ETHICS AND THE DNP-PREPARED NURSE
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wk6Socialjusticeinnursingeducation.docxSocial justice in nursing education: A review of the literature
Author links open overlay panelVictor Kpandemoi Abu, Calvin R. Moorley
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Highlights
Evidence presented here demonstrates that:
· •
There is no singular or shared or commonly held definition of social justice in nursing.
· •
Social injustice negatively impacts health and wellbeing.
· •
The visibility of social justice in nursing curriculum varies between geographic regions.
· •
The UK does not explicitly engage with social justice in its regulatory documents, to the same degree as other countries.
· •
There are opportunities to align the imperative of social justice in nursing education and practice.
Abstract
Background
Social justice is a cornerstone of nursing because nurses have responsibilities for providing equal and fair care for people from all background. Social justice as nursing imperative is clearly recognised by some professional nursing organisations, but not so by others.
Aim and objectives
The aim of this review was to establish the current state of the literature on social justice and nursing education . The objectives included to understand the meaning of social justice for the nursing profession , assess the visibility of social justice learning in nursing education, and explore frameworks for integrating social justice learning in nursing education.
Methods
The SPICE framework was applied to identify the phrases social justice and nursing education. Inclusion and exclusion criteria were used to search the EBSCOhost database, set email alerts on three databases, and search the grey literature. Eighteen literatures were identified for evaluation of predetermined themes on meaning of social justice, visibility of social justice learning, and frameworks for social justice nursing education.
Findings
Firstly, the meaning of social justice relates to general theories rather than practical issues in nursing. Secondly, social justice is embraced as an imperative in nursing profession. Lastly, critical pedagogies can support social justice learning in nursing education.
Discussion
There is consensus on need for social justice issues to be incorporated in nursing education. This would create paths for nurses to engage in actions that change health inequalities.
Conclusion
Nursing organisations embrace social justice as nursing imperative in different ways. It is important to explore how this imperative is upheld by nursing professional organisations and education institutions.
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Keywords
Social justice
Nursing education
Nursing curriculum
Critical pedagogy
Nursing responsibilities
Nursing imperatives
1. Background
The briefest search of the internet reveals that social justice is a matter of interest and urgency for the nursing profession . This interest relates to the need for nurses to be at the forefront of addressing persisting health disparities caused by unjust social systems.
Social justice as nursing responsibility is recognised in professional nursing organisation documents such as the American Nurses Association (ANA), Canadian Nurses Association (CNA) and International Council of Nurses (ICN) (ANA, 2015; Canadian Nurses Association, 2010, Canadian Nurses Association, 2017; International Council of Nurses, 2012, International Council of Nurses, 2021). Similar recognition is not given by the Nursing and MidwiferyCouncil (NMC), the only professional nursing organisation in the United Kingdom (UK) (Abu, 2020). Differences in ways that these organisations embrace social justice as nursing imperative diminish opportunities for global common ground.
Nursing profession has longstanding and enduring history of social justice responsibilities (Grace et al., 2022; Grace and Willis, 2012; Thurman and Pfitzinger-Lippe, 2017). This notion is promoted in situations where nurses engage in advocacy and social actions against poor conditions that cause ill health and death.
Florence Nightingale and Mary Seacole, who were forerunners of professional nursing in the UK, advocated for improvement in healthcare for Britons and migrants, women's rights, and social freedom (Anionwu, 2016; D'Antonio, 2013). In the USA, nursing forebearers such as Lillian Wald, Mary Brewster, Mary Eliza Mahoney, and Lavina Dock, advocated for improved healthcare for people facing marginalisation and discrimination (Baer, 2012; Ruel and Wald, 2014). These nurses used their experience of people's living conditions to engage in social reforms that addressed injustices responsible for health problems ( Thurman and Pfitzinger-Lippe, 2017). To date, nurses continue to engage in actions that support patients and families with the aim of changing unjust systems and practices that impact on health and wellbeing.
The impact of social injustice on health is recognition that illnesses and poor health can be due to unequal or unfair practices in allocating health resources . Social injustice cause portions of society to suffer greater proportion of health burden in the forms of disease, morbidity, and mortality (Perry et al., 2017). These avoidable differences in health experiences and outcomes are associated with disparities in social, economic, demographic, or geographic conditions (Marmot et al., 2020; WHO, 2020).
In the UK, high-level of health disparities, caused by hostile socioeconomic conditions, makes most deprived communities continue to lag in health outcomes (Cylus et al., 2015; Marmot, 2015; Scheffer et al., 2019). These conditions contribute to 30 to 55 % of the social determinants of health responsible for inhumane living conditions ( Marmot et al., 2020; WHO, 2020).
Other reasons for health disparities are structural conditions, power dynamics, and poverty created by discriminatory systems and practices (Garneau et al., 2016; Hellman et al., 2018; Vliem, 2015). People are discriminated because of their gender, race, sexual orientation, social class, immigration status, age, and abilities or disabilities. Discrimination produces and sustains inequities and injustices, with profound effect on access to care and overall wellbeing. This was evident during COVID-19 pandemic when higher proportion of infection-related morbidity and mortality was reported among Black and Minority Ethnic (BAME) people, compared with White ethnic groups (Public Health England, 2020). These disparities were related to social and structural issues of deprived urban settlement, overcrowded household, immigration status, and exposure to jobs with higher risk of COVID-19 infection and death (Cabinet Office, 2020; Office for National Statistics, 2020). There are comparable reports for people with mental illness, long-term health conditions, intellectual disabilities , aging health problems and Lesbian Gay Bisexual Transgender Queer and Intersex (LGBTQI) background ( Garneau et al., 2016; LGBTQI, 2017; McCann and Brown, 2020).
Despite the recognition of social issues responsible for health disparities, there remain significant barriers in fair access to healthcare and minimally decent living conditions ( Grace and Willis, 2012; Royal College of Nursing, 2017; Stonewall, 2017). These are issues that nurses need to understand because they have frontline healthcare access to people affected by unjust systems and practices.
2. Aim and objectives of review
The aim of the review was to establish the current state of the literature on social justice and nursing education .
The objectives included to understand the meaning of social justice for the nursing profession , assess the visibility of social justice learning in nursing education, and explore frameworks for integrating social justice learning in nursing education.
These purposes help to clarify the position of nursing professional organisations and education institutions on addressing social justice issues in the profession. In this review, social justice is an umbrella term for understanding social issues related to health experiences. Also, nursing education is deemed as the process of developing knowledge, skills and attitude for social justice understanding and action.
3. Methods of review
Organised methods were applied for searching databases. This was followed by synthesis and evaluation of findings on social justice and nursing education.
Firstly, the purpose of the review was clearly stated, that is, to establish the current state of the literature on social justice and nursing education. Secondly, the SPICE or Situation Perspective Intervention Comparison Evaluation framework, was used to identify the key terms “Social Justice” and “Nursing Education”. The SPICE framework is suitable for identification of search terms in social science topics, as applied in this review (Booth, 2006; Eriksen, 2018). Lastly, the EBSCOhost database was used to search for relevant literatures on “Social Justice” and “Nursing Education”. The EBSCOhost database was selected because it amalgamates social science databases such as Education Research Complete, SAGE Premier, CINAHL , ScienceDirect, SOCindex, and Taylor & Francis. The database search involved combination of Boolean operator and truncation for the search term “social just*” AND “nurs* educat*”, to limit the search to relevant literatures; publications from January 2010 to January 2021, to capture literature for the thesis that is the product of this review; publications in English language, for ease of reading; and publications from all geographic regions. See Fig. 1 for PRISMA of literature included or excluded for review.
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Fig. 1. PRISMA for inclusion and exclusion of literature.
Additional search for literature included email alerts, on Taylor & Francis, Academia, and Google Scholar databases, on “social justice and nursing education”. These databases are suitable for searching social science topics. The alerts were set at the time of writing the academic thesis from December 2019 to January 2022, to identify up-to-date literatures. These email alerts produced 161 articles.
Furthermore, the grey literature was searched for the phrase “social justice nursing education”. This was intended to assess the suitability of references found in other literatures. This search process produced 18 literatures.
The following criteria was applied for inclusion of literature: peer review journal articles that addressed social justice nursing education; seminal textbooks that addressed theories or practices of social justice nursing education; professional nursing organisation education standards; relevant literature from all geographic areas; and relevant publication from December 2019 to January 2022. Literature that did not meet these criteria was excluded.
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Fig. 2. Summary of literature included for evaluation.
4. Literature review findings
The literatures selected for review indicated different interests between geographic regions on social justice nursing education. The literatures showed greater interest on the topic in the USA and Canada. This was shown by the greater volume of publications on the topic and clearer positions by professional organisations on social justice in these countries. Also, there was consensus among writers and organisations that social justice issues are imperative in nursing profession.
Three pre-determined themes used to synthesise and evaluate the selected literatures included: meaning of social justice for the nursing profession, visibility of social justice learning in nursing education, and frameworks for integrating social justice learning in nursing education. These themes were selected because they address the key purposes of this review.
4.1. Theme 1: meaning of social justice
Two approaches in the literature for defining social justice are statements by professional nursing organisations and definitions that are products of specific studies.
Two professional nursing organisations that defined social justice in their documents are the American Nurses Association (ANA) and the Canadian Nurses Association (CNA).
In the ANA Codes on Ethics with Interpretive Statements, the organisation stated that:
Social justice as a form of justice that engages in social criticism and social change. It focuses on the analysis, critique, and change of social structures, policies, laws, customs, power, and privilege that disadvantage or harm vulnerable social groups through marginalisation, exclusion, exploitation, and voicelessness. Among its end are: a more equitable distribution of social and economic benefits and burdens; greater personal, social, and political dignity; and a deeper moral vision for society. It may refer to theory, process, or end.
( ANA, 2015, p.45)
In a document commisioned on Social justice … a means to an end, an end itself, the CNA defined social justice as:
The fair distribution of society's benefits, responsibilities and their consequences. It focuses on the relative position of one social group in relation to others in society as well as on the root causes of disparities and what can be done to eliminate them.
( CNA, 2010, p.10)
The CNA referred to this definition in their recent document on Codes of Ethics for registered Nurses ( CNA, 2017, p.26).
Also, writers have adopted definitions of social justice stated by nursing organisations. For example, Walter (2017) used the definition by ANA stated above. On the other hand, Perry et al. (2017) used the American Association of Colleges of Nurses (AACN) definition of social justice as “full participation in society and the balancing of benefits and burdens by all citizens, resulting in a just ordering of society” (AACN, 1998, p.948).
In other cases, writers used definitions produced from their work. This approach was embraced in the review study on social justice as the root of nursing by Thurman and Pfitzinger-Lippe (2017). These writers used the outcome of their review to define social justice as a concept that relates to managing the benefits and burdens of society. Similar definition was stated by Hutchinson (2015), as product of a review study on poverty simulation for teaching social justice. However, this writer added that social justice is about fairness in balancing the benefits and burdens for all citizens.
These definitions by nursing organisations and writers have comparable or shared understanding. Also, definitions stated here are rooted in philosophies or theories such as fairness and equality, rather than practical issues in nursing.
4.2. Theme 2: social justice in nursing education
The visibility of social justice learning in nursing education conveys interest of nursing organisations or institutions on promoting social justice imperative in the profession. This interest should be clearly stated in nursing organisation documents that guide the designing of nursing curricula. Organisations that lead on this drive are the ANA, CNA and ICN.
The American Nurses Association (ANA) (2015) makes two provisions for Integrating Social Justice (Provision 9.3) and Social Justice for Nursing and Health Policy (Provision 9.4). Provision for integrating social justice referred to collective nursing responsibilities for making changes to healthcare through actions that influence systems for improving determinants of health ( ANA, 2015, p.36). This provision calls nursing education institutions to develop curricula that support student nurses to address unjust systems and structures and commit to social justice issues in health ( ANA, 2015, p.36). The provision on social justice for nursing and health policy addressed the need for nurses to engage in political actions for global health and human wellbeing ( ANA, 2015, p.36). This provision incorporates eco-justice as part of nursing social justice responsibilities for engaging in actions that maintain, sustain, and repair the natural world to promote global health and wellbeing, especially for the poor ( ANA, 2015, p.37).
The CNA takes explicit position on social justice as an issue that complements the making and fulfilment of their “mission, vision and values” ( CNA, 2010, p.5). They suggest attributes that nurses can take to promote social justice, including “health equity, human rights right to health, democracy and civil rights, capacity building, just institutions, enabling environments, poverty reduction, ethical practice, advocacy, and partnerships” ( CNA, 2010 p.7). These are “ethical endeavours related to broad societal issues” for addressing social inequities “associated with health and wellbeing” ( CNA, 2017, p.3). Specifically, the CNA call for these attributes and issues to be incorporated in designing curricula on social justice ( CNA, 2017, p.31).
In the ICN Code on Ethics, the organisation requests national nurses' associations to collaborate with global organisations to address current and emergent social justice issues ( ICN, 2021, p.16).
These explicit statements by national and international professional nursing organisations demonstrate their commitment to social justice imperative in the profession. These statements provide guidance for visible integration of social justice ideals and topics in nursing education.
4.3. Theme 3: frameworks for social justice nursing education
Frameworks for social justice nursing education are ideas of curricula activities that promotes social justice learning in nursing education programmes . These activities support students to understand and take actions that change unjust practices that have negative impact on health and wellbeing. Learning activities identified for this purpose are categorised into anti-discriminatory, transformative praxis, facilitating humanisation, poverty, and cultural competence – pedagogies.
Anti-discriminatory pedagogy is the use of critical consciousness to learn to change unjust social conditions that impact on caring practices ( Garneau et al., 2016). The purpose of anti-discriminatory education is to empower student nurses to counter individualist and racialising cultures; analyse power relations in the profession; change discriminatory and oppressive systems; and focus on human rights, social justice, and advocacy in healthcare ( Garneau et al., 2016; Hutchinson, 2015). Education activities that support these purposes are reflexive learning about issues that influence behaviour, critical thinking for challenging discriminatory practices, and learning about local and global social justice ( Garneau et al., 2016; Hutchinson, 2015).
Facilitating humanisation pedagogy involves enabling learners to care for themselves and others in relation to their experience of the world ( Grace and Willis, 2012). The purpose of this learning approach is to recognise common humanities of all people; treating people in suitable ways; and promoting human wellbeing and flourishing ( Grace and Willis, 2012; Perry et al., 2017). Education activities that facilitate humanisation include critical reflection and consciousness on actions that change internal and external barriers for social justice activities in nursing (Hatchett et al., 2015; Perry et al., 2017). This knowledge allows student nurses to explore unexamined assumptions of individual or institutional cultures of healthcare. Also, it raises awareness about power relations that perpetuate inequitable social conditions.
Transformative praxis pedagogy in the context of this review incorporates emancipatory nursing praxis ( Walter, 2017), transformative pedagogy (Dyson, 2017), and social justice nursing praxis (Kagan et al., 2014). These are critical pedagogies on social justice awareness and praxis for transformation of discriminatory practices that perpetuate health inequalities. Walter (2017)explained emancipatory nursing praxis as inter-relational concepts of becoming, awakening, engaging, and transforming nursing consciousness for social justice in health. On the other hand, Dyson (2017) described transformative pedagogy as learning for uncovering and transforming hidden nursing curricula that perpetuate social and cultural injustices. These ideas connect with understanding social justice nursing praxis as increasing nursing knowledge beyond traditional ways of knowing to that of critical and emancipatory knowing ( Kagan et al., 2014). The common purpose of critical curricula is to develop critical mindsets for understanding and engaging in actions that change historical and persisting causes of injustices responsible for poor health. This critical learning can be in the form of active participation, dialogue, problem-based, reflexivity and critical reflection – activities.
Cultural competence pedagogy in nursing education is understanding and promoting actions on cultural issues that affect health and wellbeing (Chen et al., 2012). The idea of cultural competence relates to intercultural models of nursing practices, concepts of health and diseases, and communication in healthcare. Chen et al. (2012), classified cultural competence pedagogy into cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. Education activities suggested for attaining these competences include examining biases, understanding multi-cultural practices and beliefs, collecting information about different cultures, interacting within diverse cultures, and engaging in cultural competence activities ( Chen et al., 2012).
Poverty pedagogy for social justice in nursing is learning about poverty and its impact on health ( Scheffer et al., 2019; Vliem, 2015). Poverty education addresses the prevalence of poverty at local and global levels. It draws attention to the need for nursing education to maintain pace with challenges that poverty cause for health ( Scheffer et al., 2019). Poverty education demonstrates the impact of poverty on health in simulated classroom or practice learning environments in local or international areas (Hellman et al., 2015). These areas should provide safe learning environments for direct experience and reflection on issues such as homelessness, mental health, substance abuse and misconceptions about poverty ( Scheffer et al., 2019; Vliem, 2015).
5. Discussion
Social justice as nursing imperative is demonstrated in nursing actions and statements by some nursing professional organisations. Nursing actions for social justice encompass care and advocacy for people in marginalised conditions or facing discrimination. There are differences in ways that nursing professional organisations or geographic regions demonstrate interest or scholarship on social justice as nursing imperative. Nursing organisations in the USA, Canada, and the International Council of Nurses (ICN) have featured social justice issues prominently in their professional documents. These organisations or regions have produced greater volume of literatures on the subject. The situation is different in the UK, where social justice is neither prominent in nursing organisation documents, nor produced significant levels of scholarship on the subject.
One explanation for differences in featuring social justice as nursing imperative is the complexities in understanding the concept. This review has identified different meanings and attributes of social justice. Therefore, one size or definition or understanding does not fit all organisations or regions. If you ask five people to define social justice, they are likely to state five different but similar understanding of the concept. This is shown in definitions by nursing organisations and writers. Also, definitions identified in this review are rooted in philosophical or theoretical statements that may not bear direct relevance to nursing practice. Lack of clear meaning of the term in nursing education is said to be responsible for lack of clarity on ways that nursing professionals can uphold social justice values ( Perry et al., 2017).
In the UK, there is lack of clear statement about social justice in documents of the Nursing and Midwifery Council (NMC). The NMC is the only professional organisation that regulates these professions in this country. The organisation has not mentioned the term ‘social justice’ or made clear statements about social justice in their current code or education standards ( Abu, 2020; Nursing and Midwifery Council (NMC), 2015; Nursing and Midwifery Council (NMC), 2018). Nevertheless, there are implicit references to social justice issues in these documents. For example, the platform on accountable professional states that student nurses should be able to challenge discriminatory behaviour and reflect on values and beliefs and people from diverse backgrounds ( Nursing and Midwifery Council (NMC), 2015; Nursing and Midwifery Council (NMC), 2018, p.8–9). Also, the platform on promoting health and preventing ill health call on student nurses to “engage in … the reduction of health inequalities” ( Nursing and Midwifery Council (NMC), 2015; Nursing and Midwifery Council (NMC), 2018, p.10) and “understand the factors that may lead to inequalities in health outcomes” ( Nursing and Midwifery Council (NMC), 2015; Nursing and Midwifery Council (NMC), 2018, p.14). However, it can be argued that the call for students to understand health inequalities should be reinforced by guidance for actions that redress the causes of inequalities. This concern could be addressed if the NMC, as well as other nursing organisations, make unequivocal statements about social justice as nursing imperative in their documents. Such statement or position would encourage and direct nursing education institutions to visibly integrate social justice learning in their curricula.
The lack of, or ambiguity, in incorporating social justice learning in nursing education, or call for nursing action for social justice is not unique to the NMC (Bekemeier and Butterfield, 2005). These writers found inconsistences by nursing organisations in the USA on direction for social justice learning in the profession. They attributed this to the dominant biomedical focus on individual care in the profession. Thurman and Pfitzinger-Lippe (2017) described this as “think small” for the individual, rather than “think broad” for the community approach in the profession (p.4).
Community focused care increase our understanding of social justice issues connected with peoples' health experiences and outcomes. It is an experience of the journey from the community where disease is contacted to the community where people are discharged from hospital. It is a path that consists of discriminatory social policies responsible for diseases and illnesses. Community focused care avoids trivial recognition of social justice which diminishes nurses regard for the relevance of unjust practices (Valderama-Wallace, 2017). Also, community focused care contributes to greater consistency in ways that nursing organisations provide clearer path for mobilising and engaging nursing actions for social justice ( Valderama-Wallace, 2017).
Clearer paths of social justice education facilitate visible integration of critical pedagogies in facets of nursing education. This is achieved by applying critical learning activities focusing on anti-discrimination, facilitating humanisation, transformative praxis, cultural competence , and poverty – pedagogies. These education programmes support learners to develop social justice knowledge, skills, and attitudes; and creates awareness on causes and consequences of social injustice and actions for transforming unjust practices.
This review found that there are more curricula activities or concerns about cultural and poverty pedagogies, compared with the other critical pedagogies. This might be due to increasing evidence that certain cultural groups experience poorer health compared to the overall population (Drevdahl, 2018). Also, it could be due to clearer link between poorer health outcomes for people living in poverty or deprivation ( Cylus et al., 2015; Marmot et al., 2020; Scheffer et al., 2019). On the contrary, curricula on other critical pedagogies mentioned in this review are less developed in current nurse education programmes.
Similar critical learning activities can be used for integrating these pedagogies in nursing education. This includes simulation, practice placement, reflexivity, reflective practice, classroom discussion, storytelling, and arts. These activities should be organised in safe learning environments to demonstrate nuances of discrimination, poverty, humanisation, and cultural issues . They encourage learning about misconceptions, biases, judgments, and experiences regarding people affected by injustice. It allows learners to encounter marginalised communities and develop positive attitudes and support for people facing injustice. These experiences can be linked to classroom discussion on injustice, lifestyle choices, determinants of health, and health inequities at global and community levels.
6. Conclusion
This review of the literature on social justice in nursing education expose concerns that social justice as nursing imperative is not addressed consistently by nurses and nursing organisations. It is a concern that recognises the negative impact of persisting injustices on health and wellbeing of people. This interest has been addressed here by understanding the meaning of social justice, visibility of social justice learning in nursing education and courses for learning about social justice issues in pre-registration nursing education.
Evidence presented here demonstrates that there is no singular or shared or commonly held definition of social justice in nursing. Also, the visibility of social justice in nursing curriculum varies between geographic regions. Moreover, the UK does not explicitly engage with social justice in its regulatory documents, or in nursing scholarship to the same degree as countries like the USA or Canada. Lastly, there are opportunities for aligning the imperative of social justice in nursing education and practice as foundational professional responsibilities.
Collectively, these purposes identify opportunities for advancing matters of social justice in the profession. It shows connections between nurse education and the profession, wherein nurse education is the site where new nurses are educated for pursuing professional goals. The issues identified in this review could be explored in specific nursing professional organisation or education settings to determine the feasibility of social justice nursing education.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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The inclusivity approach highlights an intentional practice that fosters the inclusion of historically underrecognized racial and gender identity groups, as well as addressing marginalization within healthcare educational content (Bell, 2021; Foronda et al., 2020; Metzger et al., 2020; Puzan, 2003). The social justice approach aims to address the structural transformations needed in knowledge systems and practices to achieve health equity, dismantle discriminatory practices, and eliminate systemic biases (Abu & Moorley, 2023; Blanchet Garneau et al., 2021; Buettner-Schmidt & Lobo, 2012; Thurman & Pfitzinger-Lippe, 2017). The intersectionality approach acknowledges the multifaceted nature of individuals' experiences and identities, informing how social-political-historical factors intersect and influence healthcare outcomes (Beard et al., 2022; Beech et al., 2021; Eckstrand et al., 2016).
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© 2023 The Author(s). Published by Elsevier Ltd.
Part of special issue
Educational research in health
Edited by Amanda Kenny (La Trobe University, Australia)
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