critical social theory nursing example

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• v.9(Suppl 1); 2021

Critical social framework on the determinants of primary healthcare access and utilisation

Mohammad hamiduzzaman.

1 College of Health, Medicine & Wellbeing, The University of Newcastle, Taree, New South Wales, Australia

Anita De-Bellis

2 College of Nursing and Health Sciences, Flinders University of South Australia, Adelaide, South Australia, Australia

Wendy Abigail

Amber fletcher.

3 Department of Sociology & Social Studies, University of Regina, Regina, Saskatchewan, Canada

Associated Data

All data relevant to the study are included in the article.

This paper aims to contextualise ‘healthcare access and utilisation’ within its wider social circumstances, including structural factors that shape primary healthcare for marginalised groups. Mainstream theories often neglect complexities among the broader social, institutional and cultural milieus that shape primary healthcare utilisation in reality. A blended critical social framework is presented to highlight the recognition and emancipatory intents surrounding person, family, healthcare practice and society. Using the theoretical contributions of Habermas and Honneth, the framework focuses on power relationships, misrecognition/recognition strategies, as well as disempowerment/empowerment dynamics. To enable causal and structural analysis, we draw on the depth ontology of critical realism. The framework is then applied to the case of rural elderly women’s primary healthcare use in Bangladesh. Drawing on the literature, this article illustrates how a blended critical social perspective reveals the overlapping and complex determinants that affect primary healthcare utilisation, before concluding with the importance of situating healthcare access in sociocultural structures.

Introduction

Recognition and emancipation are connected to equitable and participatory, patient-centred primary healthcare. Access to and utilisation of healthcare generally means the availability of treatments, timely and appropriate treatment, and adequate delivery of services, and in the science of primary healthcare implementation, the emerging concepts are recognition and emancipation of people. 1 2 Since the 17h century, there has been debate between biomedical and social scientific theories on the conceptualisation of health and healthcare. 3 4 At early stage, medical scientists related health to treatment, which changed when researchers started explaining healthcare using sociological models. 5–8 This social scientific perspective is supported by biomedical scientists who acknowledge that there are vital aspects of primary healthcare, for example, recognition of patients’ needs, preferences and presence; emancipation in participation; and shared decision making, that can only be studied by social sciences, such as social determinants of health. 9 This paper contextualises a need for a critical social lens into healthcare access, and proposes a critical social framework (CSF) with methodological application to improve primary care support for disadvantaged people.

There are five major paradigms in biomedical and social sciences— biomedical, biopsychosocial, integrated healthcare, health beliefs and social determinants of health—each of which views healthcare challenges differently. Each model has been developed around the four components of philosophy, structure, process and outcomes. A move from biomedical science to a social determinants of health approach indicates an increase in diversity of philosophies and principles available to accommodate the complexities of healthcare. However, primary healthcare remains inadequate due to lack of conceptualisation of social structures and care accessibility, especially for the underprivileged population groups, for example, rural people, older adults and indigenous people. 10

The terms ‘psychosocial determinants’ or ‘social determinants’ or ‘downstream and upstream determinants’ are interchangeably used to contextualise an emerging study field of ‘healthcare access and utilisation’. This field acknowledges a variety of care system and social circumstances, such as prevention, health communication, rehabilitation, education, poverty and housing, for example, which combine to affect health and care access. 10 Within a growing academic movement towards better inclusion of determinants not acknowledged by mainstream approaches, there have been reviews of ‘causes of the causes’ surrounding health and social practices and the exploration of new factors, 11–13 such as human interactions, recognition, and emancipation. Consideration of deep causes and power structures align with a more critical approach to understand accessibility. Existing literature supports the importance of investigating power differences and personal characteristics in any health facility, family and society. 14–17 However, application of critical social science in investigating health determinants is complex in either its conceptualisation or actualisation. Several paradigms have been developed in describing healthcare, and there are debates concerning where and how to explore the determinants and their impact on primary care utilisation.

In this paper, we argue that mainstream paradigms and their determinants lack critical engagement with social structures and processes that shape accessibility and outcomes. Drawing on the strengths and limitations of mainstream healthcare paradigms—and positing the importance of a critical social approach informed by the work of Habermas, Honneth and Bhaskar—we develop a theoretical framework for critical analysis of issues in primary healthcare—a CSF. The proposed CSF is developed through a synthesis of existing theoretical approaches; it accounts for social, economic, political and cultural structures and processes that often reflect deeply engrained power differences, misrecognition and marginalisation, while also describing the exploitation of disadvantaged population groups. The causes of poor care accessibility can be seen critically through unpacking and problematising each of the places, events and interactions accounting for the circumstances. 18 19 Based on critical social science, in order to provide a scoping reassessment of existing modes and limitations of the prevailing approaches, the CSF helps to inform a multilayered analysis of primary care for marginalised people. After introducing the CSF, we then apply it deductively to an existing qualitative study of rural elderly women in Bangladesh ( box 1 : A case), which was conducted by the first author. Through this case study, we apply and assess the utility of the CSF and examine its relevance to primary care practice.

A case—rural elderly women’s primary healthcare access in Bangladesh (Hamiduzzaman 2018)

The elderly population is increasing in Bangladesh. 50 For women in particular, increased longevity coupled with high rates of chronic illness and disability cause specific health needs that have yet to be adequately addressed through primary care services. 51 52 Further, over 70% of elderly women live in rural areas and these women are less likely than their urban counterparts to seek primary care. 2 Primary health is expected to be their first point of contact that would cover their care, that is, health promotion, prevention, early intervention, treatment of acute conditions, and management of chronic condition, which are not related to a hospital visit. However, only one rural woman in every 1000 seek primary care and their community clinics visit rate is as low at 5% of all visits. 53 In Bangladesh, a pluralist primary care system exists (ie, public, private, and traditional lay treatment options) in rural areas with a disparity in accessing services and poor satisfaction in care support. 54 Rural women are highly dependent on traditional healing and home remedies provided by semiqualified healers or family members. Limited healthcare utilisation by rural elderly women in this context is shaped by interacting socioeconomic, cultural and political structures. Existing research by the lead author and others noted the significant role of cultural recognition and emancipation in shaping accessibility, 44 55–57 as the women tend to downplay their own illnesses, delay treatment and depend on lay or traditional healers who may exploit them and/or provide inappropriate care. Other interconnected barriers for their access include lack of services in rural places; low levels of education and health literacy; and gendered economic inequality—for example, Muslim women inherit only 1/8 of a deceased husband’s property and married Hindu women are not entitled to inherit their parents’ property. 58 59 Public income supports for this group are extremely lacking. 59 The combination of sociocultural, economic and institutional inequalities that shape rural elderly women’s primary healthcare access and outcomes in Bangladesh can be best analysed through a critical social science.

The present healthcare paradigms

With its origins in western positivism, biomedical science is currently the dominant paradigm to understand personal illness and disease, with two perspectives on treatment: clinical and epidemiological. 6 While the clinical perspective focuses on the diagnosis of disease and cures for patients, the epidemiological perspective emphasises the prevention of disease so that action can be taken to avoid deterioration. 20 This paradigm often defines the reasons for illness and diseases from a mechanistic outlook without considering socioeconomic aspects. 6 21 As such, this model de-emphasises consideration of such factors as the places a person lives and grows as potentially relevant to her/his illness. Koster et al argue that the biomedical paradigm is no longer adequate to explore risk factors that have an impact on healthcare usage. 21 Although biomedical science is theoretically and practically established, as well as normatively engrained, it has limited value in accounting for the dynamics of healthcare when access to and utilisation of care becomes difficult due to a lack of services, social marginalisation and inequality, or poor socioeconomic circumstances.

A biopsychosocial paradigm emerged as an extended version of the biomedical perspective with the aim of describing healthcare from a patient’s biological, psychological and social context. 22 However, this paradigm remains limited in describing the relationships among mind, body and socioeconomic status of a person. 23 It highlights the need to consider the effects of psychosocial conditions on an individual, including her/his religious beliefs, work history and previous incidents, for example. Although this approach is considered a means to include social characteristics, it does not provide any direction about which social factors need to be considered along with the psychological and biological factors and, as a result, fails to suggest practical solutions to resist the medicalisation of care. 23

The integrative healthcare paradigm is a recent addition in biomedical science that focuses on the collaboration of conventional and complementary medical care. This paradigm has been developed based on biological and ecological perspectives, with emphasis on care philosophies, organisational complexity, clinical interactions and other aspects of well-being. 24 Mann et al suggest seven dimensions of integrated healthcare including informed clinician, networking clinician, complementary clinician, multidisciplinary group practice, hospital-based integration and integrative care within an academic field. 25 Another leading perspective in the integrative healthcare paradigm, the ‘complex system measure’, suggests discussing the illness of a person in a complex and dynamic system. While this paradigm provides a focus on healthcare integration among different types of health professionals and practices, the central aspects of patient’s life such as healthcare, emotion, cultural and spiritual needs are less fully considered. Thus, it becomes difficult to explain how health beliefs and behaviours are embodied in a socioeconomic context that also affects care accessibility and utilisation. 26

In primary healthcare research, the health beliefs and behavioural paradigm appeared from a social scientific stance to guide the investigation of relationships between personal beliefs, characteristics and care seeking behaviours. 27 Different models in this paradigm provide an understanding about the particular aspects that each person possesses in seeking care. However, these models lack focus on functional system and do not consider that access is also an issue of complex healthcare policy and system measures. 28 They do not explain how health beliefs and behaviours are rooted in specific sociocultural values of a society. In addition, this perspective is limited in describing the intersections among the determinants where the transformation from potential to realised healthcare access occurs. 8

The social determinants of health paradigm of WHO (2000) investigates healthcare within the context of larger socioeconomic, political and cultural contexts. 29 This paradigm describes healthcare according to health behaviours, system and socioeconomic structures and functions that shape the milieu in which people live. 29 Further categorising social determinants into downstream and upstream determinants provides an understanding of the vertical relationships among the social and healthcare forces. Although each of the determinants have significance based on sociocultural and political realities that emerge horizontally in specific circumstances, these contextual realities were not considered in developing the paradigm. Moreover, the relationships and interactions in health settings and in society emerged as important aspects for accessing healthcare, but the social determinants of health paradigm does not address these issues. 30 Despite this challenge, recent literature has noted that ‘very few public health experts have questioned the Social Determinants of Health theoretical approach itself’. 31 Accordingly, Frank et al outlined the model’s limitations for considering complex problems, relations of power and privilege, and agency at the individual level—thus indicating the importance of both structural and contextual factors. 31

There are two major drawbacks in the current paradigms ( table 1 ). First, these paradigms tend to downplay the dynamics of relationships and interactions inherent in healthcare access. 32 33 Second, each model conceptualises healthcare from a static point of view as an ideal platform and does not consider how to explore the determinants in everyday healthcare and sociocultural settings. 2 In addition, primary healthcare is country-specific and diverse in relation to their focus and capacities; for example, WHO (2015) identified that rapid ageing places low/middle-income countries at risk of not coping with the challenges in aged care compounded by the country’s primary care policies. 10 Critical social science has scope to add a sociocultural and political understanding, such as rural elderly women’s primary care access and utilisation.

Summary of major healthcare paradigms

Designing a CSF and its methodology

A CSF, informed by the Frankfurt School of Critical Theory and CR ontology, helps expose the exploitative circumstances that people face because of power structures and their complex inter-relationships exist in a society. 34 This perspective draws attention, for example, to the socioeconomic structures that operate to oppress some people while privileging others in a systematic manner. Contemporary critical sciences—which focus on redistribution, equality, emancipation and the recognition of human beings—help reveal the realities of inequitable access conditions for elderly people. 10 A blended CSF drawing from critical theories of Jurgen Harbermas and Axel Honneth is proposed to address the issues of emancipation and recognition inherent in primary healthcare. 18 19 35 36 The addition of a depth ontology drawn from CR (eg, Bhaskar 1979), supplements these foci with attention to structural dynamics that cause interactions at multiple levels, including relations of emancipation and recognition.

The Theory of Communicative Action developed by Habermas focuses on emancipation for disadvantaged persons. 18 19 Habermas introduced a society as a lifeworld including objective, subjective and social worlds that are overlapping with each other. These worlds have potential in describing an individual’s communication and emancipation in service utilisation, connection to their personal, institutional and social structures and cultures. 19 The objective world describes a social actor (a health professional or a patient) who can understand and change existing natural and social structures. 18 It focuses on the patients’ care needs, prevention or early intervention, as well as context-specific treatment and rehabilitation. 37 The subjective world describes the personal characteristics of a social actor and the totality of their experiences and practices such as behaviours, feelings, values and beliefs that influence their competencies in accessing healthcare. These subjective issues are often reflected in cultural and traditional artefacts or in organised institutions and systems. 37 Habermas also described a social world through which an actor regulates her or his membership in social groups and structures. 19 This world is related to the social and institutional order in society such as gender, social class and economic status. This ordered social and or institutional context sets the mode of social interactions and establishes expectations of interpersonal communication, potentially creating a communicative hierarchy among disadvantaged person, healthcare system, and society.

In combination, the three-world concept is a fundamental categorical scaffold that can direct a problematic situation of any society, such as rural elderly women’s care accessibility and usage. The concept presents an abstraction of ideas, for example, healthcare system, provider–patient communication, knowledge of actors, personal beliefs and behaviours and socially ordered interactions. However, there are some limitations in this theory: (1) it does not clarify the ideal situation of an emancipatory society 37 ; (2) it ignores the capacity of a social actor and how they can meaningfully act in an oppressed situation 37 ; (3) while the relationships are identified as important, the issue of relationship remains ignored in the theorisation 2 and (4) does not fully consider ontology and causation. More specifically, the approach thus far neglects the emergent effects of pervasive social structures that exist at multiple levels, and therefore, does not allow for identification of specific causal factors that substantially shape people’s access to, and experience of, healthcare. These limitations in Theory of Communicative Action can be addressed by considering additional sources—the Theory of Recognition developed by Honneth and a Critical Realist philosophy of science, as originally articulated by Bhaskar—to further explain issues in healthcare. 38 39

The Theory of Recognition suggests that a person’s identity is intertwined with societal recognition. There are three domains of recognition identified: intimate relationships, legal framework and community. 35 Intimate relationships include both intimate and family relationships, which contribute to the development of mutual respect and positive attitudes to each other through the recognition of a person’s needs. 36 The second domain includes legal relationships or structures that define the rights and responsibilities of a person. For example, freedom from discrimination and misogyny may lead to the development of self-realisation and self-respect for a social actor, allowing them to view themselves as a legally responsible social being with a role to play in society. 40 This form of relationship also generalises the responsibilities of a health professional to respect and validate the needs and rights of persons. Third domain, community recognition, pertains to a person’s participation in social structures and activities, which involves shared values and mutual respect. 36 Community recognition can result in increased self-esteem for the individual, and potentially even models of care that encourage active participation in social and healthcare systems.

The Theory of Recognition has value in the discussion regarding recognition of oppressed or marginalised people. However, it encounters three limitations: (1) ignorance of gender inequality and the role of gender in the economic structure of family and society 41 ; (2) a lack of focus on reconstruction processes of family and social structures and relationships 42 and (3) the ongoing challenge of identifying structures that contribute in a casual manner to the experienced marginalisation, both within and beyond the healthcare context. Complex and pervasive sociopolitical structures and systems, patriarchy, for example, are relevant for understanding primary healthcare utilisation. The philosophies and domains of the two theories discussed thus far (Theory of Communicative Action and Theory of Recognition) have a mutual agreement for contextualising access to primary healthcare within the realms of emancipation and recognition. Their mutual focus on the intricacies of power relations, discrimination, and misrecognition in healthcare, social and individual spheres offers a new dimension to understand the determinants and the dynamics in healthcare access and utilisation.

Working towards a blended CSF, figure 1 illustrates the categorisation of six concepts into three spheres, which constitute the subject matter domains of the model. These spheres—all of which should be considered for a holistic analysis—include: (1) knowledge, beliefs and behaviours, as well as support in family relationships under the individual sphere; (2) institutionalised care and rights and responsibilities under the healthcare sphere and (3) socioeconomic status, patriarchy and other power hierarchies under the social sphere.

Spheres of a blended critical theoretical framework to contextualise rural elderly women’s access to healthcare.

Despite usefully mapping the domains of analysis, the model thus far lacks fulsome engagement with ontology and causation, which is necessary to examine the full reality of primary healthcare. Drawing from a critical realist philosophy, relations of recognition, emancipation and other aspects of healthcare access are seen to be governed by a particular combination of structural and contextual factors that cause events to occur as they do. 39 While the two aforementioned theories do engage with aspects of social context beyond the micro level of interaction or interpretation (Honneth’s community and Habermas’s objective world, eg), there is a need to consider how social structures and deeply rooted power relations contribute to the manifestation of certain outcomes. This kind of methodological analysis is facilitated by a critical realist philosophy, through which the two theories can be deployed.

As a philosophy of science, critical realism asserts a realist ontology (ie, there is a reality) and relativist epistemology (ie, there are multiple ways of knowing and explaining the reality). Reality, in this view, is deep and multilayered. 38 39 The empirical analysis is the realm of experience, interpretation, and perception, where events are understood through the views of people. Moving deeper, the actual level contains the entirety of the event, whether or not it is understood or perceived. Finally, the real level is the domain of deeply rooted structures and their mechanisms which, if activated in a context, can have an effect at the other levels of reality. In the context of primary healthcare implementation, the addition of a critical realist philosophy allows empirical and theoretical analysis through attribution to causal structures and mechanisms that exist within and shape, the various worlds identified by Habermas and Honneth. Like critical theories, critical realism emphasises the goals of explanation and emancipation, 43 including identification of structures that cause lack of recognition. At the same time, the critical realist approach usefully asserts an ontological reality on which critiques can be based and alternatives evaluated.

Drawing on the fully developed blended CSF, which considers not only the conceptual spheres but also structures and causal relationships ( figure 2 ), this paper now focuses on the application of such a framework to the issue of rural elderly women’s primary healthcare in Bangladesh.

Causal relationships among the determinants of rural elderly women’s healthcare access.

Studying the case: applying the CSF for primary healthcare actions

As noted previously, evidence shows that utilisation of primary healthcare is low among rural elderly women in Bangladesh. The data analysed in this paper stem from a study by the first author. 2 Here, we apply the CSF to consider what is practically happening in this healthcare context, including interactions and practices, as well as broader social, economic and/or cultural structures that shape or determine these interactions. Therefore, a multilevel causal analysis is required. By integrating the spheres of analysis ( figure 1 ) into a depth ontology informed by critical realism ( figure 2 ), a critical methodological analysis of the women’s healthcare challenges can be developed. In this applied example, we consider the various components of the phenomenon moving from the empirical level to real/causal and present them in three spheres of CSF, using empirical data excerpted from the first author’s study.

Individual sphere (knowledge, individual beliefs, behaviours and relationships)

Rural elderly women’s healthcare access and utilisation is immediately affected by individual-level knowledge, beliefs and behaviours. 16 17 These beliefs and behaviours are, in turn, influenced by communication, interaction, and relations of recognition of needs. For example, insufficient education for women due to ingrained patriarchal ideologies (lack of recognition) affects the women’s knowledge and ability to interact with health professionals and seek information and appropriate care, thus affecting how they are treated in healthcare centres. We believe knowledge makes a woman an active social actor with general understanding, systematic explanation skills and decision-making capacity. Therefore, at this level, education may enable the women to access health information and assist them in choosing and accessing healthcare. Enhanced knowledge and (by extension) increased recognition of the women may also help the professionals to be more accountable and responsible in structuring practice for underprivileged groups like rural elderly women. Our CSF highlights a role for healthcare management and professionals in generalising primary care knowledge. It can also lead to improvements in relations of communication and recognition between care providers and client, as the care provider may come to understand and even help mitigate the barriers their clients face.

Examples of empirical data

I wanted to attend school, but could not continue after sixth grade. My parents were not educated, and priority was given to my brothers. My parents wanted to ensure all facilities for my brothers in terms of schooling. Also, village people were against female education on that time. (Rural elderly woman)

I do not see a doctor until my health problems become severe. I did not see a doctor since I started living in this place. I went three times in my life to see a doctor when I failed to bear the pain and/or fever anymore. (Rural elderly woman)

My boys do not live with me—they work in the city and have their own families there. This is a big challenge. If my boys could help, my condition will be good. (Rural elderly woman)

We also consider the subjective world of Habermas and the intimate relationships domain of Honneth in explaining the women’s healthcare beliefs and behaviours, and contribution of family members in their limited access to healthcare. Our CSF examines personal experiences, feelings, beliefs and behaviours to characterise the limited healthcare access of an elderly woman in Bangladesh. It is noted that a person can only be an active social actor when she or he has capacity to play a role in changing the existing circumstances. Within cultural boundaries, limited education and reduced access to family income and savings, it is difficult for the women to flourish as active social actors and to access healthcare. Their care seeking behaviours are also shaped by socialised roles and expectations, which stem in turn from the deeper patriarchal social structure. These women also experience gendered discrimination in meeting daily needs, including healthcare access. 2 17 As such, men and women living in the same family experience the scarcity of resources in very different ways, where men have more rights to use materials such as money and land determined by family members’ values and practices.

Institutional sphere (institutionalised care and rights and responsibilities)

Current health policies and systems in Bangladesh are not designed to meet primary care needs commonly experienced by rural elderly women. 14 44 45 Our CSF includes empirical and theoretical analyses of healthcare policies and healthcare centres in the context of a stratified society. We argue that the critical social science understands the recognition of health needs of underprivileged persons in the context of their functional, clinical, personal and social needs that often include prevention, home care, safe travelling, skilled primary care, psychological services, therapies, social activities and rehabilitation. This perspective challenges the capacity of primary healthcare services relating to staff, equipment, and programmes in providing holistic care. Medical and allied health education and training on gerontology (eg, physiology, pathology, treatment options and preventive measures) and a professional code of ethics that guides clinicians and allied health workers to structure their rights in practice and responsibilities in providing adequate care, should be seen in the context of the health and social policies of a country such as Bangladesh. Another aim of our CSF is to support emancipation of women in seeking regular and complete care, hence, the women’s views need to be considered and valued in designing aged care policy and services.

In practice, they do not have anything because we obey the decision made by our higher authorities. As you know, we are progressing in maternal and child health … and have limited scope to ask them to change the focus. (Health professional)

I visited the community clinic and family welfare center few months ago as they are close from my home. I waited there for one hour and returned home without any medications. They suggested me to visit XXX hospital as they only provide care to children and pregnant women. (Rural elderly woman)

In local clinics, we are nothing in front of the doctors and nurses. They will provide you care when they want to, you can’t say anything. If someone wants to tell something, there is a chance of not being treated. However, there are some good doctors who called me ma [mother] and I always try to visit them. (Rural elderly woman)

one[]A deeper analysis ( figure 2 ) considers all of the aforementioned issues not only as primary healthcare barriers (and associated solutions), but as products of deeply rooted socio-cultural power structures. For example, relations between patient and care providers are affected by social classification of the professions and male dominance in medical practices in Bangladesh. 15 44 While health professionals are considered to be in positions of power, and health practices are male dominated, marginalisation is common for rural elderly women because they identify themselves as being in an inferior position which negatively influences their communications and relationships with care providers. The women are not likely to involve themselves in decisions that concern health knowledge and/or expertise, particularly when mutual trust is essential for sharing health information. 46 Further, due to patriarchal relations, the women often rely on male family members to assist them in using health services, which may limit their information sharing or may prevent them from seeking care in general.

Social sphere (socioeconomic status and power hierarchy)

The blended CSF is critical for understanding the historical development of a society (eg, economic condition and social forces and values) for women. The economic status of a woman is related to their employment, family income and savings; economic status is also shaped by financial support from the government and social organisations in Bangladesh. The women’s education is largely affected by low family and community education literacy. In this regard, we acknowledge the tenet of ‘community recognition’ to signify the importance of mutual recognition, honour and support among and between community people and local organisations for developing self-esteem for rural elderly women to enjoy social engagement and economic freedom from early childhood. The reasons of lifelong deprivation among the women in accessing recognition, education, and formal employment are explored by the blended CSF, which contributes to the positioning of a woman in society, as well as in access to primary healthcare.

My sons may give money if they have extra. As they have no extra, they do not give me anything. They have their own families. How could I see a doctor when I have no money? (Rural elder woman)

You cannot imagine how a woman’s life moves on. A woman started her life in her father’s family, and then she goes for husband’s family leaving all relationships with parents, brothers and sisters. I feel that it would be good for me if I could be born as a male in this society. (Rural elderly woman)

My husband used to take all decisions in our family. What are you talking about? Who will take the decision in my family? My elder son lives in the capital city ‘Dhaka’ and my younger son lives in our previous village. So, all the decisions were made by my husband including my healthcare. (Rural elderly woman)

I do not like to see doctors. Allah is everywhere and Allah will look after me. … If I suffer from any disease, I know that the health condition will be overcome after a certain period. (Rural elderly woman)

Power hierarchy strongly emerged in our analysis, encompassing the social order, cultural issues and practices of sociopolitical organisations in rural elderly women’s healthcare access. Drawing on critical social science, we argue power difference occurs in dialectical relationships and highlights the tensions, struggles and interplay between contrary tendencies. The social relationships and systems are, therefore, challenged by our CSF in the presence of religious values, distribution of power and political economy of social actions to understand the subject of healthcare in a traditional power structure. Religious values and practices are important in explaining the influence of male dominance at different stages of the women’s life including their lack of schooling, unemployment, low income and lack of decision making. Power is generally centralised to the people who have the economic means and position in a cultural and religious structure such as that of Bangladesh. A woman living with her husband and sons has more opportunities to share in the family income and savings than a woman living alone which, in turn, impacts access to healthcare. 12 The political economy is the basis of making policies and services of socioeconomic and political organisations where the women are seen to have limited value in terms of formal productivity. This social sphere is also related to the individual sphere because a person’s beliefs and behaviours are generally shaped in the social environment where the person is born, lives and works.

In this way, we facilitate an empirical and theoretical analysis of patriarchy, socioeconomic marginalisation and other sociocultural power structures that determine a disadvantaged person’s recognition and emancipation in primary healthcare. Our CSF incorporates the conceptual meaning of ‘society’ to explain the process of positioning of a person in social and economic circumstances that impacts access to healthcare. Further, social structures such as patriarchy or socioeconomic marginalisation can be considered basic causes of healthcare access inequality and thereby integrated into the analysis. According to Adams et al , in healthcare settings, there is an opportunity to expand critical social science to explain healthcare of oppressed populations at the professional, institutional and academic levels to ensure better access to primary care. 24 Use of our CSF in future research on healthcare access in culturally diverse social settings may require adaptation to include key spheres and structures that emerge as most relevant in a given context.

Translating the CSF into primary healthcare practice

Here, we describe the translation of the CSF and its methodology into the Johns Hopkins Quality and Safety Research Group’s evidence into practice approach, to recognise disadvantaged people’s care needs and emancipate them to ensure equitable and participatory primary healthcare. 47 This approach has four steps. The first step is building an interdisciplinary team to summarise the evidence for a primary care intervention to achieve specific outcomes, by reviewing the extant literature to identify the access barriers and the interventions with greatest benefits. 48 In second step, the team approaches and engages all stakeholders to understand the context in which the intervention will be implemented. The team’s role is to listen carefully and discern what a disadvantaged person may gain or lose from implementing the intervention. The third step includes a development of performance measures to evaluate how often the people access and receive the recommended healthcare. 47

The final step, in which our CSF and its methodology may play a vital role in engaging the disadvantaged people and their caregivers (family and health professionals), is to design and implement a culturally tailored intervention. We encourage giving voice to the underprivileged people to identify their real-life challenges, at individual, institutional and social spheres, in relation to their healthcare utilisation (Guiding questions: table 2 ). We also suggest engaging their family caregivers and healthcare providers by sharing their stories of patient misrecognition and marginalisation, and by identifying recognition and emancipation issues at individual, institutional and social spheres for empirical analysis (Guiding questions: table 2 ). When the events and factors are understood from their views, there is a need for theoretical analysis, that is, the actual level provides an entire picture of healthcare use, and at real level, the interdisciplinary team analyses deeply rooted structures and their mechanisms to achieve a scientific perspective into where and how to intervene ( figure 2 ). We encourage the interdisciplinary team to educate all staff and provide training on cultural competence skills to support the proposed intervention, along with concise summaries of access barriers and a checklist of evidence. Designing a culturally tailored toolkit, including two components: create a checklist of care needs, and preventive and care support services, can provide a framework for improving primary healthcare access and utilisation. 49

Translation of the blended CSF into healthcare practice

CSF, critical social framework.

This paper has proposed a blended CSF, which combines insights from critical theory and critical realist ontology, to examine access to and utilisation of primary healthcare at multiple levels of analysis. Acknowledging the limitations of mainstream healthcare models in conceptualising healthcare access, the authors highlight the value of CSF to understand multiple contextual and causal factors affecting primary care utilisation for marginalised populations. Focusing on recognition and emancipation, our CSF considers individual, healthcare and social spheres and ultimately identifies basic social structures that shape or determine the phenomenon of healthcare access inequality.

We suggest a new ontological and epistemological insight into human interaction and relationships, knowledge and power structures that are essentially related to a person’s access to healthcare. The process of recognition and emancipation, including institutionalisation of care, dynamics of relationships and way of interactions are often not conceptualised within a sociopolitically determined context. While the evolution of major paradigms has not adequately considered sociocultural processes and power relationships, viewing the primary healthcare of rural elderly women in Bangladesh from the blended CSF provides due attention to the institutional, professional, social, cultural and historical forces at play. At present, most low/middle-income countries are undergoing major healthcare policy shifts due to ageing populations, and socioeconomic and structural changes, which are occurring worldwide, and are seeking integrated policies to include healthcare demands of the older generation. Our CSF may contribute an empirical and theoretical explanation to the existing knowledge base. Incorporating the blended CSF in making policies and programmes can shift the dominant biomedical perspective, as well as societal and cultural perspectives, into an integrated model that ensures adequate primary healthcare for disadvantaged populations, particularly in low/middle-income countries.

Acknowledgments

We are thankful to Professor Jennene Greenhill, Professor M. Rezaul Islam, Professor Shafiqur Rahman Chowdhury for their valuable feedback on the paper. Also, thanks go to Dr Abraham Kuot and Elspeth Radford for reading the manuscript and contribute to the readability improvement.

Contributors: MH accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. MH made substantial contributions to conception and design, acquisition and interpretation of data, drafted the initial manuscript and revising it critically for important intellectual content. AD-B made substantial contributions to conception, design and critical contribution to the manuscript. WA contributed to the conception, design and critically revised the manuscript for important intellectual content. AF revised the manuscript and provided important intellectual content on critical realism.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Consent obtained directly from patient(s)

Ethics approval

This study is approved by Social and Behavioural Research Ethics Committee of Flinders University (Project No. 6705). Participants provided written consent.

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• Elizabeth McGibbon St. Francis Xavier University
• Sionnach Lukeman St. Francis Xavier University

There is increasing urgency to enact critical perspectives in the profession of nursing, with a resurgence of the political, a deliberative focus on social change, and a growing uneasiness with remaining neutral in the face of such pressing need. This analysis starts with a brief overview of critical perspectives, underscoring nursing’s complex positioning at the interface of witnessing peoples’ suffering, and the structural change necessary to address its root causes. Although witnessing may imply watching, or even bystanding, here it refers to historical and cultural meanings of witnessing as standing alongside in solidarity and action throughout the struggle for justice—bearing witness as a moral and a political obligation. Moral bystanding is described as a foundational barrier to achieving the moral imperative of critical perspectives. We conclude with pathways for cultivating and enacting a critical gaze, and a call for moral courage to systematically integrate critical perspectives in nursing. Throughout the discussion, we draw upon the work of nurse ethicists to provide important links about enacting critical perspectives as part of the moral foundation of nursing. Our intention is not to provide an analysis of the moral contexts of nursing, but rather to situate critical perspectives within the moral territory of social change, synthesizing key ideas that have direct salience for critical social justice in nursing.

Keywords: critical perspectives in nursing, critical social justice in nursing, moral bystanding, social change

Author Biographies

Elizabeth mcgibbon, st. francis xavier university.

Dr. Elizabeth McGibbon is a nationally recognized critical health scholar and nursing professor st STFX. Her teaching and research focus on embodied oppression, access to health care, health equity and public policy, and the political economy of health. She leads a national research project, Mapping Health Equity in Canadian Public Policy (SSHRC), and is co-researcher in a study aiming to diversify our dialogue and understanding of heart health of Manitoban First Nations People (CIHR, Lead: Annette Schultz). She is a founding member of the International Association for Qualitative Research and was one of three leads in the establishment of the National Collaborating Center, Determinants of Health (NCCDH).  She published the first Canadian books to address anti-racism specifically in health care practice (McGibbon & Etowa, 2009) and oppression as a social determinant of health (Edited Volume, 2012). She is an invited author in five multiple edition Canadian books about critical social science applications, particularly in the health fields; and the first book to address complexity science applications in the criminal justice system (Pycroft & Bartollas, Eds., United Kingdom, 2014). Along with social justice colleagues, her awards include recognition from The Nova Scotia Human Rights Commission (anti-racism community action), and the Canadian Armed Forces (refugee humanitarian work).

Sionnach Lukeman, St. Francis Xavier University

Sionnach Lukeman, MScN, RN, is a PhD student in Nursing at the University of Victoria. She is also an Assistant Professor at St. Francis Xavier University’s Rankin School of Nursing . Her practice background before academia was public health leadership and content expertise in healthy development. Her research program involves:  Public health services and systems, political economy of health, and the integration of social justice in nursing education curriculum.  

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Critical social theory in nursing.

Critical social theory refers to the study of differences between people as related to socially determined status, such as socioeconomics. As applied to the medical world, this social theory speculates about why certain groups of people are predisposed to physical ailments and deficiencies. The goal of critical social theory within nursing teaching and practice is to identify and reduce socially related health disparities between patients.

The origin of critical social theory can be traced to the 1920s and 1930s in Germany. Researchers and theorists at the Institute of Social Research in Frankfurt began to posit the idea that societal divisions and classes is not a naturally occurring structure, but rather historically based. In other words, social class is determined and set by events that have happened in the past. The assumption of these critical social theory researchers was that these divisions were kept in place to support the dominant group of any given society.

Critical Social Theory Nursing Science

The ideas at the origin of critical social theory can be connected to the medical field in different ways. In nursing science, the divisions between classes as described by critical social theory are expanded to include health problems, or vulnerabilities to health problems, that specific groups exhibit. Critical social theory in nursing does not attribute health vulnerabilities to the internal characteristics of a specific group, such as ethnicity, and rather attributes these vulnerabilities to external social factors.

Health Problems and Socioeconomic Factors

Eliminating socially derived assumptions about people groups within nursing science involves looking at the broader picture of health care and access to health care. An inability to access regular health care as a result of socioeconomic status can mean a lack of access to preventative measures. This can result in the onset of preventable disease and sickness at higher rates for specific demographics. For instance, many health difficulties can be traced back to a lack of access to good nutrition, which can be directly related to socioeconomic status.

Reduction of Inequality through Critical Social Theory in Nursing Science

The goal of critical social theory in nursing science education, practice and research is to establish a clear distinction between the false, socially derived assumptions that often are attached to marginalized groups and the real disadvantages and class structure that exists as a result of societal hierarchies. Once this distinction is established, nurses can work toward an actionable solution to amend these disparities. The theory also provides a framework for nursing science professionals to investigate any practices of inequality within the health care system that result from embedded assumptions. Through critical social theory, assumptions and stereotypes can be shattered and practices that reinforce inequality can be eliminated.

Communication

Nurses can use critical social theory to expose and reduce communication failures that result from assumptions and cultural misunderstandings between health care staff and patients. Reducing these communication breakdowns is a large part of building capacity for the equitable treatment of all patients, regardless of social status related to socioeconomics, ethnicity, age or gender.

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• All Business: "(Re)examing Health Disparties: Critical Social Theory in Pediatric Nursing"; Selena A. Mohammed; Jan. 1, 2006

Jocelyn Right has been writing professionally since 2008. Her work includes promotional material for a small business and articles published on eHow. She enjoys writing about issues in education, the arts, nature, health, gardening and small-business operations. Right holds a Bachelor of Arts in English and psychology and a Master of Arts in education.

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1.6 Application of Theories in Nursing Practice

Learning objectives.

By the end of this section, you will be able to:

• Explain the link between nursing theory and nursing knowledge
• Discuss how nursing theories help shape the future of nursing
• Recognize the use of nursing theory in the application of standards of nursing practice

In the dynamic realm of nursing practice, the application of theoretical frameworks guides the approach to patient care. This section delves into the multifaceted ways in which nursing theories are integrated into daily nursing practice, shaping the actions and decisions of healthcare professionals. As we explore the practical application of these theoretical foundations, we uncover the pivotal role they play in informing and elevating the standards of nursing care. From providing a structured decision-making framework to influencing ethical considerations and patient outcomes, nursing theories emerge as essential tools that bridge the gap between knowledge and practice.

Link Between Theory and Knowledge in Nursing

The link between theory and knowledge is the foundation on which the entire practice of nursing stands. Nursing theory acts as the compass that guides how nurses approach patient care. It also provides a structured framework shaping the knowledge that nurses acquire through education. This theoretical knowledge of established concepts forms the basis for understanding the complexities of health care and the unique role of nursing within it. As nurses apply what they have learned to real-life situations, the theoretical knowledge becomes experiential knowledge —it is the practical, hands-on learning that happens when directly caring for patients. This practical experience, in turn, feeds back into theoretical knowledge, enriching and shaping it based on the real-world scenarios encountered. The interplay between nursing theory and knowledge is dynamic and continuous, creating a cycle that ensures theoretical understanding evolves with the practical realities of patient care. This connection highlights the importance of a well-rounded, dynamic approach to knowledge that encompasses both theory and hands-on experience.

Theoretical Knowledge

Nursing theory and theoretical knowledge are interconnected and mutually beneficial. The link between them is integral to the development and advancement of the nursing profession. Nursing theory provides a framework for understanding and organizing knowledge within the field, guiding nursing practice, education, and research. Theoretical knowledge encompasses the concepts, principles, and models derived from nursing theories. These theories serve as the foundation for guiding nursing practice, influencing the way nurses approach patient care and fostering a deeper understanding of the nurse’s role.

Theoretical knowledge in nursing, derived from nursing theories, empowers nurses with a structured framework for critical thinking, enabling them to make informed decisions and provide holistic care . This knowledge not only informs nursing education, in which students learn the principles and concepts that underpin the profession, but also facilitates ongoing research efforts. Nursing theories guide research design, hypothesis formulation, and results interpretation, contributing to the growth of EBP. Moreover, the link between nursing theory and theoretical knowledge is essential for nurturing a professional identity among nurses, emphasizing the unique contributions of nursing to health care. As healthcare landscapes evolve, this theoretical foundation helps nurses adapt to new challenges while maintaining the core principles of the profession, ultimately enhancing the quality of patient care and the professionalism of the nursing field.

Experiential Knowledge

The link between nursing theory and experiential knowledge is dynamic and integral to providing safe and effective care. Imagine nursing theory as a roadmap for understanding and guiding patient care. Theoretical knowledge, born from these theories, is the foundational understanding gained through education, offering nurses a structured framework for practice. As nurses apply these theories in real-life scenarios, theoretical knowledge transforms into experiential knowledge—a hands-on, practical understanding gained through patient interactions and clinical experiences. The link between nursing theory and experiential knowledge is a dynamic loop, in which theoretical understanding both informs and evolves through hands-on experience, ensuring nursing knowledge remains adaptable and responsive to the ever-changing landscape of health care.

Reflective Skills

The connection between nursing theory and reflective skills is pivotal in fostering a culture of continuous learning and improvement within the nursing profession. Reflective skills involve the ability to critically analyze and thoughtfully contemplate one’s own experiences, actions, and decisions and then learn from them. The application of nursing theory in practice provides a rich source of experiences for nurses to reflect on. Through reflective practices, nurses can assess the alignment of their actions with theoretical principles, identify areas for improvement, and refine their approaches to patient care. This reflective process enhances self-awareness, encourages critical thinking, and contributes to ongoing professional development.

The synergy between nursing theory and knowledge gained from reflection allows nurses to bridge the gap between theory and practice, fostering a deeper understanding of the complexities inherent in healthcare delivery. As nurses engage in reflective practices, they not only refine their clinical skills but also contribute to the evolution of nursing theories by providing real-world insights and feedback. This iterative relationship between nursing theory and reflective knowledge ultimately promotes a culture of continuous improvement, ensuring that nursing practice remains evidence based, person centered, and adaptable to the ever-changing landscape of health care.

Shaping the Future Development of Nursing

Nursing theories are guiding forces that shape the future development of nursing, contributing to the profession’s evolution and ensuring its continued relevance in dynamic healthcare landscapes. These theoretical frameworks play a crucial role in defining nursing as a profession, providing a conceptual roadmap that delineates the unique identity and contributions of nurses within the healthcare spectrum. Simultaneously, they guide the establishment of professional limits and ethical boundaries, maintaining the integrity and trustworthiness of nursing practice. Additionally, nursing theories direct the recommendations for future education, ensuring that curricula and learning strategies align with the evolving needs of health care and equip nurses with the knowledge and skills required for contemporary practice. Furthermore, these theories inform the development of practice guidelines, guiding nurses in delivering person-centered care while navigating technological advancements and ethical considerations.

Defining Nursing as a Profession

Nursing theories play a pivotal role in shaping the future of nursing by contributing to the definition of nursing as a distinct and evolving profession. These theoretical frameworks provide a conceptual foundation that extends beyond the technical aspects of patient care, offering a philosophical understanding of the nursing role. By delineating the fundamental principles and values inherent in nursing practice, theories serve as a guidepost for current and future nurses, shaping their professional identity. They emphasize not only the acquisition of clinical skills but also the importance of empathy, advocacy, and holistic patient care.

Nursing theories also contribute to the nursing profession by articulating the unique body of knowledge that constitutes the nursing profession. This body of knowledge encompasses not only clinical expertise but also the ability to navigate the intricate dynamics of the nurse-patient relationship and the broader healthcare context. As nursing adapts to advancements in technology, changes in healthcare delivery, and evolving patient needs, nursing theories provide a stable foundation, ensuring that the essence of the profession remains rooted in its foundational values.

Professional Limits and Boundaries

Nursing theories play a crucial role in shaping the future of nursing by providing a framework that helps delineate professional limits and boundaries. These theoretical frameworks establish ethical guidelines and standards that guide nurses in navigating complex situations and making decisions within their scope of practice . By emphasizing the importance of ethical considerations, patient autonomy , and confidentiality , nursing theories contribute to defining the boundaries of professional conduct. As health care evolves and technology advances, nursing theories help establish limits on the integration of new practices and technologies, ensuring that ethical principle s and patient safety remain at the forefront.

Additionally, nursing theories assist in clarifying the collaborative nature of health care and the boundaries between different healthcare professions. They provide a foundation for interdisciplinary collaboration, defining the unique contributions of nursing within the broader healthcare team. This collaborative understanding is essential for shaping the future of nursing as healthcare systems become increasingly integrated and team oriented.

Nursing theories also contribute to the ongoing development of ethical guidelines and policies that regulate the profession. By engaging with ethical frameworks, nurses are better equipped to address emerging ethical challenges, set professional limits, and advocate for the well-being of their patients. This proactive approach to defining professional limits ensures that nursing remains a trusted and ethical profession in the face of evolving healthcare landscapes.

Directing Future Education Recommendations

Nursing theories significantly influence the future of nursing by serving as guiding principles for directing education recommendations. These theoretical frameworks contribute to the ongoing development and refinement of nursing education by providing a structured foundation for curricula and educational programs. By incorporating nursing theories into educational strategies, educators can impart not only technical skills but also a deeper understanding of the profession’s underlying values and principles. Nursing theories guide the identification of essential competencies, shaping the educational landscape to align with the evolving needs of health care.

In addition, nursing theories contribute to the creation of educational pathways that emphasize critical thinking, cultural competence, and ethical decision-making. As the healthcare environment becomes increasingly complex, these theoretical foundations help educators prepare future nurses to navigate diverse patient populations, emerging technologies, and evolving healthcare systems. The integration of nursing theories into education recommendations ensures that students are equipped not only with practical skills but also with the ability to think critically and adapt to dynamic healthcare challenges.

Additionally, nursing theories inform recommendations for continuous professional development, encouraging a lifelong learning mindset among nurses. By emphasizing the importance of staying abreast of theoretical advancements and incorporating EBPs, nursing theories guide education recommendations that foster a culture of continuous learning. This approach ensures that nurses are prepared to meet the changing demands of health care and contribute meaningfully to the advancement of the profession.

Directing Future Practice Guidelines

Nursing theories exert a profound influence on the future of nursing by directing and shaping the practice of the profession. These theoretical frameworks provide a structured foundation for nursing practice , guiding the delivery of person-centered care, and influencing the development of evidence-based protocols. By incorporating nursing theories into practice, nurses gain a deeper understanding of the philosophical underpinnings of their profession, leading to more thoughtful and intentional caregiving.

Nursing theories also contribute to the evolution of future practice by emphasizing holistic and patient-focused approaches. As the healthcare landscape continues to evolve, nursing theories guide practitioners in recognizing the importance of addressing not only the physical needs of patients but also their psychological, social, and cultural dimensions. This holistic perspective fosters a more comprehensive and compassionate delivery of care, aligning with the changing expectations and demographics of healthcare recipients.

Moreover, nursing theories inform the integration of technology and innovation into practice while maintaining ethical standards. As healthcare technologies advance, these theoretical foundations help nurses navigate the ethical considerations of incorporating new tools and interventions, ensuring that patient safety and well-being remain at the forefront of practice.

Additionally, nursing theories contribute to the professional autonomy and decision-making abilities of nurses. By offering a theoretical framework, these theories empower nurses to critically assess situations, make informed decisions, and advocate for the best interests of their patients. This empowerment is crucial for shaping the future of nursing practice in a healthcare environment that demands adaptability, critical thinking, and a strong ethical foundation.

Application of Theory in Nursing Practice Standards

The application of nursing theory in nursing practice standards is a fundamental aspect that enriches and informs the delivery of high-quality patient care. Nursing theories provide a theoretical framework that guides the development and refinement of practice standards, ensuring that they align with the profession’s core values and principles. By incorporating nursing theories into practice standards, healthcare organizations and professionals establish a solid foundation for decision-making, care planning, and evaluation of outcomes. For instance, a theory emphasizing person-centered care may influence practice standards to prioritize individualized and holistic approaches to patient care. Furthermore, nursing theories contribute to the establishment of ethical guidelines within practice standards, guiding nurses in navigating complex ethical dilemmas and upholding the integrity of the profession. This integration of theory into practice standards not only elevates the overall quality of care but also fosters a shared understanding among healthcare professionals, reinforcing a commitment to evidence-based and theoretically informed practice.

Clinical Safety and Procedures (QSEN)

Linking nursing theories to patient safety.

The QSEN initiative plays a crucial role in enhancing clinical safety and promoting excellence in patient care. The QSEN focuses on integrating essential competencies into nursing education and practice to ensure that nurses are equipped to deliver safe and high-quality care. When examining the link between nursing theories and clinical safety within the QSEN framework, it becomes evident that theoretical foundations contribute significantly to shaping nurses’ understanding of safety principles, risk mitigation, and delivery of patient-centered care.

• Integration of EBP: Nursing theories serve as the backbone for EBP, a fundamental component of QSEN. Theoretical frameworks guide nurses in critically evaluating evidence, making informed decisions, and implementing best practices to enhance patient safety. The integration of nursing theories into education ensures that nurses understand the theoretical underpinnings of evidence-based care, promoting a culture of continuous improvement and patient safety.
• Patient-centered care: QSEN emphasizes patient-centered care as a key competency, aligning with many nursing theories that prioritize holistic and individualized approaches. Theoretical perspectives such as Watson’s theory of human caring or Peplau’s theory of interpersonal relations provide a foundation for understanding the importance of establishing meaningful nurse-patient relationships, communicating effectively, and addressing patients’ unique needs. This theoretical grounding contributes to safer and more patient-focused clinical practices.
• Teamwork and collaboration: Nursing theories that highlight the collaborative nature of health care, such as Roy’s adaptation model or Orem’s self-care deficit nursing theory, align with QSEN’s focus on teamwork and collaboration. Theoretical frameworks guide nurses in understanding their roles within interdisciplinary teams, fostering effective communication, and promoting a collaborative approach to patient care. This integration enhances clinical safety by ensuring clear communication and coordination among healthcare team members.
• Safety competencies: The QSEN identifies safety as a core competency, and nursing theories provide the theoretical basis for understanding the principles of safety in health care. Theoretical perspectives, such as Leininger’s culture care theory or Henderson’s nursing need theory, contribute to nurses’ understanding of factors influencing patient safety, including cultural considerations and meeting patients’ basic needs. This theoretical knowledge informs safe and culturally competent care delivery.
• Informing continuous quality improvement: Many nursing theories emphasize the importance of continuous quality improvement, aligning with QSEN’s commitment to ongoing enhancement of healthcare practices. Theoretical foundations guide nurses in critically assessing their actions, reflecting on patient outcomes, and implementing changes to improve care processes. This integration supports a culture of continuous learning and adaptation, contributing to sustained clinical safety improvements.
• Informatics integration: Nursing theories contribute to the integration of informatics skills, aligning with QSEN’s focus on informatics competency. Theoretical frameworks guide nurses in understanding how to use information and technology to support decision-making, enhance communication, and improve patient outcomes. The theoretical grounding in informatics ensures that nurses can navigate and utilize health information systems effectively, promoting safe and efficient care practices. This integration supports QSEN’s goal of preparing nurses to use technology and information systems to deliver and enhance patient care while aligning with theoretical perspectives that emphasize the role of technology in health care.

Decision-Making Framework

The application of nursing theory as a decision-making framework is a cornerstone of effective and person-centered care. Nursing theories provide a structured and comprehensive foundation that guides nurses in making informed decisions across various healthcare scenarios. These theoretical frameworks help nurses analyze situations, understand patient needs, and prioritize care based on established principles. For instance, a nursing theory emphasizing the importance of environmental factors may prompt a nurse to consider how the individual’s surroundings impact their well-being.

Moreover, theories focused on the nurse-patient relationship contribute to decision-making by highlighting the significance of communication, empathy, and collaboration. By integrating nursing theory into their decision-making processes, nurses can ensure a more holistic approach that encompasses not only the physical aspects of care but also the psychological, social, and cultural dimensions. This application of nursing theory serves as a valuable tool for enhancing critical-thinking skills, fostering ethical decision-making, and elevating the overall quality of patient care.

Directing Future Research

The application of nursing theory plays a pivotal role in guiding and shaping future research endeavors within the nursing field. Nursing theories provide a conceptual framework that informs the identification of research priorities, the formulation of research questions, and the interpretation of findings. By grounding research in established nursing theories, researchers can build on a solid theoretical foundation, ensuring that studies align with the core principles and values of the profession.

Additionally, nursing theories offer a lens through which researchers can explore and understand complex phenomena, guiding the development of hypotheses and conceptual frameworks. For example, a nursing theory emphasizing patient empowerment may direct research efforts toward interventions that enhance patient engagement in their care. This application of nursing theory not only contributes to the generation of new knowledge but also ensures that research outcomes are relevant and applicable to the practical realities of nursing practice . As nursing continues to evolve, the integration of nursing theory in research remains instrumental to advancing the profession’s evidence base and promoting EBP.

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• Authors: Christy Bowen, Lindsay Draper, Heather Moore
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• Book title: Fundamentals of Nursing
• Publication date: Sep 4, 2024
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Critical social framework on the determinants of primary healthcare access and utilisation

Author affiliations

Anita De-Bellis 2 ,

Wendy Abigail 2 ,

Amber Fletcher 3 .

This paper aims to contextualise ‘healthcare access and utilisation’ within its wider social circumstances, including structural factors that shape primary healthcare for marginalised groups. Mainstream theories often neglect complexities among the broader social, institutional and cultural milieus that shape primary healthcare utilisation in reality. A blended critical social framework is presented to highlight the recognition and emancipatory intents surrounding person, family, healthcare practice and society. Using the theoretical contributions of Habermas and Honneth, the framework focuses on power relationships, misrecognition/recognition strategies, as well as disempowerment/empowerment dynamics. To enable causal and structural analysis, we draw on the depth ontology of critical realism. The framework is then applied to the case of rural elderly women’s primary healthcare use in Bangladesh. Drawing on the literature, this article illustrates how a blended critical social perspective reveals the overlapping and complex determinants that affect primary healthcare utilisation, before concluding with the importance of situating healthcare access in sociocultural structures.

• Introduction

Recognition and emancipation are connected to equitable and participatory, patient-centred primary healthcare. Access to and utilisation of healthcare generally means the availability of treatments, timely and appropriate treatment, and adequate delivery of services, and in the science of primary healthcare implementation, the emerging concepts are recognition and emancipation of people. 1 2 Since the 17h century, there has been debate between biomedical and social scientific theories on the conceptualisation of health and healthcare. 3 4 At early stage, medical scientists related health to treatment, which changed when researchers started explaining healthcare using sociological models. 5–8 This social scientific perspective is supported by biomedical scientists who acknowledge that there are vital aspects of primary healthcare, for example, recognition of patients’ needs, preferences and presence; emancipation in participation; and shared decision making, that can only be studied by social sciences, such as social determinants of health. 9 This paper contextualises a need for a critical social lens into healthcare access, and proposes a critical social framework (CSF) with methodological application to improve primary care support for disadvantaged people.

There are five major paradigms in biomedical and social sciences— biomedical, biopsychosocial, integrated healthcare, health beliefs and social determinants of health—each of which views healthcare challenges differently. Each model has been developed around the four components of philosophy, structure, process and outcomes. A move from biomedical science to a social determinants of health approach indicates an increase in diversity of philosophies and principles available to accommodate the complexities of healthcare. However, primary healthcare remains inadequate due to lack of conceptualisation of social structures and care accessibility, especially for the underprivileged population groups, for example, rural people, older adults and indigenous people. 10

The terms ‘psychosocial determinants’ or ‘social determinants’ or ‘downstream and upstream determinants’ are interchangeably used to contextualise an emerging study field of ‘healthcare access and utilisation’. This field acknowledges a variety of care system and social circumstances, such as prevention, health communication, rehabilitation, education, poverty and housing, for example, which combine to affect health and care access. 10 Within a growing academic movement towards better inclusion of determinants not acknowledged by mainstream approaches, there have been reviews of ‘causes of the causes’ surrounding health and social practices and the exploration of new factors, 11–13 such as human interactions, recognition, and emancipation. Consideration of deep causes and power structures align with a more critical approach to understand accessibility. Existing literature supports the importance of investigating power differences and personal characteristics in any health facility, family and society. 14–17 However, application of critical social science in investigating health determinants is complex in either its conceptualisation or actualisation. Several paradigms have been developed in describing healthcare, and there are debates concerning where and how to explore the determinants and their impact on primary care utilisation.

In this paper, we argue that mainstream paradigms and their determinants lack critical engagement with social structures and processes that shape accessibility and outcomes. Drawing on the strengths and limitations of mainstream healthcare paradigms—and positing the importance of a critical social approach informed by the work of Habermas, Honneth and Bhaskar—we develop a theoretical framework for critical analysis of issues in primary healthcare—a CSF. The proposed CSF is developed through a synthesis of existing theoretical approaches; it accounts for social, economic, political and cultural structures and processes that often reflect deeply engrained power differences, misrecognition and marginalisation, while also describing the exploitation of disadvantaged population groups. The causes of poor care accessibility can be seen critically through unpacking and problematising each of the places, events and interactions accounting for the circumstances. 18 19 Based on critical social science, in order to provide a scoping reassessment of existing modes and limitations of the prevailing approaches, the CSF helps to inform a multilayered analysis of primary care for marginalised people. After introducing the CSF, we then apply it deductively to an existing qualitative study of rural elderly women in Bangladesh ( box 1 : A case), which was conducted by the first author. Through this case study, we apply and assess the utility of the CSF and examine its relevance to primary care practice.

A case—rural elderly women’s primary healthcare access in Bangladesh (Hamiduzzaman 2018)

The elderly population is increasing in Bangladesh. 50 For women in particular, increased longevity coupled with high rates of chronic illness and disability cause specific health needs that have yet to be adequately addressed through primary care services. 51 52 Further, over 70% of elderly women live in rural areas and these women are less likely than their urban counterparts to seek primary care. 2 Primary health is expected to be their first point of contact that would cover their care, that is, health promotion, prevention, early intervention, treatment of acute conditions, and management of chronic condition, which are not related to a hospital visit. However, only one rural woman in every 1000 seek primary care and their community clinics visit rate is as low at 5% of all visits. 53 In Bangladesh, a pluralist primary care system exists (ie, public, private, and traditional lay treatment options) in rural areas with a disparity in accessing services and poor satisfaction in care support. 54 Rural women are highly dependent on traditional healing and home remedies provided by semiqualified healers or family members. Limited healthcare utilisation by rural elderly women in this context is shaped by interacting socioeconomic, cultural and political structures. Existing research by the lead author and others noted the significant role of cultural recognition and emancipation in shaping accessibility, 44 55–57 as the women tend to downplay their own illnesses, delay treatment and depend on lay or traditional healers who may exploit them and/or provide inappropriate care. Other interconnected barriers for their access include lack of services in rural places; low levels of education and health literacy; and gendered economic inequality—for example, Muslim women inherit only 1/8 of a deceased husband’s property and married Hindu women are not entitled to inherit their parents’ property. 58 59 Public income supports for this group are extremely lacking. 59 The combination of sociocultural, economic and institutional inequalities that shape rural elderly women’s primary healthcare access and outcomes in Bangladesh can be best analysed through a critical social science.

• The present healthcare paradigms

With its origins in western positivism, biomedical science is currently the dominant paradigm to understand personal illness and disease, with two perspectives on treatment: clinical and epidemiological. 6 While the clinical perspective focuses on the diagnosis of disease and cures for patients, the epidemiological perspective emphasises the prevention of disease so that action can be taken to avoid deterioration. 20 This paradigm often defines the reasons for illness and diseases from a mechanistic outlook without considering socioeconomic aspects. 6 21 As such, this model de-emphasises consideration of such factors as the places a person lives and grows as potentially relevant to her/his illness. Koster et al argue that the biomedical paradigm is no longer adequate to explore risk factors that have an impact on healthcare usage. 21 Although biomedical science is theoretically and practically established, as well as normatively engrained, it has limited value in accounting for the dynamics of healthcare when access to and utilisation of care becomes difficult due to a lack of services, social marginalisation and inequality, or poor socioeconomic circumstances.

A biopsychosocial paradigm emerged as an extended version of the biomedical perspective with the aim of describing healthcare from a patient’s biological, psychological and social context. 22 However, this paradigm remains limited in describing the relationships among mind, body and socioeconomic status of a person. 23 It highlights the need to consider the effects of psychosocial conditions on an individual, including her/his religious beliefs, work history and previous incidents, for example. Although this approach is considered a means to include social characteristics, it does not provide any direction about which social factors need to be considered along with the psychological and biological factors and, as a result, fails to suggest practical solutions to resist the medicalisation of care. 23

The integrative healthcare paradigm is a recent addition in biomedical science that focuses on the collaboration of conventional and complementary medical care. This paradigm has been developed based on biological and ecological perspectives, with emphasis on care philosophies, organisational complexity, clinical interactions and other aspects of well-being. 24 Mann et al suggest seven dimensions of integrated healthcare including informed clinician, networking clinician, complementary clinician, multidisciplinary group practice, hospital-based integration and integrative care within an academic field. 25 Another leading perspective in the integrative healthcare paradigm, the ‘complex system measure’, suggests discussing the illness of a person in a complex and dynamic system. While this paradigm provides a focus on healthcare integration among different types of health professionals and practices, the central aspects of patient’s life such as healthcare, emotion, cultural and spiritual needs are less fully considered. Thus, it becomes difficult to explain how health beliefs and behaviours are embodied in a socioeconomic context that also affects care accessibility and utilisation. 26

In primary healthcare research, the health beliefs and behavioural paradigm appeared from a social scientific stance to guide the investigation of relationships between personal beliefs, characteristics and care seeking behaviours. 27 Different models in this paradigm provide an understanding about the particular aspects that each person possesses in seeking care. However, these models lack focus on functional system and do not consider that access is also an issue of complex healthcare policy and system measures. 28 They do not explain how health beliefs and behaviours are rooted in specific sociocultural values of a society. In addition, this perspective is limited in describing the intersections among the determinants where the transformation from potential to realised healthcare access occurs. 8

The social determinants of health paradigm of WHO (2000) investigates healthcare within the context of larger socioeconomic, political and cultural contexts. 29 This paradigm describes healthcare according to health behaviours, system and socioeconomic structures and functions that shape the milieu in which people live. 29 Further categorising social determinants into downstream and upstream determinants provides an understanding of the vertical relationships among the social and healthcare forces. Although each of the determinants have significance based on sociocultural and political realities that emerge horizontally in specific circumstances, these contextual realities were not considered in developing the paradigm. Moreover, the relationships and interactions in health settings and in society emerged as important aspects for accessing healthcare, but the social determinants of health paradigm does not address these issues. 30 Despite this challenge, recent literature has noted that ‘very few public health experts have questioned the Social Determinants of Health theoretical approach itself’. 31 Accordingly, Frank et al outlined the model’s limitations for considering complex problems, relations of power and privilege, and agency at the individual level—thus indicating the importance of both structural and contextual factors. 31

There are two major drawbacks in the current paradigms ( table 1 ). First, these paradigms tend to downplay the dynamics of relationships and interactions inherent in healthcare access. 32 33 Second, each model conceptualises healthcare from a static point of view as an ideal platform and does not consider how to explore the determinants in everyday healthcare and sociocultural settings. 2 In addition, primary healthcare is country-specific and diverse in relation to their focus and capacities; for example, WHO (2015) identified that rapid ageing places low/middle-income countries at risk of not coping with the challenges in aged care compounded by the country’s primary care policies. 10 Critical social science has scope to add a sociocultural and political understanding, such as rural elderly women’s primary care access and utilisation.

• Designing a CSF and its methodology

A CSF, informed by the Frankfurt School of Critical Theory and CR ontology, helps expose the exploitative circumstances that people face because of power structures and their complex inter-relationships exist in a society. 34 This perspective draws attention, for example, to the socioeconomic structures that operate to oppress some people while privileging others in a systematic manner. Contemporary critical sciences—which focus on redistribution, equality, emancipation and the recognition of human beings—help reveal the realities of inequitable access conditions for elderly people. 10 A blended CSF drawing from critical theories of Jurgen Harbermas and Axel Honneth is proposed to address the issues of emancipation and recognition inherent in primary healthcare. 18 19 35 36 The addition of a depth ontology drawn from CR (eg, Bhaskar 1979), supplements these foci with attention to structural dynamics that cause interactions at multiple levels, including relations of emancipation and recognition.

The Theory of Communicative Action developed by Habermas focuses on emancipation for disadvantaged persons. 18 19 Habermas introduced a society as a lifeworld including objective, subjective and social worlds that are overlapping with each other. These worlds have potential in describing an individual’s communication and emancipation in service utilisation, connection to their personal, institutional and social structures and cultures. 19 The objective world describes a social actor (a health professional or a patient) who can understand and change existing natural and social structures. 18 It focuses on the patients’ care needs, prevention or early intervention, as well as context-specific treatment and rehabilitation. 37 The subjective world describes the personal characteristics of a social actor and the totality of their experiences and practices such as behaviours, feelings, values and beliefs that influence their competencies in accessing healthcare. These subjective issues are often reflected in cultural and traditional artefacts or in organised institutions and systems. 37 Habermas also described a social world through which an actor regulates her or his membership in social groups and structures. 19 This world is related to the social and institutional order in society such as gender, social class and economic status. This ordered social and or institutional context sets the mode of social interactions and establishes expectations of interpersonal communication, potentially creating a communicative hierarchy among disadvantaged person, healthcare system, and society.

In combination, the three-world concept is a fundamental categorical scaffold that can direct a problematic situation of any society, such as rural elderly women’s care accessibility and usage. The concept presents an abstraction of ideas, for example, healthcare system, provider–patient communication, knowledge of actors, personal beliefs and behaviours and socially ordered interactions. However, there are some limitations in this theory: (1) it does not clarify the ideal situation of an emancipatory society 37 ; (2) it ignores the capacity of a social actor and how they can meaningfully act in an oppressed situation 37 ; (3) while the relationships are identified as important, the issue of relationship remains ignored in the theorisation 2 and (4) does not fully consider ontology and causation. More specifically, the approach thus far neglects the emergent effects of pervasive social structures that exist at multiple levels, and therefore, does not allow for identification of specific causal factors that substantially shape people’s access to, and experience of, healthcare. These limitations in Theory of Communicative Action can be addressed by considering additional sources—the Theory of Recognition developed by Honneth and a Critical Realist philosophy of science, as originally articulated by Bhaskar—to further explain issues in healthcare. 38 39

The Theory of Recognition suggests that a person’s identity is intertwined with societal recognition. There are three domains of recognition identified: intimate relationships, legal framework and community. 35 Intimate relationships include both intimate and family relationships, which contribute to the development of mutual respect and positive attitudes to each other through the recognition of a person’s needs. 36 The second domain includes legal relationships or structures that define the rights and responsibilities of a person. For example, freedom from discrimination and misogyny may lead to the development of self-realisation and self-respect for a social actor, allowing them to view themselves as a legally responsible social being with a role to play in society. 40 This form of relationship also generalises the responsibilities of a health professional to respect and validate the needs and rights of persons. Third domain, community recognition, pertains to a person’s participation in social structures and activities, which involves shared values and mutual respect. 36 Community recognition can result in increased self-esteem for the individual, and potentially even models of care that encourage active participation in social and healthcare systems.

The Theory of Recognition has value in the discussion regarding recognition of oppressed or marginalised people. However, it encounters three limitations: (1) ignorance of gender inequality and the role of gender in the economic structure of family and society 41 ; (2) a lack of focus on reconstruction processes of family and social structures and relationships 42 and (3) the ongoing challenge of identifying structures that contribute in a casual manner to the experienced marginalisation, both within and beyond the healthcare context. Complex and pervasive sociopolitical structures and systems, patriarchy, for example, are relevant for understanding primary healthcare utilisation. The philosophies and domains of the two theories discussed thus far (Theory of Communicative Action and Theory of Recognition) have a mutual agreement for contextualising access to primary healthcare within the realms of emancipation and recognition. Their mutual focus on the intricacies of power relations, discrimination, and misrecognition in healthcare, social and individual spheres offers a new dimension to understand the determinants and the dynamics in healthcare access and utilisation.

Working towards a blended CSF, figure 1 illustrates the categorisation of six concepts into three spheres, which constitute the subject matter domains of the model. These spheres—all of which should be considered for a holistic analysis—include: (1) knowledge, beliefs and behaviours, as well as support in family relationships under the individual sphere; (2) institutionalised care and rights and responsibilities under the healthcare sphere and (3) socioeconomic status, patriarchy and other power hierarchies under the social sphere.

Spheres of a blended critical theoretical framework to contextualise rural elderly women’s access to healthcare.

Despite usefully mapping the domains of analysis, the model thus far lacks fulsome engagement with ontology and causation, which is necessary to examine the full reality of primary healthcare. Drawing from a critical realist philosophy, relations of recognition, emancipation and other aspects of healthcare access are seen to be governed by a particular combination of structural and contextual factors that cause events to occur as they do. 39 While the two aforementioned theories do engage with aspects of social context beyond the micro level of interaction or interpretation (Honneth’s community and Habermas’s objective world, eg), there is a need to consider how social structures and deeply rooted power relations contribute to the manifestation of certain outcomes. This kind of methodological analysis is facilitated by a critical realist philosophy, through which the two theories can be deployed.

As a philosophy of science, critical realism asserts a realist ontology (ie, there is a reality) and relativist epistemology (ie, there are multiple ways of knowing and explaining the reality). Reality, in this view, is deep and multilayered. 38 39 The empirical analysis is the realm of experience, interpretation, and perception, where events are understood through the views of people. Moving deeper, the actual level contains the entirety of the event, whether or not it is understood or perceived. Finally, the real level is the domain of deeply rooted structures and their mechanisms which, if activated in a context, can have an effect at the other levels of reality. In the context of primary healthcare implementation, the addition of a critical realist philosophy allows empirical and theoretical analysis through attribution to causal structures and mechanisms that exist within and shape, the various worlds identified by Habermas and Honneth. Like critical theories, critical realism emphasises the goals of explanation and emancipation, 43 including identification of structures that cause lack of recognition. At the same time, the critical realist approach usefully asserts an ontological reality on which critiques can be based and alternatives evaluated.

Drawing on the fully developed blended CSF, which considers not only the conceptual spheres but also structures and causal relationships ( figure 2 ), this paper now focuses on the application of such a framework to the issue of rural elderly women’s primary healthcare in Bangladesh.

Causal relationships among the determinants of rural elderly women’s healthcare access.

• Studying the case: applying the CSF for primary healthcare actions

As noted previously, evidence shows that utilisation of primary healthcare is low among rural elderly women in Bangladesh. The data analysed in this paper stem from a study by the first author. 2 Here, we apply the CSF to consider what is practically happening in this healthcare context, including interactions and practices, as well as broader social, economic and/or cultural structures that shape or determine these interactions. Therefore, a multilevel causal analysis is required. By integrating the spheres of analysis ( figure 1 ) into a depth ontology informed by critical realism ( figure 2 ), a critical methodological analysis of the women’s healthcare challenges can be developed. In this applied example, we consider the various components of the phenomenon moving from the empirical level to real/causal and present them in three spheres of CSF, using empirical data excerpted from the first author’s study.

Individual sphere (knowledge, individual beliefs, behaviours and relationships)

Rural elderly women’s healthcare access and utilisation is immediately affected by individual-level knowledge, beliefs and behaviours. 16 17 These beliefs and behaviours are, in turn, influenced by communication, interaction, and relations of recognition of needs. For example, insufficient education for women due to ingrained patriarchal ideologies (lack of recognition) affects the women’s knowledge and ability to interact with health professionals and seek information and appropriate care, thus affecting how they are treated in healthcare centres. We believe knowledge makes a woman an active social actor with general understanding, systematic explanation skills and decision-making capacity. Therefore, at this level, education may enable the women to access health information and assist them in choosing and accessing healthcare. Enhanced knowledge and (by extension) increased recognition of the women may also help the professionals to be more accountable and responsible in structuring practice for underprivileged groups like rural elderly women. Our CSF highlights a role for healthcare management and professionals in generalising primary care knowledge. It can also lead to improvements in relations of communication and recognition between care providers and client, as the care provider may come to understand and even help mitigate the barriers their clients face.

Examples of empirical data

I wanted to attend school, but could not continue after sixth grade. My parents were not educated, and priority was given to my brothers. My parents wanted to ensure all facilities for my brothers in terms of schooling. Also, village people were against female education on that time. (Rural elderly woman)

I do not see a doctor until my health problems become severe. I did not see a doctor since I started living in this place. I went three times in my life to see a doctor when I failed to bear the pain and/or fever anymore. (Rural elderly woman)

My boys do not live with me—they work in the city and have their own families there. This is a big challenge. If my boys could help, my condition will be good. (Rural elderly woman)

We also consider the subjective world of Habermas and the intimate relationships domain of Honneth in explaining the women’s healthcare beliefs and behaviours, and contribution of family members in their limited access to healthcare. Our CSF examines personal experiences, feelings, beliefs and behaviours to characterise the limited healthcare access of an elderly woman in Bangladesh. It is noted that a person can only be an active social actor when she or he has capacity to play a role in changing the existing circumstances. Within cultural boundaries, limited education and reduced access to family income and savings, it is difficult for the women to flourish as active social actors and to access healthcare. Their care seeking behaviours are also shaped by socialised roles and expectations, which stem in turn from the deeper patriarchal social structure. These women also experience gendered discrimination in meeting daily needs, including healthcare access. 2 17 As such, men and women living in the same family experience the scarcity of resources in very different ways, where men have more rights to use materials such as money and land determined by family members’ values and practices.

Institutional sphere (institutionalised care and rights and responsibilities)

Current health policies and systems in Bangladesh are not designed to meet primary care needs commonly experienced by rural elderly women. 14 44 45 Our CSF includes empirical and theoretical analyses of healthcare policies and healthcare centres in the context of a stratified society. We argue that the critical social science understands the recognition of health needs of underprivileged persons in the context of their functional, clinical, personal and social needs that often include prevention, home care, safe travelling, skilled primary care, psychological services, therapies, social activities and rehabilitation. This perspective challenges the capacity of primary healthcare services relating to staff, equipment, and programmes in providing holistic care. Medical and allied health education and training on gerontology (eg, physiology, pathology, treatment options and preventive measures) and a professional code of ethics that guides clinicians and allied health workers to structure their rights in practice and responsibilities in providing adequate care, should be seen in the context of the health and social policies of a country such as Bangladesh. Another aim of our CSF is to support emancipation of women in seeking regular and complete care, hence, the women’s views need to be considered and valued in designing aged care policy and services.

In practice, they do not have anything because we obey the decision made by our higher authorities. As you know, we are progressing in maternal and child health … and have limited scope to ask them to change the focus. (Health professional)

I visited the community clinic and family welfare center few months ago as they are close from my home. I waited there for one hour and returned home without any medications. They suggested me to visit XXX hospital as they only provide care to children and pregnant women. (Rural elderly woman)

In local clinics, we are nothing in front of the doctors and nurses. They will provide you care when they want to, you can’t say anything. If someone wants to tell something, there is a chance of not being treated. However, there are some good doctors who called me ma [mother] and I always try to visit them. (Rural elderly woman)

one[]A deeper analysis ( figure 2 ) considers all of the aforementioned issues not only as primary healthcare barriers (and associated solutions), but as products of deeply rooted socio-cultural power structures. For example, relations between patient and care providers are affected by social classification of the professions and male dominance in medical practices in Bangladesh. 15 44 While health professionals are considered to be in positions of power, and health practices are male dominated, marginalisation is common for rural elderly women because they identify themselves as being in an inferior position which negatively influences their communications and relationships with care providers. The women are not likely to involve themselves in decisions that concern health knowledge and/or expertise, particularly when mutual trust is essential for sharing health information. 46 Further, due to patriarchal relations, the women often rely on male family members to assist them in using health services, which may limit their information sharing or may prevent them from seeking care in general.

Social sphere (socioeconomic status and power hierarchy)

The blended CSF is critical for understanding the historical development of a society (eg, economic condition and social forces and values) for women. The economic status of a woman is related to their employment, family income and savings; economic status is also shaped by financial support from the government and social organisations in Bangladesh. The women’s education is largely affected by low family and community education literacy. In this regard, we acknowledge the tenet of ‘community recognition’ to signify the importance of mutual recognition, honour and support among and between community people and local organisations for developing self-esteem for rural elderly women to enjoy social engagement and economic freedom from early childhood. The reasons of lifelong deprivation among the women in accessing recognition, education, and formal employment are explored by the blended CSF, which contributes to the positioning of a woman in society, as well as in access to primary healthcare.

My sons may give money if they have extra. As they have no extra, they do not give me anything. They have their own families. How could I see a doctor when I have no money? (Rural elder woman)

You cannot imagine how a woman’s life moves on. A woman started her life in her father’s family, and then she goes for husband’s family leaving all relationships with parents, brothers and sisters. I feel that it would be good for me if I could be born as a male in this society. (Rural elderly woman)

My husband used to take all decisions in our family. What are you talking about? Who will take the decision in my family? My elder son lives in the capital city ‘Dhaka’ and my younger son lives in our previous village. So, all the decisions were made by my husband including my healthcare. (Rural elderly woman)

I do not like to see doctors. Allah is everywhere and Allah will look after me. … If I suffer from any disease, I know that the health condition will be overcome after a certain period. (Rural elderly woman)

Power hierarchy strongly emerged in our analysis, encompassing the social order, cultural issues and practices of sociopolitical organisations in rural elderly women’s healthcare access. Drawing on critical social science, we argue power difference occurs in dialectical relationships and highlights the tensions, struggles and interplay between contrary tendencies. The social relationships and systems are, therefore, challenged by our CSF in the presence of religious values, distribution of power and political economy of social actions to understand the subject of healthcare in a traditional power structure. Religious values and practices are important in explaining the influence of male dominance at different stages of the women’s life including their lack of schooling, unemployment, low income and lack of decision making. Power is generally centralised to the people who have the economic means and position in a cultural and religious structure such as that of Bangladesh. A woman living with her husband and sons has more opportunities to share in the family income and savings than a woman living alone which, in turn, impacts access to healthcare. 12 The political economy is the basis of making policies and services of socioeconomic and political organisations where the women are seen to have limited value in terms of formal productivity. This social sphere is also related to the individual sphere because a person’s beliefs and behaviours are generally shaped in the social environment where the person is born, lives and works.

In this way, we facilitate an empirical and theoretical analysis of patriarchy, socioeconomic marginalisation and other sociocultural power structures that determine a disadvantaged person’s recognition and emancipation in primary healthcare. Our CSF incorporates the conceptual meaning of ‘society’ to explain the process of positioning of a person in social and economic circumstances that impacts access to healthcare. Further, social structures such as patriarchy or socioeconomic marginalisation can be considered basic causes of healthcare access inequality and thereby integrated into the analysis. According to Adams et al , in healthcare settings, there is an opportunity to expand critical social science to explain healthcare of oppressed populations at the professional, institutional and academic levels to ensure better access to primary care. 24 Use of our CSF in future research on healthcare access in culturally diverse social settings may require adaptation to include key spheres and structures that emerge as most relevant in a given context.

• Translating the CSF into primary healthcare practice

Here, we describe the translation of the CSF and its methodology into the Johns Hopkins Quality and Safety Research Group’s evidence into practice approach, to recognise disadvantaged people’s care needs and emancipate them to ensure equitable and participatory primary healthcare. 47 This approach has four steps. The first step is building an interdisciplinary team to summarise the evidence for a primary care intervention to achieve specific outcomes, by reviewing the extant literature to identify the access barriers and the interventions with greatest benefits. 48 In second step, the team approaches and engages all stakeholders to understand the context in which the intervention will be implemented. The team’s role is to listen carefully and discern what a disadvantaged person may gain or lose from implementing the intervention. The third step includes a development of performance measures to evaluate how often the people access and receive the recommended healthcare. 47

The final step, in which our CSF and its methodology may play a vital role in engaging the disadvantaged people and their caregivers (family and health professionals), is to design and implement a culturally tailored intervention. We encourage giving voice to the underprivileged people to identify their real-life challenges, at individual, institutional and social spheres, in relation to their healthcare utilisation (Guiding questions: table 2 ). We also suggest engaging their family caregivers and healthcare providers by sharing their stories of patient misrecognition and marginalisation, and by identifying recognition and emancipation issues at individual, institutional and social spheres for empirical analysis (Guiding questions: table 2 ). When the events and factors are understood from their views, there is a need for theoretical analysis, that is, the actual level provides an entire picture of healthcare use, and at real level, the interdisciplinary team analyses deeply rooted structures and their mechanisms to achieve a scientific perspective into where and how to intervene ( figure 2 ). We encourage the interdisciplinary team to educate all staff and provide training on cultural competence skills to support the proposed intervention, along with concise summaries of access barriers and a checklist of evidence. Designing a culturally tailored toolkit, including two components: create a checklist of care needs, and preventive and care support services, can provide a framework for improving primary healthcare access and utilisation. 49

This paper has proposed a blended CSF, which combines insights from critical theory and critical realist ontology, to examine access to and utilisation of primary healthcare at multiple levels of analysis. Acknowledging the limitations of mainstream healthcare models in conceptualising healthcare access, the authors highlight the value of CSF to understand multiple contextual and causal factors affecting primary care utilisation for marginalised populations. Focusing on recognition and emancipation, our CSF considers individual, healthcare and social spheres and ultimately identifies basic social structures that shape or determine the phenomenon of healthcare access inequality.

We suggest a new ontological and epistemological insight into human interaction and relationships, knowledge and power structures that are essentially related to a person’s access to healthcare. The process of recognition and emancipation, including institutionalisation of care, dynamics of relationships and way of interactions are often not conceptualised within a sociopolitically determined context. While the evolution of major paradigms has not adequately considered sociocultural processes and power relationships, viewing the primary healthcare of rural elderly women in Bangladesh from the blended CSF provides due attention to the institutional, professional, social, cultural and historical forces at play. At present, most low/middle-income countries are undergoing major healthcare policy shifts due to ageing populations, and socioeconomic and structural changes, which are occurring worldwide, and are seeking integrated policies to include healthcare demands of the older generation. Our CSF may contribute an empirical and theoretical explanation to the existing knowledge base. Incorporating the blended CSF in making policies and programmes can shift the dominant biomedical perspective, as well as societal and cultural perspectives, into an integrated model that ensures adequate primary healthcare for disadvantaged populations, particularly in low/middle-income countries.

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Social Theory and Nursing

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Despite noteworthy exceptions, nursing’s literature largely disregards the ways in which social and sociological theory permeates, guides and shapes research, education, and practice. Likewise, social theory’s ability to position nursing within wider structures of healthcare and educational provision is similarly and puzzlingly downplayed. The questions nurses ask and the problems they face cannot however, adequately be addressed without engaging with social and sociological theory and, to progress this engagement, contributors to this book explore how social theories are used by and might apply to nursing and nursing practice.

The book draws on a wide range of perspectives – philosophical, theoretical, empirical and political – to offer a robust and wide-ranging critique and analysis. Social Theory and Nursing is essential reading for nursing researchers, academics and educators, as well as scholars and researchers in medical sociology, medicine and allied health.

TABLE OF CONTENTS

Chapter 1 | 9  pages, introduction, chapter 2 | 12  pages, accounting for knowledgeable practice, chapter 3 | 13  pages, c. wright mills and the sociological imagination, chapter 4 | 13  pages, nursing theory, social theory, and philosophy of science, chapter 5 | 13  pages, on cow-tapulting and raised drawbridges: an argument for strategic integration of social theory into nursing, chapter 6 | 15  pages, social and sociological theory: reimagining nursing’s disciplinary identity, chapter 7 | 15  pages, critical realism: a social theory for evidence-based nursing, chapter 8 | 13  pages, using theory in qualitative research: a realist perspective, chapter 9 | 15  pages, the purpose and scope of sociological theory: implications for nursing, chapter 10 | 15  pages, foucault, social theory and nursing research: a critique, chapter 11 | 10  pages, contemporary political debates, social theory and nursing practice in mental healthcare, chapter 12 | 15  pages, feminism and nursing: an un/easy alliance of silences and absences, chapter 13 | 9  pages, it’s all in the genre: sociological speculation and theorizing in the nursing literature, chapter 14 | 18  pages, lies, damned lies and stories: nursing, narrative, numbers.

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What Is Nursing Theory?

3 min read • July, 05 2023

Nursing theories provide a foundation for clinical decision-making. These theoretical models in nursing shape nursing research and create conceptual blueprints, ultimately determining the how and why that drive nurse-patient interactions.

Nurse researchers and scholars naturally develop these theories with the input and influence of other professionals in the field.

Why Is Nursing Theory Important?

Nursing theory concepts are essential to the present and future of the profession. The first nursing theory — Florence Nightingale's Environmental Theory — dates back to the 19th century. Nightingale identified a clear link between a patient's environment (such as clean water, sunlight, and fresh air) and their ability to recover. Her discoveries remain relevant for today's practitioners. As health care continues to develop, new types of nursing theories may evolve to reflect new medicines and technologies.

Education and training showcase the importance of nursing theory. Nurse researchers and scholars share established ideas to ensure industry-wide best practices and patient outcomes, and nurse educators shape their curricula based on this research. When nurses learn these theories, they gain the data to explain the reasoning behind their clinical decision-making. Nurses position themselves to provide the best care by familiarizing themselves with time-tested theories. Recognizing their place in the history of nursing provides a validating sense of belonging within the greater health care system. That helps patients and other health care providers better understand and appreciate nurses’ contributions.

Types of Nursing Theories

Nursing theories fall under three tiers: grand nursing, middle-range, and practical-level theories . Inherent to each is the nursing metaparadigm , which focuses on four components:

• The person (sometimes referred to as the patient or client)
• Their environment (physical and emotional)
• Their health while receiving treatment
• The nurse's approach and attributes

Each of these four elements factors into a specific nursing theory.

Grand Nursing Theories

Grand theories are the broadest of the three theory classifications. They offer wide-ranging perspectives focused on abstract concepts, often stemming from a nurse theorist’s lived experiences or nursing philosophies. Grand nursing theories help to guide research in the field, with studies aiming to explore proposed ideas further.

Hildegard Peplau's Theory of Interpersonal Relations is an excellent example of a grand nursing theory. The theory suggests that for a nurse-patient relationship to be successful, it must go through three phases: orientation, working, and termination. This grand theory is broad in scope and widely applicable to different environments.

Middle-Range Nursing Theories

As the name suggests, middle-range theories lie somewhere between the sweeping scope of grand nursing and a minute focus on practice-level theories. These theories are often phenomena-driven, attempting to explain or predict certain trends in clinical practice. They’re also testable or verifiable through research.

Nurse researchers have applied the concept of Dorothea E. Orem's Self-Care Deficit Theory to patients dealing with various conditions, ranging from hepatitis to diabetes. This grand theory suggests that patients recover most effectively if they actively and autonomously perform self-care.

Practice-Level Nursing Theories

Practice-level theories are more specific to a patient’s needs or goals. These theories guide the treatment of health conditions and situations requiring nursing intervention. Because they’re so specific, these types of nursing theories directly impact daily practices more than other theory classifications. From patient education to practicing active compassion, bedside nurses use these theories in their everyday responsibilities.

Nursing Theory in Practice

Theory and practice inform each other. Nursing theories determine research that shapes policies and procedures. Nurses constantly apply theories to patient interactions, consciously or due to training. For example, a nurse who aims to provide culturally competent care — through a commitment to ongoing education and open-mindedness — puts Madeleine Leininger's Transcultural Nursing Theory into effect. Because nursing is multifaceted, nurses can draw from multiple theories to ensure the best course of action for a patient.

Applying theory in nursing practice develops nursing knowledge and supports evidence-based practice. A nursing theoretical framework is essential to understand decision-making processes and to promote quality patient care.

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The importance of critical theory to nursing: a description using research concerning discharge decision-making

• PMID: 7553447

Critical theory has emerged as an important research orientation for nursing. It provides for new and broader research questions and offers the potential to extend the knowledge base of nursing. In this paper I describe some applications of Jurgen Habermas's critical theory (1984, 1987) to nursing, using the example of my recently completed doctoral research (Wells, 1994). The theory was employed as a broad perspective for the study in which I investigated the process of decision-making concerning the discharge of elderly patients from the hospital. When data from 31 patient cases were analyzed, the process was found to be determined largely by systemic forces. Habermas's theory was key in understanding the structure of the process as a means-ends, or instrumental one, and in generating ideas for change in the conceptualization of the process of discharge decision making. Critical theory can advance nursing's understanding of the social organization of everyday practice situations and whether and how they might be reorganized.

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