Place Knowing of Persons and Populations

Abstract

Place emerges when space acquires definition in social constructions of meaning as landscape-languages, which reflect assumptions about physical and social realities. The place work of nursing, which resonated throughout Nightingale’s work and the profession’s evolution, focuses on human health and healing in the historical transitions and landscape-languages of populations. However, evidence-based practice dominated by empirical knowing inadequately addresses complex health and illness dynamics between place and populations. Translating evidence to the life course experiences of individuals and populations requires place knowing of human situated embodiment within discrete space. An exploration of the concept of place, its application to nursing, and the need for a place paradigm for practice is presented. A sense of salience and situated cognition has been identified as the essential element of the transformation needed in the education of nurses. Place knowing integrates other patterns of knowing (empirical, ethical, aesthetical, personal, unknowing, sociopolitical, and emancipatory) in a situated cognition. Place knowing, like other established patterns of knowing, is a significant epistemological foundation of nursing. Place knowing allows the nuanced intricately complex dynamics of embodied situated human health and illness to be examined, the salience of the particulars to be considered, and the whole of the landscape-languages to emerge.

Keywords

place embodiment landscapes knowing displacement healing complexity

The physical and social world into which individuals are born and live out their lives generates dimensions of space, distance, and time that shape the dynamics of population health and illness. Population migrations, sociopolitical upheaval, economic crises, and environmental exposures are embedded within the experience of health and illness. Although health and illness are physical phenomena of the embodied human condition, they are also social constructions built from the interface of human populations with their environments. Place experiences affect the genesis, nature, and evolution of health and illness phenomena. The driving forces of many disease conditions, injuries, and illnesses are heavily dependent on the specific place experiences of persons and populations, suggesting there are limits to the benefits of an evidence-based nursing practice dominated by empirical knowing. Overreliance on empirical knowing diminishes the experience of place on the health and illness patterns of communities and populations occurring across generations. Discounting the impact of place can lead to health care interventions that are inappropriate, ineffective, and potentially detrimental to individuals and populations. The purpose of this article is to explore the concept of place, describe a place paradigm for theory-informed nursing practice, propose place knowing as a pattern of nursing knowing, and place work as the foundation of nursing practice.

Conceptualizations of Place

The need for a focused examination of place as different from the concepts of environment and context emanated from my research study of rural grandmothers raising grandchildren (Thomas, 2011). As with the grandmothers I studied, when individuals, communities, and populations mentally fuse the physical world and social dynamics into “organized world[s] of meaning” (Tuan, 1977, p. 179), the experience of space becomes place. Place emerges as a “negotiated reality,” the result of a social, cultural, historical, and physical environments becoming a type of language, a landscape-language, a common set of assumptions about social reality (Gesler, 1992, pp. 742-743). Past and present shape a community’s perception of place, filtering the image of the physical and social environment through a unique mental lens generating a vernacular reflecting a vision, a worldview, wherein the landscape becomes a type of language. The language-landscape is a type of text to be read, a “discourse materialized” (Cutchin, 2007, pp. 730-731) that must be translated and analyzed to determine its meaning. As the dynamics of physical and social environments change, landscape-languages evolve or rather they are always in the process of “becoming,” reflecting the dynamics of social networks and processes across space (Schein, 1997, p. 662). Tuan (1977) contends that place at every level of a social system has a dimension of meaning reflecting the politics, locale, ancestry, culture, and economics of populations across time. He describes a holistic experience of place:

The feel of a place is made up of experiences and it is a unique blend of sights, sounds and smells, a unique harmony of natural and artificial rhythms such as times of sunrise and sunset, of work and play . . . the feel of a place is registered in one’s muscles and bones. (pp. 183-184)

Microbiologist turned philosopher, Dubos (1972), examined the intense emotional experience of place, exploring how place may be experienced as sacred, spiritual, sensual, and social and suggests the spirit of a place is tied to the geologic formations, topography, climate, and latitude, that the “persistence of place results from the complex interplay between nature and culture” (p. 133). Place experiences contain a complex legacy of experiences that inscribe on the geographic terrain positive and negative labels, generating place perceptions that are powerful influences on health. The legacy of place experiences creates an embodied relationship to geographic locales across time. Persons and populations become tied to place, attached mentally and emotionally to physical locations, and experiences become internalized within the human psyche and physiology. Complex and subtle exposures to historical and contemporary physical, social, and symbolic environments of populations embed place into the sinew of society.

Place attachment has been defined by Milligan (1998) as the emotional bond to physical locations, which emerges from meanings associated with a specific site or location; a human–environment dynamic made up of two intertwined processes, the interactional past (place memories) and interactional potential (expectations about the future based on past place experiences). In agreement with Milligan’s definition of place attachment, Cutchin (2004) challenges the common adaptation-to-environment perspective that environment is a container, and human adaptation to the environment is a mechanistic, internal process. Instead, he proposes a place integration approach: “The human response to the emergent situation of place is to draw upon place, as it exists outside and inside the self, to act, and derive meaning in life” (p. 310). Place is not just setting or social structure, it is sustenance, succor to body and spirit.

The restorative effect of favorite places has been identified by Scandinavian researchers who found the more often urban residents visited their favorites places the stronger were reported feelings of well-being and being less stressed (Korpela, Ylen, Tyrvainen, & Silvennoinen, 2008). These researchers even proposed “favorite place prescriptions” to reduce stress (p. 649). In a study of urban Israeli communities the greater the number of close friends and neighbors participants could name and identify as living close by, the greater was their place attachment; place attachment was related to individual experience and subjective determination that their neighborhoods were good places to live (Mesch & Manor, 1998). Yet in physical locations with characteristics identified as conducive to good health, the internalized perception of place often appears to override the contextual infrastructure. Public health interventions, focusing on the built environment and targeting physical environmental factors such as enhanced walkability, have been found to have limited effect on outcomes (DeGuzman & Kulbok, 2012), suggesting that it is the perception of place that shapes the landscape-language. In a study of U.S. urban residents, a strong relationship between neighborhood poverty, allostatic load (physiologic stress indicators), neighborhood. and personal stress was identified (Schultz et al., 2012). Although a significant relationship existed between neighborhood poverty and allostatic load, there was no such relationship with household poverty; neighborhood poverty and allostatic load were mediated by neighborhood stress but not by health behaviors. Similarly, Johns (2011) noted that British neighborhoods, perceived to be dangerous or unsafe by young women at the time they conceived, were found to be stronger predictors of teenage motherhood than poverty indicators.

Place Exemplars

Caring for embodied persons living in complex physical and social environments across widely disparate geographic locations and care settings requires an understanding of how place shapes health and illness experiences, reflecting the need for place-centered geographic inquiry in primary health care research and practice (Andrews & Crooks, 2010). To care for embodied individuals in global populations, nursing must integrate knowledge about place experience, population health, and geography into nursing theory, research, and practice. Exploring exemplars of place-population concepts helps crystallize the implications of place dynamics that affect populations globally and builds integrated place-population knowledge development.

The place experience of rural and remote areas reflects an environment wherein symbolic meanings of physically isolated populations have been inscribed on landscapes across generations and often millenia of human habitation. Rural place dynamics shape explanatory models of illness and disease epigenesis, health behaviors, care decisions, access to care, and responses to illness that are intricately intertwined with the experience of the land. Rural belief systems stem from ideas about health, work, distance, and social relationships (Long & Weinert, 1998). Responses to geographic isolation amid the proximity of extensive social networks are different from urban communities. Rural and remote communities struggle with increased rates of diabetes, poor health, being uninsured, obesity, and preventable hospitalizations (Bennett, Olatosi, & Probst, 2008; Laditka, Laditka, & Probst, 2009; Lutfiyya, Lipsky, Wisdom-Behounek, & Inpanbutr-Martinkus, 2007). In my study of rural grandmothers raising their grandchildren, grandmothers struggled with poor physical and mental health and also grappled with the place experiences of physical and social remoteness and distance, describing them as both Isolation and Insulation, a weathering and welcoming dichotomy that they used to deal with the challenges of raising grandchildren in a rural location (Thomas, 2011).

When individuals and populations are marginalized or displaced from rural or remote areas to urban locations they carry the rural place within them, creating a dissonance between the understood landscape-language of their past and the unintelligeable landscape-language of the present. This dissonance is emotionally and physically draining when compounded with the challenge of living in a new country, where every aspect of life entails the crisis of trying to make meaning of physical and social space, trying to make place out of space.

In The Spirit Catches You and You Fall Down, Fadiman (1997) explored the cultural disconnections between the family of a Hmong child with epilepsy and the health care and social service professionals in an urban California area. Fadiman’s work has been cited extensively to highlight how poor health outcomes are related to a lack of cultural awareness and cultural competency by the health care community to its patient populations. The text presents a sobering picture of miscommunication—a lack of cultural awareness described in painful detail. However, the message lost in the narrative and in the subsequent widespread use of the narrative as a case study is the place experience impact on health and illness. At the time of Fadiman’s writing, the Hmong were a displaced rural people, political refugees following the fall of South Vietnam, living in urban American communities dramatically different from their mountainous, Southeast Asia homelands. The Hmong’s out-of-place experiences with the Californian community made their traditional practices appear bizarre to urban care providers yet made sense in their rural place experience. The Hmong were struggling with a place experience beyond culture, reflecting a historicity colored by uncertainty and chronic loss of the familiar rural place of their past.

Medical anthropologist Paul Farmer (2003) ties the health decline of the world’s poor to sociopolitical dynamics, linking political agendas and the global economy to the displacement of people, rural-to-urban migrations, and racial, ethnic, and gender discrimination. Using Haiti as a case study, he cites the concept of structural violence, identifying how the construction of hydroelectric dams displaced farmers to higher elevation, less arable land, reduced their ability to be self-sustaining, and led to massive migrations to cities for employment. He links migration of the rural poor to Haiti’s cities, economically driven employment in the sex trade, and the increase in HIV infections. The devastation of the terrain, built environment, and infrastructures by the 2010 earthquake, subsequent cholera epidemics, and tropical storms have inflicted further hardship on the beleaguered Haitian people (Ryan, 2011), providing somber reminders that disease and disability are the fallout of the physical and social context.

When people are marginalized or displaced, due to the experience of disease or illness (Bender, Andrew, & Peter, 2010; Wilde, 1999), family crises (Thomas, 2011), socioeconomics (Farmer, 2003), political upheaval (Fadiman, 1997), or natural disasters (Ryan, 2011), their life experience is characterized by being out-of-place. The urban displacement experience of rural people from farming communities and the diaspora experience of refugees transcend culture; they are about place. To focus on ethnicity or culture minimizes the immensity of the physical and social experience of place and displacement.

The accelerating demands of an increasingly aged population, the emergence of diseases of unknown origin and alarming virility (e.g., AIDS, SARS), reemergence of infectious diseases thought to be conquered or waning (e.g., tuberculosis), and chronic diseases reaching epidemic proportions in populations previously unaffected (e.g., type 2 diabetes in young children), are compelling arguments for a heightened urgency within the health care community to focus on the human experience of place in health and illness. A “qualitative epidemiology,” merging ecological and complexity theories to derive at a “person-in-context” understanding of health and illness, has been proposed as the theoretical approach needed to address the complexities of contemporary population health (Agar, 2003). A person-in-context focuses on health and illness as it is played out in the situated space of populations, “to understand the historical and social context and to emphasize the importance of diversity and local knowledge rather than looking for universal relationships” (Pearce, 1996, p. 682).

Place Theory in Nursing

Although often used interchangeably, the concepts of context and environment are not synonymous with the concept of place and are inadequate to explain the occurrence and dynamics of human health and illness. Nurse scholars have proposed theoretical explanations to guide nursing practice addressing the care of individuals and the interactions of their place experiences and social constructions, focusing on patterns created across the physical, social, and symbolic environments as critical factors in health and illness. Rogers’s Science of Unitary Human Beings conceptual model provides an organizing framework to explain the interaction between persons and the environment, describing the interaction as intertwined, dynamic energy fields, displaying discernible patterns that move pandimensionally and nonlinearly, ever evolving beyond temporal or spatial boundaries (Lutjens, 1991). Newman’s Theory of Health as Expanding Consciousness proposes the work of nursing as identifying and bringing to consciousness the patterns of the complex interactions between individuals and the environment and delving into the meanings embedded in these patterns (Newman, 1994). Parse proposes the Human Becoming School of Thought and nursing as a human science, contending that persons cannot be reduced to systems and parts (Parse, 1998). She explains that the preeminence of human subjectivity, the individual’s perception of being in the world and creation of a meaning attached to the moment, the situation, builds a co-constitution of meaning. Parse’s conceptualization of how being in the world is created resonates with explanations of the evolution of place and place experiences as described by many cultural geography, philosophy, and anthropology scholars (e.g., Tuan, Dubos, Cutchin, and Farmer). Particularly powerful is the theoretical language these nursing theorists employ, replete with the merging of words reflecting human perception, evolution, physics, and interconnectedness of person to place. Parse even specifies languaging as a concept of human becoming. The words Rogers, Newman, and Parse use in theory explication have often been criticized as obscure or so esoteric as to be alien to the everyday work of nursing. Yet this theoretical language is exquisitely consistent with the landscape-language of place perceptions and experiences. The meanings and interconnected patterns of persons and place as conceptualized by Rogers, Newman, and Parse reflect an emerging unified theoretical perspective to explain how place affects health. Place is ever changing as the uniqueness of the moment adds new import. Reflective of the paradoxical human becoming place experience patterns of Parse’s concept of cocreating, the spirit and feel of the place of a familiar location, as described by Dubos and Tuan, change as life course events, illness, loss, and social upheaval impose often paradoxical experiences of place.

Place Work and Nursing

The importance of context, the place experience of illness, and the creation of environments conducive to healing has resonated throughout the development of the nursing profession, as with the work of Nightingale and other nurses particularly those of the early and mid-19th century when creating a healing environment (“sick room management”) was viewed as the expertise of professional nurses (Selanders, 2010, Watson, 2010). The work of healers, and of nurses in particular, has been described as the creation of healing environments (therapeutic landscapes), work that requires a practice based on “a broader theoretical review of the dynamic between landscape and health” (Andrews, 2002, p. 230). However, creating healing environments requires an understanding of how place shapes human experience. Although assessment of the patient and environment of care has been foundational to nursing practice and an essential element to the nursing process, historically nursing assessment of communities is often limited, lacking depth, employing a windshield survey approach, focused on a predetermined health issues or disparities identified from database reviews of health and illness indicators. Nurses have often employed an inventory approach to population health, recording community dynamics as a function of present day social processes, and cataloguing cultural characteristics of subgroups within communities. This type of assessment sheds little light on place experiences (past and present) of communities; it provides an incomplete picture of health and illness dynamics within a population. To unravel ties between social dynamics and physical environments a place perspective is needed.

Individual and collective life experiences of the interactional past intertwined with ongoing experience shape how place influences social processes, creating the interactional potential. Examining how place goes beyond culture and reflects the interplay between humanity, topography, climate, and natural and built environments is necessary to grasp the interactional past and interactional potential of populations. However, even though there is growing support for examining lifetime allostatic load, life course pathways, fetal programming, and developmental origins of health and disease, and physical/psychosocial environmental stress exposures on population health (Armelagos, Goodman, Harper, & Blakey, 2009; Geronimus, Hicken, Keene, & Bound, 2006; Kingston, Sword, Krueger, Hanna, & Markle-Reid, 2012; Lu & Halfon, 2003; Schultz et al., 2012), nursing practice is becoming less place-focused and more dependent on technology that creates virtual places of care. Increasingly nurses interface with patients in distant locations via telemedicine, employing online case management modalities with an emphasis on evidence-based practice, best practices, care guidelines, and algorithms constructed from generalized research findings from data collected in many different locations and areas of the country, even across international borders. Evidence is often generated from practice settings, which are unlike place experience sites of rural and remote areas, or the geographic locations where people live. Recognizing the nature of evidence in contemporary health care, the nursing profession is challenged to pause and consider the imperatives demanded of site-specific practice. Nursing practice is in-place work wherein nurses engage in en face interactions with individuals, families, groups, and communities; a place work of presence that is the holistic nursing practice of persons and populations. A reexamination of practice is needed to focus on place work, the creation of health landscapes, to move beyond the uncritical implementation of evidence-based interventions, and tackle the numbing complexities of health disparities of diverse populations in often dramatically different locations and circumstances.

Place work involves delving into the in-place and out-of-place experiences of individual patients, their communities, and the sites of care. The out-of-place experiences of patients also involves coming to terms with the displacement of the healthy self to the unfamiliar place of an unwell body, described so powerfully by Wilde (1999) as the “adversarial body” (p. 33). Wilde speaks of embodiment, describing it as “being situated within the world and being affected by social, cultural, political and historic forces . . . embodied existence takes place within the contextual world that each person is born into and lives” (pp. 27-28). Sandelowski (2002) warns nurses of the challenges of contemporary practice amid the emergence of virtual realities, informatics, and interfacing with patients as images on flat screens. She cautions that nursing, traditionally a human care practice in close relationship with patients, working in the realm of attending to the ills of the body, may be losing its understanding of patients as embodied persons inhabiting discrete situated space. Sandelowski urges nurses to consider

while we have for a long time understood that “all life . . . operates on information,” only recently have we begun to think of life as information and information as life. Nurses must see body and information work as constituting each other and the body as a source of knowledge and power for nursing. (p. 68)

Place as a Pattern of Knowing

The physical and social distance, movement and displacement of individuals, communities, and populations locally and globally, requires knowledge of place to grasp the human experience of wellness and illness. Correcting the blurred confusion between place and culture requires a differentiation of and definition of the relationship of place to culture. Place is proposed as the overarching concept needed to understand population health and illness.

A place perspective allows nursing to approach practice, examining how embedded historicity and the landscape-language of communities and populations shape health and illnesses across time and space. A place perspective is suggested as that pragmatic approach, proposed by Burbank and Martins (2010), needed to build the theoretical bridge between symbolic interactionism and a critical theory perspective. Place, as a critical interactionism paradigm, incorporates a focused integration of all social levels, addressing them as reflected across the dimensions of place, yet anchors place dimensions as being embedded in the physical environments of human inhabitation. The critical interactionism Burbank and Martin describe is at its most basic, a place paradigm.

The patterns of knowing in nursing, described by Carper (1978) as empirical, ethical, esthetical, and personal knowing, identified an epistemological and philosophical foundation to build nursing science. Since Carper’s groundbreaking explication of nursing knowing, nurse scholars have expanded on her work, proposing other patterns of knowing fundamental to nursing: unknowing (Munhall, 1993), sociopolitical knowing (White, 1995), and emancipatory knowing (Chinn & Kramer, 2011). However, the challenges presented by the increasingly complex health and illness dynamics of populations across a global spectrum require an epistemological foundation for practice that supports and strengthens examination and analysis of place dynamics reflected in the health and illness of populations. A pattern of knowing that counters and challenges an uncritical dominance of the empirical knowing and embraces the experiential patterns of personal and esthetic knowing, described by Carper (1978), is needed. Nursing knowledge also must be rooted within a pragmatic perspective that encompasses and reconciles the unknowing (Munhall, 1993) of an individual’s perceptual world with the sociopolitical knowing (White, 1995) of the ecological dynamics of human societies.

Chinn and Kramer (2011) propose empirical, ethical, aesthetic (their spelling), and personal knowing are embedded within an overarching emancipatory knowing, a critical reflection of the social, cultural, and political status quo, which calls “forth action” a praxis to reduce inequality and injustice, starting with questioning why injustice exists. Conceptualizing emancipatory knowing as the embedded fusion of experiential knowledge (personal and aesthetic knowing) with logic and precedence driven knowledge (ethical and empirical knowing) assumes that an outside-looking in type of knowing (etic) can reveal the inside-looking out (emic) place experiences of individuals and populations based on observations and voiced narratives of life experiences within discrete physical and social space. Yet Parse and other nurse theorists might argue that even in the narrative revealing of one’s own life experience, the individual still conceals place experiences, holding back expression of many experiences remembered and sublimating or internalizing subtle embedded life course place experiences that still powerfully influence his or her health and illness. Beyond place experiences that may be empirically observed or measured, personally revealed or aesthetically expressed, the patterned interactions between the physical phenomena of human physiology, illness and wellness, are driven by molecular and cellular dynamics within and between embodied humans and their environments; the energy field patterns as conceptualized by Rogers (Lutjens, 1991).

Critical data gaps about disease and environmental exposure occurrences exist even as new knowledge is emerging about the varied vulnerability to environmental illness according to age, genetics, gender, and life course experiences (Butterfield, 2002). Scholarly nursing discourse about social justice and equality must consider the complexity of the genetic, cellular, and physiologic processes of human metabolism, development, aging, and immune response to microbial and toxic exposures and transmission of disease. To prioritize nursing’s work as emancipation negates the emerging understanding about the epigenesis of disease and reality and scope of human health and illness; health and illness occur within landscapes of historical, physical, social, and environmental interaction (Ackerman, 2012; Blaser, 2006). Wellness/illness inequality is not the central challenge of nursing; rather, it is the creation of health landscapes across vastly diverse environments of care for individuals and populations. Wellness and illness are place experiences occurring over time. They require a place knowing to prevent, disrupt, and mitigate physical and social factors associated with disease and disability. Place knowing, not emancipatory knowing, integrates the global to the particulars of human wellness and illness. In place knowing the other patterns of knowing become unified in a theoretical framework consistent with an ecological theoretical perspective and a person-in-context epidemiology. Place knowing reflects the integration of theoretical perspectives of health geography and medical anthropology and provides a conceptual framework to critically examine how past and present place experiences affect health and illness.

As a part of my rural grandmothers study, a heuristic model, the PLACE Ecological Matrix (PEM), was developed to explore rural grandmother-mothering across the place dimensions (politics, locale, ancestry, culture, and economics) described by Tuan (1977). Place dimensions were conceptualized as crossing all levels of the social system, a place dimensions–social systems interface represented as rows and columns (Figure 1). Although the PEM was originally developed to support qualitative research, it provides a useful framework to explicate the relationships of nursing patterns of knowing with place and place knowing. Aesthetic and personal knowing emerge from the place dimensions of locale, ancestry, and culture. Ethical and emancipatory knowing emerge from place dimensions of politics, locale, and ancestry. Empirical and sociopolitical knowing emerge from all place dimensions. Paradoxically, unknowing is reflected in all dimensions because in place knowing there is always the realm of the unknown. Ancestry and culture are often studied together to examine how people of common backgrounds experience the physical, social, and symbolic environment; however, there is a subtle yet distinct conceptual difference between the two. Ancestry is the collective history of populations; though linked with culture, it is “past tense place.” Culture is the living out of ancestry in lifeways and belief systems, place inhabiting people, “present tense place.” Ancestry is historical place, culture is contemporary place, past place experiences continuing on in the present.

Figure 1.

PLACE Ecological Matrix (PEM). From “Cushioning, weathering, place and community in rural grandmother-mothering” by E. A. Thomas, 2011, Issues in Mental Health Nursing, 32(5), p. 293. Copyright 2011 by Informa Healthcare USA, Inc. Reprinted with permission.

Conclusion

A shift from “decontextualized knowledge to an emphasis . . . of salience, situated cognition” has been proposed as necessary to transform nursing education (Benner, Sutphen, Leonard, & Day, 2010, p. 82). A sense of salience integrates the patterns of knowing (empirical, ethical, aesthetical, personal, unknowing, sociopolitical, and emancipatory) into a situated cognition, balancing generalized evidence with the experience of the particular. Place knowing, as situated cognition, integrates the epistemological perspectives of nursing knowing, allowing for the landscape-languages of individuals and communities to be valued. Place knowing, like the other established patterns of knowing, is a significant epistemological foundation of nursing. Yet unlike other patterns of knowing, place knowing allows the nuanced, intricately complex dynamics of embodied situated human health and illness to be examined, the salience of the particulars to be considered, and the whole of landscape-languages to emerge. Situated cognition, as applied place knowing, brings the patterns of nursing knowing into coherence, restores the power of place in healing, and reestablishes place work as a foundation of nursing practice.

Footnotes

Elizabeth A. Thomas is an Associate Professor in the College of Nursing, Texas A&M University Health Science Center, Bryan, Texas, and a former graduate faculty member of the School of Nursing at Texas Tech University Health Sciences Center, Lubbock, Texas.

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