Critical theory and its contribution to the nursing discipline

Teoría crítica y su contribución a la disciplina de enfermería

Teoria crítica e sua contribuição à disciplina de enfermagem

Angélica Mosqueda-Díaz¹; Vivian Vílchez-Barboza²; Sandra Valenzuela-Suazo³; Olivia Sanhueza-Alvarado⁴

¹ RN, Ph.D. candidate. Professor, Universidad de Valparaíso, Chile. email: angelica.mosqueda@uv.cl.

² RN, Ph.D. candidate. Professor, Universidad de Costa Rica, Costa Rica. email: vivian.vilchez@ucr.ac.cr.

³ RN, Ph.D. Professor, Universidad de Concepción, Chile. email: svalenzu@udec.cl.

⁴ RN, Ph.D. Professor, Universidad de Concepción, Chile. email: osanhue@udec.cl.

Receipt date: Feb 1, 2013. Approval date: Feb 10, 2014.

Subventions: none.

Conflicts of interest: none.

ABSTRACT

This article reflects on the Critical theory, stemming from the most important philosophical concepts and the modifications it has endured over time. Thereafter, we expose the contribution of the Critical theory to Nursing. This emphasizes on the contextual analysis of the phenomena and it is a self-critique to prevent dogmatisms and totalitarianisms. It postulates that in order to establish a truth, we must consider the historical conditions within which said truth emerges. Jürgen Habermas, with his Theory of Communicative Action, reorients the original postulates of the Critical theory, making it more coherent from the social point of view, through the Guiding Interests of Knowledge. Nursing professionals who follow the Critical theory highlight the need to improve the description of the construction of knowledge with an emancipating and liberating purpose, which permits Nursing to provide responses to approach reality through a global and dialectic vision and from a democratic position of knowledge, construct research from the social situational reality that is part of its daily experience; everything that can be unified as a "Philosophy of Nursing Care", which should be incorporated onto the professional formation of the discipline and onto the research area.

Key words: nursing theory; philosophy, nursing; nursing.

RESUMEN

En primera instancia, se reflexiona sobre la Teoría Crítica a partir de los conceptos filosóficos más importantes y las modificaciones que ha sufrido en el tiempo. Seguidamente, se expone la contribución de la Teoría Crítica a la Enfermería. Esta enfatiza en el análisis contextual de los fenómenos y es autocrítica con el fin de impedir los dogmatismos y totalitarismos. Además, postula que para establecer una verdad se deben considerar las condiciones históricas en las cuales surge esa determinada verdad. Jürgen Habermas, con su Teoría de la Acción Comunicativa, reorienta los postulados originales de la Teoría Crítica, haciéndola más coherente desde el punto de vista social, mediante los Intereses Rectores del Conocimiento. Los profesionales de Enfermería, seguidores de la Teoría Crítica, destacan la necesidad de mejorar la descripción de la construcción del conocimiento con una finalidad emancipatoria y liberadora, que permita a Enfermería aportar respuestas para acercarse a la realidad mediante una visión global y dialéctica, y a partir de una posición democrática del conocimiento, construir investigación desde la realidad situacional social que forma parte de su experiencia cotidiana. Todo lo cual pueda unificarse como una "Filosofía del Cuidado" de Enfermería, que debería incorporarse en la formación profesional de la disciplina y en el área investigativa.

Palabras clave: teoría de enfermería; filosofía en enfermería; enfermería.

RESUMO

Se reflexiona sobre a Teoria Crítica, a partir dos conceitos filosóficos mais importantes e as modificações que sofreu no tempo, seguidamente, expõe-se a contribuição da teoria crítica à Enfermagem. Esta enfatiza a análise contextual dos fenômenos e é autocrítica com o fim de impedir os dogmatismos e totalitarismos. Postula que para estabelecer uma verdade se deve considerar as condições históricas nas quais surge está determinada verdade. Jürgen Habermas com sua Teoria da Ação Comunicativa, reorienta os postulados originais da Teoria Crítica, fazendo-a mais coerente desde o ponto de vista social, através dos Interesses Reitores do Conhecimento. Os profissionais de Enfermagem seguidores da Teoria Crítica, destacam a necessidade de melhorar a descrição da construção do conhecimento com uma finalidade emancipatória e liberadora, que permita a Enfermagem contribuir respostas para acercar-se à realidade por meio de uma visão global e dialética, e desde uma posição democrática do conhecimento, construir investigação desde a realidade situacional social que faz parte de sua experiência cotidiana. Tudo o qual possa unificar-se como uma "Filosofia do Cuidado" de Enfermagem, que deveria incorporar-se na formação profissional da disciplina e na área investigativa.

Palavras chaves: teoria de enfermagem; filosofia em enfermagem; enfermagem.

INTRODUCTION

The Nursing discipline has evolved through history, from an initial biomedical-positivist vision to a situation where it complements the aspects named with those constructivist aspects contributed by the social sciences. To make this transition, it has received influence from diverse philosophical currents, which have contributed to it a more complex view to confront health challenges. A clear example of this is constituted by the Critical theory. This article seeks to review the conceptual structure and historical evolution of the Critical theory and analyze its contribution to the disciplinary development of Nursing, as perspective and orientation of thought for the production of knowledge and in education.

To comply with the objectives proposed, a reflexive analysis was performed of critical theory, from the most important philosophical concepts and the modifications undergone by said theory since its origin. The following exposes the contribution of the Critical theory to Nursing, within the setting of the development of theory, Nursing education, and research.

Conceptual aspects of the critical theory

The Critical theory was elaborated by a group of professors from the Institute for Social Research, created during the 1920s in the University of Frankfurt in Germany. Due to its place of origin, it is also known as the Frankfurt School.¹

The Critical theory is supported on the Marxist philosophical base, and it was Marx (cited by Fraser) who in 1843 defined it as the self-clarification (critical philosophy) to be gained by the present time of its struggles and desires.² This definition had much political impact, which has persisted over time.^2,3 Said concept was reinterpreted by the group of Neo-Marxist theorists from the Frankfurt School, translating their concern for economic determinism into a critical analysis of diverse dimensions of society and of knowledge systems.⁴

Among the exponents of the Frankfurt School and their main contributions, we have Max Horkheimer with the initial Critical theory, Theodor Adorno and his Negative Dialectics, Herbert Marcuse with Reason and Revolution, among others.¹ During the 1950s, Jürgen Habermas came along with his Theory of Communicative Action, reorienting the original postulates of the Critical theory,⁴ making it less critical, less negative, more systematic, and more coherent from the social point of view.⁵

Jiménez³ and Horkheimer⁶ indicate that the Critical theory does not criticize merely to establish postulates against others; rather, it proposes a contextual analysis of phenomena; it postulates that to establish a truth, we must consider the historical conditions within which said truth emerges. Further, this theory is not merely about passing judgment outwardly, but also toward its own creators, that is, it is self-critique to prevent the dogmatisms and totalitarianisms it questions.

The initial postulates of the Critical theory were aimed at human activities and how it influences upon the large social structures, these are:

1. Dispensing with some principles formulated by Marx.Translates domination from the economic to the world of culture, ¹ from the conscience and from subjectivity in social life.⁴ Herein, the motor of history is the subject-object confrontation, which occurs when the human being is at the center of reflection, going from subject of knowledge to object of knowledge. ⁷

2. The Critical theory poses three big questions to positivism.The first has to do with the neutrality of sciences: all knowledge would be "mediated" by economic and social interests, influencing on research topics and utilization of results.¹ Additionally, all knowledge obtained from research would be filtered by the researcher's rationality and by the theoretical windows upon which it was founded. ³ Secondly, it questions the principle of objectivity, ⁵ given that the theories in themselves are affirmations of values and, hence, science is not free from them; ⁸ discussing, in this sense, the determination of the scientific method as sole reliable, valid, and precise method. This would be an ideological imposition, constituting an incomplete model to approach reality given that it seeks access to it without considering the historical-social contexts in which it is generated.^3,4 And, in the third place, regarding the individuals studied, it questions how they have been limited to passive entities determined by natural forces, opposing the supposed docility that characterizes the study subjects, proposing to recognize them as participative players.⁴

3. Critique of modern society- given that it is a capitalist society that guides culture and technology into becoming industrialized¹ and acting as instruments of domination.⁴

4. Critique to sociology- given that it has waived its obligation to help people emerge from domination, conformity, cultural control¹ and adopt the scientific method as the only means of research.⁴

Radicalization of these proposals could not support the assault of positivism during the second half of the 19^th century,⁸ constituting Habermas' reorientation into a powerful contribution to the previously introduced concepts, postulating in 1965 specific points of view from where reality may be apprehended, which he denominated Guiding Interests of Knowledge, ⁷ these are:

1. The technical interest of the empirical-analytical sciences. Habermas holds that, although open to critique, we cannot always avoid the formulations derived from positivism, hence, he questions the radical rejection of science and technique, given that the scientific method provides information that has proven to have technical success - instrumental to guarantee the self-preservation of human life, which is why it cannot be completely dismissed.⁸

2. The Practical interest of the historical-hermeneutical sciences. Historically, individuals have organized into cultures, and within said cultures they have developed understanding amongst their members through language;⁷ this language is befitting and valid for each member of a particular culture. This is known as ways of inter-subjective understanding, which permit the survival of individuals within a social context.⁸

3. The emancipating interest of the critical sciences. Habermas postulates that a socio-critical theory is based on critical reflection and self-reflection,⁷ which permits increasing knowledge of individuals and this knowledge provides the tools to confront powers of domination and, thus, achieve emancipation.⁸

To better understand the Critical theory from the Guiding Interests of Knowledge, Guba and Lincoln⁹ point to three levels of analysis: a) at the ontological level: based on historical realism, it entails a comprehensible reality, where the social, political, cultural, economic, ethnic, and gender factors are materialized into a series of historically constructed structures and, hence, considered real; b) at the epistemological level: considered transactional and subjectivist, it assumes that the researcher and that investigated are interactively linked; and c) at the methodological level: uses the dialogic-dialectics, where the dialogue between researcher and that investigated seeks to generate informed conscience.

Understanding dialectics as defined by Kemmis.¹⁰ "... dynamic interaction processes between ideas or opposing postures that constitute the patterns and consequences of action and interaction observed in social scenarios expected to be understood and improved". In other words, the Critical theory takes Marx' postulates and makes them socio-critical upon examining the relationships of power and the social structures that produce the inequalities among members of a society. Some social representations like racism, sexism, and classism serve to reinforce the interests of the dominant groups; determining the types of employment, wages, distribution of wealth, access to education and healthcare systems, among others.¹¹ For the socio-critical theory, these cultural, political, and economic circumstances are historically created⁸ and, thus, can be transformed; therein, their emancipating possibility.¹² Also, to study these phenomena, the Critical theory proposes as tools the Guiding Interests of Knowledge, which permit empowerment of those being investigated, providing them incentives to modify the prevailing structures. ⁹

Contributions of the critical theory to the Nursing discipline

According to the aforementioned, upon applying the Critical theory a dialectic vision of health is established. For Nursing, considering it a discipline of dialectic nature, it implies, that once the theory is imparted, it should be put into practice to accomplish better learning from feedback.¹³ That is, it implies that accomplishing a real dialectic nature of the discipline requires of nurses to break with the discipline's identity of docility,¹⁴ leaving behind the technical,¹⁵ submissive, invisible, fragmentary, and pathocentric intramural professional exercise.¹⁶

Hence, this dialectic vision of the discipline contradicts the concept of health that appears since the existence of the human being until mid 20^th century, where health is defined as the absence of signs and symptoms of disease¹⁴ Dialectics appeal to paying attention to new ways of getting ill, which modify life expectancy and the causes of death, due to sociocultural aspects involved. Within this context, the Critical theory permits Nursing to consider the aspects of the socio-cultural context to offer care, which translates into being able to identify the social inequalities related to health and transform these situations through the innovative application of knowledge to face current health challenges; reflecting in greater equity. Many times, the work experience of Nursing professionals places them as witnesses of an alienated and dehumanized society;¹⁵ in this regard, the Critical theory offers a conceptual structure through which it seeks to establish a clear distinction between the false assumptions (of social origin) and the real disadvantages. Nursing through the Critical theory can work on the effective solution to modify disparities,¹¹ enabling the dialogue of science in day-to-day activities and managing greater participation from individuals in their healthcare.¹⁷

The aforementioned will allow Nursing to contribute with concrete answers to approach the diverse realities,¹¹ through: a global and dialectic vision upon conducting a social and intellectual practice committed to an ideological struggle, seeking to identify and reduce the social inequalities related to health; a democratic vision of knowledge, which refers to the understanding of meanings and the joint user-professional elaboration of emancipating and liberating knowledge,¹¹ to be applied to everyday situations that generate greater quality of care provided and, thus, improve the quality of life of people;¹⁸ and construct research from the situational, social reality, which is part of the daily experience,¹⁹ looking for and modifying possible practices of inequality within the healthcare system.

Critical theory and Nursing theories

Until now, the conceptual structure of the Critical theory has been analyzed along with its possible contributions to Nursing. However, it is necessary to carry out reflexive self-criticism²⁰ to define the service provided by Nursing to society upon applying the Critical theory, a service that must be guided by the discipline's specific knowledge; given by Nursing theories and models, given that it provides a proper conceptual framework to interpret findings and guide the practice.²¹

This is how we can identify the incorporation of the key elements of the Critical theory onto Kari Martinsen's²² theory: "Philosophy of Care", which emerges when its author takes a critical look at the Nursing practice, rejecting adoption of the characteristics and scientific bases of the profession without criticism. On the contrary, the author analyzed the discipline from a social perspective and of philosophical critique.

This theory emerged during the early 1970s, highlighting among its main contributions aspects of human beings related to behavior and their reactions against the health-disease process; stages and processes of life, as well as the context within which they develop. It analyzes the meta-paradigm of nursing from a socio-historical perspective and indicates that the person cannot be removed from the social environment and from the community in which he or she lives.²²

In this Theory, it is possible to visualize philosophical concepts derived from the Critical theory, like the following: ²²

Karl Marx:This current provided Martinsen with analytic and critical tools to describe the reality of the Nursing discipline and of the social crisis in which it was immersed. This crisis consisted in the discipline's failure, examining its nature as fragmented, specialized, and technical. Due to this, Martinsen proposes that we must question the nature of Nursing, its contents and internal structure, its historical origin and the genesis of the profession. Upon adopting a critical posture, nursing professionals can view their task and profession within womb of historical and social context, where its historical interest has a critical intention and of transformation.

Merleau-Ponty:Indicates that the human body, as natural attitude, is situated in the world; Martinsen adjusts it to Nursing as that relationship we have as professionals in this discipline with the body, through actions, attitudes, words, tone of voice, and gestures.

Michel Foucault:the phenomenology underlines the importance of history in our experiences. Based on this, Martinsen reflects on the effect diverse phenomena have on Nursing and ponders: what disciplinary structures or characteristics should be in our current practice and in its spatial disposition? What will it mean to think different from how people in our time think? This is where critical Nursing is. In this sense, what does critical practice of Nursing mean today in relation to healthcare services and research?

The Philosophy of Care implicitly incorporates two essential concepts to apply in Nursing - the communicative action of the Critical theory, these are: autonomy and responsibility, which operate independently. The concept of autonomy refers to the principle that guides an individual when speaking without external or internal coercion or barriers. The principle of responsibility refers to the implication and commitment of individuals to create communication contexts where each can express him or herself with autonomy.²² These principles permit a professional-user relationship of greater horizontality and reciprocal growth, providing the opportunity of exposing and reducing communication errors, generating more equitable care practices.

Critical theory and formation in Nursing

The philosophical support provided by the Critical theory, and incorporated to a Nursing theory, generates a disciplinary responsibility on how to integrate it to the professional formation, at the philosophical base of nursing curricula.

In this regard, Clare (cited by Medina) indicates "Nursing education is not merely a learning process; rather, it helps to create and legitimize forms of conscience that reinforce hegemonic structures".²³ A postulate that until now has not been critiqued by the Nursing conglomerate, becoming an aspect that can be observed in the different healthcare centers. Thus, the teaching-learning process can be an opportunity to construct and reconstruct new abilities and skills, enabling broader understanding of the praxis of the Nursing discipline, generating greater analytical and intervention capacity in different healthcare environments, against diverse situations that occur day to day. Through the learning process, we can demolish prevailing structures and create new forms of healthcare relationships.

The professional behavior will be directly related to the formation and to the teaching doctrine, which should explain how the socially configured ideological mechanisms impact on the educational activity, providing responses to the needs of the healthcare system and of the Nursing profession.²³ The teaching-learning process must encourage reflexive self-critique, empowering future Nursing professionals, so they can develop to their maximum potential as agents of change;²⁰ this will allow them to question that established as hegemonic, avoiding generalizing or setting up absolute truths,¹⁷ that is, they can apply a thought and action model that defies and transforms¹⁸ the relationships of power and domination institutionalized in the social world of nurse formation.²⁴

Upon this panorama, it is necessary to grant more importance to the acquisition of skills of critical thought, both in the graduate profile as in the curricular progression of the Nursing career's study program. This also requires faculty staff empowered and congruent with these lines of thought, which is evidenced through the teaching-learning methodologies used,²³ for example, using participative didactic strategies for students to reach rational consensus through democratic and non-coercive communication relationships, where each participant is responsible for creating a communication climate free of domination.²⁴ Thus, we will accomplish the graduate's projection of the academic formation received.

Critical theory and Nursing research

The Critical theory establishes that its application in the Nursing discipline is based on reflecting on what is occurring within the context and in the practice carried out, providing a framework to inquire on the possible practices of inequality within the healthcare system. Participative action-research is one of the research methods used to apply the Critical theory. It corresponds to a situation's analysis process, identification of problems, and elaboration of action strategies, which will be subjected to observation, reflection, and change. This type of research focuses its interest on the transformation of the structure of social relationships, guiding knowledge to emancipate and liberate human beings, through self-reflection and questioning of the relationships of power in their different forms.²⁵ In summary, the sequential process proposed in using this type of methodology implies Knowing-Acting-Transforming.¹⁷

The prior is illustrated in research in the field of Pediatric Nursing.¹² The study applied the critical social theory on a case of adolescents with diabetes; examining how the relationships of power in healthcare interactions affect communication between nurses and adolescents. The results expressed that the language used by the nurses interferes in the process of effective communication with adolescents. It proposed changing the language of interaction and stimulating professionals to break from the predominant stereotype of viewing adolescents as irresponsible, considering them "partners" in healthcare for decision making. Thus, better results were accomplished, given that adolescents became leading players aware of their own lives.¹² Undoubtedly, the critical theory calls on the Nursing discipline to use its postulates and apply them in its daily work to bring about progressive improvement in the praxis.

CONCLUSIONS

The Critical theory offers the philosophical foundations for the social and human disciplines, like nursing to be able to use and apply them in the different performance settings, becoming an opportunity to contextually analyze, from constructive criticism, phenomena of interest and carry out actions aimed at transformation and disciplinary growth. The proposal of using dialectics to learn of the new forms of health and disease that emerge from the population's sociocultural aspects will permit nursing to innovate in the application of knowledge to confront current healthcare challenges, responding to the question: what does a critical practice of Nursing mean today in relation to healthcare services and research?

The Philosophy of Care by Kari Martinsen permits applying the communicative action of the Critical theory in Nursing: autonomy and responsibility. This generates for Nursing emancipation and liberation spaces, both within the discipline and toward the people with whom it interacts; upon examining the relationships of power and the social structures that produce inequalities among users of the healthcare system, and proposing new, more equitable, ways of relating. To legitimize these proposals of new forms of conscience through the Critical theory, Nursing must grant greater importance to acquiring skills of critical thought, including them in the undergraduate and graduate professional profiles to construct a disciplinary transformation, along with self-reflection and questioning of the power and gender relationships.

According to the aforementioned, continued efforts are recommended to apply the Critical theory in research through the participative-action-research method, which implies identifying a visible problem in the daily practice, carrying out actions that enable improving the quality of the care provided and transforming the stereotypes and established procedures that reinforce inequality.

REFERENCES

1. Briones G. El Neomarxismo alemán. En: Teoría de la ciencias sociales y de la educación: epistemología. 2 ed. México: Trillas; 2006 (reimp. 2008). p.137-44.         [ Links ]

2. Fraser N. ¿Qué tiene de crítica la teoría crítica? Habermas y la cuestión del género. En: Benhabib S, Cornell D editores. Teoría feminista y teoría crítica. 1ra ed. España: Edicions Alfons el Magnànim; 1990. p.49-88.         [ Links ]