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Original Articles

Intersectionality and Critical Realism

A Philosophical Framework for Advancing Nursing Leadership

Aspinall, Cathleen MSc, RN; Jacobs, Stephen PhD; Frey, Rosemary PhD

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doi: 10.1097/ANS.0000000000000275
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Abstract

MANY of the current approaches to studying leadership in nursing focus on empowerment and empowering work environments as being an enabling factor.1–3 However, they do not adequately address how gender, race, class, sexuality, and postcolonialism can create an intersecting matrix of oppression, which influences nurses' perceptions and experiences of empowerment.4,5 Realizing this gap and responding to calls for nurses to acknowledge and act upon the intersectional nature of interlocking systems of power,6 we searched for a philosophical framework that could inform an intersectional study of nursing leadership.

This article presents the philosophical groundwork for an approach to studying leadership, which incorporates intersectionality theory with critical realism. A search of the literature, using Cinahl, PubMed, PsycINFO, Embase, Ovid, and Google Scholar databases, reveals that the application of intersectionality in combination with critical realism is a new approach to nursing leadership research. We justify the selection of this methodological approach for studying nursing leadership by describing how these 2 knowledge projects combine and complement each other.

Statements of Significance

What is known or assumed to be true about this topic:

Nursing leadership leads to safer health care and better outcomes for patients. Accordingly, there are calls for all nurses to be positioned to lead, so they can inspire, innovate, and transform today's health care services to meet the demands of the 21st century. With these calls come some assumptions of the neutrality of the social positions' nurses hold, including their effect on access to opportunities and empowerment.

What this article adds:

If nurses are to address inequalities and the complex needs of a multicultural society, they first need to understand how privilege and oppression can impact on their own ability to practice professionally. This article provides a philosophical framework, which can make visible the impact of a matrix of multiple social positions nurses hold. In doing so, it offers a theoretical foundation for future research and education while engaging nurses in a critical dialog about nursing leadership.

We begin by providing a critique of current theories of empowerment and their relationship with nursing leadership. Second, we review issues on the current international nursing landscape, which identify the need for intersectionality and critical realist informed research. Finally, we explore the origins and compatibility of both philosophical positions, concluding with recommendations for future studies.

NURSING LEADERSHIP AND EMPOWERMENT

Nursing leadership has been proven to contribute to safer health care, so internationally there are calls for “all” nurses to demonstrate leadership at all levels of health care organizations.7 More specifically, nurses' clinical leadership leads to safer patient care; when nurses are involved in institutional decision-making, hospitals are more likely to provide better patient experiences.7,8 A discussion of the effects of poor nursing leadership is beyond the scope of this article, but it is known to be a major contributing factor to deficient standards of patient care.9 Suggestions about how nurses can be supported to develop as leaders include empowering them by transforming their work environments, allowing them to practice to the full extent of their education and training, promoting their achievement at higher levels of education, and having nurses as full partners in redesigning health care systems.7

Currently, supporting individual empowerment and providing empowering working environments are seen as approaches that can lead to increased nursing leadership at all levels.1 Conversely, when nurses experience disempowerment, they struggle to function as clinical leaders.10 However, it is difficult to find a clear definition of empowerment in the nursing literature, mostly due to the many different theories that are in use.11 Nurses are said to be empowered when they are free from oppression, have knowledge and power which they can exercise, are psychologically empowered, can empower patients, empower themselves, or are empowered by organizational structures and others.1,2,12

Kanter's theory of structural empowerment has been used in many nursing research programs to identify the positive effects of empowering work environments.1,13 According to this theory, an organization is structurally empowering if it provides access to information, resources, support, and opportunity. To access these structures, an employee must have either formal power (specific job characteristics) or informal power (interpersonal relationships with superiors, peers, and subordinates), with their degree of success in obtaining access, resulting in either psychological empowerment or feelings of disempowerment.14

Internationally, empowerment has been a major concept in nursing research focusing on clinical leadership; it has also been influential in leadership frameworks and accreditation programs.15–18 However, critics suggest previous research has been positivist and paid little attention to context, culture, and gender.3–5 This oversight is important, as the concept of empowerment includes transforming unjust social institutions.19 One criticism of Kanter's theory is that it is not a nursing theory and therefore does not adequately address the professional context of nursing. Moreover, it is accused of maintaining a patriarchal view of empowerment.11 The social position of nurses within a health organization can affect their opportunity to access both formal and informal power and therefore warrants further exploration.

To summarize, nursing leadership at all levels is essential for safer health care and safer health care organizations. Empowerment is considered a valuable factor enabling all nurses at any level to be a leader.8 However, given the argument that not all nurses have equal access to opportunities for empowerment, there is a need for a fresh approach to examining what is ascribed to their intersecting social positions by society and within the sociopolitical context of health care organizations.

CURRENT LANDSCAPE

Reviewing the literature identifies inequities, which support concerns about equal access by all nurses to empowerment and thereby nursing leadership. For example, a growing body of international literature identifies racism as a confronting issue facing indigenous nurses in New Zealand, America, Australia, and Canada.20 Additionally, there are persistent levels of unconscious racial bias evident in health care providers in the United States who consistently demonstrate a more positive attitude toward white Americans and more negative attitudes toward people of color.21

These studies examine the impact of unconscious racism and implicit bias on patients, but it is surely not possible to switch off these attitudes when it comes to making decisions, which affect staff. For example, in many countries internationally qualified nurses report receiving lower pay, less upward mobility, and little recognition of their competency in comparison to domestically trained nurses, even when they have significantly more experience.22

Likewise, high levels of discrimination toward black and minority ethnic staff groups (BME) exist within the National Health Service in England. This prejudice against BME groups is shown to impede their ability to access leadership positions.23 These attitudes persist even in areas where BME staff outnumber white health care providers, demonstrating persistent and institutional racism. In parallel, there is an invisibility of black nurse leaders in Canada.24

Health organizations are historically hierarchical and maintain a dominant patriarchal discourse.24 This hegemony may explain why male nurses who have the same skill and experience level as females are promoted and paid more than women are.25,26 The same dominant discourse may also explain why white men most often occupy positions at the senior leadership level, and very few nurses (a predominantly female group) are found at board level.23,27

It is noteworthy that these examples from the literature demonstrate how a nurse may simultaneously experience privilege and oppression. For example, we see that, a white, female, domestically trained nurse may progress to a position of leadership more easily than an internationally qualified, black female nurse may, but still be limited by a patriarchal system.22,23,26 If these mechanisms, which are at play, are hidden, an individual may be unaware of these structures that lead to their advantage or oppression, both of which will impact how they quantify their level of empowerment.

Nurses are being called upon to explore and acknowledge the effects of intersectionality, globalization, microaggressions, privilege, and implicit bias on the marginalization of groups and individuals at the macro, meso and microlevels to resolve disparities in health.28 The effects of these same issues must also be explored within the nursing profession.29 We suggest that developing an approach to growing nursing leadership that is cognizant of the impact of multiple social positions is essential for the nursing profession. It is important to realize that a “one size fits all” approach to empowering nurses to be leaders may not work for all, because all nurses do not have equal opportunities.5,20,22 It is timely to use intersectionality theory to examine issues within the nursing profession.

INTERSECTIONALITY AND CRITICAL REALISM

Intersectionality has been used in nursing research for over a decade, mostly for addressing inequity and health disparities in the communities that nurses serve.21,30,31 Patricia Hill Collins presents a comprehensive genealogy of intersectionality, describing it as a knowledge project, which can have a fruitful dialogue with other knowledge projects. Focusing specifically on American pragmatism and its compatibility with intersectionality, Collins identifies themes, which have positive transformative possibilities for the 2 projects. Additionally, Collins noted that American pragmatism has limitations as a theory of social action.32(p20)

Given the need for action and encouraged by calls to search for the interconnections between bodies of knowledge and knowing and understanding,33 we have identified critical realism to be a worldview that can be usefully combined with intersectionality. Critical realism comes with a priori obligation to emancipate those in need34 and as such it can provide the theory of social action absent from American pragmatism.34 While a complete history of critical realism and intersectionality is beyond the scope of this article, the article does provide a concise overview of the background of each.

The origins of intersectionality in the United States extend as far back as the 1960s and 70s within the context of black women's activism and broader women's movements involving Latinas, Native Women, and Asian American women. Material produced by these earlier movements, such as the Combahee River Collective and authors such as Angela Davis, is considered early foundational work of the intersectionality knowledge project.32 Nevertheless, the term “intersectionality” was not introduced into academia and developed as a theory until 1989, by critical race theorist Kimberly Crenshaw. Since then, intersectionality can be found in many diverse academic fields. However, there are concerns that the political dimensions of social movement politics are being left behind, perhaps as they are considered nonscholarly.32 To obscure these political dimensions belie the purpose of intersectionality, which is to challenge social inequities, move beyond surface observations, and analyze the roots of injustice.35

Three central tenets form the basis of intersectionality. First, various oppressions can work together to create a complex matrix of power; the focus should be on analyzing how dominant ideologies and structures work together to create such a matrix. Patriarchy, racism, sexism, and colonialism are examples of such dominant ideologies. The emphasis of intersectionality is to discover the experiences of people who navigate such various oppressions at their intersection and to examine the processes of power at play.

Second, intersectionality holds that those who are privileged by the complex matrix of power maintain the status quo of inequity through a combination of norms about the dominant race, ethnicity, gender, and so on. Inequities such as these are evident in the implicit racism in health care organizations and the continuing dominance of white males in positions of leadership. The third tenet of intersectionality is that examining only one aspect of a person's social location will not illuminate the multiple experiences of oppression and co-occurring marginalization that a person may experience, because it hides the simultaneous processes.36

Critical realism has been recognized as useful in nursing research due to its foundation in human emancipation and its ability to assist with the complex problems that face nursing today.37 The origins of critical realism are mostly associated with British philosopher Roy Bhaskar, but as with intersectionality, there were others who were influential in its development, including Harre, Madden, and Archer.38 Emerging in the 1970s and '80s, the movement grew in the context of critical opposition to the positivist conception of science. The positivist approach held the opinion that the basis of knowledge was research of the observable.39 Bhaskar shifted the focus from theories of knowledge (epistemology) to theories of reality (ontology), with the empirical focus being to confirm the existence of real social structures through detection of their causal effects.

A central tenet of critical realism is that causal effects are identifiable through the examination of a reality that exists on 3 levels: the empirical, the actual, and the real.40 The empirical domain is one which we can observe, perceive, and experience as a result of the events and actions that transpire in the actual domain of which we may or may not be aware. The real domain contains underlying generative mechanisms (causal effects), which govern and facilitate events in the actual domain, and lead (whether or not detected) to experiences in the empirical domain.

A fundamental belief of critical realism is that of agency and structure. Bhaskar's theory argues that social structures emerge from the actions of individuals; these structures then exert influence over but do not determine individual behavior. The significance of this theory is that individuals can demonstrate the free will to act back against the structures at play. In a recent study, Porter demonstrates the interplay of 2 structures and their different effects on nurses (agents).41 The structure of racism was evident in 2 study settings, but in 1 the nurses' behaviors were influenced by the structure of professionalism. While not eradicating racism, the influence of professionalism curtailed outward expressions of it. This example demonstrates how multiple structures can influence each other and how people behave.

THE RELATIONSHIP BETWEEN INTERSECTIONALITY, CRITICAL REALISM, AND NURSING LEADERSHIP RESEARCH

Predating critical realism, intersectionality was born in the context of American black women's activism, proposing the belief that those frameworks, which look at race or gender in isolation, offer partial and incomplete analyses of social injustices. The call from these movements was to look beyond the surface and recognize the interconnectedness of multiple systems of oppression. We suggest that such an intersection of oppression exists within nursing, but as yet, its effect on developing nurses as a leader has gone underresearched.

Critical realism grew as a movement in British philosophy in light of a significant and vigorous critique of the positivist view of science that dominated the first two-thirds of the 20th century.38 It also was a call to look beyond the surface of what we know (epistemology) and to give a more complete explanation of generative mechanisms, analyzing how dominant ideologies and structures can work together to create a matrix of oppression. Similarly, previous positivist approaches to nursing leadership research have failed to look beyond the surface, an approach that can only lead to partial or incomplete analysis of a sociopolitical context4 in which nurses practice. Critical realism together with intersectionality can expose the connection between the intersecting oppressions individual nurses may experience and the dominant ideologies and structures of a health care organization. Once this connection is illuminated, the impact on nursing leadership development for all nurses can be examined.

Bhaskar, like philosopher Jean-Jacques Rousseau, held the belief that “people are born free but are everywhere in chains” and his work was dedicated to human emancipation.42 A strong feature of critical realism is the need to identify factors that may constrain actions taken by participants. Only once this is achieved can a person take steps to remove the constraints. This feature of critical realism springs from the notion of emancipatory action, where knowledge of why certain situations occur can provide the power to change them.43 This belief is synergistic with activist June Jordan's statement: “Freedom is indivisible and either we are working for freedom, or you are working for the sake of your self- interest, and mine.”44(p133) With the intent of freeing society from the restraints of earlier science structures, critical realism provides an emancipatory nature of knowledge. Emancipatory scientific knowledge moves from a monist perspective of a closed social reality and provides a basis for freeing people from oppressive social structures.45 For nursing, this means freeing nurses from structures that can privilege some but disadvantage others in respect to empowering them to lead.

Both intersectionality and critical realism aim to challenge the status quo by looking at what lies beneath the surface of what we observe and experience.32,40 Knowledge of what causes oppression, including how it comes to manifest at the empirical level, can provide the impetus to make changes and take action, which is fundamental to both knowledge projects. Intersectionality calls for the recognition of the effect of multiple oppressions on a person. Critical realism provides the tools to identify the structures, which contribute to this matrix of oppression and the generative mechanisms. The combination of both will allow for a more nuanced approach to studying leadership including the effects of intersectionality, globalization, microaggressions, privilege, and implicit bias on the leadership enabling empowerment of nurses.

A further point of contact between intersectionality and critical realism is that there is no prescribed way of “doing” either. Critical realism is not a true theory, methodology, or a single framework for doing research.46 Rather it is a metatheoretical position that draws from a philosophical well and supports both qualitative and quantitative methods of inquiry. Similarly, confusion exists regarding the application of intersectionality, partly due to ambiguity in its basic definitions and inconsistency in its conceptualization; it is considered to be a paradigm, a framework, a lens, a theory, and a perspective.46

Previous studies identify the value of combining the 2 approaches, although debate ensues around the categorization of social positions such as “women”.47 Taking a positional approach can go some way to resolving the issue of labels. Accepting that categorization of any social position does not provide a true reflection of “lived experience,” the positional approach uses them merely as starting points.48 This stance allows for the “lived experience” of each position to unfold as a part of the research process. This ambiguity in both knowledge projects, rather than being a weakness, provides for innovation and leaves the researcher with the ability to select the methods that most suit their question of inquiry.

This article suggests there are points of contact between intersectionality and critical realism resulting in a fruitful dialogue. For one there is confluence on the existence of multiple structures, which affect and influence the behavior of an individual. Second, there is the concept of agency, which means individuals can act back against the structures that may influence them, allowing for free will and action. These concepts underpin activist behaviors, which can result in activist movements. Furthermore, making these structures visible can provide the impetus for change at an individual level and can influence policy development at a societal level.49 We propose that identifying racism and bias, which privilege some nurses while discriminating against others, can inform education, promotion, and recruiting practices.

Regarding nursing leadership research, we believe that critical realism and intersectionality can shed light on the intersecting matrix of oppression some nurses experience, which will act as a barrier to empowerment and developing as a leader. Only when the impact of these intersections is known, can work begin to empower all nurses to be leaders.

CONCLUSION

The importance of leadership at all levels of nursing cannot be underestimated, and empowerment is an enabling factor of leadership.7,10 Empowering a diverse, globally transient, gendered profession who holds multiple social positions to be leaders calls for emancipatory ways of knowing. Knowledge of the impact of the matrix of sociopolitical, patriarchal, and hierarchical structures of a health organization on nurses and leadership also calls for an emancipatory approach. To date, studies of nursing leadership and empowerment do not adequately address these issues.

The combination of critical realism with intersectionality provides a new philosophical approach to underpin nursing leadership research. Both knowledge projects apply to many disciplines, but combining critical realism with intersectionality theory can be seen as providing a philosophically robust underpinning for nursing research.32,48 The shift, from an empirical- epistemological focus to ontological-emancipatory, is relevant to nursing's knowledge development and the advancement of the discipline of nursing due to the focus on critical reflection of the social, cultural, and political status quo.

This philosophical framework will support rigor in the preparation of any study design, while simultaneously offering evidence by which to judge the merits of the chosen methodology.50 Future recommendations are to apply this philosophical base to a study searching for a more nuanced understanding of the relationship between nursing leadership and empowerment. The integration of the 2 knowledge projects should be transparently reflected in each stage of the study design, informing the methodology, choice of methods, data collection tools, and data analysis.

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Keywords:

critical realism; discrimination; empowerment; intersectionality; leadership; methodology; nursing; nursing research; patriarchy; philosophy; racism; sexism; theoretical framework

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