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Theory in practice

Nursing theories 6: social class

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This article, the sixth in a six-part bite-size series looking at nurse theories and their implications for practice, explores the theory of social class

Citation: Chapman H (2018) Nursing theories 6: social class. Nursing Times [online]; 114, 4, 51.

Author: Hazel Chapman is postgraduate tutor, University of Chester.


Social class is a hierarchical ordering of society that has a more enduring effect on life experiences and life chances than socioeconomic status alone – particularly when social mobility is difficult. It is a socially created inequality with implications for child development, education, employment, housing, criminality, economic security, health and wellbeing.

Where does it come from?

Karl Marx’s theory on social class related to the owners of the means of production (the bourgeoisie who owned land, buildings, machinery and wealth) and those required to sell their labour to survive (the proletariat). Marx contended that the bourgeoisie exploited the proletariat by paying wages at a lower rate than the value of their labour. The capitalists then kept the surplus value as profit, oppressing the working class by creating greater inequality. This oppression was maintained through the ruling-class ideology, and the bourgeoisie, through control of legal and political power, reinforced their ownership rights and the primacy of wealth in gaining access to resources.

Marx predicted the growth of the super-wealthy, the increase in the gap between rich and poor and the pauperisation of the lower middle classes. He contended that eventually the differences would be too great; the working classes would become conscious of their own exploitation and withdraw their labour in a collective struggle to overthrow the ruling classes.

Increasing globalisation has made it difficult to identify and respond to the relationships between corporate power and political power, leading to fears that even democratically elected national governments must operate within the demands of market forces to maintain economic and political stability. It has been argued that reduced potential to achieve economic security, particularly for the white, male working class in the US, has led to ultra-right protest voting patterns (Williams, 2017) in an attempt to rebalance economic policy towards their needs.

Pierre Bourdieu (Grenfell, 2014) has argued that, in addition to the economic capital of material goods, we also possess cultural, social and symbolic capital; this can become another means for those who are economically dominant to maintain class distinction, through education, ‘highbrow’ taste and lifestyles, and even physical appearance.

Social capital focuses on connections and reciprocal assistance, while symbolic capital relates to status and respectability. These class attributes determine the society within which we move and affect our judgement of self and others. These additional hierarchical determinants of class affect children’s success in education and make movement out of one’s habitus (physical) or cultural class difficult.

Some people who are rich in cultural capital, such as educators, may be economically poor, while those who are economically wealthy may use their money to buy education and social connections, for themselves and for their families.

Social class and health

The goal of Public Health England is to “protect and improve the nation’s health and wellbeing, and reduce health inequalities”, and clinical commissioning groups (local, clinically led groups responsible for commissioning services to meet health needs according to government policy) have a responsibility to reduce inequalities of access to healthcare. However, since “the conditions in which people are born, grow, live, work and age and inequities in power, money and resources that give rise to them” (Marmot, 2013) largely determine people’s health chances, prevention of ill-health largely depends on socio-economic policy. Health outcomes are worsened by declining social mobility and social cohesion, so challenging social injustice is necessary to improve health. 

Box 1. Implications for practice

  • Recognise the interactions between life events and social class, and promote access to healthcare for all groups in society, particularly vulnerable groups, such as people with learning disabilities, those in the criminal justice system, older people and those from minority ethnic groups
  • Avoid labelling and judging people – person-centred care is essential
  • Listen to the person’s needs before imposing behavioural change – a concordant relationship is most likely to promote a healthy lifestyle. For example, smoking cessation may be a low priority compared with psychological and physical abuse
  • Advocate for more inclusive policies in your place of work.
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