The Journal of School Nursing
2021, Vol. 37(1) 51-60
© The Author(s) 2020
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DOI: 10.1177/1059840520972003
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Shoshana V. Aronowitz, PhD, APRN, FNP-BC , BoRam Kim, BSN, RN, PhD Student, and Teri Aronowitz, PhD, APRN, FNP-BC, FAAN
Zero-tolerance school disciplinary policies have contributed to the proliferation of exclusionary practices, which increase the risk that minoritized students will be harmed by the school-to-prison pipeline (STPP). The purpose of this review was to explore factors that influence the STPP and highlight the role school nurses can play in protecting students from this public health crisis. We used a systematic mixed-studies review method, and 14 studies were included. Exclusionary discipline disproportionately affects minoritized students, but decreased student–teacher ratios, wellness-focused environments, and lower levels of school punishment can improve student achievement and health. The National Association of School Nurses position statement provides a framework to guide school nurses in the dismantlement of the STPP. School nurses should advocate for their position on the interdisciplinary team, funding for alternative disciplinary programs, abolition of school policing, restorative justice approaches, support for at-risk students, and anti-racism education programs for all school staff.
school nursing, school-aged youth, school-to-prison pipeline, minoritized youth, systemic racism
The 1990s brought a shift in U.S. public policy with an increased focus on social control as an approach to crime. This approach led to the proliferation of policies and law enforcement approaches such as the War on Drugs, which disproportionately target and harm Black and Brown communities (Smith-Fornili, 2018). These policies have filtered into public school systems and impacted school discipline, resulting in school disciplinary practices often referred to as the school-to-prison pipeline (STPP; Heitzeg, 2009). Nurses are called to recognize and respond to situations of social injustice as we have a contract with society to understand and act to support anti-racism, social ethics, and equity (Fowler, 2010; Grace & Willis, 2012; Grant, 2020). We believe that nurses need a call to action to respond to disproportionate rates of disciplinary action, suspension, and expulsion of minoritized students, especially Black boys, in U.S. schools (National Clearinghouse on Supportive School Discipline [NCSSD], 2014).
Exclusionary discipline (i.e., suspension and expulsion) is a type of school punishment that removes students from their usual classrooms and may result in removal from school completely. These disciplinary actions are used in an attempt to stop undesired behavior and deter other students (NCSSD, 2014). However, exclusionary disciplinary actions disrupt student learning and lead to students feeling less connected to and invested in school rules and course work (Gregory et al., 2010). Exclusionary discipline is associated with lower academic achievement at both the individual student and the school level and has led to more minoritized youth being placed in special education classes (Skiba et al., 2014). Schools with punitive policies focus on punishment rather than preparing students for postgraduation work and life (Hirschfield, 2008). In addition, studies have shown an increase in criminal justice system involvement among students who were forced out of school; hence, the term “STPP” (Basford et al., 2014; Heitzeg, 2009). The STPP has a clear impact on community and public health in addition to school health, as the communities served by schools with high rates of suspension and expulsion suffer when young community members are unable to complete their education and/or become incarcerated. In addition, Black individuals are at especially high risk of violence and brutality in interactions with law enforcement officers, including school-based law enforcement (Brown et al., 2017; Ehrenfeld & Harris, 2020; Morris et al., 2017).
A teacher’s assessment of whether a behavior is too severe to handle in the classroom is influenced by the student’s disciplinary history, the context of the behavior, and the teacher’s tolerance level and skill in managing disruptive behavior (Skiba et al., 2014). Schools with low-suspending rates are more likely to consider the context when making decisions of consequence, while high-suspending schools adhere to the disciplinary policy regardless of the context of the behavior in question (Skiba et al., 2011). Students who are not suspended after being referred to the principal’s office are less likely to be disciplined in later semesters as compared to students who were suspended, meaning that protecting a student from an initial suspension may also help keep them in school in the future (Meek, 2009).
Zero-tolerance school disciplinary policies expanded in the 1990s as an attempt to prevent drug use and gun violence (Heitzeg, 2014).The Safe Schools Act of 1994 and the 1998 amended Omnibus Crime Control, and Safe Streets Act funded a proliferation of school-based law enforcement officers—also known as school resource officers—in elementary, middle, and high schools. This led to a decrease in funding for wellness programming and an increase in surveillance (i.e., metal detectors, drug testing, drug sniffing dogs; Basford et al., 2014; Meiner, 2007). An influx of school resource officers in schools has eroded the traditional disciplinary roles of teachers and school authorities, has led to increasing levels of exclusionary discipline, and disproportionally impacts Black and Brown students (Hirschfield, 2008; Morris et al., 2017). Searches, drug-sniffing dogs, and other surveillance techniques lower morale and interfere with students’ ability to learn (Advancement Project, 2013). The No Child Left Behind (NCLB) Act of 2002 increased the federal role in holding schools accountable for student outcomes by focusing on high-stakes standardized testing and also contributed to the change in school disciplinary policies (Heitzeg, 2014). The NCLB linked teachers’ performance rankings to their students’ national examination scores. This incentivized teachers to have a lower tolerance of disruptive student behavior, as time spent disciplining students in class meant less time spent teaching material that would appear on the national examinations (Heitzeg, 2014).
Controversy and public outcry about facets of the NCLB lead to its replacement in 2015 by the Every Student Succeeds Act (ESSA), which allows for more local control by paring back the federal role (Blackborow et al., 2018). An important difference noted between ESSA and NCLB is that the new legislation did not define disability. States were expected to determine which students were eligible for alternative assessment rather than traditional standardized testing (Samuels, 2016). ESSA also recognized that bullying and harassment in schools occur at a higher rate among students with disabilities (Samuels, 2016). The regulations allow states discretion with regard to designing and implementing assessment systems (Department of Education, 2016).
School nursing focuses on the health promotion of schoolaged children and the promotion of public health in the communities where schools are located (Doi et al., 2018). In 2015, the National Association of School Nurses (NASN) published a student-centered framework for practice (Maughan et al., 2015) that is in alignment with the Whole School, Whole Community, Whole Child Model (Centers for Disease Control and Prevention, 2019). This framework can be used to examine the role of school nurses in dismantling the STPP in order to protect students from this public health crisis. The framework includes five key principles: Standards of Care (the grounding principle), Care Coordination, Leadership, Quality Improvement, and Community/Public Health. The framework reflects NASN’s position related to evidence-based best practice and priority school nursing activities and illustrates the key principles of professional school nursing practice. It provides guidance for the practicing school nurse to reach the goal of supporting student health and academic success by contributing to a healthy and safe school environment and advocates for studentcentered nursing, acknowledging the importance of taking into consideration the context of students’ families and communities (NASN, 2016). Student-centered care is respectful of and responsive to individual student preferences, needs, and values, ensuring that student values guide all clinical decisions. This includes disciplinary practices that are supportive of growth rather than punitive and harmful for the students’ academic and psychological development.
The purpose of this review was to explore factors that influence the STPP and the role school nurses may play in protecting students from this damaging public health crisis. The research questions were (1) what factors influence exclusionary discipline in schools, and secondary to the findings of the review and the lack of nursing research related to STPP, we posed a second question and (2) employing the Framework for School Nursing Practice, what impact can nurses have on dismantling the STPP?
We completed a systematic mixed-studies review (Pluye & Hong, 2014) with a results-based convergent synthesis design (Hong et al., 2017). As prescribed by this design, we first analyzed quantitative and qualitative data separately and then performed a third synthesis of qualitative and quantitative data jointly. Systematic mixed-studies design allows for a review of diverse types of studies.
Search Methods
EBSCO CINAHL, ERIC, JSTOR, Criminal Justice Abstracts, PsycINFO, and PubMed were searched for articles published 1990–2019 using the terms “School-to-Prison,” “School-to-Prison Pipeline,” “Exclusionary Discipline in Schools,” and “School Nursing.” The starting date was selected because zero-tolerance policies were enacted in the early 1990s. This search did not yield any articles focused on school nursing and the STPP. One article was written by a nurse and was included in the background (Smith-Fornili, 2018) but did not meet the inclusion criteria for the review. Included studies were peer reviewed, quantitative, or qualitative data-based studies that focused on the STPP and were published in English. Studies from Canada were included because of similar zero-tolerance policies that were enacted at the same time as in the United States (Milne & Aurini, 2015). Research about schools outside of North America was excluded. Studies focused on incarcerated family members, education in prison, and aftercare were also excluded.
A total of 719 articles were initially screened. The CINAHL search yielded five articles, ERIC yielded 57, JSTOR yielded 312, Criminal Justice Abstract and PsycINFO yielded 285, and a search in PubMed yielded 60 articles. An additional seven articles were extracted from reference lists. Duplicates (n = 13) were removed. After initial abstract screening, 605 articles were excluded because they did not meet inclusion criteria, and the remaining 108 fulltext articles were manually reviewed for relevance. A total of 14 research studies met inclusion criteria and were included in this review (see Figure 1). Studies were evaluated by the three independent raters. All articles included in the final sample were agreed upon by the team. The author, study design, sample size, study setting, and relevant study findings for each study can be found in Supplemental Table 1.
We used the Mixed Methods Appraisal Tool (MMAT) to appraise the studies, which involves narrative rather than numerical quality appraisal (Hong, Fàbregues, et al., 2018; Pluye et al., 2011). The present version of the tool was developed on the basis of findings from a literature review of critical appraisal tools, interviews with MMAT users, and an e-Delphi study with international experts (Hong et al., 2018; Hong, Gonzalez-Reyes, & Pluye, 2018). The narrative quality appraisal tool questions and the outcome of the appraisal can be found in Supplemental Table 2.
First, numerical data were extracted from the 11 quantitative studies and synthesized narratively, which are presented in the first section of the results with the themes (systemic racism and impact on learning) used as subheaders. Next, we abstracted and synthesized data from the three qualitative studies using qualitative thematic synthesis (Hong et al., 2017; Thomas & Harden, 2008), which involves reading studies, coding findings, and grouping findings together in order to form themes (Hong et al., 2017; Pluye & Hong, 2014; Thomas & Harden, 2008). This is presented in the second section of results (theme: importance of supportive school staff and future aspirations). As per results-based convergent synthesis design, we then performed a third synthesis, in which we compared and combined quantitative and qualitative findings (Hong et al., 2017). This yielded a third theme, impact on health.
There was a total of 11 quantitative studies using state (eight) or federal (three) data sets. Sample sizes ranged from 1,872 to 900,000 students from elementary to high school age. Several studies framed their work in an ecological systems approach addressing multiple systems (i.e., individual, family, school) to understand the racial and ethnic differences in exclusionary disciplinary actions in schools (Beck & Muschkin, 2012; Skiba et al., 2014). Discussed across all 11 of the quantitative studies was the discriminatory treatment of minoritized students.
Systemic racism. Minoritized youth (i.e., Black, Latinx; Native American; lesbian, gay, bisexual, transgender, and queer [LGBTQ] youth; and youth with disabilities) are more likely than their nonminoritized peers to receive exclusionary discipline (odds ratio [OR] = 1.76, p < .01, 95% confidence interval [CI] [1.32, 2.34]; Barnes & Motz, 2018). Black students are more likely than White students to receive exclusionary discipline for violent offenses (88% vs. 72%, z = 17.22, p < .001), weapons offenses (95% vs. 85%, z = 4.34, p < .001), and tobacco offenses (55% vs. 37%, z = 5.02, p < .001; Nicholson-Crotty et al., 2009) and are also more likely than White students to be placed in juvenile detention (OR = 1.99, p < .001; Vanderhaar et al., 2014). Schools in low-income, urban areas with a majority Black student population have higher suspension rates, which may be secondary to a belief among school leadership that these students require more supervision, leading to higher rates of disciplinary action (Barnes & Motz, 2018; Beck & Muschkin, 2012; Pesta, 2018; Skiba et al., 2014). Principals of schools with higher percentages of minoritized students and students receiving special education are more likely to report the use of corporal punishment at their schools (OR = 2.06, p < .001, 95% CI [1.95, 2.19]; OR = 1.83, p <.001,95% CI [1.41, 2.37], respectively; Han, 2011).
Minoritized students are referred for disciplinary action at earlier ages (Nicholson-Crotty et al., 2009), with elementary school–aged Black students having higher discipline rates than White students of the same age (OR = 1.36, p < .001; Rocque & Paternoster, 2011). Although dropout rates are high for all students who have been suspended and/or expelled, White and Latinx students without high school diplomas have better employment options compared to Black students without high school diplomas. Black adults who were expelled from school as children are more likely than their White adult peers who were not expelled to report engaging in crime, and Black adults who were expelled to have an 40% increase in odds of reporting engagement in crime than Black adults who were not expelled, z =-4.03, p < .001 (Pesta, 2018). However, being expelled was not significantly associated with reported engagement in crime for White or Latinx adults (Pesta, 2018). This is likely due to systemic barriers and racism in hiring practices that prevent Black adults without a high school diploma from finding work.
Impact on learning. A culture of social control in schools interferes with student academic success (Skiba et al., 1997), for both the students who are suspended and students who are not suspended (Perry & Morris, 2014). Reading and math scores of nonsuspended students are negatively impacted by suspensions and expulsions at their schools, and this impact is felt more strongly in schools with a culture of greater social control and expulsionary discipline (reading scores: β = 2.75, SE = .35, p < .001; math scores: β = 2.67, SE = .28, p < 0.001; Perry & Morris, 2014). Higher percentages of new teachers in a school are associated with lower achievement for Black students compared to White students, but higher percentages of Black teachers in a school are associated with higher achievement for Black students (Beck & Muschkin, 2012). Students at combined schools (schools with students in elementary and junior–high as well as high school) are at higher risk of experiencing exclusionary policies and juvenile justice referral than students at schools that are not combined (combined junior and high schools: β = 1.04, OR = 2.83, p < .001; combined elementary–high schools: β = 0.58, OR = 1.75, p < .001; Marchbanks et al., 2018).
Our search yielded three qualitative studies. One study used journal mapping methodology as well as interviews and observations. The second study used focus groups, and the third study used teacher interviews and participant observation.
Importance of supportive school staff and future aspirations. Participants in the study using journal mapping methodology reported experiences of systemic racism and gross lack of support by schools that had expelled them (Annamma, 2016). Some participants reported that their expulsions were in response to “infractions” that occurred due to serious issues outside of school (i.e., missing school due to abuse at home) that school leadership did not make the effort to understand. Participants also shared that they had difficulty trusting school leadership and teachers, as they acted more like “agents of the carceral state” than supportive adult figures (Annamma, 2016, p. 1221). Despite these traumatic histories, all 10 student participants stated that they were resisting their current circumstances in a juvenile detention center by planning for future careers in helping professions such as teaching and health care and looked forward to reengaging with school in order to achieve these dreams (Annamma, 2016).
Student and teacher participants across the three qualitative studies believed that minoritized youth are assumed by teachers and school leadership to be “up to trouble,” and this can lead to misunderstandings and disciplinary action without school staff finding out what had happened to cause the disruptive behavior (Gass & Laughter, 2015; Hambacher, 2018). Teachers stated that educators and school staff must focus on improving their students’ school lives by expressing to students that they can and will succeed and that it is a teacher’s duty to explore what is causing disruptive behavior and address it through teaching rather than discipline (Hambacher, 2018). Students expressed that minoritized students are more likely to trust teachers who display clear commitment to combating systemic racism and the STPP and that supportive teachers can be an extremely important source of encouragement and guidance (Gass & Laughter, 2015). Participants in all three studies believed that teachers and school staff can support students’ success by being responsive to the context of learning for the youth and involving family and community.
Impact on health. Taken together, the findings of the quantitative and qualitative syntheses point to the STPP’s clear detrimental impact on the health and well-being of students, especially minoritized students and the communities where these students live. The STPP detracts from student learning, which not only negatively impacts students’ personal educational futures but also harms the communities where students reside as adults. Students benefit from future aspirations and career goals, and lacking adult community members with careers to aspire to—because these adults were forced out of school as children—can also disrupt student learning. In addition, given what is known about Black individuals’ risk of violence at the hands of law enforcement officers (Ehrenfeld & Harris, 2020), the STPP’s disproportionate impact on students of color represents a threat to students’ physical, cognitive, and emotional health and safety.
Although minoritized boys have the highest rate of exclusionary discipline, the suspension rate of Black girls is six times higher than that of White girls (U.S. Department of Education, 2014). In fact, Black youth represent 17% of the youth population but account for 45% of all juvenile arrests (Bureau of Justice Statistics, 2012; Han, 2011; Heitzeg, 2014). There is a direct link between exclusionary discipline and school dropout rates for all students of all races, but Black youth face more barriers to employment after dropping out than do their White or Latinx peers (National Center for Juvenile Justice, 2014; Pesta, 2018).
Academic success is impeded in overly punitive environments. Normal developmental characteristics exhibited by all youth, such as struggles with identity and independence, can create issues with authority figures and lead to behaviors such as “talking back” (Skiba et al., 1997). School faculty and staff should be prepared to deal with normal adolescent development with a nonpunitive approach, which might reduce the disciplinary referrals at the middle school level (Skiba et al., 1997). Findings from the review of qualitative studies suggest that a teacher’s responsiveness to youths’ social and family contexts and willingness to involve family and community supports when addressing student behavior are linked to student success. In addition, student participants voiced the belief that teacher encouragement, specifically regarding helping students set goals and complete assignments, was key for promoting academic success (Annamma, 2016; Gass & Laughter, 2015; Hambacher, 2018). This echoes findings from previous studies that instilling future aspirations is important in the development of resilience in youth (Aronowitz & Morrison-Beedy, 2004; Donovan et al., 2015). Programs that support students’ development of selfdiscipline through habits of the mind and planning for future life goals may be an important alternative to exclusionary disciplinary practices (Winn et al., 2011). States can support these efforts by enacting policies that require the provision of quality alternative educational programs for students who require disciplinary action rather than expulsionorsuspension(Han&Akiba,2011).
The majority of teachers in the public school system across the United States are White (Goldring et al., 2014), and diversification of the school workforce, including teachers, school nurses, and other staff, is urgently needed (Simon & Johnson, 2015). In addition to diversifying the workforce, there is a need for anti-racism continuing education and training for school faculty and staff. This type of training requires explicit, ongoing education and reflection about how structural racism is currently present in every facet of society, accompanied by thoughtful and sustained action to address racism present in curriculum and school operations (Alumni for Change, 2020; DiAngelo, 2018; Saad, 2020).
Policymakers in the United States might look to successful interventions in other countries. Finland does not use high-stakes testing to rank students or schools and does not evaluate teachers based on student test scores (Wagner, 2011). Like the United States, Canada turned to zerotolerance policies in the 1990s. However, a lack of success with these approaches led to their replacement with Progressive Pedagogy policy in Ontario public schools. With this approach, school faculty considers the larger context of students’ disruptive behavior and involves families in decisions on how to engage students in school (Milne & Aurini, 2015).
School nurses are in the position to affect change regarding disciplinary action in schools, and it is critical that nurses realize this public health issue and work to address it. Following the American Nurses Association’s Code of Ethics, nurses must speak out against all forms of systemic racism (Grant, 2020), including the STPP, which disproportionately harms minoritized students. Although disciplinary practices are not explicitly mentioned in the NASN guidelines for practice, all principles are relevant when considering the role of school nurses (Maughan et al., 2015) and in this case in the dismantlement of the STPP. We will discuss each principle with examples of ways nurses can intervene. Implementing the framework is an iterative process; therefore, there are overlapping concepts between the principles.
Care coordination. Case management and interdisciplinary teams are key to care coordination. School nurses coordinate and provide complex care for the nation’s public school students very effectively (McClanahan & Weismuller, 2015) and are involved in individualized health plans (IHPs) for students. These IHPs should focus not only on students with chronic illnesses but rather consider all social determinants of a student’s health (Fleming & Willgerodt, 2017). Nurses must be aware of all potential factors that can impact a student’s academic achievement including systemic racism present in the U.S. school system that fuels the STPP and risks that students (especially Black students) face if they are expelled from school or subject to unnecessary involvement with law enforcement.
Leadership. Advocacy is a major competency for leading change in policy development and implementation. Nurses should be change agents and partners with other school faculty and staff in health care and educational reform, particularly with regard to disciplinary practices. The foundation of effective discipline is based in trust, affirmation, and caring relationships (Noguera, 2003). Little research is focused on the school nurse’s role in school discipline, although nurses have been intimately involved in assessing students after disciplinary action (e.g., restraints; Fraley et al., 2020) and are thus aware of the harmful impacts of such disciplinary techniques. Nurses should demand school discipline reform and promote restorative and transformative justice approaches, which are based on the core principles of repairing harm, reducing risk, and empowering the community (Pavelka, 2013). There are several models that may be considered, including peer mediation and peer accountability. These approaches bring together the student accused of wrongdoing, the victim (in this case, a student who may have been harmed by another students’ actions), and student peers to discuss how the actions in question harmed the victim and school community and what might be done to repair this harm (Bazemore & Umrbeit, 2001; O’Brien, 2008). In October 2019, the U.S. Department of Education (2019) announced $71.6 million USD in new funds to address school safety and improve mental health of students. School nurses should work with faculty and leadership to apply for this and other funding, which can be used to support alternatives to exclusionary discipline.
Quality improvement. Alternatives to exclusionary disciplinary policies, such as restorative and transformative justice programs, are an important step in dismantling the STPP (Pavelka, 2013). Nurses need to not only demand and help implement these types of programs but also collect data and complete program evaluations. Completing a community assessment to understand norms, values, and desires with regard to school discipline is key to successful implementation of any alternative to exclusionary discipline. Nurses can work with school faculty and staff to organize forums and school-based meetings to involve both parents and community stakeholders.
Community/public health. Traditional examples of nurse engagement in public health programming include enrichment programs like HeadStart (Beck & Muschkin, 2012) and transitional care programs like the Nurse–Family Partnership, which provides support to young new mothers during pregnancy and after their first child’s birth (Nurse–Family Partnership, 2020). These programs are also relevant to school nursing because they can help support students to stay in school even if they become parents. School nurses must also consider the community health impacts of exclusionary discipline, which include high rates of arrest and incarceration in the communities served by schools that utilize these disciplinary techniques. High rates of arrest and incarceration have numerous negative health impacts on communities by contributing to ill mental and physical health in formerly incarcerated individuals and their families and community members (Wang & Wildeman, 2017). Police violence against Black communities not only harms those who physically experience the violence but also has serious mental health impacts on Black individuals who hear about the incidents (Bor et al., 2018).
According to the NASN’s position statement, “school nursing is grounded in community and public health ...-school nurses employ cultural competency in delivering effective care in culturally diverse communities,” and “the school nurse strives to promote health equity” (NASN, 2016). In order to truly deliver equitable, effective care to all students, school nurses must address the STPP as it is a dire threat to the health and safety of minoritized students. Like other threats to the safety and health of students, such as infectious disease, the school nurse cannot just focus on individual children but consider the environmental and societal factors that put them at risk. Systemic racism present in the school environment and in greater society must be addressed.
Increased policing and decreased funding for wellness and health promotion in schools with large populations of minoritized students, in addition to implicit or explicit biases among school faculty and staff contribute to racial disparities in school disciplinary approaches. Although this review uncovered the lack of literature focused on nursing’s role in addressing the crisis of exclusionary discipline, nurses have an important opportunity to impact these policies. Grounded by standards of practice, services provided by the school nurse include Care Coordination, Leadership, Quality Improvement, and Community/Public Health (NASN, 2016), all of which are relevant to the school nurse’s role in helping shape school systems that are free from harmful disciplinary practices. To effectively participate in the dismantling of the STPP, school nurses should advocate for (1) a greater role in the interdisciplinary team within their school districts, (2) increased funding for wellness and alternative disciplinary programs, (3) a decrease in policing of school environments, (4) identifying and supporting students at risk for disciplinary action, and (5) continuing education for all school staff that addresses systemic racism in the U.S. school system.
Shoshana Aronowitz, BoRam Kim, and Teri Aronowitz contributed to conception or design and acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Shoshana V. Aronowitz, PhD, APRN, FNP-BC https://orcid.org/0000-0003-2169-9562
Supplemental Material for this article is available online.
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Shoshana V. Aronowitz, PhD, FNP-BC, is a National Clinician Scholars Program Fellow at the University of Pennsylvania.
BoRam Kim, BSN, RN, is a PhD student in the Department of Nursing at the University of Massachusetts Boston.
Teri Aronowitz, PhD, APRN, FNP-BC, FAAN, is an associate professor in the Department of Nursing at the University of Massachusetts Boston.
1 National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
2 Department of Nursing, University of Massachusetts Boston, MA, USA
Corresponding Author:Shoshana V. Aronowitz, PhD, APRN, FNP-BC, National Clinician Scholars Program, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA.Email: shoshana.aronowitz@pennmedicine.upenn.edu
