Week 6: Public Health Ethics, Social Justice and Poverty 1. Social Justice vs. Market Justice Public health nurses are also guided by the principles of?market justice and social ju

CONCEPT ANALYSIS

Social justice: a concept analysis

Kelly Buettner-Schmidt & Marie L. Lobo

Accepted for publication 17 September 2011

Correspondence to K. Buettner-Schmidt:

e-mail: [email protected]tstateu.edu

Kelly Buettner-Schmidt BSN MS RN

Assistant Professor

Department of Nursing

Minot State University, Minot, North

Dakota, USA

and PhD student

Robert Wood Johnson Foundation Nursing

and Health Policy Doctoral Study,

University of New Mexico, Albuquerque,

New Mexico, USA

Marie L. Lobo PhD RN FAAN

Professor

College of Nursing

University of New Mexico, Albuquerque,

New Mexico, USA

BUETTNER-SCHMIDT K. & LOBO M.L. (2012)BUETTNER-SCHMIDT K. & LOBO M.L. (2012) Social justice: a concept analysis.

Journal of Advanced Nursing 68(4), 948–958. doi: 10.1111/j.1365-2648.2011.05856.x

Abstract Aim. This article is a report of an analysis of the concept of social justice.

Background. Nursing’s involvement in social justice has waned in the recent past. A

resurgence of interest in nurses’ roles about social justice requires a clear under-

standing of the concept.

Data sources. Literature for this concept analysis included English language articles

from CINAHL, PubMed, and broad multidisciplinary literature databases, within

and outside of health-related literature, for the years 1968–2010. Two books and

appropriate websites were also reviewed. The reference lists of the identified sources

were reviewed for additional sources.

Review methods. The authors used Wilsonian methods of concept analysis as a

guide.

Results. An efficient, synthesized definition of social justice was developed, based

on the identification of its attributes, antecedents and consequences that provides

clarification of the concept. Social justice was defined as full participation in society

and the balancing of benefits and burdens by all citizens, resulting in equitable living

and a just ordering of society. Its attributes included: (1) fairness; (2) equity in the

distribution of power, resources, and processes that affect the sufficiency of the

social determinants of health; (3) just institutions, systems, structures, policies, and

processes; (4) equity in human development, rights, and sustainability; and (5)

sufficiency of well-being.

Conclusion. Nurses can have an important influence on the health of people

globally by reinvesting in social justice. Implications for research, education, prac-

tice and policy, such as development of a social justice framework and educational

competencies are presented.

Keywords: concept analysis, health promotion, nurse roles, politics, public health

nursing, public policy, social justice

� 2011 The Authors

948 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

‘Social justice is a matter of life and death’.

Commission on Social Determinants of Health

(CSDH 2008, p. 3)

Introduction

Nursing has a long history of involvement in social justice,

although interest in it has waned in the recent past.

Nightingale (Watson 2008) and Lillian Wald (Sklar 2003,

Anderson 2007) were social justice advocates. Nightingale’s

political efforts in social and economic issues ‘kindled the

light of justice’ (Boykin & Dunphy 2002, p. 14). Fitzpatrick

(2003) questioned at what point nursing left the path of

having social justice principles and respect at its core.

Leuning (2001) stated, ‘‘The question of ‘Who suffers and

why?’ should always be in the foreground of our scholarly

discussions and in our practice’’ (p. 300). Appeals for nursing

to have a multidisciplinary social justice language (Boutain

2005) and to reinvest in social justice (Drevdahl et al. 2001)

have occurred. Social justice has been identified as the

broadest outcome in a conceptual model for nursing and

health policy (Fawcett & Russell 2001, Russell & Fawcett

2005).

The primary aim of this concept analysis is to identify

social justice’s attributes, antecedents and consequences and

to develop a synthesized definition though the use of

Wilsonian concept analysis methods based on a multidisci-

plinary literature review (Wilson 1963, Hupcey et al. 1996,

Rodgers & Knafl 2000). A secondary aim is to determine

whether or not involvement in social justice issues is

appropriate for the nursing profession and whether or not

nursing has reinvested in social justice, thereby reclaiming its

role in addressing global social injustices.

Background

Social justice took a back seat when the perspective of nurses

changed from viewing health as a social mandate to viewing

it as an individual responsibility (Boutain 2005); however,

there is a resurgence of interest in nursing’s role in social

justice issues. Watson (2008) questioned ‘a world that is

spending close to $600 billion for a war on terrorism and

little or nothing to combat poverty and provide basic child

health care for its citizens’ (p. 54). She identified poverty,

mortality rates, disease, and suffering as the ‘outer manifests

of social injustice’, stating that bioethics frames this ‘as issues

of race, ethnicity, and power’ (Watson 2008, p. 55).

The American Nurses Association (ANA) incorporated

social justice into its Code of Ethics (2001), Social Policy

Statement (2003), Nursing Scope and Standards of Practice

(2004) and Public Health Nursing: Scope and Standards of

Practice (2007). Social justice concepts are included in some

nursing undergraduate curricula (i.e. Boutain 2005, 2008,

Beaty 2008, Vickers 2008). Of the nursing specialties, public

health nursing is most attuned to social justice as a corner-

stone of public health [Minnesota Department of Health

(MDH) 2001].

However, do nurses currently embrace their history and

role in advocating for social justice? Do they understand

social justice, apply nursing knowledge to rectify injustices

and view advocacy beyond individual clients to include social

justice advocacy? Do the ANA and other organizations

provide a social justice framework empowering nurses to

apply social justice in practice? Does social justice need to be

explicitly addressed by the profession so that nurses can once

again be a force for addressing social injustices?

This article provides an analysis of the social justice

concept guided by Wilsonian methods of concept analysis

(Wilson 1963, Hupcey et al. 1996, Rodgers & Knafl 2000).

Using Wilsonian methods requires explicating the following

iterative steps: Step 1 – isolating the questions of the concept;

Step 2 – developing the right answers; Step 3 – identifying

uses of the concept; Step 4 – answering the questions of the

concepts; Step 5 – reanalysing the initial concept for current

relevance in nursing; and Step 6 – identifying potential uses of

social justice for nurses.

Wilson (1963) described the questions of concepts as

potentially questions of fact, value and concept. This analysis

isolated four questions of concept (Step 1): (1) a question of

fact: What is social justice and how is it defined; (2) a

question of value: Is social justice appropriate for the nursing

profession; and two questions of concept: (3) What are the

attributes, antecedents and consequences of social justice;

and (4) Has nursing reinvested in social justice?

Data sources

To develop the right answers (Wilsonian Step 2), the

boundaries of the analysis must first be determined (Hupcey

et al. 1996), which for this analysis are defined by data

sources, search terms and other limits. Second, all the uses of

social justice within the boundaries need to be identified.

Then, the right answers can be developed.

A CINAHL database search for articles published from

1994 to 2010 was conducted using the term ‘‘social justice’’

without selection of a specific field, resulting in 2245 articles;

this was refined by limiting the results to full-text articles,

leaving 830 articles. Further refinement with ‘social justice’ in

the Title field resulted in 80 articles; the term ‘nurs*’ reduced

the list to 29 articles, which were then reviewed.

JAN: CONCEPT ANALYSIS Social justice

� 2011 The Authors

Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd 949

A PubMed database search for articles published from

1968 to 2010 was conducted for the term ‘social justice’,

resulting in 10,663 citations; limiting the results to humans,

English language and full-text availability left 1029 articles.

Further refinement of articles with ‘social justice’ in the Title

field resulted in 25 articles, 9 of which were included in the

public health related and 3 were in the nursing related and 2

were not pertinent, leaving 11 medical-related articles

reviewed. Additional sources were identified through broad

searches of the literature in numerous disciplines. Two social

justice books were reviewed, and relevant websites were

searched. The reference lists of identified sources were

appraised for additional sources. Only English language

sources were used.

Results

This section continues with Wilsonian Steps 3 and 4 and

includes the findings of the multidisciplinary literature

review, developing the right answers, provision of cases and

a discussion of uses and contexts. A synthesized definition is

provided along with attributes, antecedents and conse-

quences.

All uses of social justice within the identified boundaries

No social justice definitions were found in commonly used

dictionaries and thesauri; this was not surprising, as Hayek

(n.d., as cited in Novak 2000) stated that entire books and

treatises have been written on this topic without defining it. A

recent community health concept analysis discussed social

justice without providing a definition (Baisch 2009). Searches

of discipline-specific references and reviews of literature in

discipline-specific databases revealed lengthy explanations.

Health: nursing

Although social justice was previously considered a critical

value for all nurses (Fahrenwald et al. 2007), Liaschenko

(1999) found that justice as a central moral concept lacked

attention in the literature and argued for Young’s (1990)

view of justice inclusive of action and enabling full social

participation. Drevdahl et al. (2001) found that when nurses

did address social justice, a social justice framework was not

used. A specific social justice framework does not exist;

however, several nursing frameworks include social justice

(Fawcett & Russell 2001, MDH 2001, Boykin & Dunphy

2002, Boutain 2005, 2008, Russell & Fawcett 2005, Schim

et al. 2007, Pacquia 2008, Watson 2008). Boutain (2005,

2008) called for a more complex view to assist nurses to

participate in social justice, and Schim et al. (2007) placed

social justice at the centre of the nursing paradigm. Reimer

Kirkham and Anderson (2002) stated that ‘postcolonial

nursing scholarship will permit more thoughtful attention to

the issues of equity and social justice within health and health

care that fall within the mandate of nursing’ (p. 16).

Educating nurses on social justice has been discussed in recent

literature (e.g. Boutain 2008, Cohen & Gregory 2009). The

need to find and use nursing’s political will to address equity

issues globally was stressed (Drevdahl et al. 2001, Ervin &

Bell 2004) through organizational and individual action

(Liaschenko 1999).

Varying opinions exist as to the adequacy of ANA

guidance on social justice, with some authors expressing

support for ANA’s guidance (Fahrenwald et al. 2007, Bou-

tain 2008, Manthey 2008) and others finding it lacking

(Bekemeier & Butterfield 2005). Two of the five strategic

priorities of the Public Health Nursing Section of the

American Public Health Association (Anderson 2007) are

ensuring social justice and eliminating health disparities.

Ervin and Bell (2004) added concerns related to international

threats to the common good as further priorities.

The American Association of Colleges of Nursing’s (AACN

2008) Essentials of Baccalaureate Education for Professional

Nursing Practice identified social justice as a core nursing

value and defined it as ‘acting in accordance with fair

treatment regardless of economic status, race, ethnicity, age,

citizenship, disability, or sexual orientation’ (p. 28). Previ-

ously, in examining the 1998 Essentials, Fahrenwald et al.

(2007) found AACN’s focus narrow and not inclusive of the

broad issues of health and determinants of health. The 2008

Essentials does discuss determinants of health, vulnerable

populations and health disparities, although its primary focus

remains on individuals and healthcare systems.

The Canadian Nurses Association’s (CNA’s 2008) Code of

Ethics for Registered Nurses lists ‘Promoting Justice’ (p. 17)

as one of seven values and responsibilities and provides

explicit practice recommendations to address social justice.

The Code includes terminology such as rights, equity,

fairness, allocation of resources, system and structural

changes, social determinants of health and global health.

The Code’s focus is inclusive of individuals, groups, commu-

nities, programmes, policies, legislation, regulations, systems

and structures. Supporting information File S1 in the online

version of the article in Wiley Online Library includes

additional nursing articles defining and describing social

justice (Pangman & Seguire 2000, Drevdahl 2002, Redman

& Clark 2002, Fitzpatrick 2003, Jackson 2003, Reimer

Kirkham et al. 2005, Davison et al. 2006, McGee 2007,

Browne & Tarlier 2008, Foley 2009, Weisz 2009,

Dysart-Gale 2010).

K. Buettner-Schmidt and M.L. Lobo

� 2011 The Authors

950 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd

Health: public health

The foundation of public health is social justice (Powers &

Faden 2006, National Association of County and City Health

Officials 2010), with equity and social justice frequently

interchangeable (Levy & Sidel 2006, CSDH 2008).

Beauchamp’s (1976) ‘Public Health as Social Justice’ defined

justice as the fair and equitable distribution of society’s

benefits and burdens. Braveman and Gruskin (2003) clarified

that equities focused on distribution of resources and other

processes that drive health inequality, and Stanley (2002)

called for ‘rigorous science to improve public health and

social justice’ (p. 44).

Providing international leadership, the World Health

Organization developed the CSDH (2008), which determined

that health inequities were impacted by political, social and

economic forces and recommended influencing the social

determinants of health to improve health equity. Achieving

health equity to ensure social justice was described using the

terms rights; fairness; distribution of power, income, goods

and services; unequal distribution of health-damaging expe-

riences; economic arrangements; politics; distribution of

healthcare; society; social stratification; and living conditions.

Other public health social justice language included the terms

disadvantaged (van den Bergh et al. 2009); disenfranchised

and political rights (Peréz & Martinez 2008); financing of

healthcare, prestige, deprivation, marginalization, equal

opportunities, freedom to participate fully in one’s society

and social structures (Braveman & Gruskin 2003); and

caring, dignity and collective health (Krieger & Birn 1998).

A book by Powers and Faden (2006) focused on people in

social communities or groups, social institutions such as

governments and markets, inequalities, politics and the

means of allocation. They identified social justice concerns

as ‘worries about subordination and stigma, lack of respect,

lack of institutions, and social practices that adequately

support capacities for attachment and self-determination’

(p. 6). Powers and Faden stated that their primary concern

was the ends to be achieved through social justice, although

they also stated that public health should be concerned about

the distribution of resources and outcomes of social justice.

They identified six essential dimensions of well-being to be

achieved at a sufficient level for all: health, reasoning, self-

determination, attachment, personal security and respect.

These dimensions related to disadvantage and privilege.

Levy and Sidel’s (2006) book focused on social injustices,

defined as ‘the denial or violations of…rights of

specific…groups…based on the perception of their inferiority

by those with more power or influence’ and ‘policies or

actions that adversely affect the societal conditions in which

people can be healthy’ (p. 6); also that social justice is

grounded in distributive justice. Root causes were identified

as poverty, the income gap between people, unequal distri-

bution of resources, discrimination, the lack of human rights

protection and political disenfranchisement. Social injustice

was considered a principle cause and consequence of war and

terrorism (Levy & Sidel 2006).

As the leading cause of death worldwide, tobacco use has

been identified as a social justice issue, with calls to action for

healthcare providers and others to address the related

injustices (Healton & Nelson 2004, Buettner-Schmidt 2005,

2006). Associated terminology includes disparities, exploita-

tion, basic human rights of good health, education, fair and

equal treatment, disenfranchisement, well-being and health

promotion (Healton & Nelson 2004). A full listing of public

health references reviewed can be found in supporting

information File S2 in the online version of the article in

Wiley Online Library.

Health: medicine

The Online Medical Dictionary ‘Social justice’ (1998) defined

social justice as, ‘An interactive process whereby members of a

community are concerned for the equality and rights of all’ (–1).

Thirteen articles on social justice from medical journals were

reviewed, 11 from the initial search and 2 identified from the

readings. Nineteen social justice-related terms were identified

within the articles; see supporting information Tables S1 and

S2 in the online version of the article in Wiley Online Library

for matrices linking terms to articles. Lee and Cubbin (2009)

hypothesized that social injustices can lead to poor health

outcomes and called for equitable opportunities for all to be

healthy. Van Rosendaal (2006) described physicians’ ethical

conflicts as a struggle between the doctor–patient relationship

requirements and social justice responsibilities and recom-

mended that physicians have ‘a broader sense of community

responsibility in their practice of medicine’ (p. 1525). Azetsop

and Rennie (2010) argued that medical individualism has led to

‘[a] moral vacuum, exaggeration of human agency, and a

thin…conception of justice’ (p. 1).

Philosophy

Rawls (1971, 1999, 2001) stated, ‘Justice is the first virtue of

social institutions’ (Rawls 1999, p. 3). Rawls clarified that

justice and fairness are not the same concepts and that

equality is a hypothetical concept to begin the development of

the justice concept.

According to Wenar’s (2008) interpretation of Rawl’s

social justice philosophy, a just society has ‘free citizens

holding basic equal rights cooperating within an egalitarian

system’ (– 1) institutions included the political constitution,

legal system, economy and organizations that ‘distribute the

JAN: CONCEPT ANALYSIS Social justice

� 2011 The Authors

Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd 951

main benefits and burdens of social life’, including rights,

opportunities, work, recognition, distributions of income and

wealth and more (4Æ1 The Basic Structure section, – 1).

Wenar found that Rawls’ theory of justice related to citizens’

good, collective good, reciprocal advantage of all, fair equal

opportunity of all, economic equality, political equality,

equal basic rights, self-respect and affirmation of self.

Law

The American Bar Association (ABA) does not have a legal

definition for social justice, although representatives of the

organization have made statements about their duty to ‘bring

social justice to the world’ (Rand 2006, p. 461). The ABA

Center for Racial and Ethnic Diversity promotes social justice

in the justice system (ABA n.d. ). Current legal social justice

issues include racism, sexism, the environment and the ‘rela-

tions between rich nations and poor nations, to the first world

and the rest of the world’ (Kennedy 2005, p. 93). Rand pro-

vides descriptions of social justice: ‘empowerment of under-

represented minority groups’ (Solorzano & Yosso 2001, as

cited in Rand 2006, p. 460) and ‘the process of remedying

oppression’ (Edwards & Vance 2001, as cited in Rand 2006).

Psychology, sociology and social work

Psychological social justice definitions were influenced by

authority, power and peer pressure, which affect how others

are treated (Hatfield & Rapson 2005). Oppression was

recognized as the domination and control of others through

institutional systems and policies, with social justice

described as full and equal participation of all of society’s

groups, equal distribution of resources, physical and

psychological safety, security of all and included the pro-

cesses and institutional context (Morgan & Vera 2006).

The sociological literature differentiated social justice from

legal, political and economic justice (Alwin 2001) and

discussed social and economic inequalities and the allocation

of goods (Marshall 1998). ‘Distributive justice’ was an

alternate term for social justice (Marshall 1998, Alwin

2001). Alwin (2001) defined social justice as ‘the realm of

status, respect and the sense of worth given and received in

social interaction or in relation to society’ (p. 2696).

The Code of Ethics of the National Association of Social

Workers (2008) deems social justice to be a value and an

ethical principle. ‘Social workers challenge social injustice’

and ‘pursue social change, particularly with and on behalf of

vulnerable and oppressed individuals and groups of peo-

ple….focused primarily on issues of poverty, unemployment,

discrimination….[They] strive to ensure access…equality of

opportunity; and meaningful participation in decision

making for all people’ (Ethical Principles section, – 3).

Geography

Geographical social justice definitions included, ‘The distri-

bution of society’s benefits and burdens, and how this comes

about’ (‘Social justice’ 2000, Social Justice section, – 1) and a

sharing of resources and power (Ross & Rosati 2006), with

questions related to spatial access to resources and exposure

to environmental hazards.

Economics

The World Bank (2005) focused on social justice as inequal-

ities in opportunity and stated that a reduction in inequities

was consistent with and may be necessary to obtain long-term

greater efficiency and prosperity. The ABA (n.d.) Center for

Economic and Social Justice (n.d.) included economic justice

in their social justice definition, stating that soci

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