Risky Publishing in a Risk-Averse Profession

Tom Olson, Eileen Walsh, Ming-Bao Yue and William Lewis

Academic nursing has long operated under a legacy of deference: to medicine, to institutional hierarchy, to structures that reward order over disruption. In the mid-twentieth century, as the profession fought for legitimacy, it adopted a cautious, orderly scholarly style.^[1] Controversy –​​ especially when it challenged racism, authority, or internal power – was often seen as too risky, particularly when voiced by women. The American Nurses Association itself did not fully desegregate until 1950, and the battle to admit Black nurses into its ranks continued into the second half of the century.^[2] This history of caution still shapes nursing’s publishing culture today.

Against this backdrop, four educators – a nurse (Olson), a women’s historian (Walsh), a laboratory scientist (Lewis), and a literature professor (Yue) – set out to write about the profession’s deepest discomforts: racism, moral compromise, and institutional silence. We grounded our work in lived experience, anonymized but real, using richly contextualized composite case studies to explore complexity and ambiguity. Our goal was to make readers feel the tension and the stakes.

The Stories We Tried to Tell

One case study, written by the nurse alone, highlighted racial injustice in a minority-serving institution.^[3] Another, co-authored by the nurse and historian, grappled with moral compromise in nursing leadership.^[4] The third, shaped by all four of us, confronted institutional racism in higher education.^[5]

Each placed a dean of nursing at the center – a deliberate choice, not to assign blame or inhabit their perspective, but to examine leadership as a site of ethical tension. Given the profession’s standing as the most trusted in the United States, we used the figure of the dean to explore how institutional values, personal convictions, and systemic pressures converge in moments of decision.^[6]

Except for the single-authored piece, we worked collaboratively, sharing firsthand experiences from leadership roles in California, Hawai‘i, Colorado, Minnesota, Virginia, Massachusetts, New York, Texas, and the U.S. Virgin Islands. These accounts grew into short written narratives, which we then reviewed for recurring themes. Points of disagreement were set aside. What remained became composite cases – grounded in lived experience, shaped by many hands, and kept anonymous so that sensitive realities could be ethically explored.

We chose the case study format intentionally. Social scientists have long shown that cases bridge theory and lived reality, drawing readers into the complexities of actual decisions.^[7] Our aim was not to prescribe answers but to invite reflection on the dilemmas leaders face and the ethical tensions that often remain hidden.

“Too Real”: The Limits of Acceptability

Over decades of scholarship, we have grown accustomed to rigorous review and thoughtful critique. However, our submissions to ten leading nursing journals met with resistance – sometimes pointed, sometimes personal in tone.

The contrast with interdisciplinary journals was striking. Although nursing journals responded with unhelpful and at times harsh reviews, we found more thoughtful engagement outside the field. Reviewers there accepted all three articles and welcomed the questions we raised. This divide became a case study in itself.

These reviewers’ and editors’ responses – spanning disciplines, institutions, and editorial cultures – offer a rare glimpse into what academic nursing finds acceptable, and what it resists. By analyzing the language of praise, discomfort, and rejection, we aim in this essay to illuminate the profession’s publishing norms: what is welcomed, what is silenced, and what is deemed “too real.” This analysis is not about individual reviewers or journals, but rather about the broader culture of scholarly gatekeeping and the implications for truth-telling in nursing.

From more than twenty-five pages of reviewer comments, two areas of agreement emerged. First, nearly everyone inside and outside nursing acknowledged the cases were important: “crucial and timely,” “worthwhile,” “acutely important.” Second, reviewers agreed they felt real: “This anonymized case study is real-life.” “It feels real.” “This case is hardly one of a kind and yearns to be openly discussed.”

But within nursing, this realism was a liability. “I think maybe this is too real,” wrote one reviewer, worrying that “readers/employees in the institution in question will sooner or later recognize the institution you are referring to, and that is a red flag. In publishing, one must always be very cautious.” This concern was directed at the following case setting, which we included to illustrate the legally and ethically complex terrain that academic nursing leaders must navigate – where public, private, non-profit, and for-profit educational enterprises increasingly intersect in a volatile and competitive landscape:

The setting for this case is AimHighest University, a non-profit, comprehensive urban university with a combined undergraduate and graduate enrollment of 15,000 students. Enrollment is distributed across three campuses. AimHighest aspires to enter the top tier of research universities while at the same time adding two more campuses. To fund the new campuses, each of the eight university schools was charged with doubling enrollment in their school’s professional master’s programs. School administrators were given wide latitude in developing strategies for expanding graduate enrollment. The School of Nursing, with the approval of university leaders, sought to increase enrollment through partnership with a for-profit educational company, BizEd Enterprises.^[8]

Although fictionalized and composite, the realism was, in the reviewer’s words, “a red flag.” We found this response telling. Reviewers viewed even carefully anonymized realism – intended to illuminate systemic pressures – as threatening. That reaction underscores the profession’s deep unease with confronting its own institutional landscape.

Other critiques became more personal in tone: “This sounds like an act of revenge.” “The tone here is of someone who is just angry.” One reviewer, for example, was reacting to a case study in which “Dr. N,” an academic dean, voiced her frustration at being unable to address a professor’s repeated demeaning comments to Filipino-American students. “It just feels wrong,” she lamented. “Shouldn’t I at least try to find out the truth?”^[9] Even anonymized, this kind of unguarded candor proved enough to unsettle nursing journal reviewers. Expressions of moral distress – especially from a woman in leadership – struck us. Reviewers often read these not as ethical concern but as personal grievance, revealing a deeper discomfort with emotional honesty in nursing scholarship.

Outside nursing, reviewers also had critiques but focused on strengthening the work: “A more detailed description of how you captured the dimensionalities of the studied problem would make this stronger.” “What are the implications of this ethical dilemma in structural versus post-structural terms?” Personal observations tended to be encouraging: “I can’t wait to use this in my classes.”

In short, nursing reviewers saw risk; others saw rigor.

What Nursing Journals Wanted Instead

None of the ten nursing journals invited a revision. Their comments revealed a preference for:

• “Something that is more general or on a conceptual level.”
• “A position paper that lays out the broad issues and what steps should be taken.”
• “Guidelines” or “specific strategies” in place of detailed cases.

In other words, they wanted abstraction, prescription, and distance – approaches historically favored in academic nursing, especially on topics implicating the profession itself. Racism, the central ethical issue in two of our case studies, has long been one of those discomforting topics.

This feedback did not surprise us. Two of us had documented nursing’s linear, step-by-step, craft-like scholarly tradition, which is excellent for defining the seventeen steps for a safe injection, but less helpful when grappling with ethical dilemmas that have no single correct answer.^[10]

Our case studies were meant to shift perspective, to build meaning from multiple angles. We hoped to illuminate how ethical complexity lives in lived experience – not in abstract principles – and to invite readers into a mode of inquiry that resists easy resolution. In rejecting them, nursing journals demonstrated the same impulse toward simplification that once led to avoiding frank discussion of segregation in the profession.

Toward a More Courageous Scholarship

To imagine a different path, we turned to nursing practice itself. Beyond its mechanical aspects, good nursing demands the ability to see the whole person – to integrate clinical acuity, cultural sensitivity, emotional intelligence, and system awareness. This was the aim of our published case studies: to model a scholarly approach that mirrors the best of nursing practice, one that honors complexity, centers lived experience, and resists the impulse to simplify what is ethically fraught.

Consider Mr. Kanoa, eighty-four, leaving the red dirt and ocean winds of Kaua‘i to live with his daughter in California. He arrives at the outpatient clinic with heart failure, diabetes, fading memory, and a quiet grief. He speaks mostly in Pidgin; mainland medicine feels foreign. The nurse who meets him doesn’t just catalogue diagnoses: she listens to his silences and understands that healing also means restoring meaning, identity, and connection. For Mr. Kanoa, this approach affirms his full humanity – his language, his grief, his history – before his diagnoses. It allows him to be seen not as a collection of symptoms, but as a person whose healing depends on cultural understanding and relational care.

Approaching Mr. Kanoa in abstract terms would not promote healing, just as reducing our case studies to generalities would not foster genuine understanding. Clinical courage – holding the whole story, even when it is uncomfortable or unresolved – must have its counterpart in scholarly courage. In calling for scholarly courage, we are challenging a publishing culture that too often rewards neutrality over nuance, and procedural clarity over ethical reckoning. We hope to move beyond a tradition that avoids discomfort, toward one that embraces complexity as a site of learning and change.

If we can hold complexity in practice, we can hold it in publication, to make our voices heard. If we can care for patients with courage, we can reflect on our profession with the same courage, even when that reflection means naming racism or questioning structures of authority.

Risky publishing, grounded in strong theory and method, should not be feared. Without it, we risk something far greater: silence. And silence has always diminished nursing, just as the ANA’s exclusion of nurses of color once did. Inclusivity matters in the clinic, in the classroom, and in our scholarship. With courage, we can write differently: centering stories that unsettle, naming injustices that persist, and publishing work that invites reflection rather than resolution. This is what our articles sought to do, and what we hope others will continue.

Featured image courtesy Kaboompics.com.

Tom Olson

Tom Olson is a nurse and educator who has held leadership roles at the University of Hawai‘i at Mānoa, the University of Texas, New York University, Mercy University, and Northeastern University. He is co-author, with Eileen Walsh, of the award-winning book Handling the Sick (Ohio State University Press, 2004), which traces the evolution of early American nursing.

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Eileen Walsh

Eileen Walsh is a freelance historian who has taught at Bemidji State University and California State University, Fresno. Her work explores intersections of gender, labor, and healthcare history.

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Ming-Bao Yue

Ming-Bao Yue, a first-generation immigrant, is Director of the Center for Chinese Studies at the University of Hawai‘i at Mānoa. Educated in Germany, China, and the U.S., she is fluent in five languages and known for scholarship that centers women’s voices in Chinese literature and film.

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William Lewis

William Lewis is a laboratory scientist who has held leadership positions in Colorado, Minnesota, Texas, and Hawai‘i. His work bridges clinical practice and ethical inquiry, with a focus on interdisciplinary collaboration.

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