Politics of difference in nursing: social construction and maintenance

¶ … Politics of Difference in Nursing Socially Constructed and Maintained

The politics of difference and nursing

The significance of the politics of difference

The issue of diversity and the 'politics of difference' have assumed an important and compelling part of modern discourse in many fields and disciplines. This interrogation of difference extends along the axis of culture, ethnicity, gender, race and many other trajectories of diversity in modern society. As Colleen Varcoe (2004) states;

Diversity is a broad yet powerful idea that encompasses the ideas of difference and complexity. Multiple forms of diversity are important in nursing and health care, yet it is often only "cultural" diversity that comes to mind and commands attention. (Varcoe, 2004)

Vaecoe makes the important point germane to any discussion on the politics of difference that culture is often conflated with aspects such as ethnicity and that, "...attention to cultural diversity often focuses narrowly and defines people by nation, ethnicity, or race" (Vaecoe). This is indicative of the need for a rigorous and penetrating examination of the politics of difference in order to ascertain and prevent the marginalization and exclusion that often results from perceived difference and 'otherness'. This has become a central sociological, ethical and philosophical concern since the middle of the last century with the demise of colonialist ideologies.

While this chapter will explore the various modernist, post-structural as well as postmodern interpretations of the politics of difference, the focus of this discussion will revolve around the way that these views and debates impact on the healthcare and nursing profession. While there is a comparative paucity of studies that deal with specifically with the relationship between the politics and difference and nursing, this is addressed to some extent by writers like Vaecoe. In a study entitled, Advancing Nursing Scholarship in Diversity: Complexity and Equity the author states that "Diversity is of critical concern to Canadian society in general and Canadian health care and nursing in particular, because of our expressed commitment to justice and equity, especially in health care" (Vaecoe, 2004). This is a view that can be extended to other societies and cultures and refers to the various inequities and inequalities that take place in terms of the concept of difference and in relation to aspects such as age, ability, income, ethnicity, sexual orientation, geography, and other forms of difference. As Vaecoe emphasizes, "... attention to diversity is fundamental to a lessening of health inequities" (Vaecoe, 2004).

It is this sentiment and its implications for nursing profession that will be a central guiding trajectory of this study. This point is worth emphasizing at this juncture as it forms a fulcrum that will guide the following discussion. The issue of difference and its meaning in both a political and social sense in the society is even more relevant to the professional nurse. This refers to the expanded role of the professional nurse in the contemporary medical and healthcare environment. This role often includes aspects of community and social intervention and necessitates the need to understand the cultural background of patients. This is an aspect that will be dealt with at more length in the final section of this chapter.

In order to deal with and address the inequalities and the disparities in society that are encountered in the healthcare profession, it is important to realize that "....analyses of diversity must attend to language, power dynamics, the intersections among various forms of inequity, and the specific contexts within which inequities occur" (Vaecoe, 2004). Consequently, many theorists in the medical and other fields have seen the need to turn their attention to diversity with a "...conscious analysis of how various forms of diversity and difference intersect, and how language, taken-for-granted ideas, and dominance operate to foster inequity based on difference" (Vaecoe, 2004).

2. Understanding difference useful view of the politics of difference is provided by theorists who see this concept as an important means of understanding marginalization and oppression in modern post- colonial society. Scholars such as Michael Peters in his article Radical democracy, the politics of difference and education (1995) states the following.

The politics of difference emerges as the new desideratum for understanding the complex nature of oppression in education and the way in which multiple and contradictory subjectivities and identities are socially constructed at the intersections of race, gender, and class, among their configurations. (Peters. 1995, p. 55)

In essence the important concept of "social construction" is one that underlies the issue of difference and political difference; in that such difference is not innate but is often constructed by the cultural norms or societal structures that dominate that particular society. This also brings with it the implication that such differences may be socially constructed or constituted to deprive or marginalize certain groups or individuals.

In essence, Peters and others point out that the politics and exploration of difference is an essential aspect of modern, or postmodern, discourse that has emerged in the wake of the dissolution of colonialism. Importantly, this area of social and political discourse has been developed in an effort to counter a world view that is based on binary opposites and contraries. As many theorists and philosophers such as Derrida, Habermas, Heidegger and others point out, the method of binary opposites supports the existence of ' master narratives' and ideological bias, which does not take into account the validity and the relevant status of social, cultural and individuals differences. This interrogation of the binaries of difference is motivated by the realization that people cannot to be simplistically defined by sets of opposites such as black, white, working class, and middle class, female, male; and that these opposites are in reality socially constructed. This mode of thinking tends to reduce the essential individuality and humanity of the individual, resulting in false perceptions that translate into negative actions. This theoretical stance is the foundation of the deconstruction of hierarchical structures that is based on oppositional thinking.

Probably the most important strategy at work in deconstruction is the tracking down of hierarchical structured oppositions. According to Derrida, it has been a characteristic of the western philosophical and scientific tradition since the classical times to think in binary oppositions. Presence opposes absence, speech opposes writing, philosophy opposes literature, the literal opposes the metaphorical, the central opposes the marginal, life opposes death, the real opposes the imaginary, the normal opposes the pathological, etc. Derrida shows how one of the oppositional terms is always privileged, controlling and dominating the other (dominating 'the other').

Hierarchical Oppositions)

The above extract is quoted at length as it encompasses many aspects that need unpacking and which will form a locus of the present discussion. As will be discussed in this chapter, it therefore becomes obvious in the light of these points and the various aspects noted in the introduction to this section, that the study of difference is especially pertinent to the healthcare profession and nursing.

2.1. The concept of difference

The concept of difference raises a number of complex and intricate issues in the modern and postmodern context. What precisely is meant by difference? It can be argued that the question of difference in its deepest sense lies at the core of the problematics of Western philosophizing, extending from Plato's concept of the ideal as opposed to mundane reality. In a postmodern, or more correctly a post-structuralist context, the meaning of difference is related to the word 'defer' in the writings of Derrida. Essentially, the understanding of difference in Western thought is an important prolegomena to the understanding difference in the political and social sense in contemporary thought. The following brief overview of the concept of difference as it emerged from dualistic thinking in Western thought will provide necessary insight into the meaning of the politics of difference in the modern healthcare and nursing environment.

The dualistic view of reality has been a central area of concern in Western thought since the inception of Greek philosophy. As noted, the Platonic view of the ideal and the real forms constitutes the underlying basis of Western thought. This also refers to the separation between being and Being which is, according to important modern thinkers like Martin Heidegger, the fundamental and underlying structure of Western metaphysics. In other words, the dualism and difference between things was seen in the history of Western metaphysics as the basis for all reality and knowledge of the world.

The theory of Forms in Plato is a theory of reality that has profound implications for modern thought. Essentially, it is a philosophical standpoint that views reality as divided into truth and illusion. The world of illusion refers to the world of particulars and everyday experiences while the Forms are the ideal and 'real' reality that hides behind the material world. The ideal forms relate to the concepts of perfection and wholeness, while the particulars of the world are inferior and lack any real unity of nature.

There was just one world, the world of ideas. The sensible world was merely an image of the real world, full of imperfections and decay. But the real world was a whole and perfect entity." (Philosophy Is a Way of Life)

The theory of dualism and its implications in term ethics and politics can be derived from the following concise but insightful analysis.

A dualistic view of reality understands there to be two (thus dualism) levels of existence. The top level... is ultimate reality, and consists of ideas, such as truth, beauty, goodness, justice, perfection. In other words, the ultimate reality is non-corporeal, or non-physical. It is the level of spirit and deity. The lower level is the physical world which in which we live. It is the opposite of ultimate reality, thus it is not real in the sense that it is not ultimate. It contains the imperfect physical manifestations of the ideas that exist in the perfect plane, so by definition it is characterized by falsehood, ugliness, evil, injustice, imperfection.

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Note that the separation of truth and falsity or illusion clearly implies that those aspects of reality which do not accord with the ideal are relegated to a subservient and marginalized status. This leads to the present discussion of the politics of difference in that difference in the Platonic sense divides existence into positive and negative polarities. In other words, the dualistic understanding of difference is judgmental and can be used to separate society or culture into "us" and "other," which is a division that the politics of difference attempt to analyze and redress.

Therefore, dualistic thought has permeated Western thought and has only recently been interrogated in the postmodern refusal to accept the idealistic constructs and ideologies of the past. However, what Platonic thought achieved was to create the dualistic separation of the real and the unreal, the known and the unknown and to accentuate the difference between things in a pejorative sense. This has important implications for any discussion of the meaning of the politics of difference.

Consequently, dualistic or binary thought was critiqued and interrogated by Nietzsche and later in the works of Jacques Derrida, among others. Nietzsche critiqued the trajectory of Western metaphysics from a materialist perspective and viewed the Platonic ideal forms as a 'fantasy," which he considered to be dangerous in that it misled humanity and falsified the nature of truth and reality. One needs only to consider Hitler and the ideology of a superior race to see the relevance of this critique

However, the purpose of this chapter is not to digress into a discussion of the convoluted area of the critique of Western metaphysics. What is important in the present discussion is the understanding of the postmodern critique of the metaphysics of dualism as it relates to the discourse on difference. The Western metaphysical tradition was interrogated by Heidegger, Derrida and many other Marxist and post-structural thinkers. The work of Derrida in particular can possibly be cited as a leading example of the general trend towards an understanding of difference that moves beyond dualism in western thinking.

Derrida, like many other deconstructionists and postmodern thinkers, worked from the assumption that truth is not "fixed" or limited in any ideal sense, but rather that truth and reality are relative and contingent. This is an extremely important aspect in terms of the understanding of the modern concept of difference.

Derrida also criticizes the notions that was derived from Plato that truth is fixed and stable. Language for Derrida is the vehicle or the means which determines truth and reality and the relative nature of truth is embedded in the structure of language. Heidegger approaches the problem in a different way and sees the fault lines in Western thought to be centered on the obsession with a humanistic and subjective approach to Being or reality, which he works out in his discussion of Ereignis and Dasein.

In summary, and for the purpose of the present discussion, while one could elaborate endlessly on these postmodern and post-structuralist thinkers, what is important to consider in terms of difference is that the Derrida and others attempted to show that the dualistic and logocentric worldview which presupposed a fixed and stable reality or truth is severely flawed and in need of "deconstruction." For Derrida in particular truth and reality lies in difference and not in essence.

Things only can be by virtue of differing. Without differing, no time and space; if time and space are constituted through differing/deferring as constitutive of them, there are no absolute identities nothing 'is itself' by virtue of its being, is simple and absolute identity with itself. Any ultimate, transhistorical truth is only a truth by virtue of difference; so that no ultimate 'truth' can be, and be itself, nor can it be outside of time and space, and hence beyond contingency. Any 'truth' exists, then, only continently, and relationally, through differance. Before essence comes existence, the conditionality of space and time: existentialism.

Difference)

Similarly, Heidegger suggests that that reality is much more complex and evasive than the logocentric or rational traditions suggest. Furthermore, there is a gap or a difference between man and reality or Being, which is the true focus of philosophical attention. Derrida sees modern thought and logocentrism as "...another philosophical hierarchy that somehow constructs itself" (Nuncio R, V.). The problematics of the search for truth is central to Derridean thought. "What is truth? Whether a truth formulated is universal or relative, the grounding principle is to locate its presence of truth somewhere, within, beneath and endless or temporal searching" (Nuncio R, V.).

In the study, Differance, Derrida plays on this term and shows how meaning can never be grasped but is always displaced or deferred. In other words, meaning and truth are not static and understanding reality through language is not a simple matter of connecting the signifier with the signified; or the word and its apparent designated meaning. In fact for Derrida the connection between the signifier and signified is "disrupted'. Meaning is always in a process of relative knowing or unknowing and always moving away from the human attempt to appropriate it or contain it. Heidegger goes even further and states that the attempt to contain or control truth in a subjective context is the very thing that distances us from truth and separates man from Being and from an understanding of reality.

To take the Derridean analysis of Differance a step further, the important aspect is that through language reality is constructed and not discovered. Reality is not a static entity that can be observed but we, through language, actually construct realties, which are relative and contingent on history, time and place. This leads Derrida to suggest that all constructions of knowledge such as the traditions of Western metaphysics are in reality "fictions" that can be deconstructed and not a final truth in themselves. Meaning is continually eliding and evading attempts to confine it to a certain context or interpretation. This would lead Derrida in the late 1970's to put forward the argument that Western language was constituted by dichotomies and binary oppositions to produce meanings. An obvious example is 'gender', which relies on male and female, masculine and feminine, boy and girl to help grasp meaning on gender. Western languages tries to find fixed meanings that are final for words (both spoken and written) through these oppositions.

There are many examples in political and sociological theory of the way that the binary opposites that constitute language and culture play a decisive role in the issue of difference and otherness. The significance of binary oppositions is that the 'other' is not equal to the main part of the pair. As one scholar states, the naming of difference not only mark, it signifies and speaks. In a world that is material and not merely symbolic, they shape the spaces we can and cannot inhabit our physical landscapes (Frankenberg, 1993). The other is imprisoned within a different space. In other words, the spaces in which 'we', 'I', and 'they' are positioned, are constrained by the way subjectivity is made spatial. Positionality is not simply a matter of places but of the spatial relationships between places and spaces and the distribution of people between them. This view is emphasized by Ghandi (1998), who states there is a hierarchy of value, set culturally in binaries and dichotomies. One always has the higher ranking and is 'privileged' over the 'other'. It is the privileged term that tends to establish the cultural standard of normality as they have more status.

Theorists like Spivak describes the subaltern as the person of such marginalized social position that she is left with no words to speak, cannot speak at all. (Chow, 1998). The other, the native, is something slimy (Bauman, 1997b), and is the bad thing to be replaced (Chow, 1993). Identities therefore tend to operate through exclusion, through the discursive construction of a constitutive outside and the production of abjected and marginalized subjects (Hall, 1996b). To reiterate in this context, Derrida's work critiques how writing produces otherness. He links the hierarchisation of meanings that produce the possibility of otherness. He argues that the 'other' is not only socially constructed but it is often silenced or repressed. Deconstruction opens up these binaries and shows how meaning is given, how each side depends on the other for its meaning and points to the relations of power in between. Grosz (1990, p. 95).

While it may be informative to explore the Derridean concept of Differance as continual deferment as well as other postmodern constructions of otherness, the present discussion will focus on the way that this concept and the postmodern understanding of difference impacts on the nursing and healthcare environment.

3. Difference and its understanding in the postmodern context

The above brief overview sets the stage, as it were, for an understanding of the meaning and significance of the politics of difference. Difference is no longer seen in a postmodern context as separation and division but rather in terms of variation and diversity; which escapes the negative connotations that are embedded in the dualistic mode of thought. This view follows from the relative understanding of difference and the deconstruction of the way that difference is constructed and created through language and ideology.

This overview leads to a more everyday and practical understanding of difference that refers to multiplicity, which may be understood as the true energizing force in life. This view has consequences in terms of the following issues. How can we make sense of difference and differences? Why are they important to those in healthcare and education? What do and can they tell us?

In its origins, difference is linguistically or language based in that it perpetuates a form of oppositional thinking or an "either-or" view of reality and creates binary opposites such as bad or good or black and white. Language as an instrument of difference is an area that is particularly germane to the post -structural perspective; which will be discussed in more detail in this thesis. However, what is particularly important to any discussion of the politics of difference is the way that difference has been used as a method of subjugation and marginalization of the "other" in society. This refers in the past century particularly to colonialism and post-colonialist phase in modernism.

Post-colonialism as a concept refers to the disruptive revisioning associated with histories of and resistances to colonialism and imperialism. Whether it is an academic field and discourse, a political stance, a critique, or, for that matter, an educational intervention is open to debate: certainly education has been one of the key sites for colonialist, neo-colonial and postcolonial work. It may be useful at this point to indicate that my deployment of the term 'cultural difference' derives from Bhabha's formulation. This refers to the view that, 'Cultural difference marks the establishment of new forms of meaning, and strategies of identification, through processes of negotiation where no discursive authority can be established without revealing the difference of itself" (Bhabha, 1990, 313-317). Furthermore, Bhabha states that,

Cultural difference is to be found where the 'loss' of meaning enters, as a cutting edge, into the representation of the fullness of the demands of culture. Cultural difference emerges from the borderline moment of translation. The transfer of meaning can never be total between differential systems of meaning, or within them it is the articulation through incommensurability that structures all narratives of identification, and all acts of cultural translation. (Bhabha, 1990, pp. 313-317).

Dualistic thought and its use in colonialist ideologies, as well as in the general metaphysics of opposites, in effect means a division between the accepted and perceived norm and the "other." The other is marginalized or perceived as inferior in status and privilege. This is essentially the argument behind the feminist critique of patriarchal and male centered society, where the female gender is perceived as the "other."

This is far-reaching implications for healthcare and other areas. As noted in the above section, referring to or labeling a group of people as different is an exercise of power. Definitions and categories based on binary oppositions are a means of 'placing' or restricting individuals. In effect the assumption of difference based on aspects such as gender or social class is subject to the dualistic mode of thought that is intent on a static and logocentric view of reality. This is in contrast to the view of difference that takes into account a more open and relativistic view of reality.

Sweeping generalizations and stereotypes based on categories can mean that the complex similarities and differences within and between groups or social entities are obscured and ignored and this process can result in decisions relating to health care being based on assumptions - such as, one size fits all. Negative stereotyping reflects differential power in that the majority is catered for and the minority or those who are considered to be 'different' are marginalized.

Furthermore, negative stereotyping not only reflects existing inequalities but it also perpetuates them. Stereotyping people as different frequently leads to discrimination. This categorizing of the powerless by using labels is often the response by those in power. Thus, Rob Irvine (2002, p. 32) argues that the concept to the health consumer is..."integral to the exercise of power and instrumental to the operation of power relationships that shape the way things look and state what things mean." Therefore, it is essential to uncover the apparently hidden agenda of the adoption of the term 'consumer' for those requiring health care services as (in a power relations theory) conflict between various groups is seen as inevitable (Sargent, 1991).

People within the health care system are defined by their labels, and they are actually redefined by the medical discourse in such a way that the label itself "...functions as a master status that overshadows all other aspects of the person's life" (Schaefer, p.395). An example given by Hughes et al. is that a person with a mental illness such as schizophrenia is labeled schizophrenic, often regardless of whether or not treatment is being sought, thus rendering the label itself to have the effect of "lock[ing] the individual into outsider status." (Hughes et al., 2002, p. 147).

In other words categories or labels render people "...subject to the interpretation by others" (Schaefer, p.395). Labeling people as 'disabled' reflects the discourse - uncritically accepted by policy makers - which was created by the medical approach to identifying people. The creation of a discourse of medical expertise "...disempowers disabled people by allocating to them the role of patient, client or consumer" (Sherry, 2002, p.4). Labeling theory has evolved as a method of explaining society's reaction to deviance. Essentially, something that is deviant is contingent on the label of deviance being successfully applied. (Van Krieken et al., 2002, p. 442) in a sense, by attempting to expose the deviance within the term 'consumer' we are also responsible for creating the label or category which is in effect a means of isolating the individual or group because of their 'difference." The question whether the consumer label is inherently deviant, is entirely dependent on our frame of reference, which in this case is the neo-liberal perspective. Furthermore,

Bauman (1997b) describes the process of making the other as the social production of strangers; people who do not meet the cognitive, moral or aesthetic map of the world

4. The politics of difference

An understanding of what is meant by the politics of difference and its significance of the healthcare and nursing profession is therefore facilitated by the preceding discussion. It is a contention that in 'post-modernity' - in the post-colonial age, an age where many ethnic peoples have won their political independence, 'difference' provides a more insightful 'logic' for understanding identity assertions and struggles. This is one of the main lessons that so-called post-colonial theorists (e.g. Said, Spivak, Bhabha) have learned from the French poststructuralists. Michael Peters (1995, p. 48) makes the point that the new politics of difference is developed by Young, Yeatman, Mouffe, and Dalimayr who draw their inspiration for a notion of politics based on the meaning of difference from Derrida, Deleuze, Foucault, Lyotard, and Kristeva. This will be dealt with in more depth in the section of this thesis that explores the idea of conceptions of difference through the employment of Derrida's notion of diffe'rance as well as Lyotard's (1988) notion of the Differend.

It therefore becomes clear that the political implications of human diversity have become a central concern of political theory. The following extract from an article entitled J.G. Herder and the Politics of Difference by Frazer (2007) summarizes some essential aspects of difference in terms of modern politics.

The wide variety of social groups in our own society makes it difficult to imagine what political principles could prove acceptable to all those whose lives they are meant govern. Herder believed the tremendous space between different worldviews and cultures made normative judgments across such chasms impossible, precluding the possibility of a single set of truly universal moral or political standards. (Frazer, 2007)

The above clearly posits the complexity of the issue of diversity in a political context. However, the article goes on to state that "... Herder actually argues that the recognition of human diversity, far from leading us to moral relativism, can only serve to improve the accuracy and enhance the authority of our universally applicable moral convictions" (Frazer, 2007). This view does not however disregard the formidable challenge of "... finding acceptable principles to govern the increasingly interconnected global order... "(Frazer, 2007).