggest that while well-intended (and perhaps a requisite for some careers tracks and promotions) the neoliberal underpinnings of such imperatives must be unpacked and challenged.
“…we urge the AACN to resist calls to further quantization, metricization and ‘badge-ification’ of scholarship”
Page 28 line 1169:
The Task Force’s draft guidance devotes considerable prescriptive detail and numerous pages to detailing recommended curricular elements, with a particular focus on technology, “precision medicine” concepts such as genetics, and data science. In fact, the term “data science” appears at least 32 times throughout the document not including references. Big data-driven technologies alluded to, such as “A.I. for health care”, have important implications for health equity and social justice, including planetary health and the climate (Dhar, 2020).
Recent research from the University of Massachusetts Amherst indicates that training a single A.I. algorithm such as a large model using natural language processing can have climate impacts equivalent to the carbon footprint of 125 round-trip flights between New York and Beijing (Strubell, Ganesh & McCallum, 2019).
Related technologies, such as blockchain, fare no better. The carbon footprint of the cryptocurrency company BitCoin alone has been estimated to be roughly equivalent to that of the entire country of New Zealand (Browne, 2021). And yet, climate change — indeed, the climate emergency urgently facing our planet — is not mentioned even once in this document. If this document aims to be prescriptive, the omission of nurse researchers’ commitments to co-creation of a sustainable future, including adaptation to and mitigation of the harms of climate change, is a glaring omission (Walker, Pereira-Morales, Schenk & Kerr, 2020).
“climate change — indeed, the climate emergency urgently facing our planet — is not mentioned even once in this document”
While some forms of big data and A.I. technologies have yielded important scientific breakthroughs and benefits for human health, the technochauvinist drive to build bigger/better/more interconnected data systems has already harmed myriad communities (Broussard, 2019; Benjamin, 2019). These harms have disproportionately impacted individuals and communities subjected to marginalization and precarity under the matrix of domination, including but not limited to Black, Latina/o/x and Indigenous persons, trans and gender-diverse persons, disabled persons, persons residing in the Global South, the very poor, and migrant and refugee populations (Eubanks, 2018; Crawford, 2021).
Failure to interrogate and challenge assumptions underlying the primacy of big data, A.I., and technosolutionism in this document reflects a certain epistemic violence not unique to this body, in fact, it is embedded throughout research agendas for nursing and other health researchers.
Nursing knowledge here is co-opted for the aims of other dominating structures, such as surveillance capitalism and empire. We do not have to accept this. We can create new and different futures, if we choose to (Gance-Cleveland, McDonald & Walker, 2020).
Many of us who are students enrolled in or faculty for research-focused doctoral programs in nursing are oversubscribed and exhausted by the pandemic. While the Task force insists this process has taken two years and must reach closure: many of us have only just now received permission to provide direct input on the operationalization of new guidance (on the record). We appreciate this opportunity to submit our thoughts to the AACN Task Force. Thank you for extending the period of public comment for this draft from 2 weeks to 4 weeks.
We look forward to a future where not only established doctorally-prepared academic nurse administrators, but patient advocates, community leaders, multidisciplinary scholars, current and prospective students are fully engaged and recognized for their leadership and expertise in the co-creative process.
This statement reflects a revised and expanded version of feedback originally provided as a response to a request for public comment. You can view the original version, submitted by Dr. Rae Walker and Dr. Jess Dillard-Wright to the AACN Research-focused Doctoral Programs Pathways to Excellence Task Force on December 12, 2021, here.
Email correspondence can be sent to Dr. Walker at firstname.lastname@example.org