IN THIS ARTICLE, we discuss nursing from a critical perspective in relation to person-centeredness, equality, and sustainability. Our point of departure is a Western postmodern context. With a special focus on a nursing environment, we will construct a theoretical framework for nursing that can serve as a tool for nurses to meet the requirements of social justice in health care. Inequity in health care is, on the one hand, caused by different structures in society, and, on the other hand, by norms and stereotypical values from health care professionals, both leading to unequal care of different patient groups. An underpinning perspective for this article is the everyday lifeworld of human beings in today's society. Subsequently, we also use the metaparadigm concepts—environment, health, person and care, in the light of the lifeworld.
THE WESTERN HEALTH CARE CONTEXT
Since the 1980s, New Public Management (NPM) has had an influence on health care in all Western societies; including Sweden.1 NPM is an approach to running public service organizations in government and public service institutions. It was first introduced by academics in the UK and Australia to describe approaches that were developed during the 1980s as part of an effort to make the public service more “businesslike” and to improve its efficiency by using private sector management models.2 The introduction of NPM approaches also led to a shift in health and welfare values and changes in how we speak and think. We now talk about “produce” health, “perform” service, do “quality assure” work, and give “value for money.”
Statement of Significance
What is known or assumed to be true about this topic:
The metaconcepts of nursing are well known worldwide but are given different meanings depending of perspectives in the diverse nursing theories. The concepts constitute a guide for both research and practical nursing care. The concept that is less developed is nursing/caring environment, and since Nightingale and the first nursing theorists the concept environment has been in infringed in favor of the development of, for example, the concept of health. Nursing is a normative discipline, and generally it lacks critical aspects (eg, who is receiving care and who is not) and there is also a lack of knowledge of environment issues that enable inequality in care.
What this article adds:
This article adds a reconceptualization of the metaconcepts where the concept environment is in focus. Environment is expressed as different “rooms” that affect people's lifeworld, including health, illness, and the opportunities of getting equal care. The article also highlights the importance of AOP regarding discriminative structures in some “rooms” in societal and health care institutions. Just as important, is an awareness of how the own attitudes, values, and norms can affect the encounter with care-seeking persons in the “room” for interaction and practical care. The article finally adds a model that illustrates the “rooms” of the metaconcept environment.
In many Western countries, changing demographics, advances in technology, and a need to care for an increasing number of elderly people have become a fact. Although equality, social justice, and human rights permeate ideals concerning how care should be provided, this is not in reality always the case. Equal care is linked to human rights,3 which is consistent with the International Council of Nursing's code of ethics.4 However, the hegemonic structure in health care, as in society, where white middle- and upper-class men are the dominant group, has remained relatively unchanged,5 and at the same time as the population becomes more heterogeneous. According to Hutchinson,6 nursing's interest in social justice has come at a time when disparities between the rich and the poor have widened.
Social justice in health inequalities is closely linked to social determinants of health such as socioeconomic status, age, gender, and ethnicity.7 , 8 In recent years, studies have shown that many patients are dissatisfied with the care they receive, and this dissatisfaction involves neglect or unequal treatment.9 This increases the requirement on nurses to have knowledge to pursue emancipatory nursing, including an antioppressive practice (AOP), as well as an awareness of how one's own norms and stereotypes affect the encounters with patients.
In this article, we highlight theoretical knowledge to formulate a theoretical framework that can serve as a tool for nurses when providing emancipatory nursing and encounter the person behind the patient role.
PERSPECTIVES ON EMANCIPATORY NURSING
Theories and models developed within nursing have had their base in modern society.10 Many of the older nursing theories have tended not to highlight structures of oppression, where focus was on individuals in relation to either biological models or self-care, or on holistic care and more recently on patient-centered care.11 However, there are theories that highlight social justice as a core nursing value. Watson12 discusses social justice as part of her theory, which challenged nursing to deal with the social inequalities that cause suffering for individuals and communities. Internationally, postcolonial theory and emancipatory knowing are stressed as being important to nursing.13 , 14 Postcolonial theory can offer a means for addressing health disparities; it can also provide nurses with tools for analyzing social inequities and a framework for understanding health inequalities. Several authors have pointed out the importance of developing a critical emancipatory caring praxis to improve and protect human rights and health equity.8 , 14–16 According to Boutain,17 social justice advocates use of critical paradigms to explore how oppression based on racial, ethnic, class, and gender relationships influences health.
AOP has had a predominant position with regard to developing a more equal and emancipatory nursing.6 The focus of AOP is on scrutinizing and questioning structural factors, such as economic and political elements, that construct preconditions above and beyond the patient-nurse encounter. In addition, there is a growing awareness of the interaction between interpersonal approaches and societal structures. This concerns, for example, questioning personal issues, values, perceptions, and assumptions.8 Health care professionals' conscious or unconscious norms, values, and attitudes have been identified as partial explanations for health care inequity.18 , 19 According to Martinsson and Reimers,20 norms refer to ideas about the cultural forces that regulate and control human notions and behavior. Although social norms are essential to making the world understandable, they may also imply power and privileges, as dominant groups in society have the authority to identify their norms and values as the right ones. This can result in inequity, marginalization, “otherization,” and oppression of people who fall outside these norms. The goal of a norm-critical perspective is to contribute to more equitable health care that includes an awareness of different norms, which can enable an understanding of power orders and inequity.21 Different norms work through the social categorization of groups and individuals, based on what is considered normal (eg, being a white woman). Awareness of norms can thus promote an understanding of unequal power distributions due to various generalizations (ie, different patient groups). Hence, we claim that a theoretical emancipatory perspective in nursing that focuses both on norms and on structural inequity is lacking and needs to be adapted to today's health care. Therefore, the aim of this article was to develop a theoretical framework in nursing with an emancipatory critical perspective that integrates structural inequity and intra-/interpersonal approaches with a focus on environment.
EVERYDAY LIFEWORLD AS AN UNDERPINNING PERSPECTIVE
The concept of lifeworld has its basis in phenomenological philosophy,22 and from a lifeworld perspective, a person's life situation is perceived as personal and shared, and as social, material and cultural. van Manen23 defined various meanings within the concept by talking about relations, time, body, space, and place as lived and as things that constitute the lifeworld. However, in this article, we have chosen to use Alfred Schütz's theory of lifeworld perspective, as it includes, in addition to philosophical themes, the idea of a social and shared reality. According to Schütz, the lifeworld can be divided into 2: On the one hand, there are fellow-men in the direct and present world with whom we share space and time. On the other hand, there is a “world of contemporaries,” representing both the past and the future world, for example people and cultures with whom we have no direct personal contact. We do, however, share a community of room, time, and a “world of contemporaries.”24 From an emancipatory critical perspective, the focus could be on seeing a person from a daily lifeworld perspective, including the person's experiences of health and the meaning he/she gives these experiences, in light of person-centeredness and equality aspects. The concept of sustainability has an evident position within such a perspective. The United Nations25 has established 17 goals to be globally implemented as part of the effort to achieve sustainable development. The third goal primarily targets health care, in that it aims to ensure healthy lives and promote well-being for all at all ages. Issues related to the consequences of sustainability in nursing involve the challenge of developing curriculums in nursing education programs, nursing care practices, and in health care organizations.8
Although the focus is on the metaparadigm concept environment, we briefly present, from a lifeworld perspective, the other metaparadigm concepts; health, caring, and patient, as they both affect and are affected by the environment.
On the Environment and Lifeworld
The concept of environment in nursing is insufficiently problematized in relation to what is currently needed in both hospital and home nursing care.10 Today, a question to pose is: What in the caring environment is vital in supporting good quality nursing? Already in the 19th century, Florence Nightingale mentioned the environment as a key concept in relation to prevention of health and in recovery from illness.26 A modern definition of the metaparadigm concept of environment refers to human beings, significant others, and physical surroundings, as well as to the settings in which nursing occurs, which range from private homes to health care facilities, to communities, to society as a whole. According to Fawcett and DeSanto-Madeya, the metaparadigm concept environment also “refers to all local, regional, national, and worldwide cultural, social, political, and economic conditions that are associated with human beings' health.”27 (p6) In addition, the concept of nursing geography is of great interest for research on the significance of places and spaces in terms of nursing care and practice.28 , 29 Phenomenology and existentialism have inspired postmodern perspectives on geography, by highlighting the cultural and the social conditions. This reflects an interest in what meanings people ascribe to places and spaces and nursing geography consequently explores the lived places and spaces in which professional care takes place. Furthermore, space and place can be understood as the material room of society, such as infrastructures and institutions. How people experience themselves in relation to societal institutions, including health care, are pivotal when it comes to equality and sustainability. According to Foucault,30 institutions are constructed with surveillance built into the system to create docile human bodies. Expressed in another way, all institutions are carriers and constructers of power, leading to a power order that both professionals and patients are affected by and must relate to. For nurses, performing emancipatory nursing, it is important to be aware of both structural and interpersonal barriers to meet requirements of equal care. The goal of nursing is to create a room where people can dwell and that the persons inhabiting such a place understand the interactions they are a part of and feel secure in them. Unlike how people live and experience a room, lived place refers to how they perceive the physical spatiality of a room,31 and nursing geographical perspective has the potential to inform clinical practice about how the environment matters in nursing.32
On health and the lifeworld
The metaparadigm concept of health is pivotal in nursing theory and caring practice, however, from different perspectives—perspectives that signify in what ways nurses should work to promote and restore health, prevent disease, and alleviate the suffering caused by illness. Nightingale pointed out the importance of a good care environment in promoting reparative processes and optimizing patients' ability to achieve, retain, or maintain health.26 Furthermore, during the 20th century, the view on environmental influences on health found in nursing theories has shifted in content. There has been a movement from seeing health as a person's capacity to adjust to the environment toward holism, that is, from viewing health as dependent on the surrounding environment to viewing a person as a unified whole who interacts with his/her environment. Knowing the complexity involved in defining health is basic to understanding a person's experiences of health. But, in contemporary nursing, definitions of health need to be complemented by more explicit critical and environmental aspects, the aim being increased equality and social justice.15
On the person/patient and lifeworld
The predominant philosophy in conceptual models of nursing is humanism, although in the face of different perspectives on the concept of the person.
In contemporary nursing, the assumption is that a person has a desire to feel wholeness and deeper values, which would be promoted by a lifeworld perspective with the main focus on “Who is this person”? Four different but related qualities concerning the concept of person have been explored, namely the attribute, the reflective, the moral, and the embodied quality. When these qualities are integrated, they represent the authentic self.33 The patient's narrative will be the starting point in establishing person-centeredness and an equal caring relationship, in knowing who the person is.34 Conceiving of the patient as authentic may be the most facilitative approach for applied emancipatory nursing, which relies on understanding the person and the person's lifeworld.
On caring and the lifeworld
The term “care” originates from the Latin caritas, meaning loving, graciousness, and charity.35 In literature with a lifeworld perspective, caring has often been described using metaphors such as “caring for insiderness,”36 and together with Hutchinson6 and Todres et al,36 we argue for a lifeworld-led care. However, what does this mean? We claim that, from a lifeworld and caring perspective, meaning has its foundations in values and beliefs that focus on the care-seeking person's perspective. This includes assuming a certain responsibility for patients and their relatives as well as for oneself as a professional. As we see it, responsibility becomes manifest through the fact that nurses are academically educated, skilled, and paid for their work. Caring is a way of “being in the world,” and when adapted to nursing it extends from the ontological level to practical nursing work,37 directed at patients' bodies. Very few professions deal with bodily intimacy, bodily fluids, and excrements in the way that nurses do, and already in 1991 Lawler37 described nursing as “dirty work.” Later researchers Lindahl38 and Rudge and Holmes39 have used the concept “abject” to describe this dimension of care.
A THEORETICAL FRAMEWORK FOR A CRITICAL AND EMANCIPATORY APPROACH IN NURSING
The framework that we have formulated is a way to illustrate how an emancipatory nursing can be conducted. It encompasses both overall ideological structures with inherent value systems and ontological aspects of the everyday world; see the Figure. Prevailing ideologies or ontological starting points contain regulative ideals, or norms, that are simultaneously constructed by and construct society. Different structures and institutions in society both construct and differentiate the population, thus governing possible identity positions, which is something that all humans must relate to. To illustrate our framework, a model illustrating emancipatory nursing has been developed. The model is inspired by Bronfenbrenner's model40 showing how ecological systems are surrounding the person at the center.
All levels in the model (Figure) affect all person's activities and lifeworlds that is both the professional and the one who is cared for.
In this room, we find the different ideologies that rule a society we call our own, containing general values taken from political, economic, and religious perspectives. In all societies, there is an ongoing struggle over what beliefs and ideas are to be the hegemonic.41 The hegemonic ideology is then spread through various discourses, which point to, among other things, what is and what is not considered normal and desirable in a particular time and context.20 Having a critical emancipatory approach to nursing at this level means being able to review and evaluate the consequences of the various discourses in health care (ie, how do we talk about care?). One critical reflection concerns whether the economic and political discourses are in line with humanism and human rights, or whether the dominant discourses contain other central values. An AOP requires this sociopolitical knowledge, as it becomes necessary when the nurse-patient relationships requires that the patient's situation be put within a wider sociopolitical context. Doing this also includes facing one's own assumptions about health, health care, and wider health policy that are taken for granted.8
The focus of AOP is on scrutinizing and questioning structural factors, such as economic and political elements, that create preconditions above and beyond the patient-nurse encounter.6 The societal room consists of societal and organizational structures in society and health care, which establish the prerequisites and conditions for encounters between health professionals and care-seeking persons. According to Schutz,24 the everyday lifeworld is a practical and social world, giving us a shared reality. His theory of the everyday lifeworld is not limited to purely philosophical questions, but also to human individuals' life in society. Thus, on a material level, the societal room affects the everyday life of both those seeking care and those who provide care and treatment. It is in this room that health care can create docile human bodies according to the surveillance built into the system. The power order constructed also involve issues of unsustainability, as they are connected to sociopolitical and socioeconomic inequalities, in a wider perspective the equal right to health.8 With a critical emancipatory nursing approach, we can pose questions about how health care can ensure that care is given equally, and about the extent to which the patient is considered to be involved in his care.
In order to succeed in emancipatory nursing, it is important to be aware of what a room is doing to a person in need of care. This room illustrates how the physical and material aspects in, for example, a hospital or in a private home, affect the autonomy and power of the patient. The goal for emancipatory nursing must be to create a room where people can dwell (Figure). This means a room that allows the people who inhabit it to understand the interactions they are part of and feel secure in them. The person inhabiting a room is never present in anonymity, but always in a degree of intimacy. In a patient room at a hospital, however, the opposite situation exists. Boundaries between the private and the public sphere may be blurred when professional care and technologies enter the room.42 , 43 Tacit agreements about how to behave in this room communicate power relations that affect the atmosphere. When planning new or refurbished patient rooms in hospitals, nursing homes or in home settings in the future, issues of sustainability need to be considered.44
At the next level, the focus is on the encounter between the professional and the care seeker. Implicit rules, or tacit agreements, concerning how to care for a patient may be hard to discern or observe, even for professionals. The power order relates to the professionals' superior position, which is based on their medical expertise and knowledge of the organization's routines. The patient, on the other hand, often has a subordinate position, where the illness itself causes unease and existential anxiety. People who belong to a nonprivileged group, due to gender, class, or ethnicity, are at risk of being treated in a lesser way compared with the groups that constitute the “norm” in society. This mays lead to marginalization, or “otherization” of patients falling outside these norms.21 For emancipatory nursing, it is pivotal that the nurses' own preunderstandings, including awareness of different norms, are reflected and made conscious. This can be one way of enabling an understanding of power orders and inequity,8 , 18 as these conscious or unconscious norms, values, and attitudes can be an explanation for health care inequity. Likewise, persons with high social positions can lose the superiority they are used to, due to low health literacy. Encounters between nurses and patients thus shape a shared experience, both through talk and activities, and in this interpersonal encounter, a norm-critical approach is of value. When people interact with each other, it is possible to create a “you-orientation,” becoming aware of each other, in a simple and mutual way. It is in these “face-to-face” relationships, in encounters with care-seeking persons, that lived experiences can build interpersonal relationships. The professional can be a “fellow-man who shares with me a community of space and a community of time.”24
The everyday lifeworld room
The center of the model is the lived world of individuals. A person's everyday lifeworld includes the body, self-identity, and subject positions as well as his/her values, health experiences, and knowledge built on previous experiences. People are primarily oriented toward the future, where individual acts depend on thoughts, executed in comprehensive ways.24 This also applies to the person in need of professional care. The model contributes additional content to the concept of the body in nursing. Perceiving the body as lived means encountering the authentic person and seeing the body as vulnerable, unforeseen and representing identity and a variety of cultural and social values. Merleau-Ponty,45 commonly considered the “philosopher of the body,” wrote that the body is often taken for granted. However, when meeting another person, it is generally the body we perceive and judge, based on our individual norms. Foucault30 described this as culture, society, gender, and class are affecting the body. Schutz (in Zahavi),46 as well, perceived the physical body as a field of expressions that reveals experiential life. Bodily behaviors both express and indicate subjective experiences, but also deliberately seek to express messages through behaviors toward others. A person, a patient as well as a professional career, can be understood as being authentic when he/she can communicate personal beliefs, values, and experiences. These expressions have to be understood in light of that person's being in the world,33 a being that can be labeled as intrapersonal and affected both by power structures and power order.
The aim of this article was to develop a theoretical framework in nursing with an emancipatory critical perspective that integrates structural inequity and intra-/interpersonal approaches with a focus on environment. Structures and organizations put limits on the possibilities for the people's health and/or access to care and treatment. What then is required in the various “rooms” described in our model (Figure) to enable nurses to provide equal treatment and avoid discriminating care? Our answer is that there is a need for both structural AOP and norm-critical competence in nursing. The nurses need to engage in critical reflection, which includes questioning their own values, perspectives, and assumptions, as well as those of other people. According to Wilson and Beresford,47 emancipatory models focusing on purely structures have failed to involve the professionals' own norms and stereotypes. There is a risk that by that the focus will remain on structural understandings of power.6 Together with other professionals, nurses are part of the health care structures, and due to lack of knowledge, they may discriminate against or oppress patients.47 Our critical lifeworld approach is an attempt to integrate intra-/interpersonal approaches with the focuses on societal structures.
Dahlberg et al48 argue that a person-centered approach to professional care can be improved by a lifeworld-led care. Such an approach involves an existential view on the person and well-being and a philosophy of care grounded in a lifeworld perspective that directs care practices. We argue that the norm-critical approach requires one to scrutinize one's own preunderstandings and attitudes before the encounter with the care-seeking person. The everyday lifeworld is a practical and social world, giving us a shared reality (see Schutz)24 and, thereby, not limited to purely philosophical questions; it also affects the human sciences.
Caring through use of a normcritical lifeworld approach can minimize the risk of discriminating against people (ie, treating them unequally). Illness and disease often transform the body and this becomes awkward. Cultural markers such as tattoos and piercings can thus interfere with values, norms and caring practices. Through the idea of normality and abnormality, different norms comprise regulative ideals about both bodies and behaviors. Consequently, some people are seen as normal while others are defined as deviant. Persons with “deviant” characteristics can be categorized as being “otherized.”21 The Western perspective on the body is undeniably connected to a slim, fit, and perfect working body. Hence, norms about a clean body do not fit with a body in illness, disease, or the closing stage of life, which becomes a body in need of professional nursing care. This work is imbued with integrity, intimacy, and respect for another person's body, even when our norms do not match the patient's body as (ie, a female body) a weary body or a transgender body. Body and embodiment are aspects that need to be reflected on and verbalized in nursing, in a more comprehensive way.38 , 49
Schutz's24 description of a face-to-face encounter can be compared with person-centered philosophy, as they require the nurse to invite patients to narrate their experiences. If this does not occur, the result may be stereotypic judgments of patients. Hence, it is easier to become fellow-men if you have a similar background (ie, gender, class, or religion) when the risk of “being otherized” is minimized. The health professional's awareness of his/her own prejudices is an important prerequisite for treating the care seeker in an equal way. This also implies having an intersectional perspective (ie, being aware that social positions such as class, gender, sexuality, functional ability, age, and ethnicity affect the caring encounter). The care-seeking person does not necessarily share the values and attributes of his own culture, meaning that not all human beings are heterosexual, that families can look different, etc. Being “wide awake,” a concept used by Schutz,24 means having a willingness to be open and to change one's presumptions, and not let stereotypical attitudes prevail. The term “norm criticism” has been developed from gender considerations in a Swedish context.21 We suggest that it can fill the gap between structural AOP and interpersonal equity in health care. An attribute of a norm-critical lifeworld-led approach is being aware of excluding norms, and this awareness includes critical self-reflexivity and questioning societal systems of dominance and oppression. The meaning of the norm-critical lifeworld-led approach is to contribute to more equitable health care, in all context that struggles with prejudice, discrimination, and exclusion. Enhancing nurses' awareness of marginalized perspectives may be a start in eliminating health inequity and ensuring that the health care provided is respectful, appropriate, and of high quality.18 Our model can illustrate how inequity not only is created by structures, but also in encounters. The different rooms can illustrate what and how subordination and superiority are constructed (ie, how the sick room is designed, or the nurses' preunderstanding and norms for a patient's body). Central to the model is not only the patient's lifeworld but also the nurse's own lifeworld. According to Schutz,24 things that are unfamiliar do not become a fellow person if they still remain a person in the “world of contemporaries,” and they maybe also be “otherized,” if they are outside what the nurse views as the norm.
Neoliberalization of welfare services had taken the radical egalitarian vision of social justice, and in line with this, Rush and Keenan50 argue that the limitations of AOP and its emancipatory intent have to be understood in terms of the restoration of welfare. Making use of AOP and norm-critical reflexive lifeworld-led care can be a tool for realizing and recognizing the mechanisms that operate when people are discriminated against, or “otherized,” on both a structural and an interpersonal level. To combinate reflexivity with AOP increases the chances to perform an emancipatory nursing, which can increase social justice in health care.
CONCLUSIONS AND PRACTICAL IMPLICATIONS
Our critical lifeworld approach can be seen as a guide for developing a critical emancipatory perspective in nursing care practice. Our model can be used in nursing education, giving nursing students time to reflect and discuss how they have exposed patients or persons to otherization. This can be done in workshops where students reflect and transform their feelings into thoughts about their own experiences, when being exposed to norms through others' eyes and can feel the chafe.
Suffering and well-being are included in the concept of health, and we have developed our thoughts on emancipatory care based on a lifeworld perspective. The demographic structure of today's heterogeneous societies is different from past structures, changes caused by migration, but also by the increasing number of old people in the Western world. Health and care tend to be more unequal, even though social sustainability is an important part of nursing care today. With a critical emancipatory nursing approach, we can pose questions about how health care can ensure that care is given equally and about the extent to which the patient is considered to be involved in his care.
The knowledge we contributed is aimed at our critical lifeworld approach where we highlight the complexity of giving and receiving care through a model. Both societal structures and personal values and norms cause social injustice in health care and the model can be used as a tool for nurses to highlight critical reflections on equality in nursing and also, and for nurses to question their own values, perspectives, and assumptions, as well as those of other people. Both health care and its underlying theories are undergoing constant construction. Thus, the present contribution is based on conditions for today's Western society.
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