Power is tolerable only on condition that it masks a substantial part of itself. Its success is proportional to an ability to hide its own mechanisms.
FROM THE TIME of the early Greek philosophers, humans have been interested in the concept of power: from who exerts power over others to how power operates in society.2 Historically, one way in which groups wield power is by achieving the status of a profession. With this designation, professions are able to self-regulate in the interest of the public good. The extent to which a professional group exercises control over both its self-regulatory practices and external pressures on its disciplinary domains (practice, education, and research) is a direct reflection of the professional group's status.3–5
Statements of Significance
What is known or assumed to be true about this topic?
There is a long history of philanthropic foundations influencing the discipline of nursing on its developmental trajectory to become a self-regulating profession, yet there is little critical scholarship in this area in nursing. We question the underlying assumption in the profession that engagements between foundations and nursing are benign, or without potentially adverse consequences for the profession.
What this article adds:
In this first article of a 2-part series, we use the theoretical lens of Foucault to add a critical social perspective of these engagements, specifically questioning how power dynamics have operated through discourse in the most recent Robert Wood Johnson Foundation's Future of Nursing initiatives.
Achieving high-level independence and control over a profession's destiny is seen as attained by some professions (medicine)6 and as an evolving endeavor for others (nutritionists).7 Although nursing considers the matter settled as to whether or not it is a profession,8 ongoing discussions about nurses in the United States “practic[ing] to the full extent of their education and training”9(p1) undermine these claims. In addition, others conclude that nursing remains a “semiprofession” as it lacks “autonomy from outside control and authority over clients,”10(p300) despite the discipline's proclamations to the contrary.8 Notwithstanding nursing's claim to professional status,8 external agents continue to have leverage over nursing's professional evolution.
In the United States, organized medicine has used coordinated strategic actions to affect nurse practice legislation. For example, as states and federal agencies expanded advanced practice registered nurses' (APRNs) scope of practice, the American Medical Association (AMA) and individual state medical groups entered the discourse to shape public perceptions of APRNs as unqualified and potentially dangerous if allowed to practice as independent health care providers.11–13 This is only the latest effort in medicine's extensive and consistent history of ensuring that nurses remain subordinate to physicians.10,14
To date, accounts of nursing acting collectively to further the discipline's interests, that is, acting with collective agency, have focused on how it has responded to threats to scope of practice.15,16 Missing in the literature, however, are accounts of the influence powerful groups (other than organized medicine) have on nursing and how nursing may be complicit in allowing external forces to shape the discipline. Also absent are accounts of how these powerful groups operate—seen and unseen, intentional and unintentional—with respect to nursing as a disciplinary body exercising collective agency and self-regulation. To that end, in this first article of a 2-part series, we explore how a different class of powerful groups—philanthropic foundations (henceforth, foundations)—has played an influential role in the nursing profession. Summarizing a burgeoning literature depicting foundations as powerful institutions able to shape select sectors within society, we also consider the self-regulatory societal expectations of professional disciplines in light of these external forces and the role of collective agency in withstanding these pressures and expectations. In part II, we focus on select Future of Nursing (FON) activities, the Robert Wood Johnson Foundation (RWJF) as progenitor of FON initiatives, and the 2 resulting FON reports.9,17 Through critical discourse analysis, we examine how control of enunciative privilege in FON initiatives challenges nursing's ability to enact collective agency. We conclude the 2-part series by considering RWJF's role on actions nursing takes (or fails to take) in determining its future.
INSTITUTIONS, DISCIPLINES, AND POWER/KNOWLEDGE
One cannot comprehend how a particular group or organization wields its influence without a grounding in the concept of power. Foucault is considered one of the preeminent voices for understanding the nature of power in society, particularly, how institutional power (eg, schools, prisons, hospitals) reaches into the fabric of everyday life.18 Foucault, whose work is used widely in discourse analysis, presents the difficulty of not having a unified theory; there is no one Foucauldian theory. However, Foucault does offer “a series of quite specific, precisely theorized analyses, each one mobilizing a customized methodology designed to address a theoretically defined problem from a strategic angle of inquiry.”19(p366) Common threads emerge from his work: the importance of power, knowledge, and their relationships, and the use of history to explain the present. Foucault believed that all societies generate means and mechanisms through which discourses of every kind (speech, text, images, etc,) are controlled, organized, and distributed, and in doing so, regulate the very power of those discourses.20
Power and discourse
For Foucault, power is a continuous thread woven throughout society; power is everywhere and works at the microlevel in routine practices (everyday speech or word selection), as well as at macrolevels (enacting laws). Thus, power is both productive and repressive; it creates and constructs and is created and constructed by thoughts (knowledge) and behaviors (actions) within a society.21 In other words, “Power is the thin, inescapable film that covers all human interactions.”22(p4) All of us constitute “political surfaces” on which power plays out; we are “mapped and territorialized by dominant discourses.”23(p5) Of particular importance in Foucault's conceptualization is that power often operates sans conscious recognition. The effects of power often are invisible and understood as individual or collective knowledge of how the world operates; it is the belief that our current situations and the social dynamics driving them are just how things are. Given that power frequently is used for social control and oppression purposes, Foucault makes clear that an analysis of power must encompass “the techniques and tactics of domination.”18(p102) His inquiry of power does not end with asking which people or institutions dominate over others but rather, his work focuses on mechanisms of power: of how power operates in everyday social interactions and how individuals take up the effects of power in forming their working knowledge of the world.18 Symbolized by the term “pouvoir/savoir” or “power/knowle-dge,”24(p55) Foucault views power and knowledge as inextricably linked—operating in dynamic fashion, through discourse. Nursing's power over and knowledge of itself, then, is produced within discourses of and about nursing.
Archaeology and genealogy: analyzing the power of discourse
Foucault's early work used archaeology for analyzing power/knowledge, shifting later to genealogy. Foucauldian scholars note that distinctions between these 2 methodologies are not exact.25 In general, archaeology focuses on systems and procedures that regulate the “appearance and control of discourses, along with the processes of exclusion and inclusion within them.”20(p30) Archaeology reveals the hidden and buried conditions of power/knowledge, including how discourse constrains what can be considered, spoken, written, and/or implemented.25 In a 1971 interview, Foucault stated:
I have dealt especially with phenomena of the past ... because I saw in them ways of thinking and behaving that are still with us. I try to show, based upon their historical establishment and formation, those systems that are still ours today, and within which we are trapped. It is a question, basically, of presenting a critique of our own time, based upon retrospective analyses.26(p192)
In contrast, genealogy probes how power and knowledge produce and maintain discourses that comprise our reality.25 This form of analysis tracks how contemporary practices, organizations, and systems arise from earlier “struggles, conflicts, alliances, and exercises of power” and, in so doing, points out that the “institutions and practices we value and take for granted today are actually more problematic or more ‘dangerous’ than they otherwise appear.”19(p372) Using genealogy helps us understand how we come to know ourselves, including the roles and identities we take up, along with the “relations of power that produce and maintain our present discourses.”25(p481) Genealogy views the present day as descended from historical struggles over power and domination19; it is about how what we know and act in the present is created in and determined by the past.27
Despite their differences, both archaeology and genealogy invoke a critical look at the past with respect to the present, and as such, these approaches are useful in analyzing nursing phenomena. We are interested in nursing's agency as a profession, and, specifically, the collective agency of nursing as enacted through its professional organizations. Critiques using an archaeological and genealogical lens “create a ... rupture in discourses and practices to deflate hyperbole, question truth claims, challenge inconsistencies and open up possibilities for dialogue and change.”28(p6) Analyses from these perspectives often focus on the known rather than the unknown so that taken for granted assumptions can be disclosed. Foucault's methodologies help us see how the power, truth, and knowledge of a particular phenomenon—in this instance, FON initiatives—evolve and change over time and ultimately reproduce conditions that make a phenomenon possible.29
In this first of a 2-part set of articles, we introduce principles related to the genealogy of power/knowledge specific to the nursing profession and foundations and trace nursing-foundation encounters through a genealogic lens. We begin by describing foundations' past efforts to exert power over a range of social phenomena, including key reports determining the profession's status. This foray into the past assists us in becoming aware of foundations' power and situates RWJF's current authority and prestige in the United States with respect to nursing within this broader context. From this perspective, the goal is to recognize how the past defines and directs current practices.19 In part II, we turn to an archaeology of RWJF FON activities to illustrate how procedures and processes controlled the discourse about nursing and, by extension, critical directions of the discipline.
THE SCOPE OF FOUNDATIONS' REACH
Across the globe, a wide range of foundations have controlled, negotiated, or brokered outcomes of events in political, economic, education, and other social spheres. Many authors point to foundations' societal contributions (eg, the development of a 911 emergency call system).30–32 Others, however, employ a more critical social analysis of foundations' societal contributions, including how ideology may guide foundations' pursuits.33–35
Despite the diverse ideologies embedded and embodied in foundations and initiatives they support, some scholars argue that foundations seek to sway societal outcomes in the direction of their operating beliefs, with little regard for what local communities or other societal groups may desire.36 Levine37 provides some indication for why this may be, pointing out that foundations are accountable to no one but themselves and, as such, are free to choose the problems they wish to address, and how they choose to address them. By extension, questions have surfaced around the broader implications for society when governments turn to foundations to fill voids in financing public goods and services, particularly when each foundation is pursuing its own set of goals.36 Giridharadas34 argues that although foundations' giving generates an outward appearance of serving the public good by addressing racial/ethnic, gender, wealth, or other inequalities, at the core, these interests are largely self-serving. He makes the case that although foundations support work in vastly different sectors, a shared feature is that the initiatives foundations pursue overwhelmingly result in maintaining the very wealth and power inequities they often claim to be countering.34
There are several examples of how foundations have influenced and continue to influence a number of social sectors, including education and economic systems, social movements, and public health. In education, Baltodano38 delineated how multilayered, highly-nuanced efforts of US foundations supported a neoliberal approach to public education systems' funding and configuration. Such efforts included targeted media campaigns designed to shape public perceptions in support of increasing the proportion of federal and state dollars used to fund charter schools.38 In the case of global free trade, Guilhot39 examined how funding from foundations was used to establish a university in Budapest with the explicit goal of creating an intellectual hub of economists whose theoretical and epistemological positions bent toward limiting regulations on global financial markets. These positions then helped disrupt critical leanings in Europe that challenged free market ideology. In a US economic example, Domhoff40 described how a “network”(p957) of foundations came together to fund the Natural Resources Defense Council and the Environmental Defense Fund to reduce public confrontation and anticorporate critique by environmental activists. Fundamentally, one of the foundations' goals was to constrain the forms of discourse in which environmental advocacy groups engaged, moving from very public mass protests to acquiescence.40
Another example of the intersection of social movements and foundations is from the National Association for the Advancement of Colored People (NAACP) and the effect its largest funding source, the Garland Fund, had on the organization's early direction.41 Founded in 1909, the NAACP's early focus was countering lynching and racial violence.41 This focus, however, was “misaligned”41(p291) with the Garland fund's mission, which was “exclusively pledged to support activities in the areas of organized labor, education, and the protection of minorities,”41(p285) in that order. In her historical analysis, Francis41 details how Garland Fund trustees rejected funding the NAACP's priority concerns and pivoted the NAACP's agenda to education-related issues, particularly desegregating public schools. As noted in the analysis, the collaboration between the NAACP and the Garland Fund “was the product of a black organization desperate for funding and a white philanthropy that exploited this resource disadvantage.”41(p305) Finally, the health care arena also has been at the receiving end of foundations' leverage. For example, efforts addressing HIV/AIDS in India, led by nongovernmental organizations, shifted from the local communities' priority of adolescent health issues to the Gates Foundation's target population of high-risk truck drivers.42
These examples, along with other emerging critical scholarship,33,34 demonstrate what can occur when foundations' interests are inserted into, and ultimately overtake, the struggles of marginalized, oppressed, and disenfranchised groups. Resource-deprived groups may feel compelled to accept offers of assistance from well-financed, influential others. Although nursing historically has been socially privileged in a number of ways,43 it too has sought (and continues to seek and accept) assistance from various foundations; as such, interactions between nursing and foundations are not benign.44 Actions foundations take to shape professional nursing raise issues about nursing's understanding of and commitment to its social contract with the public. Namely, concerns arise relative to nursing as a self-regulating profession and how it enacts collective agency to meet its obligation of self-regulation as set forth in nursing's social contract.45
PROFESSIONAL SELF-REGULATION AND EXTERNAL INFLUENCES
Professional self-regulation is defined as an organized body of professionals overseeing itself and its members through powers granted to it by the state,46 such that “the professional, guided by an understanding of public responsibility, [can] be trusted to render what [is] needed.”47(p188) From its core of reciprocal privileges and responsibilities, extended through Rousseau's48 concept of the social contract, the sole purpose of professional self-regulation is to ensure the public good.
Nursing's social contract with the US public is made explicit in Nursing's Social Policy Statement: The Essence of the Profession.8 The American Nurses Association (ANA), widely recognized as the preeminent organization for US nurses, “performs an essential function in articulating, maintaining, and strengthening the social contract that exists between nursing and society” through its custodial role in updating and publishing Nursing's Social Policy Statement.8(p6) Nursing's social contract obligations are codified in ANA's Code of Ethics,49 ANA's Nursing Scope and Standards of Practice,50–52 and the American Association of Colleges of Nursing's The Essentials series of documents.53–56
Most content across these guiding documents address aspects of self-regulation of individual nurses' practice roles. There are, however, clearly articulated expectations that the profession, as a collective entity, holds the authority to shape disciplinary and professional domains that define its structure and function for the good of the public. The ANA Code of Ethics underscores these expectations, stating that not only do professional associations and organizations “give [a] united voice to the profession”49(p35) but that “[i]t is the shared responsibility of professional nursing organizations to speak for nurses collectively in shaping health care and to promulgate change for the improvement of health and health care locally, nationally, and internationally.”49(p36)
Professional self-regulation, however, does not occur in a vacuum; external factors, such as societal trends, public perceptions, and private entities, drive regulatory processes and outcomes. On occasion, the discipline has recognized these external factors. For example, the 2015 ANA Scope and Standards document explicitly addressed these external factors, stating “Many organizations seek to influence society and nursing through similar and/or shared purposes, goals, and agendas. Each nurse must be aware of historical, contemporary, and future internal or external influences that can impact nursing practice.”51(p28) These influences occupy the space between nursing as a discipline and the broader public it serves. As such, individuals, groups, and organizations, including, and perhaps most profoundly, foundations, hold sway in ways visible and invisible, and internal and external to nursing, shaping the profession's contours and functions.
The RWJF was explicitly identified as an external organization affecting nursing in Scope and Standards documents that were current when FON initiatives were underway.50,51 The 2015 version, for example, specifically pointed to the 2010 FON report and the report's implementation entity, the RWJF's FON Campaign for Action,57 as “providing strategies for nursing and nurses to become more influential ... and positioned in strategic positions in the public arena (emphasis added).”51(p30) In the context of self-regulation, whether or not external organizations can leverage change that positively or adversely affects nursing is moot; the key point is that nursing carries the responsibility for defining the standards for, and direction of, the profession. We contend that it is the profession itself that must decide whether and how to act—or exercise its collective agency—in response to outside forces such as RWJF.
COLLECTIVE AGENCY AND POWER/KNOWLEDGE IN NURSING
Consistent with the broader academic literature, nurse scholars often examine the concept of agency as a form of personal agency, rather than in its collective form.58–61 Applicable to both individual and collective forms of agency, we employ Emirbayer and Mische's62 definition of human agency as “the temporally constructed engagement by actors [within] different structural environments,” which “both reproduces and transforms those structures in interactive response to the problems posed by changing historical situations.”(p970) In extending the concept of agency to groups, Hainz and colleagues63 define a collective agent as a social entity with the following characteristics: (1) it “consists of an unspecified number of individuals who share some properties that allow for their identification as a collective,”(p2) (2) it allows the entity to act as a collective agent in expressing ideas and values and fulfills the group's needs, and (3) it can hold attitudes partially independent of its members' attitudes and has the authority to overrule members within the group who have dissenting opinions.63 Despite the lack of nursing scholarship on collective agency in the literature, we contend that nursing acts as a collective agent through its professional organizations. Once given the authority to act by governmental institutions, nursing is expected to regulate the parameters of its own discipline. We maintain that with this responsibility comes others: that the ways in which collective agency is expressed by nursing be deeply theorized, problematized, and critically analyzed at a broader societal level.
Emirbayer and Mische's62 description of how agency is enacted informs how nursing as a collective has engaged with RWJF's FON initiatives. From this angle, agency is embodied in “human actors within temporal passage.”62(p971) Thus, nursing's collective agency can be thought of as a property manifested in relational acts between RWJF and groups representing nursing that occur over time, within socially and temporally structured contexts. A temporal view of agency encompasses past, future, and present orientations, whereby actors reactivate “past patterns of thought and action”62(p971) in responding to novel or recurring situational demands; have the capacity to envision future social circumstances different from what they currently experience; and self-reflect on how they have responded to situations in the past and make evaluative judgments about actions required to achieve an envisioned future. With every social encounter, outcomes of agentic acts reflect Foucault's view of the power/knowledge dynamic,18 as each action works to either reinforce or challenge the stability of the social order, structure, and/or conditions in which agents situate themselves.
In applying these theoretical underpinnings of agency, we propose that nursing's interactions with RWJF FON initiatives reify dominant social structures, positioning nursing as a subordinate (semi) profession. Ironically, these interactions occur concurrently with nursing's continued pursuit of a future-oriented, fully self-regulating, self-actualized vision of itself as a profession. With the evaluative dimension of collective agency in mind, we view critique and analysis of nursing's encounters with RWJF FON initiatives as part of the evaluative process—a process that allows us, as agents who belong to the nursing collective, to reveal the extent of those “patterns of action” and consider what meaning these patterns have for nursing's ability to enact collective agency.62(p994)
NURSING'S COLLECTIVE PAST: EXTERNAL INFLUENCES, POWER, AND AGENCY
Nursing, as with all disciplines, is bound to a complicated sociohistorical past. Originating as women's work,43 nursing's social location along a gendered axis has profound implications for the profession's developmental trajectory and continued relevance today. Class and race played synergistic and oppositional roles to gender in the origins of professional nursing via Florence Nightingale, in which her wealthy class position and her White racial identity offered legitimacy and authority to counter the lower social status of her gendered identity.10
External foundations also have shaped nursing's professional evolution. For example, although medicine and nursing both sought to elevate their respective professions by defining educational requirements for training programs, very different outcomes resulted reinforcing, rather than altering, existing stereotypes and nurses' positioning.10 Following the Civil War, philanthropic entities such as foundations were instrumental in growing the number of nurse-training programs.44 Unfortunately, nursing programs at the time were abysmal, with instructors having limited education and students working as essentially indentured servants.44 Despite an ongoing need to improve nursing education conditions, foundations shifted their focus to medicine. Sponsored by the Carnegie Foundation for the Advancement of Teaching (henceforth, Carnegie Foundation), the 1910 Flexner report on the state of US medical education enabled medicine to achieve a superior social standing through “raising the minimum educational level of physician training and reducing the numbers of physicians available to practice medicine.”10(p302) Although the Carnegie Foundation turned down a request from the American Society of Superintendents of Training Schools for Nurses to address similar reforms in nursing,44 nursing leadership was able to obtain The Rockefeller Foundation funding support for the 1923 Goldmark Report. The likelihood of implementing the Goldmark report's recommendation of creating a nursing educational system analogous to medical schools, however, seemed dim, as it would have upended standard hospital lines of authority. Such potential changes would have unsettled medicine's ability to preserve “jurisdictional boundaries” from nursing.10(p303) Seeing these potential threats, the American medical establishment characterized nursing as “instrumental in nature” and thereby limited the profession to its publicly perceived position as “secondary to and supportive of medicine”64(p78)—a position that lives on.13
Foundations' interests in shaping nursing education continued unabated throughout the rest of the 20th century. For example, the 1948 Brown report,65 funded by the Russell Sage Foundation, recommended situating nursing within higher education. Starting in the 1950s, the W. K. Kellogg Foundation was the primary supporter of locating nursing education within community colleges,44 and in the 1970s, RWJF was the major promoter of nurse practitioner programs.66 It is noteworthy that none of these foundation efforts were led by nurses.
In addition to the authority exercised by foundations, medicine also has wielded power over nursing through “discursive strategies” embedded in patriarchal language.67(p125) An early example is the AMA's tactics deployed in the 1920s to limit public health nursing's independence. Following the Flexner Report's release and subsequent advancement of the scientific model, the AMA, threatened by public health nursing's successful rural maternal-infant programs, opposed further government funding for nursing efforts and claimed that, in addition to being wasteful and extravagant, these programs “promoted communism.”68(p13) In the end, the AMA's campaign and the discursive strategies it used were successful as federal aid for maternal and child programs was not renewed, contributing to the eventual demise of public health nursing's independent practice.68 It is noteworthy that while foundations' support of medicine elevated and solidified its status position, the opposite effect occurred for nursing.
The examples presented in this section of the insidious power that foundations have exerted over the discipline illuminate the contradictions that inhabit nursing's claims of being a self-regulating profession. Oppressive moves against nursing by dominant groups play a major role in nursing's professional development, as do intersections with race, class, and gender. Jurisdictional claim as a profession depends not only on the work nurses perform but also on existing social divisions and the social status of those nurses.10 For much of the discipline's history, actions taken by powerful others—physicians, hospitals, and foundations—have contributed to constructing nursing as a limited/semiprofession without full autonomy and authority over how it serves the public good. To some degree, this semiprofessional construction frames nursing as perpetually needing assistance from powerful others to carry out its social contract, guide its way as a discipline, and legitimize its existence as a profession.
The striking accounts of how foundations act as power brokers in education, civil rights, economic, and public health should cue nursing to heed the role foundations have taken with respect to the nursing discipline. Key to understanding the impact of RWJF-commissioned consensus studies9,69 and recommendations that emerged from them is recognizing the part external forces play in professional self-regulation.70 In part II, we employ critical discourse analysis to examine the context in which nursing has engaged with RWJF FON initiatives and the elements of power operating through the structure of discourse that ultimately culminated in the FON 2010 and 2020-2030 reports.
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