Received: 18 January 2022 | Revised: 20 July 2022 | Accepted: 29 September 2022

DOI: 10.1111/nup.12415

DIALOGUE CONTRIBUTION

Positionality

Carole Rushton PhD, Honorary Research Fellow

School of Nursing and Midwifery, College of Science, Health and Engineering, LaTrobe University, Melbourne, Victoria, Australia

Correspondence: Carole Rushton, PhD, Honorary Research Fellow, School of Nursing and Midwifery, College of Science, Health and Engineering, LaTrobe University,
Melbourne, VIC, Australia.
Email: clogs2clogs@gmail.com

KEYWORDS
positionality, power, transformation, translation

1 | INTRODUCTION capabilities, is enormous. They are impelled to actively participate

In this essay, I discuss the implications of the notion ‘positionality’ for
understanding the transformative capacity of nurses and the nursing
profession. Positionality can be used to denote ‘how’ and from
‘where’ nurses construct meanings for themselves relationally and
how they then act in accordance with these meanings in the places
where they work. Drawing from the nonnursing literature which is
heavily influenced by Foucault, an argument is put for why nursing
must take seriously this notion of positionality, first, when trying to
understand nurses' participation in health policy and reforms and,
second, why these may or may not be enacted as expected. Examples
of positionality from the nursing literature are drawn on to support
the argument for more specific theories of power and to make sense
of the heterogeneity and indeterminacy of nurse's positionalities.
I conclude this discussion by proposing that positionality be viewed
from within the combined schemata of power provided by govern-
mentality and actor‐network theory: ‘governmentality in action’.
Finally, I suggest that nurses focus on controversies, paradoxes and
dilemmas in health because this is where the transformative potential
of nurse's positionalities become most apparent.
2 | BACKGROUND
Nurses are ubiquitous and typically comprise the largest component
of most health care workforces (World Health Organisation, 2020).
The transformative potential of nurses and their aggregate, that is,
‘nursing’, through individual enactments of their collective
in health policy agendas and health reforms translated via the various
codes and mandates fashioned to govern their practice (International
Council of Nursing, 2012; World Health Organisation, 2020).
For example, nurses are mandated to ‘promote an environment in
which the human rights, values, customs and spiritual beliefs of the
individual, family and community are respected’ and to advocate ‘for
equity and social justice in resource allocation, access to health care
and other social and economic services’ (International Council of
Nursing, 2012, p. 2). Promoting respect and addressing social
disparities across health care systems are formidable tasks indeed.
However, evidence demonstrating nurses' success in either of these
two arenas remains ambiguous (Altman et al., 2020; Hassouneh,
2006; Johnson et al., 2021; Kerr & Macaskill, 2020; Phelan et al.,
2020; Rafferty, 2018). For example, there are too few reports from
practice, in the nursing literature, detailing successful implementation
of person‐centred care. Narratives espousing the benefits of person‐
centred care are far outweighed by those highlighting obstacles to its
implementation suggesting that person‐centred care policy and
strategies remain largely aspirational. Nurses' ability to mitigate
racism and social disparities have also been brought into question
(Altman et al., 2020; Johnson et al., 2021). Some attribute the lack of
progress in this arena to contemporary approaches in nursing
education such as the ‘cultural competency model’ and ‘transcultural
nursing’. Some claim these approaches depoliticise social difference
and disparity by ignoring the power differentials that brought them
into effect in the first place (Altman et al., 2020; Hassouneh, 2006).
Central to the problematics of person‐centred care and social
disparities in health is a proclivity within nursing towards

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https://doi.org/10.1111/nup.12415

2 of 5 | RUSHTON
dualistic ways of thinking about relationships. Furthermore, to
assume a position as a ‘nurse’ means assuming an identity that
maybe paradoxical, essentialised, normative, static, epistemically
privileged/epistemically oppressed and politically neutral (Alcoff,
2005). Correspondingly, nurses' relationship to power is oftentimes
represented as one of oppression and constraint. This ignores
the subtle ways in which nurses are willingly conscripted into or
else resist regimens of power. It also raises questions about the
‘transformative capacity’ of nurses for meeting contemporary
expectations that they perform as ‘agents of change’, ‘entrepreneurs’
or ‘innovators’ (Cusson et al., 2020; International Council of Nursing,
2012; Rafferty, 2018; World Health Organisation, 2020). The
construct ‘positionality’ displaces the hegemony and binarity of
agency versus structure, essentialisms and oppressive, omnipotent
conceptualisations of power intrinsic to prevailing constructions of
the nurse identity. Positionality assumes, instead, that nursing
identities are multiple and diverse and co‐constructed within
networks of power that are both repressive and liberatory
(Alcoff, 2005).
2.1 | The relevance of positionality for nursing
Many have written on the topic of positionality but it was cultural
feminists, such as Alcoff (2005), that popularised the term in the late
1980s. Alcoff (2005) used the construct positionality to address the
‘identity crisis in feminist writing’ and to subvert hegemonic and
essentialist constructions of what it meant to be a ‘woman’. Alcoff
(2005) argued that rather than viewing ‘women’ as having natural and
innate or ‘essential’ qualities, positionality requires that ‘women’ be
viewed instead as being constructed relationally within a ‘constantly
moving context’. Alcoff (2005) argued further that ‘women’ as a
specific positionality can be seen as the place of the ‘self’, where
values and meaning are mediated by lived experience, constructed
and deployed purposefully into a context in ways that alter that
context. In 2011, Lutter reported findings from a study that explored
the influence of gender on registered nurses' intentions to leave the
profession, which are particularly germaine given global nursing
shortages (World Health Organisation, 2020). Lutter (2011) con-
cluded that experiences and career intentions were affected not only
by gender but also by ‘social structures’, which impacted on the
nurses' positionality, the nurse's access to power and intentions to
leave. We might derive from Alcoff's (2005) description of
positionality and findings by Lutter (2011), that lived experience
alone does not contribute to a person's positionality and transforma-
tive potential nor should we consider the systems of power and the
nurse's positionality as two discrete forces. As Alcoff (2005, p. 86)
urged, we need to consider the coconstitutive effects of power and
positionality.
Where the salience of identity is affirmed, it is
sometimes all too easy to then concretize identity's
impact, to assume clear boundaries, and to
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decontextualize and dehistoricize identity formations.
In reality, identities are much more complex than any
of these caricatures will allow.
The concept of positionality, as it applies to nursing, politicises
the role of ‘nurse’ as a definitive yet fluid identity which is mediated
by the nurse's lived experience and the socio‐materiality of the
contexts within which they work. To be a ‘nurse’, therefore, is to
assume a position in a mutable context bounded by its materiality and
social mandates that sanction the ‘nurse’ to speak and act in certain
ways that alters not only ‘the nurse’ but also the people and things
that surround them.
Despite the obvious relevance to nursing, particularly as a
female‐dominated profession, the construct positionality has only
limited presence in the nursing literature, except in discussions about
nursing research and specifically qualitative research (Borbasi et al.,
2005; Fenge et al., 2019). The relevance to nursing practice is less
well explored which is interesting because this is where real change is
enacted through the choice nurses make during the delivery of care.
For example, in the 2020 review of developments in person‐centred
health care, Phelan et al. (p. 20) make reference to positionality, but
only in relation to the conduct of nursing research. This contrasts the
importance afforded positionality in the implementation of health
reforms noted by Lee et al. (2021). Reporting on the translation into
practice of equity and inclusion policy in health care in Aotearoa/
New Zealand, Lee et al. (2021, p. 1) found that, “The translation of
such policy into practice is…convoluted by subjective interests and
power differentials and thus the outcomes of policies may deviate
from their original objectives.” The authors concluded that personal
biographies and the study participants' positions within the organisa-
tion had influenced their enactments of policy that deviated from the
original intent of the policy. Extrapolating from Lee et al. (2021),
nurses must take seriously the notion of positionality for practice
because of the effects it may have on the translation of policy and
health reforms. It follows, therefore, that understanding positionality
has implications for understanding the transformative potential of
nursing.
2.2 | What do examples of positionality in nursing
tell us about positionality?
Insights gleaned from the study by Lee et al. (2021) are useful for
understanding how policy crafted in one context might be subjected to
alternate translations in another, such as practice. However, if we accept
the central premise of positionality as being constituted with relations of
power, then the above merely states the obvious. An essential
presupposition of positionality is that it is mediated in part, by a
person's lived experience and personal biographies where
reinterpretation is inevitable and can lead to the production of multiple
and indeterminate outcomes. Lee et al. (2021) later conceded that their
analysis had reinforced the need to examine broader structures of
power, particularly the productive effects of these.

RUSHTON
To illustrate this latter point, accounts from two of the very few
examples in the nursing literature where nurses' positionalities during
practice were explored explicitly, revealed how nurses' different
positionalities resulted in very different actions and outcomes. For
example, the first study involved an exploration of the management
of pain by nurses working in a multicultural setting. Rushton (1995)
reported how the nurses' positionalities influenced whether they
sought ‘control over’ or ‘control for’ the person experiencing the pain.
How nurses positioned themselves relative to the person and by
drawing on their own experiences as Other, influenced how they
subsequently managed their time and approached the pain manage-
ment needs of the person. This is summed up in the following quote
by one of the participants in that study.
I try to take the time because I understand the
frustration of not being able to get the message
across. If you sit and take the time. And even in a few
limited words they know, it's just you sit and take the
time, you, they, will be able to get their message
across.
In a second study, Kerr and Macaskill (2020) reported on advanced
emergency nurse practitioners' perceptions of their role, positionality,
their professional identity and the implications of these for recruitment,
changes to organisational culture and supported transition into the role.
Unlike other studies at the time, Kerr and Macaskill (2020) elected to
explore the qualitative aspects of the role. They observed, that how
medical officers and senior nurse managers perceived the role and how it
had been operationalised had undermined the legitimacy of the role.
Correspondingly, nurses described a heightened sense of responsibility
and autonomy accompanied by higher levels of scrutiny than that
typically afforded to other nurses. For example, advanced emergency
nurse practitioners' performances were assessed primarily through their
capacity to balance provision of quality nursing care with predetermined
wait times and protocols (p. 1206). These factors combined to limit the
capacity of advanced emergency nurse practitioners to negotiate and
exercise influence within the organisation. The impact of these
constraints are summed up in the following quotes by the nurses (Kerr
& Macaskill, 2020; pp. 1206 & 1207).
The key stakeholders, who need to give you the
support because if you do not have support from the
Director of Nursing, who professionally is really your
line manager and then from the clinical perspective
from the Consultant, the governance just won't be
there for it to happen.
My work is defined by the protocols that I have to
work to…. and even within those protocols I am
limited as to what I can do.
Both the above studies reflect the diversity and heterogeneity of
nursing practice. They also illustrate that how power is exercised can
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| 3 of 5
be both freeing and constraining to produce very different,
sometimes undesirable outcomes.
2.3 | Revisiting positionality
In the preceding commentary, I argued that positionality needed to
be taken seriously if nurses are to understand the transformative
potential of their roles within the health care system and the
implications this has for making sense of their involvement in the
implementation of policy and reforms. I also argued that it was not
sufficient to merely situate nurse's positionalities within a ‘system of
power’ or as comprising the sum of ‘lived experiences’ or ‘personal
biographies’ Positionality is a composite of power, not just of one or
two but all of the aforementioned ‘factors’. Therefore, what is needed
are schemata of power that explore the interplay of power and
positionality, that implicates both human and nonhuman enactments
of power and which makes power recognisable. It is only when power
is enacted, irrespective of how mundane its presentation (Foucault,
1982; Law & Urry, 2004), that nurses might see where and how they
might either deploy or oppose power to achieve particular ends.
Governmentality and actor‐network theory (ANT) provide robust
theoretical bases from which nurses might consider the effects of
power in relation to nurse's positionalities and their transformative
potential as a profession (Dean, 1999; Law, 2004). Both have their
origins within poststructionalism and social constructionism which
assume that the world is both real and constructed. Where these two
approaches converge most intensely is around the assumptions that
how we give meaning to the world is constructed discursively and
politically and that these meanings are bounded by language (Berger
& Luckmann, 1967). Governmentality and actor‐network theory
(ANT) embrace ways of describing the complexities of social life as
something diffuse, plural and indeterminate. As well as these broader
epistemological contributions ANT studies in particular comprise
specific nominalisations, metaphors and neologisms that can be used
‘taxomatically’, to make visible the socio‐material effects of power,
such as governmental power. Furthermore, when used in unison,
each approach addresses well‐documented limitations of the other.
For example, ANT complements governmentality approaches by
overcoming their insensitivity to social variation and social heteroge-
neity (O'Malley et al., 2006) by focusing on the specific processes
through which power insinuates its way into our everyday lives (and
positionalities) by way of ‘translation’. Translation as defined by Rose
and Miller (2010, p. 279) is,
The relation between political rationalities and such
programmes of government is not one of derivation or
determination but of translation—both a movement
from one space to another, and an expression of a
particular concern in another modality.
Put simply, the construct ‘translation’ can be used to describe the
means by which a nurse's interests become tethered to the interests

4 of 5 | RUSHTON
of government. Governmentality approaches complement ANT by
providing ways to describe to the broader socio‐political context that
some ANT studies have been accused of lacking. The utility of
governmentality and ANT is enhanced when used in combination
(i.e. ‘governmentality in action’). The taken‐for‐granted and mundane
and ‘messy actualities’ (O'Malley et al., 1997, p. 509) of life can be
seen instead as effects of governmental power. A ‘Governmentality
in action’ approach (Rushton, 2014) challenges the inevitability and
obduracy of governmental practices by recasting governmental
power as mutable and therefore amenable to contestation. Power
is made more ‘real’, actual, relatable and perhaps most importantly,
recognisable. The normative and normalising effects of power that
typically work to conceal power itself, are made visible thereby
opening up spaces in which nurses might think about and do things
differently (Dean, 1999). Importantly, governmentality and ANT
provide languages that can be used to describe, in terms both general
and specific, how power is experienced and responded to by nurses.
If we take positionality as described by Alcoff (2005) and recast it
within the complex schema of ‘governmentality in action’, this
enables us to become more attuned to where in general we need
to look and, specifically, what it is we need to look at to register
power as it is being enacted. Positionality might be rewritten as:
How a person translates themselves (which includes
their lived experience and personal biographies) and is
in turn translated, relative to the objectives of
government, through a network of people and things
in ways that alters them (the person), other people, the
things and the network.
2.4 | The focus on controversies
The effects of power become most apparent during the controversies
that arise from different, sometimes competing values, attitudes,
practices and beliefs. It is here, also, that through the enactment of
nurses' multiple and diverse positionalities, that the transformative
potential of these positionalities can be seen most clearly (Dean,
1999; Venturini, 2010). As Foucault (1982) elaborates,
A relationship of confrontation reaches its term, its
final moment (and the victory of one of the two
adversaries), when stable mechanisms replace the free
play of antagonistic reactions…It would not be
possible for power relations to exist without points
of insubordination which, by definition, are means of
escape.
Here, Foucault (1982) introduces us to the notion of ‘stable
mechanisms’ where struggles for power are finalised and com-
pleted. In nursing, this might refer to whatever nurses accept as
‘given’, ‘as imperative’ or as ‘true’. For example, ‘key performance
indicators’ can be seen as ‘power tools’ that are normalising and
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evaluative when used for calculating the performances of
individuals and organisations (Dean, 1999). For example, Kerr
and Macaskill (2020) noted that the nurses in their study were
under constant pressure ‘to quantify and justify their workload’
against a whole range of ‘power tools’ including key performance
indicators. Interestingly, the normative status of these ‘power
tools’ meant that they did not register as such by either the
researchers or the nurses themselves. Foucault also proposed that
‘the free play of antagonistic reactions’ (or controversies) provided
a ‘means of escape’. The construct ‘translation’ was composed of
ANT theorists to encapsulate Foucault's unique conceptualisation
of power as being implicitly transformative and instituted through
contestation and controversy (Callon & Law, 1982; Callon, 1991;
Law, 2000). It follows therefore, that controversies in nursing
practice represent those sites where alternate realities and
outcomes can still be pursued. Take, for example, the study by
Sharp et al. (2018) where the researchers explored person‐centred
care in the context of an acute surgical ward. Contradictions
between nurses' positionalities and prevailing expectations regard-
ing the delivery of person‐centred care were seen by the
researchers as controversial. They recounted,
This nurse's suggestion that she must choose between
paperwork or time with patients is ironic because the
very documentation designed to promote individua-
lised care appeared to detract from it for these nurses.
Closer examination of the nurse's positionality might have provided
more insight into the choices made regarding care. It may have also
resulted in different questions being asked such as, ‘Why did the nurses
feel they had to choose between paper work and providing patient care?’
and, ‘Why was there not enough time to do both?’
3 | CONCLUSION
The purpose of this essay was to reinvigorate interest in the
construct positionality and to explore its utility for understanding the
transformative potential of nurses and the nursing profession.
Research demonstrates the importance positionality in the transla-
tion of policy and enactment of health reforms. Although researchers
recognised the importance of power in relation to nurse's position-
alities and their transformative capabilities, it is argued that more
robust theories of power were needed to provide more insight into
the heterogeneity and indeterminacy of these capabilities. I proposed
that ‘Governmentality in action’, which combines governmentality
and actor‐network theory, be used to help nurses become more
attuned to, and to register power as it is being enacted. By locating
positionality within these two complex schemata of power and
focusing on controversies, both the general and specific effects of
power, that either inhibit or potentiate a nurse's transformative
potential, become more crystalline. Specifically, more research is
needed to reveal how nurses' positionalities are being enacted and
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RUSHTON | 5 of 5

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