ESSAYS EXPERT PROFESSOR
MSNNursing2020
ContestedPracticePoliticalActivisminNursingandImplicationsforNursingEducation.pdf
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d DE GRUYTER International Journal of Nursing Education Scholarship. 2017; 20160026
Ellen Buck-McFadyen2 / Judith MacDonnell1
Contested Practice: Political Activism in Nursing and Implications for Nursing Education 1 Nursing, York University, Toronto, Ontario, Canada 2 Trent University, Nursing, Peterborough, Ontario, Canada, E-mail: [email protected]
Abstract: Canadian nurses have a social mandate to address health inequities for the populations they serve, as well as to speak out on professional and broader social issues. Although Canadian nursing education supports the role of nurses as advocates for social justice and leadership for health care reform, little is known about how nurse educators understand activism and how this translates in the classroom. A comparative life history study using purposeful sampling and a critical feminist lens was undertaken to explore political activism in nursing and how nurse educators foster political practice among their students. Findings from interviews and focus groups with 26 Ontario nurse educators and nursing students suggested that neoliberal dynamics in both the practice setting and in higher education have constrained nurses’ activist practice and favour a technical rational approach to nursing education. Implications and strategies to inspire political action in nursing education are discussed. Keywords: neoliberalism, nursing education, activism, political action DOI: 10.1515/ijnes-2016-0026 Received: May 16, 2016; Revised: June 23, 2017; Accepted: July 9, 2017
As witnesses to the downstream effects of public policies that influence the social determinants of health, nurses are well positioned to take a leadership role in addressing the root causes of health inequities (Falk-Rafael, 2005; Reutter & Kushner, 2010). Although social justice and advocacy are central themes in documents that currently guide Canadian nurses’ practice, political activism is a contentious concept within the discipline of nursing, with little agreement on how to define the term and what constitutes appropriate activist practice within the scope of nursing. Despite perceived support for advocacy and social justice, questions persist about whether nurses have let slip their mandate for socio-political activism, in part hampered by low political efficacy that can lead to limited engagement in systemic change or policy advocacy (Mahlin, 2010; Spenceley, Reutter & Allen, 2006; Vandenhouten et al., 2011). Given the role of nursing educators in socializing a new generation of nurses, educators have an opportunity to influence nursing students’ understanding of activism and foster knowledge and skills that support this aspect of practice. In this paper, the researchers explore nursing activism from the perspective of nurse educators and nursing students in Ontario, Canada.
Since the beginning of modern-day nursing, nurses have played an important role in tackling the root causes of health inequities, providing care to society’s most vulnerable and increasing access to health care for all (Falk-Rafael, 2005; Hardill, 2007; Thompson, 2014). Nurses like Florence Nightingale and Lillian Wald moved beyond individual care of the sick to address the broader social determinants of health through advocacy for policy change (Hardill, 2007), while in Canada, groups like Nurses for Social Responsibility brought to the forefront issues of social justice and the political nature of nursing in the 80s and 90s (Falk-Rafael & Bradley, 2014). If nurses recognize that health is political, in order to adequately address the prerequisites of health, nurses must become political activists (Canadian Nurses Association, 2000; O’Connor, 2014).
There are several documents that guide Canadian nurses in their roles: standards of practice, codes of ethics, and entry-to-practice competencies (Canadian Association of Schools of Nursing, 2014; Canadian Nurses Asso- ciation, 2008; College of Nurses of Ontario, 2014; Community Health Nurses of Canada, 2011). These documents thread social justice and advocacy throughout the practice expectations of nurses. While “the salience of social justice in nursing is impossible to ignore” (Thompson, 2014, p. E30), the language of how this social justice agenda is to be enacted is less clear within these guiding documents. In 2008, the Canadian Nurses Association (CNA) revised the Code of Ethics for Registered Nurses to reflect nurses’ involvement in social justice. Social justice was named an ethical endeavour rather than a core responsibility, language that was critiqued as “weak” and out of step with international codes (Peter, 2008; Yanicki, Kushner & Reutter, 2015). The terms individual and collective action are frequently used in the Code of Ethics, but nowhere can the term “activism” be found. This is in contrast to the Canadian Nurses Association (2000) publication from eight years earlier that described
Ellen Buck-McFadyen is the corresponding author. © 2017 Walter de Gruyter GmbH, Berlin/Boston.
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Buck-McFadyen, E., & MacDonnell, J. (2017). Contested practice: Political activism in nursing and implications for nursing education. International Journal of Nursing Education Scholarship, 14(1), 743-761. doi:http://dx.doi.org.ezproxy.uky.edu/10.1515/ijnes-2016-0026
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nursing as a political act requiring nurses to become “political activists”. The term activism is also missing from all other guiding documents for nurses in the province of Ontario, Canada.
In the scholarly literature, there are also mixed messages about how nurses are engaging politically or are alternatively seen to be politically apathetic. According to Boswell, Cannon, and Miller (2005), nursing apathy is “pandemic” with respect to participation in the political process, and several authors surmise about the causes of nurses’ political inertia (Mahlin, 2010; Rains & Barton-Kriese, 2001; Spenceley, Reutter & Allen, 2006; Vandenhouten et al., 2011). Analysis from a critical feminist perspective however, reveals that nurses are indeed engaging in political action in their everyday personal and professional lives, but this work is often invisible and overlooked as political work when it occurs outside of the traditional male-dominated electoral or legislative arena (Falk-Rafael & Betker, 2012; Falk-Rafael & Bradley, 2014; MacDonnell, 2010).
Regardless of these tensions about nurses’ level of participation in politics and what language to use around advocacy, political action, or activism, there is strong agreement that nurses have an important role to play in influencing public policy and fostering social justice (Boswell, Cannon & Miller, 2005; Carnegie & Kiger, 2009; Falk-Rafael, 2005; Murphy et al., 2005; Rains & Barton-Kriese, 2001; Reutter & Kushner, 2010; Spenceley, Reutter & Allen, 2006). These authors point to undergraduate nursing curricula as the place to foster the knowledge, values, and skills necessary for nurses to engage in political action and that, when embedded within a social justice curriculum, this learning enables nurses to enter their profession as “agents for social change and citizens of the world” (Boutain, 2005, p. 404). To the authors’ knowledge, no research to date has examined how nursing educators understand activism or foster activism among their students, a gap in the literature that the current study sought to fill.
In this paper, the authors report on a subsample of a larger qualitative study (MacDonnell & Buck- McFadyen, 2016) that used a critical feminist lens to explore the meanings, practices, and impacts of nursing activism among four generations of nurses from diverse practice settings in Ontario, Canada. This larger study had a particular focus on understanding generational differences in relation to nursing activism. However, it seemed important to separately analyze the interview and focus group data from educators and nursing students for several reasons. First, it became clear that nursing education frequently surfaced as a point of dis- cussion. Secondly, during the course of this study, starting in January of 2015, the credentialing examination for Ontario nurses was changed so that nursing students would be required to write the American-based Na- tional Council Licensure Examination (NCLEX) rather than the traditional Canadian Registered Nurse Exam (CRNE). This development has generated significant dialogue across Canada with respect to preparing bac- calaureate degree nursing students for practice due to concerns about the exam’s misalignment with Canadian curriculum (Woodend & Medves, 2015, December 14).
This paper reports on the analysis of a nursing educator and nursing student subsample that situates nurs- ing activism in a context of higher education with a focus on three questions:
1. How do nursing educators and nursing students understand activism?
2. What are barriers and facilitators to teaching about political activism in nursing?
3. How do nursing educators foster activism among their students? Findings are shared that illustrate how some educators are finding success in inspiring new graduates to become politically active on issues of social justice, as well as implications for education and research.
Methods
As part of a larger qualitative exploratory study on activism in nursing (MacDonnell & Buck-McFadyen, 2016), a comparative life history methodology was used to explore how activism was integrated into nurses’ career lives. These career histories captured meaningful personal and professional activities that included, but extended be- yond the boundaries of official nursing jobs (Bascia & Young, 2001). Activism was defined as “a combination of individual and social action designed to gain political commitment, policy support, social acceptance, and system support for a particular health goal or programme” (World Health Organization (WHO), 1998, p. 5). Through interviews and focus groups, career histories were explored in ways that did not typically reflect chronological life histories, but rather revealed particular events or experiences that participants identified as meaningful to their activism, which researchers and participants collaboratively situated within the larger pro- fessional and social contexts (Goodson, 1992; MacDonnell, 2011). A critical feminist lens was applied to examine the meaning of activism in participants’ everyday lives and identify patterns within and across these life his- tory narratives, while accounting for the broader political, social, cultural, historical, and economic contexts that shaped participants’ stories and the context of Canadian nursing education (MacDonnell & Buck-McFadyen, 2016).
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Purposeful convenience sampling was used to recruit nurses and nursing students who had an interest in political activism and who represented a diversity of practice settings, educational backgrounds, and genera- tional cohorts. Study recruitment information was posted in online and professional networks. When analysis of narratives from the first 11 participants in the larger study revealed an emerging focus on educational is- sues, targeted recruitment of educators and nursing students began. Subsequent focus groups and interviews allowed for a more fulsome exploration of the role of education in nursing activism. Data collection occurred between 2011 and 2015. The study protocol was approved by the appropriate Research Ethics Board prior to recruitment. Semi-structured interviews were conducted with individuals both in person and via telephone, and focus groups took place at multiple sites and included educators and nursing students. Combining inter- views and focus groups allowed the researchers to accommodate participant preferences for time and location that best met their needs, and also promoted data completeness as each method may reveal different aspects of the phenomenon of interest (Lambert & Loiselle, 2008). A core group of questions for both focus groups and individual interviews addressed participants’ understanding of activism, their everyday political activities, and factors that influenced their activism such as their education, involvement in professional organizations, and perceived supports and barriers. Some additional questions were added for individual interviews that provided more depth regarding career histories and critical incidents that informed their activist practice. The interview guide was also adapted slightly for each participant category, with a question for students about how they pictured themselves getting involved after graduation, and a question for educators about the boundaries of appropriate activist practice among students and their role in fostering activism. Additionally, as a strategy to spark focus group discussion, all focus groups began with the review of a scenario that involved university student and Senate page Brigette DePape who drew a “Stop Harper!” sign out from beneath her skirt during the Throne Speech in 2011 at the opening of parliament with Prime Minister Harper. This scenario was used to initiate discussion about appropriate forms of political activism and how this might have been perceived in a context of nursing. In retrospect, this was highly effective in prompting nuanced discussions of activism. Although intended only as a tool for data collection, it became evident over the course of the study that this scenario could be used in the classroom as a tool for teaching activism.
A consent form and demographics form were completed prior to each interview or focus group. All in- terviews and focus groups were audiotaped and transcribed verbatim. Data analysis and collection occurred concurrently, without separation by sample (educators versus students) or interview technique (interview ver- sus focus group), and emergent findings informed subsequent interview questions in an iterative approach (Carter & Little, 2007). Two researchers examined transcripts for themes and patterns; themes were coded us- ing qualitative research software NVivo10™. All transcripts had identifying information removed and names were replaced with a numeric code that also indicated interview format and participant status as either a stu- dent or educator.1 Data files were kept in a locked cabinet and will be destroyed as per the institution’s research policy.
Lincoln and Guba’s (1985) concept of trustworthiness was used to ensure rigor. The analysis was grounded in the voices of participating nursing educators and nursing students. The researchers, who also had experience with activism and nursing education, regularly debriefed to reflect on how their experiences and assumptions were influencing the study process. Extensive verbatim quotes representing a spectrum of participants in in- terviews and focus groups were used in reporting of the findings in order to provide a thick description to contextualize the findings.
Findings
The findings reported here focus on data from 26 participants, described in Table 1, who were either nursing educators (n=13) or nursing students (n=14)2 from six Ontario postsecondary institutions. Nine educators and nine students participated in individual interviews while four educators and five students participated in fo- cus groups. Student focus groups included only students who were enrolled in the same program of education, so that one group was made up of three undergraduate students and a second group included two graduate students. One educator focus group involved two educators and the other was a mix of two educators and two nurses from other settings who had experience as preceptors of undergraduate students and could speak to is- sues of activism in education. Students were enrolled in programs that ranged from baccalaureate to doctorate programs, and educators taught both undergraduate and graduate level nursing courses. The sample included three male and 23 female participants who identified as primarily white, middle-class individuals living in the Greater Toronto Area or Eastern Ontario. Participants’ ages ranged from 23 to 73 years, with most undergradu- ate students belonging to Generation Y/Millennials (Date of Birth: 1979–2000), most educators belonging to the Boomer generation (1946–1964), and fewer participants from Generation X (1965–1978) or Over Boomers (born
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before 1946). These educators and nursing students were currently or historically engaged in various forms of activism, from the local to international level, in areas that included civil and reproductive rights, workplace health and safety, health care access, and issues of social justice like homelessness, food security, and violence.
Table 1: Participant demographics.
Variable Statistics
Gender Female: 23 (88.5 %) Male: 3 (11.5 %)
Generation Gen Y: 8 (30.8 %) Gen X: 4 (15.4 %) Boomer: 12 (46.1 %) Over boomer: 2 (7.7 %)
Educators: Highest level of education (N=13) Baccalaureate in nursing: 1 (7.7 %) Masters: 8 (61.5 %) PhD: 4 (30.8 %)
Students: Current program of enrolment (N=14) Undergraduate: 9 (64.3 %) MScN/NP: 4 (28.6 %) Doctorate: 1 (7.1 %)
Three themes emerged from the findings, which were named a “Changing Landscape for Nursing Practice”, “Drawing a Line in the Sand”, and “Inspiring Nursing Activism in Education”. The first theme describes the prevailing neoliberal dynamics in health care and higher education, with neoliberalism defined as a philosophy centred on the principles of individualism, efficiency, and a free-market economy (Browne, 2001; Tomm-Bonde, 2012). This changing landscape for nursing practice contributed to challenges promoting high quality clinical care or nursing education, and often strengthened nurses’ convictions about the need to challenge injustices or contribute to professional or organizational change. At the same time, the climate in higher education that focuses on cost cutting, efficiencies, and standardization, had ripple effects on curricular priorities, expecta- tions for educators, and delivery of education, which constrained nurses’ ability to promote activism in the classroom. There was little consensus among educators on what constituted appropriate avenues for nursing activism, and a second broad theme of “drawing a line in the sand” represents the varying perspectives and identities that were shaped by nurses’ career histories, supports, and education. A final theme, “inspiring nurs- ing activism in education”, relates to how nursing educators found success in inspiring a new generation of activists as evidenced by their pedagogical approaches and students’ understanding of activism as a part of their future roles and responsibilities.
Changing landscape for nursing practice
Several nursing educators identified concerns with trends in health care system reforms that began in the 1990s under a neoliberal government and continue today in Canada and many westernized nations. The changing landscape in health care and higher education could be further divided into two subthemes. The first subtheme reflects concerns that nurses are “losing our core”. Under this subtheme, and most commonly among Boomer generation educators, nurses expressed concern about the loss of the essential elements that contribute to per- sonal and professional meanings of what it is to be a nurse and do nursing. The second subtheme involves the “challenges of teaching political action” in the classroom.
The dominant neoliberal ideology which values efficiencies and free market principles has translated into a landscape for practice where participants were witnessing registered nurse (RN) replacement with registered practical nurses (RPN), poor working conditions, pressure to deliver quality nursing care with increasing bud- getary constraints, privatization of services, and the corporatization of health care. As II#5E said, “We can’t get our heads out of the corporate mindset, which is really on today’s bottom line, not tomorrow’s value.” Some nurses reflected on the poor working conditions in acute care, where “It’s terrible on the floor … the way peo- ple are understaffed” (II#13E), and nurses are “rationalized beyond belief” (II#16E). The realities of this nursing practice environment meant nurses were asking themselves how they could “meet [their] standards in nursing with all the current cutbacks?” (II#7S). II#16E contrasted these policies of fiscal restraint with the government subsidies provided to banks during the recession of 2008, which saw “bailouts for the wealthy people who … then got their … bonuses in the States”. This practice environment provided “no shortage of issues” around which to speak up and organize (FG#1E).
The impact of a neoliberal climate in higher education was also felt by nurse educators who described pressures associated with increasing class sizes, lack of job security for professors, a predominance of part-time
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clinical faculty, and the switch to the NCLEX exam. Two educators identified hesitation at earlier points in their career to engage in activism as faculty members without job security, in which they would “think twice before going against the party line – especially pre-tenure” (II#17E). Educators also expressed concern about the recent change in the licensing exam required for registration to practice as a nurse in Canada from the CRNE to the American based NCLEX. II#16E was concerned about community content being removed from the exam and the lack of consultation with educators that she saw as a “patronizing” use of power by the nursing regulatory body. II#14E echoed concerns about the content of the NCLEX exam as a reduction of nursing to the “lowest common denominator of clinical knowledge and expertise”. Despite political action that saw several nurses and nursing interest groups express concern about the adoption of the NCLEX exam, II#16E felt “completely ignored with our concerns” as this significant change to nursing in Canada moved forward and was presented as “an apolitical event”.
Losing our core
Participants described troublesome trends that II#14E suggested felt akin to “losing our core” through health reforms and structural constraints to nursing practice. Several nurse educators perceived that the role or scope of nursing practice was being reduced, with public health nursing (PHN) jobs in particular being identified as compromised through amalgamations and top-down decision-making. “We’re constantly being told that the reason why we can’t do any of our stuff is because public health doesn’t do that … they did in the past, and all of a sudden we’re not …” (II#2S). II#17E suggested, “We used to do so much” within public health, and now she felt that with the loss of home visiting and the one-to-one relationship, nurses are answerable to authorities rather than the individual clients. A dominance of the evidence-based practice paradigm was also considered a narrowing of nursing scope. As one educator remarked, employers are looking for nurses to be “drones”, asking, “Have we shifted our focus away from being advocates to being professionals who practice best practices?” (II#16E).
Nurse educators and students were concerned about physician assistants pulling things away from nurses in a model similar to the USA, and replacement of RNs by RPNs for “cheaper labour”. II#4S felt that “Nursing is going to be obsolete in a sense, particularly the RN in general”. RN replacement was also identified as “scary” and “going backward” by a post-RN nursing student (II#3S). One nurse educator identified the need to advocate on behalf of the profession of nursing or else “… nursing will get farmed out. We will lose our discipline because we are giving parts away” (FG#1E). The changing landscape for nursing practice, which may serve to narrow the nursing role in an attempt to achieve efficiencies required under neoliberal reforms, was also deemed a critical influence for some nurses to inspire engagement in activism and resist the structural constraints affecting the discipline and the quality of health care. A more detailed description of these influences on activist practice is described elsewhere (MacDonnell & Buck-McFadyen, 2016).
Challenges for teaching political action
There was significant variation in how political action or activism was taught and supported across university nursing programs. Some educators identified social justice as one of the themes within their nursing program, and activities in this area were encouraged by the key faculty leaders, threaded throughout the curriculum, and perceived to be at the forefront of faculty’s work and teaching. Yet an educator whose institution was supportive of political action stated, “Do we inspire this political activism in nursing? I think unfortunately we don’t, but we need to” (FG#3E). Another suggested that despite institutional support to teach political action, there was no effort to “enforce or regulate” political action on the part of the regulatory body for nurses and this was deemed a threat to nursing advocacy (II#5E).
In contrast to those educators who felt supported in their role to teach political action, one participant who had taught at more than one post-secondary institution commented on the variability of institutional support, and another participant had a very different experience within her setting where “I think in our faculty political action is almost non existent” (II#16E). This educator felt that despite social justice being a stated value within that educational institution, there was little role modelling from colleagues, and resistance to experiential learn- ing of political action, where the participant felt “it’s in the doing that you actually have the big learning”. This educator, who has expertise in primary health care (PHC), remarked that, “It’s getting more difficult to teach political action”, with a shift in the dominant discourse toward acute care, a narrow view of evidence based practice, and a focus on completing the tasks of “caring for bodies” rather than building relationships. In ad- dition to organizational and regulatory support that was deemed necessary for teaching political action, the number of part-time faculty teaching within nursing programs may also have been a factor in how political
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action was taught and modelled. One part-time educator stated that there was no place for activism within her work due to competing priorities, although “There should be. How to fit it in is the question” (II#12E/S). If political action is not an explicit component of the course content, part-time contract faculty, many of whom work more than one job or are concurrently enrolled in graduate programs, may see little opportunity to adapt the course material due to the realities of heavy workloads and constraints on time and resources.
Drawing a line in the sand
Interviews addressed stories of activism, including reflections on how nurses understood their role and identi- ties as activists, and the range and nature of their nursing activist practice. There was little consensus on what was deemed appropriate activist practice, and the subtheme “influences on identity as an activist” describes some of the factors that contributed to where participants drew their line in the sand. For many educators and students, personal experience and theoretical knowledge that was congruent with ethical practice, critical so- cial theory, PHC, and/or a political economy lens, informed their understanding of political activism and its fit with their personal and professional identities. Yet starting focus groups with the page scenario provided an opportunity for lively dialogue about just “what” constitutes political action and appropriate professional nursing practice, serving as a “point of contention” among participants. This is the second subtheme.
Inflluences on identity as an activist
Students who self-selected for this study were enthusiastic about the opportunity to engage in activism as a way to make a difference in the world. Few had faced negative consequences related to their activism at this point in their careers and many commented on the rewarding nature of this type of work, deemed by one participant to be “good for spiritual growth” (II#11S). Most of the undergraduate students were Millennials and had not yet practiced as RNs, therefore their opportunities to speak to the realities of activist nursing practice were limited. Undergraduate students spoke of curricular activities that encouraged them to engage in activism. Several identified key faculty who stood out as strong proponents of political action and facilitated students’ awareness of the possibilities for political action within the profession. At the same time, some students expressed feeling overwhelmed with the multitude of issues and injustices to address so that they did not know where to begin or “where to go to try to make a difference” (II#15S). There were fewer graduate student participants in this study, although one educator who had recently completed a masters program contrasted undergraduate curriculum’s attention on activism with a shift in graduate studies focus to influencing policy. Two graduate students used language of advocacy and leadership rather than activism and cautioned about ensuring that proper channels were taken in advocating for a cause.
Some nurse educators had strong convictions about nursing being political and clearly identified as activists, with one educator describing activism as “in your bones” (FG#1E). Political and historical events that occurred early in some nurses’ lives, family that encouraged them to “have a voice”, activist colleagues or mentors, and strong convictions about social justice and/or feminist ideologies played key roles in nurses’ identification as activists. II#13E, whose activist work with marginalized women was clearly aligned with social justice and fem- inist values, reflected on the struggles encountered earlier in her career against dominant notions that “nurses were supposed to be good little girls.” The challenges that several nurse educators encountered as a result of their activist work led some nurses to adopt a cautious approach with fostering activism among students. II#16E was concerned about the impact of activism on students’ job security, stating, “I encourage people not to do their political activities through their job … the only people I know that are paid to do community political work … are the street health nurses.” Another encouraged her students to advocate with the resources and power behind them that only a union or professional association can offer. Yet experiences of negative personal consequences from activism did not consistently translate into a cautious stance with students. For instance, two educators who had been arrested for political protest involving women’s rights in the 1960s were among the stronger supporters of the need for both individual and collective political action and beginning as early as during undergraduate studies.
All educators supported political action through a union or collective body like the Registered Nurses’ Association of Ontario (RNAO). However there was great variation in what was deemed appropriate activist practice at the individual level. The page scenario proved an effective tool to explore these notions of what students and educators deemed were legitimate forms of political action.
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Page scenario as a point of contention
At the beginning of each focus group and during some individual interviews, the researchers summarized the 2011 scenario in which a Canadian Senate page drew a “Stop Harper!” sign from under her skirt in the House of Commons as an act of political protest. Educators shared contrasting ideas about whether this constituted meaningful or effective political action, with those in support of this protest calling it a brave and powerful gesture that gained significant media attention, and others condemning it as a “foolhardy” strategy that ac- complished very little. Some educators mulled this question over for some time, and one decided that while this was a “powerful gesture”, the risks were high, saying, “I think that our strength in our activism is more um, utilizing … what we have at our fingertips which is our knowledge and our experiences.” (II#14E). Another agreed that this strategy was not part of a well laid out plan or a targeted message, and some talked about the need to be backed up by the union. Yet other educators felt strongly that this was an example of legitimate political practice.
Students also had mixed feelings about this form of political protest and weighed risks to their future careers against what one perceived to be a brave, peaceful, and effective strategy for political action. One undergradu- ate student expressed concern about not “hav[ing] the guts” to carry this out, lacking the confidence and level of knowledge to back up the protest. Another surmised that such a form of political action could put the rep- utation of nurses at risk or give RNs a “bad name”. A graduate student in a nurse practitioner program felt strongly about the inappropriate nature of such a strategy because it was not endorsed by an organization or professional nursing body. In her view, more appropriate forms of political action required nurses to “play by the rules” and “act smartly” (FG#5S), for instance, RNAO letter writing campaigns or advocacy at the indi- vidual level to connect directly with stakeholders or leaders. In effect, these dialogues, in which participants actively reflected on the nature of nursing activism, illustrated the spectrum of understandings of the concept and how activism and its relationship to professional practice were situated in particular historical, economic, and political contexts. RNs with extensive career histories, and to some extent, participating graduate students who brought practice experience, approached activism in ways that were clearly shaped by this broader con- text and their personal and professional experiences, which influenced what they deemed legitimate activist practice. Undergraduate students that lacked practice experience were more heavily influenced by particular faculty members and opportunities for experiential learning within their nursing programs. Graduate students also offered insight into how the concept of activism was taken up in graduate programs in nursing.
Inspiring nursing activism in education
Nursing educators and students described educational strategies they believed were integral to developing a political activist identity. These suggestions were based on their own formative educational experiences and/or from educators’ notions about what was proving successful in the classroom. Strategies are described in the subthemes of “mentorship”, opportunities for “experiential learning,” and “threading political action through- out the nursing curriculum.” A fourth subtheme of “small group dialogue and story telling” demonstrated its potential as a tool to foster reflection on activism that could be applied in the nursing classroom.
Mentorship
Educators and students identified the importance of mentors within nursing, including educators, as well as those outside of the profession who could foster political socialization and inspire political action in students. Students offered examples of faculty who were “into politics” and courses such as community health that were particularly transformative in their understanding of the potential for activism within nursing and that sparked their developing political identities and actions. “She’s not just teaching it, she really, really loves it … I don’t think I was politically active until her class.” (FG#8S). Students suggested that the focus on political action was to some extent dependent on the professor, some of whom strongly encouraged students to learn about RNAO, read the newspaper, and develop opinions on issues, while others “were less interested in what you do beyond [their course material]” (II#8S). An experienced nurse educator reflected on the impact of an educator earlier in her own nursing career, who inspired her to mentor students in a similar way: “I think we need our educators desperately in the same way that that educator made a huge difference for me” (II#5E).
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Experiential learning
As one educator stressed,
The primary thing that I think all of them come away with is a sense of voice. In my view it is absolutely critical as nurse educators that we help these folks to find their voice, to learn about ways in which to use that voice both individually and collectively because it’s just essential to our moral survival, frankly, as people and as a profession. (FG#1E)
There were many examples of opportunities created by faculty to encourage student participation in political action, including assignments to write letters to the editor. Students were encouraged to attend RNAO board meetings; others attended Board of Health meetings as part of a community course with its PHC focus. At times, students were supported to attend certain political rallies as part of their clinical learning, such as a rally for public health care in which students “could use those hours toward (their) clinical hours” (II#11S). However, these narratives suggested that students understood the need to separate their personal activism from their educational institution in any activities that could be considered controversial.
Threading political action throughout the nursing curriculum
Many participants identified the importance of integrating political action concepts throughout nursing cur- riculum and connecting the everyday work of nurses to politics. “Political action has to be threaded in the same way that safety and leadership need to be threaded through a curriculum” (II#5E). One educator suggested political action should be explicit within the organizational mission statement and a job expectation of all nurs- ing faculty. Several educators made an effort to look at structural issues within all courses and practicums to get students “fired up” (II#13E); to connect current events and politics to nursing, “because as far as I’m con- cerned it’s all political” (FG#1E); and to demonstrate a critical reflection and political stance with everyday life. “It’s all around us, and it’s a question of helping (students) to see it” (II#14E). One educator spoke at length about primary health care principles, with their explicit valuing of nurses’ roles in policy and political action as “the basis for my practice” (II#17E). Another felt that the curriculum should include historical struggles for fair wages and the activism of nurse leaders in the past, “to know where we came from I think is very important, to look back at the history” (II#7S). An undergraduate student agreed that connecting curriculum to current events by reading the newspaper supported her transformation into becoming an activist: “I think that’s a re- ally great way of knowing what’s happening, and when you know what’s happening, it can be harder to shy away from it” (II#8S). In addition to a focus on political content, one educator reflected on the importance of a fit between actions and being. “It is so much more than what you do. It’s about how you are” (FG#1E), a focus that links praxis and critical pedagogy.
Small group dialogue and story telling
The focus groups, while intended as solely a data collection method, proved to be a valuable model for several educational strategies to create dialogue on political action. First of all, the “page scenario” offered a way to spark reflection and discussion of how various educators and students conceptualize the notion of “activism”. Secondly, the small group environment encouraged dialogue among nurses and students on a range of personal and professional activist experience across domains of practice including education, administration, policy, and point of care. This format for story telling and sharing political knowledges, identities, practices, and impacts with other nurses created opportunities for dialogue which are often not part of Toolkits for undertaking polit- ical action. While participants identified mentorship experiences and inspiration within or outside of nursing as important to their political socialization as nurses, they also illustrated how providing spaces for storytelling and critical reflection on activism, professionalism, and ethics is a valuable tool that can be extended into the classroom. As one educator stated, it is important to provide an opportunity to “examine how power and influ- ence work” (FG#1E), which may not be easily accomplished using traditional didactic pedagogical approaches in large classroom or lecture hall settings.
Despite the challenges encountered by nursing educators due to a changing landscape for practice and education, mentorship, experiential learning, threading of activism through the curriculum, and small group engagement were strategies that showed promise for fostering activism among students, who demonstrated enthusiasm about integrating political action into their future practice.
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Discussion
The aim of this paper was to provide insight into how nursing educators and students understand activism, describe barriers and facilitators they encountered in teaching and learning about political activism, and to share strategies of how nursing educators were able to foster activism among their students. Nursing educators and students with RN practice experience described an environment within health care and higher education that was dominated by cutbacks, efficiencies, and a narrowing role for nursing practice. While there was little consensus on what constituted appropriate political action to resist these workplace challenges and other issues of social justice, the participants consistently voiced an understanding of the political nature of nursing, and educators described the need to instill a sense of responsibility for addressing injustices in a new generation of nurses.
The findings suggest that education plays an important role in nurses’ political socialization, while a com- plexity of factors in the current neoliberal climate is undermining this aspect of nursing education. Neolib- eral reforms in health care have negatively affected the practice environment, reduced the scope of practice of nurses, and created organizational constraints that impacted the opportunity for participants to engage in political action. In the education context, neoliberal reforms have implicitly and explicitly affected curricular priorities and educators’ capacity to teach activism, and the legitimacy of political action as part of professional practice. Despite these challenges, it is clear that a number of nurse educators are committed to an explicitly po- litical focus for understanding and preparing students to meet their social justice mandate in these increasingly complex times.
Although the study questions did not directly address issues of health care reform or neoliberal dynam- ics, these themes consistently emerged among most educators and students who had RN practice experience, which is a unique contribution of this research. This theme of the neoliberal landscape is relevant to how ed- ucators and nursing students understand activism as well as their motivation and ability to act. While these various dynamics can create barriers to teaching about activism, they offer many examples that educators may draw on to prompt discussions of activism in nursing and health care. Neoliberal policies of fiscal restraint, business model management, and top-down decision making created constraints on nursing practice, and pro- vided fuel for political action. Nurses described health care cutbacks, RN replacement, increased workloads, and reduced scope of practice as some of the challenges faced by nurses providing direct patient care. Similar trends toward finding efficiencies within higher education led to reduced job security for faculty, large class sizes, and a recent change in credentialing with the NCLEX exam, that were perceived as pressing issues for nursing educators. These findings align with views that the corporate notion of health sector accountability is threatening the Canadian health system, quality of care, and the wellbeing of nurses, while often ignoring the social determinants of health, the ideal of health as a public good, and the tenets of PHC (Bryant et al., 2011; Choiniere, 2011; Duncan, Thorne & Rodney, 2015; Rudge, 2015). The study findings extend the literature that attributes neoliberal reforms to a narrowing of PHNs’ roles and barriers to policy advocacy in a Canadian context (Cohen & Marshall, 2017; Duncan, Thorne & Rodney, 2015; Falk-Rafael & Betker, 2012; Falk-Rafael, Fox & Bewick, 2005). In clinical practice settings, this can play out as nurses’ diminished advocacy role in favour of a narrow view of nursing practice aligned with the biomedical model and a technical rational approach to care that focuses on tasks and standardized care (MacDonnell 2009; 2010). An emphasis on care that is informed by post-positivism, rationalism, and evidence-based nursing that favours empirical ways of knowing while marginalizing other forms of nursing knowledge may serve the needs of governments in making cost-cutting decisions at the expense of support for meaningful relationships and nurses’ ability to practice holistic nursing care (Choiniere et al., 2014; Holmes, Perron & O’Byrne, 2006). A technical rational approach to nursing practice and education “rewards rationality more than reason, technical knowledge more than human understanding” (Rolfe, 2015, p. 151).
The impacts of neoliberalism, such as a focus on developing students’ marketable skills, have been well described in the higher education literature (Acker, Webber & Smyth, 2012; Kandiko, 2010), but are more limited with respect to Canadian nursing education (Duncan, Mahara & Holmes, 2014; Holmes, Perron & O’Byrne, 2006; Ronan, 2011). Intensified workloads, reduced job security, and a growing reliance on part-time teaching faculty are the realities facing educators from many disciplines (Acker et al., 2012). Fierce competition has developed for the scarce resources that support education, scholarship, and innovation (Duncan, Mahara & Holmes, 2014), while the “publish or perish” mantra at some universities can lead faculty to avoid pre-tenure research on controversial subjects that could limit career direction (Condon, 2015; MacDonnell, 2014; O’Connor & Yanni, 2012). With the added pressure on nurse educators to help their undergraduate students pass the newly instituted NCLEX exam, an American exam that has been critiqued for its misalignment with current Canadian curriculum (Woodend & Medves, 2015), an even stronger shift to a technical rational approach to nursing education may be imminent. Meanwhile, the dominance of neoliberal policies and resultant health
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inequities across society exacerbate the challenges nurses and educators face in their capacity to achieve social justice (Thompson, 2014).
While social justice has been thoroughly integrated into professional discourse of Canadian nursing, nurse educators were more pragmatic about the realities of how this mandate is being operationalized. The findings illustrate the highly contextualized nature of activism, which is represented with the phrase “drawing a line in the sand”. Although Canadian community health nursing content at the undergraduate level aligns with PHC philosophy and identifies engagement with political action as a role of community health nurses (Com- munity Health Nurses of Canada, 2011), even educators with experience teaching community health in this study represented diverse stances in relation to the nature and parameters of professional activism. Both nurs- ing unions such as the Ontario Nurses Association (2016) and the RNAO provide opportunities for collective action. Among professional nursing bodies that guide Ontario nurses’ practice, RNAO is unique in their po- litical stance and explicit support for nurses’ activism through toolkits and action alerts to encourage political involvement (Registered Nurses’ Association of Ontario, 2015). However, the invisibility of the term activism in nurses’ main guiding documents and practice standards, in favour of “advocacy” with its sanitized overtones, demonstrates the muted and often contested nature of nurses’ activist practice. This contributed to the variation in how educators who teach across nursing curriculum understood and promoted the legitimacy of nursing activism in the classroom.
Political action that aims to improve the health of individuals and communities and to transform systems of care is an important aspect of caring practice (Falk-Rafael, 2005; Kagan et al., 2010; MacDonnell & Buck- McFadyen, 2016). These study findings point to the need for ongoing discussion among nursing educators to clarify their perspectives on activism and use them as a basis for recommendations to leaders of nursing ed- ucation, practice, research, and policy regarding effective political actions and strategic direction for nursing curricula and pedagogy that can ultimately improve patient, community, and societal outcomes.
Despite the challenges that result from a neoliberal climate in health care and in higher education, and the in- consistent organizational and professional support for teaching activism identified by participants, these study findings reveal several practical implications for curriculum development and pedagogy in nursing education in Ontario. These include experiential learning and use of critical and narrative pedagogies in the classroom, as well as a need for explicit organizational and professional support to build student nursing activist compe- tence and capacity. Experiential learning to foster political competence was a strategy that students valued in their transformation into nurse activists. While “educating for justice is only realized when students learn to act” (Fahrenwald et al., 2007, p. 195), the study findings demonstrate the importance of organizational supports for moving political practice beyond classroom borders, a strategy that was inconsistent between institutions yet praised by students whose faculty facilitated participation in field trips and political rallies. Students and educators also identified role modeling of political competence, such as educators and guest speakers shar- ing stories of their activist work, threading activism throughout the curriculum, and bringing current affairs and politics into the classroom through class discussions and assignments as key strategies to foster their ac- tivism. These suggestions are echoed in the literature (Fahrenwald et al., 2007; Gehrke, 2008; Murphy et al., 2005; Vickers, 2008). The Canadian Nursing Students’ Association (2013) adopted a resolution to advocate for the inclusion of political education and activism competencies in the nursing curricula, demonstrating nursing students’ appetite for the political knowledge and tools to meet their social justice mandate. These educational strategies require institutional and regulatory supports that extend beyond a statement of social justice values, with clear language about the political nature of nursing and the need to incorporate political activism in the education of the next generation of nurses (MacDonnell, 2009).
Educators whose pedagogical approaches embrace a critical lens can help students understand the mul- tidimensional nature of activism, how power and influence work, and the historical, sociocultural, political, economic, and gender dynamics in the profession that shape issues of health equity and social justice. These dynamics contribute to what have been identified as political knowledges, practices and impacts that situ- ate nurses’ engagement with policy and politics (MacDonnell, 2010). Educators can use research on nursing practice and education that points to the normative features of gender and femininity that can influence ex- pectations for nursing work and the legitimacy of activism that includes exercising individual agency and expressing dissent (Giddings, 2005; MacDonnell 2009; 2010). Learning to live with ambiguity, to value dissent, and move beyond the superficial right answers are important aspects of teaching/learning that challenge gen- dered norms in nursing and are at odds with the current technical rational emphasis on predictable outcomes. The focus group dialogues as a venue for telling stories about activism and reflecting on these stories within and across generations illustrated the value of narrative pedagogy (Mitchell, Jonas-Simpson & Cross, 2013), and importance of creating spaces in the undergraduate and graduate nursing curriculum for dialogue on the complexities of nursing activism. Educators can build political competence using such a relational focus with its priority on dialogue and developing understanding of diverse perspectives and contexts that shape the com- plexity of nurses’ decisions to undertake individual or collective action. While education on political action may
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focus on well renowned nurses such as Cathy Crowe, whose work with homelessness has been the inspiration for nurses across ages, in fact, these findings point to important dialogues that are about the core meaning of professionalism and ethics as also key to meaningful education on political activism. Critical gender, primary health care, and political economy approaches are also recommended as lenses through which to understand health inequities (Doane & Varcoe, 2005; Falk-Rafael, 2005; Kagan et al., 2010; MacDonnell, 2014; Murphy et al., 2005; Reutter & Kushner, 2010; Vickers, 2008), which help to shed light on issues of power and privilege, how neoliberal policies influence the health care system and health equities, and thereby reveal opportunities for emancipatory nursing practice.
Research (Giddings, 2005; MacDonnell, 2014) has pointed to gendered norms in the profession that shape nurses’ activism. This paper expands our understanding of nursing education-related factors, identifying men- torship, role modeling and experiential learning, along with strong social justice and/or feminist convictions, as critical influences that inform student and educator activist identities and practices (Doane & Varcoe, 2005; Kagan et al., 2010). Further research with diversely situated nurses across Canada that examines the effects of the NCLEX exam in particular on activism, as well as other aspects of Canadian nursing education and cur- riculum, is needed. There are also implications for undertaking further research to examine how activism is taken up in diverse undergraduate and graduate programs across Canada, as well as comparative research that considers how the concept is addressed in international nursing education contexts.
Limitations of this exploratory study include the limited geographic diversity and the small sample size of self-selected students and educators with an interest in nursing activism that may not reflect the diversity of views in nursing education or diversity of race, class, and other social location of the Ontario nursing workforce or nursing student body. While the larger study (MacDonnell & Buck-McFadyen, 2016) sought a sample rep- resentative of the generations that comprise Canada’s current nursing workforce, this subsample of educators and students was too small to analyze the impact of generation on activism. Students were primarily under- graduates, with too few institutions represented or graduate student participants to compare across types of programs.
Conclusion
Social justice is an integral component of Canadian nurses’ mandate, and this study highlights the transfor- mative potential of nursing education in developing political activists. In order to move beyond the dominant technical rational approach to nursing education and nursing advocacy and to foster engagement in emanci- patory practice that meets nurses’ social justice mandate, meaningful spaces are required in undergraduate and graduate level curricula to reflect on the complexities of activism and to foster political competence. The current neoliberal climate in Canada has constrained both nursing practice and education environments, while contributing to health inequities that demand political competence and upstream action on the social deter- minants of health. Despite the challenges of defining activism and delineating what constitutes appropriate political practice, educators are finding ways to reaffirm the importance of recognizing the political nature of nursing practice and to inspire a new generation of nurse activists to tackle these 21st century challenges. This study points to the need for curricular, pedagogical, organizational, and professional supports for nursing educators as they undertake this mandate.
Funding
Social Sciences and Humanities Research Council of Canada, (Grant /Award Number: ‘410-2010-2555’)
Notes 1Individual Interview = II, Focus Group = FG, Student = S, Educator = E 2One participant was both a nursing educator and student
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