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Posts tagged ‘intersectionality’

Re-examining Marginalization

The first featured article for the latest issue of ANS is authored by Joanne M. Hall, PhD, RN, FAAN and Kelly Carlson, PhD, APRN-BC. The article addresses complex issues that perpetuate health disparities, and is titled “Marginalization: A Revisitation With Integration of Scholarship on Globalization, Intersectionality, Privilege, Microaggressions, and Implicit Biases.” The article is available to download at no cost while it is featured; I join the authors in inviting you to read it and return here to share your comments and ideas.  Here is a message from Dr. Hall about her work:

Why talk about marginalization? Marginalization refers to principles that can be transferred across contexts, yet we are learning that so many nursing problems, especially in the US, where healthcare is a pluralistic, patchwork

Joanne Hall

Joanne Hall

structure require attention to situation-specific factors, and situation-specific theories? The beginning of this thread of scholarship was the question, is there anything marginalized groups, or people in marginalizing situations have “in common?”  This not only included marginalization based on identity or group status, but on social processes, cultural expectations, environmental and socio-political factors. We agree with Chinn and Kramer that emancipatory knowledge is foundational to nursing science and practice.

There is an aspect of person that is potentially universal, a striving toward survival, thriving, and belongingness in such a way that supports diversity, equality, equity and justice. But this is not feasible for so many in the world at this time in history.

As a newly practicing RN, I was also, (in my spare time), an activist in the Catholic Worker Movement, and part of a group who opened a house of hospitality for women and children in Dubuque Iowa, my home town.  Eventually, we became a “discharge plan” and patients were sent from the local hospitals to “Catholic Worker House.”  The patients I cared for from noon to midnight in the psychic unit the night before might arrive in time for dinner the next evening and stay for two weeks.  This 6 years of my life was a great education about the highest-risk people in our communities.   We as a community combined providing food, clothing and shelter for those in immediate need with political action on larger justice issues.  At that time, liberation movements were growing in Latin America, and I became involved in discussions with various liberation and feminist theologians. In particular, I formed a partnership with my friend and mentor, now deceased, Manolo Barreno. Mano was a liberation theologian from Ecuador who had been thrown out by the Jesuits from a seminary in Rome for “associating with communists,” poor folks, who then not only took him in but supported his journey to the US,  to Iowa to finish his PhD at Aquinas Institute of Theology, which happened to be in Dubuque. Mano and I were fast friends, and became agitators in the group, pressing for justice not only in Latin America, and locally, but for structural changes in the Catholic Church itself. The movement by survivors of sexual abuse by ministers and priests (SNAP), was emergent.  Those who joined Mano and me pressed for women in the Catholic priesthood, and support for a local woman who taught at a Catholic school, and was fired specifically because she had a baby and was not married. We pressed for LGBT full recognition by the church.

My years in the Catholic Worker Movement eventually convinced me that this movement had a useful personalist philosophy, political analysis, an action orientation, especially focused on poverty, economic and anti-military issues, but that it would not take strong positions for women, African Americans, LGBTQ people, and in opposition to the emerging sexual abuse scandal, which eventually proved to be more expansive that anyone imagined at that time. (As I understand it, the movement has “come around” on these issues in recent years.)

I took a graduate course at Aquinas Institute in christology, the search for the historical Jesus. I realized the complex level of scholarship that had been done to determine hermeneutically, anthropologically, and historically who Jesus of Nazareth was.  I knew the power of writing that could influence sociopolitical and health outcomes.  I realized I was capable of taking a graduate class.

Fast forward, I decided that I might have more influence in solving the problems I became so familiar with as an activist, by contributing scholarship as a nurse leader as a nurse scientist. Working with Afaf Meleis and Patricia Stevens, we began in 1994 to answer that initial question, “Is there any thing, process, or set of elements, that is common in the experience of being marginalized?  Rather than an “identity categories” approach, the scholarship on marginalization focuses on the fact that anyone can be targeted, or suddenly find themselves in the high-risk situation of being marginalized.  This more contextual approach is consistent with an intersectionality framework, in which we realize that a person is potentially subject to marginalization based on a number of factors, and that, for a Black lesbian woman, for example, interpersonal slights may set off a whole energy-consuming and stressful problem-solving process for the woman, who is in a quandary about what the basis for the insult is.  “Is this based on race?  Is this because I am a woman and he is a man?  Do they know I am gay?  Is he just pissed off about something else? etc….  This is far less often a subjective experience of White, privileged males.  In fact research shows that those who are privileged, including White health care providers, have implicit biases, prejudices leading to racial microaggressions that White people are usually not aware they are perpetrating, and that has harmful effects on the target person.  We discuss much of this in this article, which is an update on recent scholarship relevant to marginalization.

Why should we as nurses be concerned with understanding political dynamics of the world we live in?  We hope this perspective helps nurses to be able to see the striving of human beings toward fullness of their lives, without amputating their culture, their understanding of their gender identity, their sexual orientation, their partner, their color, their religion, their abilities, and /or their substance use/abuse status. The emancipatory nature of human beings is as real as is their psychological, social, and physiological developmental processes. It is striving toward autonomy, self-determination, group-self-determination and respect as equals among other groups.  Therefore as nurses, we should assess where people are in terms of their own liberation.  This starts with safety, but goes far beyond, to wisdom, transcendence and action for those defined as “other.”  Or “them.”  This is advocacy.

I asked Dr. Kelly Carlson, coauthor what she might feel is relevant for this blog, and she replied that if we apply analysis to what is being said in the Trump presidential campaign about the Muslim parents who have spoken out in opposition we will see the discourses underlying such comments, and their implications. We are in an era in which, for instance, crowds, or mobs yelling “lock her up” about Hillary Clinton is reaching a level of social “acceptability.”  Instability and globalization have now led to xenophobia and the migrations of millions brown people from diverse regions affected by extreme poverty, political persecution and terrorist attacks. In the US, White privilege is systemic, and we have seen biased decisions by police resulting in statistics that look like systematic execution of people of color. The War on Drugs resulted in mass incarceration of African Americans and Latino/as.  The privatization of many of our prison facilities means that services, and even administration is “outsourced” to corporations, for profit, and the labor of prisoners becomes part of an enterprise reminiscent of slavery.

As psychiatric nurses, Kelly and I are particularly concerned with the “non-state” of mental health care following closure of state hospitals. The private corporations who stepped into that gap have been found to be far less concerned with quality of care, and are inadequate to meet the needs. Thus many enter the health system in costly ways, such as through the ED.  They fall through the cracks, at taxpayer expense.  Kelly pointed to another example of the return of a “slavery” system in the network of human trafficking, now pervasive in the US. We need to see the many ways people are marginalized, and how that affects health.  We need to end health disparities.

Nurses can develop knowledge through the lens of marginalization, viewing the person in part as an emancipatory being, striving toward impacting their sociopolitical environment.  It is about exerting self-will, and group self will.  We challenge nurse scientists, and health related scholars to include marginalization, and the real-life contexts of our patients, whether we are providing hands-on care, or making policy decisions at the population level. We can use social media, and mainstream media more effectively to shape the public discourse about health, and to define it broadly to include issues of discrimination, stigmatization, violence and symbolic violence.

Emancipatory knowledge will always need updating, as it is so closely tied to structures and processes of the larger social, cultural and political environment. It requires a historicist perspective.  We invite dialogue on this article, and the issues and questions it raises for nursing.

Cultural Meanings of Mothering

Our current featured article describes a study that uses an intersectional approach to examine the simultaneous and cumulatie effects of gender, race and class.  The article, byDebora M. Dole, PhD, CNM; Donna Shambley-Ebron, PhD, RN, CTN-A, is titled “Cultural Meanings of Mothering Through the Eyes of African American Adolescent Mothers.”  Please visit the ANS website to download your copy of this important article at no coast while it is featured, then return here to share your responses and ideas!  Here is a message from Dr. Dole about her work in this area:

It is an honor to have this article featured in the Advances in Nursing Science blog.  I am thankful for the opportunity to share the work that has opened my own eyes in ways I was not prepared for. This article

Debora Dole

Debora Dole

represents a critical reflection as a researcher and practicing midwife of what inner strength, empowerment, humility and support looks like through the eyes of young African American mothers.  The use of Photovoice as a method to explore cultural meanings from the inside out invited critique and deconstruction of presupposed ideas of what mothering looked like, how it was perceived internally and externally, and how it was ultimately constructed by the mothers themselves.  Photovoice, a method using photography to represent and interpret the daily lives and concerns of participants, gives “voice” in a way that ethnography or qualitative inquiry alone could not provide.

As an experienced practitioner but a novice researcher, I struggled with how to explore the concept of cultural mothering from a perspective I had never experienced.  I am white, middle-aged, middle-class and live in a rural suburb.  While my clinical practice has been primarily in service of young, urban African American women, my experience did not provide the lens I felt was necessary to truly understand. The development of a theoretical framework representing the methodology as well as interpretation of study findings was necessary to understand more deeply the question, “What does mothering look like through the eyes of African American adolescent mothers?”

Intersectional Theoretical Framework

The theoretical framework for this study provided support for exploring mothering through the intersectional lens of gender, race and class.  It was important for my own understanding to have a framework that represented the process of deconstructing each of these.  No one theory alone seemed to fit.  Critical feminist, race and social theories represented the intersectional trifecta of being female, Black and poor.  It was my belief that mothering from what I viewed as a disadvantaged position would prove to be difficult in such a fragmented environment.

The interpretative nature of the study required a cultural lens constructed using concepts of Black Feminist Thought, Womanism, and Africana Womanism to bring meaning to the themes of building a network, sharing responsibilities, and seeing the future. Participant photography was accomplished in response to prompts such as: 1) What does mothering look like to you? 2) Who or what are the things that help you be a mother? 3) What makes it hard to be a mother? 4) What motivates you as a mother? 5) What does the future look like?   The cornerprocess of participant photography, discussion and analysis provided unique insight into a complex network of extended family, “other mothers”, friends and kin constantly under construction.  The power of a simple photograph cannot be overstated.   The photograph to the right is titled “Backed into a Corner”.  The photograph was taken and presented to the group for discussion by a participant who expressed her feeling of being trapped with few options.  It was through group discussion among the participants that the window represented a way out.

If the purpose of research is to uncover, explain or understand phenomena, the unexpected insight gained through this process has accomplished more than that.  This process has changed me.  It has made me a better midwife, a better researcher, a better learner, a better teacher and a better person.  I have a group of young, inexperienced, and “disadvantaged” mothers to thank for showing me what lies beneath the surface.  I hope you enjoy the article.  Maybe it will provide the reader another perspective.  Take a step back and “see”.  The clinical application of this research can be realized in how those that care for mothers and their children see their role, the power relationships that exist in healthcare and ultimately change how care is delivered.  The change has begun with the development and expansion of models of care that put mothers and their families at the center of their care such as CenteringPregnancy and CenteringParenting ®.

I would like to thank my co-author, Dr. Donna Shambley-Ebron for guiding me, sharing her wisdom, her insight and showing me the value of dwelling with the data.

Toward an understanding of social determinants of health

The current featured article in ANS, titled “Using an Intersectional Approach to Study the Impact of Social Determinants of Health for African American Mothers Living With HIV,” addresses the very difficult challenges involved in ameliorating social determinants of health that result in health inequities.  The authors, Courtney Caiola, MSN, MPH, RN; Sharron L. Docherty, PhD, PNP-BC, FAAN; Michael Relf, PhD, RN, ACNS-BC, AACRN, CNE, FAAN; and Julie Barroso, PhD, ANP-BC, APRN, FAAN use an example based on Courtney Caiola’s research to explore ways in which an intersectional approach can be used to better understand social determinants of health

I came to doctoral studies in my forties after a fairly solid stint of working as maternal/child health nurse both domestically and in a limited resource setting. My writing skills were rusty and forming a paragraph longer than a typical email was a challenge, but I felt strongly about the health inequities I was observing as a frontline health worker and learning to co-create research seemed like a logical approach to addressing such social injustice.Caiola250

So, I entered a doctoral program and set about the task of reading the works of giants. The words of intersectional scholars resonated with me immediately.

Their work gave me a framework to examine the structural inequities and power dynamics I had been observing in the clinical setting for years. They helped me to develop my own thoughts on how social determinants, social location and intersecting identities of race, class, gender and other social roles like motherhood generate health outcomes. Additionally, I have come to appreciate and embrace the important role nursing scholarship can play in the social transformation.

I have received very important critiques from mentors, colleagues, study participants and reviewers during this process – the kind of critiques that sting, critically and rightfully exposing my assumptions often steeped in my whiteness. I am extremely grateful for all of the feedback and thankful to have the most patient dissertation committee on the planet. I realize this manuscript is a work in a progress – work that I imagine will take a lifetime of study, introspection, partnerships, critical dialogue, and thoughtful actions to develop.

We welcome your feedback and appreciate ANS for providing a forum in which such critical dialogue can occur in a dynamic and timely way – so, please, let us know your thoughts! – Courtney

You can download this article while it is featured on the ANS web site  – visit the site today and return here to share your ideas, feedback and questions!

Spirituality and Social Justice

In the current ANS featured article, author Sheryl Reimer-Kirkham, PhD, RN explores an area of scholarship that is rare in nursing literature – the interplay between social justice, religion, spirituality, health, and nursing. The article is titled “Nursing Research on Religion and Spirituality Through a Social Justice Lens.” Dr. Reimer-Kirkham uses the critical perspectives of postcolonial feminism and intersectionality to inform nursing’s perspectives on spirituality and social justice. She has shared this background about her work in this area:

Bringing together critical perspectives (such as postcolonial feminism and intersectionality) and research on religion and spirituality in nursing has opened up new and productive terrain.  And yet, conversations on religion/spirituality and social justice can be contentious:  for some religion is dismissed as too irrational, too political or violent, or too bound up in structures of power; for others religious/spiritual beliefs are held as too “sacred” for objective, scholarly analysis.  Such contentions leave many to appeal to secularism as the way to manage religion and spirituality in the public sphere.

Dr. Reimer-Kirkham

Dr. Reimer-Kirkham

However, attempting neat separations between religion and the secular can, according to philosopher Charles Taylor, do more to obscure what is going on in our world than clarify the moral issues we face.  Shying away from critical analyses of the intersections of faith with nursing, religion/spirituality with social justice and equity, leaves us open to incomplete analyses, and fails to account for influences on the values, beliefs and practices of many of our patients.  Several recently published books by nurse scholars move beyond generic approaches to spirituality to engage more specifically with the influence of various religious traditions.  See for example Stajduhar and Coward’s (2012) Religious understandings of a good death in hospice palliative care, SUNY Press; Taylor’s (2012) Religion: A clinical guide for nurses, Springer; and Fowler et al.’s (2011) Religion, Religious Ethics and Nursing,Springer.

My entrée into the integration of religion/spirituality with critical research came about during my doctoral research that examined intergroup relations in hospital settings.  As I conducted this ethnographic research, I realized that many of the hardspots described by nurses and patients in intergroup interactions were directly shaped by religious perspectives and often involved accommodating religious values and rituals, and yet these situations were nearly always conveyed to me as cultural matters.  While there is significant overlap between culture and religion/spirituality, there are also important distinctions. So I have worked toward more intentional analyses of religion and spirituality in the context of health and healthcare, and am convinced of the importance of intersectional approaches in such scholarship. Intersectional analyses inevitably require that we take seriously social relations of power mobilized through religion as it intersects with gender, race, class, ability, and other social categories; particularly as these social relations contribute to equity and inequity.  The relationship between social justice and religion is critical, but not always straight forward.  Human rights and religious accommodation can, in fact, represent competing interests (e.g., religious freedom vis-à-vis heteronormativity or patriarchy).

In this manuscript, I propose critical nursing scholarship on how religion and spirituality relate to social justice and social transformation in the context of health and healthcare. I look forward to your views on the matter!

I too hope you will read Dr. Reimer-Kirkham’s article and return here to join in a discussion of her ideas!  You can download the article at no cost while it is featured on the ANS web site!  

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