There is growing recognition that the health care delivery system is responsible for only a modest proportion of what makes and keeps Americans healthy; therefore, it is critical to recognize that interventions outside the health care system are more likely to affect health and well-being than the care rendered within institutions (Artiga & Hinton, 2018; Robert Wood Johnson Foundation, n.d.). What's more, the burden of illness, premature death, and disability disproportionately affects underserved populations (Zuckerman, Duncan, & Parker, 2016). These differences or disparities are often rooted in the environmental contexts and conditions in which people live, most often shaped by structural realities such as the distribution of wealth, power, social mores and cultural norms, economic, and political forces (Artiga & Hinton, 2018; Commission on the Social Determinants of Health, 2008). Thus, the differences are persistent and pose a significant economic burden to both the affected individuals and all Americans.
As the single largest group of health care providers, nurses could serve as powerful advocates for a health in all policies approach (HiAP) to improve the conditions faced by underserved populations. An HiAP approach looks at policies for their influence on health with the understanding that all policies affect the conditions of living (Centers for Disease Control and Prevention, 2016). Evidence-based strategies related to housing, education, food security, transportation, and health services, when legislated and resourced, hold the potential for improving health for all (Farrer, Marinetti, Cavaco, & Costongs, 2015). Nurses can and should take a leading role in partnering with communities, public health agencies, community-based organizations, schools, businesses, and many others to identify, advocate, and help mitigate circumstances that contribute to poor health (Institute of Medicine, 2014).
Unfortunately, too few nursing education programs have developed comprehensive community-based immersive experiences that integrate the social determinants of health (SDOH) into the curriculum at the undergraduate or graduate levels despite the historical underpinnings of nurses like Lillian Wald and Mary Brewster (Thornton & Persaud, 2018). Wald and Brewster recognized that sicknesses encountered in families should be viewed as part of a larger set of social problems (Buhler-Wilkerson, 1993). Working with multiple sectors of the community (e.g., businessmen, lawyers, and others), Wald and Brewster established the Henry Street Settlement House to address the social and economic problems of those residing in the Lower East Side of New York City (Buhler-Wilkerson, 1993). In planning the educational processes of the future nursing workforce, this example could serve as a guide for community engagement. Are the concepts on the culture of heath and the SDOH taught beyond the single community health or public health course? If so, are the concepts embedded throughout the curriculum? Are the students exposed to real-world experiential learning opportunities that demonstrate the relationship between environment and health? Are there opportunities for students to work with multiple community partners over time? Do students learn about an HiAP?
Consider that most, if not all, of the eight task statements promulgated by The Future of Nursing 2020–2030 study attend to the nurse's role in addressing the SDOH, outside of the hospital walls and across care settings with multisectoral engagement and partnerships to achieve health equity (National Academies of Sciences, Engineering, and Medicine, 2019, para. 2):
- The role of nurses in improving the health of individuals, families, and communities by addressing social determinants of health and providing effective, efficient, equitable, and accessible care for across the care continuum, as well as identifying the system facilitators and barriers to achieving this goal.
- The current and future deployment of all levels of nurses across the care continuum, including in collaborative practice models, to address the challenges of building a culture of health.
- System facilitators and barriers to achieving a workforce that is diverse, including gender, race, and ethnicity, across all levels of nursing education.
- The role of the nursing profession in assuring that the voice of individuals, families, and communities are incorporated into design and operations of clinical and community health systems.
- The training and competency-development needed to prepare nurses, including advance practice nurses, to work outside of acute care settings and to lead efforts to build a culture of health and health equity, and the extent to which current curriculum meets these needs.
- The ability of nurses to serve as change agents in creating systems that bridge the delivery of health care and social needs care in the community.
- The research needed to identify or develop effective nursing practices for eliminating gaps and disparities in health care.
- The importance of nurse well-being and resilience in ensuring the delivery of high-quality care and improving community health.
Now is the time to revisit the long-held mental models of nursing education that primarily focused on individualized care in acute care or primary care settings. The time is ripe to embrace curricular opportunities that allow students to be immersed in environments at the intersections of health care (physical and behavioral) and the social environment, particularly in underserved communities where disparities most often exist. As the work of the Future of Nursing 2020–2030 study (National Academies of Sciences, Engineering, and Medicine, 2019) progresses and the recommendations are set, I believe the established ways of operating nursing education will change, perhaps back to the future, to the days of Wald and others who worked within communities and with multiple stakeholders to optimize health care and employ justice for the good of all.
Teri A. Murray, PhD, APHN-BC, RN, FAAN
- Artiga, S. & Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. KFF Henry J Kaiser Family Foundation, May issue brief. Retrieved from https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
- Buhler-Wilkerson, K. (1993). Public health then and now: Bring care to the people: Lillian Wald's legacy to public health nursing. American Journal of Public Health, 83, 1778–1786. doi:10.2105/AJPH.83.12.1778 [CrossRef]
- Centers for Disease Control and Prevention. (2016). Health in all policies. Retrieved from https://www.cdc.gov/policy/hiap/index.html.
- Commission on the Social Determinants of Health. (2008). Closing the gap in a generation. Health equity thru action on the social determinants of health. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/social_determinants/thecommission/finalreport/en/
- Farrer, L., Marinetti, C., Cavaco, Y.L. & Costongs, C. (2015). Advocacy for health equity: A synthesis review. The Millbank Quarterly, 93, 392–343. doi:10.1111/1468-0009.12112 [CrossRef]
- Institute of Medicine. (2014). Population health implications of the affordable care act: Workshop summary. Washington, DC: National Academies Press.
- National Academies of Sciences, Engineering, Medicine. (2019). The future of nursing 2020–2030. Retrieved from http://www.nationalacademies.org/hmd/Activities/Workforce/futureofnursing2030.aspx
- Robert Wood Johnson Foundation. (n.d.). Building a culture of health. Retrieved from https://www.rwjf.org/en/how-we-work/building-a-culture-of-health.html
- Thornton, M. & Persaud, S. (2018). Preparing today's nurses: Social determinants of health and nursing education. The Online Journal of Issues in Nursing, 23(3). Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-23-2018/No3-Sept-2018/Social-Determinants-of-Health-Nursing-Education.html
- Zuckerman, D., Duncan, V. & Parker, K. (2016). Building a culture of health equity at the federal level. Retrieved from https://nam.edu/building-a-culture-of-health-equity-at-the-federal-level/