1. A 16-year-old African American female patient presents to a clinic reporting she missed her last menstrual period. The patient has been with five partners in the past 2 weeks and reports discharge and vaginal itching.
a. In what ways do patients’ preferences and behaviors affect access to care?
b. In what ways do healthcare system factors affect access to care?
c. In what ways do provider-related factors affect the use of birth control methods?
2. A 35-year-old G1P1 woman comes to a clinic with abdominal pain. She was recently diagnosed with pelvic inflammatory disease (PID) but was unable to take all of her medication. She reports her medications were stolen. She is facing housing and food insecurities and has been sleeping on the streets since being treated for PID. She has a 17-year-old child who is currently in foster care.
a. In what ways do her behaviors affect access to care?
b. What healthcare system factors may affect care?
c. What provider-related factors may affect her care?
3. A 35-year-old G6P4 African woman presents to the clinic for a postpartum visit. The patient speaks Amharic and needs an interpreter. Her two youngest children are 13 months apart, and the patient does not want to start a contraceptive method, yet desires better birth spacing.
a. What is optimal birth spacing?
4. A 17-year-old female patient presents to the clinic for an annual exam. She is sexually active and does not want a birth control method.
a. Does pregnancy intention always match contraceptive use?
b. What are strategies you could use to increase contraceptive knowledge?
36 Chapter 3 Intersection of Racial Disparities and Privilege in Women’s Health
References
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37 References
▸ Introduction
This chapter explores how social justice was conceptualized in the nursing literature between the years 2000–2018. Analysis of this literature reveals that various authors subscribed to social, distrib- utive, and market views of justice. Most authors, however, do not explicitly define the type of jus- tice used in their work, or attend to the differences among these concepts. The three predominant models of justice are reviewed first in this chapter, and then a framework for how nurses can focus on injustice awareness, amelioration, and transformation as forms of social justice action is pre- sented. The multiple methods of promoting a social justice agenda, from consciousness raising to the re-creation of social policies, are also delineated. Recognizing the many ways to promote social justice can have a transformational impact on how nurses teach, research, and practice.
Although social justice is not a new concept, the nursing literature lacks a coherent and com- plex understanding of its implications for studying societal health (Buettner-Schmidt & Lobo, 2012;
Drevdahl, Kneipp, Canales, & Dorcy, 2001; Grace & Willis, 2012; Lipscomb, 2011). Social justice is
OBJECTIVES
At the end of this chapter, you will be able to:
1. State differences in how social justice is defined in nursing.
2. Compare and contrast the definitions of social justice used in the nursing literature.
3. Develop a concise statement about how to incorporate social justice awareness, amelioration, and transformation into nursing research, education, or practice actions.
Social Justice in Nursing:
A Review of the Literature
Doris M. Boutain
Chapter Opener Image Credits: Left to Right: © RichLegg/ E+/ Getty Images; © Dragana991/ iStock/ Getty Images; © Gustavofrazao/ iStock/ Getty Images
39
CHAPTER 4
often mentioned only briefly, as an afterthought to elaborate discussions about ethics. When ethics is defined in the forefront, the concept of social justice often recedes to the background, appearing fleetingly in articles’ conclusion sections. Inattention to the subtle variations in how social justice is conceived can inadvertently result in nursing practice, research, and education that are antithet- ical to a social justice agenda.
▸ Literature Search Methodology
A search of the Cumulative Index of Nursing and Allied Health (CINAHL) database from the years 2000 to 2018 identified a total of 618 publications classified with the terms social justice and nurs- ing as major words in the subject heading. The manuscript authors ascribe a major subject head- ing to identify the main focus of their work. Those publications about social justice and nursing included academic journal publications (n = 450), magazine publications (n = 57), dissertations (n = 10), continuing education units (n = 16), and a book (n = 1).
Only resources published between 2000 and 2018 in English (n = 595) and with an abstract available for review were assessed for inclusion in this chapter (n = 354). These criteria limited the number of resources reviewed. Twenty-three articles were written in languages other than English.
Resources from academic journals (n = 255), dissertation abstracts (n = 10), continuing education unit modules (n = 4), and nursing magazines (n = 4) were reviewed. Only publications empha- sizing uncommon points are included in the reference list to limit the chapter’s length. The litera- ture reviewed in the sections about views of justice in nursing education, research, and practice is limited to resources written in the stated time frame. Publications from nursing, sociology, social work, philosophy, public health, and religious studies supplement the literature analysis in the sec- tions about the literature review critique and implications. Many of these resources were written prior to the literature review time frame.
This chapter will first define how the concept of justice is used in nursing. Then we will explore the different ways of viewing justice. The chapter also provides examples about how social justice is articulated in articles focused on nursing education, research, and practice. Last, we provide a more complex view of social justice actions for nurses to consider before the chapter summary.
Defining Justice in Nursing
The ethical principle of justice was referenced frequently in the nursing literature surveyed. More than half the publications retrieved equated justice with what is fair. Authors primarily described ethics as a framework for understanding how values, duties, principles, and obligations informed a person’s sense of societal fairness. The notion that two prominent orientations to ethics exist was also highlighted in the literature (Mathes, 2004, 2005; Woods, 2012). Specifically, ethics can be de- fined by a care orientation or by a justice orientation. For example, ethics can be defined by univer- sal truths—justice orientation—or in relationship to caring for others in context—care orientation (Mathes, 2004, 2005).
Although many authors mentioned justice, few articles defined justice beyond notions of ethi- cal fairness (Drevdahl et al., 2001; Harris, 2005; Kneipp & Snider, 2001) or ethical relationship for- mation (Myhrvold, 2003). Most articles focused on caring for persons after injustice had already occurred, not changing ways of thinking, policies, or procedures to promote justice. A few articles focused on the contradictions of working for justice in the context of unjust nursing environments (Galon & Wineman, 2010; Giddings, 2005a). Another scholar provided insight about how to promote 40 Chapter 4 Social Justice in Nursing: A Review of the Literature
policy changes for health disparity reduction (Roberts Kennedy, 2013). Only one article examined the theoretical connection between social justice and spirituality (Pesut, Fowler, Reimer-Kirkham, Taylor, & Sawatzky, 2009).
Exploring the philosophical underpinning of justice, Drevdahl et al. (2001) compared the concepts of social justice, distributive justice, and market justice. They posited that most nurses neither consider the distinction among concepts related to justice (Drevdahl et al., 2001) nor dis- tinguish between social justice and social analysis (Stys, 2008). A few authors broaden the discus- sion of ethics to globalization (Falk-Rafael, 2006) or structural inequality (Sistrom & Hale, 2006) as having implications for social justice.
Without an intricate understanding of the different views of justice, nurses may limit their prob- lem-solving abilities and direct-action possibilities when attempting to understand how unjust social conditions influence health status, access, and delivery. Although concepts such as care (Boersma, 2006) and culture (Jackson, 2003) are not mutually exclusive to a justice ideology, inattention to the distinctions between care and justice may result in limited theoretical analysis and, thus, action. A review of the American Nurses Association’s Code of Ethics with Interpretive Statements, Nursing’s Social Policy Statement, and Nursing: Scope and Standards of Practice, for example, revealed incon- sistent and superficial conceptualizations of social justice (Bekemeier & Butterfield, 2005). These points were also a cause for debate in review of the Canadian Nurses Association’s (CNA) 2002 Revised Code of Ethics (Hubert, 2004; Kikuchi, 2004). The disjunctions among the practice, policy, and politics of justice, however, have a long history in nursing (Murphy, Canales, Norton, &
DeFilippis, 2005). For this reason, it is important to explore the most prominent forms of justice in nursing literature today.
Social, Distributive, and Market Justice: Within and Beyond the Nursing Literature
Nurses have consistently lamented the inconsistent definitions of social justice in the nursing litera- ture (Buettner-Schmidt & Lobo, 2012; Falk-Rafael & Betker, 2012; Grace and Willis, 2012; Matwick &
Woodgate, 2017; Thurman & Pfitzinger-Lippe, 2017). Even when social justice is defined, it is rarely acted on (Drevdahl, 2013). These trends have been noted for years.
This review identified social, distributive, and market justice as the most common forms of justice referenced in the nursing literature. Social justice is often defined as a concern for the equit- able measuring of benefits and burdens in society (Boutain, 2005, 2008; Redman & Clark, 2002).
Social justice is also—albeit less often—defined as changing social relationships and institutions to promote equitable relationships (Drevdahl et al., 2001). In addition to creating, maintaining, and supporting equitable relationships, social justice is concerned with the use of equitable policies, procedures, and practices. Distributive justice is discussed in reference to the equal distribution of goods and services in society (Silva & Ruth, 2003). Market justice posits that people are entitled only to those goods and services that they acquire according to guidelines of entitlement (Young, 1990).
Although these forms of justice may appear similar at first glance, there are distinct differences between them when using multidisciplinary sources (Beauchamp, 1986; Whitehead, 1992). Social justice is concerned with making equitable the balance between societal benefits and burdens, and having this balance evidenced in ways of being, acting, and governing. It posits that social rights exist, and that collateral responsibilities accompany those rights (Lebacqz, 1986). There is a com- bined focus on accepting both the benefits and burdens in society. Social beings are to both give and receive in equitable measure, using equity as a framework for relating to one another. Equity, derived from the Greek word epiky, means that persons must conduct themselves with reasonableness and Literature Search Methodology 41
moderation when exercising their rights (Whitehead, 1992), and consider the social good in light of their access to power. Distributive justice involves equality more than equity; this concept is used most often to discuss the allocation or distribution of goods and services in society (Young, 1990).
Equality focuses on giving the same access and resources to different socially vulnerable groups, without consideration for what factors created those differences. In social programming, this of- ten results in an uplift for all populations, those with and without the targeted vulnerability, with- out a concurrent diminishing of inequality.
Social justice advocates explore social relationships, including how those relationships form the basis for the allocation of goods and services (Young, 1990). Social justice focuses on equity, not equality or sameness. The concepts of social and distributive justice are somewhat parallel yet have different primary foci of study (Drevdahl et al., 2001).
Market justice is also viewed as a form of justice in nursing (Drevdahl, 2002), which is based on honoring the rights of those who have earned entitlement to those privileges. Market justice permits inequality as long as those inequalities result from a fair market system. Only those who earn rights can receive their entitled privileges in a market system. Those who earn no rights do not have secured privileges.
Critics of the market justice agenda note that using the word market as an adjective for justice is an oxymoron (Beauchamp, 1986). Justice is a word most often used to discuss fairness, equity, or the process of deliberation. The term market is most often concerned with the balance between monetary value and goods allocation. According to these critics, the two terms do not work together when discussing equity. Simply “applying the word ‘justice’ to ‘market’ does not bring the concept into the realm of justice” (Drevdahl et al., 2001, p. 24). Social justice is not a parallel model to mar- ket justice; rather, it is antithetical to a market model (Beauchamp, 1986). These two ways of view- ing the world, therefore, diametrically oppose each other and simultaneously coexist.
An example may clarify the difference among social, distributive, and market justice. Using a social justice framework, everyone in the United States would be entitled to health care as needed if health care was deemed a right of citizenship. Health care, using a social justice view, is a moral obligation and a right of citizenship. A distributive justice framework would give a certain level of health care to everyone because of citizenship. The leveling of health care is needed to make sure that enough healthcare services are available for all citizens to receive at least minimal benefit. Within a distributive justice model, health is a right of citizens but not necessarily a moral responsibility.
Persons can receive health care as a result of how much they can pay for those services in a market system. The focus of a market system is not on moral or citizenship rights, but rather on making sure that those citizens who want the good of health care, for example, can pay for those services.
All forms of justice, although somewhat distinct, may coexist to varying degrees. For example, some healthcare services in the United States are given as needed, such as the care given to chil- dren who are orphaned. In other cases, minimal health care is given, such as the medical and den- tal benefits associated with Medicaid. Persons who can afford more treatment or faster treatment may get those services as well if they can pay a particular price; an example is healthcare clinics that are designed to give expanded services if clients pay certain access fees. Although these three forms of justice are noted in the nursing literature to varying degrees, seldom does the literature discuss how these views of justice guide nursing education, research, or practice.
Views of Justice in Nursing Education Articles
Several scholars have called for a reexamination of social justice in nursing, both in the descrip- tions of social justice in foundational documents used to teach students (Valderama-Wallace, 2017) 42 Chapter 4 Social Justice in Nursing: A Review of the Literature
and in use of theoretical frameworks about social justice that do not move beyond the individual nurse-patient dyad (Thurman & Pfitzinger-Lippe, 2017). An analysis of foundational documents in nursing like the Code of Ethics, Scope and Standards of Practice, and Social Policy Statement reveals inattention to the sociopolitical context and conditions in which nurses work and provide care (Valderama-Wallace, 2017). Nursing students are resultantly not taught to use their collective power as future nurses to address structural injustices that continue to minimize health opportu- nities and create health disparities. Nursing education could benefit from civic education (Clark, Miller, Leuning, & Baumgartner, 2017), whereby nursing students are taught to use their agency to promote citizen and professional investments in health.
Most resources about nursing education and justice focus on the clinical preparation of under- graduate students to meet the needs of a culturally diverse population (Ezeonwu, 2013; Herman &
Sassatelli, 2002; Leuning, 2001; Mohammed, 2014; Redman & Clark, 2002; Scanlan, Care, & Gessler, 2001). Simulations are viewed as novel ways to educate future nurses using a social justice framework (Menzel, Willson, & Doolen, 2014) in addition to service-learning education (Groh, Stallwood, &
Daniels, 2011). Since the mid-2000s there has been an increased focus on using online learn- ing (Breen & Jones, 2015), co-curricular experiences (Davis, Sullivan, & Guzman, 2018), digital storytelling (LeBlanc, 2017), and poverty simulations (Menzel et al., 2014) to promote thinking about social justice issues.
Other publications proclaim the need for a global consciousness (Leuning, 2001; Messias, 2001), critical thinking (Pereira, 2006), culturally sensitive evidence-based practice ( McMurray, 2004), and human rights education (Fitzpatrick, 2003) among nurses as the starting point for jus- tice awareness. Also present in the nursing literature are curricular considerations (Fahrenwald et al., 2005; MacIntosh & Wexler, 2005; Myrick, 2005; Vickers, 2008), teaching models (Bond, Mandleco, & Warnick, 2004; Boutain, 2005; Fahrenwald, 2003; Lapum et al., 2012; Leuning, 2001), clinical evaluation frameworks (Boutain, 2008), case examples, and service-learning ex- periences (Groh et al., 2011; Herman & Sassatelli, 2002; Redman & Clark, 2002) that use justice as a framework to educate undergraduate students. A limited number of articles focus on teach- ing justice content in general (Abrams, 2009) or in graduate education (Browne & Tarlier, 2008;
Shattell, Hogan, & Hernandez, 2006). Only one article was found that explored how teaching so- cial justice affects faculty directly (Fahrenwald, Taylor, Kneipp, & Canales, 2007). Few articles use social justice as a theoretical framework for educational scholarship (Kirkham, Hofwegen, &
Harwood, 2005; Moule, 2003) or to understand how to conduct educational research in nursing (Comer, 2009).
Although some nurse educators discuss the practical application of justice principles, few dis- tinguish between the use of social justice and distributive justice concepts. For instance, authors may define social justice using distributive justice principles of equality or as working with vul- nerable populations (Redman & Clark, 2002). One manuscript introduces justice in terms of con- tractual justice, meaning the fair and honest contract between equals (Oddi & Oddi, 2000). In one instance, the term social justice was used but never defined (Herman & Sassatelli, 2002). Rarely is social justice used as a framework to critique nursing education models, examine student-faculty relationships (Oddi & Oddi, 2000; Scanlan et al., 2001), or develop a comprehensive curriculum (Boutain, 2005; Snyder, 2014).
Continuing nursing education activities focus on promoting an ethics orientation to justice or social justice actions in nursing role enactment. The ethics orientation is illustrated in continu- ing education offerings about nursing practice concerning cancer pain control (Paice & Coyne, 2017), infants (Carter, 2017), children (Purdy & Wadhwani, 2006), persons in prison with cancer (Lyckholm & Lucas Glancey, 2016), hospice care (Longenecker, 2010; Turkoski, 2005), and women Literature Search Methodology 43