Paula N. Kagan’s "Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis" explores nursing theory, research, practice, and education within a framework of critical social theory and social justice. In 2015, the American Journal of Nursing named it the “best book of the year” in two categories: History and Public Policy and Professional Issues.

Reviewers say “it fills a significant gap in the literature and makes an exceptional contribution as a collection of new writings from some of the foremost nursing scholars.” Here, the associate professor of nursing talks about the book’s innovative and timely ideas.

What’s the premise of your book?

In the book, we examine the systemic and structural marginalization of certain persons and groups in health care interactions and settings. How do inequality, injustice, and disrespect affect outcomes? The authors believe in the importance of ‘wholeness’ in care, since health is affected by every aspect of a person’s life, including food, housing, education, violence, and the quickly changing environment. 

We advocate for nursing practice that creates and embraces social justice: Borrowing from Paulo Freire, author of “Pedagogy of the Oppressed,” we call this approach praxis, meaning practice intentionally aimed at achieving social justice goals. As evidenced in the authors’ research (including my own and that of my co-editors/authors, Marlaine Smith and Peggy Chinn), a praxis approach to nursing practice has two components:

One, it’s critical: it challenges dominant truths. For example, praxis takes into account structural inequities that cause health problems, while supporting preventive approaches; it exposes power systems that give some people privilege while marginalizing others; and it contributes to frameworks that would transform nursing education and practice.

Two, it’s emancipatory: it humanizes health care by disrupting the structural inequities that damage bodies and minds and by building authentic relationships with communities. Praxis begins with thinking about one’s own oppressive ideas, habits, values, and actions. This self-reflection should be a big part of the education of any health professional.

When planning the book, we looked for contributors who were focusing on praxis in their research, practice, and/or pedagogy. We chose 60 nurse scholars who are “unpacking” the policies, practices, theories, and ethics within nursing and looking for the ways that power and privilege can affect the quality of care for everyone.

Key to praxis is an intersectional perspective.

What does that mean?
In every part of society, including the delivery of healthcare, there are intersecting dimensions of oppression, dominance, and prejudice—usually along lines of gender, color, class, and sexuality. Black feminist scholars first developed this critical framework in the 1960s, questioning their own marginalization from two movements: the white, heterosexual, middle-class-dominated women’s movement and the male-dominated, black power movement.

In nursing, an intersectional perspective means seeing how systemic oppression affects a person’s or a community’s well-being and health. What are the dominant ideas in our society and where do they come from? Who is advantaged or disadvantaged? Which voices are heard and which dismissed in the prevailing power structure?  In healthcare, disadvantage isn’t just about whether people have access: It’s also about how they’re treated once they get in the door. If we could eliminate racism, misogyny, homophobia, and greed in health care, outcomes would improve significantly.

An intersectional perspective is also very Vincentian: We’re advocating a just way of looking at vulnerable people. If a health care provider is not thinking of social justice and not acting from a critical perspective, he or she will miss a lot and people will suffer.

How about examples?

Historically, the testing of drugs and disease interventions has used white males as the “generic” subject. But women and people of color often have different symptoms, responses, or relationships to providers because of physiological, social, and environmental factors. The same holds for lesbians, gay men, and transgender persons, for the poor, and for any undervalued/marginalized group in society.

Women are often under-treated for cardiovascular disease, as health care providers diagnose their symptoms as anxiety. Lesbians visit providers at a later stage of a disease because they want to avoid homophobic interactions; thus, they often miss early intervention opportunities. When a black woman has abnormal bleeding, it’s more likely she’ll be told to get a hysterectomy than will a white woman who will be provided with options. 

It wasn’t until women and people of color became scientists and were funded for research that health care professionals started to look seriously at how health and illness are manifested, and how protocols and treatments work, in a broader and more complex spectrum of humans. For decades, nurse researchers have made significant contributions to the art and science of achieving better health outcomes. Many of these pioneers are featured in the book.  

What’s the first step?

Listening to the patient. My research tells me that “being heard” is what people want most in health care interactions.

Nursing has a strong history of thinking that “people are the experts” about their own health: By adding critical and emancipatory perspectives, a nurse can gain a better understanding of the whole person and can better honor his or her life context and experiences. That understanding enhances health and quality of life.