Socio-Political awareness among undergraduate student nurses.
“For the remainder of this century, the most worthy goal that nurses can select is that of arousing their passion for a kind of political activism that will make a difference in their own lives and in the life of our society.”
(Peggy Chinn, 1984, quoted by Beall 2010).
Nurses have a history of engaging in health promotion and public health and both roles are reflected in the Nursing and Midwifery standards for education. However, current and future issues such as population ageing, new medical technologies, war, food security, health service access, equity and comprehensiveness and climate change, suggest that their current understanding need to develop to adapt to a very different future. Nurses need to quickly move beyond adopting individualistic and behaviour changing perspectives (Kemppainen, Tossavainen and Turunen 2012), to that of also adopting an ethico-socio-political awareness and analysis (Falk-Raphael 2006). This should be based on a wider understanding of what health and health promotion may mean.
Various nursing theorists have suggested or implied that politics and political awareness and knowledge is, or ought to be, a component of nursing knowledge (Chopoorian 1986, Stevens 1989, Albarran 1995, Cameron et al 1995, Chinn 2000), and of nursing advocacy (Philips 2012) and leadership (Antrobus 1998, Cunningham and Kitson 2000). Nancy Roper referred to the sociocultural, environmental and politico-economic factors influencing the Activities of Living, while also lamenting a lack of their application (Siviter 2002). Jill White (1995) developed Carper’s patterns of knowing to include the Socio-political domain; Jane Salvage (1985) argued that politics needs to be understood and acted upon and that nurses should ‘wake up and get out from under’. Celia Davies (1995) has written about the gendered nature of nursing and its ‘professional predicament’ and Michael Traynor (2013) has written a whole book on politics and the profession.
Other writers on the socio-political context include White (1985, 1986 and 1988), Lewenson (2000) and Falk Rafael (2006). Kath Melia (1984) illustrated the contextualised pressures on student nurses, while more recently Alexandra Hillman and colleagues (2013) has described how patient care can be compromised by the systems nurses work within. Tadd et al (2011) also outlined the context and its effects on dignity in care in acute hospitals. I have argued it is explicitly part of the sustainability agenda for nursing, while the social determinants/political determinants of health approach are predicated upon it. Other health concepts such as Barton and Grant’s (2006) health map, Lang and Rayner’s (2012) ecological public health domain and Ottersen et al’s (2014) focus on global governance for health centre it for health care delivery and outcomes. The inequalities in health literature, for example “Fair society Healthy Lives” (Marmot 2010) and Danny Dorling (2013, 2014), refer to health being a matter for social justice and fairness.
Some authors have highlighted the health policy role for nurses (Ennen 2001, Fyffe 2009) which although advocating for nurse involvement in public policy making, does so probably within accepted frames of reference devoid of critical concepts such as Foucault’s ‘governmentality’ or deeper analyses of for example, managerialism, neoliberalism and the ‘capitalist class-command dynamic’ (Scambler 2015). Cameron et al (1995) argued for post structuralism and a focus on subject positions and discourse as tools for analysis, which could be usefully employed by critically aware nurses.
In the education and curriculum development literature writers such as Paulo Freire (1970), Carl Rogers (1969, 1983) Stephen Sterling (2001), David Orr (1994) and Peter Scrimshaw (1983) suggest that teaching and learning should go beyond skills teaching in an instrumental fashion to address personal growth and social transformation. Romyn (2000) discusses ‘emancipatory pedagogy’ in nurse education which accords with aspects of ‘provocative pedagogy’ (Morrall 2009). The sociological literature, for example critical social theory, marxism and feminism of course, are wholly socio-political in nature. For nursing, each has also something to say about the interplay between health, illness, society and gender.
Undergraduate Nursing – the missing link
It is my contention that undergraduate nursing education is one in which politics is largely absent in nursing curricula (Byrd 2012) and fails to equip student nurses with tools of analysis that renders them blind to social and political systems that are often unfair, unjust and oppressive. It also fails to politically socialise them. It is a self marginalised education denuded of any critical importance and ignores the vast sociological literature on health and illness. Nurse educators themselves, beyond a few ‘individual enthusiasts’ (Fyffe 2009), might lack the requisite skills or concepts to engage. This may result in the lack of politics or health policy in nurse education (Carnegie and Kiger 2009). This is not to say nursing education, as it currently is, lacks importance as the requirement for clean, kind and compassionate care will be emphasized daily in seminars, lectures and tutorials.
This assertion might be supported if it can be shown that student nurses lack a critical understanding of the socio-political context in which they work. This is not to say however that student nurses are not political or are not interested in politics. Rather that their interest and understanding especially in relation to health (delivery, funding, inequalities, access, outcomes and determinants) may be lacking and only slightly better than their peer groups. Further, that any student nurse who is active, interested and knowledgeable is so despite not because of nursing education. I take it as self evident that this matters and not merely for the reason that it suits the capitalist executive and political power elites to have a huge number of health workers (600,000 registrants in the UK alone) ignorant, confused, uninterested and inactive in regards to the eco, social and political determinants of health. We have nurses schooled in the biomedical aspects of health delivery (or rather disease treatment), but rather less in what I would inelegantly call the EcoPoliticoPsychoSocial (EPPS) approach to health. Student nurses are introduced to a BioPsychoSocial (BPS) model to health however, the curriculum process and learning experiences may often dilute this emphasizing the bio at the expense of the Psycho-Social while ignoring the Ecological. The ‘BPS’ becomes ‘Bps’.
To test the hypothesis that student nurses lack a critical understanding of a socio-political approach to health, a survey of student nurses in two or three HEI in the UK could be undertaken. Mccullough (2012) undertook a survey on politics in NI in which 81% of students claimed ‘not much knowledge’ of politics and 60% claimed either ‘never’ or ‘less than once a week’ to follow politics in the media. Of course a caveat in this must be that politics in this context may mean ‘Party, Westminster/Stormont politics rather than political issues.
What is Politics?
Chafee et al (2012) suggested that politics can be defined simply as ‘the process of influencing the scarce allocation of resources’ (p5). The RCN’s Frontline First, while laudable, is also a very narrowly focused campaign which is about resource (staff) allocation. However, this does not go far enough as it fails to engage with more critical analyses of power and the legitimacy of the exercise of power, concerning itself with more relatively mundane issues of resource allocation within uncritically accepted frames of reference. Politics is much more than knowing the manifestos of political parties or the internal machinations at Westminster. Political action is much more than the 5 year placing of crosses on ballot papers. Engaging in politics requires at least a critical understanding of power. Tony Benn outlined questions to ask the powerful: We should know who has power, what power they have, where did they get it from, in whose interest do they wield it, to whom are they accountable and how do we get rid of them? This does not apply only to Westminster, but in every organisation including an NHS Trust. Socio-political awareness also addresses the wider determinants of health as outlined in the Social Determinants of Health literature and in such books as ‘The Energy Glut’ (Roberts and Edwards 2010) ‘Lethal but Legal’ (Freudenberg 2014), ‘The Spirit Level’ (Wilkinson and Pickett 2010), ‘Unequal Health’ (Dorling 2013) and ‘Hard Times’ (Clark and Heath 2014).
If Russell Brand’s youtube site is any guide, or the interest in Jeremy Corbyn’s bid for the Labour leadership in 2015, many people are very interested in politics, just not the dominant media fed variety of political talking heads, and representatives of mainstream political parties. If we widen the definition of politics to include social movements around health, climate change and human rights then according to Paul Hawken (2007) there is a global ‘Blessed Unrest’ involving millions of people, a global ‘environmental and social justice movement’ that does not often appear in the mainstream media.
Nurses are a disparate group politically; nurses are not to be treated as an homogenous group for political purposes. For example, the free market nurse think tank Nurses for Reform (NFR):
“….long argued that the NHS is an essentially Stalinist, nationalised abhorrence and that Britain can do much better without its so called ‘principles’ (Cave 2010), although whether this group actually has a huge number of nurses supporting it has been questioned (Liberal Conspiracy 2010). Nonetheless the point remains that nurses will probably vote for all parties, and none, at elections. To what degree nurses are part of the ‘blessed unrest’ is unknown, Mcculloghs small survey does not answer that question.
Public Health and Health Promotion
Both of these two concepts are multi faceted, and nurses will draw upon their own definitions. If nurses are to ‘empower and enable’ people to increase control over and improve their health then this will require not only education to change individual behavior, but also a deep critical analysis of power and vested interests that often put profit before people and that result in inequalities in health outcomes. Nurses will then have to decide what their personal sphere of influence may be and work towards change in those areas. For some this will mean working on a one to one basis only, for others it may even result in taking part in organized political structures, be it pressure group or a political party.
Albarran J (1995) Should nurses be politically aware? British Journal of Nursing , 4 (8). pp. 461-466.
Antrobus S (1998) Political Leadership in Nursing. Nursing Management 5(4): 26-28
Barton H and Grant M (2006) A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health . 126(6): 252-261.
Beall F (2010) The important role of nurses in political action http://www.thefreelibrary.com/The+important+role+of+nurses+in+political+action.-a0234309354
Brown, S. G. (1996) Incorporating political socialization theory into baccalaureate
nursing education. Nursing Outlook. 44, 120 – 123
Byrd, M.E., Costello, J., Gremel, K., Blanchette, M.S. and Malloy, T.E. (2012) Political Astuteness of Baccalaureate Nursing Students Following an Active Learning Experience in Health Policy. Public Health Nursing. 29 (5), pp433-443.
Cameron P, Willis K and Crack G (1995) Education for change in a postmodern world: redefining revolution. Nurse Education Today 15 (5):336-340
Carnegie, E. and Kiger, A. (2009) Being and doing politics: an outdated model or 21st century reality, Journal of Advanced Nursing, 65(9), pp1976-1984.
Carper B (1974) Fundamental Patterns of Knowing in Nursing Advances in Nursing Science.
Cave T (2010) Nurses for Reform. BMJ 340: c1371 doi: http://dx.doi.org/10.1136/bmj.c1371
Chaffee, M.W., Mason, D. J. and Leavitt, J.K. (2012) A Framework for Action in Policy and Politics. in Mason, D.J., Leavitt, J.K. and Chaffee, M.W. (eds) Policy and Politics in Nursing and Healthcare. (6th edn) St Louis. Elsevier Saunders.
Chinn P (2000) Looking into the crystal ball: positioning ourselves for the year 2000. Nursing Outlook. 39 (6): 251-256
Chopoorian T (1986) Reconceptualiszing the Environment, in Moccia P ed. New Approaches in theory development. New York National league for Nursing
Clark T and Heath A (2015) Hard Times Inequality, Recession, Aftermath Yale University Press New Haven
Davies C (1995) Gender and the professional predicament of Nursing. Open University Press. Buckingham
Davies, C. (2004) Political leadership and the politics of nursing. Journal of Nursing
Dorling D (2013) Unequal health. Polity Press
Dorling D (2014) Inequality and the 1%. Verso Press.
Ennen K (2001) Shaping the future of practice through political activity: how nurses can influence health care policy. American Association of Occupational Health Nurses Journal 49(12): 557-569
Falk-Rafael A (2006) Globalization and global health: toward nursing praxis in the global community. Advances in Nursing Science. 29, 1, 2-14.
Freire P (1970) Pedagogy of the Oppressed. Penguin, London
Freudenberg N (2014) Lethal but Legal. OuP New York
Fyffe T (2009) Nursing shaping and influencing health and social care policy. Journal of Nursing Management 17 (6):698-706
Hawken P (2007) Blessed Unrest How the Largest Movement In the World Came Into Being
and Why No One Saw it Coming. Viking Press New York
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. doi: 10.1111/1467-9566.12017 pp1-17
Kemppainen, Tossavainen and Turunen (2012) Nurses’ roles in health promotion practice: an integrative review. Health Promotion 28(4):490-501
Lang T and Rayner G (2012) Ecological public health: the 21st century’s big idea? British Medical Journal 345:e5466 doi 10.1136/bmj.e5466 (online) http://www.cieh.org/assets/0/72/998/1022/1064/92246/dd0cbc07-a918-458f-9a03-a8935b5a5b8a.pdf
Lewenson S (2000) Nurses in the political arena. The public face of nursing. Springer. New York.
Liberal conspiracy (2010) Where are all the ‘nurses’ for reform? available at http://liberalconspiracy.org/2010/01/25/where-are-all-the-nurses-for-reform/ accessed 1st May 2015.
Mccullough S An exploration of political awareness among a cohort of all field students in one University in Northern Ireland. Presentation at Queens University Belfast http://www.rcn.org.uk/__data/assets/pdf_file/0007/615958/4.3.1-McCullough.pdf
Melia K. 1984 Student nurses’ construction of occupational socialisation. Sociology of Health and Illness 6 (2): 132-151
Morrall P (2009) Provocation: reviving thinking in universities. In: Warne T and McAndrew
S (editors) Creative approaches in health and social care education and practice: Knowing me,
understanding you. London: Palgrave, Chapter 1
Orr, D. (1994) Earth in Mind. On Education, Environment and The Human Prospect. Island press. Washington
Ottersen O, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk j, Fukuda-Parr S, Gawanas B, Giacaman R, Gyapong J, Leaning J, Marmot M, McNeill D, Mongella G, Moyo N, Mogedal S, Ntsaluba A, Ooms G, Bjertness E, Lie A, Moon S, Roalkvam S, Sandberg K and Scheel I. (2014) The Lancet-University of Oslo Commission on Global Governance for Health. The political origins of health inequity: prospects for change. The Lancet 383:630-667 February
Phillips C (2012) Nurses becoming political advocates Journal of Emergency Nursing 38 95) 470-471
Roberts, I and Edwards, P (2010) The Energy Glut. London: Zed Book
Rogers, C. (1969, 1983) Freedom to learn, revised as freedom to learn for the 80’s. Colombus. London.
Salvage J (1985) The Politics of Nursing. Heineman. London
Scambler G (2015) Taking Social Class seriously. Available at http://www.grahamscambler.com/taking-social-class-seriously/ accessed 1st May 2015.
Scambler G (2012) The Greedy Bastards Hypothesis. Available at https://grahamscambler.wordpress.com/2012/11/04/gbh-greedy-bastards-and-health-inequalities/
Siviter B (2002) Personal interview of Nancy Roper at RCN Congress, Association of Nursing Students, reported in Fall 2002 edition “The ANSwer” (RCN)
Sterling, S. (2001) Sustainable Education – Revisioning Learning and Change, Schumacher Briefings 6.Green Books, Dartington.
Scrimshaw, P. (1983) ‘Educational Ideologies’, Unit 2, E 204, Purpose and planning in curriculum’, Milton Keynes, Open University Press.
Stevens P (1989) A critical reconstruction of environment in nursing: implications for methodology. Advances in Nursing Science. 11(4):56-68
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor M (2013) Nursing in context: Policy, politics profession. Palgrave Macmillan Basingstoke.
White J (1995) Patterns of knowing: review, critique and update, Advances in Nursing Science 17(4):73-86
White R (1985) Political issues in Nursing Volume 1 Wiley Chichester
White R (1986) Political issues in Nursing Volume 2 Wiley Chichester
White R (1988) Political issues in Nursing Volume 3 Wiley Chichester
Wilkinson, R and Pickett, K (2010) The Spirit Level: Why More Equal Societies Always Do Better. Harmondsworth: Penguin