Public Health Nursing Vol. 24 No. 1, pp.

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0737-1209/r 2006, The Authors
Journal Compilation r 2006, Blackwell Publishing, Inc.

SPECIAL FEATURES: THEORY

Social Justice: Added Metaparadigm

Concept for Urban Health Nursing
Stephanie Myers Schim, Ramona Benkert, Sue Ellen Bell, Deborah S.Walker, and Cynthia A. Danford
ABSTRACT Historically, the nursing metaparadigm has been used to describe 4 concepts of nursing
knowledge (person, environment, health, and nursing) that reflect beliefs held by the profession about
nursings context and content. The authors offer an assessment of the metaparadigm as it applies to
community and public health nursing in urban settings and offer an amendment of the metaparadigm to
include the central concept of social justice. Each of the metaparadigm concepts and the central concept of
social justice is discussed as it applies to a model of urban health nursing teaching, research, and practice.
Key words: nursing metaparadigm, social justice, urban health.

Nursing has within its power the theoretical and practical foundations to do great good in improving the
health of urban populations through social justice interventions. The reality, however, is that in many arenas, ideals are a vision of the possible, not the usual.
Coming together as an informal group of ve faculty
members from various nursing specialties (community health, pediatrics, midwifery, womens, and adult
health), we sought to articulate what we meant by urban health nursing (UHN) as a core curricular and
practice focus. We began this endeavor by considering

Stephanie Myers Schim, Ph.D., C.N.A.A., A.P.R.N., B.C.,

is Associate Professor,Wayne State University College of
Nursing, Detroit, Michigan. Ramona Benkert, Ph.D.,
A.P.R.N., B.C., is Assistant Professor,Wayne State University College of Nursing, Detroit, Michigan. Sue Ellen
Bell, Ph.D., A.P.R.N., B.C., is Associate Professor, School
of Nursing, Minnesota State University, Mankato,
Mankato, Minnesota. Deborah S. Walker, D.N.Sc.,
W.H.N.P., C.N.M., F.A.C.N.M., is Associate Professor,
Wayne State University College of Nursing, and School
of Medicine, Department of OB/GYN, Detroit, Michigan. Cynthia A. Danford, Ph.D., A.P.R.N., B.C., is Assistant Professor, Wayne State University College of
Nursing, Detroit, Michigan.
Correspondence to:
Stephanie Myers Schim,Wayne State University College
of Nursing, 240 Cohn Building, 5557 Cass Avenue,
Detroit, MI 48202. E-mail: s.schim@wayne.edu

the traditional nursing metaparadigm concepts of

person, environment, health, and nursing and then
describing the way in which we include the concept
of social justice in our teaching, research, service,
and practice in urban health and community health
nursing.

A Conceptual Model for

Urban Health Nursing
In the United States, the nursing metaparadigm has
been widely used to describe four spheres of nursing
knowledge that reect beliefs held by the profession
about nursings context and content. Historically, the
metaparadigm has encompassed the four concepts of
person, environment, health, and nursing (Fawcett,
2005). Alternatives have been proposed and challenges have continued (Reed, 1995), but most nurses
in the United States have some awareness and understanding of the metaparadigm. It is with this common
awareness in mind that we examined our UHN
practice using these concepts as a foundation. As we
discussed our experiences and vision of UHN practice,
we concurred that the concept of social justice belonged at the center of our model (Fig. 1).
The concept of social justice interconnects UHN
practice with the four acknowledged concepts of the
nursing metaparadigm. It is our contention that UHN
centered on the practice of social justice ensures distribution of life resources in a way that benets the

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PERSON

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HEALTH

Social
Justice

ENVIRONMENT

NURSING

Figure 1. Conceptual Model for Urban Health

Nursing with Social Justice at the Center
marginalized and constrains the self-interest of the
privileged. It is our goal in this paper to articulate a
model for urban health nursing that is organized
around the central concept of social justice.

Urban Community
The rst definition to consider within UHN is urbanness. We utilize U.S. census definitions to dene an
urban metropolitan statistical area (MSA). In 2003,
the United States Census Bureau classied an urban
MSA as an area with a population density of at least
1,000 people per square mile and a surrounding overall density of at least 500 people per square mile.
MSAs contain a large population nucleus and a high
degree of economic and social integration with their
adjacent communities. The largest city in each MSA is
the principal city.
For almost 20 years, the international movement
called Healthy Cities has attempted to improve conditions in urban areas. A healthy city or community is
dened as one with affordable housing, accessible
transportation systems, employment for all who want
to work, a healthy and safe environment with a
sustainable ecosystem, and accessible health care
services that focus on prevention and staying healthy
(Awofeso, 2003). Although many of the issues
important to urban health have counterparts in rural
and suburban areas, there are critical health issues
that are unique to U.S. urban settings. Special urban
issues include: (1) economic and social marginalization of inhabitants, (2) disparate access and use of
health care systems, (3) higher mortality rates from
an array of acute and chronic diseases, and (4) higher
rates of morbidity from preventable diseases. The
authors have argued that the leading health issues in

January/February 2007

the United States demand public health solutions (Lee

& Estes, 2003; Smedley, Smith, & Nelson, 2003).
Dismantling the systemic issues of urban settings
requires population focus.
Social justice should be the central conceptual
philosophy for urban community and public health
nursing practice. The discussion of nursings metaparadigm concepts with social justice added as the
central concept demonstrates why many of the gaps
between the Healthy Cities initiatives and the realities
of American city life continue to exist. The gaps are
related to social justice disparities that can only be
addressed through the persistent pursuit of change at
the systemic and population level with political and
economic solutions.

Social Justice
While the need for social justice as a central theme in
nursing is acknowledged by nurses (ANA, 2001), our
collective definition of social justice is often assumed.
Contemporary philosophers have written and discussed a variety of social justice theories. These theories include definitions and demands of social justice
from the perspectives of: (1) communitarian (Barry,
1989; Etzioni, 1998; Sandel, 1998; Tams, 1998;
Waltzer, 1983), (2) contractarian (Gauthier, 1990;
Rawls, 1993), (3) egalitarian (Dworkin, 2000), (4) feminist (Gilligan, 1982; Hampton, 1998; Okin, 1989), (5)
libertarian (Nozick, 1974), and (6) religious (National
Council of Catholic Bishops, 1986; Niebuhr, 1996).
In our conceptual model, social justice, as described by Barry (1989), is the guiding philosophical
orientation (theory) and the dynamic implementation
process (practice). Barrys approach to social justice
requires that institutions and nations must be motivated to act in ways that can be defended . . . without
appealing to . . . advantage (p. 361). Barry calls this
approach social justice as impartiality. In social
justice as impartiality, justice is decided as if neither
side knew which position they were in: the advantageous (stronger bargaining) position or the disadvantageous (weaker bargaining) position. Thus, instead
of an intervention or action being deemed just
because it advantages one side or the other, it is done
because its outcome would be just when viewed by a
dispassionate outsider. The point of negotiations,
then, is to get an equal share and no more. Self-interest is rationally put aside in favor of the greater good.

Schim et al.: Social Justice and Urban Health Nursing

The difference between this approach to social

justice and previous similar approaches (e.g., Rawls
veil of ignorance, walking a mile in anothers shoes,
or the biblical Golden Rule) is that Barry applies the
principle to institutional and international populations rather than to individuals. Nurses traditionally
have been taught to place the individual patient
foremost in care planning, a position that does
not correlate with Barrys social justice. As a guiding
philosophical orientation, social justice in nursing
must go beyond current pedagogy and simple definitions of ethical principles. Individual-based nursing
relies on a material principle of justice that recognizes the characteristics of patients in distribution of
health care resources. These characteristics include
individual need, effort, societal contribution, merit,
and a desire for distribution of equal shares among
individuals. Barry and other communitarian philosophers criticize these approaches because they promote
microallocation of health care resources at the patient
level. The individual patient is unfairly given an
advantage just because they happen to be somewhere
(in the bed, in the clinic, in the emergency department, etc.). Social justice in nursing must be viewed
from a population vantage point that supersedes individual characteristics and the advantage of presence
as the basis for claims of disproportionate shares of
health care resources. If the nursing profession is to
improve the well-being of persons, environments,
health, and nursing in the urban setting, it must
endorse and implement a revised nursing metaparadigm that places the communitarian notion of social
justice at its center. Additionally, the extant metaparadigm concepts need to be reconsidered at the
community and population levels (Ervin, Bickes, &
Schim, 2006).

Person
The concept of person has been central to nursing
theories. Yet, the research and theory development
have been founded on a generic (individual) person
from an ahistorical, acontextual, and holistic discourse (Drevdahl, 1999). Thorne et al. (1998) noted
that nursing scholars have attempted to improve upon
the subjectivity of person by increasing the complexity of the concept. Yet, categorizing the generic person
as an individual agent risks categorization of persons
from an either-or viewpoint in an attempt to ease the
challenges of complex subjectivity. Our view holds

75

that the metaparadigm concept of person must be

multicentered and incorporate an evolving population-level agency (Drevdahl, 1999); it must transcend
the individual to address diverse persons within
aggregates, communities, institutions, and nations.
The person metaparadigm would also hold that the
nurse is a multicentered (institutional) person
within the nursing metaparadigm concept.

Environment
Nursings concept of environment includes the physical environment, as well as the psychosocial environment. It has traditionally been circumscribed by the
connes of the clinic, hospital, or geographic community in which nurses worked. Interventions are often
individually targeted and mistakenly based on an
assumption of individual free choice in altering
the impact of the environment on health (Kneipp
& Drevdahl, 2003). Chopoorian (1986) expanded
the context of environment to include political and
economic structures and the relationship between
these structures and the origins of health or illness.
Kleffel (1996) and Buttereld (2002) propose a shift
in nurses environmental consciousness that would
lead to upstream or population-level solutions to
health care problems associated with environmental
causes. We endorse these conceptualizations of environment that focus on a movement from the solely
individual downstream approaches to look at
upstream community, societal, and global solutions.

Health
The concept of health within nursing developed from
multiple and disparate paradigms (Newman, 1991;
Smith, 1981). Research based on a wellness-illness
continuum conformed to scientific methodology and
sought to control contextual effects. A unidirectional
developmental perspective sought to address the
dynamic nature of health experiences. Health from
both perspectives is viewed as a personal or individual
process. Newman describes an interaction between
person and environment in the definition of health;
yet, the consequence of this perspective remains a
focus on the individual with limited emphasis on
the larger institutional and societal effects. These
conceptualizations place excess responsibility for
improved health within the individual person, as
opposed to the environment. Our view of health must

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be expanded to include the dynamic agency of a

person within a dynamic institutional and societal
environment. Our view uses a simultaneous-action
worldview in which the sociopolitical aspects of a persons life that impact on health are considered along
with the individual aspects (Reed, 1995).

Nursing
Nursing theorists have variously dened nursing as a
learned humanistic art and science that focuses upon
personalized individual and group care and a caring
relationship (McEwen & Wills, 2007). These and
other theoretical definitions of nursing have generally focused on the individual; however, problems
that affect health in urban communities are complex,
requiring multifaceted resources, knowledge, and
efforts. Nursings ability to respond to the multitude
of community-level health system and environmental
challenges will have a great impact on the effectiveness of the profession in urban settings.
We believe that urban health nursing requires a
population consciousness. Nurses with a population
consciousness see the community and global aspects
of health care beyond the immediate situation
(Thorne, 1997). Nursing from this viewpoint requires
a critical analysis of the status quo in health care
and the larger society, exposing oneself to the larger
societal issues that form the upstream precursors
to urban health disparities. Nursing as population
consciousness holds the view that traditional professionalism focused on the individual may lead to
cultural paternalism and racism. It may also lead
to the dominance of high-technology and facilitybased Western biomedicine.

Nursing and racial/ethnic competence

At a minimum, nursing will require an emphasis on
racial and cultural competence to uphold the population consciousness described above. Yet, nursing has
not always supported the ethical ideal described by
Barry. An emphasis on a colorblind perspective was
common to the assimilation models of early nursing
theory (ONeill, 1992). Likely, unconscious classism
and racism interlocked and operated together to inuence the early scholars. Although nursing theorists
were working to separate the discipline from the
dominance of medicine, these scholars put forth theoretical underpinnings that were inuenced by

January/February 2007

the nurses own generic person, environment, health,

and nursing biases.
Limitations in nursings perspectives toward persons of color, those with foreign or immigrant status,
and people with nontraditional lifestyles continue to
exist. Benkert, Pohl, & Coleman-Burns (2004) found
that nursing school undergraduate and graduate education was not cited as the primary source for student
knowledge about diverse cultural groups. In fact, most
Nurse Practitioners (NPs) in Benkerts study reported
that their primary learning about people from various
backgrounds was derived directly from their patients.
Among those NPs reporting familiarity with the concept of social justice, the knowledge grew out of their
personal desire to learn more; neither the profession
nor their schooling had prompted their learning. NPs
who retained the patient as the sole source of their
knowledge were limited in the ability to recognize the
larger systemic issues confronting patients (Benkert
et al., 2002). Bell (2005) reports that nurses lack
an understanding of the distinctions between the
concepts of social justice and cultural competence.
Recent work suggests that nurses and other health
providers at all levels of practice demonstrate deficits
in understanding and working with diverse clients
and communities (Doorenbos & Schim, 2004;
Doorenbos, Schim, Benkert, & Borse, 2005; Schim,
Doorenbos, & Borse, 2005; Schim, Doorenbos, Miller,
& Benkert, 2003).
Nursing has the theoretical foundations to engage
in a proactive shift toward social justice. Reed (1995)
described a neo-modernist perspective in her treatise
on nursing knowledge for the 21st century. Within this
perspective, nursing scientists must link the process
of critique to a metanarrative that is found in nursing
philosophy and nursing practice. Still, it is important
to be cautious as in many arenas of nursing, these ideals are visions of the desirable rather than the actual
(Corley & Goren, 1998). The institutions, societal
norms, and reference groups within nursing practice
create a dark side of nursing (p. 99) that perpetuates
stigma and lack of just care. As Drevdahl (1999) suggests, staying moored to the familiar and comfortable in nursing theory [and practice] is limiting (p. 1)
and potentially destructive to the profession.

Nursing education, practice, and research

We provide a revolutionary challenge: to develop approaches to nursing education, practice, and research
that utilize an expanded nursing metaparadigm with

Schim et al.: Social Justice and Urban Health Nursing

social justice added at its very core. We believe

that there are four initial approaches to achieving this
ambitious goal.
First, urban health nurses can adopt Barrys
justice as impartiality as the common definition of
social justice that is free from the political inuence of
the moment. Emphasis must shift to population
health over individual health, to disease prevention and health promotion over intensive care, to
community care over hospital care, and to the pursuit
of quality of life over quantity of life.
Second, the new metaparadigm of nursing with
social justice at its center must be taught to nurses
currently engaged in practice as well as those entering
the eld. As demonstrated by Bell (2005), some
nurses do not accurately dene social justice, let
alone apply a social justice as impartiality orientation in their practice. Bell found that only nurses age
50 and older had social justice as part of their vernacular or their lived experience. Nurse educators can
seek ways to teach and model social justice through
service learning, community commitment, and emphasis on the common good. One community health
faculty member, for example, assigns a Heart & Soul
project to senior undergraduate students. Books are
selected from a reading list of ction and nonction
works that address such issues as ability/disability,
race, ethnicity, gender, immigration, marginalization,
discrimination, and health economics. Students then
work in groups to present the books to their colleagues through skits, videos, slideshows, poetry, or
other creative expressions (Schim, 2004). Student
evaluations reveal that for many, this assignment
provided a rst opportunity to think in-depth about
the worldviews of people who are in various ways disadvantaged and to consider the moral implications
for the students own nursing practice.
The third way to utilize the expanded metaparadigm is for nurses to work consciously to diversify the
profession. Nursing and other health professionals
are making only modest gains in recruiting traditionally underrepresented minorities into the discipline
(Barbee & Gibson, 2001; Buerhaus & Auerbach, 1999;
Coffman, Rosenoff, & Grumback, 2001; Sullivan Commission on Diversity in the Healthcare Workforce,
2004). A concerted effort to enhance the recruitment
and retention of racial, ethnic, gender, and other diverse groups into nursing, and specifically engaged in
urban public and community health nursing, has the
potential to enhance our service with multiple popu-

77

lations. Diversication of the nursing workforce is one

of the national goals of Healthy People 2010 (2000)
because it is associated with expanded public trust,
acceptance, and access to quality health services
(Objectives 18). One example of an initiative in
this area is a Midwestern nursing college, which has
obtained state and federal funding to enhance specifically the recruitment and retention of African American prenursing students through a Future Nurse
Professionals program. The program provides
mentoring and guidance to students who may benet
from additional support during their initial year of
socialization in an academically challenging college
environment.
Next on the list of ways we can achieve a new
paradigm is for nurses to promote primary and secondary prevention at the local, state, national, and international levels through political action. Using a
variety of approaches such as coalition building, campaigning, confronting, and convening community
partnerships, nurses working for urban health have
the skills and abilities to leverage political power for
change. Nurses can work to ensure that communitybased health care services survive politically motivated cost cutting. We can speak along with those
who are, all too often, not given a voice when budgets
must be right sized. We can assist communities to
speak for themselves. We have demonstrated the ability to conduct research that addresses health concerns
from the perspectives of diverse populations that have
not had active roles in the creation and use of research
ndings before (Jackson, Early, Schim, & Penprase,
2004; Kulwicki, Miller, & Schim, 2000; Kulwicki &
Rice, 2003). Nurses must also advocate for increased
and continued funding for Medicare, Medicaid,
and nurse-managed centers, along with health departments and community social and health service
agencies. Building bridges of social justice across
populations requires available, accessible, affordable,
and sustainable health care that is equitably and
impartially distributed without regard to personal
advantage or disadvantage.
Equally important, nurses can keep doing what
we in public health nursing have been doing for many
years: demonstrating the efciency and effectiveness
of nursing services for meeting the needs of special
urban populations. For example, nurse-managed
centers have provided direct primary health care
access to uninsured and underinsured communities
for many years (Glass, 1989; Glick, 1999). In fact,

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a consortium of nurse-managed centers in Michigan,

which included several clinics associated with the authors own institution, has provided a safety net of
needed health care to multiple urban communities
(Pohl, Vonderheid, Barkauskas, & Nagelkirk, 2004).
Increased use of Certied Nurse-Midwives (CNM) is
also making positive contributions to womens perinatal outcomes in urban environments. CNMs have
historically cared for women who are ethnically
diverse, using Medicaid or reporting no insurance,
and clients representing younger age groups (Declercq
et al., 2001). In addition, Davidsons (2002) comparison of high-risk womens outcomes in an urban health
setting revealed that the CNM clients experienced incidences of complications that were similar to or better
than national averages. In an era of limited access
to care in urban medically underserved areas,
advanced nurse practitioners, such as CNMs, provide
high-quality cost-effective care within the context of
overall community social justice principles.
Preparation of more advanced practice nurses
(MSN/CNS) for community health and urban public
health practice and administration is necessary to
support an expanded focus on population health.
Nurses educated at the MSN level are able to bring a
unique and valuable population perspective to their
various roles in traditional health departments, health
systems, workplaces, schools, jails, parishes, and community agencies. As both graduate and undergraduate
curricula are pressured to include ever-increasing
amounts of critical care and primary care content,
community and public health programs are threatened. Introduction of the core content specific to
population health with an emphasis on social justice
is imperative in the preparation of nurses for practice
in urban health nursing at all levels.

Conclusion
Our revised model of urban health nursings metaparadigm can enhance our effectiveness in addressing
pressing urban health issues and add signicantly to
acquisition of disciplinary knowledge (Thorne, 1997).
Margaret Mead is often quoted as having said, never
doubt that a small group of thoughtful committed
people can change the world. We have no doubt that
nurses can change the future, but it remains a challenge to each of us to embrace the notion that part of
nursings social mandate is to assure the health care
rights of all people, whether known to us as patients or

January/February 2007

not. We must not perpetuate a health care system that

needlessly abandons nearly one-third of its patients in
the United States and countless millions in the world
at large. Nurses are in a unique position of access to
diverse communities and have the privilege of working with the most vulnerable groups as well as with
people at their most vulnerable moments. We are experts at helping patients, families, and communities
to navigate and negotiate in complex systems to get
their needs met. We need to expand our efforts now to
focus on a new social justice orientation that propels
us to change systems and then to change ourselves as
a profession. The preferred future requires a proactive
and conscious decision to change our traditional philosophy of social justice as practiced at the individual
level to one practiced at the population level.
We offer a challenge to our nursing colleagues to
embrace the notion that nursings focus should be
assuring the rights of all people. We hope to spark a
revitalization of the metaparadigm concepts with
an added central philosophy of social justice. Equal
access to the benets and protections of society
are characteristics of a just society and a caring
profession. We cannot maintain a status quo that epitomizes the divisions between rich and poor, urban
and suburban, dominant race/ethnicity and dominated race/ethnicity, by being a separate enclave with
little access, relevance, or tolerance for the majority of
our populations. We must stand up for a social justice
framework of care.

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