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Developing the concept of sustainability in nursing.
Abstract
Sustainability, and the related concept of climate change, is an emerging domain within nursing and nurse education. Climate change has been posited as a serious global health threat requiring action by health professionals and action at international level. Anåker & Elf undertook a concept analysis of sustainability in nursing based on Walker and Avant’s framework. Their main conclusions seem to be that while defining attributes and cases can be established, there is not enough research into sustainability in the nursing literature. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing and grey literature and, for example, the literature in the developing web based ‘paraversity’. Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability and its suggested links with social and health inequalities and the dynamics underpinning unsustainable neoliberalist political economy. This understanding is based on the social and political determinants of health approach and the emerging domain of planetary health. However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice.
Introduction
Sustainability, and the related concept climate change, is an emerging domain within nursing (Adlong & Dietsch, 2015; Allen, 2015; Aronsson, 2013; Goodman, 2011; Hunt, 2006; Polivka, Chaudry & Mac Crawford, 2012; Sattler, 2011) and nursing education (Goodman, 2008; Goodman, 2011; Goodman & East, 2013; Goodman & Richardson, 2009; Johnston et al., 2005; Richardson et al., 2013). Climate change has been posited as a serious health threat (Costello, Grant & Horton, 2008; IPCC, 2014; McMichael, Montgomery & Costello, 2012) requiring action by health professionals (Costello et al., 2011; Gulland, 2008; Harding, 2014; Patton, 2008; Reale, 2009; Thomas, 2014) and action at international level (Durban Declaration on Climate and Health, 2011; WHO (2016) . The status of climate change as health threat has however been contested (Goklany, 2009a; Goklany, 2009b; Goklany, 2012; Goodman, 2014), but it remains an important determinant of health (Barton & Grant, 2006; Griffiths, 2009). In this context, Anåker & Elf (2014) undertook a concept analysis (Walker & Avant, 1982) of sustainability in nursing. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing literature, to address the socio-political context in more depth. This should include going beyond accepted peer reviewed nursing journals and include literature such as that written by Wendell Berry (Berry, 1995) who writes eloquently on human health and our relationship to the natural environment. There is also a growing body of work online and of an academic standard to qualify for what might be called the ‘Paraversity’ (Goodman, 2015a; Rolfe, 2013). Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability. There is a need to link social and health inequalities (Dorling, 2013; Marmot, 2015) and the dynamics underpinning unsustainable neoliberalist political economy (Harvey, 2005; Harvey, 2014; Sayer, 2015) with the concept of sustainability. Climate change is just one aspect, albeit a very important aspect, of that linkage. This understanding is based on the social (Davidson, 2015; Raphael, 2004; WHO, 2013) political (Ottersen, Frenk & Horton, 2011) and ecological (Goodman, 2014; Goodman, 2015b; Lang & Rayner, 2012; Lang & Rayner, 2015; Rayner & Lang, 2012) determinants of health (Barton & Grant, 2006). However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice. Before addressing the definition of sustainability in nursing, the socio-political ‘pattern of knowing’ will be outlined to form the justification for the ensuing discussion.
The fifth ‘Pattern of knowing’ in Nursing
Jill White (White, 1995) added a fifth pattern of knowing in nursing to Barbara Carper’s four (Carper, 1978): the ‘Socio-Political’. White argued the other four patterns provided answers to the ‘who, how and the what’ of nursing practice but not the ‘wherein’, the context. This, White argued, is the pattern of knowing essential to an understanding of all the other four. Socio-political knowing that is gained from a fuller understanding of the ‘sustainability literature’, might lift the ‘gaze’ from introspective nurse patient relationships at the bedside and requires the situating of that relationship within the wider socio-political context. This may result in challenging the taken for granted assumptions about practice, health, the profession and wider health policy. To that could be added the raising of questions about political economy and engaging in philosophical enquiry about such concepts such as ‘non duality’ (Loy, 1988), a concept Wendell Berry implies in his essay ‘health is membership’ (Berry, 1995).
White quoted Chopoorian who suggested: “nursing ideas lack an archaeology of the social, political and economic worlds that influence both client states and nursing roles’ (White 1995 p84). This ‘archaeology of ideas’ still seems relatively poorly uncovered. Davies argued that ‘some of our concepts are missing’ in a critique of the Sociology of Health and Illness (Davies, 2003). By that is meant that there had been a lack of a ‘sociology’ of organizations in the sociology of health and illness, a sociology which is able to reveal concepts such as discourses of managerialism (Gilbert, 2005; Traynor, 1996; Traynor, 1999; Traynor, Boland & Buus, 2010), or to reveal patterns of power and accountability for policy and its consequences (Freudenberg, 2014; Scambler, 2012; Schrecker & Bambra, 2015). Davies argued that
“sociology needed to take seriously the politics of NHS modernisation” (p183)
It is suggested here that many nurses also don’t have such a set of critical concepts to give them a more critical discourse upon which to base critical action or ‘praxis’ (Cox & Nilsen, 2014). There are a few papers addressing political activism in nursing, providing critical theories and concepts (Antrobus, Masterson & Bailey, 2004; Hewison, 1994; Phillips, 2012; Racine, 2009; Shariff, 2014) and other papers which discuss politics and nursing (Davies, 2004; Masterson & Maslin-Prothero, 1999; Salmon, 2012; Traynor, 2013). These works suggest an interest in the interplay of the socio-political context and nursing practice and provide some evidence of relevance of this ‘pattern of knowing’. White argued that nurses must “explore and expose alternative constructions of health and health care, find means of enabling all concerned to have a voice in care provision and develop processes of shared governance for the future” (p85). Exploring sustainability, climate change and health assists in that work. Indeed a focus on global governance for health in the context of climate change and environmental challenges is a key theme of recent reports (Ottersen, Dasgupta & Blouin, 2014; Ottersen, Frenk & Horton, 2011) in non-nursing literature. This leads us onto consider how nurses are to understand what sustainability means.
Defining Sustainability in Nursing
Anåker & Elf (2014) argue that the “term is not clearly defined and is poorly researched in nursing” (p382). This applies not only in nursing. Sustainability has diverse and contested meanings in many disciplines (Thompson, 2011; Williams & Millington, 2004). The quest to tie down the concept is possibly futile, as Anåker and Elf themselves suggest that: “a concept analysis is never a finished product” (p388). They provide a definition which is a helpful contribution to the discussion, and their model and contrary case illustrate for clinical nurses the value of trying to understand sustainability in practice. Throughout the paper they provide attributes and definitions from various sources and refer to, but do not foreground, social and health inequalities arising from wider determinants of health including political economy, which also underpins understandings of sustainability and climate change (Goodman & Richardson, 2009; Sayer, 2015).
The defining attributes identified in Anaker and Elf’s concept analysis were: ecology, environment, the future, globalism, holism and maintenance. The attribute ‘globalism’ indicates that they are getting close to discussing and emphasising political economy underpinning such issues as climate change, ocean acidification and soil erosion which are three of the nine planetary boundaries which, it is argued, delineate a ‘safe operating space for humanity’ (Rockstrom et al., 2009; Steffen et al., 2015) . Nonetheless, the analysis misses something important, i.e. the neoliberal (Freudenberg, 2014; Harvey, 2005) and environmental, socio-political context of health (Barton & Grant, 2006; Ottersen, Frenk & Horton, 2011; Sayer, 2015; Scambler, 2012; WHO 2015) characterised by social and health inequalities (Dorling, 2013). This is the link between capitalism, climate change and sustainability (Goodman, 2014; Griffiths, 2009; Klein, 2014; Sayer, 2015). Various writers (Hamilton, 2010; Jackson, 2009; Marshall, 2014; Sayer, 2015; Urry, 2011) suggest or imply, that it is our political orientations (Douglas & Wildavsky, 1992), moral intuitions (Haidt, 2012) and our social and economic relationship with carbon which are foundations upon which we as communities and individuals assess environmental issues and our reactions to them.
Urry particularly on this point, (2011) coins the term, ‘high carbon economy-society’ to describe capitalism. He argues that the starting point for an analysis of why society engages in particular practices and habits is the observation that energy is the base commodity upon which all other commodities exist. Thus, community behaviours are implicitly locked into high carbon systems that are taken for granted aspects of our lifeworld. Urry suggests that much of social science has been carbon blind and has analysed social practices without regard to the resource base and energy production that we now know are crucial in forming particular social practices. It is these social practices that provide the structure within which our agency operates.
“most of the time people do not behave as individually rational separate economic consumers maximising their individual utility from the basket of goods and services they purchase and use given fixed unchanging preferences…(we are) creatures of social routine and habit…fashion and fad…(we are) locked into and reproduce different social practices and institutions, including families, households, social classes, genders, work groups, schools, ethnicities, generations, nations…. (Urry 2011 p4).
These social practices arise out of our ‘lifeworld’ (Husserl 1936, Habermas 1981), i.e. our internal subjective viewpoints as well as the external viewpoints of the social and political ‘system’. A high carbon economy society thus provides the backdrop for values, assumptions and social practices that are taken for granted in everyday life. Defining sustainability therefore requires acknowledgment of such lifeworlds and the socio-political systems in which they ‘operate’.
Nursing, sustainability and acontextual Concept Analysis?
The wider body of literature, including that in the social and political sciences and philosophy, may give nurses tools and concepts to further develop their understanding of sustainability and its relationship to human health. Importantly this could include an understanding of the political economy of capitalism (Harvey, 2011) and its link with growth, climate change and sustainability (Hamilton, 2003; Jackson, 2009; Johnson, Simms & Chowla, 2010; Sayer, 2015). Without this understanding, and application in nursing scholarship, nurses may miss the arguments linking the growth dynamics underpinning the neoliberalist capitalist political economy (Chomsky, 1997; Harvey, 2005; Sayer, 2015), climate change (Klein, 2014; Sayer, 2015) and unsustainable lifestyles (Hamilton, 2010). This sits within the social and political determinants of health approach (Barton & Grant, 2006; Davidson, 2015; Ottersen, Frenk & Horton, 2011; Scambler, 2012) and the emerging domain of planetary health (Lang & Rayner, 2012; Lang & Rayner, 2015). This paper argues that to fully develop the concept in nursing, an analysis or at the least an understanding, of the political economy of neoliberal capitalism could be a component of nurses’ understanding of sustainability and health. This is because political economy relates to both health and social inequalities (Dorling, 2013; Dorling, 2014; Marmot, 2015; Schrecker & Bambra, 2015; Stiglitz, 2012; Wilkinson, 2005; Wilkinson & Pickett, 2009) and to issues around sustainability and climate change. However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge (White, 1995), a reflection which might reject this as irrelevant to much of nursing practice.
Anåker & Elf’s (2014) inference that nursing misses foregrounding political economy and society might be a result of the method employed to search the literature, as well as their acknowledged lack of discussion in the nursing literature of political economy. Of course there might be very little reason currently for nursing literature to discuss political economy, based as it is on knowledge (biosciences, biomedicine) that may well be largely antithetical to critical social and political science. Adult nurses in particular might face a real challenge in accepting this idea in practice as Ion and Lauder argue:
“For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care” (Ion & Lauder, 2015).
In addition, Walker and Avant’s method was originally published (1982) before the development of academic blogs and websites such as academia.edu and therefore may not be explicit in its direction to search beyond accepted channels. This emerging literature, which may contribute to the construction of the ‘paraversity’ (Goodman 2014, Rolfe 2014), will therefore be missed as source of information and discussion on topics such as linking sustainability, health, climate change and capitalism.
There are several key papers discussing the link between human health, political economy and the environment. Goodman and Richardson (2009) explicitly link Sustainability, Climate Change and Health conceptualizing them as three sides of a triad. To fully understand one requires an understanding of the other two. The three, in this conception, are indivisible. Further, the link involves political economy and socio-economic behavior as crucial underpinnings for climate change and sustainability issues. Barton and Grant’s (2006) health map discusses key determinants for health including Biodiversity, Global Ecosystems and Climate change. Each one of those of course involves human activity and disruption to create what some are calling a new geological era, the ‘Anthropocene’ (Zalasiewicz et al., 2010). Lang and Rayner (2012) discuss the concept of ‘Ecological Public Health’, while the Canadian Public Health Association (2015) has just published its own report on ‘Global Change and Public Health: Addressing the ecological determinants of health’ which on page 1 argues:
“…changes in the earth’s ecological systems are driven principally by our social and economic systems, and by the collective values and institutions that support them”.
This echoes the World Health Organisation’s definition of the social determinants of health which explicitly mentions distributions of resources, money and power (WHO 2015). The report does not name, or analyses, in any more depth what that economic system is, as it seems to take for granted that it is capitalism. Ottersen et al emphasize the political determinants of health (Ottersen, Dasgupta & Blouin, 2014) which, alongside the WHO’s (2008) social determinants of health approach, acknowledges the role of powerful global actors and the lack of global governance for health. Health equity and social determinants are now a crucial component of the post 2015 sustainable development goals (WHO 2015).
For example, powerful global actors, i.e. the Fossil Fuel Industry, may be acting in a way to either downplay the risks to human health from rising atmospheric carbon dioxide, or engaged in protecting their assets’ (coal oil and gas) value for the short term over and above longer term risks to climate. Exxon Mobil have argued that world climate policies are highly unlikely to stop the production and selling of fossil fuels (Exxon Mobil shrugs off climate change risk to profit – BBC News, 2014) while Shell have been accused (Macalister, 2015) of accepting a 4 degree rise in global mean temperatures. This is in the context of a reported $5 trillion annual subsidy in fossil fuel subsidies (Coady et al., 2015) while the Bank of England considers a ‘carbon bubble’ (Carrington, 2014) i.e. the drop in value of assets if fossil fuels are kept in the ground through the imposition of any global governance regimes to curb carbon emissions. This is an aspect of the political economy of capitalism that must be understood as a driver underpinning human health. At the time of writing, world leaders and delegates are meeting in Paris for COP 21. At this meeting there will be another meeting of the The Sustainable Innovation Forum (SIF15) which is a business focused event held during the annual Conference of Parties (COP). The two day Forum will convene participants from business, Government, finance, the United nations, Non-governmental organisations, and civil society to “create an unparalleled opportunity to bolster business innovation and bring scale to the emerging green economy” (COP21 Paris 2015). This forum operates within the paradigm of capitalism rather than seeking radical reform. However, it illustrates the complexity of players dealing with sustainability issues.
Scambler (2012) outlines ‘The Greedy Bastards Hypothesis’ to describe how the Capitalist Class Executive can ‘command’ the Political Power Elite to enact policies in their favour, with the unintended consequences of exacerbating health inequalities. Evidence that corporate activities impacts on political decision making is provided by the delays to air pollution standards, Euro 6 (Archer, 2015; Neslen, 2015). Volkswagen’s use of software to cheat emissions testing in the United States (Topham, 2015) indicates the lengths corporates will go (Freudenberg, 2014; Oreskes & Conway, 2011) to avoid externality costs resulting in the externality of for example, increased air pollution. Therefore any concept of sustainability in nursing that does not understand political economy misses something important in understanding both the concept of sustainability and of health.
Anaker and Elf’s definition of sustainability:
“…a core of knowledge in which ecology, global and holistic comprise the foundation. The use of the concept of sustainability includes environmental considerations at all levels. The implementation of sustainability will contribute to a development that maintains an environment that does not harm current and future generation’s opportunities for good health”. In this it echoes the Brundtland commission’s definition of sustainable development (WCED1987) which has been critiqued for being uncritical of business and growth based capitalism (Sinclair 2009).
This definition is a good start but requires development. Nurses, particular nursing scholars interested in health and public health, need to consider the argument already suggested around the dynamics of capitalism as a major driver for both carbon emissions and unsustainable practices. It is perfectly possible to begin the study of sustainability and environmental health within taken for granted paradigms, but what is required is a cultural critique of the values and systems that support environmental damage (Martusewicz 2014) and a better understanding how the economy and sustainability issues such as climate change, interact (Better Growth, Better Climate, 2015). Nurses, if they stick to nursing journals and literature, will not find a large amount of material that discusses this. For example the Royal Society of Arts has a wealth of papers, presentations and works streams addressing climate change (Hahnel, 2015; Rowson, 2015) which address causes, behaviour changes, political economy and culture change.
Conclusion
Anåker & Elf (2014) argue that there is a need for theoretical and empirical studies of sustainability in Nursing. This could include accessing literature unknown to most nurses. Writers such as Aldo Leopold, Wendell Berry, Paul Hawken, Mike Hulme, John Urry all provide insights into human wellbeing, health and the social context. Related concepts include ecojustice education, education for sustainability, dualism, anthropocentrism, anthropocene, neoliberalism, modernity and capitalism. A problem for nursing scholars is that these related concepts are not readily seen as relevant to nursing and thus there may be a reticence of nursing journals to publish them, and a reticence in nurse education to discuss them. There may be a need to resort to both non nursing peer reviewed journals but also to web based materials open to all. Anaker and Elf acknowledge in their limitations (p387) ‘the lack of research literature available for review in which sustainability was the major topic and in which sustainability was not linked to other concepts’. This paper goes further in trying to make those wider links for nurses. A problem however for nurses, is the sheer scale of literature and concepts that are involved. The task for nursing scholars is to consider just what is feasible, useful and relevant as part of their scholarly development and curriculum work.
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