Redefining nursing solidarity

What is already known about the topic

• Solidarity and care are relational practices.

What this paper adds

• An interdisciplinary examination of the primary meaning of solidarity.

Introduction

Solidarity is at the heart of nursing practice, and education as an intrinsic component of care and, more generically, a value-driven factor for sustainable healthcare systems.^1–4 Moreover, the COVID-19 pandemic lifted the idea of solidarity to its peak by increasing the possibilities of practicing it, especially by frontline nurses. ⁵

Recent research shows that among other things (1) solidarity and care are relational practices ⁶ ; (2) colleague solidarity influences positive, innovative behavior, self-efficacy, and nursing career success ⁷ ; (3) intergenerational solidarity benefits the individual’s physical, mental, and social well-being as well as a country’s economic well-being ⁸ ; and (4) solidarity plays a relevant role in mental well-being during the COVID-19 pandemic. ⁹

However, as Derpmann has pointed out, ¹⁰ there is no coherent notion of solidarity. In the area of bioethics, Prainsack and Buix have similarly concluded that “There is, on the whole, no coherent way in which the term solidarity is used in bioethics.” (11, p. 36) In the area of healthcare, as Ben Davies and Julian Savulescu have noted, the word is used in the general sense of mutual support, which “includes a willingness to promote others’ interests, or the interests of the group, even at personal cost” (12, p. 133). It can act as a “descriptive concept” or a “normative motivation,” and it is sometimes characterized as “we-thinking” (12, p. 134).

Due to the variety of relations, attitudes, and dispositions that are commonly referred to as solidarity, Uslusoy and Alpar ¹³ developed a Colleague Solidarity Scale for Nurses (CSSN), measuring values such as respect, trust, honesty, teamwork cohesion, tolerance, mediation, spiritual relief, orientation, participation, friendship, sharing job experiences and knowledge, integrity, responsibility to achieve a common goal, and mutual collaboration. All of these values are related to solidarity, but none of them is precisely solidarity.

Prainsack and Buyx affirm that “most people have a need and greatly benefit from helping and supporting others and from seeing what connects us instead of what sets us apart” (14, p. 154). They based solidarity in healthcare on “people’s recognition of similarity with others” (14, p. 154). In the 2017 Nurse Declaration of Solidarity and Resistance, solidarity appears only in the title, but it is related to integrity, nondiscrimination, nonintimidation, nonviolence, and nonoppression. ¹⁵ In the 2018 Report on Health Systems for Prosperity and Solidarity, ¹⁶ the word solidarity is used about equality and participation in the sense of “leaving no one behind.” ¹⁶ Examples abound.

To solve the problem of an ambiguous and confusing use of the notion of solidarity in the area of nursing and the lack of a clear definition of nursing solidarity, this article tries to capture the original or primary meaning of solidarity. The original or primary meaning of a concept was called by classical authors^17,18 the first analogate (primum analogatum) because it presupposes no other meaning (and is therefore primary) but is itself presupposed by any other added meaning (analogy) of the concept. The primary meaning comes before the development of any other meanings of the word, and it is always authentic and genuine because it does not derive from something else.

This article finds the most original idea of solidarity in ancient Roman law --specifically, in the so called obligatio in solidum, which involved group liability of joint debtors (Solidarity: A Roman law concept). Other meanings of solidarity --adopted during the French Revolution and international labor movements, and in social ethics or classics of sociology, such as Émile Durheim’s The Division of Labor in Society (1893) --are deeply based on this archetypal meaning found in Roman law.

Once the article establishes the archetypical meaning of solidarity, it translates this meaning into the area of nursing and offers a completely new definition of nursing solidarity. The authors acknowledge the limitations of the presented analysis but also underscore its potential benefits for nursing theory and practice. Clarification is always an achievement, and this is exactly the goal of this article: to make the concept of nursing solidarity less confusing and more beneficial and to establish a broad framework for the idea of nursing solidarity.

Solidarity: A Roman law concept

The word “solidarity” is derived from the Latin solidus (solid). Although the term was first pronounced in French (solidarité) and in the context of the French Revolution, the idea of solidarity is as old as Roman law.^19–25

Roman law uses “solidarity” (in solidum) to describe joint and several liabilities—for example, when several debtors, creditors, or wrongdoers share entirely and at the same time in certain obligations stemming from a stipulation, a contract, or a private wrong (delictum).^24–26 Roman solidarity captures the idea of one for all and all for one. ²⁷

In his well-known textbook called Institutes, the Roman jurist Gaius resorts eight times to the expression in solidum. ²⁸ For example, in Institutes 3.121, Gaius tells us that, before the emperor Hadrian changed the law through an official letter (epistula), sureties were bound jointly and severally for the entire amount of the debts of the principal debtor. The creditor was at liberty to collect the whole debt either from the debtor or from each of the sureties. ²⁸ In another example, in Institutes 4.71, Gaius explains that when a father places his son or his slave in charge of a ship or other business, the liability is in solidum—shared by the father and the son or slave. ²⁸

Roman law required that such solidary liability be expressly stated in cases of entire (in solidum) liability deriving from a contract or stipulation. Solidarity is, however, presumed in the case of contracts concluded in the name of all the collective partners of a bank.^29,30 Examples of liability in solidum abound in the Roman sources.^24–26 Yet the idea that underlies and unifies the various cases is always the same: the obligation is rendered as a whole, and everyone is bound by or liable for the whole because even if more than one person is involved, only one obligation is rendered (plures in unum—many in one). For this reason, if one person bound by the whole dies, the remaining persons remain liable for the entire. ²⁵

According to the primary Roman law pattern, solidary liability can be for evil as well as for good (e.g., two thieves acting in solidarity to steal a painting). Solidarity refers to the liability derived from an action, but it does not establish a moral judgment over the concrete action linked to solidary liability. Following this original meaning, for instance, Martin Luther King Jr affirms that, alongside absolutely charitable solidarity, one also finds the “brutal solidarity” of those “who act out of the opposite of love—for example, working together with the common goal of burning down the huts of a poor village for exploitative purposes” (31, p. 162). There is thus a need to connect the concept of solidarity more closely with good causes and, specifically, with justice and love.

Constituent elements of solidarity

The transplantation of the term solidarity from its original legal field to other areas, deleting all exclusive legal components, shows that the primary meaning of solidarity is a responsibility shared as a whole by two or more people. Therefore, constituent elements for the existence of solidarity are (a) something to be shared (a unit); (b) responsibility as a whole derived from the common sharing (entirety); and (c) a relation of interdependence among the sharers (a plurality of persons).

These constituent elements can be identified in different areas in which solidarity is applied. For example, ecological solidarity is the responsibility to look after the universe, and particularly the earth, as a shared treasure to be enjoyed by all people responsibly, without damaging it, to preserve it in its integrity for future generations.^22,29 Ecological solidarity exists because humanity (a plurality) has a responsibility as a whole (entirety) for the conservation of the planet (unit). This means that if only one human being remained on the earth after a cataclysm, that lone individual would have to continue carrying the entire responsibility for the planet’s conservation.

These constituent elements of the definition of solidarity are also present in the area of nursing and should be a part of the definition of what can be called nursing solidarity.

Defining nursing solidarity

In view of the original meaning of Roman law solidarity, the authors define nursing solidarity as the responsibility for the healthcare of a person (unit) shared as a whole (entirety) by that person and a nurse or a nursing team (plurality).

a) Responsibility: Nursing responsibility is the professional commitment (with legal and moral implications) to participate in a healthcare interpersonal relationship. Nursing responsibility is not about minimums (legal liability) but about maximums (free and voluntary service). This explains, for instance, the supportive behavior of thousands of retired nurses who have provided free services during the pandemic far beyond legal and even ethical responsibilities, and the heroism of millions of nurses during the pandemic who suffer from lack of personal protective equipment, risk of contracting COVID-19, extreme workloads, and burnout.^32,33 Volunteers are one of the greatest strengths in nursing practice, especially in critical-care nursing practice. And responsibility affects these volunteers too.

The continuous practice of solidary responsibility turns into a stable spiritual attitude that can be appropriately called a moral virtue. As John Paul II pointed out, this virtue “is not a feeling of vague compassion or shallow distress at the misfortunes of so many people, both near and far. On the contrary, it is a firm and persevering determination to commit oneself to the common good; that is to say to the good of all and of each individual because we are all really responsible for all” (34, no. 38). Because cultural distillations of collected virtues become values (35, p. 255), solidarity can also be considered as a value (36 nos. 114-17), and even as a vocation: the vocation to take care of others in solidarity (36, p. 16).

b) The person as a unit: Solidarity requires an entire unit to be shared, that is, an entity regarded as single and complete but capable of being a part of a larger or more complex whole. In nursing, this unit refers not to the patient’s health but to the person of the patient as a whole.

Individual physical and mental health as such cannot be the object of solidarity because it cannot be shared by others, strictly speaking. Individual well-being is not shareable. But although one cannot share, so to say, one’s own pain, one can communicate it to others. This communication is the beginning of a personal relationship in which the entire person, as an indivisible unit, is involved and becomes the unit shared among the patient and healthcare providers.

Persons are not self-enclosed beings. Personal identity goes deeper than every specific human quality. ³⁸ Any person is open by nature to relation, communion, and love with other humans possess and can share rationality and the capacity to know and love and pursue the good. As French philosopher Jacques Maritain (39, p. 148) affirms: “The human person tends to overflow into social communications in response to the law of superabundance inscribed in the depths of being, life, intelligence, and love.”

Since healthcare affects the whole person, nursing is a person-centered practice, in the sense that it puts persons and their families and their preferences, needs, and values at the core of all decisions. ⁴⁰

The fact that the health unit is the person as such has at least the following implication: Nursing solidarity is universal in scope. Nursing solidarity can be practiced by people of different cultures, values, and beliefs and for people of different cultures, values, and beliefs. If nursing solidarity were only a matter of sharing values and beliefs, feelings, and emotions, no matter how important they might be, nursing solidarity could be selective and exclusive and not applied to critically ill patients whose beliefs, values, and emotions are hard to discern. Again, nursing solidarity touches the person as such—each individual human being—not just an abstract idea, however good it might be.

This universal character of nursing solidarity demands a multidimensional or holistic approach to nursing solidarity, which implies the recognition of the physical, emotional, psychological, social, and spiritual dimensions of each person and their families and communities.^37,41–44 This holistic approach is not optional but is the only approach compatible with practicing profound solidarity in nursing and therefore the only one possible according to the definition of solidarity this article proposes.

c) Plurality of persons: Nursing solidarity requires a relation of holistic interdependence between at least two persons: a patient and a nurse. They develop a true partnership in which each one has a specific role. The sharing of responsibilities, born from a personal encounter between the nurse and the patient, emerges when the patient recognizes his or her dependence on others. The nurse accepts that partnership and subsequent responsibilities after realizing her or his caring capacity. Although the roles of patient and nurse are different, both are equal in this personal relationship. Nursing solidarity rejects any sort of submission, coercion, or discrimination. Any dominant position is incompatible with true nursing solidarity.

Paraphrasing the American Nurses Association statement, one can say that “nursing is the solidarity that holds a patient’s health care journey together” (45). Without solidarity, no care is possible, and without care, nursing does not exist. Without solidarity, one can administer medicine, check vital signs, and develop many other simple or complex health practices, but this is not strictly caring or nursing. As the American Nurses Association affirms, “nursing is the glue that holds a patient’s health care journey together” (44 website). This metaphorical glue is technically called solidarity.

This basic pluralistic structure of nursing solidarity can be expanded horizontally, both on the patient’s side and on the nurse’s side. On the patient’s side, solidarity is extended to the whole family community and facilitates the development of person- and family-centered care. ⁴⁰ Person- and family-centered care takes advantage of the relevant roles played by the patient’s family members as devoted companions, loyal advocates, close care providers, and faithful surrogate decision makers.

On the nursing side, solidarity is expanded horizontally to the nursing team, the health community, the public health system, or even humanity, as in the case of COVID-19. Since the multidisciplinary teamwork approach to practice care is the ordinary and more effective way of working in healthcare communities, the possibilities of expanding solidarity in nursing have grown in our time.

Some implications of the proposed definition of nursing solidarity

The definition of solidarity proposed in this article has relevant implications in nursing practice and education. The main reason is that any system, such as the healthcare system, which basically depends on the sharing of responsibility must also share a common set of values that encourage an effective sharing of these responsibilities.

This section links the proposed definition of solidarity with some important values in the area of nursing practice and education. This definition of solidarity contributes to:

a) Fostering respect and avoiding discrimination: The “we” of nursing solidarity established by the sharing of responsibility does not undermine the individual self but enhances and expands it. Therefore, the first requirement of nursing solidarity is a deep respect for each human person of the health community and for his or her rights and dignity. The most basic sign of this respect is avoiding any discrimination, whether based on race, sex, sexual orientation, religion, belief, age, culture, nationality, health status, lifestyle, mental or physical ability, or socioeconomic status. ⁴⁶

Any discrimination (e.g., based on religion or race) ⁴⁷ constitutes non–solidarity-based exclusion and must be eradicated from the healthcare community. On the other hand, solidarity-based exclusions (e.g., disqualifying corrupt nursing from practice) are not discriminatory because they protect the solidarity of the whole health community in accordance with justice. This distinction between solidarity-based and non–solidarity-based (i.e., discriminatory) exclusion is crucial for developing a healthcare community based on justice and solidarity. ²⁵

b) Promoting cohesion in health communities: The sharing of responsibility that characterizes solidarity promotes cohesion, order, and integration in health communities instead of fracture and isolation. The sharing of responsibility contributes to creating a we-centered culture and thinking, that is, a conscious identification with the health community. Nursing solidarity, understood from its original idea, helps increase Jenson’s ⁴⁸ five dimensions of cohesion: the sense of belonging, inclusion, participation, recognition, and legitimacy.

Nursing solidarity joins nurses and patients in a single health community (plures in unum). It also helps coordinate efforts with others to achieve common goals and interests and increase the capacity to act as members of the healthcare community. Economists agree that cohesion has an essential impact on economic growth and other social outcomes^49,50 since solidarity creates communities based on a commitment to values. These values are community-centered and not self-interest-centered since they are based on a sharing of responsibility.

c) Increasing individual responsibility and spirit of service: Nursing solidarity, in the sense in which it is understood in this article, is a way of expanding the personal responsibility of sharing and serving. Solidarity helps one to see others as persons to be in communion with (sharing) and to capture the needs of the other members (plurality) of the health community (serving), especially the patients (caring). It also helps to increase healthcare communities’ capacity to produce collective goods. ⁵¹

Conclusion

Solidarity is a significant concept in nursing, but it is used in a vague and unclear way. This article has explored the idea of solidarity from its historical concept in Roman law, from the perspective of a shared responsibility, and then from the notion of nursing solidarity being a shared responsibility in care.

Following the steps of determining the primary or archetypal meaning of solidarity, this article has proposed a new definition of nursing solidarity as the responsibility for the healthcare of a person (unit) shared as a whole (entirety) by that person and a nurse or a nursing team (plurality). Thus, nursing solidarity is a responsibility—that is, a professional commitment—with legal and ethical implications and, by extension, an attitude, a virtue, a value, and ultimately a way of being and living in nursing. Nursing solidarity in the sense explained in this article has a lot of potential in the area of nursing because it touches the nursing metaparadigm at its heart, and especially the nurse/patient personal relationship. The proposed definition of solidarity leads to the idea that nursing is the science and practice of healthcare solidarity.

Being consciously aware of this definition of solidarity and its constituent elements (unit, plurality, and shared responsibility) may influence nursing practice and education in the following directions: (a) fostering respect and avoiding any kind of discrimination; (b) promoting cohesion in health communities; (c) increasing individual responsibility and spirit of service; (d) stimulating motivation; (e) producing a more engaging workplace, which can impact nursing care and well-being; f) improving communication; and g) developing leadership.