The aim of this contribution is to briefly outline the meaning of Material Care Studies in terms of thematising and researching the material aspect of nursing and care, that is, their things [1], and what new insights and findings this approach can generate.

Prima facie, the expression ‘Material Care Studies’ seems an enigmatic term. Rather than ‘material care’ referring to caring for, or even looking after, things in terms of their material nature, this subject is not about maintaining technological apparatus. Instead, Material Care Studies refers to the idea perhaps already suggested by the term’s similarity to ‘Material Culture Studies’. The latter is a transdisciplinary undertaking with various methodologies and themes; its explanatory power derives from the fact that it examines extremely multifaceted contexts. The field considers things in terms of their material nature, exploring how they are embedded in and interrelate with interactions, social ties and discourses and investigates how they produce and reproduce social contexts. In the same way, Material Care Studies seeks to focus on the material aspect, examining and investigating nursing and care on the basis of things. On the one hand, its raison d'être as a separate field of research comes from the specifics of how people interact with one another using things in situations of nursing and care (which are characterised by forms of dependency and requiring sensitivity) [2], and of the specific approaches to physicality and corporeality related to this field [3]. On the other hand, the establishment of Material Care Studies does justice to the aspect of materiality, as there has been very little research until now into the concrete materialities of nursing and care or how things shape the processes involved. [4]

In Material Care Studies, the term ‘care’ refers to a broad field, from childcare and child-raising to caring for and nursing the elderly, people with disabilities or people suffering from psychological or physical disorders, who are in need of physical and/or psychological support and advice and care (medical or otherwise) to medical assistance in the consulting room or operating theatre – these are all areas where care is provided. Alongside pedagogical/socio-pedagogical fields of work, nursing (using a very broad understanding of the word, as defined by the International Council of Nurses [5]) is understood here as a key area within the wider field of care, and will be the main focus of this contribution. In this article, when statements are made in which ‘care’ is understood as extending beyond nursing, this will be explicitly indicated; otherwise, what will be outlined is the narrower field of nursing the sick and elderly, which is the main focus of this journal.

It seems remarkable that there are very few studies tackling the things used in nursing, when one considers that the very first textbooks and instructions on caring for the sick in the early 19th century went into great detail on the material form of patients’ physical environment, granting it a central position. [6] Although more recent studies also testify to that interest in the context of nursing, they tend to be purposive or evaluative studies from the fields of healthcare, nursing, architecture or medical geography. There are very few empirical, qualitative studies, and of these only a few deal with the tangible things specific to nursing. [7]

The contribution which Material Care Studies can make is, firstly, to highlight and explain how things are part of current or past processes in the field of nursing. Until now, their role has only rarely been considered in research into nursing – even though nursing cannot be imagined without such things. Secondly, as a source of information which has so far been neglected, things can enrich and extend research into nursing and (more broadly) care, as taking materiality into account can open up new insights which would not be revealed without things.

Last but not least, this is also a means of countering the general invisibility of the topic of nursing in academic and public discourse, as although nursing can be described as a central practice of human interrelations and social cohesion [8], and it receives a great deal of attention in current political debates, for a long time it led a shadowy existence in academic (and public) perception. [9] Currently, a great deal of attention is being focused on things, whether in research funding or the public eye [10], meaning that addressing the topic of nursing through the lens of things could make it more attractive.

In the following, we sketch out a rough outline of the field of Material Care Studies. We see its central approaches as coming from Material Culture Studies, which we will specify below for our own subject field (1). We define things of nursing which come from the past (historical things of nursing) as material cultural heritage, and thus subjected to the requirements expected of other specialised collections (2). Moreover, mainly due to the historical legacy of nursing and care, Material Care Studies (3) can also be located in the conflictive field of the gender-sensitive approaches taken in recent debates on care, for example, as discussed in Feminist Materialism or Science and Technology Studies.

One central point of Material Care Studies, whose methods are heavily based on Material Culture Studies, is the fundamental assumption that things are ambiguous and uncertain. [11] This inability to pin them down due to their ambiguity, which Hahn labels ‘polyvalence’, applies particularly strongly to the things of nursing, as nursing is characterised by multi-professionalism (welfare-based, treatment-based, medicinal or therapy-based approaches and so on), and things can be used for various purposes, or even repurposed. In view of this, things in general, and in this case in particular, constantly appear impossible to determine. It seems possible to read their ‘script’ in a variety of ways [12]. Nurses can use a kidney dish, for instance, in dental care, as somewhere to place a set of dentures, or in medical assistance, to hold unsterile instruments, or in post-operative care, to collect bodily fluids such as blood or stomach contents. All these uses are based on different interactions, social structures and processes of negotiation regarding how to deal with things or people.

In the wake of the ‘material turn’ [13] in the Arts, Humanities and Social Science, and following various (misguided) attempts to explain things as actors which are ‘equal’ to people [14], the focus is increasingly on relational construction via the relationship between people and things (for example, their things) [15]. What is meant by this is that things are only given meaning through their relationship with people, with people’s behaviours and with other things. For things to be put to productive use when researching into nursing, they thus have to be studied and understood in their various social contexts. With regard to the balance between things and social actions, Hahn summarised the situation of research into the everyday world (a category in which we also place nursing) as follows:

For Material Care Studies, in the sense of advanced research into the things of nursing [17] from a historical, a cultural and a socio-scientific point of view, this implies what the social historian Dorothee Wierling describes as ‘self-sociation as a basic process of coexistence’ [18]:

The way people deal with and make reference to things in nursing is influenced by a range of factors. On the one hand, there is their materiality and the effects they have, in accordance with the laws of nature. A urinal bottle made of glass, for example, can be expected to be used differently to one made of plastic. On the other hand, the way things are used – how people relate to things – is also affected by their sensory perceptions. [20] With regard to the physical design of nursing settings, for instance, Michael Heinlein [21] discovered that patient lifts or hoists can have negative associations for people in need of nursing, even though their intended purpose has the positive effect of safely moving people with restricted mobility. Using these devices, which involves patients being strapped in or placed in slings, can make them immediately aware of their failing physical condition, it is made abundantly clear to them in a manner which they cannot ignore.

This has consequences in terms of how the things of nursing are dealt with scientifically: when the polyvalence of things is being investigated, it calls for different levels of context and meaning to be examined in each case. At the same time, there has to be a constant effort to return to the material itself, that is, the physical source: „The analysis is generally carried out in three steps, covering the materiality of the things, how they are used and the meaning they are ascribed.“ [22] In other words, when analysing things, research has to go beyond simply looking for and describing the information and meanings attached to the things, in order to reconstruct them in their particular contexts. Meanwhile, Material Care Studies places an emphasis on research into the materiality of things, an aspect which is often lost sight of: this is its central method. A good way of achieving this is via collections-related research, as established in scientific collections: here, investigating the materiality of objects is understood as the first step in analysing things. [23]

Whether in a firmly historical or contemporary light or in view of approaches to the material culture of nursing in the social sciences or cultural studies: the different interests in things, including things of nursing, share an approach to (material) objects which sees them as resources and participants in social interactions, rather than as a result or expression of broader structures. [24] As in Material Culture Studies, with regard to Material Care Studies this means reconstructing the concrete role and meaning of a thing, for example, a thing of nursing, in view of its observed (or historically reconstructed) usage; a usage which is always contextualised and socially situated. [25] This implies a firmly praxeological approach to things [26], whether these are historical or contemporary things of nursing. The activities which are understood as nursing (and care) are also materially mediated, historically and socially contextualised practices which are subject to constant change. In this respect, the added benefit of Material Care Studies is that it shifts the focus onto the things of nursing as a source of research into present and past nursing that has so far been disregarded and promises a wealth of new findings.

Material Care Studies aims to give the things of nursing a new (enhanced) status as historical artefacts and as part of a society’s cultural heritage. For this reason, Material Care Studies explicitly concentrates not only on things which are currently in use but also on the material remains of cultures in contexts of nursing. In both cases, this means researching into the things of nursing as bearing material testimony to the culturo-historical genesis of nursing as an aspect of care. In 2011, the German Council of Science and Humanities emphasised the significance of material heritage (not only of things in the context of nursing) in relation to academia and society:

Internationally, there is no question that objects are accorded great significance for culture and society in Germany and elsewhere. In its ‘Standards for Museums’, for example, the German Museums Association (Deutscher Museumsbund (DMB)) describes a museum’s central role as collecting, conserving, researching into and communicating objects, noting that:

Moreover, initiatives such as the European Union’s 2018 Year of Cultural Heritage show that objects are also increasingly coming into the focus of social and political discourse, as our material legacy.

Fundamentally, all these statements and initiatives are based on the assumption that three-dimensional objects acquire great social and academic relevance through, because of and with their materiality, as they reveal information and connections that would otherwise remain hidden. Despite this significance, and although care and nursing are academically and socially relevant fields, at present their objects have slipped through the net of well-known collection classification systems in the context of material heritage. Over decades there has simply been no special place for them to be collected, conserved, researched into or presented. [29] Until now (in Germany, at least), neither care nor nursing, nor the things related to them, have come up in the discussion on material cultural heritage. Instead, nursing and its historical things have largely been conserved in the context of medical history collections, which, however, mainly deal with medical issues from the perspective of doctors. [30]

Nursing, however, brings up its own politically and socially widely discussed questions which are highly charged in light of demographic change. These reflect not only specific issues regarding policy implementation but also the field’s own ethical and social aspects, and challenges for society. [31] Nursing is a practice that is considered central to human relationships and a society’s social cohesion. It shapes both the communities of people where it is practiced and the welfare state that provides the structural conditions required for nursing to be performed. Nursing is thus a society’s silent social capital. Material Care Studies’ view of the things of care and nursing as material heritage shifts the focus onto the cultural and historical significance of care and nursing, with all their ambivalence.

Over the years, many different disciplines have tackled the subject of nursing in its numerous forms. From the point of view of their different fields, experts in the fields of Nursing Studies, Sociology, Social Pedagogy and Cultural Studies have all examined the current nature and practice of nursing – for example, the form of nursing arrangements – on personal, institutional, structural or social levels. [32] To face up to future social challenges, however, it is equally important to remember the historical roots of the practice of nursing; to uncover them and interpret them in the light of our knowledge of past contexts, allowing us to view current developments (sometimes critically) through the lens of past experiences and develop possibilities in building for the future. Although nursing is a socioanthropological constant, throughout its history it has continually been reshaped in line with social, political, personal or moral requirements. [33] The ways and means by which nursing was and is carried out thus reflect part of a society’s cultural identity. [34]

The task of researching into and appraising the historical roots of the practice of nursing falls under the remit of the History of Nursing. Although there are numerous international chairs dedicated to the History of Nursing or museums on the subject, this development is only in its infancy in Germany. However, researchers from diverse faculties are increasingly turning towards this relatively new discipline in German academia. While written sources from German-speaking countries are increasingly used [35], until now little attention has been paid to the material evidence of the history of nursing in the research. [36] One reason for this is that, to date, there has been no special place in Germany for the historical things of nursing, in the form of a scientifically run collection or a comprehensive, professionally run museum. Things of nursing do exist, but are not recognised as such. This is despite the fact that things played a crucial role in the practice of nursing in the past, just as they do today. Material Care Studies, which examines both care and nursing as cultural heritage which is, and can be, conveyed materially, thus not only examines interactions and interpersonal relationships within nursing but also the way in which things made, and still make, nursing and care possible in the first place, or how they influenced, and still influence, the social order and the form it took and takes. [37] Many of the things of nursing which we are familiar with today were developed in former situations of need or supplied to nurses to use at particular times. Research into these aspects also provides us with a deeper understanding of later developments and of nursing as we know it today.

Just like modern objects, things of nursing from the past can be subjected to historical and praxeological interpretation to offer a unique insight into the field of nursing, its history/histories and past social situations or ideas. As material cultural heritage, historical things of nursing open up aspects which can provide compelling insights, opportunities for self-reflection and stimuli in the present, or equally for the future. They inform issues related to nursing, as well as ethical and social questions. They also enable interdisciplinary transfer between nursing, medicine, Cultural Studies and the social sciences. [38]

Parallel to the issue of the lack of collections, the invisibility of things in nursing and care is also related to nursing and care being rarely accorded the recognition due to them as one of a society’s central social practices (and have historically scarcely received that recognition). [39] The historical and current reason behind this is that nursing and care are occupations and fields of activity with feminine connotations, in part because they have always been considered tactile, emotional and sensorial. [40] However, one of the central premises of Material Care Studies is that it should shift the focus onto the physical component of interactions between people and things in contexts of nursing. This perspective is especially significant with regard to the subjects of nursing, as patients’ bodies (whether regarded as ill or old bodies, with disabilities, etc.) themselves become the subject of nursing practices and the use of things. It is partly because their bodies run the risk of being materially and discursively degraded to the status of ‘misfits’ [41] that Material Care Studies firmly sees itself as among the gender-sensitive ways of engaging with care, as set out below.

Somewhat similarly to the relevant feminist debates on care, in the field of Feminist Materialism and some works in Science and Technology Studies, a broad definition of the term ‘care’ is used (extending beyond interpersonal relationships), whilst at the same time an emphasis is placed on reciprocity and interdependency in the relationships between people and things. Both are discussed in the context of how the way people are dealt with and/or the material environment in situations of nursing and care are affected by, and simultaneously help to reproduce, gendered inequalities. [42]

This approach to care is relevant to Material Care Studies insofar as nursing (or looking after and caring for people and things, see below) is primarily about interpersonal relationships and interactions between people and things. In the practice of nursing, even more than in other fields, interdependencies and vulnerabilities, dependencies and affective actions particularly come to the fore. This, in turn, requires the focus to be turned towards relationships between people or between people and things, and how these relationships are experienced in different contexts and situations – just as feminist works have been doing for quite some time. [43] The feminist psychologist Carol Gilligan [44] stresses especially strongly that nursing relationships should be viewed from the point of view of those in (relatively) powerless positions, such as the people being nursed. [45]

The primary focus of Material Care Studies is not so much about calling into question social balances of power and thus criticising unequal patriarchal, capitalist relationships, but about an inclusive way of thinking that is especially sensitive to the fact that the use of things is embedded in specific discursive formations, social structures and normative notions which are permeated with power. For this reason, Material Care Studies is close to Feminist Materialism, even though (unequal) power relations have to be situationally reproduced in the form of concrete interactions, characterised partly – mainly – by their material manifestations (showing that Material Care Studies is primarily aligned towards Material Culture Studies). Accordingly, when analysing Material Care Studies (which is based on things), there is a focus on the micro-politics of power which often occur in the background and rarely come to attention. Things generally become part of routines; they add routine to actions [46] and thus (indirectly) help reproduce the status quo and thus structurally organised inequalities. However, as this always has to be repeated, there is always also some room for manoeuvre. Relationships can change. Some things, if especially awkward and disruptive, can even provoke that change. Karen Barad [47] lays emphasis on the interplay between discursive ascription and materiality, which can basically not be separated from one another, as (immaterial) meaning and material circumstances are always a material/discursive interweaving of different patterns of meaning and objects.

From the (gender-sensitive) perspective of Material Care Studies, interdependency thus not only occurs between people, but also between people and things, and is thus initiated by things. [48] Transferred to the field of nursing, this implies that an electronic lift (hoist) opens up new courses of action both to nurses and to people whose mobility is limited and whom they help to stand up – but at the same time, they are dependent on the thing (in this case the lift). [49] However, it is not only feminist works that stress the interdependency between people and things (and ideas, notions, discourses etc.). ‘Conventional’ (socio-scientific) research into objects has also done so for some time now. Daniel Miller, for instance, criticises the ‘tyranny of the subject’, meaning the overly strong focus on people in the social sciences. [50] Instead, he calls for a „dialectical republic in which persons and things exist in mutual self-construction and respect for their mutual origin and mutual dependency“ [51]. Feminist works such as that by Barad similarly underline the processual, incomplete nature of material/discursive entanglements [52]. A thing’s meaning and what it does with people changes, it cannot be fixed, but is subject to constant change and contingencies.

Some works from the field of Science and Technology Studies can also be compared with these perspectives. Here, too, particular attention is paid to the material aspects of social interactions, but with a stronger focus on technologies or technical/technological circumstances. Science and Technology Studies, spearheaded by the anthropologists Annemarie Mol and Jeanette Pols, place greater emphasis on the idea that technology itself also requires care. [53] The interactions between people and technology are constantly being examined and re-examined to determine how they can socially produce care. [54] By contrast, one point which has emerged from Material Care Studies that are oriented towards Feminist Materialism is that things (not just technical items but all material objects) are also matter [55]; objects and (significant) circumstances. Accordingly, a social constructivist analysis of science and technology should always be connected to a critical view of how, in the reproduction of gendered orders, specific epistemological cultures contribute to the rational and technological being ascribed to masculine connotations. [56] This critical view is also similarly applied to nursing, where interpersonal, more tactile work – touch as an aspect of nursing and care work – is considered sensorial and feminine and thus as not ‘threatening’ but instead pleasant and gentle. [57]

Yet the things of care and nursing are not only connected to current, gendered orders that are permeated with power. As things’ materiality allows them to last beyond their era, these orders can be reconstructed, in terms of their historical trajectories and more. Things generally bear testimony to the historical genesis and current state of nursing. Material Care Studies thus examines not only the things of the present, but also, always, nursing’s material cultural heritage.

The argument in favour of setting apart Material Care Studies as its own area of research is based firstly on the specific personal interplay and the interactions mediated by things which are of relevance in nursing situations (requiring research that shows particular sensitisation and sensitivity) and secondly on the potential offered by things when investigating the topics that fall under nursing (and care), which has so far been accorded too little attention. Understanding things as a central element of nursing (and care) and including them, as in this volume, or even making them the focal point and thus taking them seriously as a source of information, promises a deeper understanding of the historical processes and developments behind nursing and care.

Isabel Atzl (MA), Institute for History of Medicine (Robert Bosch Foundation), Germany

Lucia Artner (Dr), Institute for Organisational and Social Pegagogy, University of Hildesheim, Germany

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