Contributor: Liliana Barroso de Sousa (Portugal)

My initial concern in writing this post is the difficulty that professional nurses have in thinking and acting in the political dimension. This reluctance is expressed in statements such as: “my policy is work” or “my party is nursing.” With the purpose of obtaining knowledge useful for understanding the real meaning of this apparent difficulty in accepting and assuming the role of politics in the profession, but also in trying to determine the political influence of nursing itself, I took on the preliminary investigation of these problems:  Is Nursing a political thing? How do nurses invest today in the political dimension of the profession?

Based on what I have learned so far, I can say that yes, nursing is definitely a political thing. That is why I share in this post some information regarding this topic and what some of the most prominent theorists of the discipline have been saying.

It was Aristotle who stated that the human being, more than a “gregarious animal, is a political living being in the full sense …” (Aristotle, 2016,1253a5-15). “Politics” is a word of Greek origin that is etymologically related to the polis (city-state) of Ancient Greece, as the highest expression of the organization of human beings in society and also to the systematic and orderly knowledge of political phenomena.

With the exception of what happens to human beings, all animals act improgressively, conditioned by the environment in which they are born, live and die. Even in a bee – an animal in which we recognize a society of complex architecture – it is not possible to have a different destiny or the transformation of the group’s structures. The non-human animal can never change its social destiny.

Nursing, from its historical foundation to its essential current domain, is political (Warner, 2003). It is necessary to start from the understanding that its main metaparadigmatic concepts – person, health, environment and nursing – and disciplinary field problems are related to the contexts socio-economic and political aspects of the person and community, and with the historical conceptualizations of health. The example of Florence Nightingale is paradigmatic, not only in the influence of the concept of health at the time, but also in health policies, public health and policies that informed the nursing profession (Frella & Carraro, 2013; Pfettscher, 2014).

The structural purpose of the nursing profession is to intervene in the context of health, to fulfill the social contract it has with society and its health needs, conditions and traditions by acting responsibly and conscientiously on health policies (Fawcett & Russell, 2001; Russell, G. & Fawcett, 2005).

As people’s experiences and their meanings are contextualized by history, significant others, politics, social structures, gender and culture. Nurses are interested in these perspectives and the way they shape people’s actions and reactions by being in a situation of health challenges.  It is this interest that grounds nursing as a practice-oriented discipline, which in turn contributes to the definition of the discipline’s own perspective (Meleis, 2018, p.87).

In the same line of thought as Meleis, I think that politics not only contextualizes the experience of nurses and the people and/or communities they care for, but is also an interest of nursing as a practice-oriented discipline. In the structure of the nursing discipline, the political dimension is one of the dimensions of the domain of nursing knowledge and is one of the constitutive parts of the discipline (Meleis, 2018) that can be influenced and influence the development of the domains, contextualizing and engaging with all the core concepts.

I have found the following to be recurring themes in the theories of the discipline:

• Recognize and understand the political nature of nursing (Leininger, 1978, 1995; White, 1995), 
• The political dimension of care (Ray & Turkel, 2012; Turkel & Ray, 2003; Turkel, 2007; Turkel & Ray, 2000), 
• Commitment to social justice and the fight against social and health inequalities (Kagan, 2014; Kagan, Smith & Chinn, 2014; Walter, 2017).

Knowledge, according to Kramer & Chinn (1988) reflects how humans perceive and understand the world. Perception and understanding occur as a result of multiple interactions with different sources of knowledge. The paths that shape action developed from what is known emerge from experience, reflections, observation, books and what is learned from others.

Bárbara Carper (1978) identified four patterns of knowledge in nursing called empirical, aesthetic, personal and ethical. Subsequently, Jill White, in 1995, added a fifth pattern called sociopolitical and Chinn and Kramer, in 1999, included the emancipatory pattern.

Jill White, in her critical review of Carper’s patterns of knowledge, proposes a sociopolitical understanding in which, according to the author, it is possible to frame all other patterns of knowledge. The questions that arise in this pattern are: does the nurse know the patient’s context? How is the nursing context known? However, the ontological restlessness remains, what is the meaning of the context for the patient and the nurse?

The pattern of sociopolitical knowledge (White, 1995) contextualizes the nurse-patient relationship in a broader context in which nursing and health care take place. Sociopolitical knowing can be conceptualized either in terms of the sociopolitical context of the person (nurse and patient) or in the sociopolitical context of nursing as a profession, that is, the understanding that society has of nursing and the understanding that nursing has of society and of societal policies. I believe that nurses must have an understanding of the mechanisms of control and access to the field of political decision, to influence policies. Nurses and the knowledge nurses contribute need to be recognized by others as important in political debate and decision.  It is also important for the public to recognize that what nurses understand about human experience, their knowledge, is important to creating a political, social and culturally contextualized world.

According to Castano (2016) when addressing the epistemological issues of the patterns of knowing, it is important to include all sources of knowledge – not only empirics.  Science is affected by knowledge of the context. That is, the development of science and specifically the science of nursing requires knowledge of contextual elements, such as the availability of financial and logistical resources derived from institutional, local or national policies; accessibility to sources of information (including people who participate in research), clarity about gaps in theoretical and practical knowledge, real and potential needs of the people cared for in all their dimensions, and of the individual through the family and the collective. Disregarding these contexts or knowing them partially has a negative impact on scientific progress, but the way of knowing these contextual elements differs from the way in which the empirical is known.

In the article “Stages of nursing’s political development: where we’ve been and where we ought to go” Cohen and colleagues (1996), starting from the initial question of how nursing developed as a political body, systematized a model in which they identified four stages of nursing policy development and recommended strategies for the implementation of the fourth and most complex stage of policy development: that of leadership in developing public health policies. The model design was based on a literature review on nurses’ political activism and analysis of the political involvement of nursing at the time, in the United States of America. It is a model contextualized in a space and time with particular characteristics, but which provides clues about the political behavior of nurses and nursing.

This theory describes 4 stages of political development. These stages start from the understanding that political action is important to provide leadership in the political arena. Specifically, stage 1 was conceptualized as the “buy in” phase, when an individual or group reactively recognizes the meaning of political activism. Stage 2 has been conceptualized as the “self-interest” phase, when individuals or groups react and use political expertise for their own interests. Stage 3 is the “political sophistication” phase, when individuals or groups are proactive about issues and use progressively more effective political activism. Stage 4, “leading the way” is the phase of proactive leadership on public health policy issues.Throughout the different stages of development, nurses learn to change the nature of their action, language, and alliance building. They are able, through their expertise and knowledge in the field of nursing, to influence and ultimately lead the change process and construct public health policies.

It is most relevant to underline also the work of Jaqueline Fawcett who built a conceptual model of nursing and health policy (Fawcett & Russell, 2001; Russell, G.; Fawcett, 2005). This model was designed to expand substantive knowledge of health policies from the perspective of the nursing discipline. The model has as its main philosophical basis the idea that nursing can and should seek to influence health policies: “nurses are active participants in the formulation, implementation and evaluation of public policies aimed at improving the health of individuals , families, groups, and communities.” (Fawcett, 2001, p.109).

It is important to understand what drives people to political participation and how they do it, especially the population of nurses,who have common professional interests. Nursing and nurses must develop systematized knowledge about politics, political systems, the influence of decision-making centers in the political system and uncover how we could and can, in certain historical and social circumstances, influence decision-making centers. The main question for me at this point is how nurses use their influence over the decision-making centers of the political system to improve not only the conditions of professional practice but also (as a result of the increase in our autonomy, training and working conditions) the health of populations?

Sources

Aristóteles. (2016). Política (trad. de António Amaral e Carlos Gomes) (2ª ed.). Lisboa: Nova Vega.

Carper, B. (1978). Fundamental Patterns of Knowing in Nursing. ANS. Advances in Nursing Science, 1(1), 13–24.

Chaffee, M., Mason, D., & Leavitt, J. (2007). Policy and Politics in Nursing and Health Care (5ª ed.). St Louis, MO: Saunders Elsevier.

Chinn, P L; Kagan, P; Smith, M. (2014). Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis. New York: Routledge.

Cohen, S.S, Mason, D. J., Kovner, C., Leavitt, J. K., Pulcini, J., & Sochalski, J. (1996). Stages of Nursing’s Political Development : Where We ’ ve Been and Where We Ought to Go. Nursing Outlook, (November/December 1996), 259–266.

Fawcett, J., & Russell, G. (2001). A Conceptual Model of Nursing and Health Policy. Policy, Politics, & Nursing Practice, 2(2), 108–116. http://doi.org/10.1177/152715440100200205

Frella, Ariane; Carraro, T. (2013). Contribuições de Florence Nightingale: uma revisão integrativa da literatura. Esc Anna Nery (Impr.), 17(3), 573–579.

Jacobs-Kramer, M. K., & Chinn, P. L. (1988). Perspectives on knowing: a model of nursing knowledge. Scholarly Inquiry for Nursing Practice, 2(2), 129–144.

Kagan, P. (2014). Power, empowerment, and change in nursing and health care. In K. S. Amen (Ed.), Quality and Safety for Transformational Nursing: Core Competencies (1ª ed., pp. 70–97). Pearson Editors.

Leininger, M. (1978). Political Nursing: Essential for Health Service and Educational Systems of tomorrow. Politics and Power.

Leininger, M. (1995). The Power of Caring: Issues and Strategies. In Anne Boykin (Ed.), Power, Politics, and Public Policy: a Matter of Caring (pp. 48–59). New York: National League for Nursing,U.S.

Leininger, M. (2002). Transcultural nursing: concepts, theories, research and practice (3ª ed.). Michigan: Macgraw-Hill.

Leininger, M. M. M. (2006). Culture Care Diversity and Universality (2ª ed.). Boston: Jones & Bartlett Pubs.

Meleis, A. I. (2018). Theoretical nursing : development and progress (6ª ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Pfettscher, S. (2014). Florence Nightingale: Modern Nursing. In M. Alligood (Ed.), Nursing theorists and their work (8ª ed.). Elsevier Inc.

Polifroni, E. C., & Welch, M. (1999). Perspectives on philosophy of science in nursing : an historical and contemporary anthology. Philadelphia: Lippincott.

Ray, M., & Turkel, M. (2012). A Transtheoretical Evolution of Caring Science within Complex Systems. International Journal for Human Caring, 16, 28–49.

Reichert, F. (2014). The prediction of political competencies by political action and political media consumption. Journal of Social Science Education, 13(4), 95–114. http://doi.org/10.2390/jsse-v13-i4-1340

Russell, G.; Fawcett, J. (2005). The Conceptual Model for Nursing and Health Policy Revisited. Policy, Politics, & Nursing Practice, 6(4), 319–326. http://doi.org/10.1177/1527154405283304

Turkel, Marian; Ray, M. (2003). A process model for policy analysis within the context of political caring. Journal for Human Caring, 7(3), 17–25.

Turkel, M. C. (2007). Dr. Marilyn Ray´s Theory of Bureaucratic Caring. International Journal of Human Caring, 11(4), 57–70.

Turkel, M. C., & Ray, M. A. (2000). Relational Complexity: A Theory of the Nurse-Patient Relationship Within an Economic Context. Nursing Science Quarterly, 13(4), 307–313. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/08943180022107843

Walter, R. R. (2017). Emancipatory nursing praxis: A theory of social justice in nursing. Advances in Nursing Science, 40(3), 225–243. http://doi.org/10.1097/ANS.0000000000000157

White, J. (1995). Patterns of knowing: Review, critique, and update. Advances in Nursing Science, 17(4), 73–86. http://doi.org/10.1097/00012272-199506000-0000

About Liliana Barroso de Sousa

I am a nurse in a long-term care unit in Portugal. I have been a nurse specialist in Mental Health since 2014, in the area of dementia. I am also a PhD Student in Nursing at the University of Lisbon, studying the political influence of nurses in the construction of health policies and health care.