Positionality
Carole Rushton
Abstract
In this essay, I discuss the implications of the notion ‘positionality’ for understanding the transformative capacity of nurses and the nursing profession. Positionality can be used to denote ‘how’ and from ‘where’ nurses construct meanings for themselves relationally and how they then act in accordance with these meanings in the places where they work. Drawing from the nonnursing literature which is heavily influenced by Foucault, an argument is put for why nursing must take seriously this notion of positionality, first, when trying to understand nurses' participation in health policy and reforms and, second, why these may or may not be enacted as expected. Examples of positionality from the nursing literature are drawn on to support the argument for more specific theories of power and to make sense of the heterogeneity and indeterminacy of nurse's positionalities. I conclude this discussion by proposing that positionality be viewed from within the combined schemata of power provided by governmentality and actor-network theory: ‘governmentality in action’. Finally, I suggest that nurses focus on controversies, paradoxes and dilemmas in health because this is where the transformative potential of nurse's positionalities become most apparent. Nurses are ubiquitous and typically comprise the largest component of most health care workforces (World Health Organisation, 2020). The transformative potential of nurses and their aggregate, that is, ‘nursing’, through individual enactments of their collective capabilities, is enormous. They are impelled to actively participate in health policy agendas and health reforms translated via the various codes and mandates fashioned to govern their practice (International Council of Nursing, 2012; World Health Organisation, 2020). For example, nurses are mandated to ‘promote an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected’ and to advocate ‘for equity and social justice in resource allocation, access to health care and other social and economic services’ (International Council of Nursing, 2012, p. 2). Promoting respect and addressing social disparities across health care systems are formidable tasks indeed. However, evidence demonstrating nurses' success in either of these two arenas remains ambiguous (Altman et al., 2020; Hassouneh, 2006; Johnson et al., 2021; Kerr & Macaskill, 2020; Phelan et al., 2020; Rafferty, 2018). For example, there are too few reports from practice, in the nursing literature, detailing successful implementation of person-centred care. Narratives espousing the benefits of person-centred care are far outweighed by those highlighting obstacles to its implementation suggesting that person-centred care policy and strategies remain largely aspirational. Nurses' ability to mitigate racism and social disparities have also been brought into question (Altman et al., 2020; Johnson et al., 2021). Some attribute the lack of progress in this arena to contemporary approaches in nursing education such as the ‘cultural competency model’ and ‘transcultural nursing’. Some claim these approaches depoliticise social difference and disparity by ignoring the power differentials that brought them into effect in the first place (Altman et al., 2020; Hassouneh, 2006). Central to the problematics of person-centred care and social disparities in health is a proclivity within nursing towards dualistic ways of thinking about relationships. Furthermore, to assume a position as a ‘nurse’ means assuming an identity that maybe paradoxical, essentialised, normative, static, epistemically privileged/epistemically oppressed and politically neutral (Alcoff, 2005). Correspondingly, nurses' relationship to power is oftentimes represented as one of oppression and constraint. This ignores the subtle ways in which nurses are willingly conscripted into or else resist regimens of power. It also raises questions about the ‘transformative capacity’ of nurses for meeting contemporary expectations that they perform as ‘agents of change’, ‘entrepreneurs’ or ‘innovators’ (Cusson et al., 2020; International Council of Nursing, 2012; Rafferty, 2018; World Health Organisation, 2020). The construct ‘positionality’ displaces the hegemony and binarity of agency versus structure, essentialisms and oppressive, omnipotent conceptualisations of power intrinsic to prevailing constructions of the nurse identity. Positionality assumes, instead, that nursing identities are multiple and diverse and co-constructed within networks of power that are both repressive and liberatory (Alcoff, 2005). Where the salience of identity is affirmed, it is sometimes all too easy to then concretize identity's impact, to assume clear boundaries, and to decontextualize and dehistoricize identity formations. In reality, identities are much more complex than any of these caricatures will allow. The concept of positionality, as it applies to nursing, politicises the role of ‘nurse’ as a definitive yet fluid identity which is mediated by the nurse's lived experience and the socio-materiality of the contexts within which they work. To be a ‘nurse’, therefore, is to assume a position in a mutable context bounded by its materiality and social mandates that sanction the ‘nurse’ to speak and act in certain ways that alters not only ‘the nurse’ but also the people and things that surround them. Despite the obvious relevance to nursing, particularly as a female-dominated profession, the construct positionality has only limited presence in the nursing literature, except in discussions about nursing research and specifically qualitative research (Borbasi et al., 2005; Fenge et al., 2019). The relevance to nursing practice is less well explored which is interesting because this is where real change is enacted through the choice nurses make during the delivery of care. For example, in the 2020 review of developments in person-centred health care, Phelan et al. (p. 20) make reference to positionality, but only in relation to the conduct of nursing research. This contrasts the importance afforded positionality in the implementation of health reforms noted by Lee et al. (2021). Reporting on the translation into practice of equity and inclusion policy in health care in Aotearoa/New Zealand, Lee et al. (2021, p. 1) found that, “The translation of such policy into practice is…convoluted by subjective interests and power differentials and thus the outcomes of policies may deviate from their original objectives.” The authors concluded that personal biographies and the study participants' positions within the organisation had influenced their enactments of policy that deviated from the original intent of the policy. Extrapolating from Lee et al. (2021), nurses must take seriously the notion of positionality for practice because of the effects it may have on the translation of policy and health reforms. It follows, therefore, that understanding positionality has implications for understanding the transformative potential of nursing. Insights gleaned from the study by Lee et al. (2021) are useful for understanding how policy crafted in one context might be subjected to alternate translations in another, such as practice. However, if we accept the central premise of positionality as being constituted with relations of power, then the above merely states the obvious. An essential presupposition of positionality is that it is mediated in part, by a person's lived experience and personal biographies where reinterpretation is inevitable and can lead to the production of multiple and indeterminate outcomes. Lee et al. (2021) later conceded that their analysis had reinforced the need to examine broader structures of power, particularly the productive effects of these. I try to take the time because I understand the frustration of not being able to get the message across. If you sit and take the time. And even in a few limited words they know, it's just you sit and take the time, you, they, will be able to get their message across. The key stakeholders, who need to give you the support because if you do not have support from the Director of Nursing, who professionally is really your line manager and then from the clinical perspective from the Consultant, the governance just won't be there for it to happen. My work is defined by the protocols that I have to work to…. and even within those protocols I am limited as to what I can do. Both the above studies reflect the diversity and heterogeneity of nursing practice. They also illustrate that how power is exercised can be both freeing and constraining to produce very different, sometimes undesirable outcomes. In the preceding commentary, I argued that positionality needed to be taken seriously if nurses are to understand the transformative potential of their roles within the health care system and the implications this has for making sense of their involvement in the implementation of policy and reforms. I also argued that it was not sufficient to merely situate nurse's positionalities within a ‘system of power’ or as comprising the sum of ‘lived experiences’ or ‘personal biographies’ Positionality is a composite of power, not just of one or two but all of the aforementioned ‘factors’. Therefore, what is needed are schemata of power that explore the interplay of power and positionality, that implicates both human and nonhuman enactments of power and which makes power recognisable. It is only when power is enacted, irrespective of how mundane its presentation (Foucault, 1982; Law & Urry, 2004), that nurses might see where and how they might either deploy or oppose power to achieve particular ends. The relation between political rationalities and such programmes of government is not one of derivation or determination but of translation—both a movement from one space to another, and an expression of a particular concern in another modality. How a person translates themselves (which includes their lived experience and personal biographies) and is in turn translated, relative to the objectives of government, through a network of people and things in ways that alters them (the person), other people, the things and the network. A relationship of confrontation reaches its term, its final moment (and the victory of one of the two adversaries), when stable mechanisms replace the free play of antagonistic reactions…It would not be possible for power relations to exist without points of insubordination which, by definition, are means of escape. This nurse's suggestion that she must choose between paperwork or time with patients is ironic because the very documentation designed to promote individualised care appeared to detract from it for these nurses. Closer examination of the nurse's positionality might have provided more insight into the choices made regarding care. It may have also resulted in different questions being asked such as, ‘Why did the nurses feel they had to choose between paper work and providing patient care?’ and, ‘Why was there not enough time to do both?’ The purpose of this essay was to reinvigorate interest in the construct positionality and to explore its utility for understanding the transformative potential of nurses and the nursing profession. Research demonstrates the importance positionality in the translation of policy and enactment of health reforms. Although researchers recognised the importance of power in relation to nurse's positionalities and their transformative capabilities, it is argued that more robust theories of power were needed to provide more insight into the heterogeneity and indeterminacy of these capabilities. I proposed that ‘Governmentality in action’, which combines governmentality and actor-network theory, be used to help nurses become more attuned to, and to register power as it is being enacted. By locating positionality within these two complex schemata of power and focusing on controversies, both the general and specific effects of power, that either inhibit or potentiate a nurse's transformative potential, become more crystalline. Specifically, more research is needed to reveal how nurses' positionalities are being enacted and what impact this has on promoting respect and addressing social disparities across health care systems globally. Data sharing not applicable—no new data generated, or the article describes entirely theoretical research