Emancipatory knowledge development
http://evolve.elsevier.com/Chinn/knowledge/
Why have women passion, intellect, moral activity—these three—and a place in society where no one of the three can be exercised?
Florence Nightingale (1852/1979, p. 25)
Specifically, there is a need to further explore the political, economic, and social forces in communities around the country that influenced the growth of both nursing and medicine during this century. The rigidities and inflexibilities of mythical conceptions about the roles of men and women in health care and the resulting responses of community members need examination also.
J. Ashley (1976, p. x)
After one has worked for a time in healing wounds which should never have been inflicted, tending ailments which should never have developed, sending patients to hospitals who need not have gone if their homes were habitable, bringing charitable aid to persons who would not have needed charity if health had not been ruined by unwholesome conditions, one loses heart and longs for preventive work, constructive work . . . something that will make it less easy for so many illnesses and accidents to occur; that will help to bring better homes and workshops, better conditions of life.
L. L. Dock (1902–1903, p. 531)
The women who wrote these opening quotes represent a long tradition of emancipatory knowing in nursing. Nightingale’s quote makes explicit the challenges that women of her time faced if they wanted to step outside of the role that Victorian society had prescribed for them. The Ashley quote highlights the importance of examining the social processes that formed nursing and how those processes contribute to nursing’s ability to deliver health care. The quote by Dock goes deeper and suggests the need to shape social processes so that they eliminate social inequities in the first place, thereby making changes that would abolish the need for emancipatory knowing and knowledge.
In relation to our model of nursing knowledge, Nightingale’s quote is important because it points out the importance of the awareness of inequities, and it is a form of critical questioning; Ashley’s quote suggests the need to critique, to imagine a future, and to create formal expressions that can be shared. The quote from Dock highlights a defining dimension of praxis by suggesting the need to bring about change that creates situations of empowerment and social equity. It is the Dock quote that addresses the core reason for developing emancipatory knowledge.
If you think about your own nursing experience, perhaps you can recall a situation in which someone you cared for was managed in a way that you found unfair or unjust. Perhaps they were discriminated against or treated rudely because they had no insurance. On a more subtle level, perhaps they were treated fairly and courteously by providers but were inadequately treated for breast cancer. Think about the underlying reasons that these situations may have occurred. These are conditions that cannot be controlled by the individual. Often, a circumstance such as having no medical insurance is connected to a whole cascade of events: job loss as a result of corporate decisions to move manufacturing overseas as a result of stockholders demanding higher profits. Many pathologies, such as breast cancer, have a relationship with environmental pollutants. Emancipatory knowing challenges you to become aware of social conditions that are often subtle and hard to recognize and to change them for the better.
In this chapter, we describe the concept of emancipatory knowing and provide an overview of the foundations from which emancipatory knowing in nursing has developed. We detail the dimensions of emancipatory knowing that were introduced in Chapter 1.
As represented in Figure 3-1, the dimensions of emancipatory knowing surround and connect with the four fundamental patterns of knowing that are represented by the lighter center oval. In this way, emancipatory knowing places a critical lens on both nursing’s knowledge development activities and on the practice of nursing. The hazy indistinct outer circle that the double arrows extend beyond underscores the need for nursing to also have a critical lens that addresses the social and political contexts within which nursing functions. This chapter includes examples of approaches that can be used to address the critical questions posed from an emancipatory perspective: “What are the barriers to freedom?” “Who benefits?” “What is wrong with this picture?” and “What needs to change?” The creative development processes of critiquing and imagining are further explained, and we describe ways in which the formal expressions of emancipatory knowledge are presented and authenticated. Praxis—the process of critical reflection and action used to achieve emancipatory change—is positioned at the center of the model as well as at its outer edges. This signifies the need for an emancipatory knowing focus in the moment of practice as well as in relation to the social context in which the discipline is located.
The concept of emancipatory knowing
Emancipatory knowing is the human ability to recognize social and political problems of injustice or inequity, to realize that things could be different, and to piece together complex elements of experience and context to change a situation as it is to a situation that improves people’s lives. Emancipatory knowing cultivates awareness of how problematic conditions converge, reproduce, and remain in place to sustain a status quo that is unfair for some groups within society. Awareness of social injustices and inequities leads to processes that culminate in praxis, which is the integrated expression of emancipatory knowing.
Emancipatory knowing requires critical examination that aims to uncover why injustices seem to remain invisible and to identify specific social and structural changes that are required to right social and institutional wrongs. Emancipatory knowing seeks freedom from institutional and institutionalized social and political contexts that sustain injustices and that perpetuate advantages for some and disadvantages for others.
Emancipatory knowing in nursing means questioning the nature of knowledge and the ways in which knowledge itself—or what is taken to be knowledge—contributes to larger social problems. Emancipatory knowing takes into account the power dynamics that create knowledge as well as the social and political contexts that shape and influence knowledge and knowing. From an emancipatory perspective, knowledge and knowing are constructed in ways that reflect prevailing hegemony or problematic assumptions about “the way things are.” Hegemony is the dominance of certain ideologies, beliefs, values, or views of the world over other possible viewpoints. These dominant perspectives privilege certain groups over others. Hegemonic views are often hidden and are taken for granted as fact or as the only possibility. Moreover, hegemony tends to recreate itself in ways that make it difficult to change.
A dominant assumption or hegemonic view in nursing is that nurses practice as employees of an agency or a corporation rather than as independent practitioners. Institutionalized reimbursement practices of insurance companies and licensure laws are powerful social and political structures that keep this view of how nurses can and should practice in place. Policies that govern how nurses are paid for their services make it difficult to secure reimbursement for independent nursing services. Even when reimbursement is possible, it is more difficult for nurses to receive reimbursement than it is for other health care workers, or they must be reimbursed indirectly. A few nurses have refused to accept the hegemonic assumption that they cannot or should not practice independently, and most nurses are aware that there is such a thing as being self-employed or practicing independently. However, the prevailing hegemonic view is that the norm is to be an employee and to work within the structures of an agency or corporation and that it would not be feasible to practice any other way.
Hegemonic ideologies and patterns of thinking tend to recreate themselves, and, in this way, they continue to seem natural and normal across time and generations. This perpetuation of hegemony happens in part when leaders and spokespersons in power speak and act in a way that is consistent with hegemony, thus reinforcing in public their ideas of how the world is and how it should function. This sort of public understanding becomes pervasive and effectively inhibits public awareness of other possibilities.
Without awareness of how things could be different, people conform to hegemonic practices and values. People are often not aware that they are trapped within a hegemonic pattern that creates disadvantages for them, and they remain unaware of alternatives. Alternatively, if they are aware, they may see the alternatives as not truly being possible.
Emancipatory knowing gives rise to the realization that there is something wrong with the way things are and that it is possible to change what is for the better. This awareness can happen when things become intolerable or when someone comes along and challenges or questions the hegemonic status quo. As people come to understand situations as being unjust they can mobilize to challenge the way that things are. In this way, these individuals exercise what may be considered emancipatory human interest: they clarify and define what is problematic about their situation from their point of view, and they take action to change it. They also begin to recognize that there are others who share their experience of the situation. Together, they begin to develop actions, insights, and knowledge about the problem and about what is required to correct it or to change the situation for the better.
The emergence of the women’s movement during the latter half of the 20th century is another example of this emancipatory process. During the decades of the world wars in the early part of the 20th century, the hegemonic view of women that dominated public discourse included ideas about the ideal wife and mother who remained a subservient homemaker who was devoted to her family. These views of womanhood were reflected in the media, government policies, business practices, religious beliefs, and virtually every aspect of public life.
As women realized that a hegemonic construct of women dominated their experience, small groups of women in the United States and other countries began to examine the circumstances of their lives in consciousness-raising groups. In these groups, they shared experiences and feelings about their lives and formed ideas about how their lives could and should be. Many of their ideas became formalized as feminist theory. Those who spoke publicly were often derided by men and women who were threatened by the social and cultural changes that feminist ideas suggested. However, despite widespread resistance, feminist ideas began to make sense to more and more people, and many significant social and cultural changes started to happen.
One of the first changes that feminist leaders called for was a shift to gender-neutral language, and widespread changes began to occur. For example, newspapers stopped publishing their classified ads in separate “Help Wanted—Male” and “Help Wanted—Female” columns; these ads were changed to fall under a heading that simply read “Help Wanted.” In this example, emancipatory knowing for women involved in consciousness-raising groups began with their shared awareness of the distress that they experienced with the restrictions that hegemonic ideals of womanhood imposed on their lives. As the outcomes of their shared awareness evolved, emancipatory knowing grew as others began to hear about and comprehend the alternatives that feminist perspectives offered.
Emancipatory knowing and problem solving
Emancipatory knowing is different from but related to problem solving. It is much more than problem solving in that it requires a deep awareness of often hidden injustices and those problematic social practices that create them. Unlike problem solving, which usually focuses on a single discrete instance, emancipatory knowing requires seeing the larger picture and correcting social processes, patterns, and structures that create social inequities and injustices.
As an example, before the social changes that came about with the women’s movement in Western societies, some women who wanted to perform a “man’s” job, such as medicine or the operation of heavy machinery, solved the problem by dressing and posing as a man. These women may have been aware that the policies and practices of their culture were unjust. Despite potential awareness of the unfairness of the practice, rather than pursuing a critical or emancipatory approach to changing societal rules and policies, they simply solved the problem by accommodating for a fundamentally unfair practice. In this example, accommodating rather than changing can be seen as a discrete, individual, and temporary solution rather than a long-term one. Asking the critical questions associated with emancipatory knowing when you meet challenges that require this form of problem solving is one way to initiate the corrective processes of emancipatory knowing.
Emancipatory knowing and critical thinking
Emancipatory knowing differs from critical thinking in that it does not simply seek to improve one’s thinking ability, judgment, and problem-solving skills. Once again, the emphasis is on seeing what lies beneath issues and problems and redefining those issues and problems to reveal linkages among complex social and political contexts that create injustices. For example, a critical-thinking approach to hiring practices that are based on gender would focus on gathering the evidence and examining the rationale for restricting hiring in some jobs to women only and in others to men only. The soundness and logic of each explanation for the practice would be examined, and conclusions would be drawn about the practice. Critical-thinking approaches could reveal injustices and inequities and might result in an attempt to reduce gender-specific hiring. However, critical thinking alone would not fully examine the underlying network of social practices that keep the injustice of gender-specific hiring in place or challenge the status quo in a way that would demand long-term change.
Emancipatory knowing and reflective practice
Emancipatory knowing is akin to reflective practice in that emancipatory knowing involves a constant interaction between action and reflection. This process is praxis: the integrated expression of emancipatory knowing, which is described in more detail later in this chapter. Reflective practice is a significant personal process that leads to insight about one’s actions and the rationales for actions that have the potential to improve one’s practice. However, unlike reflective practice, praxis requires going beyond personal reflection to deliberately uncover what is unfair and unjust in a situation, to envision how it could be different, and to form alternate explanations and possibilities for change that come from a range of perspectives that is much broader than that of the individual alone (Schön, 1983).
Many women find a great deal of satisfaction and personal joy in their roles as mothers and homemakers. From a reflective practice perspective, they might recognize that their experience fits a hegemonic view of ideal womanhood that could be restrictive in certain ways, but their personal experience is satisfying and rewarding and therefore requires no change.
Alternatively, the emancipatory knowing process of praxis would call for looking beyond personal experience alone to reflect on the broader social and cultural implications of such role prescriptions and for considering the political as well as personal implications of the situation. The personal satisfactions and rewards of homemaking for some women are not negated, but the focus shifts to broader issues and to the outcomes for women and society in general when homemaking and motherhood are prescribed as being primarily women’s roles.
To summarize, emancipatory knowing does not undo hegemonic social structures by just thinking critically about injustices, solving individual or discrete problems, or reflecting on unfair social conditions. Rather, it asks, “Why do we have this problem in the first place?” For example, when approaching the situation from an emancipatory perspective, you ask, “How can we create opportunities for women in the workplace?”; you also ask, “ Why are women excluded from full access to employment in the first place?” As a nurse, you ask, “How can we overcome the stigma of human immunodeficiency virus/acquired immunodeficiency syndrome?”; you also ask, “Why is this condition stigmatized in the first place?” You ask, “How do we create tolerance for transgendered persons?”; you also ask, “Why does intolerance persist?” You wonder, “How can we end the unfair policy of mandatory overtime for nurses?”; you also consider, “Why has this practice emerged and who benefits from this policy?” As we have said many times, after these questions are asked, emancipatory knowing demands that an individual work toward the elimination of these situations.
The rebirth of emancipatory knowing in nursing
There is a long history of nurse activists who have worked to change desperate social conditions in an effort to improve health. However, with the focus on scientific inquiry that took hold during the 1950s, an appreciation for other forms of knowing and inquiry was temporarily lost. During the 1960s and the 1970s, when different forms of scholarship became more legitimate, critical perspectives began to emerge. Much of this early critical scholarship was grounded in the work of prominent critical, liberation, and poststructuralist thinkers.
Critical theory
In the discipline of nursing, the term critical theory refers to a foundational perspective that grounds emancipatory knowing. This term can be confusing in that it does not reflect the usual connotation of theory in nursing. The concept of critical has a range of negative common meanings that are not relevant in the context of critical theory. In this context, critical implies analysis that moves beyond the surface and beyond what is usually assumed. Generally, critical theory is a broad term that is used to describe both the process and the product of work that takes a historically situated and sociopolitical perspective and that challenges social inequities and injustices. Such theory is critical in the sense that it analyzes the roots and consequences of social inequities and injustices that privilege one group over another (Carnegie & Kiger, 2009).
As a method, critical theory has roots in the classic sociologic traditions of Karl Marx, Max Weber, and Emile Durkheim (Morrow, 1994). These early philosophic traditions were quite unfavorable to capitalist governments such as that of the United States and were viewed in the United States as being allied with communist ideology. The extreme anti-communist sentiments that prevailed in the United States during the 20th century made it difficult for U.S. scholars to engage in discourse surrounding the emergence of critical theory and philosophy. Scholars in countries that have strong social welfare policies and values have generally been more open and accepting of critical theory. As the political structures of the world began to change and the 40-year Cold War that began in the late 1940s abated, scholars in the United States gradually became more open to critical theory. This circumstance illustrates the tremendous influence of context on people’s thinking in that fears of communism created barriers to understanding critical theory and suppressed openness to the possibilities offered by critical theoretic approaches.
Critical theory began to emerge as a specific approach to the study of society through the work of scholars who were exiled from Germany by Adolf Hitler in 1932. These scholars became known as the “Frankfurt School.” Within the Frankfurt School, the term critical theory designated a form of sociologic theory that recognized society as evolving historically and that promoted a deliberate engagement with the problems of society and the processes of social transformation. Typically (but not always), when the term critical theory is capitalized, it refers specifically to the work of the Frankfurt School (Morrow, 1994). We use the lowercase format throughout our discussion to indicate a perspective that encompasses a broad range of philosophies, methods, and approaches that share a common fundamental engagement with the problems of society.
During the 1960s, Jürgen Habermas assumed a prominent position in shaping new conceptions of critical theory with broad interdisciplinary connections between the human sciences and philosophy (Morrow, 1994). Habermas’s critical social theory posited three fundamental human interests, each of which demanded its own method: (1) Technical interest is the human capacity to create things and processes to understand the physical world; this requires empiric methods. (2) Practical interest is the human capacity to communicate and to get along within a social community; this requires interpretive and philosophic methods. (3) Emancipatory interest is the human capacity to see that something needs to change and to take action to change it; this requires critical and reflective methods. Each of these interests is necessary for human survival (Habermas, 1973, 1979). Although critical nurse scholars have grounded their thinking in the work of a number of critical scholars and philosophers, the influence of Habermas is significant.
Liberation theory
Paulo Freire was an important liberation theorist whose ideas have also had a significant influence among nursing scholars. Freire was a Brazilian educator who championed critical approaches to education. His work was philosophically grounded in the ideas of Karl Marx, Friedrich Engels, Georg Hegel, Gyorgy Lukacs, Herbert Marcuse, and Erich Fromm (Freire, 1970). Freire’s work grew out of a project to teach peasants in rural Brazil how to read. His ideas were not only specific approaches to teaching; they could also be used for any grassroots project of human liberation. Traditional education is based on the assumption that its primary purpose is to pass along the existing knowledge and values of the culture. Freire questioned this assumption, and, in doing so, formalized liberation theory, which considered education as a means of challenging the existing knowledge and values of the culture (Freire, 1970; hooks, 1993; Weiler, 1991). Because of the broad significance of his philosophy and the practical action-oriented perspective that he articulated, Freire’s ideas have had a widespread influence that has gone well beyond the scope of education.
Poststructuralism
Michel Foucault’s poststructuralist philosophy has also had a major influence on nurse scholars because of his insights with regard to the power imbalances that are embedded in and sustained by verbal and symbolic social discourses. Social discourses are whole systems of representation—writing, images, advertisements, artwork, and everyday verbal and nonverbal language—that create perceptions of social reality. For critical poststructuralists, there is no reality in an objective sense. Rather, what seems real is created for us by dominant social discourses. Verbal and symbolic discourses are powerful because they interconnect to both enable and limit what it is socially acceptable to know (Aston, 2008; Bradbury-Jones, Sambrook, & Irvine, 2008).
For example, discourses of beauty for young women suggest that a flawless face is more beautiful than a normally flawed and plainer face. Discourses also reinforce the idea that beauty of a certain type—that which is achieved by cosmetics and airbrushing—is attainable and a normal way to be. Because these messages appear everywhere, young women may only understand “beauty” as what is constructed and prescribed by these systems of discourse. Such discourses are powerful because they create barriers to societal resources for some as well as opportunities for others. Young women who cannot or choose not to achieve the popular standard of beauty may develop low self-esteem, and they run the risk of being denied social resources, such as popularity among peers and the social interactions for which most young people yearn.
This same example could be applied to young men, for whom popular discourses prescribe what is considered a typical movie-star appearance (being handsome, having well-defined muscles, and wearing well-fashioned clothing) as opposed to that which is considered “geeky” or “nerdy” (being thin, wearing glasses, and having casual, disheveled, or mismatched clothing). It is in this way that discourses construct “realities” that create power imbalances (in our example, between young women and men who are “beautiful” or “handsome” and those who are not). As alternative discourses that counter notions of beauty begin to undermine dominant discourses, they begin to lose their power to control how young people spend their money and time (Phillips, 2006).
As a poststructuralist, Foucault viewed language and discourse, including theory, as systems of representation that are necessary in the social order in that they produce meaning or ways to comprehend the world. However, as the examples of discourses related to beauty illustrate, these systems of language and discourse also limit what is understood, known, or perceived in a way that has lasting negative consequences. According to Foucault, we can only know things as they have meaning, and it is systems of discourse that produce or construct meaning (Hall, 2001). Critical poststructuralism analyzes how discourse functions to create imbalances that creates disadvantage for whole classes of persons in an effort to illuminate possibilities for change (Doering, 1992; Foucault, 1980, 1984).
Nursing’s early literature related to emancipatory knowing
During the latter half of the 20th century, a growing number of nurse scholars and activists began to develop disciplinary perspectives that are clearly connected to an emancipatory pattern of knowing. During the 1960s, Lydia Hall—who declared that there is no “shortage of nurses” but rather a “shortage of nursing”—established the Loeb Center for Nursing and Rehabilitation at Montefiore Hospital in the Bronx, New York. Her ideas and what proceeded from them are notable examples of emancipatory knowing in nursing. Believing that nursing was the chief therapy for those recovering from chronic illness, Hall established the Loeb Center as a place where nursing (rather than medicine) could be practiced and where physicians were under the direction of nurses (Hall, 1966). Hall envisioned the Loeb Center when she noticed that nurses were taking on medical tasks and becoming what she called “physician extenders” rather than providing bodily care and nurturing the cores of individuals after medicine’s curative role. Hall’s model of nursing at Loeb was revolutionary because it differentiated nursing from medicine and allowed nurses to practice in an environment that did not require the performance of curative tasks associated with the growth of medical technology during the 1960s.
Early literature in nursing that reflected emancipatory knowing also grew out of feminist perspectives. As reluctant as nurses in general were to accept feminist ideas and to align themselves with the women’s movement of the 1960s and 1970s in the United States, there were those who spoke out and published ideas that challenged the status quo. One of the earliest publications that reflected an emancipatory perspective was an article by Wilma Scott Heide published in the American Journal of Nursing in which Heide made a case for the importance of feminist ideas for nursing (Heide, 1973). In 1976, JoAnn Ashley’s book entitled Hospitals, Paternalism, and the Role of the Nurse was published. Basing her argument on historical evidence, Ashley contended that the apprenticeship system of education that prevailed in nursing situated nurses and nursing in a context that not only exploited the labor of women in hospitals but that also undermined the fundamental values of nursing related to health and health care. Her feminist analysis drew the essential connection between a misogynist (woman-hating) society and the resulting health policies and practices that constricted the role of nurses in the delivery of health care (Kagan, 2006).
Another significant publication that reflected nursing’s development of emancipatory perspectives was the 1983 publication of Susan Jo Roberts’ article entitled “Oppressed group behavior: Implications for nursing.” Drawing on Freire’s work and from literature about colonized Africans, Latin Americans, African Americans, Jews, and women, Roberts made the case that nurses also can be viewed as an oppressed group. Emphasizing that this insight can lead to substantive action to change nursing and health care, she concluded the following:
Nurses are an oppressed group with characteristics similar to those of [other oppressed] groups. It is hoped that with this understanding nurses can learn from the experience of others to liberate themselves and develop an autonomous profession that can greatly contribute to the improvement of health care. (Roberts, 1983, p. 30)