Antonio Gramsci on intellectual thought – challenging nursing.

Antonio Gramsci on intellectual thought – challenging nursing.

 

 

Antonio Gramsci (1891-1937), leader of the Italian Communist party, was arrested and imprisoned by the fascist regime in 1926 and died in the Quisisana clinic in Rome in 1937, aged 47. His pre prison work and his ‘prison notebooks’ have hugely contributed to the examination and development of political philosophy and intellectual thought. Among the ideas he developed are the role of the intellectual in culture and politics and the concept of hegemony. The prosecutor at his trial was acutely aware of his intellectual abilities, and thus threat, and stated:

 

“We must prevent this brain from functioning for twenty years.”

 

(Buttigeig 2011 p16).

 

Gramsci found himself in a concrete prison not of his own choosing. Nurses find themselves in an abstract prison of the mind put there by their own reason, their lifeworld colonised by the systematic distorted communication of the strategic action of powerful others.

 

This is all a world away from the daily work of nursing, and so at first pass may appear of interest only to the likes of critical social scientists or historians of political thought. Reading Gramsci opens up a discussion on what being an intellectual might mean and of how power is exercised and maintained. Nurses going about their clinical work will not be vexed by such questions and it might be the case that academic nurses will not be either. That could be a mistake given the current context outlined by Streek (2016) of global challenges to social order which have current and future impacts on health and health care delivery.

 

That context is variously called late modernity, post modernity, post industrial, disorganised, financial, rentier, or neoliberal capitalism. Wolfgang Streeck (2016) echoing Gramsci, suggests this context is actually a post-capitalist interregnum in which the old system is dying but a new social order cannot yet be born. Streeck calls the current order one of multi-morbidity, climate change being one of many frailties as we head towards social entropy, radical uncertainty and indeterminancy. Streeck argues that the current context is anchored in a variety of interconnected developments:

 

  1. Intensification of distributional (capital v labour) conflict due to declining growth.
  2. Rising social inequality.
  3. Vanishing macroeconomic manageability.
  4. Steadily increasing indebtedness (private and sovereign).
  5. Pumped up money supply (from quantitative easing).
  6. Possibility of another financial crisis as per 2008.
  7. The suspension of democracy.
  8. Slowdown of social progress.
  9. Rising Oligarchy and Plutocracy.
  10. Governments’ inability to limit the commodification of labour, money or nature.
  11. Omnipresence of corruption.
  12. Intensified competition in winner takes all markets.
  13. Unlimited opportunities for self enrichment (for the 1%).
  14. Erosion of public goods and infrastructure.
  15. The failure of the US to establish a stable global order.
  16. Public cynicism towards economics and politics.
  17. Rising populist nationalism and the spectre of fascism and isolationism in the US.
  18. Fracturing political blocs and alliances.
  19. Erosion of Democratic legitimacy and thus a democratic deficit.

 

 

To that:

 

  1. Health Inequalities.
  2. Potential Ecosystem collapse.
  3. Disruptive technologies: Automation, Artificial Intelligence and digitalisation.

 

 

Streeck seems to suggest that it is the very success of neoliberal capitalism, its defeat of social democracy and forces that would otherwise tame its destructive tendencies, that has paved the way for such developments that characterise its internal contradictions. There is nothing left to save capitalism from itself.

 

There are countervailing voices such as Joseph Norberg (on the possibility and actuality of progress), Daniel Ben-Ami (on growth based capitalism to solve ecological problems) and Stephen Pinker (on reducing levels of global violence) who paint more positive pictures. Add of course the voices of politicians who promise to ‘Make America Great Again’, to create “A country that works for everyone’ or establish ‘Russia as a Normal Great Power’ or to regain ‘primacy in South East Asia after a century of humiliation’. The picture now is one of complexity, tension, dynamics and unpredictability.

 

None of this bothers most UK nurses who work with individuals who are ill, distressed, living with long term conditions, or dying in hospital and at home. They are also involved in public health basing their approaches in general health management, health education and health promotion. Their training and education focuses on instrumental competency based knowledge and skill acquisition but it lacks critical enquiry into the context in which they work. Gramsci’s approach to intellectual enquiry could provide a blueprint for alternative or complementary critical nurse education that has to consider wider socio-political determinants of health, the sort of developments that Streeck outlines.

 

 

 

Gramsci’s thinking

 

We get an insight into how Gramsci’s brain functioned from a letter he wrote in 1929 to the wife of a comrade who also was in prison for ‘anti-fascist’ activity. The context is that of how to study while in prison. The prison referred to, of course, had concrete existence. However, if we consider that today nurses may imprison themselves within the conceptual walls of stultifying paradigms that block freedom of critical thought, for example biomedical empiricism, his thoughts on reflection and analysis might be useful. The letter predates Wright Mills’ 1959 chapter on intellectual craftsmanship, a reading of which shows some commonality in approach and is an alternative to the metrics used today in our research excellence framework assessments. One wonders if Gramsci was writing today, would he secure tenure in some contemporary Universities.

 

He wrote in the letter that one must abandon, in the prison context, the ‘scholastic mentality’ and banish the thought of pursuing a regular and in depth course of study. Along with Wright Mills who later wrote about avoiding empirical work if he could help it as it was merely about sorting out facts and disagreements about facts, this statement appears to be counter intuitive until one considers that a goal of intellectual life could be about criticality, understanding philosophy, self, culture, history, politics and society. Again put this way, many nurses may well eschew intellectual enquiry as irrelevant.

 

Gramsci urged language learning as rewarding, but more interestingly is his outlook on the relative paucity of texts in prison libraries. He argued that a political prisoner must extract “blood from stones” (Buttigeig 2011 p15). The paucity of books in prison was of course a function of the external constraints imposed by the regime. The ‘paucity of books’ available to students today may be a result not of external concrete constraints but of internal self imposed constraints as to what counts as proper reading for a degree in Nursing. Gramsci experienced a concrete prison of walls imposed by the fascist regime. We might experience a ‘prison of the mind’ constructed by dominant cultural ideas (hegemony) imposed by ourselves upon ourselves through the process of normative governmentality. Gramsci argued for ‘extracting blood from stones’, the stones being whatever he could get.

 

To get the most of the books available to him, often popular novels, Gramsci adopted the following viewpoint:

 

“Why is this always the most read and most published literature?”

“What needs does it satisfy?”

 

“What aspirations does it respond to?”

 

“What sentiments and views are represented in these awful books that have such broad appeal?”

 

For student nurses, these questions could be applied to many of the texts, for example the professional body’s literature, that they read to assist with the development of critical thinking. Critique could be emancipatory but in actuality reading ends up in uncritical acceptance. I’m not talking about appraising and critiquing research evidence or engaging in critical analysis of for example leadership theories in nursing. Criticality is lacking in the socio-political and power domain.

An example of the lack of such criticality is the almost universal acceptance of the UK’s Nursing and Midwifery Council’s revalidation process. The requirement is for nurses to renew their registration every three years by following the process outlined by the NMC. The surface reason for revalidation is that it ‘promotes greater professionalism among nurses and midwives and also improves the quality of care that patients receive by encouraging reflection on practice against the revised code’. If we apply Gramsci’s questions above to the texts on revalidation put out by the NMC, a possibility arises that we just might make alternative and critical analyses of just such banal statements in official publications.

 

“Why is the NMC always the most read and most published literature on professional behaviour?” Because of its statutory position as the regulator to protect the public. Because Nurse educators use it as the basis for their teaching. Because the NMC has the power to discipline nurses…..

“What needs does it satisfy?” Neophyte nurses, especially, need guidance on professional behaviour and standards and don’t have the time, or resources or educational preparation to consider this in an in depth way. NMC guidance provides the generally widely accepted standard……

 

“What aspirations does it respond to?” To keep one’s registration and to bolster one’s subject position as ‘safe practitioner’

 

“What sentiments and views are represented in these awful books that have such broad appeal?” The sentiment of nursing as ‘character based moral work’, of nurses as ‘caregivers’, as self sacrificial angels who always cope……

 

The answers to the 4 questions of course are myriad and those above are merely some examples requiring further reflection, reflexivity and criticism.

 

The lack of critique of the NMC on revalidation illustrates ‘normative governmentality’, in that nurses and midwives, and perhaps more interestingly nursing academics, have internalised certain norms, values and assumptions that prevent them from seeing anything other than the official line. This could be an example of what Furedi (2006) refers to as philistinism underpinned by instrumentalism in higher education, in which academics become educational technocrats rather than what Gramsci refers to as organic intellectuals.

 

Intellectuals are those with broad reading, vision and a concern for public issues. Graham Scambler argues intellectuals are not only engaged in the public sphere but do so around an identifiable moral or political position. A question arises about the degree nurses and midwives are, or wish to be, engaged in moral and political questions, the degree to which they can engage in communicative action free from systematic distorted communication.

 

The questioning of texts exemplifies the Gramscian notion of critical enquiry and action and allows us to consider such questions as, for example, what counts as research in contemporary nursing faculties. The answer to that is political in that it frames what nurse academics study, write about and publish, and it frames what students of nursing count as valid knowledge. If we apply those questions to the published outputs of contemporary nursing scholarship what answers would we get? For example, does a high h index always indicate intellectual rigour or criticality? Given the wider determinants of health, which include the social, political and ecological, it could be suggested that health care professionals would be aided in their understanding of health and illness, and hence what to do about it, by critical enquiry that goes beyond accepted epistemologies.

 

Nursing students have been told to be critical thinkers and many University curricula claim to foster such thought. Texts are not to be accepted at face value, and that we should examine assumptions and viewpoints of writers. This should go beyond for example appraising research literature for methodological rigour. Should we also appraise the metaparadigms and epistemological assumptions of ‘acceptable’ and ‘REFable’ nursing research? Should we ask what degree does contemporary scholarship in nursing reflect the sort of intellectual enquiry that Gramsci and Wright Mills advocate? In a world increasingly characterised by forces that threaten to disrupt stability and global order in ways that could be catastrophic to human health, are we preparing nurses to face that?

 

Gramsci died far too soon, and ‘without honour in his own country’. Whether he considered his life a failure in that fascism still held power, nonetheless he provides a template for thinking, studying and critique in difficult circumstances. He had a vision, he was an intellectual, he had a political purpose. Whether academic nurses in the 21st century find this inspiring or irrelevant may depend on what vision we have for nursing praxis for the future.

 

 

 

Buttigeig J (2011) in Gramsci A (1975) Prison Notebooks. Volume 1 Ed. Einaudi G. Columbia University Press. New York.

 

Furedi F (2006) Where have all the intellectuals gone? Confronting 21st Century Philistinism. Continuum.

 

Gramsci A. (1975) Prison Notebooks. Vos 1-3. Edited Einaudi G. Columbia University Books New York.

 

Scambler G (2013) What is an intellectual? http://www.grahamscambler.com/what-is-an-intellectual-2/

 

Streeck W (2016) The post-capitalist interregnum: the old system is dying, but a new social order cannot yet be born. Juncture 23 (2): 68-77

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

Poverty Privilege and Health

In two of the richest nations ever to have existed on planet earth we have a separation which allows affluent whites to exist in a bubble of privilege; a bubble of privilege which survives the shooting of police, deindustrialisation, poverty, precarity and the social gradient in health. Privilege understands and sees how radical losers exploit poverty and exclusion, but does not want to address social and economic structures; privilege understands that pain and anger can be turned both inward and outward but looks for solutions in the individual and ‘security’; privilege sees the transmission of poverty and exclusion only in the personal agency of the poor themselves.

Washington Heights is a suburb of the most segregated city in America. Charles lives in a part of Milwaukee where the residents are 99% white, yet a few blocks up are black neighbourhoods where shops are boarded up, many houses have repossession notices on their front doors, and the air is one of decay and poverty. The separation of black and white in Milwaukee is replicated in big cities right across the US, and separation breeds a lack of empathy.”

“Local authorities which report the highest rates of people facing severe and multiple disadvantage are mainly in the North of England, seaside towns and certain central London boroughs”

“Women who live in the least deprived parts of Kensington & Chelsea can expect almost a quarter of a century more of good health than their female counterparts in the most deprived part of the borough. For females at birth, the number of years an individual could expect to live in good health based on current rates – known as healthy life expectancy – differed by an average of 24.6 years between the most and least deprived parts of the borough” (ONS, 2015)

…and yet politicians like to focus on a ‘moral underclass’, blaming them for their behaviour that causes poverty. Drink and drugs are key factors in this regard:

“Ian Duncan Smith, Secretary of State for Work and Pensions, shocked readers of the Daily Mail with: ‘Addicts and alcoholics cost us £10billion a year, says Duncan Smith: Blitz launched to help people with drink drug problems find work’ “. (Glen Bramley LSE Blog)

There is a very old debate about whether poor people owe their circumstances to structural economic factors or to moral/behavioural failings. Sandra Carlisle in 2001 argued that there are ‘contested explanations, shifting discourses and ambiguous policies’  for health inequalities: there is the ‘Moral Underclass’ discourse, the ‘Social Integrationist’ Discourse and the ‘Redistrubutive’ discourse. Each has its own explanation as to why there are inequalities and then what to do about them.

Since Sandra Carlisle wrote her paper, there has been a a good deal of evidence to suggest that structural/economic forces are a major factor in people’s health and illness. There is some evidence also of ‘transmitted poverty‘ due to adverse childhood experiences. The misuse of Alcohol and Illegal substances (they are all drugs) are of course correlated:

“There is a huge overlap between the offender, substance misusing and homeless populations. For example, two thirds of people using homeless services are also either in the criminal justice system or in drug treatment in the same year”.

Many people faced with adverse social situations learn to cope, or they become fatalistic,  or they cling together in supportive communities or they become activists fighting for social justice.  Some self harm, some drink to excess, some go to University and become doctors or lawyers or politicians.  They exercise their personal agency and succeed or fail within structurally determined circumstances. They succeed, despite not because of, the activities and ideology of the privileged. A few of the successful however, then refuse to provide more ladders while shouting “I did it so can you”.

The lack of empathy, the total separation of lifeworlds, arises partly from moral intuitions that both blinds many politicians and commentators to alternative explanations pf poverty and binds them together in a bubble of privilege that prevents them from analysing the evidence. As we all do, they engage in post hoc rationalisations – in their case that that the poor are a moral underclass who are less intelligent, lazy, and hard working than the successful – to explain and justify their own positions.  This is almost a moral imperative, because not to blame the poor opens one up to the need to justify or critique the structural and economic privileges one has unequal access to. Placing the focus on the work, drinking and drug taking habits of a ‘moral underclass’ provides one with a sense of superiority and entitlement so much on show in both US and UK politics. No doubt the same occurs in Russia and China. To acknowledge that there are structural and economic conditions, for example the public school system or the service sector low wage economies,  or the inverse care law, opens up the middle class to accusations of champagne socialism.

This is a common tactic to deflect the argument away from an examination of causes to one of ‘ad hominem’.  Another tactic is to argue that the best way to address structural and economic factors is more of the same economic policies that have held sway especially in the US and UK. Indeed on a global scale the numbers of people living in absolute poverty is decreasing. Inequality is also decreasing with in the UK (gini coefficient). However these two factors are not the only issue.  Both the UK and the US are rich and other measures of inequality have increased, see for example the use of the Palma ratio. It matters greatly for very poor people to get incomes, and mortality rates, enjoyed by the poor in the UK and the US, but that is not enough as the social, health and political problems in both countries testify.

Privilege looks around and is satisfied knowing that the ‘have nots’ only have themselves to blame. They reach for the moral underclass theory and publish it relentlessly in their newspapers and commentary. They also have the wealth and political power to ensure this ideology is accepted by the poor themselves. However, many do not. In this context:

The losers get sick.

The losers get poor.

The losers get defeated.

The losers get mad.

The losers get even.

‘Many professions take losers as the object of their studies and as the basis for their existence. Social psychologists, social workers, nurses, doctors, social policy experts, criminologists, therapists and others who do not count themselves among the losers would be out of work without them. But with the best will in the world, their clients remains obscure to them: their empathy knows clearly-defined professional bounds’ (Enzensberger 2005). Enzensberger (2005) goes on to argue:

‘one thing is certain: the way humanity has organized itself – “capitalism”, “competition”, “empire”, “globalisation” – not only does the number of losers increase every day, but as in any large group, fragmentation soon sets in. In a chaotic, unfathomable process, the cohorts of the inferior, the defeated, the victims separate out. The loser may accept his fate and resign himself; the victim may demand satisfaction; the defeated may begin preparing for the next round. But the radical loser isolates himself, becomes invisible, guards his delusion, saves his energy, and waits for his hour to come’.

Shoots a Policeman, drives a truck through a crowd, blows himself up in an airport…..all the while privilege looks on in dumb uncomprehending horror calling for more security and economic crackdowns on the moral underclass upon whom the often middle class radical loser preys.

Hunt’s agenda

The ideology of health care provision.

 

 

Amid the junior doctors strike of 2016, the health secretary Jeremy Hunt was embroiled in a conflict with the BMA over doctors’ contracts designed to address a 7day NHS. This is the surface issue but sits upon a deeper ideological conflict, one that many of the doctors will be unaware of but will suspect, especially if they have read Alysson Pollock’s works on the privatisation and corporatisation of the NHS. Hunt argued he has a ‘mandate’ to introduce a 7 day NHS and perhaps realises that if this policy cannot be introduced, the balance of power over the future of the NHS will swing back towards the BMA and other health professional groups. The irony is that the BMA opposed the introduction of the NHS back in 1948 but now is one of the strongest supporters. Since 2012 however, the NHS has been dismantled and been replaced with privatised and corporatized service provision, with ‘patient choice’ and ‘patient safety’ being used as the ideological veil which masks the corporate face. People have not noticed this detail because so far ‘free at the point of delivery’ is still in place, but this principle, along with universal and comprehensive cover, is under threat. The government remain the almost monopoly purchaser of health services on our behalf but for how long? The care home crisis points in the direction of travel. This will be withdrawal of state funding and reliance on private provision which will not be ‘free at the point of delivery’.

 

 

 

In 2005 ‘Direct Democracy – an agenda for a new model party’ was published, the authors include the current health secretary Jeremy Hunt. It is not government policy and does not represent the full range of conservative views. The Tory party itself is home to those of a ‘one nation’ persuasion who mix ideas of ‘noblesse oblige’ with a modicum of a social welfare, safety net, public service ethos. It is also home to ‘neoliberalism’ rooted in anti State sentiment based on freedom of the individual and free market economics. This ideology can be clearly seen in the 2012 book ‘Britannia Unchained – Global lessons for growth and prosperity’ which argues for further free market economics based on a bonfire of employment laws. The book suggests:

 

“The British are among the worst idlers in the world. We work among the lowest hours, we retire early and our productivity is poor. Whereas Indian children aspire to be doctors or businessmen, the British are more interested in football and pop music.”

 

This one quote conveys the disdain neoliberals have in general for those less well paid, less “successful” and less powerful than themselves. Boris Johnson’s speech in 2013 on the impossibility of equality being based on differences in IQ, implied some people are too stupid to get ahead. This individualises issues, while ignoring structures of class, gender, ethnicity and privilege. He said:

 

And for one reason or another – boardroom greed or, as I am assured, the natural and god-given talent of boardroom inhabitants – the income gap between the top cornflakes and the bottom cornflakes is getting wider than ever. I stress: I don’t believe that economic equality is possible; indeed, some measure of inequality is essential for the spirit of envy and keeping up with the Joneses that is, like greed, a valuable spur to economic activity.”

 

Two ideas are core here: that the working class and the poor are so because they are more lazy and stupid than the ruling class, and that the answer to this is to increase competition and to use inequality as incentives for personal improvement. Of course said like that to the electorate, it would seriously threaten voter support. Instead the discourse of market efficiency, effectiveness and choice is used to justify privatization and corporatization of public services. The message to the public is clear: take responsibility for education, health, social care and housing. It is down to individuals and families to provide by working hard and being prudent.

 

The arguments over the NHS have to be seen within this wider context. At heart, many in the current Tory party viewed the state run NHS as anathema. As such they have succeeded in dismantling the post war structure of the NHS following the Health and Social Care Act 2012. This allowed for private providers to bid for the provision of health services but keeps in place, for now, principles such as ‘free at the point of delivery’.

 

According to Alysson Pollock, the Health and Social Care Act 2012:

 

  1. Removed the duty of the Secretary of State for health to secure and provide health care for all.
  2. Introduced US style insurance schemes.
  3. Gives the secretary of state legal powers to create a market, allows providers to pick and choose which patients will get care, services to be provided and what will be charged for.

 

A market has been introduced into health service delivery, and markets operate through risk selection and appraisal resulting in fragmentation of provision. That is to say a market provider needs to pick and choose which patients are profitable in competition with other providers. We now have clinical commissioning groups modelled on insurance based lines. Those with high risk or multiple needs will be expensive to provide care for.

 

The ‘NHS’ is now fragmented in which:

 

  1. Services are broken up and put out to tender to commercial companies.
  2. Commercial shareholders have new legal powers to decide who gets care, what the get and what they pay for.

 

This current state of affairs is not enough for neoliberal thought. So what is the vision of this group of neoliberal Tories? How did this happen?

 

Direct Democracy argues:

 

“Several other countries operate political systems based on localism and direct democracy. Two outstanding examples – one much smaller than the United Kingdom and one many times larger – are Switzerland and the United States. In their different ways, both states respect the principles of the dispersal of power, the direct election of public officials and the use of the referendum as a legislative tool. Our proposals for the devolution of power directly to the citizen – notably in the fields of education and health care – have also been successfully trialled abroad, often in unlikely places. No less corporatist a state than Sweden has introduced a form of school voucher, while almost every state in Europe, at least since the fall of the Berlin Wall, now provides for an element of health insurance”.

 

This goes to the heart of the matter, note how the US and the Swiss are held up as models. The principles of localism and direct democracy are invoked as justifications hiding their argument and belief about market mechanisms. The United States is a beacon for the dispersal of power? One cannot expect anything other than this nonsense from neoliberals, wilfully ignorant as they surely must be of the work of C Wright Mills, Herbert Marcuse, Jurgen Habermas, David Harvey, Thomas Picketty, Graham Scambler, and Yanis Varoufakis? This also ignores the literature on social inequalities and inequalities in health and the social and political determinants of health. At this point we must also point to the wealth of feminist and post-colonial literature on ‘power’. In short it is an invocation of bourgeois patriarchal perspective on the exercise of power which blinds them to actuality.

 

As for Switzerland, the OECD reports that compared to the UK’s 9.3 % of GDP, the Swiss pay 11.4%. The UK used to pay under 6% but has seen a rise, not totally due to actual health spending but to cater for administration and profit for private companies. The US spends 16.9% (OECD 2014) and has introduced ‘Obama care’ to address the plight of uninsured americans. Obama care is an outcome of class struggle which has been hotly contested in the ‘land of the free’.

 

 

 

‘Direct Democracy’ claims to hold to three principles:

 

  1. Decisions should be taken as closely to the people they affect.
  2. Law makers should be directly accountable.
  3. The citizen should enjoy maximum freedom from state control.

 

 

On the face of it who would argue with that? Certainly not anarchists, socialists or libertarians. The problem is that these principles exist within a social and historical context, one characterised by imbalances of power along class, gender and ethnic lines and this cannot deal with the reality on the ground. Hunt et al are blind to the context in which ‘men of wealth buy men of power’, a world in which the capitalist class executive and the political power elite exercise a new class/command dynamic which neoliberal ‘reforms’ ushered in since about the 1980’s especially in the US and UK.

 

Yanis Varoufakis (2016) clearly discusses the effects of such things as the “Nixon Shock’ on the post war global financial settlement, the outcome being that the ‘strong do what they can and the weak suffer what they must’. Global health corporations need new markets and looked to the UK’s NHS as a source of rich pickings. This is the context in which Hunt’s bourgeois democracy operates.

 

  • Decisions about who provides health care, what health care looks like and where it is provided are taken by unelected clinical commissioning groups operating within a profit driven market context.
  • Patients do not have an electable secretary of state who has a statutory obligation to provide health care services.
  • Freedom from state control for health service provision has morphed into control via corporate decision making.

 

 

Direct Democracy (2005) argues:

 

‘The problem with the NHS is not one of resources. Rather it is the system remains centrally run, state monopoly designed over half a century ago’ (p74).

 

Clearly this is a statement that ‘the system’ needs to go. The resource issue in the context of increasing demands and costs is brushed aside. This remark now looks questionable at best in 2016.

 

“We should fund patients either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means would have their contributions supplemented or paid for by the State.” (p74).

 

Holding on to a notion of ‘free at the point of delivery’ implied here, it is clear that private provision is to be introduced. The language is anodyne, context free, taking no notice of what private provision might look like, who would provide it and what the consequences of the inevitability of a market might be. The State at least has a role in providing for the poor. The writers of this document are part of the political power elite, or may wish to be, and the coherence of interests with the corporate/capitalist class executive are hidden. Those who sell insurance have not been lobbying for this change then? A bit of research into who benefits from this change might prove insightful. Are there links between corporate interest and the politicians who are driving the changes?

 

Hunt et al feared the NHS would only be second to the US in terms of % of GDP spent. This has not occurred. They report a study ranking the UK 18 of 19 countries. This is selective in the extreme, and is now way out of date.

 

Many of the critiques they evoke of the NHS are a result of the rise of new public management, or ‘managerialism, introduced into the system by previous governments both New Labour and Tory. For about three decades managerial control, targets and distrust of professionals have eroded the ability of the NHS to be the best in the world.  The judgment about the efficiency and effectiveness of health services partly depends on what criteria are being used to judge them. The % spend of GDP is a crude figure as it hides a plethora of costs and profits.

 

Other measures of success could include universality of access, comprehensiveness of cover, mortality and morbidity outcomes, and the publics’ safety and satisfaction.

 

Mark Britnall has written ‘In search of the Perfect Health System’ (2015) of the complexity of comparing health systems. Britnall is no Tory ideologue and describes his approach as more brown mud than blue sky thinking:

 

He also wrote in 2011 before the 2012 Act:

 

“[o]f course, the vast majority of care – quite rightly in the UK context – will always be provided by public sector organisations (currently, about 95% of it) and will be paid out of taxation” and “[t]he issue of competition, which now seems to be conflated with privatisation, is unhelpful and misleading and, at best, only a small part of reform. Competition can exist without privatisation and the NHS can maintain its historic role in funding care while dealing with a richer variety of providers – public sector, social enterprise and private organisations”.

 

This 2011 comment predated the 2012 Act and can be seen as a statement of intent than actuality on his part. In 2010 there was some controversy over his statements in the US about private provision.

 

One area in which private provision is facing severe challenges is the care home sector.

 

Roy Lilley, writes a daily blog, and has considerable experience in the health service and with private sector organisations. He is no left wing radical. He writes in ‘They don’t matter’ (3rd May 2016) that success in private provision in the community has been ‘patchy’, citing Circle’s loss of £5 million and the paying of another £2 million to get out of the Hinchinbrooke contract, while SERCO and Bupa ‘bailed out’ of provision leaving Virgin clinging on. He argues that the private sector can be nimble and quick to adapt, but of course needs to make a profit.

 

However, the largest care home provider, Four Seasons, is in talks to ‘restructure its debt’ as they face a 39% drop in profits. Most of their ‘customers’ have their fees paid by social services. This amounts to some local authorities paying £385 per week which is just not enough. The living wage is also an issue for them, they have over 30,000 staff but with no way of adjusting prices to pay for the increase and with no operating surplus. It has a debt of £510 million. If Four Seasons go broke they have 450 care homes at risk.

 

The bottom line is that health and social care costs money. There is not enough money in the system to pay for the care required. Some private families are paying £1,250 per week. Company Watch data which covers 20,000 homes, indicates that there is a funding black hole of half a billion pounds. This is market failure due to inadequate funding by design. It is almost as if the government is deliberately forcing people to find the money themselves either through savings, insurance or property while state funding through local authorities is slowly wound down.

 

Mark Britnall’s approach is scholarly, based in experience managing health care organisations and a deep knowledge and overview of many health systems. However, is Britnall sufficiently aware of the political economy of neoliberalism and its agenda for health?  Roy Lilley’s highlighting of the care home crisis clearly shows the political, austerity driven nature of the issue.

 

‘Direct Democracy’ and ‘Britannia Unchained’ are ideological approaches to health and social care. Whether Hunt has the temper for addressing Britnall’s insights or whether he still stands by the document he co-wrote is anyone’s guess. However, I know where the smart money would go. His face down of the doctors is more to do with power and who exercises it rather than the future of the health service as we knew it. If the neoliberals can get away with it, then free at the point of delivery will be severely challenged perhaps using spurious arguments stigmatising drug users, alcoholics, smokers, the obese, self harmers, self inflicted sports injuries, prostitutes, the promiscuous and Johnson’s ‘stupid’ as a wedge driven between the deserving and the undeserving ill. The care home crisis indicates that older people are ignored and the costs increasingly privatised as the state withdraws, or should we say abdicates, support. The NHS was to socialise risk, to spread its cost across the whole population. Instead we are rapidly moving towards individualising risk and private insurance based provision as the state withers away.

 

Choose your parents

Alejandro Nieto.

Bernal Heights. San Francisco.

What has the death of a young man, shot by four police officers in a park in California got to do with with understanding health outcomes in the United Kingdom?

Mary Sue and Miriam. Two women born at similar times whose grandparents came from the same small town in the United States. One will be going to an Ivy League University while the other struggles with drugs and hopelessness writing on her Facebook page ‘Love hurts, Trust is dangerous’.

What links them is that Alejandro and Mary Sue ‘chose the wrong parents’, while Miriam chose wisely, a Harvard professor for a grandfather (Robert Putnam), and University educated parents.

Their cases illustrate that health and well being is ‘structured but not determined’, that to truly understand their life chances we have to consider the transformations in society that impact on the choices made and opportunities open to individuals and their families.

Alejandro was born to Mexican immigrants who came to San Francisco in the 1970’s. His mother worked all her life while his father took on most of the child care duties. San Francisco has a history of immigrants from other parts of the US as well as from elsewhere. Being Hispanic in California is ‘normal’ but not to the white, male, educated tech engineers from Silicon Valley who have moved to the area en mass ushering in gentrification and myopia. Alejandro was described to the Police as probably ‘foreign’ who had a gun, his red jacket marking him out as a gang member. All of this was supposition and assumption. Alejandro had lived in Bernal Heights all of his life, the gun was a taser, carried because he worked as a security guard. His red jacket was a sports jacket, the colour of the local sports team the 49’ers. Those doing the describing were white tech engineers making assumptions about behaviour. Indeed, Alejandro was holding a taser, but he had just been harassed by a dog barking and jumping up at him to get at his chips. The dog owner was 40 feet away, distracted by a ‘jogger’s butt’ and unable to keep his dog under control.

The police arrived, and shot him, one unloading over 20 bullets and had to reload.

Alejandro, Mary Sue and Miriam live at a time when the United States is experiencing growing inequalities in wealth, segregation in its communities, family instability and a collapse of both good working class jobs now being followed by a squeeze on middle class opportunities. While the wealth of the 1% has increased based on their increased share of wealth being created – they are getting an even bigger slice of the pie, working class incomes have stagnated. Mary Sue’s grandfather used to have a decent income from a solidly working class job, now gone leaving ‘flexible’, low paid insecure work.

As economies restructure, as cities adapt to new social conditions, people experience changing social structures that enhance or diminish their chances. The white Ivy League tech engineers are likely to know only other white Ivy Leaguers, to come from Ivy League parents, went to the same schools and know only their own kind in a networked bubble of privilege, social myopia and self satisfying smugness. They don’t know the ‘other’ and can thus label a sports fan as a gang member with in this case lethal consequences.

Perhaps representing their views:

“I know people are frustrated about gentrification happening in the city, but the reality is, we live in a free market society. The wealthy working people have earned their right to live in the city. They went out, got an education, work hard, and earned it. I shouldn’t have to worry about being accosted. I shouldn’t have to see the pain, struggle, and despair of homeless people to and from my way to work every day.”

 

So ‘free market society’ justifies the breakdown of community, segregation, inequality, fear and mistrust. Wealth is ‘earned’ rather than a result of circumstances (right time, right family, right ethnicity, right gender, right neighbourhood, right education, right opportunities and often the inheritance of not only financial but social and cultural capital). Indeed, no one should have be be accosted, no one should see pain and struggle and despair, but don’t blame the victims of unjust social, political and economic systems. Don’t blame the dog for barking when someone’s kicked it.

Alejandro’s ‘personal trouble’ (being shot) is now a public issue. When only one young man is shot by police, we might consider the character of the man and look to him as an individual for reasons and solutions. When hundreds of young men are being shot by police this individual analysis is no longer useful, we must look to social structures, to link personal stories to this point in time in this particular society.

Miriam can look forward to a bright future, she experienced great parenting, great education backed up of course by well resourced material assets. Mary Sue, is a single parent with no education, self harm, a drug habit and abusive partners. Her child will very probably not go to Harvard. Alejandro made the mistake of being born Hispanic and thus a potential threat to the White denizens of a newly gentrified neighbourhood.

If you are struggling to apply this to the UK context, you don’t know the truth and you lack the ‘sociological imagination’.

Alejandro’s story is in Rebecca Solnit ‘Death by Gentrification’. Opinion. The Guardian. March 22nd 2016.
Mary Sue and Miriam’s story is in a talk by Robert Putnam to the RSA in London, March 2015, on ‘Inequality and the Opportunity Gap’. https://www.thersa.org/discover/videos/event-videos/2015/10/robert-putnam-on-inequality-and-opportunity/#

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.

 

Simone de Beauvoir: The second sex – the social construction of women and implications for wellbeing.

Simone de Beauvoir: The second sex – the social construction of women and implications for wellbeing.

 

In 1949 Simone de Beauvoir published ‘The Second Sex’, a book that was put on a ‘prohibited list’ by the Vatican. In 2015, the ideas within should also make the non-religious think again about what makes for femininity and why. Women suffering from eating disorders, or spending a great deal of money on cosmetic surgery, might wish to consider why they are doing so and who profits from it. Nurses as women, and a nurse education interested in the personal growth of its students, might profit from this analysis as they experience, almost daily, images of what the ideal body type should be. This experience is implicated in negative evaluations of body shape (e,g, anti-fat bias); evaluations that even health professionals engage in (Teachman and Brownhill 2001), and the prevalence of eating disorders (Garner and Garfinkel 2009).

 

Biology is not destiny. To begin with, the fact of female biology is an ‘is’ but should not be automatically linked to the ‘ought’ of social roles around, for example, child rearing and the plethora of social and domestic roles women have played for centuries. In 1740, the Scottish Enlightenment philosopher David Hume, in his ‘Treatise on Human Nature’, pointed out that human reasoning can so easily jump the gap between what ‘is’ and then declare that it also ‘ought’ to be. This gap between the ‘is’ of fact and the ‘ought’ of value requires examining rather than uncritical acceptance. Just because we eat meat, ought we to eat meet? For women, examining the gap between fact and values means realising that reproductive biology (an ‘is’) is not their destiny linked to a subordinate domestic role (an ‘ought’). In part 1 of the book ‘Destiny’, Beauvoir argues that the facts of biology must be viewed in the light of the ontological, economic, social, and physiological contexts in which they exist.

 

Beauvoir goes further into the nature of female sexuality and their feminine forms to suggest that notions of female beauty are socially constructed, and most often by men. In addition, women learn how to be women often in relation to male ideals. Beauvoir argued: “one is not born a woman, one becomes a woman” (book 1, part 2 ch 1). This feels counterintuitive and goes against natural thinking at the birth of a child in which the sex of the child is established by biological factors but almost immediately gender constructions begin. Sex and gender are intertwined and erroneously conceptualised as being the same thing. In western societies, the bestowal of the pink and the blue begins that process of the social construction of gender which then overlays the biological sex of the baby. Howard Garfinkel (1967) in ‘Studies in Ethnomethodology’, later described the continuous process of the social production of gender roles, whereby ‘Agnes’, born with a penis, passed as a woman.

 

In part two ‘History’ Beauvoir describes the historical subjugation of women by men for example quoting Proudhon who valued a woman at 8/27th the value of a man. The almost total subjugation of women, and their subsequent invisibility in history, results from patriarchy often underpinned by religion. Biology (the ‘is’) is invoked to put and keep them in their subordinate place (the ‘ought’). However, in the modern era, two key factors were involved in the evolution of the female role in society: 1. participation in production and 2. freedom from reproductive slavery. ‘Modern’ women, such as Rosa Luxembourg and Marie Curie, who were able to exploit these factors:

 

brilliantly demonstrate that it is not women’s inferiority that has determined their historical insignificance: it is their historical insignificance that has doomed them to inferiority” (p131).

 

Industrial, and now postindustrial capitalism as a dynamic system, has both freed women and created new forms of subjugation. Factory work, especially during war, gave opportunities for women to, en masse, demonstrate their strength and provide alternatives to lives of domestic labour. Nursing arguably began its professionalisation following these factors, and nurses themselves enjoy almost total freedom from obligatory reproductive labour secured by the contraceptive pill. Yet, new forms of subjugation have been created. Advances in cosmetic technologies and medical practices have now given women new tools to construct themselves as befitting whatever cultural artefact is now considered as beauty. We now have labiaplasty offered, not to correct genital ‘malfunction’ but as an aspect of new norms of beauty possibly in response to exposure to pornography (Davis 2011). Beauvoir pointed to the male gaze, but it now seems that women themselves are complicit in this reconstruction of the feminine.

 

In part three ‘Myths’, Beauvoir discusses such as issues as men’s ‘disappointment’ in women revolving round issues such as menstruation, virginity, copulation and motherhood. Myths about the female role abound in literature written by men, especially the ‘mystery’ of woman to man, perhaps foreshadowing Betty Friedan’s later work, ‘The Feminine Mystique’ (Friedan 1963). Friedan argued that male editorial decisions in women’s magazines, insisted on articles that showed women as either happy housewives or unhappy careerists. This was the “feminine mystique” the idea that women were naturally fulfilled by devoting their lives to being housewives and mothers. In both books there is this suggestion that men misunderstand, or perhaps even fear women, and engage in creating a simulacrum (Baudrillard n.d.) of femininity to best fit their own gendered and sexual needs. It might be that male fear of women, their lack of control of female reproduction, is at the root of ‘femicide’ – the killing of females by males because they are females (Russell and Harmes 2001).

 

Volume two of the work is also divided into 4 parts; ‘Formative years’, ‘Situation’, Justifications’ and ‘Towards Liberation’. Beauvoir describes the learning of appropriate femininity and subsequent domestic roles. Her critique of marriage and acceptance of lesbianism no doubt helped the Vatican in its decision.

 

Beauvoir assembles an historical account using examples from literature, politics and philosophy to argue that to fully understand what it is to be a women requires moving beyond biology as destiny to examining the myths of femininity, myths often created by and for men, and then towards constructing emancipatory practices.

 

Women should come to see that they are under a ‘male gaze’ which constructs who they are and that beauty itself is a social construct. It is through other people’s assumptions and expectations that a woman (sex) becomes ‘feminine’ (gender). Part of that feminization is the requirement of women to strive after beauty, defined by mens’ view of what they would like women to be. A view that denies women the capacity for action and thought, to be passive objects of the male gaze, and to use artifice in order to be ornamental, to disguise the more animal aspects of their bodies, e.g. the removal of body hair in western aesthetics. The pressure on women to become an object, to be conventionally beautiful, to diet, is intense.

 

Of course, the male gaze can be internalized by women, and it is the case that women’s magazines produced and edited by women perpetuate beauty myths (Wolf 1991). Aesthetic technologies, such as dermal fillers and botox, are often advertised by women, performed by women, performed on women. Beauvoir focused on patriarchal values and concepts as drivers for these processes, whereas and especially since the development of liquid modernity (Baumann 2000) characterized by individualism, consumerism and atomization, and by the increasing marketisation of society (Sandel 2012, Marquand 2014), consumer capitalism has also targeted men as consumers of beauty products. We have now the construction of the male body type with the ‘six pack’ as its apotheosis.

 

The creation of dissatisfaction with one’s body, be it male or female, is now a marketing tool to sell product. This process may have become a dominant ethic in contemporary society. Booth (2014) refers to a contemporary concerns with ‘mammon worship’ defined as ‘seeking satisfaction through the superficial’ while Skidelsky and Skidelsky (2012) focus on the dominance of the values of acquisition and ‘insatiability’ while societies have lost the sense of what the good life might be. If this is the case, then Beauvoir’s focus on patriarchal values and the male gaze, allied with more and more of a concern with financialisation and the creating of new markets for profit,  come together as dominant social ethics to create who we are at both emotional and physical levels.

There is resistance of course. Since Beauvoir’s publication, some have suggested that ‘second wave’ feminism (Gamble 2001) and ‘third wave’ feminism (Tong 2009) arose to address the rights of women. Resistance to the male gaze can be seen in Susie Orbach’s work (1978). For Orbach, gender inequality makes women fat; compulsive eating and being fat is one way to avoid being marketed at or being seen as the ideal woman. Orbach suggested it was some womens’ way of rebelling against powerlessness in society. More recently, the ‘Everyday Sexism’ project exists to address instances of sexism experienced by women on a daily basis. Within a health context, Hagell (1989) discussed the conceptualization of nursing work as women’s work while Aston (2011) have used feminist post structuralism (FPS) as a way of understanding obesity. Sundin-Huard (2001) used subject positions theory to illustrate how nurses in a gendered profession can be positioned into subordinate roles within hierarchical medical and managerial structures.

 

The value of returning to Beauvoir’s work is in reminding us that what seems normal and natural for women’s place in society and what seems normal in their ‘natural’ attributes as carers and nurterers, may not be normal or natural. We need to remember the ‘is’ and the ‘ought’. The pressures women experience, and the tools they use to provide an acceptably pleasing face to themselves as well as to men, are cultural artefacts bound up within systems of power. Powerlessness in the face of the social construction of feminities that lead to abject and subordinate subject positions can lead to reaction which might even be self harming. Feminist theory may not find a home in nurse education, perhaps it should?

 

 

 

 

 

 

Aston M, Price S, Kirk S, and Penney T. (2011) More than meets the eye. Feminist poststructuralism as a lens towards understanding Obesity. Journal of Advanced Nursing.

Baudrillard, J. “XI. Holograms.” Simulacra and Simulations. transl. Sheila Faria Glaser. http://www.egs.edu/faculty/jean-baudrillard/articles/simulacra-and-simulations-xi-holograms/ retrieved 20 February 2015

Baumann Z. (2000) Liquid Modernity. Polity. Cambridge.

Beauvoir, Simone de (1949 (translated 2009)). The Second Sex. Trans. Constance Borde and Sheila Malovany-Chevallier. Random House: Alfred A. Knopf.

Booth, P. (2014) Straw Mammon: An essay on Mammon’s Kingdom by David Marquand. Institute of Economic Affairs. July 2014. http://www.iea.org.uk/blog/straw-mammon-an-essay-on-mammon’s-kingdom-by-david-marquand

Davis, R. (2011) Labiaplasty surgery increased as a result of pornography. Women. The Observer 27th February http://www.theguardian.com/lifeandstyle/2011/feb/27/labiaplasty-surgery-labia-vagina-pornography

Garfinkel, H. 1967 Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice Hall.

Gamble, s. (2001) ed. The Routledge companion to feminism and postfeminism . Routledge London.

Garner, David M.; Garfinkel, Paul E. (2009). Socio-cultural factors in the development of anorexia nervosa. Psychological Medicine 10 (4): 647–56

Hagell, E (1989) Nursing knowledge: Women’s knowledge. A sociological perspective. Journal of Advanced Nursing, 14: 226–33

Hume, D. (1739-1740) Treatise on Human Nature. Section 3.1.1. Moral Distinctions Not deriv’d from Reason. http://davidhume.org/texts/thn.html

Marquand, D. (2014) Mammon’s Kingdom: An Essay on Britain Now. Allen lane. London.

Orbach, S (1978) Fat is a feminist issue. Arrow. London.

Russell, D and Harmes, R. (eds) Femicide in Global Perspective. Ch 2 p 13-14. Teachers College Press, New York.

Sandel, M. (2012) What money can’t buy. The moral limits of markets. Allen lane. London.

Skidelsky, R and Skidelsky E, (2012) How much is enough? Money and the Good Life. Other Press. New York.

Teachman, B.A.; Brownell, K.D. (2001). “Implicit anti-fat bias among health professionals: Is anyone immune?”. International Journal of Obesity 25 (10): 1525–1531

Tong, R. (2009). Feminist Thought: A More Comprehensive Introduction (Third ed.). Boulder: Westview Press. pp. 284–285, 289

Wolf, N. (1990) The Beauty Myth. How Images of beauty are used against women. Vintage. London.

Why do nurses behave as they do?

Subject Positions Theory.   Why do individual nurses behave as they do?

SPT tries to explain how ‘subjects’ will behave in certain situations. It can be used to explore what ‘positions’ we take up and what identities we either assume or refuse within a social context that is characterised by power relationships. It allows the question about how powerful ‘others’ (i.e. Health Secretaries, CEOs, Consultants, Managers) position the relatively powerless ‘subject’ (staff nurse, patient) into certain subject positions (e.g. handmaiden, passive recipient) simply through an unconscious, uncriticised and shared language, discourse and power. Objective formal power involving clear boundaries, sanctions and authority also operate in social relationships. Objective formal power needs to be called out, and its foundation clearly described as operating often on an unspoken ideology. In the current context of health care delivery, that ideology is founded upon the twin pillars of neoliberalism and managerialism. These are macro level positions, whereas SPT allows exploration of informal power at the micro level that might go otherwise unanalysed.

 

The ‘subject’ within this theory refers to the individual human being who engages in creating an identity and does so partly by being the ‘subject’ of language, discourses and power relationships. The subject position, or identity, one takes is created by language, discourse and power and in doing so also creates that identity. This operates within a set of social relationships that are characterised by differences such as ethnicity, sexuality, gender and class. These relationships are also relationships of power. They operate through and within language. Our subject positions are partly defined by others unless we recognise the process of positioning and resist it. However, a good deal of positioning by others can be successful because we take subject positions often unconsciously. We have already accepted the language, discourse and power of others. Within any social interaction, powerful ‘others’ may engage in ‘interpellation’ (Althusser 1989). They ‘call’ us into a subject position by our intersubjective acceptance of the language, discourse and power of the other.

 

When a doctor, or manager, calls upon a nurse to do something, they are often ‘interpellating’ the nurse into a subject position of obedience to a medical or hierarchical regime. This can only work if the nurse recognises and accepts the subject position of junior partner. This process of identification creates an identity. The doctor identifies the nurse and the ‘subject’ within the nurse becomes a nurse. The subjective ‘I’, which in other social situations is not identified as a nurse, now becomes one. This is not to be confused with the formal title that the qualification RN bestows upon someone. Merely having been registered with the Nursing and Midwifery council does not identify a subject as a ‘nurse’, it is merely a formal recognition of one’s status on a register. One becomes and assumes the identity of nurse through social interaction and the ‘interpellation’ of others. A nurse is a nurse only when others say so within a social context. Upon leaving the clinical setting, the subjective ‘I’ is now free to assume other identities such as mother, friend, runner or dancer.

 

When a nurse is called in this manner, it may well be the case that the nurse recognises this calling, and that the subjective ‘I’ is now the subject position of ‘me’ as nurse. This operates through the unconscious acceptance of that subject position. Through such mechanisms as ‘occupational socialisation’ the calling out of ‘me as nurse’ feels natural and in that acceptance further cements this identity. The nurse has been ‘recruited’ into that subject position and over time bonds with that identity and its underlying ideological sets of discourses and power relationships that go with it.

 

Within the occupation of nursing there may be a number of subject positions open to individual nurses. Some of those positions are overt and openly discussed, others operate within the covert, intersubjective, lifeworld of nursing. Thus, nurses assume certain subject positions, such as ‘nurse advocate’, and attempt to assume this identity to further patient care. In doing so, do other ‘powerful subjects’ may position the ‘nurse advocate’ identity into one of ‘whistleblower’ or ‘uppity nurse’, ‘non-medical care worker’ or ‘junior partner’.

 

Potential Subject Positions that might be open to nurses: they operate as binaries – one position is assumed other is an ‘abject’ position.

 

·       Advocate/Non advocate

·       Carer/patient

·       Empathiser/task completer

·       Doer/Organiser

·       Whistleblower/Compliant worker

·       Educator/Student

·       Trainer/Trainee

·       Supervisor/worker

·       Female/male

·       Good nurse/uppity nurse

·       Coper/Whinger

·       Emotional supporter/distant professional

·       Responder/avoider

 

 

‘Subjects’ have the ability to occupy and move between a variety of identities, or ‘subject positions’, within an interaction in the clinical setting but this depends on the power dynamics and context of that exchange. We can therefore try to analyse in any given interaction what those power dynamics are and what the context consists of. So, how do nurses either comply with or resist positioning for example as a ‘doer’ within a power struggle?

 

Lacan (1977) suggests we assume identities, or positions, in response to punishments or threats of punishment. In the clinical context that might include bullying, intimidation, snubbing, patronising language or lack of promotion. The fear of punishment arises out of ‘knowing’ the rules of interaction and being aware of power and the rules of hierarchy.

 

Once an identity has been assumed it is associated with a particular discourse, i.e. a stock of words, phrases, concepts, theories, that support and explain the position taken. The subject position of nurse, according, to society, should display feminine attributes based in an ethic of care. The discourse associated with this is about being a ‘good nurse’ emphasising nurturance, obedience, support, listening and helping. This recently has been given even more support through emphasising the 6 Cs. This sits in opposition to critical advocacy especially in relation to the medical profession and NHS management. The discourse available to critical advocacy emphasises challenge, assertiveness, rights, and standards. The subject position of whistleblower is similarly contradictory, at once being that of advocate and patient champion while the reality is also one of irritant, turncoat and rebel to the hierarchies of power. SPT requires a critical theory of power to move beyond analysis at the micro level to critique of power structures (be they gendered, class, managerial) at the macro.

 

Clinical decision making, such as advocating a certain course of action such as moving an older person within the hospital at night, or changing the operating list to avoid delays, or getting analgesia prescribed, operates within this matrix of subject positions involving negotiating the social order of hierarchy and power. Sundin-Huard (2001) argues the subject position of advocate is countered by the subject position of ‘good nurse’ in that in exercising advocacy the nurse threatens the identity of ‘good nurse’ and becomes the ‘uppity nurse’. A vignette illustrating this positioning is used as an exemplar. In the vignette, a neonatal nurse advocates, unsuccessfully, for analgesia as she is positioned and assumes the position of advocate and uppity nurse. In the training film ‘just a routine operation’, two nurses are similarly positioned as ‘junior without formal decision making power’ within a critical airway emergency in theatre. The resulting death of the patient in that scenario clearly demonstrates that this analysis is no mere sociological abstraction.

 

Conclusion

 

Nursing does not operate in a neutral power context. Nurses work in a gendered occupation underpinned by a range of discourses using certain languages that often position them into subordination. Those in formal power positions also understand these discourses and through language use can ‘call’ nurses into subordinate and contradictory subject positions. Hierarchies of gender, class and occupation provide the context for these positionings to take place. In order to minimise moral distress and the burden of emotional labour, nurses require an emancipatory understanding of these taken for granted power plays to enable practical resistance to develop. In this they can be aided by the discourse of humanism recognising the requirement for patient safety, comfort and cleanliness in the provision of quality care. The nurse who feels emotional and moral distress as a result of the actions and omissions of other power actors in the workplace, requires an analysis of the basis of this power relationship so that rather than turning in on oneself in defeat, a resistance can be mounted by creating alternative languages, discourses and power bases. Resilience in the face of threat in this context is not enough. Nurses need to find a language to speak truth to power and then forge political alliances with other actors, e.g. patient advocacy groups, to create alternative visions and structures to that which is advocated by neoliberals and the dead hand of managerialism.

 

 

 

 

 

 

 

Althusser, L. (1989). ‘Ideology and ideological state apparatuses’ in Lenin and Philosophy and other Essays: pp 170-186. London. New Left Books.

 

Lacan, J. (1977). Écrits: A Selection. Trans. Alan Sheridan. New York: Norton

 

Sundin-Huard D. Subject Positions Theory. Understanding conflict and collaboration in critical care. (2001). Journal of Advanced Nursing 34 (3) pp 376-382

How to do thinking in Nursing?

The picture above is the colorado river cutting its way through the rocks on its way down to the Grand Canyon.

Nursing and ‘On Intellectual Craftsmanship’ (C. Wright Mills 1959)

‘Doing’ professional registered nursing involves ‘hands on’ practical skills, but it also involves ‘thinking’. If there is no thinking then nursing has been reduced to a ‘procedure’, a sequence of ‘hands on’ practical skills which requires training rather than higher education and which can then be undertaken by care assistants. The thinking required is not just the recollection of facts to be applied to a patient situation. For example knowing what a drug does, what the correct dose is, and whether it is right for the patient, is a recollection of factual information. The mere collection of thousands of ‘facts’ in your head to be applied to patient care, reduces registered nursing, again, to a procedure, albeit complicated by the sheer number of facts. In a rapidly changing world of demographic changes, new technological developments, environmental damages, shifting health care delivery systems, geo-political conflicts and global socio-economic challenges, what is required is critical thinking supported by scholarship. The professional nurse with a higher education preparation will, or ought to be, engaged in critical thinking to move beyond merely recalling facts as we cannot insulate ourselves from the social and political contexts in which we work.

How do we do this? Sociologist C Wright Mills in 1959 clearly called for scholarship and criticised some sociologists at that time for not doing this. In the appendix to ‘The Sociological Imagination’ Wright Mills outlines his view on ‘doing’ social science in which he suggests that ‘Scholarship’ (“scholarship is writing”) is more important for the social, as opposed to the ‘natural’ scientist, than empirical research. If nursing is as much a social science based practice discipline as one that is also rooted in the biomedical sciences, then this argument applies.

Wright Mills referred to empirical science as the “mere sorting out of facts and disagreements about facts”. I would argue that this equally applies to professional nursing (Goodman 2011). Student nurses study evidence based practice and the application of research to practice. A good deal of this is factual information based upon empirical research . Students will, however, we required to critique this research. This will involve studying ‘rules of method’, i.e. how do we ‘do’ research, but arguments on this, e.g. is an interview better than a survey to help us answer this research question, are just so much navel gazing which Wright Mills wished to avoid if he could possibly do so, as he argued:

“Now I do not like to do empirical work if I can possibly avoid it” (p205).

Wright Mills was clear on this. He argued that the task of social science and I would add professional nursing is thus to critically engage in the real world, joining the nurse’s personal experience and intellectual life through critical reflective reason as the

“advance guard in any field of learning” (p205).

Empirical ResearchA central concept in modern science and the scientific method is that all evidence must be empirical, or empirically based, that is, dependent on evidence that is observable by the senses. The term refers to the use of working hypotheses that are testable using observation or experiment. In this sense of the word, scientific statements are subject to, and derived from, our experiences or observations. Crudely, this means we need to be able to measure things, we need to be able to see, touch, hear…..

 

Wright Mills in arguing for craftsmanship in intellectual life implicitly acknowledges in the ‘Sociological Imagination’, the need to go beyond simple empirical knowledge in forming policy action when he asks social scientists in their political and intellectual tasks to clarify the contemporary causes of uneasiness and indifference (p13) to personal troubles and public issues.

The personal trouble of lying in soiled sheets in a hospital ward has to be linked to the public issue of the provision of care for older people in acute hospitals. This issue and our indifference to it, or our unease with it, has to be critically examined to seek answers beyond simply blaming uncaring individuals.

The social scientist is not to merely describe the contemporary elements of social life but to engage with it. The nursing ‘scientist’ is not to merely describe contemporary elements of patients’ experiences, e.g. abusive care, but to engage with it. Professional nurses charged with delivering care are thus asked to engage in critically understanding the social, political and economic structures in which care occurs.

Craftsmanship

Wright Mills uses the word ‘craftsmanship’. The use of the word ‘craft’ appears here to differentiate the activity from that of mere mastery of elaborate discussions about research method and which would quickly make one “impatient and weary” (p195). A craft suggests development of skill by diligent constant practice, honing one’s technique by reference to finished products and products in the process of being created to evaluate their flaws and strengths and then adjust accordingly. This is reflexive practice in that the work as it continues is being constantly worked and reworked as required. It suggests leaps of imagination and intuitive thinking and practice in the creation of a project. It calls for a departure from strict adherence to a rigid structure of routines, methods and frameworks. It also suggests a measure of artistry in thinking. In other words a potter ‘crafts’ his pot, as the clay spins there is a constant feedback to the craftsmanship of what is happening, he or she constantly adjusts the application of skill to fashion what they want. Some of this is under conscious control, some of it is unconscious based on years of experience and input. Likewise, thinking and scholarship can be a craft in this manner. The end product is not a pot but a theory, an argument, a series of questions, an hypothesis. In fact there may not be an end product as thinking may be continuous.

The scholarly craftsman is his or her work as their craft develops alongside who they are. Scholarly craftsmanship then is a state of being not only doing:

“Scholarship is a choice of how to live as well as a choice of career” (p196).

When Wright Mills wrote that:

“admirable thinkers…do not split their work from their lives” (p195)

…he preconceives notions of lifelong learning that are to follow.

Nursing practice if it were to take this concept on board may then have to consider a break away from a wage based employee model where a nurse works for 37.5 hours per week to a salaried professional/intellectual model whereupon the nurse would continue to critically reflect on issues pertinent to speciality and patient group outside of NHS contracted hours. Given the current context of the NHS and clinical practice this seems highly unlikely for clinically based nurses. But if not them, who? If not now, when? If not here, where?

To undertake this craft he asks students and social scientists to keep a journal to enable the development of the intellectual life, of the craftsmanship of social science. This should consist of ideas, personal notes, excerpts from books, bibliographical items and outlines of projects. He suggests that journals should record ‘fringe thoughts’, snatches of conversation and even dreams. This will also include the taking of copious notes from books and this needs developing into a habit.

Since Wright Mills outlined notes on journal keeping there has been the explosion onto the scene of information technologies, elearning and web 2.0. These are now new tools that were unavailable to Wright Mills. However the essential nature of scholarly activity should not be lost in any infatuation with new technologies, rather these gateway technologies could facilitate critical enquiry and journal keeping.

Wright Mills’ work thus calls for the development of scholarship as a core intellectual activity. However, critical scholarship within nursing is under threat both in practice and in Universities, skewed as it is towards empirical enquiries and buckling under the weight of bureaucracy, managerialism and the demands of the corporate University. There is an urgent need to rediscover it if we are to address the complex questions and serious issues of our age such as inequalities in health, care of frail older people, health service funding, diabetes, obesity and cardiovascular disease, depression, anxiety, the social and political determinants of health and climate change. Nurses can choose to engage with this agenda or not.