The struggle for health equity and social justice is more urgent than ever as the gap between socioeconomic groups continues to widen, deepening already appalling disparities in health. Promoting equality and justice in our communities requires “full participation in society and the balancing of benefits and burdens by all citizens,” a principle on which health equity is built (Buettner-Schmidt & Lobo, 2012, p. 948). Although social justice is a theme in many nursing programs' mission statements and core practice models, the path of action remains unclear (Minnesota Department of Health, 2001; Pollitt, 2016). Equipping nurse educators with foundational tools to address injustice in our communities is a critical first step toward igniting a desire to right the wrongs in society and create a healthier, better world. This desire is essential to becoming a citizen nurse, a role that is focused on generating change through the emancipatory power of knowledge formed in practice—praxis.
Emancipatory knowledge requires nurse educators to explore critical questions with their students. Questions such as “who suffers and who benefits?” from the way things are can highlight inequity or injustice embedded in a system or situation (Chinn & Kramer, 2015; Falk-Rafael & Betker, 2012; Kim, 1994; Leuning, 2001; Ray, 1999). Because awareness of the injustice is a first critical step to addressing inequity, it is essential to develop ways of recognizing injustice, as well as ways of fostering a passion within nursing students and faculty to make a difference in health care practice. Putting awareness together with a passion for changing unjust situations in local and global communities and the skills and everyday political savvy to actually create change characterizes the citizen nurse.
Citizen nurses are deeply connected to individuals as co-creators of change through invested public work that is both meaningful and timely. Citizen nurses realize the importance of deemphasizing the expert models to form purposeful relationships for the common good and practice from a social justice framework (Boyte, 2008; H. Boyte, personal communication, October 8, 2014).
It is important to remember that the scope and practice of nursing extends far beyond the bedside, as nurses bear witness to the daily lives of people who have complicated circumstances that affect their health (Farmer, 2003). Through working skillfully with people in local and global contexts, nurses can play vital roles in creating more humane processes for individuals who are seeking liberation from the unfairness created by the dominant technocratic health care culture (Kagan, Smith, & Chinn, 2014; Milstein, 2008; Wilkinson & Pickett, 2009). As such, nursing education is in a unique position to prepare nurses to learn the skills required to collaborate with communities, understand and impact complex power systems, and organize for change. Professional nurses need to tackle the barriers to desired health outcomes through a lens focused on solution-driven approaches instead of problem-motivated approaches. This pedagogy of thought is deeply embedded within teachings from educators such as Paulo Freire (1970) and N.F.S. Grundtvig (Allchin, 1997). Both of these educators deemphasized the role of the expert and focused on learning through relationships with people living in local contexts.
The Citizen Nurse: Background
Students learn about health care challenges, injustices, and disparities that exist in care settings worldwide In all levels of nursing education, students learn about health care challenges, injustices, and disparities that exist in care settings worldwide—acute care, ambulatory care, and local community health care. This new knowledge often invigorates students to want to take action and create change. However, the structure of academic curricula fails to teach students effective or applicable means of taking action. Often, students oversimplify the situation for those who are being oppressed or fail to co-create just means of change. Students frequently become frustrated and lose momentum in creating systemic, sustainable differences as they encounter endless barriers, such as intimidating institutional constraints or complicated community partnerships driven by numerical means of success.
The Sabo Center for Democracy and Citizenship (SCDC) at Augsburg College, located in an urban setting, has been rooted in the ongoing community and academic efforts to use public work to build civic agency embedded in democratic principles and create a change in professional systems (Boyte et al., 2007). Nursing faculty from Augsburg College and leaders from the SCDC began exploring means of educating students on civic problem solving and transforming health care for the common good. For many decades, faculty members, students, and volunteers practiced transcultural care practices in a health-focused drop-in center with marginalized community members who were living in poverty or without shelter. Many times, the faculty found it difficult to articulate the skills needed to develop an emancipatory praxis approach to social justice issues. Nursing faculty began collaborating with the SCDC staff to focus on nursing student education of democratic skills to develop agency. Agency, in this context, means that nurses are engaged in developing their ability to self-organize, co-create, and shape the world around them, whether at the bedside or in local communities.
The SCDC and Augsburg College's department of nursing held workshops throughout the academic year to facilitate the application of civic agency practices into a conceptual framework of practice for nursing faculty to use in practice and curricular design. The term citizen nurse emerged from the collaboration (Boyte, 2008). Faculty explored this term and the habits of organizing, which was then applied to nursing scholarship and teaching methods.
Questions surfaced about the role of the citizen nurse as it compares with a public health nurse. Although the role of the public health nurse is built on social justice principles, many differences were discovered. A citizen nurse is not employed or governed by an organization or health department with assigned priorities and required reporting and financial accounting. A citizen nurse is a nurse who is part of local grassroots efforts that co-creates efforts and programs with community members and also works effectively as an agent of change in health institutions of all kinds. Boyte described this as “being on tap, not on top” (2008, p. 144). In this example, community is broadly defined as a geographic location, such as a neighborhood, town, or an institution. Citizen nurses are viewed as collaborators or catalysts who are engaged in public work while minimizing their role as the expert, but also as equals who value the knowledge of all peoples. A citizen nurse can work in a variety of settings and communities with a strong sense of place. This way of being in the world strengthens the work already being done in this department of nursing, which has a strong focus on experiential learning and incorporates the concept of accompaniment of people on their journeys to change to create health.
As the process of integrating the new knowledge learned from the collaborative effort with SCDC, lectures were designed and implemented at all levels of the nursing curriculum. The lessons of these lectures inspired the faculty to create curricular changes, where skills of the citizen nurse have intentionally been threaded throughout the various plans of study. The skills identified by faculty were (a) the ability to act, (b) building public relationships, (c) analyzing complex and multidimensional dynamics of power in concrete terms, and (d) the capacity to use and evaluate different means of change. Faculty embraced these learned skills and integrated them into their scholarship, practice, and classroom teaching in meaningful and intentional ways.
Skill Building: The Creation of the Citizen Nurse
Level 1: The Ability to Act
The citizen nurse must first critically reflect on his or her self-interests, biases, or motivations (Boyte, 2008). Self-interests, understood as the unique and distinctive passions, stories, and concerns of each person, are important to understand and engage, as they are the reasons or issues that drives individuals to want to take action or create change (Clear Vision, 2011). This will not only allow the nurse to be aware of personal interests for participating in public work, but will also help the nurse identify the self-interests in others. By establishing one's self-interest, the process of being political understanding politics as different than partisan stances and the engagement of diverse interests to get things done, makes action more strategic and purposeful. For example, the nurse will need to build public relationships with community members, despite differences of opinions or values, to be able to examine the self-interest in others. This will allow the nurse to better understand the starting point to engage in relationships with various community members (Boyte et al., 2007). The nurse will need to begin to recognize the dynamics of power because power, understood as the capacity to act, influences individuals working toward the common good. For example, the nurse must examine his or her attitudes toward the word power. Power, through the lens of the citizen nurses, needs to be relational and establish a means to act (Boyte, 2004). As a citizen nurses, power is essential to building relationships.
These concepts were embedded in coursework in meaningful ways. One curricular design was to incorporate a guest lecturer from SCDC in a selected graduate course. During this presentation, students, faculty, and the community organizer discussed power in health care institutions, assumptions of the word itself, and the importance of coping with tensions in the world. Students shared meaningful examples of times they felt they lacked power to act. The class then brainstormed on ways that meaningful change could have been made through developing relationships with key leaders in the community. Students were then assigned to complete one-to-one relational interviews in their communities or place of practice. During subsequent classes, students shared their experiences with the exercise.
Level 2: Building Public Relationships
The ability to mobilize communities as a co-creator calls for a citizen nurse to create meaningful relationships with community members. The nurse needs to explore the neighborhood or organization by immersing himself or herself in the local context to learn the resources, the influence of policies, and means of culture while respecting the wisdom of cultural brokers (Boyte, 2008). The nurse will need to conduct one-to-one relational interviews with community members to build public relationships and discover key partners for future efforts (Boyte, 2008). A one-to-one meeting is a “conscious exploration of another person's interests, passions, most important relationships, and stories” as a means to collaborate or take action in future efforts (Boyte, 2008, p. 32). The nurse must create an environment of free spaces to provide opportunities for citizens to share and brainstorm freely without political constraints (Boyte, 2004). The importance of having conversations with members in the community or within an organization is vital at this stage in the process. The nurse must focus on developing relationships built on mutual benefit, as it deepens one's respect for the value of local knowledge and fosters accompaniment in the journey of health (Farmer, 2003).
Level 3: Analyzing the Influence of Power
Taking meaningful action means that the nurse must first understand fundamental power dynamics influencing a situation (Boyte et al., 2007). The nurse must collaborate with community members or other health care professionals to map out the key power figures and influences in any given situation (Boyte et al., 2007). During this process, the nurse must find value in the practical wisdom of others, regardless of the role of the individual. For example, if a nurse is attempting to gather individuals in the community who are addressing food sustainability and lack of access to fresh produce in the hopes to partner, the nurse would have to first create a power map of all the people, groups, and institutions that influence this work. Then, the nurse would begin to conduct one-to-one relational interviews with those individuals or groups identified to discover each person's or organization's self-interest. The knowledge learned from these interactions will guide the path of change created by the community members.
Level 4: Evaluating the Means of Change
Change is fluid and ongoing in political work (Boyte, 2004). The nurse must find the freedom to conduct praxis while negotiating institutional constraints or navigating cultural norms to create collective action (Kagan et al., 2014). Ongoing evaluations of engagements and action plans will be conducted to develop sustainable and lasting change. Dominant themes that influence a nurse's ability to create change and act freely need to be examined from multiple perspectives (Boyte, 2004). The courses of action must be embedded with deep roots in community knowledge and problem solving from a grassroots approach.
In one graduate course, students are required to apply one civic skill to their DNP projects. One student identified barriers institutions of power had created for indigenous Mayan people in Guatemala to prevent practice of traditional methods of healing. She was working with community health workers at a rural Guatemala clinic to promote culturally congruent care and change the model of care to incorporate indigenous wisdom. This student and the community health workers designed a power map of people who held decision making power at the clinic. The group then formulated a plan to conduct one-to-one relational interviews with people in leadership at the clinic. This allowed the community health workers to advocate for themselves, analyze informal power relationships, influence models of care, and tackle health inequities.
Reflections in Nursing Education
Following the first year of curricular integration of these concepts and ideas, students provided faculty with positive feedback. One student reported, “I believe that although I am in my second semester of the nursing doctorate program, I am already beginning to view problems in a new light and the aspect of the citizen nurse is an interesting concept.” Another student stated that she was inspired by the concept of the citizen nurse and it reminded her of “the importance of being nonjudgmental.” Because of student comments such as these and other reinforcing experiences, the faculty members plan to continue to more deeply integrate the concepts of the citizen nurse and the role of civic skills into future coursework and scholarship.
The citizen nurse is a nurse who understands the tensions that exist in creating desired health outcomes and health equity in a world that is continually divided by ineffective policies, structural violence, and unequal distribution of resources in communities (Farmer, 2003; Wilkinson & Pickett, 2009). The skills involved in the formation of citizen nurses need to be embedded in the curriculum at all levels of nursing education to facilitate students' agency. The goal of such curricular design would produce citizens who can understand the importance of relationships, the urgency of taking action, and the means to lead change in the processes of health and healing.
- Allchin, A.M. (1997). N.F.S. Grundtvig: An introduction to his life and work. Aarhus, Denmark: Aarhus University Press.
- Boyte, H.C. (2004). Everyday politics: Reconnecting citizens and public life. Philadelphia: University of Pennsylvania Press.
- Boyte, H.C. (2008). The citizen solution: How you can make a difference. St. Paul: Minnesota Historical Society Press.
- Boyte, H.C., Elkin, S., Levine, P., Mansbridge, J., Ostrom, E., Soltan, K. & Smith, R. (2007, September). Summer institute of civic studies—Framing statement. Retrieved from http://activecitizen.tufts.edu/civic-studies/summer-institute/summer-institute-of-civic-studies-framing-statement/
- Buettner-Schmidt, K. & Lobo, M.L. (2012). Social justice: A concept analysis. Journal of Advanced Nursing, 68, 948–958. doi:10.1111/j.1365-2648.2011.05856.x [CrossRef]
- Chinn, P.L. & Kramer, M.K. (2015). Knowledge development in nursing: Theory and process (9th ed.). St. Louis, MO: Elsevier Mosby.
- Clear Vision. (2011). Clear Vision Eau Claire toolkit. Retrieved from http://clearvisioneauclaire.org/wp-content/uploads/2014/03/Clear_Vision_Eau_Claire_Toolkit_9-6-2011.pdf
- Falk-Rafael, A. & Betker, C. (2012). The primacy of relationships: A study of public health nursing practice from a critical caring perspective. Advances in Nursing Science, 35, 315–332. doi:10.1097/ANS.0b013e318271d127 [CrossRef]
- Farmer, P. (2003). Pathologies of power: Health, human rights, and the new war on the poor. Los Angeles: University of California Press.
- Freire, P. (1970). Pedagogy of the oppressed. New York, NY: Herder and Herder.
- Kagan, P.N., Smith, M.C. & Chinn, P.L. (2014). Philosophies and practices of emancipatory nursing: Social justice as praxis. New York, NY: Routledge.
- Kim, H.S. (1994). Action science as an approach to develop knowledge for nursing practice. Nursing Science Quarterly, 7, 134–138. doi:10.1177/089431849400700309 [CrossRef]
- Leuning, C.J. (2001). Advancing a global perspective: The world as classroom. Advances in Nursing Science, 14, 298–303.
- Milstein, B. (2006). Hygeia's constellation: Navigating health futures in a dynamic and democratic world (Doctoral dissertation). Graduate College of Interdisciplinary Arts and Sciences, Union Institute & University, Cincinnati, OH.
- Minnesota Department of Health. (2001). Public health interventions: Applications for public health nursing practice. Retrieved from http://www.health.state.mn.us/divs/opi/cd/phn/docs/0301wheel_manual.pdf
- Pollitt, P.A. (2016). Esther McCready, RN: Nursing advocate for civil rights. The Online Journal of Issues in Nursing, 21(2). doi:10.3912/OJIN.Vol21No02PPT01 [CrossRef]
- Ray, M. (1999). Critical theory as a framework to enhance nursing science. In Polifroni, E.C. & Welch, M. (Eds.), Perspectives on philosophy of science in nursing (pp. 382–386). Philadelphia, PA: Lippincott.
- Wilkinson, R. & Pickett, K. (2009). The spirit level: Why greater equality makes societies stronger. New York, NY: Bloomsbury.