SOCIAL JUSTICE is central to the nursing profession. Nurses have a professional obligation to address health inequities, especially among systemically minoritized communities. Social justice is particularly problematic among transgender and gender-diverse (TGD) people (ie, people whose gender identity is incongruent with their sex assigned at birth), where the literature is sparse. Many argue that nurses are inadequately empowered to advance social justice to address health gaps.1-3 Social justice is vaguely defined within nursing, and a theoretical framework of social justice is limited.4,5 Nurses should take concrete steps to eliminate structural barriers that affect the health and wellness of TGD people. Social justice frameworks that inform and guide nursing practice can facilitate meeting this need.5,6

While social justice is rooted in well-established critical feminist and intersectional frameworks, critical social theory is too broad to be operationalized.5 To address this gap, Walter5 created a middle-range nursing theory on social justice-the theory of emancipatory nursing praxis (ENP). Walter described how nurses experience a transformative learning process by engaging in social justice. However, this middle-range theory has not been evaluated within the context of stigma among TGD people.5 Therefore, this article aims to analyze the theory of ENP within the context of stigma among TGD people.

Statements of Significance

What is known or assumed to be true about this topic?

Professional nursing organizations emphasize the importance of social justice in the discipline of nursing. However, experts argue that nurses are inadequately prepared to engage in social justice. Limited theoretical frameworks and the ambiguous definition of social justice within nursing may contribute to social injustice. The theory of emancipatory nursing praxis (ENP) is a novel middle-range theory of transformational learning, created to explore the process of emancipatory practice among nurses engaged in social justice. Unfortunately, current nursing literature lacks a theoretical analysis of ENP.

What this article adds:

This article analyzes and evaluates the theory of ENP within the context of stigma among transgender and gender-diverse (TGD) people. ENP is a novel middle-range theory with limited generalizability and testability. This analysis provides an objective evaluation of ENP's origins, structure, logical adequacy, usefulness, generalizability, parsimony, and testability. Further, this analysis offers tangible strategies for applying the theory of ENP to nursing pedagogy, practice, research, and policy.

SIGNIFICANCE

Social justice is an essential component of the discipline of nursing. Foundational documents by the American Nurses Association (ANA) describe social justice as an essential professional duty of nurses in bringing health equity while addressing unjust systems.7-9 The American Association of Colleges of Nursing (AACN)10 also describes social justice as a critical component of nursing education, curriculum content, and an expected competency among nursing students. The AACN explains that nurses must advocate for social justice and promote fair treatment of people, regardless of gender. While these nursing organizations emphasize social justice as a keystone of nursing, the conceptualization of social justice remains unclear. As Fahrenwald et al11 point out, ANA and AACN documents do not guide nurse educators in incorporating social justice within nursing pedagogy. Integrating social justice into nursing education is necessary, and a nursing practice informed and guided by social justice is needed.5

TGD people experience poor health outcomes, including higher rates of depression, anxiety, disability, and multiple chronic health conditions than their cisgender (ie, people whose gender identity is the same as their sex assigned at birth) counterparts.6,12 These health disparities manifest the stigma TGD people experience at the interpersonal, intrapersonal, and structural levels when accessing health care services.6 At the interpersonal level, TGD people experience enacted forms of stigma such as verbal abuse, physical violence, and refusal of care by health care providers.6 At the intrapersonal level, stigma contributes to isolation, marginalization, anticipatory rejection, and shame.6 Furthermore, at the structural level, cisnormative discourse (ie, dominant discourse based on the assumption that everyone is cisgender and privileges this over other gender identities) shaping sociocultural norms and legislations influence how TGD people access care.6 Indeed, in the United States, several states have passed legislation to criminalize health care professionals from providing gender-affirming care to TGD people, especially TGD youth.13 Similarly, TGD people are criminalized in many countries (eg, Brunei, Indonesia, Jordan, Lebanon, Nigeria, and the United Arab Emirates) for expressing a gender not congruent with their sex assigned at birth.14 Some countries also place stringent provisions (eg, medical castration) before a TGD person can access legal transition such as name and gender marker change.14 The medicalization of TGD identity and a biomedical model that pathologizes TGD identity (ie, TGD identity being classified as a mental health disorder) creates significant stigma-related barriers to health care access among TGD people, subsequently making health care providers gatekeepers to gender-affirming care.6,15

Nurse activists stress that nurses must actively participate in social justice to achieve transformative and emancipatory nursing education, research, and practice.16 In their analysis of the Nursing Manifesto-a landmark document challenging dominant medical and social discourses that center around traditional nursing practices-Kagan et al16 call for nurses to commit to social justice driven by nursing praxis and reengage in the theory-informed processes of self-critiquing power and privilege. Nurses must recognize the power of nursing, acknowledge their positionality in advancing social justice, and leverage this privilege to abolish unjust systems that create and maintain the stigma TGD people experience when accessing care.6 The multilevel, stigma-related experiences TGD people share globally underline the critical role nurses play in addressing health care gaps TGD people experience worldwide. The theory of ENP provides a pathway to understanding how nurses can be a catalyst in creating a more just society, especially in addressing stigma among TGD people.

THEORETICAL EXPLANATION

Walter used a constructivist grounded theory methodology based on subjective and contextual meanings of social justice among nurses. She developed the theory of ENP by using theoretical sampling and qualitative analysis of interviews. Data from these interviews were collected in 2 phases. In the first phase of the study, 27 registered nurses engaged in social justice were recruited from 9 countries.5 Phase I interviews were conducted until redundancy of themes was achieved. Four theoretical and 2 contextual categories emerged after the completion of theoretical sampling. The second phase of data collection involved a focus group of 6 registered nurse experts in social justice. The focus group interview was utilized to triangulate the data and confirm the findings from the first phase of the study.5 Comparative analysis was then used by coding the data in 2 phases: initial and focused. In the initial phase, Walter5 coded words, lines, and segments of the interviews. These codes were then analyzed into thematic groupings using focused coding. This iterative process was utilized until conceptual categories were constructed from the data. Walter also uses a quantum spiral to describe the 4 conceptual categories as a continuous and dynamic iterative and nonlinear process (Figure 1). The movement of the quantum spiral illustrates the "ongoing, evolutionary ... unpredictable, unitary-transformative, and dialectical nature of the theory of ENP."5^(p238) The arrows exiting the Relational Context and Reflexivity boxes represent a churning-like motion that fuels the transformative learning process. The quantum spiral portrays how transformative learning is a growing and dynamic process mobilized upward by the 4 conceptual categories and downward by the conceptual subcategories. The flourishing nature of the quantum spiral illustrates that growth does not cover the same ground. While the theory of ENP does not explicitly include stigma in its conceptualization, this middle-range theory can be applied to how stigma operates in various contexts. Thus, ENP can explain how nurses address stigma-related health inequities through social justice engagement.

Figure 1. Relationship between core concepts of the emancipatory nursing praxis and stigma. Adapted from the emancipatory nursing praxis model.

EVALUATION OF THE THEORY OF ENP

Walker and Avant17 point out that theoretical analysis and evaluation are essential in nursing. Theory analysis aims to use a systematic and objective approach to understanding a theory's strengths, weaknesses, and applicability. In comparison, theory evaluation determines if the theoretical concepts and concept relationships contribute to nursing science. This method was used to systematically and objectively analyze and evaluate the theory of ENP.

Origins of the theory of emancipatory nursing praxis

Critical social theory lends to a foundational conceptualization of social justice within the nursing context, but it is broad and abstract. In contrast, middle-range theories can be operationalized and tested.18 In developing the theory of ENP, Walter explored how nurses identify their role within the context of social justice engagement. This meaning-making process is influenced by the attitudes, perceptions, reflections, and behaviors produced from the interactions between nurses and the social spaces they occupy. Walter used a "systematic inductive approach and then evolve[d] into an iterative, comparative, interactive, and abductive process focused on theory construction."5^(p277) This methodology reflects some of the theory-generating approaches proposed by Liehr and Smith,18,19 which include theory generation through research. As Polit and Beck20 explain, research has been instrumental in developing novel middle-range theories, particularly research based on grounded theory methods-an approach Walter used. Additionally, Walter clearly articulates that the theory of ENP is consistent with a nursing disciplinary perspective despite being rooted in critical social theory.

Structure and meaning of the theory of emancipatory nursing praxis

While social justice is central to the nursing profession, Walter explains that nurses are poorly engaged in social justice. She argues that nurses must have a solid theoretical foundation of social justice within the nursing context to achieve emancipatory social justice goals. Without understanding the context by which such disparities exist is a significant omission in treating the "whole patient." Nurses must be actively interrogating the unjust structures that produce these health disparities. When nurses fail to incorporate social justice in their practice, they intentionally or unintentionally displace the burden on systemically minoritized individuals and communities rather than the oppressive systems that create and maintain unjust conditions. As Walter explains, "current nursing practice may tacitly reinforce dominant hegemony ... by helping individuals, families, and communities adjust and cope with vulnerability within their immediate milieu, rather than by helping them seek emancipation from it."5^(p226) Thus, the overriding definition of social justice as the fair distribution of benefits and burdens of society displaces attention from the structural root causes of injustice.5

Definitions of concepts

Walter5 describes ENP as a theory of transformational learning with 4 conceptual and 2 contextual categories. These conceptual categories are linked to the contextual categories:

* Becoming. Walter describes becoming as a "largely unconscious, initial exploration of perceptions and ways of being in the world."5^(p231) These experiences include nurses' earliest memories-shaped by intrapersonal characteristics and environmental factors-that influence how social injustice is perceived. At this point, nurses are unaware of their privilege, social position, and the root causes that lead to social injustices.

* Awakening. Awakening is described as an inflection point where nurses "come to identify or recognize their role or place in the larger, societal-structural forces that impact the health and well-being of others."5^(p31) This juncture can be a significant event or a process that develops over time, eventually leading toward a worldview shift. Awakening involves 4 conceptual subcategories: positioning, dialoguing, dismantling, and confirming (Table 1).

Table 1. Definitions of the Subcategories of Awakening

* Engaging. Engaging is defined as a dynamic and interactive process of achieving transformative goals.5 This conceptual category is also characterized by 4 conceptual subcategories: praxis, analyzing power, collective strategizing, and persisting (Table 2). This process explores nurses' actions and interactions when interfacing with social justice issues.

Table 2. Definitions of the Subcategories of Engaging

* Transforming. Walter5 defines transforming as a goal-directed process and is described through its 3 subcategories of human flourishing, achieving equity, and transforming social relationships (Table 3). This process includes a change in worldview and reconditioning of the nurses' thoughts, feelings, and actions.

Table 3. Definitions of the Subcategories of Transforming

* Relational context. Relational context is the first of the 2 contextual categories. Relational contexts include various ecological realms where social justice is practiced: individual, group, organizational/institutional, community, national, and international/global contexts. Nurses could simultaneously practice social justice within one relational context or across multiple relational contexts.5

* Reflexivity. The second contextual category is reflexivity. Walter5 describes reflexivity as a self-examination of nurses' role in creating or maintaining structures or practices through the 4 dimensions of reflection: descriptive, self-aware, critical, and emancipatory. Walter5 explains that descriptive reflection involves a surface-level and objective description of events. Self-aware reflection is described as the intrapersonal recognition of feelings, emotions, and biases but is devoid of context. Walter5 explains critical reflection is achieved when nurses acknowledge both individual and structural barriers that sustain social injustice. While reflexivity is mostly a self-reflective process, critical reflection is fully executed by engaging in critical dialogues that challenge personal worldviews.5 Furthermore, critical reflection allows deconstruction of assumptions, feelings, beliefs, and biases and facilitates emancipatory reflection. Reconstruction-the collaborative creation of a new understanding of the world from a deconstructed worldview-also describes emancipatory reflection. This collective and dialogic meaning-making process is "more than a communication tool for change; [rather], it [is] the very medium through which change occur[s]," and thus, promotes praxis.5^(p236)

Abstraction, relational propositions, and appropriateness to nursing

The meaning of the theory is shaped by its concepts and relational propositions.17 Walter provides a clear definition of relational and reflexive contextual categories. While the reflexive contextual category is more abstract than the relational contextual category, the 4 dimensions of reflection decrease its ambiguity. Similarly, Walter uses conceptual subcategories (in red on the left in Figure 1) to describe their corresponding main conceptual categories (in blue on the left in Figure 1). The conceptual and contextual categories are consistently used without deviation in meaning or intent when describing the theory of ENP. The relational propositions are also specific, especially when explaining how conceptual subcategories are related to their main conceptual categories. Decreasing ambiguity is essential to improve hypothesis generation.21

The concepts described also reflect values important to nursing. As Carper22 explains, the methods by which we generate knowledge also reflect the richness and complexity of the discipline of nursing. In addition to the 4 patterns of knowing (ie, empirics, aesthetics, personal knowledge, and ethics), Chinn and Kramer23 argue that emancipatory knowing is an equally essential and foundational pattern of knowing in nursing. The integration of these patterns of knowing leads to reflection-into-action and facilitates the transformational learning process described by the theory of ENP. These patterns of knowing and the reflection-action that defined nursing praxis are also relevant within the context of ENP and social justice. As Chinn and Kramer explain, "praxis is possible when all patterns of knowing are integrated in a way that supports social justice."23^(p2)

Logical adequacy

Analyzing the logical structure of concepts and the relationships between these concepts is essential in understanding a theory's logical adequacy.24 Identifying any logical fallacies and the theory's ability to create analytical predictions based on premises and concepts presented are also crucial.17 In the theory of ENP, predictions can be made independent of content. While the main contextual categories do not have linear relationships, they are interrelated and recurring.5 While the theory of ENP had logical adequacy, the numerous categories and subcategories could further be condensed and refined. The relationships between the main conceptual categories and subcategories are illustrated in Figure 2.

Figure 2. Relationships between main contextual categories and subcategories of emancipatory nursing praxis.

The theory of ENP is a novel middle-range theory and has yet to be applied or tested in a larger context. However, the theory of ENP can be used in understanding how nurses experience transformational learning when engaging in social justice, particularly from the perspective of an intermediary between patients and the health care system. Similarly, the theory of ENP can be tested within a pedagogical context, specifically in understanding the role of social justice in the educational and professional development of nursing students. Further still, within the context of health care policy, the theory of ENP can be utilized to understand how past or current social justice engagement among nurse leaders reflects their attitudes, perceptions, reflections, and behaviors when developing and implementing policy decisions. The applicability of the theory of ENP in understanding social justice within various nursing contexts highlights its testability.

The emancipatory framework of ENP and its focus on social justice is rooted in well-established philosophical and scientific traditions of critical social theory. As nurse scholars and activists remind us, the discipline of nursing has the professional mandate to question unjust systems and abolish oppressive structures that perpetuate injustice.25,26 Nurses must engage in praxis that challenges asymmetrical power relationships and act upon unjust social conditions to achieve equity, equality, and justice for all.25

Usefulness

A theory is considered useful if it generates research, addresses clinical nursing problems, and influences nursing practice, education, policy, and research.17 The usefulness of a theory is also determined if it adds to a body of knowledge.17 Although the concept of social justice has been examined across various disciplines, literature on social justice-related theory within the nursing context is limited.27-30 The theory of ENP provides a critical framework for probing contextual and conceptual categories that may clarify the transformation process experienced by nurses engaged in social justice. Indeed, the theory of ENP has been cited in several topics, such as the future of nursing31 and nursing policy32 as well as studies exploring COVID-19 and racism33 and unhoused women experiencing violence.34 The theory of ENP has also influenced the creation of a middle-range theory in forensic nursing35 and in a concept analysis of nursing activism.36 To date, there has only been one other analysis on the theory of ENP.37

While other disciplines define social justice as a just distribution of benefits and burdens in society, this definition does not reflect social justice within a nursing context.28,29 As Thurman and Pfitzinger-Pippe explain, it is not within nursing's mandate "to decide what is equitable or fair in terms of the distribution of health care resources."3^(p187) Instead, nurses must engage in social justice by addressing inequitable and oppressive systems. While the theory of ENP is in its infancy, it illustrates its usefulness in clarifying the definition of social justice within nursing and describing social justice as a critical function of nursing in addressing stigma-related health inequities among TGD people.

As Kagan et al26 explain, nurses can disrupt the social conditions and power dynamics birthed by systems that privilege some over others. The theory of ENP can influence nursing practice, as it allows nurses to reimagine the discipline of nursing. Nursing must be reconceptualized as a force that leads to systemic changes and a catalyst for emancipation.26 Within the context of stigma among TGD people, the theory of ENP provides nurses a new path to engage in social justice by choosing action over standing by and being complicit in the system that sustains power differentials. Indeed, when nurses privilege their professional knowledge and skills to address gendered oppression and liberate themselves from the dominant discourses rooted in cisnormativity, they can genuinely experience transformational learning. The theory of ENP emphasizes nursing's professional and ethical obligation to address health inequities among TGD people. It echoes the nursing code of ethics, calling nurses to advocate for and deliver culturally congruent care to TGD people.30 However, it is vital to recognize that nurses must engage in social justice, not by speaking for minoritized individuals or communities but by facilitating collective action and partnering with others and their communities.

Generalizability and parsimony

Walker and Avant17 describe generalizability by determining the theory's applicability in various contexts. While the primary research used in developing the theory of ENP was sound and had an adequate sample size, this theory has limited generalizability. For instance, the theory of ENP describes the transformative learning process of nurses who were already engaged in social justice; thus, further research is needed to explore how other nurses experience social justice-related transformational learning. Furthermore, while the study participants represented 9 different countries, nurses from Asia, Central and South America, and most of Africa were not represented.5

The parsimony of a theory is described by its simplicity despite its broad context.17 As the nature of social justice is complex and contextual, it is unsurprising that the theory of ENP has several concepts, categories, and subcategories. While these categories, subcategories, and conceptual relationships are elegantly presented to form a cohesive and sound theory, the theory of ENP is not parsimonious. Additionally, Walter17 uses a model to illustrate the conceptual relationships in the theory of ENP. However, the model alone cannot describe the relational propositions between concepts. Further testing of the theory and a more representative sample is needed to improve its generalizability and parsimony.

Testability

Walker and Avant17 emphasize that a theory must be testable in principle to evaluate its validity. The theory of ENP requires theory testing to refine its concepts and relationship propositions.5 Water also highlights the need for understanding the transformational learning process of nurses who are members of marginalized communities and the importance of defining how nurse educators could incorporate social justice in nursing pedagogy. Theory testing is also needed in describing related concepts of privilege, power, oppression, and dominance within the context of social justice.5 Several experts have created various scales and instruments, such as the Privilege and Oppression Inventory38 and Social Privilege Measure,39 to assess privilege, power, oppression, and dominance. However, these concepts have only been explored in fragments. Thus, examining these interrelated concepts is critical to understanding how nurses experience transformational learning related to social justice.

Furthermore, while Walter5 does not offer instruments to measure and verify the concepts in the theory of ENP, these concepts and the relational propositions are clearly defined and supported by empirical data and could generate potentially testable hypotheses. As Carper22 explains, nursing science illustrates the natural history stage of inquiry by which nursing theorists describe and classify phenomena lending toward theory development. Indeed, Walter5 uses a scientific approach in describing, organizing, and explaining interview data collected to form concepts and relational propositions in her theory.

Overall, the theory of ENP is valuable and has the potential for significant usability. While its generalizability is limited, contains numerous concepts and propositional relationships, and has not been extensively tested yet, the theory of ENP has multiple implications in nursing research, practice, education, and policy. Indeed, ENP, with its focus on social justice and transformational learning, is valuable, especially in understanding the role of nurses in addressing stigma among TGD people.

IMPLICATIONS: A CALL TO ACTION!

Theory analysis expands the nursing body of knowledge in multiple ways.17 In nursing education, theory analysis supports students' learning and development of critical thinking skills, provides a foundational framework for research, and facilitates curriculum development and nursing pedagogy.17 Theory analysis also informs nursing practice and supports the development of standards of care.17 Furthermore, theory analysis is valuable in nursing research, as gaps and inconsistencies during the analysis often lead to research ideas and further theory development.17 Finally, theory analysis challenges conventional nursing and constructs a new pathway for nurses to inform policy and enact systemic changes.

Critical pedagogy

The theory of ENP can inform nurse educators how stigma among TGD people influences nursing education. In a US survey of over 1000 nursing faculty members, Lim et al40 report that nursing programs spend 2.12 hours on lesbian, gay, bisexual, transgender, and queer (LGBTQ)-related content in the nursing curriculum. While most nurse educators report that TGD-related education is vital in preparing nursing students to become culturally informed nurse professionals, many attributes limited space in the nursing curricula as a barrier to not including LGBTQ-related discussion in class.40 Inadequate TGD-related education among nurse educators reflects institutional-level stigma among TGD people. While this may be unintentional, insufficient education and training result in inadequately prepared nursing students providing care to TGD people.

In the AACN Essentials Tool Kit, Smith et al41 underline integrating nursing knowledge in both curriculum and practice. This integration can be accomplished by weaving social justice into the nursing curriculum by using patterns of knowing (ie, empirics, ethics, aesthetics, personal knowing, and emancipatory knowing) as threads that connect didactic and practical knowledge and experience. To create transformative and emancipatory interventions, nurses engaged in social justice must address these deficiencies brought on by TGD identity-based stigma. The theory of ENP could guide nursing pedagogy to address the gaps in nursing education, particularly in addressing minimal LGBTQ-related content in the nursing curriculum.

Collaborating with the TGD community in educating nurses about gender-affirming care and contextualizing the stigma experienced by TGD people is a strategy to magnify the importance of social justice in nursing education. One tactic to achieve this strategy is to create partnerships with community agencies that engage with the TGD population and provide experiences that intentionally expose students to learn about life experiences of stigma.42 Another strategy promotes simulation-based education to provide students with opportunities to make real-time interactions with virtual TGD persons aimed to enhance communication skills, cultural sensitivity, and self-reflection.43

Nurses can transform how health and wellness are experienced. To advance the discipline, nurses must be intentional in guiding the future generation of nurses in integrating social justice into their practice.10 Understanding the interplay between social, political, and economic factors and the humanization of health experience situates nurses in a prime position to enact change. Thus, foundation nursing documents must reflect the importance of social justice in the discipline of nursing.

Canales and Drevdahl44 reported that several foundational documents by the AACN identified social justice as a professional value necessary to the discipline of nursing. Indeed, the Essentials of Baccalaureate Education for Professional Nursing Practice,45Essentials of Master's Education in Nursing,46 and Essentials of Doctoral Education for Advanced Nursing Practice47 referenced social justice as a critical component of nursing education. However, these documents do not provide a clear pathway to incorporating social justice in nursing practice, nor do they guide how nurses address social inequities. Similarly, critical documents by leading nursing education organizations such as the National League of Nursing48 and the National Task Force on Quality Nurse Practitioner Education49 do not reference social justice. In an analysis of published nursing literature on social justice from 2006 to 2012, Canales and Drevdahl44 reported that social justice is poorly described in essential documents among US credentialing organizations. The extant literature on social justice in nursing education also does not provide a rich discussion of how social justice should be incorporated into the nursing curriculum.44 As Canales and Drevdahl explained, "how students are socialized into the profession has a major impact on how they practice once they graduate and enter the workforce."44^(p154) Without a deliberate effort to transform nursing education and truly integrate social justice as its core value, nurses will remain powerless to act and address injustice at various levels. Thus, it is critical to understand how social justice can be incorporated into the academic curriculum to build a strong nursing foundation for future nurses.

In 2021, the AACN published The Essentials: Core Competencies for Professional Nursing Education.10 Unlike previously published AACN documents, the 2021 publication provided a more robust discussion of social justice. The AACN10 was intentional in incorporating social justice in envisioning nursing education in the 21st century. Domains, competencies, and subcompetencies were listed to guide nurse educators in integrating social justice into the nursing curriculum.10 Social justice as an integral aspect of advancing equitable population health policy, demonstrating advocacy strategies, demonstrating accountability, and integrating diversity, equity, and inclusion in nursing's professional identity are discussed.10 The AACN10 also recognized the relationship between social justice and health inequities and underlined the role of social justice within the interrelated concepts associated with professional nursing practice.

Social justice as praxis

As Walter5 explains, social justice is central to the theory of ENP. Nurses must be aware of the social structures that privilege some people and, by effect, disadvantages the health and well-being of others. This position provides nurses the access to understand social justice on multiple levels and the power and privilege others may not have. Furthermore, ENP enables nurses to acknowledge power structures that sustain inequities in health and encourages nurses to identify the root causes of such disparities. For instance, nurses may create interventions that address the immediate needs of TGD people accessing care. However, TGD people experience multilevel stigma that contributes to individual, interpersonal, and structural health care barriers.6 For instance, the 2015 US Transgender Survey50 reports that approximately 33% of TGD adults experienced a negative stigma-related experience (eg, verbal abuse, physical violence, and being denied care) when accessing care. Consequently, 23% of TGD people avoided care due to fear of being mistreated due to their gender identity.50 Without addressing the underlying causes (eg, inadequate TGD-related education and training among health care providers, the medicalization of TGD identity, and cisnormative policies), TGD people will continue to face poor health outcomes related to poor access to care.6 Nurses can address these health inequities by integrating social justice within their practice and taking steps to address the stigma experienced by TGD people in health care settings. Nurses must create environments where TGD people can feel safe and affirmed. These strategies include advocating for policies that encourage TGD people to use bathrooms that align with their gender identity and gender-affirming medical records that provide an option for gender self-identification and chosen names. Recruiting and retaining TGD-identifying nurses in all levels (eg, licensed vocational nurses, registered nurses, and advanced practice nurses) and settings (eg, acute, postacute, and ambulatory) is critical in ensuring a diverse nursing workforce that reflects the diverse patients they care for.43 Additionally, integrating person-centered, trauma-informed care with every patient interaction is essential in promoting social justice and equalizing the power dynamics between nurses and TGD patients.

Social justice as praxis involves continued engagement and critical dialoguing to understand the changing world that sustains these social inequities.51 These conversations must also be partnered with collective emancipatory actions. Nurses are well-positioned to partner with the community in addressing social injustices by dismantling the systems that allow these disparities to occur in the first place. ENP can empower nurses to engage in actions that can free themselves, others, and their communities from the shackles of social injustice.

Research as a vehicle for transformation

The discipline of nursing and its phenomena of concern "focus[es] on the human as a whole being, the environment, and health ... [as well as] other concepts, such as nursing and caring."52^(p52) The interrelationships between these nursing domains influence how health and wellness are experienced. Kagan et al explain that social justice as "a dimension and outcome of caring, is essential to health, well-being, and human flourishing."26^(p9) As such, social justice falls under the nursing domain as a product of caring. It is then imperative that the practice of social justice be a tenet of the discipline, including nursing research.

Kagan et al26 also explain that several scientific paradigms guide nursing research (eg, empirical-analytic and phenomenologic-interpretative). However, a critical poststructural approach, driven by emancipatory practice, provides nurse researchers an opportunity to visualize another way of understanding health, the environment, caring, and nursing.26 The theory of ENP offers a new path for future research. Since the application of the theory of ENP is limited in contemporary nursing literature, it can guide future research aiming to understand the role of social justice in nursing. Furthermore, the theory of ENP can help describe the role of nurses in social justice, particularly in addressing stigma-related health disparities among TGD people and other historically marginalized communities. Using the theory of ENP to guide such research can help examine its testability and generalizability in different contexts. Future research can also help illuminate how nurses incorporate social justice in their practice, evaluate nursing preparedness to engage in social justice, and identify gaps in nursing education. For instance, studies that explore how nurses of systemically minoritized identities (eg, TGD-identifying nurses) experience transformational learning are needed. Similarly, understanding the role of social media platforms, such as Twitter, in engaging nurses in critical dialoguing and interactive reflexivity is worth exploring. Related constructs such as privilege, advocacy, and allyship within the context of social justice and stigma among TGD people can also be explored.

Social justice and nursing policy

Several experts argue that nursing education is insufficient to prepare nurses to address social justice issues, especially at the public policy level.53 Nurses often envision public policy as a function outside the realm of nursing.53 However, public policy, intertwined with social justice, is within the sphere of nursing practice. Nursing care must extend outside the interpersonal care nurses provide to their patients. Nursing includes system-level advocacy and social justice engagement. While nurses often feel limited by the medical and social institutions that dominate the health care system, nurses need to realize that nursing practice covers beyond the clinical, research, or academic spaces.54 A biomedical model that focuses on diseases rather than the human experience of health also contributes to the disconnect between the actualization of social justice as a nursing function. These limitations prevent nurses from leveraging the personal and relational nature of nursing when interfacing with and providing care to others.

While incorporating nursing policy as an essential aspect of nursing education is critical to improving policy engagement, nurses must also understand the discipline of nursing and its inherently political nature to enhance their political competence.54 While foundational nursing documents mention social justice as a fundamental aspect of the nursing profession, it is unclear how it should be taught or integrated into the nursing curriculum. Furthermore, since the concept of social justice is deeply implanted within current sociopolitical structures, nurses must see beyond these institutions and create a new path to practice nursing guided by social justice principles. As Walter poignantly explains, "ENP prompts nurses to engage ... in social justice ... in a manner that is deliberate, reflexive, and always in concert with those with whom we aligned ourselves ... Otherwise, our initiatives may serve ... oppressive systems, rather than transform them."5^(p242)

CONCLUSION

While social justice is central to the discipline, it is poorly described within the nursing context, particularly in addressing health inequities among stigmatized communities. The theory of ENP bridged this gap and provided a theoretical foundation for transformational learning among nurses engaged in social justice. ENP also provided a theoretical framework for incorporating social justice in nursing research, practice, and education. While ENP is a novel middle-range nursing theory and has not been extensively tested, it is testable by principle and illustrates logical adequacy and usefulness. Indeed, the theory of ENP demonstrated potential for knowledge development within the discipline, particularly in the role of nurses in addressing stigma-related health inequities among TGD people.

The theory of ENP is novel, and literature on its application to nursing research is limited. Since most of the participants included in the study came from the Global North (ie, countries associated with economic development), the theory of ENP has limited generalizability within a global nursing context. The numerous concepts and propositional relationships described in the theory of ENP add to its complexity, calling for further refinement. Despite these limitations, the theory of ENP provides promising implications for the discipline of nursing.

REFERENCES