The Transition to Professional Practice. The reality for the Newly Qualified Nurse (NQN).

Photo by Daan Stevens on Unsplash

 

The current context of nursing is complex. The Health and Social Care Act (2012), Deficit Reduction targets (‘Austerity’), Brexit, the NHS funding gap and Trust deficits, lack of integration of health and social care, ‘safe’ staffing levels, skill mix, post Francis fall out, and for the NQN: preceptorship and managerial support, competence worries and occupational socialization. The NQN also has to consider ‘patient opinion’, the 6Cs, revalidation and the new nursing framework. These latter three may be passing fads, but it is too early to say.

 

Philip Darbyshire (2017) writes on the perennial issues faced in health care delivery that is also the context for the NQN:   http://onlinelibrary.wiley.com/doi/10.1002/nop2.80/epdf

 

 

  1. Staff working under constant pressure (notwithstanding substantial increases in the number of clinical staff in recent years) in the face of growing demand from an ageing population with complex needs
  2. Difficulties for hospital staff in communicating with GPs about patients who are admitted to hospital, including knowing who patients’ GPs are
  3. Problems in communication within the hospital between acute medical staff and A&E staff, as well as between different specialist teams
  4. Difficulties in communicating with staff in other hospitals when patients are transferred
  5. Delays in ordering and receiving the results of diagnostic tests, which in turn lead to delays in treatment and increase in the time patients spend in hospital
  6. Challenges in teamworking, for example, on ward rounds when consultants are sometimes not accompanied by trainees and nurses
  7. Information systems that do not link data about patients held in primary and secondary care, and that are often slow in use
  8. Patients having to repeat their histories (where they are able to) at different stages in their treatment
  9. Care being delivered inefficiently and often ineffectively because of the amount of re-work required by the above
  10. Old buildings and cramped layouts that do not allow privacy and sometimes dignity for patients, or space for staff to work without interruption
  11. Poorly organized paperwork and documents
  12. Inefficient organization of supplies and workflows on hospital wards

 

Linking these together is the NQNs ability to exercise personal agency within these structures.

A small part of the literature on the experiences of NQNs:

Horsburgh and Ross (2013) stated that we know that inadequate staffing levels, eclectic support and concerns over competence provide the challenging context for NQNs.

In their study the NQNs stated:

 

“…flung in at the deep end”

 

“…sink or swim”

 

Colleagues were perceived as “ingrained in the woodwork” and resistant to change, even of a minor nature. That there was:

 

“Institutional negativity”

 

They suggest undergraduate nursing programmes should prepare students for the reality of delivering care despite competing commitments.

 

Whitehead et al (2013) undertook a systematic review of support for newly qualified nurses in the UK. This was done in 2011. Three themes were identified:

 

  • Managerial Support Framework.
  • Recruitment and Retention.
  • Reflection and critical thinking in action.

 

They conclude that there is strong evidence that NQNs benefit from supported and structured preceptorship which then improves retention. This could have been hypothesized beforehand. The three themes indicate contextual issues.

 

 

 

Kelly (2014) commenting on Horsburgh and Ross argues:

 

“However, the need for individual nurses instinctively to take personal responsibility for quality healthcare delivery, to break through cynicism and malaise and to effect change requires individual leadership attributes described by Friedman et al. (2003) as resilience which includes self-mastery, bounce-back-ability or ability to handle stress together with resourcefulness, self-belief and motivation. These are all traits which can and should be nurtured through supportive clinical environments but to a large degree should be innate in the next generation of nurses and cannot always be reliant on others to direct and instruct on these matters”.

(my emphasis)

 

 

 

 

 

Is the emphasis on ‘personal responsibility/resilience’ placing undue burdens on new nursing staff who have to exercise responsibility without full control?

 

 

Horsburgh D and Ross J (2013) Care and Compassion. The experience of newly qualified staff nurses. Journal of Clinical Nursing. 22(7-8):1124-1132

 

Whitehead B, Owen P, Holmes D, Beddingham E, Simmons M, Henshaw L, Barton M and Walker C. (2013) Supporting newly qualified nurses in the K: A systematic literature review. Nurse Education Today. 33(4):370-377

There is a critical need for Socio-Political awareness among undergraduate student nurses.

There is a need for Critical 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).

When I read this I almost literally fist pumped (I’m British, so we don’t actually do that – a bit too flamboyant!). I’m a lecturer in the UK teaching mainly from a public health/sociological perspective. I’ve noted that various writers have suggested or implied that politics and political awareness and knowledge is, or ought to be, a component of nursing knowledge and advocacy, if a rather neglected one. Nancy Roper referred to it as one of the 5 factors influencing the Activities of Living, while also lamenting its lack of application. Jill White developed Barbara Carper’s patterns of knowing to include it, Jane Salvage argued that it needs to be understood and acted upon. Celia Davies had written about the gendered nature of nursing and its ‘professional predicament’ and Micheal Traynor has written a whole book on politics and the profession.

Other writers include Adeline Falk Rafael, and Kath Melia long ago illustrated the contextualised pressures on student nurses while more recently Alexandra Hillman and colleagues have described how patient care can be compromised by the systems nurses work within. Alec Grant suggests politics is implicit in some qualitative research methods such as autoethnography. 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 health map, Lang and Rayner’s ecological public health domain and Ottersen et al’s 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” refer to health being a matter for social justice and fairness. Some authors have highlighted the health policy role for nurses, 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’.

In the education and curriculum development literature writers such as Stephen Sterling and David Orr suggest that teaching and learning should go beyond skills teaching in an instrumental fashion to address personal growth and social transformation. Others discuss ‘emancipatory pedagogy’ in nurse education which accords with aspects of ‘provocative pedagogy’ as advocated by Peter Morrall. 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.

It is my contention that undergraduate nursing education is one in which politics is largely absent in nursing curricula 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 largely ignores the vast sociological literature on health and illness. Nurse educators themselves, beyond a few ‘individual enthusiasts’ lack the requisite skills or concepts to engage, resulting in the lack of politics or health policy in nurse education. This is not to say nursing education, as it currently is, lacks importance as the requirement for clean, kind and compassionate care will be emphasised 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 (power, social justice, indigenous rights, post-colonialism, 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 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. BPS becomes Bps.

Politics can be defined simply as ‘the process of influencing the scarce allocation of resources’. The Royal College of Nursing’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 ‘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/Washington. 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, a UK Labour party stalwart now no longer with us, 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 and the Whitehouse, but in every organisation including a hospital.

To test the hypothesis that student nurses lack a critical understanding of an EPPS approach to health, a survey of student nurses in two or three HEIs in the UK could be undertaken. There is a handy online tool called ‘political compass’ (https://www.politicalcompass.org) which is a self test indicating where one sits across two axes: Authoritarian left/right and Libertarian left/right.

Siobhan Mccullough undertook a survey in Northern Ireland in which 81% of nursing students claimed ‘not much knowledge’ of politics and 60% claimed either never or less than once 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. Bear in mind that Northern Ireland had been a highly politicised society suffering the ‘troubles’ since the 1960’s in which the Irish Republican Army fought a guerrilla/terrorist/resistance war against the British.

If Russell Brand’s  website, The Trews, is any guide, many people are very interested in politics, just not the dominant media fed variety of political talking heads, and the 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 there is a global ‘Blessed Unrest’ involving millions of people, a global ‘environmental and social justice movement’ that does not appear in the mainstream media.

This will be 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“.

Whether this group actually has a huge number of nurses supporting it, has been questioned. Nonetheless the point remains that nurses probably voted for all parties, and none, at the last 2015 election in the UK. I was recently informed by a colleague that while in the United States he visited a Nursing Faculty and discovered that many nurses in the Faculty voted for Donald Trump. If my memory is correct the figure was over 50%. He put it down to ‘localism’ and ‘regionalism’ – a distaste for the remote Washington elite. That, I can understand.

The close vote for Brexit in the UK is a paradox, given the reliance by the NHS on EU citizens for the day to day delivery of health care. We have no idea how many nurses voted leave, all we do know is that the leave voter is more likely to be older (55+), living in rural environments and in the smaller towns and cities outside the major metropolitan cities such as London, and white. The leave vote crossed party lines. They were affluent Eurosceptics, the older working class and a smaller group of disadvantaged anti-immigration voters.

The current context of rising ethno-nationalism, if not fascism, isolationism, nativism and tribalism within a world threatened by climate change requires an urgent response by everyone. We cannot be anything other than political. Stating ‘neutrality’ is still a political position. Disinterest, disengagement and disillusionment are political positions by default. However they are not viable positions for student nurses to take given the social, ecological and commercial determinants of health.

To what degree nurses are part of the Paul Hawken’s ‘blessed unrest’ is unknown, Siobhan Mcculloghs small survey does not answer that question. Perhaps we should start asking?

Manifesto

 

This manifesto calls for a social movement for political activism by nurses and other health professionals, to address inequalities in health and the social inequalities that highly structure, but do not determine, health outcomes. This action can operate at individual, clinical, organisational, national and international level.

Our aim is to respond to threats to health and socialised health service delivery from corporate, financial and political interests.

Our vision is for decreasing social and health inequalities in which the social gradient is greatly diminished.

Our goal is to create a networked social movement involving political and civic activism to bring critical understanding and action into the public sphere.

See:

A Manifesto for Action Nursing

The More Beautiful World Our Hearts Know is Possible. Part 1

The More Beautiful World Our Hearts Know is Possible.   Charles Eisenstein (2013) North Atlantic Books. Berkeley.

 

This book should be required reading for all. Student nurses especially interested in health should read and discuss the implications. It will appeal to a wide range of people and is written in a very accessible style. This is not a book that would interest Donald Trump, Boris Johnson or the ‘Masters of the financial Universe.’ It would be too ‘fluffy’ for hard line leftists mired in economic determinism. It draws upon a re-emerging world view: a ‘systems view’, of life central to ecological and sustainability discourse. It has a long history; one crushed by the forces of colonialism, genocide, imperialism, extractive and other form of capitalism, patriarchy, Abrahamic religion and scientism. Its roots are to be found in the three social movements for social justice, indigenous rights and ecology.

A ‘Systems view of Life’ challenges the fragmentary, mechanistic, individualist view of life. Charles Eisenstein thinks, along with writers such as Fritjof Capra (the ‘rising culture’) and Paul Hawken (the ‘blessed unrest’) that we are in transition from one to the other. Stephen Sterling suggests that the sustainability transition cannot be made without adopting a ‘systems view’. Nurse education and practice has not fully caught up with the implications of such thinking.

Much of nurse education is founded on the old view; and thus we learn to reduce the human body to its constitutive parts (reductionism), that the most important knowledge is anatomy, physiology, biology, that health is about disease processes, specific aetiology, cure (biomedicine), that the focus of diagnosis is the individual apart from their social and ecological context, and we can understand illness and health in a cause and effect manner.  There are of course exceptions to this overly simplistic description yet it is probably the case that when in clinical practice the focus is on acquiring skills, knowledge and attitudes to undertake a certain role. This is done with the implicit acceptance of a fragmentary, mechanistic worldview. Up to a point that is as it should be. However, if nurses in their personal as well as their professional lives are to join in creating that transition then they need to be critically reflexive (challenging ourselves, our own thoughts, our own sense of self) and critically reflective:

In ‘An Invitation to Social Construction’ (2009) Kenneth Gergen introduces this concept with the following explanation:

‘Critical reflectivity is the attempt to place one’s premises into question, to suspend the ‘obvious’, to listen to alternative framings of reality and to grapple with the comparative outcomes of multiple standpoints…this means an unrelenting concern with the blinding potential of the ‘taken for granted’…we must be prepared to doubt everything we have accepted as real, true, right, necessary or essential’.

Eisenstein poses some key questions to assist with this process (p4):

  1. Who am I?
  2. Why do things happen?
  3. What is the purpose of life?
  4. What is human nature?
  5. What is sacred?
  6. Who are we as people?
  7. Where did we come from and where are we going?

 

These questions may come across as a bit ‘new agey’ but are of course questions scientists and philosophers have asked. They are not questions often found explicitly in nurse education.

The following answers to those questions have been the dominant discourse leading to our fragmented, reductionist and dualist paradigm. Eisenstein calls this the ‘Story of the World’, while Capra and Luisi (2014) outline its origins in western philosophy, locating it with the giants of science and philosophy: Newton, Descartes, Hobbes, Locke and Mill to name just a few. A passing note: they are all white men. Much of today’s science, including some medical practice, and philosophy has moved on, but has not yet reached into our emerging worldview as practical activity in the social, economic and political worlds dominated still by the neoliberal imaginary in the Anglo-American world view, and by other various forms of materialist capitalism elsewhere (e.g. Russia, China, India).

 

  1. Who are you? The liberal humanist self of the sovereign individual; a separate individual among other separate individuals in a material universe that is separate from you. There are clear boundaries between us and the material world. You are ‘skin encapsulated ego’. You are a ‘flesh robot’ programmed by genes to maximise your reproductive self- interest. Your mind is a separate ‘bubble of psychology’, separate from other minds and materiality. A ‘soul encased in flesh’ or a mass of particles operating according to the laws of physics. A separate biological, anatomical, physiological you.
  2. Why do things happen? The impersonal forces of physics (gravity, light, mass) act upon all particles including you. All phenomena are a result of mathematically determined interactions. There is no purpose, intelligence or design behind it all. There are only impersonal forces and masses. This is life, the sum of the interaction of force and mass.
  3. What is the purpose of life? There is only cause. The universe is blind and dead, inanimate and uncaring about your existence. There is nothing that can ‘care’. Life exists and reproduces itself. Thought is only electromechanical impulses; love is a ’hormonal cascade’. Life is based on the self interest of the reproducing unit, its self interest is in conflict with the self interest of other units, everything that is not self is either indifferent or hostile. Dog eat dog, survival of the fittest.
  4. What is human nature? As we live in a hostile universe of competing individuals and impersonal forces, we have to protect ourselves and this means exercising control. Anything that assists with control: money, power, status, security, information, is valuable and must be acquired. We are at heart ruthless maximisers of self interest. Economically we are utility maximising rational actors, ‘homo economicus’.
  5. What is sacred? As the ruthless pursuit of self interest is anti-social we must aspire to ‘higher things’. This means controlling the desires of the flesh, engaging in self denial and self discipline. We must ‘ascend’ into the spiritual realm if religious, or into the realm of reason, principles and ethics, if secular.
  6. Who are we as people? Anthropocentric: The apex of evolution, the highest form of life, a special kind of animal. We are unique created in the image of God (if religious) or unique in having a rational mind (if scientific). We alone possess consciousness, we alone can design the world.
  7. Where have we come from and where are we going? We started out as naked, ignorant animals barely able to survive in a hostile environment; lives were ‘nasty, brutish and short’. Our brains enabled the transition to be the lords and possessors of nature, having ‘dominion over all we survey’, our destiny is to free ourselves from work, from disease, even from death itself.

 

These answers are the ‘old story’ that are still somehow the, albeit torn, fabric of much of our reality. The answers are changing, the old is emerging into the new but the transition is not complete. The new story has no coherent programme, no powerful political party, no country, no organising principles. It does have a movement however. This movement is not to be found in the mass media, filled as it is with mass culture. The movement is not to be found in the palaces, the parliaments or in presidential residences. The movement does not have a giant multi-national corporation, trade agreement or is backed by a military-industrial complex. It faces the forces of the old story, of capital flows, of religious fundamentalism and of scientism. It is not an ‘it’.

 

As you read this, consider your own world view and answer for yourself the above questions. In addition reflect on what this means for nursing practice. To what degree are we still in the old story in actual practice? Put aside the espoused theory of ‘holistic practice’ and look for what the ‘theory in action’ is. Are there clinical areas which heavily depend on individualising, separating, fragmenting, reducing human experiences to biomedical and scientific processes? Are you able to discern what assumptions and values underpin the daily work?

 

Finally, consider the issue of care and support for older people: what assumptions, values and interests are at play here? Have we separated the old from the rest of us? Do we feel their pain? Have we created a system that integrates and values their existence? What priorities drive the whole system of care? A clue is that in the UK’s parliament, the needs of older people for care and support is seen as a huge ‘commercial opportunity’.

 

 

 

How responsible am I for my health 2

How responsible am I for my health?

 

The answer to that question from the dominant discourse is an overwhelming “very”.

This response sits alongside more scholarly understandings of the social determinants of health.  This ‘upstream’ understanding is open to ‘Lifestyle Drift’ , ‘downstream’, responses to health. Lifestyle Drift is:

“the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors” (Popay et al 2010)

McKenzie et al (2016) argue:

“Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances)”.

Nurses might understand the concept of the social gradient in health inequalities but drift into advocating lifestyle changes for the individual, centring around smoking, diet, and exercise messages.

So why is this happening? Why resort to lifestyle approaches to health when we know health is largely socially and politically determined?

 

One answer is that lifestyle answers fit within the neoliberal social imaginary which individualises health and social problems and seeks market solutions to those problems. Neoliberalism is a doctrine well known to many scholars and academics but is hardly mentioned in popular discourse.  To understand responses to health inequalities and poverty , we need to understand the tenets of neoliberalism underpinning much of current thinking:

 

  • Neoliberalism sees competition as the defining characteristic of human relations. Therefore competition between service providers should be introduced into the NHS.
  • It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. So patients can and should choose between hospitals and GP practices as consumers of health care using their purchasing power (not yet realised in the NHS). This way, poor service providers should go out of business.
  • It maintains that “the market” delivers benefits that could never be achieved by planning. Therefore NHS = bad, US private health insurance = good; BBC = bad,  SKY/Fox = good;  British Rail = bad, Great Western/Virgin = good; Royal Mail (state owned) = bad, Royal Mail (privately owned) = good.
  • Attempts to limit competition are treated as inimical to liberty. Thus socialised NHS service provision must be broken up to allow freedom in the market. The BBC must be sold off because it is unfair competition for Sky.
  • Tax and regulation should be minimised, thus the use of offshore tax havens, reduction in top rate of tax, mistrust of EU environmental standards and hatred of health and safety regulations.
  • Public services should be privatised. The Health and Social Care Act 2012 facilitates this, there may well be more to come for the NHS.
  • The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Unison, RCN, BMA etc, must have their power curtailed. The Junior doctors cannot be allowed to win or else it will be a victory for organised labour.
  • Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Those at the bottom require incentives to better themselves, therefore benefits need cutting, those in the middle will benefit from wealth creation.
  • Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve. The arguments from books such as ‘The Spirit Level’ are therefore irrelevant. If there is a social gradient in health then this is the natural outcome of people’s decisions and choices and any attempt to change this invokes  ‘moral hazard’ arguments; that is if people know they have a safety net (someone else takes the risk) they will not try to avoid poor choices.

(Monbiot 2016 The Zombie Doctrine)

 

 

 

Tory Rituals on poverty:

 

 

·         Blame the individual for their illness and poverty.

·         Benefits cause dependency , repeat this ad nauseam.

·         Deny any political responsibility for ill health, emphasise culture as causative.

·         Divide population into:  skivers v strivers, deserving v undeserving poor, low achievers v high achievers.

·         Deny the ‘social’ exists, there are only individuals

·         Privilege wealth through tax breaks and preferential treatment.

·         Deny one’s own privilege as a white affluent male.

 

 

These attitudes underpin the ideology of neoliberalism.

 

For a statement about what the Conservative Party should be about see:Direct Democracy – an agenda for a new model party’ (2005) especially the chapter on health:

 

 

“The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago”.

 

 

 

All of this results in the politics of blame and shifting responsibility for health fully onto individuals.

If material health assets are paramount, poverty and our response to it is a foundation for understanding health in society. Poverty can be defined as 60% of the median income or using the ‘consensual method’  it is “enforced lack of necessities determined by public opinion”.

However, the UK government’s position is that poverty is not caused by lack of income. Based on Charles Murray’s idea of the ‘Culture of Poverty’, poverty is a result of individual deficits, as Kitty Jones writes:

“the poor have earned their position in society, the poor deserve to be poor because this is a reflection of their lack of qualities, poor character and level of abilities”.

Kitty Jones has written clearly on this issue in 3 blogs, which can be found here.

The alternative view, expressed in for example the ‘Greedy Bastards Hypothesis’ is that poverty, and health inequalities, is caused by the rich, often through unintended consequences of their actions but also through design. It results from structural socio economic conditions that neoliberal governments encourage: for example, low wages, withdrawal of benefit provision and the use of offshore tax regimes. Osborne’s ‘living wage’ is a cynical political manoeuvre designed to woo middling swing voters rather than to address structural economic issues such as under and unemployment , lack of investment in a green economy, deficits in the housing stock and affordability and a zero hours, self employed precarious job structure.

 

Nurses offering health advice, are not immune to this dominant discourse. It suffuses health advice on such sites as NHS choices and is supported by health campaigns which focus on changing individual habits. Action on social inequalities as root causes for ill health sits within specialised public health literature, for example ‘Fair Society,  Healthy Lives’, and unless nurses are exposed to an alternative perspective they will naturally draw upon dominant explanations for health inequalities. These are often either biologically/hereditarian explanations* or a ‘moral underclass discourse’ (Ruth Levitas) or a mix of the two. The politics of neoliberalism encourages the latter perspective.

 

 

Benny Goodman 2016

 

*See Chapter 4 in Psychology and Sociology in Nursing  Goodman 2015 for explanations.

Watch Richard Wilkinson discuss inequalities at a TED talk.

https://www.facebook.com/groups/Sociologyhealthnursing/

 

 

 

 

 

 

A manifesto for Action Nursing

A manifesto for Action Nursing

(Acknowledgement: Many thanks to Graham Scambler for his work on action sociology which inspired this manifesto).

“NOTICE: this is the author’s version of a work that has been sent for publication in Social Theory and Health.  Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may be made to this work since it was submitted for publication.

 

This manifesto calls for a social movement for political activism by nurses and other health professionals, to address inequalities in health and the social inequalities that highly structure, but do not determine, health outcomes. This action can operate at individual, clinical, organisational, national and international level.

 

Our aim is to respond to threats to health and socialised health service delivery from corporate, financial and political interests.

 

Our vision is for decreasing social and health inequalities in which the social gradient is greatly diminished.

 

Our goal is to create a networked social movement involving political and civic activism to bring critical understanding and action into the public sphere.

 

As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care, nurses must ally themselves with the progressive forces which seek to redress the balance of power of the ‘Greedy Bastards’. To paraphrase Graham Scambler, it is the largely unintended consequences of the actions of the ‘Greedy Bastards’ which results in gross social inequalities and inequalities in health. Action Nursing, alongside an ‘Action Sociology’, wishes to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from understanding care as vital, as central, to our ‘species being’ and is not mere adjunct, to be ignored within the private (female) domain.

As many governments embrace austerity policies within a neoliberal political economy, capital accumulation takes on various anti-democratic forms unaccountable to the people engaged in what Marcuse (1964) called ‘the pacification of the struggle for existence’.  The provision of nursing may be seen as a cost and not a benefit to those who decide where the investments should be made. Capital accumulation practices in health care delivery, especially in the care of older people and those with mental health issues, often results in absent or stretched services, or hiring under educated and poorly trained staff who too often lack supervision and development and who work in high patient to staff ratios. It also seeks private insurance based schemes and prefers services which can return profits. Care givers also work in the private domain, the informal sector, providing vital support to the wider business of capital accumulation but with very little or no recognition or return for such efforts. This ideology is maintained by appeals to the moral character of such work, often locating it firmly within kin networks as a ‘reciprocal gift’ that would be sullied by any suggestions of a cash nexus.

Nurse educators, clinicians and students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, or disdain apart from those engaged in teaching the social sciences in nursing. Nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. We need to argue for the social value of care and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.

Intrinsic to the nursing project is a concern for the health of individuals, communities and populations but in any point in history nurses will find themselves confronting ideologies; these are erroneous worldviews or theories that justify, sanction or provide cover for financial, business or political interests. Nursing’s ethics of care should include opposing forces that suppress truths about the societies we inhabit.

Nursing care in an often uncaring society should necessarily be oriented to justice and solidarity. It should be active not passive and should exist as a form of intervention against ‘distorted communication’ that interpellates nursing and nurses into subservient subject positions.  This has never been developed fully in Nursing theory because the discipline has been focused on other laudable aims. The result is a large number of workers in health services have no analytical tools or critical thought in which to contextualise and critique their experiences with vulnerable people. Critical theoretical concepts, such as ‘governmentality’ or ‘praxis’ or ‘frontiers of control’ ‘or ‘critical reflexivity’, would be sadly be alien to most nurses.

Action Nursing therefore contests the (often biomedical) ‘taming’ of nursing especially in the post-1970s neo-liberal era, including the shying away from arguing about contentious or ‘risky’ issues. Witness the uncritical passivity with which nurses in the UK have accepted ‘values based recruitment’, the ‘6Cs’ and ‘revalidation’ as panaceas to the issues of the quality of care; witness as well the lack of action regarding the structural conditions of the NHS following the Health and Social Care Act.

 

An Action Nursing cannot stand on the sidelines as a passive recipient of the decisions made by other powerful actors. It has to dwell on exploitation and oppression that result in inequalities in health for the population and stress, burnout and compassion fatigue for nursing staff and other care givers in their homes. Action Nursing should engage in the Marcusian ‘Great Refusal; it stands against the actions of the wealthy and powerful and actions whose consequences include the social gradient seen in the mass of data on health inequalities and evidenced in people’s lives in such works as ‘The Life Project’ (Pearson 2016).

 

This manifesto also allies itself with the manifesto ‘from Public to Planetary Health’. This is the voice of health professionals who together with empowered communities could confront entrenched interests and forces that endanger our future. This could be a powerful ‘social movement from below’ based on collective action at all levels to create better health outcomes, protect our futures and support sustainable human development.

Marcuse H (1964) One Dimensional Man. Routledge. London.

Pearson H (2016) The Life Project. Penguin. Allen Lane. London.

The missing two C’s – commodity and critique

http://tinyurl.com/the-missingtwoCs   This is the link to the published article in the Journal of Research in Nursing.

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses  (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist context that characterise many healthcare and other public sector organisations. The implications of this analysis for health care policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies which may include patient groups, to put care in all its guises and consequences central to the political agenda.

 

Developing the Concept of Sustainability in Nursing

“NOTICE: this is the author’s version of a work that has been submitted for publication in Nursing Philopsohy. If accepted, changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication.

 

Developing the concept of sustainability in nursing.

 

Abstract

 

Sustainability, and the related concept of climate change, is an emerging domain within nursing and nurse education.  Climate change has been posited as a serious global health threat requiring action by health professionals and action at international level. Anåker & Elf undertook a concept analysis of sustainability in nursing based on Walker and Avant’s framework. Their main conclusions seem to be that while defining attributes and cases can be established, there is not enough research into sustainability in the nursing literature. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing and grey literature and, for example, the literature in the developing web based ‘paraversity’. Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability and its suggested links with social and health inequalities and the dynamics underpinning unsustainable neoliberalist political economy. This understanding is based on the social and political determinants of health approach  and the emerging domain of planetary health.  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice.


 

Introduction

 

Sustainability, and the related concept climate change, is an emerging domain within nursing (Adlong & Dietsch, 2015; Allen, 2015; Aronsson, 2013; Goodman, 2011; Hunt, 2006; Polivka, Chaudry & Mac Crawford, 2012; Sattler, 2011) and nursing education (Goodman, 2008; Goodman, 2011; Goodman & East, 2013; Goodman & Richardson, 2009; Johnston et al., 2005; Richardson et al., 2013). Climate change has been posited as a serious health threat (Costello, Grant & Horton, 2008; IPCC, 2014; McMichael, Montgomery & Costello, 2012)  requiring action by health professionals (Costello et al., 2011; Gulland, 2008; Harding, 2014; Patton, 2008; Reale, 2009; Thomas, 2014) and action at international level (Durban Declaration on Climate and Health, 2011; WHO (2016) . The status of climate change as health threat has however been contested (Goklany, 2009a; Goklany, 2009b; Goklany, 2012; Goodman, 2014), but it remains an important determinant of health (Barton & Grant, 2006; Griffiths, 2009). In this context, Anåker & Elf (2014) undertook a concept analysis (Walker & Avant, 1982)  of sustainability in nursing. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing literature, to address the socio-political context in more depth. This should include going beyond accepted peer reviewed nursing journals and include literature such as that written by Wendell Berry (Berry, 1995) who writes eloquently on human health and our relationship to the natural environment.  There is also a growing body of work online and of an academic standard to qualify for what might be called the ‘Paraversity’ (Goodman, 2015a; Rolfe, 2013). Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability. There is a need to link social and health inequalities (Dorling, 2013; Marmot, 2015) and the dynamics underpinning unsustainable neoliberalist political economy (Harvey, 2005; Harvey, 2014; Sayer, 2015) with the concept of sustainability. Climate change is just one aspect, albeit a very important aspect, of that linkage. This understanding is based on the social (Davidson, 2015; Raphael, 2004; WHO, 2013) political (Ottersen, Frenk & Horton, 2011) and ecological (Goodman, 2014; Goodman, 2015b; Lang & Rayner, 2012; Lang & Rayner, 2015; Rayner & Lang, 2012) determinants of health (Barton & Grant, 2006).  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice. Before addressing the definition of sustainability in nursing, the socio-political ‘pattern of knowing’ will be outlined to form the justification for the ensuing discussion.

 

The fifth ‘Pattern of knowing’ in Nursing

Jill White (White, 1995) added a fifth pattern of knowing in nursing to Barbara Carper’s four (Carper, 1978): the ‘Socio-Political’. White argued the other four patterns provided answers to the ‘who, how and the what’ of nursing practice but not the ‘wherein’, the context. This, White argued, is the pattern of knowing essential to an understanding of all the other four. Socio-political knowing that is gained from a fuller understanding of the ‘sustainability literature’, might lift the ‘gaze’ from introspective nurse patient relationships at the bedside and requires the situating of that relationship within the wider socio-political context. This may result in challenging the taken for granted assumptions about practice, health, the profession and wider health policy. To that could be added the raising of questions about political economy and engaging in philosophical enquiry about such concepts such as ‘non duality’ (Loy, 1988), a concept Wendell Berry implies in his essay ‘health is membership’ (Berry, 1995).

White quoted Chopoorian who suggested:  “nursing ideas lack an archaeology of the social, political and economic worlds that influence both client states and nursing roles’ (White 1995 p84). This ‘archaeology of ideas’ still seems relatively poorly uncovered. Davies argued that ‘some of our concepts are missing’ in a critique of the Sociology of Health and Illness (Davies, 2003).  By that is meant that there had been a lack of a ‘sociology’ of organizations in the sociology of health and illness, a sociology which is able to reveal concepts such as discourses of managerialism (Gilbert, 2005; Traynor, 1996; Traynor, 1999; Traynor, Boland & Buus, 2010), or to reveal patterns of power and accountability for policy and its consequences (Freudenberg, 2014; Scambler, 2012; Schrecker & Bambra, 2015). Davies argued that

“sociology needed to take seriously the politics of NHS modernisation” (p183)

It is suggested here that many nurses also don’t have such a set of critical concepts to give them a more critical discourse upon which to base critical action or ‘praxis’ (Cox & Nilsen, 2014). There are a few papers addressing political activism in nursing, providing critical theories and concepts (Antrobus, Masterson & Bailey, 2004; Hewison, 1994; Phillips, 2012; Racine, 2009; Shariff, 2014) and other papers which discuss politics and nursing (Davies, 2004; Masterson & Maslin-Prothero, 1999; Salmon, 2012; Traynor, 2013).  These works suggest an interest in the interplay of the socio-political context and nursing practice and provide some evidence of relevance of this ‘pattern of knowing’.  White argued that nurses must “explore and expose alternative constructions of health and health care, find means of enabling all concerned to have a voice in care provision and develop processes of shared governance for the future” (p85). Exploring sustainability, climate change and health assists in that work. Indeed a focus on global governance for health in the context of climate change and environmental challenges is a key theme of recent reports  (Ottersen, Dasgupta & Blouin, 2014; Ottersen, Frenk & Horton, 2011) in non-nursing literature. This leads us onto consider how nurses are to understand what sustainability means.

 

Defining Sustainability in Nursing

 

Anåker & Elf (2014) argue that the “term is not clearly defined and is poorly researched in nursing” (p382). This applies not only in nursing.  Sustainability has diverse and contested meanings in many disciplines (Thompson, 2011; Williams & Millington, 2004). The quest to tie down the concept is possibly futile, as Anåker and Elf themselves suggest that: “a concept analysis is never a finished product” (p388). They provide a definition which is a helpful contribution to the discussion, and their model and contrary case illustrate for clinical nurses the value of trying to understand sustainability in practice. Throughout the paper they provide attributes and definitions from various sources and refer to, but do not foreground, social and health inequalities arising from wider determinants of health including political economy, which also underpins understandings of sustainability and climate change (Goodman & Richardson, 2009; Sayer, 2015).

The defining attributes identified in Anaker and Elf’s concept analysis were:  ecology, environment, the future, globalism, holism and maintenance. The attribute ‘globalism’ indicates that they are getting close to discussing and emphasising political economy underpinning such issues as climate change, ocean acidification and soil erosion which are three of the nine planetary boundaries which, it is argued, delineate a ‘safe operating space for humanity’ (Rockstrom et al., 2009; Steffen et al., 2015) . Nonetheless, the analysis misses something important, i.e. the neoliberal (Freudenberg, 2014; Harvey, 2005) and environmental, socio-political context of health (Barton & Grant, 2006; Ottersen, Frenk & Horton, 2011; Sayer, 2015; Scambler, 2012; WHO 2015) characterised by social and health inequalities (Dorling, 2013). This is the link between capitalism, climate change and sustainability (Goodman, 2014; Griffiths, 2009; Klein, 2014; Sayer, 2015). Various writers (Hamilton, 2010; Jackson, 2009; Marshall, 2014; Sayer, 2015; Urry, 2011) suggest or imply, that it is our political orientations (Douglas & Wildavsky, 1992), moral intuitions (Haidt, 2012) and our social and economic relationship with carbon which are foundations upon which we as communities and individuals assess environmental issues and our reactions to them.

Urry particularly on this point, (2011) coins the term, ‘high carbon economy-society’ to describe capitalism. He argues that the starting point for an analysis of why society engages in particular practices and habits is the observation that energy is the base commodity upon which all other commodities exist. Thus, community behaviours are implicitly locked into high carbon systems that are taken for granted aspects of our lifeworld. Urry suggests that much of social science has been carbon blind and has analysed social practices without regard to the resource base and energy production that we now know are crucial in forming particular social practices. It is these social practices that provide the structure within which our agency operates.

most of the time people do not behave as individually rational separate economic consumers maximising their individual utility from the basket of goods and services they purchase and use given fixed unchanging preferences…(we are) creatures of social routine and habit…fashion and fad…(we are) locked into and reproduce different social practices and institutions, including families, households, social classes, genders, work groups, schools, ethnicities, generations, nations…. (Urry 2011 p4).

 

These social practices arise out of our ‘lifeworld’ (Husserl 1936, Habermas 1981), i.e. our internal subjective viewpoints as well as the external viewpoints of the social and political ‘system’.  A high carbon economy society thus provides the backdrop for values, assumptions and social practices that are taken for granted in everyday life. Defining sustainability therefore requires acknowledgment of such lifeworlds and the socio-political systems in which they ‘operate’.

 

Nursing, sustainability and acontextual Concept Analysis?

 

The wider body of literature, including that in the social and political sciences and philosophy, may give nurses tools and concepts to further develop their understanding of sustainability and its relationship to human health. Importantly this could include an understanding of the political economy of capitalism (Harvey, 2011) and its link with growth, climate change and sustainability (Hamilton, 2003; Jackson, 2009; Johnson, Simms & Chowla, 2010; Sayer, 2015). Without this understanding, and application in nursing scholarship, nurses may miss the arguments linking the growth dynamics underpinning the neoliberalist capitalist political economy (Chomsky, 1997; Harvey, 2005; Sayer, 2015), climate change (Klein, 2014; Sayer, 2015) and unsustainable lifestyles (Hamilton, 2010). This sits within the social and political determinants of health approach (Barton & Grant, 2006; Davidson, 2015; Ottersen, Frenk & Horton, 2011; Scambler, 2012) and the emerging domain of planetary health (Lang & Rayner, 2012; Lang & Rayner, 2015).  This paper argues that to fully develop the concept in nursing, an analysis or at the least an understanding, of the political economy of neoliberal capitalism could be a component of nurses’ understanding of sustainability and health. This is because political economy relates to both health and social inequalities (Dorling, 2013; Dorling, 2014; Marmot, 2015; Schrecker & Bambra, 2015; Stiglitz, 2012; Wilkinson, 2005; Wilkinson & Pickett, 2009)  and to issues around sustainability and climate change. However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge (White, 1995), a reflection which might reject this as irrelevant to much of nursing practice.

 

Anåker & Elf’s (2014) inference that nursing misses foregrounding political economy and society might be a result of the method employed to search the literature, as well as their acknowledged lack of discussion in the nursing literature of political economy. Of course there might be very little reason currently for nursing literature to discuss political economy, based as it is on knowledge (biosciences, biomedicine) that may well be largely antithetical to critical social and political science. Adult nurses in particular might face a real challenge in accepting this idea in practice as Ion and Lauder argue:

 

“For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care” (Ion & Lauder, 2015).

 

In addition, Walker and Avant’s method was originally published (1982) before the development of academic blogs and websites such as academia.edu and therefore may not be explicit in its direction to search beyond accepted channels. This emerging literature, which may contribute to the construction of the ‘paraversity’ (Goodman 2014, Rolfe 2014), will therefore be missed as source of information and discussion on topics such as linking sustainability, health, climate change and capitalism.

 

There are several key papers discussing the link between human health, political economy and the environment. Goodman and Richardson (2009) explicitly link Sustainability, Climate Change and Health conceptualizing them as three sides of a triad. To fully understand one requires an understanding of the other two. The three, in this conception, are indivisible. Further, the link involves political economy and socio-economic behavior as crucial underpinnings for climate change and sustainability issues. Barton and Grant’s (2006) health map discusses key determinants for health including Biodiversity, Global Ecosystems and Climate change. Each one of those of course involves human activity and disruption to create what some are calling a new geological era, the ‘Anthropocene’ (Zalasiewicz et al., 2010). Lang and Rayner (2012) discuss the concept of ‘Ecological Public Health’, while the Canadian Public Health Association (2015) has just published its own report on ‘Global Change and Public Health: Addressing the ecological determinants of health’ which on page 1 argues:

“…changes in the earth’s ecological systems are driven principally by our social and economic systems, and by the collective values and institutions that support them”.

This echoes the World Health Organisation’s definition of the social determinants of health which explicitly mentions distributions of resources, money and power (WHO 2015). The report does not name, or analyses, in any more depth what that economic system is, as it seems to take for granted that it is capitalism. Ottersen et al emphasize the political determinants of health (Ottersen, Dasgupta & Blouin, 2014) which, alongside the WHO’s (2008) social determinants of health approach, acknowledges the role of powerful global actors and the lack of global governance for health. Health equity and social determinants are now a crucial component of the post 2015 sustainable development goals (WHO 2015).

For example, powerful global actors, i.e. the Fossil Fuel Industry, may be acting in a way to either downplay the risks to human health from rising atmospheric carbon dioxide, or engaged in protecting their assets’ (coal oil and gas) value for the short term over and above longer term risks to climate. Exxon Mobil have argued that world climate policies are highly unlikely to stop the production and selling of fossil fuels (Exxon Mobil shrugs off climate change risk to profit – BBC News, 2014) while Shell have been accused (Macalister, 2015) of accepting a 4 degree rise in global mean temperatures. This is in the context of a reported $5 trillion annual subsidy in fossil fuel subsidies (Coady et al., 2015)  while the Bank of England considers a ‘carbon bubble’ (Carrington, 2014)  i.e. the drop in value of assets if fossil fuels are kept in the ground through the imposition of any global governance regimes to curb carbon emissions. This is an aspect of the political economy of capitalism that must be understood as a driver underpinning human health. At the time of writing, world leaders and delegates are meeting in Paris for COP 21. At this meeting there will be another meeting of the The Sustainable Innovation Forum (SIF15) which is a business focused event held during the annual Conference of Parties (COP). The two day Forum will convene  participants from business, Government, finance, the United nations, Non-governmental organisations, and civil society to “create an unparalleled opportunity to bolster business innovation and bring scale to the emerging green economy” (COP21 Paris 2015). This forum operates within the paradigm of capitalism rather than seeking radical reform. However, it illustrates the complexity of players dealing with sustainability issues.

 

Scambler (2012) outlines ‘The Greedy Bastards Hypothesis’ to describe how the Capitalist Class Executive can ‘command’ the Political Power Elite to enact policies in their favour, with the unintended consequences of exacerbating health inequalities. Evidence that corporate activities impacts on political decision making is provided by the delays to air pollution standards, Euro 6 (Archer, 2015; Neslen, 2015).  Volkswagen’s use of software to cheat emissions testing in the United States (Topham, 2015) indicates the lengths corporates will go (Freudenberg, 2014; Oreskes & Conway, 2011) to avoid externality costs resulting in the externality of for example, increased air pollution. Therefore any concept of sustainability in nursing that does not understand political economy misses something important in understanding both the concept of sustainability and of health.

 

Anaker and Elf’s definition of sustainability:

“…a core of knowledge in which ecology, global and holistic comprise the foundation. The use of the concept of sustainability includes environmental considerations at all levels. The implementation of sustainability will contribute to a development that maintains an environment that does not harm current and future generation’s opportunities for good health”. In this it echoes the Brundtland commission’s definition of sustainable development (WCED1987) which has been critiqued for being uncritical of business and growth based capitalism (Sinclair 2009).

 

This definition is a good start but requires development. Nurses, particular nursing scholars interested in health and public health, need to consider the argument already suggested around the dynamics of capitalism as a major driver for both carbon emissions and unsustainable practices. It is perfectly possible to begin the study of sustainability and environmental health within taken for granted paradigms, but what is required is a cultural critique of the values and systems that support environmental damage (Martusewicz 2014) and a better understanding how the economy and sustainability issues such as climate change, interact (Better Growth, Better Climate, 2015). Nurses, if they stick to nursing journals and literature, will not find a large amount of material that discusses this. For example the Royal Society of Arts has a wealth of papers, presentations and works streams addressing climate change (Hahnel, 2015; Rowson, 2015)  which address causes, behaviour changes, political economy and culture change.

 

Conclusion

 

Anåker & Elf (2014) argue that there is a need for theoretical and empirical studies of sustainability in Nursing. This could include accessing literature unknown to most nurses.  Writers such as Aldo Leopold, Wendell Berry, Paul Hawken, Mike Hulme, John Urry all provide insights into human wellbeing, health and the social context. Related concepts include ecojustice education, education for sustainability, dualism, anthropocentrism, anthropocene, neoliberalism, modernity and capitalism. A problem for nursing scholars is that these related concepts are not readily seen as relevant to nursing and thus there may be a reticence of nursing journals to publish them, and a reticence in nurse education to discuss them. There may be a need to resort to both non nursing peer reviewed journals but also to web based materials open to all. Anaker and Elf acknowledge in their limitations (p387) ‘the lack of research literature available for review in which sustainability was the major topic and in which sustainability was not linked to other concepts’. This paper goes further in trying to make those wider links for nurses. A problem however for nurses, is the sheer scale of literature and concepts that are involved. The task for nursing scholars is to consider just what is feasible, useful and relevant as part of their scholarly development and curriculum work.

 

 

Adlong, W. & Dietsch, E. (2015) ‘Nursing and climate change: An emerging connection’. Collegian, 22 (1). pp 19-24.

 

Allen, P. L. J. (2015) ‘Climate change: it’s our problem. Pediatric Nursing, 41 (1). pp 42.

 

Antrobus, S., Masterson, A. & Bailey, J. (2004) ‘Scaling the political ladder’ Nursing Management 11 (7). pp 23.

 

Anåker, A. & Elf, M. (2014) ‘Sustainability in nursing: a concept analysis’. Scandinavian Journal of Caring Sciences, 28 (2). pp 381-389.

 

Archer, G. (2015) Governments double and delay air pollution limits for diesel cars | Transport & Environment. http://www.transportenvironment.org/press/governments-double-and-delay-air-pollution-limits-diesel-cars (Accessed: 3rd December).

 

Aronsson, J. (2013) ‘How can SCPHN school nurses contribute to the sustainability agenda?’. Community practitioner : the journal of the Community Practitioners’ & Health Visitors’ Association, 86 (7). pp 38.

 

Barton, H. & Grant, M. (2006) ‘A health map for the local human habitat’. The Journal for the Royal Society for the Promotion of Health, 126 (6). pp. 252-253..

 

Berry, W. (1995) Another turn of the crank – health is membership. Washington: Counterpoint.

 

Better Growth, Better Climate.  (2015) Global Commission on the Economy and Climate. http://2014.newclimateeconomy.report/ accessed 3rd December 2015.

 

Carper, B. (1978) ‘Fundamental patterns of knowing in nursing’. Advances in Nursing Sciences, 1 (1). pp 13-23.

 

Carrington, D. (2014) ‘Bank of England investigating risk of ‘carbon bubble”.  The Guardian.  online, 2014-12-01.

 

Chomsky, N. (1997) ‘Profit over people; neoliberalism and the Global order’. New York: Seven Stories Press.

 

Coady, D., Parry, I., Sears, L. & Shang, B. (2015) How large are Global Energy subsidies? IMF: International Monetary Fund. Available at: http://www.imf.org/external/pubs/ft/wp/2015/wp15105.pdf (Accessed: 3rd December 2015).

 

Costello, A., Grant, M. & Horton, R. (2008) ‘The Lancet–UCL Commission: health effects of climate change’. The Lancet, 371 (9619). pp 1145-1147.

 

Costello, A., Maslin, M., Montgomery, H., Johnson, A. M. & Ekins, P. (2011) ‘Global health and climate change: moving from denial and catastrophic fatalism to positive action’. Philosophical transactions. Series A, Mathematical, physical, and engineering sciences, 369  pp 1866.

 

Conference of Parties (2015) COP21Paris available http://www.cop21paris.org/ accessed 3rd December 2015

 

Cox, L. & Nilsen, A. G. (2014) We make our own history : Marxism and social movements in the twilight of neoliberalism London. Pluto Press.

 

Davidson, A. (2015) Social determinants of health : a comparative approach Oxford. Oxford university press.

 

Davies, C. (2003) ‘Some of our concepts are missing: reflections on the absence of a sociology of organisations in Sociology of Health and Illness’. Sociology of Health & Illness, 25 (3). pp 172-190.

 

Davies, C. (2004) ‘Political leadership and the politics of nursing’. Journal of Nursing Management, 12 (4). pp 235-241.

 

Dorling, D. (2013) Unequal Health: The Scandal of Our Times. Bristol: Policy Press.

 

Dorling, D. (2014) Inequality and the 1%. London: Verso.

 

Douglas, M. & Wildavsky, A. (1992) Risk and Culture: An Essay on the Selection of Technological and Environmental Dangers. Berkeley: University of California Press.

 

Durban Declaration on Climate and Health.  (2011). http://www.env-health.org/IMG/pdf/Durban_Declaration_on_Climate_and_Health_Final.pdf Accessed: 1st December 2015.

 

Exxon Mobil shrugs off climate change risk to profit – BBC News.  (2014). http://www.bbc.co.uk/news/business-26830555 Accessed: 3rd December 2015.

 

Freudenberg, N. (2014) Lethal But Legal: Corporations, Consumption, and Protecting Public Health. Oxford: OUP USA.

 

Gilbert, T. P. (2005) ‘Trust and managerialism: exploring discourses of care’. Journal of Advanced Nursing, 52 (4). pp 454-463.

 

Goklany, I. (2009a) ‘is Climate change the defing issue of our age? Energy and Environment, 20 (3). pp 279-302.

Goklany, I. (2009b) ‘Climate change is not the biggest global health threat’. The Lancet. 374, 973-974.

 

Goklany, I. (2012) ‘Is climate change the number one threat to humanity?’. Wiley Interdisciplinary Reviews- Climate Change. 3, 489-508.

 

Goodman, B. (2008) ‘Nursing the planet’. Nursing Standard, 22 (22). pp 61-61.

 

Goodman, B. (2011) ‘The need for a ‘sustainability curriculum’ in nurse education’. Nurse Education Today, 31 (8). pp 733-737.

 

Goodman, B. (2014) ‘The debate on climate change and health in the context of ecological public health: a necessary corrective to Costello et al.’s ‘biggest global health threat’, or co-opted apologists for the neoliberal hegemony?’. Public Health, 128 (12). pp 1059-1065.

 

Goodman, B. (2015a) ‘The academic in the University of Excellence: The need to construct the ‘paraversity’ using the web’. Nurse Education Today 35, 638-640.

 

Goodman, B. (2015b) ‘Climate change and ecological public health’. Nursing Standard 29 (24). pp 37.

 

Goodman, B. & East, L. (2013) ‘The ‘sustainability lens’: A framework for nurse education that is ‘fit for the future’’. Nurse Education Today, 34 (1). pp 100-103.

 

Goodman, B. & Richardson, J. (2009) ‘Climate Change, Sustainability and Health in United Kingdom Higher Education: The Challenges for Nursing.  in Jones, P., Selby, D. and Sterling, S. (eds.) Sustainability Education: Perspectives and Practice Across Higher Education. London: Earthscan.

 

Griffiths, J. (2009) The health practitioner’s guide to climate change : diagnosis and cure. London: Earthscan.

 

Gulland, A. (2008) ‘Doctors encouraged to take lead in tackling climate change’. BMJ: British Medical Journal (International Edition), 336 (7648). pp 794-795.

 

Hahnel, R. (2015) The Political Economy of Climate Change  – RSA. https://www.thersa.org/events/2014/12/the-political-economy-of-climate-change-/ Accessed: 1st December 2015.

 

Haidt, J. (2012) The righteous mind : why good people are divided by politics and religion London. Penguin.

 

Hamilton, C. (2003) Growth Fetish London: Allen and Unwin.

 

Hamilton, C. (2010) Requiem for a Species. London: Routledge.

 

Harding, S. (2014) ‘Climate change may be debatable, but promoting sustainability is not’. Nursing standard: 28 (46). pp 34.

 

Harvey, D. (2005) ‘A brief history of neoliberalism’. Oxfrod. Oxford University Press..

 

Harvey, D. (2011) The enigma of capital : and the crises of capitalism. London: Profile.

 

Harvey, D. (2014) Seventeen contradictions and the end of capitalism. London: Profile Books.

 

Hewison, A. (1994) ‘The Politics of nursing – a framework for analysis. Journal Of Advanced Nursing, 20 (6). pp 1170-1175.

 

Hunt, G. (2006) ‘Climate change and health’. Nursing Ethics, 13 (6). pp 571-572.

 

Ion, R. & Lauder, W. (2015) Willis and the generic turn in nursing. Nurse Education Today.

 

IPCC (2014) WG11 AR5 Climate Change 2014: Impacts Adaptation and Vulnerability, Chapter 11 Human health Impacts, Adaptation and Co-benefits. Intergovernmental Panel on Climate Change.

 

Rowson,J. (2015) The Seven Dimensions of Climate Change: Introducing a new way to think, talk, and act – RSA. https://www.thersa.org/discover/publications-and-articles/reports/the-seven-dimensions-of-climate-change-introducing-a-new-way-to-think-talk-and-act/.

 

Jackson, T. (2009) Prosperity without growth. Economics for a finite planet. London: Earthscan.

 

Johnson, V., Simms, A. & Chowla, P. (2010) ‘Growth isn’t possible’. New Economics Foundation. Available at: http://www.neweconomics.org/publications/entry/growth-isnt-possible Accessed 1st December 2015.

 

Johnston, N., Rogers, M., Cross, N. & Sochan, A. (2005) ‘Global and planetary health: teaching as if the future matters’. Nursing Education Perspectives, 26 (3). pp 152-156.

 

Klein, K. (2014) This Changes Everything: Capitalism vs. the Climate. New York: Simon & Schuster.

 

Lang, T. & Rayner, G. (2012) ‘Ecological public health: the 21st century’s big idea? An essay by Tim Lang and Geof Rayner’. BMJ : British Medical Journal, 345

 

Lang, T. & Rayner, G. (2015) ‘Beyond the Golden Era of public health: charting a path from sanitarianism to ecological public health’. Public health, 129 (10). pp 1369..

 

Loy, D. (1988) Nonduality: A Study in Comparative Philosophy. New Haven: Yale University Press.

 

Macalister, T. (2015) Shell accused of strategy risking catastrophic climate change. The Guardian. 2015-05-17. Available at: http://www.theguardian.com/environment/2015/may/17/shell-accused-of-strategy-risking-catastrophic-climate-change (Accessed: 3rd December 2015).

 

Marmot, M. (2015) The Health Gap. London: BloomsburyBooks.

 

Marshall, G. (2014) Don’t Even Think About It: Why Our Brains Are Wired to Ignore Climate Change. Bloomsbury. USA.

 

Martusewicz, R, Edmundson, J and Lupinacci J. (2014) EcoJustice Education: Toward Diverse, Democratic, and Sustainable Communities (Sociocultural, Political and Historical Studies in Education). London: Routledge.

 

Masterson, A. and  Maslin-Prothero, S. (1999) Nursing and politics : power through practice. Edinburgh: Edinburgh : Churchill Livingstone.

 

McMichael, T., Montgomery, H. & Costello, A. (2012) ‘Health risks, present and future, from global climate change’. BMJ (Clinical research ed.), 344 pp e1359.

 

Neslen, A. (2015) EU caves in to auto industry pressure for weak emissions limits. The Guardian. 2015-10-28. Available at: http://www.theguardian.com/environment/2015/oct/28/eu-emissions-limits-nox-car-manufacturers Accessed: 3rd December 2015.

 

Oreskes, N. and Conway, E. M. (2011) Merchants of doubt : how a handful of scientists obscured the truth on issues from tobacco smoke to global warming London. Bloomsbury.

 

 

Ottersen, O., Dasgupta, J. & Blouin, C. (2014) The political origins of health inequity: prospects for change – The Lancet. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62407-1/fulltext Accessed: 3rd December 2015.

 

Ottersen, O., Frenk, J. & Horton, R. (2011) ‘The Lancet– University of Oslo Commission on Global Governance for Health, in collaboration with the Harvard Global Health Institute’. The Lancet, 378 (9803). pp 1612-1613.

 

Patton, R. M. (2008) ‘Inside ANA. From your ANA president: Climate change’. American Nurse Today, 3 (11). pp 16-16.

 

Phillips, C. D. (2012) ‘Nurses Becoming Political Advocates’. Journal of Emergency Nursing, 38 (5). pp 470-471.

 

Polivka, B. J., Chaudry, R. V. & Mac Crawford, J. (2012) ‘Public Health Nurses’ Knowledge and Attitudes Regarding Climate Change’. Environmental Health Perspectives, 120 (3). pp 321-325.

 

Racine, L. (2009) ‘Applying Antonio Gramsci’s philosophy to postcolonial feminist social and political activism in nursing.’ Nursing Philosophy 10 (3): 180

 

Raphael, D. (2004) Social determinants of health : Canadian perspectives. Toronto: Toronto : Canadian Scholars press Inc.

 

Rayner, G. & Lang, T. (2012) Ecological Public Health. Reshaping the conditions for good health. London: Routledge.

 

Reale, E. (2009) ‘ANF joins union climate change campaign’. Australian Nursing Journal, 17 (4). pp 9-9.

 

Richardson, J., Grose, J., Doman, M. & Kelsey, J. (2013) ‘The use of evidence-informed sustainability scenarios in the nursing curriculum: Development and evaluation of teaching methods’.Nurse Education Today 34 (4), 490-493.

 

Rockstrom, J., Steffen, W., Noone, K., Persson, A., Chapin, F. S., III, Lambin, E. F., Lenton, T. M., Scheffer, M., Folke, C., Schellnhuber, H. J., Nykvist, B., de Wit, C. A., Hughes, T., van der Leeuw, S., Rodhe, H., Sorlin, S., Snyder, P. K., Costanza, R., Svedin, U., Falkenmark, M., Karlberg, L., Corell, R. W., Fabry, V. J., Hansen, J., Walker, B., Liverman, D., Richardson, K., Crutzen, P. & Foley, J. A. (2009) ‘A safe operating space for humanity: identifying and quantifying planetary boundaries that must not be transgressed could help prevent human activities from causing unacceptable environmental change, argue Johan Rockstrom and colleagues’. Nature, 461 (7263). pp 472.

 

Rolfe, G. (2013) The University in Dissent; Scholarship in the Corporate University. London: Routledge.

 

Rowson (2015) Ten thoughts on climate change – RSA. Climate Change. https://www.thersa.org/discover/publications-and-articles/rsa-blogs/2014/10/ten-thoughts-on-climate-change/ Accessed: 3rd December 2015.

 

 

Salmon, M. (2012) ‘Policy and Politics in Nursing and Health Care, 6th ed (book review) JAMA307(1):94-95.

 

Sattler, B. (2011) ‘Environments & Health. The Greening of of a Major Medical Center: An interview with nurse and ‘sustainability manager’ Denise Choiniere’. American Journal of Nursing, 111 (4). pp 60-62.

 

Sayer, A. (2015) Why we can’t afford the Rich. Bristol: Polity Press.

 

Scambler, G. (2012) GBH: Greedy Bastards and Health Inequalities. @wordpressdotcom. 2012-11-04. Available at: https://grahamscambler.wordpress.com/2012/11/04/gbh-greedy-bastards-and-health-inequalities/ Accessed: 1st December 2015.

 

Schrecker, T. and Bambra, C. (2015) How politics makes us sick: neoliberal epidemics Basingstoke.Palgrave Macmillan.

 

Shariff, N. (2014) ‘Factors that act as facilitators and barriers to nurse leaders’ participation in health policy development’. BMC Nursing, 13 pp 20-20.

 

Sinclair, F. (2009) ‘What is sustainability?’ ecohearth.com/eco-news/eco-op-ed/300-what-is-sustainability-.html accessed 25 March 2009

 

Steffen, W., Richardson, K., Rockström, J., Cornell, S. E., Fetzer, I., Bennett, E. M., Biggs, R., Carpenter, S. R., de Vries, W., de Wit, C. A., Folke, C., Gerten, D., Heinke, J., Mace, G. M., Persson, L. M., Ramanathan, V., Reyers, B. & Sörlin, S. (2015) ‘Sustainability. Planetary boundaries: guiding human development on a changing planet’. Science (New York, N.Y.), 347 (6223). pp 1259855.

 

Stiglitz, J. (2012) The Price of Inequality. London: Penguin.

 

 

Thomas, M. M. (2014) ‘Navigating health care sustainability: hospitals and nurse leaders addressing climate change through cost savings, adaptation, and mitigation.(Green Space)’ 70, 6.

 

Thompson, M. (2011) Sustainability is an essentially contested concept. http://sapiens.revues.org/1177 Accessed: 1st December 2015.

 

Topham, G. (2015) Volkswagen scandal – seven days that rocked the German carmaker. The Guardian. 2015-09-25. Available at: http://www.theguardian.com/business/2015/sep/25/vw-emissions-scandal-seven-days Accessed: 3rd December 2015.

 

Traynor, M. (1996) ‘A literary approach to managerial discourse after the NHS reforms’. Sociology of Health & Illness, 18 (3). pp 315-340.

 

Traynor, M. (1999) Managerialism and Nursing: Beyond Oppression and Profession. London: Routledge.

 

Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Basingstoke: Palgrave MacMillan.

 

Traynor, M., Boland, M. & Buus, N. (2010) ‘Professional autonomy in 21st century healthcare: Nurses’ accounts of clinical decision-making’. Social Science & Medicine, 71 (8). pp 1506-1512.

 

Urry, J. (2011) Climate change and society. Cambridge: Polity.

 

Walker, L. & Avant, K. (1982) Strategies for Theory Construction in Nursing. Norwalk, CT: Appleton-Century-Crofts.

 

White, J. (1995) ‘Patterns of Knowing – Review, Critique, and Update’. Advances in Nursing Science, 17 (4). pp 73-86.

 

World Health Commission on Environmental Development (WCED) (1987) Our common future: The report of the World Health Commission on Environmental Development. Oxford. OUP.   http://www.un-documents.net.wced-ocf.htm

 

 

World Health Organisation (2013) WHO Commission on Social Determinants of Health – final report. World Health Organization. Available at: http://www.who.int/social_determinants/thecommission/finalreport/en/ accessed 3rd December 2015.

 

World Health Organisation (2016) WHO launches country profiles to help action on health and climate change. http://www.who.int/globalchange/mediacentre/news/country-profiles/en/ Accessed: 1st December 2015.

 

World Health Organisation (2015) WHO Social determinants of health World Health Organization. 2015-09-23 12:29:00. Available at: http://www.who.int/social_determinants/en/ Accessed: 2nd December 2015.

 

Wilkinson, R. (2005) ‘The Impact of Inequality. How to make sick societies healthier’ London: Routledge.

 

Wilkinson, R. & Pickett, K. (2009) ‘The Spirit Level. Why Equality is better for Everyone’ London: Penguin.

 

Williams, C. & Millington, A. (2004) ‘The diverse and contested meanings of sustainable development’. Geographical Journal, 170 pp 99-104.

 

Zalasiewicz, J., Williams, M., Steffen, W. & Crutzen, P. (2010) ‘The New World of the Anthropocene’. Environmental Science & Technology, 44 (7). pp 2228-2231.

 

 

Sustainability – what can a nurse do?

Sustainability – what can a nurse do?

 

This appears to be a common question, perhaps indicating that the debate has moved on from questioning the scientific basis for both climate change and the data around environmental damage caused by human activities such as ocean acidification. These are of course global issues which can make one feel powerless. This need not be so.

 

In June 2015, The Lancet argued:

 

“tackling climate change could be the greatest health opportunity of the 21st century”

 

If this is so, then nurses could play an important role in both climate change and health.

 

This report followed on from Pope Francis’s encyclical ‘Laudato Si  – care for our common home’.

The National Health Service Sustainable Development Unit (NHS SDU) welcomed the Lancet’s publication and argued that:

 

“The health sector can play a real role in making sure that its activities promote lower carbon and a more resilient infrastructure. This holds true in relation to every part of the sector including travel and transport systems, in relation to building infrastructure and through the procurement of products and services”.

 

Stefi Barna et al (2012) set out what nurses need to know about climate change and elsewhere I (Goodman 2013) challenge nurses in the NHS to act on climate change and suggests ways of thinking to do so. The NHS SDU is a great resource to support clinicians in their attempts to make the NHS responsive to sustainability and climate change issues.

 

This sets the context for nurses, but what can the nurse actually do. First of all we could consider those sectors of the health service in which that the SDU outline action can take place and ask what roles nurses can play, if at all in each.

 

A start for the nurse would be to consider what level they can work at:

 

 

 

  1. On a personal level:

 

  • Understand the facts: for example, learn what ‘carbon footprint’ means and what your personal footprint is. Access the resources published by The Lancet and the National Health Service Sustainable Development Unit. Access the literature on the subject. Understand the social political and ecological determinants of health.
  • Reflect on your values and assumptions about what the good life means on this planet. Consider the effects of consumerism, materialism and individualism on the quality of human relationships and our relationship to nature. Consider if modern culture is sustainable in its current form.
  • Eat better: e.g. reduce your intake of red meats; perhaps try to cut out/down on processed/packaged foods; shop for locally and seasonally produced foods.
  • Drink better: Consider your use of bottled water. See the ‘Story of Stuff’
  • Move better: g. use public transport walk more, reduce your use of the car, buy a bicycle (called ‘active transport’).
  • Communicate better: make full use of digital technologies.

 

  1. On an organisational level:
  • Consider the core aspects of energy, travel, food, gases and drugs, waste, and medical devices .

 

  • Energy: Between 2007/08 and 2013/14the NHS carbon footprint in relation to building energy use dropped by 3.5% despite increases in activity of 13%. The decrease represents around £50m of energy costs for the NHS in England in 2013/14. Nurse action: is there a plan for your clinical area to address energy consumption? Are you involved in innovations to reduce carbon emissions and increase renewables?   Work with your organisation’s carbon reduction team (if it has one) or consider getting a carbon reduction team developed if it does not.

 

  • NHS Derbyshire Community Health Services saved more than 3,000 hours of staff travel time, 20 tonnes of carbon, and over £100,000 by using teleconferencing services. Nurse action: consider how patients and staff travel to and from services and whether it is always necessary.

 

  • Nottingham University Hospitals NHS Trust shows how part of the health system can lead sustainable food systems.  It serves fresh, healthy meals made with local, seasonal and organic ingredients.  Nurse Action: find out where your food comes from and what it is? Discuss nutrition and food choices with your patients.

 

  • Gases and medicines. The use of anaesthetic gases represents 5% of acute hospital CO2e emissions. These could be reduced with lower flow rates or substituted for instance moving away from nitrous oxide. Inhalers which represent 4.3% of the English health and care sector’s footprint could be replaced by a pulverised form as in Scandinavian countries. New meter dose inhalers without high environmental impact propellants could save nearly 7 million tCO2e over five years. Medicines are often a cornerstone of our health response be this through immunisations, diagnostics or therapeutic drugs. It is however sometimes more effective to prescribe physical activity, dietary changes or talking therapies.  The pharmaceutical industry is similarly keen to help reduce environmental impacts involved in the production, use and disposal of medicines so are already important partners in this journey. Nurse action: Find out about these practices if they apply to you, work with colleagues to address these issues.

 

  • Contaminated waste. The health sector produces waste in vast quantities, some of which is contaminated and needs to be separated and disposed of effectively. We hold the key to doing this effectively and  safely as well as reducing environmental impacts. Nurse action: review waste management practices in your clinical area, search the literature for new approaches to waste. Find out what the waste process is and what it costs and how it is segregated.

 

  • Medical devices. The use of multi-use or single use items, balancing the ethical sourcing and material use with decontamination and/or recycling approaches needs to be fully understood and effectively implemented to minimise both visible and hidden costs and environmental impacts.  Work with organisations such as the Infection Prevention Society on issues such as single use.

 

  • The SDU argues “The very nature of our business which is now considered unsustainable economically, environmentally and socially means that we need to focus on improving health and reduce our reliance on acute settings. The NHS Five Year Forward View is addressing some of these through the development of Vanguard sites and it would be exemplary to be able to demonstrate the benefits in environmental and social terms too”.


  1. On a national/international level:

Nurses may wish to see this as a menu of choices for tackling climate and health, but remembering always climate change and carbon emissions are only one aspect of sustainable healthcare. We have to consider the economic, social and other environmental aspects of sustainability as well. This is because social and political inequalities adversely affect the health of individuals, communities and populations.

We need to consider whether the global economic system is fair, just, equitable and is not a cause of environmental damage. There are concerns over social inequalities leading to health inequalities adversely affecting those lower down on the socio-economic scale. This takes nurses away from clinical considerations and into socio-political debates about how global governance affects human health and well being. Another Lancet commission report questions whether the current system is fit for that purpose.

 

Selby’s 10 propositions.

 

David Selby, in 2007, produced 10 propositions for education that might be useful as another framework for action:

 

  1. Confront denial (of climate change, health crises) by challenging our own base assumptions, knowledge and responses. We need to feel unease at the current situation. Nurses should reflect on the potential a very different world in which current cultural assumptions will not hold up to be true. For example, a belief in progress, that our children will have a better standard of living may not happen.

 

  1. Given the threat to human health, nurses need to address personal issues of despair, grief, loss. Once some of the facts are known, we may have to make a personal journey through challenging long cherished world views, hopes and dreams. Our perspectives may have to shift to embrace wider loss and grief issues that flow from climate change.

 

  • Shift to a holistic dynamic understanding of the relationship between humans and nature is an end in itself not a means to an end. Nurses may already have a holistic understanding of human health and approaches to care, but this goes beyond the individual to embrace the social and the natural. Health is too often reductive, i.e. it is reduced to body parts and systems existing as separate entities from other bodies and the physical environment. It is also thus individualistic, being located within a single individual’s body. Within this reductive individualised view of health people can still view themselves as healthy in a

 

 “disintegrating family, community or a destroyed or poisoned ecosystem” (Wendell Berry p89).

 

  1. Cultivate a poetic understanding alongside a rational understanding – we need to develop awe, celebration, enchantment, reverence as well as classification, prediction, evaluation and exploitation of nature. This mirrors the ongoing debate within nursing education concerning the art/science dichotomy and would provide another useful lens to address the need for scientific competence and artistic appreciation and application in nursing praxis. There needs to be space to allow this and perhaps even academic credit?

 

  1. Marginalised ‘educations’ will be important, e.g. the field of non –violence. Rather more challenging for some fields of health care such as acute hospital care but may well be core to therapeutic approaches within mental health.

 

  1. Given the heating – sustainable and emergency education need to come together. Social dislocation, hunger, environmental disaster, tribalism necessitates nursing action that can respond, e.g. global citizenship, peace education, conflict resolution, anti-discriminatory education. Health care staff may well be key professionals in dealing with emergencies and disaster management and thus education and training that explicitly addresses these skills may well be valued and developed.

 

  1. Alternative ideas of what ‘the good life’ means need exploring: Again this could be core to philosophy especially within the contexts of mental health and palliative care and living with long term or life limiting conditions.

 

  1. Rethinking notions of democracy, citizenship and sustainability could be part of the professional responsibilities of health care staff. ‘Global citizenship’ could be a core feature.

 

  1. Shift from atomistic/reductionist thinking to holistic ways of mediating reality. This means that nurses change their paradigms, their world views away from focusing on the individual as the core unit of being, to understanding that the individual cannot exist with community and nature. They are indivisible.

 

  1. Finally Selby asks: “Everyone has to understand and come to terms with the fact that we are threatening our own existence. To confront this requires a Copernican revolution in aims, structures, processes of education and perhaps in the loci of learning ... as the heating happens, education and educational institutions ... will be deeply disrupted and if unresponsive to the need for transformation, will disintegrate as people find other more relevant loci for learning what they have to learn”. Although this is written for education in general it is a challenge to nurse education. If nurse education is too focused on developing professional competencies based in a biomedical paradigm, then it is an education that will have failed the future nursing workforce, who will be passive recipients of policies and climate change rather than active in prevention and adaptation to the changes.

 

 

So what can a nurse do?

Nursing is an ethical practice and nurses are asked to address the health not just of individuals but of communities and populations. Health education, promotion and public health are core to nursing practice. Nursing organisations have accepted both environmental issues and climate change as a health threat. All health services need to save money and use resources better. Population health would improve through adopting low carbon lifestyles. Clinical leaders can assist in the transition from unsustainable health care delivery and lifestyles towards sustainable health care as they are on the ground  and would be able to see where innovations and changes could be made.

 

  • Read – widely, inform yourself.
  • Reflect – on your personal values, assumptions and beliefs.
  • Revise – current ways of working.
  • Renew – yourself, your workplace, your community.
  • Reconnect – to your family, community, your social and political networks.
  • Remember- this will not be easy.

 

 

 

Suggested reading

 

Barna, S, Goodman, B. and Mortimer, F. (2012) The health effects of climate change; what does a nurse need to know? Nurse Education Today. 32(7) pp 765-71

Goodman, B. (2013) The Role of the nurse in addressing the health effects of climate change. Nursing Standard. 27 (35) pp 49-56

 

Griffiths, J. et al (2009) The Health Practitioner’s Guide to Climate Change. Earthscan. London.

 

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

Action Nursing? Addressing politics and ideology?

I read this http://www.cost-ofliving.net/a-case-for-action-sociology/ a while ago, and I published this on the one dimensional state of UK nurse education, http://www.nurseeducationtoday.com/article/S0260-6917(11)00135-3/abstract back in 2011. Graham Scambler’s outline of an action sociology (AS) made me think about an ‘action’ nursing. To use/paraphrase Graham:

 So what might action sociology/nursing deliver? It has a number of discernible properties:

It is intrinsic to the sociological/nursing project: in any era sociologists will find themselves contesting ideologies (that is, erroneous worldviews or theories that sanction or provide cover for financial, business or political interests). Sociology’s very rationale is to oppose forces that suppress truths about the societies we inhabit: pace Habermas, it is necessarily oriented to justice and solidarity. It is active not passive: it lives or dies as a form of intervention against – Habermas again – ‘distorted communication’.

Nursing similarly has an ethical dimension to it, to confront the same forces, and to fulfil its role in public health at individual, community and population levels. This has never been developed fully in Nursing theory because the discipline has been focused on other laudable aims. The result is a large number of workers in the NHS have no analytical tools or critical thought in which to contextualise and critique their experiences with vulnerable people.

‘AS’ therefore contests the ‘taming’ of sociology in the post-1970s neo-liberal era, including a shying away from contentious or ‘risky’ issues.

This taming has certainly occurred in Nursing as it is largely bereft of critique.

Sociology’s focus is the study and theorizing of what Comte called society’s ‘statics’ and ‘dynamics’ in general, and of collective action to accomplish change in particular. This encompasses recruitment, context, and the dialectics of framing and implementing strategies. Same goes for Nursing?

Sociology’s brief extends to forays into Giddens’ ‘utopianrealism’, involving the mapping of alternative futures. This may well involve challenging or superceding the discourses or narratives for change on offer at any given time. An example of utopian realism would be a model for an NHS beyond the truly iniquitous Health and Social Care Act. There is a lack of positing alternative futures by nurse scholars that is leaving the field to others.

Scambler argues: “The Health and Social Care Act, designed to re-commodify health care in England, will accentuate health inequality.  It is a paradigmatic example of policy-based evidence. The data do not speak loud enough for elite politicians, let alone their financial and business masters, to bend their ears in fear of a crisis of legitimation. So how to remove from the statute book an Act inimical to the wellbeing of most citizens?  An action sociology cannot shrug its shoulders. It has to dwell on and exploitation and oppression. It is the actions of the wealthy and powerful that condemn those in low-income households to suffer more than their share not only of long-term but of acute illness and to die prematurely, as the likes of Engels and Virschow who charged rulers with ‘murder’ recognized in the 19th century. And health inequalities afford but an illustration here: we could have pinpointed welfare as a whole, education, housing and so on with the self-same consequences. Action sociology offers resistance to ‘formal’ democracy in the name of ‘substantive’ democracy. It underwrites ‘effective’ as opposed to symbolic resistance”.

 

This aspect (e.g. health inequalities, social determinants of health, ecological pubic health) of action sociology surely should resonate with nurses? We have been interested in how the social sciences inform nursing education and practice, well this is one way. What we do not have perhaps is a journal which is read by nurses which will focus on critical theorising and exploration of the context of nursing practice. The Sociology of Health and Illness often does a sterling job but do you think there is a gap here? if so how might we go about filling it? My very small sphere of influence is nurse education and arguing for a more fully rounded curriculum, so I’m feeling my way forward for an ‘action nursing’. Thoughts? Of course I almost blush at such a ‘radical’ action is suggesting a ‘journal’, the anthropologist David Graeber at the LSE (http://www.thewhitereview.org/interviews/interview-with-david-graeber/), or of course C Wright Mills,  might laugh at such a ‘bold’ move.