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Social Justice in Nursing Pedagogy: A Postcolonial Approach to American Indian Health
SELINA A. MOHAMMED, PHD, MPH, RN
DEBBY A. PHILLIPS, PHD, PMHCNS
16 Teaching, Research, and Service Synthesized as Postcolonial Feminist Praxis
LUCY MKANDAWIRE-VALHMU, RN, PHD, PATRICIA E. STEVENS, PHD, RN, FAAN, AND PENINNAH M. KAKO, PHD, RN, FNP-BC, APNP SECTION IV
Critical Practice Approaches and Methodologies
17 Cultivating Relational Consciousness in Social Justice Practice
GWENETH HARTRICK DOANE, RN, PHD
18 Facilitating Humanization: Liberating the Profession of Nursing from Institutional Confinement on Behalf of Social Justice
DANNY WILLIS, DNS, RN, PMHCNS, DONNA J. PERRY, PHD, RN, TERRI LACOURSIERE-ZUCCHERO, PHD, RN, FNP-BC, AND PAMELA GRACE, PHD, RN, FAAN
19 Promoting Social Justice and Equity by Practicing Nursing to Address Structural Inequities and Structural Violence
COLLEEN VARCOE, RN, PHD, ANNETTE J. BROWNE, PHD, RN, AND LAURIE M. CENDER, RN, MSN
20 Military Sexual Trauma and Nursing Practice in the Veterans Administration
URSULA A. KELLY, PHD, RN, ANP-BC, PMHNP-BC
21 Through a Socio-political Lens: The Relationship of Practice, Education, Research, and Policy to Social Justice
JILL WHITE, AM, RN, RM, MED, PHD
AFAF I. MELEIS, PHD, DRPS (HON), FAAN, AND CAROLINE
G. GLICKMAN, MIM
PAULA N. KAGAN, PHD, RN
Foreword: Social Justice: Continuing the Dialogue
“Although we may speak the words of social justice, it is how we act that clearly demonstrates our philosophy.”1(p29)
This book comes at a time when social justice as praxis has never been more urgent. The inequalities and inequities we are witnessing are not new. However, as we move deeper into the 21st century, wars and unrest in many parts of the world; increasing economic uncertainties locally and globally; income disparities with the widening gap between rich and poor; and perceived and actual inequities, all of which thwart life opportunities and profoundly influence health and well-being, make the enactment of social justice an urgent issue particularly in a discipline such as nursing, with its accompanying professional mandate. Bekemeier and Butterfield2 among others remind us that progressive nurse reformers—on whose shoulders we stand—“grew indignant from witnessing the destructive health outcomes of institutionalized poverty and of gender and ethnic inequalities. These nurses harnessed their indignation to work toward the creation of progressive health policies,”2(p153) and so must we! In Canada, the Canadian Nurses Association’s (CNA) commitment to advancing social justice has been articulated in various policy documents over the years, culminating with a policy discussion paper in 2010.3 Yet, despite our attentiveness to social justice in policy documents and scholarly discourse over many decades, the vexing problem of injustices and inequities remain visible in some of the populations with whom we, as nurses, work. At issue is the complexity of the concept of social justice, the competing and divergent theoretical perspectives that have informed the discourse and how we see our responsibility as nurses. But regardless of the perspectives from which we come, we might be in agreement with Amartya Sen4 that “justice cannot be indifferent to the lives that people can [emphasis added] actually live.”4(p18)
Given the opportunity to contribute to this book, there are a few points—implicit in any discussion of social justice—which I would like us to consider as we embark upon reading through this very fine collection of essays. I should point out that the intent of this foreword is not to review the
chapters—the editors have done this. Rather, I offer a few brief comments on issues I have observed as I have participated in nursing discourse through the years, and reflected on, and attempted to put social justice into action.
One of the issues, I believe, that has impeded our work as we strive towards the “ideal of social justice” in the discipline and profession of nursing pertains to the tension between “individual agency” and “structure”—a tension that is pervasive in many disciplines, but which is, perhaps, more poignant in disciplines such as nursing as we struggle with the complexity of these concepts and the boundaries of our responsibility as nurses. In discussions with health professionals over the years about the structures that shape the health and illness experiences of patients and their families, some (by no means all!) have seen the socioeconomic-political “structural constraints,” often highlighted in such conversations, as outside of their mandate and as independent of their individual actions. Some stressed their commitment to treating individuals equally, an approach that is sometimes coupled with the perspective that everyone should receive the same kind of care and information, e.g., patients and their families are encouraged to engage in post-discharge planning prior to admission to hospital (for example, filling up the fridge with food prior to elective surgery, preparing and freezing meals, etc.) to facilitate the transition from hospital to home. There is often the expectation that families ought to look after their loved ones when they are ill or needing care in old age. The subtext here, I believe, is that people ought to take responsibility for their care. Although there is merit in this approach—I certainly would not quarrel with the notion that people should make adequate preparations for post-discharge prior to being admitted to hospital—the risk is that the structural constraints of economics, social inequalities, and such like may be overlooked if we are not attuned to the varied social locations of people’s everyday lives. We should keep in mind that not only do some people have few social support networks, but also, there are those who have no home to return to after hospitalization.5 Nursing scholars through the years have been reminding us to do just that, including scholars such as Drevdahl and her colleagues1 in their article on “Reinvesting in Social Justice: A Capital Idea for Public Health Nursing?” I was struck by the trenchant insights in this excellent article. One sentence—“[a]lthough we may speak the words of social justice, it is how we act that clearly demonstrates our philosophy”1(p29)—the quote that appears at the beginning of this foreword— held my attention; clearly, these scholars, and others before them, are holding us to account to demonstrate socially just actions, which by their very nature would see us engage with the material context of human existence and the structural constraints that shape some lives more than others.
At the same time we should be mindful that critical discourses in nursing—at the level of discourse—often tend to privilege “structure” in so far as there is overriding emphasis on the structural constraints and injustices that shape the experiences of patients and their families. As I look back on my own writings, I must confess that I, too, have tended to put emphasis on structural constraints, often reifying economic and political structures as
Justice: Continuing the Dialogue xiii if they were “something” “out there,” to be critiqued. In other words, such processes may be conceptualized as created by a “ruling elite” and independent of our own actions. Yet Iris Marion Young6 reminds us that each one of us has a responsibility for social justice: “ when the injustice is structural there is no clear culprit to blame and therefore no agent clearly liable for rectification. . . . [S]tructural injustice is produced and reproduced by thousands or millions of persons usually acting within institutional rules and according to practices that most people regard as morally acceptable.”6(p95) But Young does not leave us with a feeling of helplessness. She points out that what we do matter, as do Drevdahl and her colleagues. These scholars all remind us that each one of us has a responsibility for structural inequalities; they tell us that we must find the political will to engage in conversations about social justice not only at the local level but at the global level as well. They hold us to account and marry the concept of social justice with praxis—as do the editors of this book—and, in so doing, illuminate the agency/structure dialectic.
The distinction between “treating people equally” and “treating people equitably”—the latter, a concept that grounds social justice—has consequences for our practice. Treating people equitably requires that we understand the complex context of health, illness, and suffering, including individual agency and resiliencies; the oppressive structures—often historically located—that are constraints to agency; and, that we grapple with the dialectics of theory and action. This, in my view, underpins what praxis means in nursing, and what is, from a critical perspective, aligned with social justice. Although praxis might be interpreted in different ways, I take it to mean translating the critical perspectives that we theorize about into action—action with the political intent of changing oppressive structures. Thus, it could be argued that working for social justice can never be from a politically “neutral” position that is unquestioning of the power structures and injustices within societies that profoundly influence health and well-being. As we have learned more about the social, political, and economic determinants of health, we have become acutely aware that although access to health care remains out of reach for many; having access, in and of itself, does not guarantee good health or recovery from illness. For instance, it became apparent to me in some of my early research with women who were balancing living with a chronic illness, minding a family, and holding down a job in the lower tiers of Canada’s workforce to make ends meet, that the mediating circumstances of women’s lives had a profound impact on their ability to manage their health, even when they had access to health care and worked with compassionate health care professionals whom they held in high regard. We know that the resources for managing illness and achieving health, even in societies as affluent as Canada and the United States, are inaccessible to many. Yet, theories and perspectives that do not take into account the texture of the structural constraints operating at the intersections of various social relations such as “race,” “gender,” “class,”
and “age,” among others, put the blame squarely on the shoulders of those who are not able to live up to the ideals of “good health” even when material deprivation makes everyday survival a struggle. So, the question to be considered is whether we can speak about social justice in nursing without critically examining and questioning the social, political, and economic structures in which inequities that profoundly influence health, well-being, and human suffering are embedded, and reflecting on the ways in which each one of us, by virtue of being members of a society, unwittingly maintain and reproduce the very structures we challenge and critique.
This book robustly addresses the complex issues of agency and structure, and in so doing, provides new insights to inform “emancipatory nursing.” We know from past experience that assumptions about “power” and “powerlessness”—which often deflect attention away from the structures that perpetuate social inequities—are often the subtexts for words such as “emancipatory,” “empowerment,” and the like.7 Although such terms have powerful meanings when examined in the context of “constraints” to agency—which the editors have done—as we continue the dialogue on social justice into the future, we need to be vigilant not to slip into using them to imply that those who live on the margins are bereft of human agency. Instead, we need to continue to focus on constraints to their agency and the triumph of agency over oppressive structures. From a postcolonial perspective, one is reminded of the words of Homi Bhabha8: “it is from those who have suffered the sentence of history—subjugation, domination, diaspora, displacement—that we learn our most enduring lessons for living and thinking.”8(p172) In articulating emancipatory perspectives, we have sometimes projected the notion, though unintended, that as health professionals and academics we are positioned to emancipate those whom we regard as “oppressed,” or living on the margins. In other words, we may see ourselves as having the “power” to “emancipate” the “powerless” by doing “for” them that which they cannot do for themselves. But Bhabha draws our attention to the lessons to be learned from subjugated and subaltern voices—those who have been positioned on the margins through the sentence of history. He beckons us to recognize their human agency and capabilities to be our teachers. Through the process of critical reflexivity on the historical processes that have shaped all of our lives, and the ongoing processes through which inequities are reproduced, we come to recognize that the emancipatory process touches all of us, in ways we may not have imagined. As the editors have so eloquently described, emancipatory nursing then becomes a process of critical reflection on our own history and positionality and how others have been positioned. The recognition of the human agency and potentialities of all of us calls for working in a partnership with, to use Bhabha’s words, “those who have suffered the sentence of history.” This engagement with, and learning from one another, is emancipatory for all and holds promise for transformative social and political action.
xiv Anderson
But how can emancipatory action be sustained? Mention of a knowledge translation study on translating “critical knowledge” into practice that colleagues and I conducted some years ago seems relevant here in light of one of sections in this book on critical practice approaches. Colleagues and I conceptualized critical knowledge as “constructed through methods of critical inquiry and as fostering an understanding of historical, political, economic, and other social processes that can be drawn on as explanatory resources as we engage with patients in promoting health and ameliorating the suffering of illness. Critical knowledge is both social and reflexive in nature, prompting us to question our assumptions, the status quo, and the taken-for-granted. It is linked to praxis as the dialectical relationship among knowledge, theory, research and action. Among its outcomes are equity and critical social justice in health and health care delivery.”9(p110)
We have argued that critical knowledge is central to a social justice agenda in nursing, as we draw upon theoretical perspectives that bring critical and political awareness into practice. This knowledge may serve to mobilize political action among nurses, not only to change the conditions under which we work but also, as a collective, to influence broader political structures to work towards addressing inequities in health and health care. Yet we have found that there are many challenges in sustaining the knowledge translation process for the integration of critical knowledge, which requires intensive engagement in clinical settings over a protracted period of time. Such initiatives may very well come to an end upon the completion of a research project, even when there is strong collaboration and solid team building in the organizations with which we work and “champions” within these organizations who wish to carry on the work. Perhaps as we think through issues of the sustainability of social justice in different organizational contexts, we might well consider models of academic/practice relations that go beyond building strong collaborative relationships between the academy and practice settings. Might we explore, for example, models in which academic nurses become the leaders and “expert practitioners” in practice settings to blur the division between the academy and practice settings? This would call for major organizational change in some jurisdictions, but might such a model provide the continuity within organizations that is needed for the translation of complex theoretical concepts into practice? Might it ensure sustainability over time? Clearly, this is an issue that requires ongoing conversation.
The focus on social justice as praxis in this book sets it apart as breaking new ground in nursing. The editors have assembled chapters that not only open up a discursive space to keep social justice on the agenda; the chapters provide rich conceptualizations of social justice and emancipatory nursing by drawing on research and different theoretical perspectives. Importantly, the authors challenge us to action not only within the universities in which some of us work, and in communities far from academia, but also in exploring interorganizational connections for sustainable social justice. The book
therefore provides significant knowledge for the enactment of social justice at the level of nursing practice, within the curricula of health professionals, and within the policy domain. The essays in this book provide a foundation for continuing the dialogue on social justice as praxis well into the future.
Joan M. Anderson
REFERENCES
1. Drevdahl D, Kneipp SM, Canales MK, Dorcy KS. Reinvesting in social justice: a capital idea for public health nursing? ANS. Advances in Nursing Science 2001;24(2): 19–31.
2. Bekemeier B, Butterfield P. Unreconciled inconsistencies: a critical review of the concept of social justice in 3 national nursing documents. ANS. Advances in Nursing Science 2005;28(2): 152–162.
3. Canadian Nurses Association (CNA). Social justice . . . a means to an end, and end in itself. 2nd ed. 2010. http://www2.cna-aiic.ca/CNA/documents/pdf/ publications/Social_Justice_2010_e.pdf. Accessed July 31, 2012.
4. Sen A. The Idea of Justice. Cambridge, MA: The Belknap Press of Harvard University Press; 2009.
5. Anderson JM. Discourse: the politics of home care: where is “home”? Canadian Journal of Nursing Research 2001;33(2) 5–10.
6. Young IM. Responsibility for Justice. New York, NY: Oxford University Press; 2011.
7. Anderson JM. Empowering patients: issues and strategies. Social Science & Medicine 1996;43(5): 697–705.
8. Bhabha H. The Location of Culture. New York, NY: Routledge; 1994.
9. Anderson JM, Browne AJ, Reimer-Kirkham S, et al. Uptake of critical knowledge in nursing practice: lessons learned from a knowledge translation study. Canadian Journal of Nursing Research 2010;42(3): 106–122.
Introduction
Paula N. Kagan, Marlaine C. Smith, and Peggy L. Chinn
This anthology is a work of audacious hope and optimism. It is a collection of papers in which nurse scholars share their musings, methodologies, and actions about creating social justice through nursing practice in novel ways. The genesis of the book emerged when the three editors, joined by our friend and colleague, Richard Cowling, published A Nursing Manifesto: An Emancipatory Call for Knowledge Development, Conscience, and Praxis in Nursing Philosophy in 2009.1 That article was inspired by our collective experiences attending the combined Nursing Knowledge Development and International Philosophy of Nursing (IPONS) Conference in Boston in 2008, whose theme was social change for the good of people and society. Our analysis of the Nursing Manifesto2 specified the philosophical frameworks grounding the manifesto and our own philosophical beliefs about nursing.
A FOUNDATION OF PRAXIS
We defined praxis then, as now, as professional practice directed by and toward social justice goals and outcomes—which include reflexivity, action, and transformation. We conceptualize an emancipatory framework as asserting that all persons, regardless of hierarchy, status, or privilege, should have full access in sharing awareness and participating in social processes. Praxis, as conceptualized by Paulo Freire, is simultaneous reflection and action in order to transform the world.3 Chinn, in extending Freire’s idea, has maintained that the nature of the transformation that emerges from praxis alters the social conditions and power dynamics that sustain disadvantage for some and privilege for others in the direction of equality, fairness, and justice for all persons.4 We believe that there exists a type of nursing—which we name emancipatory nursing—that is capable of bringing to the forefront new forms of nursing practice, research, and education that are grounded in a critical theory or philosophical awareness and intent. Freedom is an essential concept that underpins praxis and represents the ability to choose action. Freedom is the foundational component in arriving
Smith, and Chinn
at progressive social change, and reflects the essence of being human: freedom to think independently, live safely, in the manner of one’s choosing, perhaps even well, to speak one’s views, and to protect and advocate for others. Freedom, in an emancipatory context, only exists when each person shares equally in the rights and responsibilities of the culture so that no person or group is privileged or advantaged over others. Willis, Perry, LaCoursiereZucchero, and Grace, in their chapter titled “Facilitating Humanization: Liberating the Profession of Nursing from Institutional Confinement on Behalf of Social Justice,” emphasize the necessity for nursing as a profession to be liberated from institutional confinements in order to remain grounded in the ideals of nursing’s ontological, epistemological, and ethical foundations and exercise the freedom to transform health care. They state:
liberation of the profession from institutional confinement begins with the critically reflective and creative “essential freedom” of nursing consciousness that will devise the necessary changes to expand the range of “nursing effective freedom” for social justice action. Only then will we be able to become full actors in the efforts to transform society and facilitate humanization in the fullest sense. (Willis, Perry, LaCoursiereZucchero, and Grace, this volume, p. 263)
From an emancipatory nursing perspective, freedom for the professional nurse is viewed as:
• emancipation from the dogma and constraints of privileged dominant health and social discourses and practices;
• emancipation from medical model and illness-cure frameworks; emancipation from prescribed interventions derived from the experiences of white, middle-class, heterosexual, and male privilege; and
• professional emancipation from society’s misunderstanding and devaluing of nursing knowledge and expertise, an emancipation that fosters acknowledgment that the nurse is central in leading health policy, ethics, research, and practice from nursing science, critical, caring, and health promotion perspectives.
From our perspective as editors, this is emancipatory nursing: nursing that embraces and nurtures social justice goals and outcomes, where practice becomes praxis. It is nursing aimed at forms of knowing and doing in order to better humankind in all its variant and valued manifestations.
We hope that this anthology will inspire and guide other nurses, regardless of their area of practice, level of education, or years of experience, toward a praxis that encompasses awareness of social injustice, understanding of how social injustice is sustained, and the knowledge on which actions aimed at challenging social injustice may be based.
OVERVIEW OF AIMS AND GOALS
This anthology includes the philosophical, theoretical, and practice perspectives of nurse scholars whose work centers on frameworks of social justice and critical theories. It makes a unique contribution to the literature in that it contains original, new writings from leading nursing scholars whose works are informed by critical and/or unitary theoretical frameworks. The number of nurse scholars dedicated to non-traditional perspectives such as critical social theory, critical feminisms, intersectionality, post-colonial discourse, American Pragmatism, and unitary-transformative and caring nursing theories as underlying frameworks for practice, research, and pedagogy has increased worldwide.5–10 However, until this volume, there has been no single collection of works such as those forwarded here.
Currently, the discipline of nursing lacks a resource focused on praxiological approaches. Nurses, nurse educators, and students have identified a need for new concepts, models, and theories encompassing scholarship and practice aimed at purposive reformation of the nursing profession specifically and health care systems and practices generally. We believe the authors of the chapters in this book provide the pathways nurses need if they are to bridge critical theoretical frameworks, nursing science, and practice in a way that is understandable and useful for all nursing to embrace the practice of emancipatory nursing.
The International Council of Nurses,11 and other organizations and institutions, have stated that the complexity of contemporary issues facing human beings poses a broad array of questions that beg for answers; they have called for the development of suitable methods of addressing these questions. New answers need to be articulated and considered in relation to their potential for resolving the health problems of both individual persons and society as a whole. The Council further suggests that nurses’ work, ideas, and knowledge development efforts should not be limited to problems and solutions emerging from the dominant discourse or tradition. It is the ethical obligation of the profession to work towards establishing alternative forms of knowledge capable of capturing both the roots and complexity of contemporary problems as distributed across a wide diversity of people and communities.
This anthology aims to address these concerns. In different ways, the authors of the works collected here advance suggestions for envisioning and enacting reformed health care services and delivery that could lead toward more equitable, sustainable, and humane models of nursing praxis. We hope this book inspires inquiry that engages participants while providing evidence of the success of novel approaches. We hope that the book prompts significant shifts in nursing education that engage and inspire learners to experience concern for social justice as central to nursing practice.
Moreover, we hope that readers will find meaningful ways to understand and practice emancipatory nursing and health care that embody a variety of social justice and critical perspectives. We anticipate that readers will revise and expand their thinking, develop frameworks, and modify their practices based on the expertise of the authors collected here, all of whom make explicit their philosophical standpoints, methods justifications, and in many cases, practical ways to “just do it.” It was our goal, as editors, to offer the reader a collection that will be useful as well as inspiring and lead the reader to consider and engage in creating change for social justice.
PEDAGOGICAL APPROACHES IN NURSING AND ACROSS DISCIPLINES
In addition to appealing to nursing professionals and students, the works contained here may be helpful and informative to those from other disciplines. Educators and students in women’s and gender studies, public health, social work, education, and sociology are actively seeking innovative approaches to addressing health concerns, often consulting with and collaborating with nurse scholars. We believe this anthology will be accessible to readers across disciplines for application in fields other than nursing. Nurse scholars are developing perspectives and methods that uniquely combine thought and action reflecting an ideal that is valued as praxis in many disciplines. Health professionals across disciplines are actively seeking new research processes, methodologies, and ways to resolve health disparities. The individual works collected here provide progressive ideas for addressing health problems by way of health research, education, and practice innovation.
Those disciplines and programs that are grounded in critical studies are turning their focus to health as a content area. For example, students and scholars in women’s and gender studies have an increasing interest in health related to the varied way people live and identify as men and women including those of lesbian, queer, and transgender persons and communities. These researchers turn to nurse scholars for their expertise in the health, quality of life, and risks associated with such populations. Nurses have the disciplinary focus and knowledge base to guide the study of health. But without a clear commitment to issues and population health for minority and marginalized persons and communities, health knowledge alone will not adequately serve the interests of social justice in health care. Blending health knowledge with emancipatory knowledge, nurses as well as other professionals can achieve better health outcomes that respect community difference and diversity and seek methods that speak to health promotion, quality of life, and environmental sustainability. This book serves as a resource for professors and students working on health issues within critical, feminist, and/or postmodern frameworks.
EMANCIPATORY KNOWLEDGE AND PRACTICE: CONCEPTUALIZATIONS AND CHALLENGES
Within the frameworks of critical social theory, critical feminisms, intersectionality, post-colonial discourse, American Pragmatism, and unitarytransformative and caring nursing theories, we encouraged contributing authors to present their own conceptualizations and particular definitions of key terms, which, not surprisingly, they did! So, although there is a certain common theme throughout the book concerning the importance of social justice as a valued and valuable goal for nursing, there are important distinctions that bear collective reflection. These distinctions are not essentially contradictory of one another; instead, they represent the changing perspectives that emerge from envisioning a single room, depending upon where one is seated. Quite consistently, the authors link that which is “critical” and “emancipatory” with social justice—suggesting processes and remedies that seek to address social injustice. Although both concepts contain elements of “knowing and doing” in their meanings, there is a clear distinction connecting “critical” as a frame of reference for seeing what might be beneath the surface. The meanings of “emancipatory” tend to be more clearly associated with frames of reference for action. Those chapters that do not explicitly define the terms focus instead on discussing scholarly work that is conducted from a critical/emancipatory perspective, and their results/conclusions are consistent with a focus on social justice and social systems that structure justice and injustice.
The purpose of our analysis was two-fold: first, to glean the richness of meaning that emerges when the content of this book is viewed as a whole and, second, to discern any contradictions or areas of tension in meanings our authors forwarded.
From a process of summary and analysis of the authors’ manuscripts, four characteristic elements central to the meaning of “critical” and “emancipatory” emerged. These elements overlap, but they are also distinct. Taken together, they provide a rich description of the array of meanings related to nursing and health.
Conceptualizations of Critical
In this text critical is consistently conceptualized as having to do with social justice—becoming aware of processes and remedies that seek to address social injustice. There are four major areas of emphasis that occur around definitions of what constitutes a “critical” approach:
Unpacking hegemonies—challenging what we know as truth, bringing to the surface truths that have been concealed or suppressed, and recognizing how one’s own assumptions and material conditions determine what we take as “reality.”
Upstream thinking—accounting for structural inequities—the “causes of causes” of health and social inequities, such as globalization of neoliberal economic and social policies, ongoing racialization of wealth and health, and the persistence of gendered inequities.
Interrogating historical/social context—examining the matrix of power relationships inherent in theories and systems—systems that privilege some knowledges and marginalize others.
Framing/anticipating transformative action—dialectic, analytic operatives of deconstruction and construction, providing a visionary inclusive framework that fosters widespread dispositions and professional habits supporting social justice.
This last characteristic reflects the inseparability of thought and action. However, it is important to note that “critical” approaches are often criticized as failing to offer constructive alternatives to that which is identified as lacking. Sally Thorne addresses this concern in her chapter titled “Nursing as Social Justice: A Case for Emancipatory Disciplinary Theorizing,” with a particular emphasis on the imperative to remain grounded in nursing’s disciplinary core. Here, she calls upon nursing’s critical social scholars to “find their way back into the intrigue of nursing theorizing” so that our “our most prominent thought leaders remain aligned with nursing’s disciplinary core”. (Thorne, this volume, pp. 86, 87). Thorne’s call for attention to nursing action provide the perfect segue for turning attention to the meanings of “emancipatory.”
Conceptualizations of Emancipatory
In this collection the term emancipatory is consistently associated with actions that seek to change unjust social and political structures and to encourage a community’s capacity to strive toward freedom from unjust constraints. The following four elements emerged to define characteristics of emancipatory action:
Facilitating humanization—transformative action for social justice that is grounded in the ideals of nursing’s ontological, epistemological, and ethical roots.
Disrupting structural inequities—intersectional approaches to changing social structures taking into account the complexity of social life and allowing for the intersection of multiple interacting contexts.
Self-reflection—paying particular attention to the ways in which one’s own experiences foster or inhibit one’s ability to effectively engage in action directed at social change.
Engaging communities—building authentic relationships with communities and engaging collective action that is aimed toward political awareness, empowerment, and equitable social policy.
There are two tensions related to “emancipatory” approaches that bear particular discussion. The first tension involves the process of change itself.
The other concerns the related concepts of socio-political knowing and action and emancipatory knowing and action. There are many complex issues surrounding change itself. There is a persistent tension around the presumption that we can “make change” on behalf of others, when at the same time we seek to respect and advocate on behalf of those with whom we work. The ethics of change involve our right to privilege our professional knowledge and insights, not over those we serve, but with them. Our responsibility to honor the choices of others or to enter into a dialogue and cooperative relationship that addresses the ethical tensions involved in making change is paramount.12 It is generally understood, and it is our position as editors, that making change in an emancipatory context does not mean “doing for” others. However the term “emancipatory” is sometimes used in a way that implies a paternalistic intent to make change on behalf of others. Some efforts to change social conditions do hinge on making broad judgments about needed shifts in policy or practice that are eventually imposed on others without their knowledge or consent (for example, consider the social policies that have emerged with mandated seat belt use and bans on smoking in public spaces). The tensions surrounding efforts intended to create change for the better deserve ongoing dialogue and debate. Just like the social problems that emancipatory approaches seek to address, these very tensions often appear overwhelming. Gweneth Hartrick Doane, in her chapter titled “Cultivating Relational Consciousness in Social Justice Practice,” provides an explanation of relational complexity and offers a notable commentary related to tensions around creating change:
Increasing our relational complexity requires the development of a relational consciousness, a consciousness that involves paying close attention to how we are relating within situations, and inquiring into our own relational comportment—to the how, what, where, why, and when of the situation we find ourselves in. (Doane, this volume, p. 245)
. . . . A relational consciousness asks: Who/what am I primarily relating to? What is dominating my attention, including my interpretations, emotions, and responses? What am I privileging? What am I not wanting to relate to? And how is my relational orientation shaping my experience and my action? Central to this inquiry process is letting things be without adding our own by-lines that result in static still shots and bounded views of people and situations. It includes noticing and exercising the skill of holding our by-lines of good/bad, right/wrong in abeyance and focusing our attention on engaging more concertedly. As we step out of the subject-object stance and relate more wholeheartedly through this inquiry process, it is possible to see beyond the dualism of letting be or change (and beyond the assumption that to ‘let be’ means everything stays the same). By extending ourselves to know and relate to ‘what is,’ we are better able to correspond within and to the situation at hand. (Doane, this volume, p. 246–247)
The second issue that is conceptually related to “emancipatory” approaches involves distinctions that can be drawn between emancipatory knowing and the concept of “socio-political” knowing. Jill White first introduced the concept of “socio-political” knowing in her insightful critique of Barbara Carper’s fundamental patterns of knowing. Peggy Chinn and Maeona Kramer chose the term “emancipatory” when constructing a pattern of “emancipatory knowing” because of its link to underlying philosophies associated with critical perspectives and also because the term pointed to a desired outcome of nursing action. This is related to, but distinct from, Jill White’s concept of socio-political knowing. Indeed, in her chapter for this volume, White addresses a distinction between “emancipatory” and “socio-political” knowing as follows:
in my view socio-political knowing and emancipatory knowing are different. It may be that socio-political knowing is a necessary precursor to emancipatory knowing, but it is also a positioning and practice itself. Socio-political knowing is a broadening of the nurse’s gaze to include the “wherein” or context of nursing and those who influence it. Whilst inevitably raising questions of equity and circumstance, of privilege and of invisibility, socio-political knowing does not necessitate a critical social theory or critical feminist lens. Introduction of the language of emancipation without depth of philosophical understanding can leave people with a shallow veneer of critical social theory or critical feminist theory and a rhetoric of change and emancipation without the knowledge and ability to follow through with the social challenge inherent in its philosophical stance. (White, this volume, p. 298)
The central issue, therefore, is not simply a matter of semantics but rather of the tensions between theory and action, notably the extent to which one depends upon the other, as well as the extent the two are distinct from one another. Thus far our introduction has focused on the circumstances that led us as editors to initiate this project, our underlying intents and conceptualizations that we brought to its creation, and analysis of some of the tensions and issues inherent in the varied perspectives that constitute emancipatory nursing. We now turn to a specific description of the content that appears in this volume.
Section Overviews
This anthology is organized in sections that represent the most common domains of practice in the discipline of nursing:
• Section I—Philosophical and Theoretical Considerations: Innovative Frameworks for Health;
• Section II—Research Methodologies and Practices: Critical New Knowledge Development;
• Section III—Pedagogy of Praxis: Teaching for Social Justice; and
• Section IV—Critical Practice Approaches and Methodologies.
We offer our interpretation of the significance of each section, keeping in mind that discrete boundaries do not exist between the domains, particularly when viewed and practiced from the perspective of emancipatory praxis. We recognize a synthesis of theory, pedagogy, new knowledge acquisition, and social action in all forms of nursing praxis.
The foreword is written by Joan M. Anderson, an eminent scholar in nursing who has distinguished herself as one of the leaders in social justice research and practice. Emerita Professor of Nursing at the University of British Columbia, her record of scholarship covers almost three decades. With publications in most of the major nursing journals, Dr. Anderson’s work reflects a level of productivity and critical thought that is equaled by very few. Her 1985 publication in Advances in Nursing Science titled “Perspectives on the Health of Immigrant Women: a Feminist Analysis” illustrated her influence in moving the discipline to a new level of discourse.13 One of her many landmark publications in the Canadian Journal of Nursing Research illustrates her lasting influence: “The Conundrums of Binary Categories: Critical Inquiry through the Lens of Postcolonial Feminist Humanism.”14 In the foreword to this book, Anderson continued that trajectory emphasizing the many tensions that create challenges to emancipatory nursing, the problematic meanings of the concept emancipatory, and the sustainability of social justice knowledge translation as praxis.
Section I: Philosophical and Theoretical Considerations: Innovative Frameworks for Health
Social justice is embedded in nursing’s ontology, epistemology, and ethic. Nursing’s distinctive focus as a discipline is the study of human health and healing through caring.15(p50) Human-environment relationships, including physical, social, political, and economic environments, are all central to human health and healing. It follows, then, that analysis of the critical environmental interrelationships that impact health and healing fall within the discipline of nursing’s domain. Social justice, as a dimension and outcome of caring, is essential to health, well-being, and human flourishing. Multiple ways of knowing are necessary to understand phenomena of concern to the discipline and to inform nursing practice. Those multiple ways of knowing have been articulated individually by Carper, White, and Chinn as empirical, aesthetic, ethical, personal, sociopolitical, and emancipatory. Emancipatory knowing has been defined at length earlier in this chapter; its foundations are rooted in critical-post-structural epistemologies that assert the influence of socio-political structures on knowledge and the purpose of reflection and action to produce transformative social change. From our earliest history nurses cared for the poor, suffering, and oppressed. Nurses
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have been and continue to be social activists, removing barriers, creating just systems, and working directly with communities to address what is most important to them in advancing their health. Social justice, with its emphasis on equality and equity, is part of nursing’s DNA. Section I introduces readers to the philosophical and theoretical foundations of emancipatory nursing and social justice praxis.
In chapter 1, “Problematizing Social Justice Discourses in Nursing,” Annette J. Browne and Sheryl Reimer-Kirkham present a critical analysis of nursing’s discourse on social justice. They focus their analysis on four problematics: 1) situating social justice in the politics of difference; 2) dangers in presuming a universal epistemology of social justice; 3) the need for an ontology of social justice in the discipline and professional practice of nursing; and 4) the challenge of equity fatigue. They propose a refocused conceptualization of social justice for the discipline through a dialectic that ends in a new synthesis that can be a foundation for emancipatory praxis: 1) critiquing structures of oppression AND envisioning conditions for human flourishing; 2) understanding determinants of inequity that impact human suffering AND supporting people’s resistance, self-determination, strength, and quality; 3) valuing human dignity and equity AND enacting virtues of compassion, generosity, and humility; and 4) foregrounding ideas and analysis AND focusing on goals for action.
Chapter 2, “Towards an ‘Ethics of Discomfort’ in Nursing: Parrhesia as Fearless Speech,” written by Amélie Perron, Trudy Rudge, and Marilou Gagnon, is an essay about parrhesia, or frank speech, in nursing. The concept of parrhesia is explored from the perspectives of the Greek philosophers and Michel Foucault. The authors share their own experiences with parrhesia and assert that truth telling or speaking without fear is an emancipatory strategy that can be useful in situations of discrimination and oppression.
In chapter 3, “Compassion, Biopower, and Nursing,” Jane M. Georges advances an emancipatory theory of compassion for contemporary nursing. She analyzes power, suffering, and compassion through the philosophy of Giorgio Agamben and narratives of nurses who practiced in Nazi Germany. She draws on Foucault’s definition of “biopower” as “power over life” and argues that compassion is especially critical when an individual holds such power. She questions whether the current conditions of nursing practice make compassion less possible, or at times impossible, and urges nurses to speak unspeakable truths by giving voice to both the suffering and the absence of compassion they have witnessed.
Jean Watson writes about social/moral justice from a caring science cosmology and a unitary worldview. Chapter 4, “Social/Moral Justice from a Caring Science Cosmology,” presents her view of social justice informed by Emmanuel Levinas’ ethic of belonging and principle of universal love and nursing’s disciplinary foundation in human rights. She calls for a unitary caring science, sacred science, and sacred activism that honor human
unity and engender social justice that is steeped in love, connection, and belonging.
In chapter 5, “No Hiding Place: The Search for Impermeable Boundaries,” Beverly Malone shares a very personal essay about the search for safety or impermeable boundaries. She recalls her experience during the horror of September 11, 2001, while working in London, and reflects on the illusions of omniscience, immortality, omnipotence, and safety and how these illusions were shattered on that day, ushering in an era of disillusionment. She concludes that although it is not possible to hide from harm, enhanced knowledge and compassion can help us to create places and spaces for healing.
In the final chapter of Section I, “Nursing as Social Justice: A Case for Emancipatory Disciplinary Theorizing,” Sally Thorne argues that social justice is not a departure from conventional theorizing in nursing but is a natural extension of the disciplinary focus. She asserts that social justice should be within the disciplinary core and traces the historical roots of social justice in nursing. She concludes with a call to action aimed at working for social justice to permeate nursing practice.
Section II: Research Methodologies and Practices: Critical New Knowledge Development
Nursing research has been guided by several scientific paradigms. The most prominent influence on nursing research has been the traditional science or empirical-analytic paradigm. The epistemology grounding this paradigm of science is rooted in the belief that truth is “out there” waiting to be discovered; that knowledge is gained through methods that separate the influence of person and context from what we are seeking to know or understand; and that we must reduce what we are seeking to know or understand to discrete units that can be measured and compared to each other. The essence of this paradigm is radical objectivity. The human science or phenomenologic/ interpretive paradigm of science is founded on the tenets that truth is subjective and value-laden, and that knowledge is cocreated through the researcher’s interpretations of experiences and observations. Its essence is radical subjectivity. In the critical-post-structural or emancipatory paradigm of science truth is viewed as coconstructed through social, cultural, and political dynamics often related to power and privilege. Reflection and action are foundational to knowledge development and occur in partnership with those invested in the process and outcomes of inquiry. Critical approaches of unveiling and questioning the “truth” lead to liberating awareness and transformation. The essence is radical contextualism.16 These paradigms of science have engendered research methodologies, methods, and practices for new knowledge development. In this section the research methods and practices within the critical-post-structural or emancipatory paradigm are described.
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Chapter 7, “Community-Based Collaborative Action Research: Giving Birth to Emancipatory Knowing,” written by Margaret Dexheimer Pharris and Carol Pillsbury Pavlish, focuses on community-based collaborative action research (CBCAR) as a praxis approach to engaging communities in a process of understanding their reality, addressing inequities, and advancing social justice. CBCAR is rooted in action science, the unitarytransformative and participatory paradigms, and a commitment to social justice and human rights. The authors describe the principles for and the steps in the CBCAR process.
In chapter 8, “Social Justice Nursing and Children’s Rights: A Realist and Postmodern Intersectional Feminist Analysis of Nurses’ Reflections on Child Risk and Protection within Domestic Violence,” Nel Glass and Kierrynn Davis introduce a critical realist and postmodern intersectional feminist analysis of child protection in the context of domestic violence. Through listening to nurses’ experiences of caring for children at risk for abuse and needing protection, they discovered that risk for and protection from child abuse were polarized activities, and that nurses working in this area were more focused on risk than protection. The authors argue that their analysis affords a deeper understanding of the complexities of risk and child protection within domestic violence situations.
In chapter 9, “The Identity, Research, and Health Dialogic Interview: Its Significance for Social Justice-Oriented Research,” Doris M. Boutain shares her Identity, Research, and Health Dialogic Interview approach as a way to collect and interpret meaningful information about how identity relates to health and how persons with particular identities can provide insights into identity-related research findings. Born from a critical paradigm and grounded in social justice, this process transforms the intent of gathering demographic data during research from identifying static categories to engaging with participants in a process of discovering relationships between self-described identity and health. The author also provides a detailed interview guide.
Robin A. Evans-Agnew, Marie-Anne Sanon, and Doris M. Boutain offer a critical exploration of the use of Photovoice as a research method for nursing knowledge development. In chapter 10, “Critical Research Methodologies and Social Justice Issues: A Methodological Example Using Photovoice,” these authors explain the process of Photovoice, provide critiques of its use, and offer two examples from a critical ethnography and critical discourse analysis, along with suggesting questions to consider when planning to use Photovoice with critical methodologies.
Section III: Pedagogy of Praxis: Teaching for Social Justice
The chapters collected in Section III focus on emancipatory pedagogy or teaching social justice within nursing. Pedagogy refers to the art and science of teaching. Emancipatory pedagogical approaches reflect the values of
coparticipation of teacher and student in the process of teaching-learning; the full engagement of the teacher and student in discovery and critical thinking; and the creation of a safe environment in which the expression of diverse points of views is encouraged.
In chapter 11, “Social Justice: From Educational Mandate to Transformative Core Value,” Mary K. Canales and Denise J. Drevdahl present a critical analysis of the inclusion of the concept of social justice in key literature in nursing in the United States. They reviewed the core documents that guide curriculum development in nursing education and 20 journal articles related to some aspect of social justice, and found that social justice was weakly represented or absent from the guiding documents for nursing curricula in the United States. They conclude that without our concentrated efforts, social justice may exist as mere words on the pages of mission statements and philosophies, without impact and meaning for educating the next generation of nurses and those they’ll serve.
C. Susana Caxaj and Helene Berman, in chapter 12, “Anticolonial Pedagogy and Praxis: Unraveling Dilemmas and Dichotomies,” describe their anticolonial approach to praxis and pedagogy evident in Caxaj’s dissertation research. The authors privileged indigenous knowledge systems of the Guatemalan Mayan community as they engaged the community in activism to address the mining of their land by a Canadian company. Their emancipatory approach to can be broadly applicable within nursing education.
In chapter 13, “ ‘And That’s Going to Help Black Women How?’: Storytelling and Striving to Stay True to the Task of Liberation in the Academy,” JoAnne Banks provides a deeply personal essay about her journey of reflection and discovery leading to living an authentic academic life. Storytelling is the unifying theme of her work, and she reveals how she has stayed true to this theme in the academic missions of teaching, research and service. She says, “I am an academic, a nurse scholar and a black woman, part of a group that continues to be colonized within the U.S. . . . Survival depends of the willingness to push back.” (Banks, this volume, p. 198)
Chapter 14, “Social Justice in Nursing Pedagogy: A Postcolonial Approach to American Indian Health,” authored by Selina Mohammed, focuses on a postcolonial course in American Indian Health for RN-BS students. The 10-week elective course is taught using principles of emancipatory learning. Students explore how colonialism perpetuates health disparities and how decolonizing approaches are important in working with these communities.
In chapter 15, “Human Violence Interventions: Critical Discourse Analysis Praxis,” Debby A. Phillips offers a synopsis of post-structural psychoanalytic discourse analysis as a way to deconstruct harmful social structures. She makes the point that unconscious judgments about normalcy are encoded unconsciously and neurobiologically and are reflected in language. Making visible the reflected meaning in language is an important consideration in both teaching and learning in nursing.
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The final chapter in this section, chapter 16, “Teaching, Research, and Service Synthesized as Postcolonial Feminist Praxis” by Lucy MkandawireValhmu, Patricia E. Stevens, and Peninnah M. Kako provides examples of the integration of the academic missions of teaching, research, and service into a post-colonial feminist praxis that uses emancipatory strategies to eliminate oppression and empower health. The authors sponsor a study abroad experience in East Africa for community health students, support service learning for students with nongovernmental organizations in Kenya and Malawi, and conduct their research with the communities in the region.
Section IV: Critical Practice Approaches and Methodologies
Human beings around the world daily suffer from social, political, and economic conditions that seriously compromise their health. Western systems of care delivery most often focus efforts on treatment of or rescue from illness and death, using medico-technological approaches to treat or cure. The United States has the highest per capita expenditures for health care, and yet outcomes there are less favorable than most developed countries. To improve health and well-being attention must be given to the humanenvironment relationships that facilitate health and well-being. This is nursing’s disciplinary focus and our unique contribution to healthcare. Nurses must claim their expertise in relational caring that enhances the health and well-being of individuals, families, and communities through attention to the environment, including the social, political, and economic forces that influence health and well-being. Critical emancipatory approaches are needed to realize these goals.
The United Nations Millenium Development Goals chart a course for improved health for all citizens of the world. These eight goals are: 1) eradicating extreme poverty and hunger; 2) achieving universal primary education; 3) promoting gender equality and empowering women; 4) reducing childhood mortality; 5) improving maternal health; 6) combating diseases such as HIV/AIDS and malaria; 7) ensuring environmental sustainability; and 8) creating global systems for development. These goals can only be accomplished through advancing social justice through emancipatory practices of empowerment, equality, equity, and justice. Other countries, such as Canada, have embraced primary health care as a model to address health for all through community partnerships that address the social determinants of health, improving access to care, and focusing on disease prevention and health promotion. The Institute of Medicine/Robert Wood Johnson Foundation’s report on the Future of Nursing17 in the United States contains recommendations that nurses should practice to the full extent of their education, and that nurses should be prepared to lead change to advance health in full partnership with physicians and other health professionals in redesigning U.S. healthcare systems. Nurses practicing from a disciplinary perspective that considers human-environment-health interrelationships,
freedom to participate fully in healthcare decisions, and health and caring relationships as primary can be instrumental in re-forming the current healthcare delivery system.
In “Cultivating Relational Consciousness in Social Justice Practice,” the first chapter of the section, Gweneth Hartrick Doane provides a compelling call for nurses to cultivate a relational consciousness as they navigate toward social justice practice in the current complex healthcare environment. She offers suggestions of how to develop this relational consciousness including understanding how embracing imperfection and the dark side of human nature can lead to compassion for self and others.
Danny Willis, Donna J. Perry, Terri LaCoursiere-Zucchero, and Pamela Grace focused on humanization and authored chapter 18, “Facilitating Humanization: Liberating the Profession of Nursing from Institutional Confinement on Behalf of Social Justice.” They argue that social injustice leads to dehumanization that impacts health and well-being. They link social justice to nursing ontology, epistemology, history, and ethics, and draw on Lonergan’s philosophy, concluding that nursing must liberate itself from institutional confinement to realize its full potential.
In chapter 19, “Promoting Social Justice and Equity by Practicing Nursing to Address Structural Inequities and Structural Violence,” Colleen Varcoe, Annette J. Browne, and Laurie M. Cender use a critical anticolonial stance and an intersectional lens to examine how structural inequities and structural violence impact health and quality of life, and they offer strategies to enhance health equity. These authors describe nine principles for health equity and social justice and identify practices to transform inequities in health care.
In chapter 20, “Military Sexual Trauma and Nursing Practice in the Veterans Administration,” Ursula A. Kelly addresses the critical contemporary issue of military sexual trauma (MST). Using intersectionality as a framework she calls attention to the factors contributing to MST and presents an exemplar analysis of African-American women’s experiences of MST and PTSD. Implications for social justice praxis both within and outside the VA system are detailed.
Jill White describes sociopolitical knowing in chapter 21, “Through a Socio-political Lens: The Relationship of Practice, Education, Research, and Policy to Social Justice,” as an epistemological accelerant for social justice. She argues that by “shifting the gaze beyond the dyad” to the environment of care nurses can perceive the inequities driven by social-politicaleconomic forces. She traces the roots of nursing’s sociopolitical involvement to promote societal health and calls for the involvement of nurses in political action to foster new models outside of illness care within hospitals.
The final chapter, “A Passion in Nursing for Justice: Toward Global Health Equity,” written by Afaf I. Meleis and Caroline G. Glickman, focuses on reclaiming nursing’s mission of social justice. They describe the problem of health inequities, nursing’s commitment to social justice, the
