Not everything that is faced can be changed, but nothing can be changed until it is faced.
As a public health nurse, I often reflect on the days when early public health nurses embraced social reform, saw connections between the social environment and health, and advocated for social policies that reflected social justice. Today, clinical education leans heavily toward practice in acute care settings in most traditional prelicensure academic nursing programs. This occurs despite evidence that the resources needed for health are grounded in the social and structural determinants of health and extend beyond clinical care (National Academies of Sciences, Engineering, and Medicine, 2019). Most clinical courses are focused on individual care, with far too few glimpses into the social context of an individual's life, and how that life can be viewed in the broader social context. For instance, consider COVID-19—the morbidity and mortality rates were much higher in racialized populations than the dominant White, non-Hispanic population (Centers for Disease Control and Prevention, 2020). COVID-19 exposed the hidden ills that affect health and laid to bare that health disparities track closely with race, zip code, low-paid service sector employment, substandard and overcrowded housing, and other social and structural determinants of health (Centers for Disease Control and Prevention, 2020).
Health disparities are rooted in the structural inequities of how resources are allocated. All too often, my public health colleagues and I learn of situations where students, when enrolled in a public health course, have been assigned to a clinical site that serves marginalized populations. The students tour the site, provide the requisite care to the vulnerable, impoverished, and racialized population, then leave with the assumption that the lifestyle and life choices of the individuals were cultural norms, when in fact those individual lifestyles are grounded in structural inequities. People are bound by the choices they have. I wondered, to what extent do we prepare students with the knowledge, skills, and abilities to envision how the broader structural contexts are responsible for the conditions they are seeing in the individuals before them (Woolsey & Narruhn, 2018)? Do we teach students about the structural issues that influence health, that disparity is due to the allocation of resources, that differences in health outcomes are unjust and preventable, and to not assume that marginalized populations have made bad choices or lifestyle decisions (World Health Organization, 2019)? Do we help students make the connections that many of the health-related factors previously attributed to culture or ethnicity represent the downstream consequences of many upstream decisions made within larger structural contexts about matters related to health care access, food sources, residential living, zoning, and urban and rural infrastructures (Neff et al., 2020)?
These structural contexts include the policies, economic systems, judicial systems, academic institutions, and so on, that have produced the inequities that lead to disparities in marginalized groups (Neff et al., 2020). Helping students to see how the broader determinants of health are ingrained into the social fabric of the United States enables students to identify forces that influence health and health outcomes beyond the level of the individual (Davis & O'Brien, 2020). Hence, it enables them to develop a structural awareness that hopefully leads to structural competence. A structural competence approach integrates the student's clinical knowledge with their liberal education so students are better able to recognize the social and economic structures that contribute to the disparities in the distribution of illness, as well as the biases that undergird attitudes about health and illness in marginalized groups (Metzl & Hansen, 2014).
Whether in acute care or public health settings, when faculty teach students about the social determinants of health and the conditions in which people are born, live, learn, work, play, and age, they must also delve into the structural processes that perpetuate the inequities that led to the disparities. Consistent with the American Nurses Association's Code of Ethics (2015), Fawcett (2019) related social justice as the active examination of, critique, and advocacy for change in the social structures, policies, laws, customs, power, and privilege that disadvantage marginalized groups. Accordingly, nursing has a long history of advocacy for justice. Thus, my editorial plea is that nursing faculty consider the following recommendations when educating students about, and working clinically with, marginalized populations:
Place social justice and injustice at the center of teaching about health and illness in marginalized groups. A social justice orientation positions students to be an ally in social movements and advocate for systemic change consistent with American Nurses Association's (2015) principles of social justice. The result of social justice is equity and the concomitant elimination of inequities that lead to disparities in the health of populations (Fawcett, 2019).
Develop an antiracist pedagogy—that is, help students to reflect on privilege and power and understand how the inequities embedded in societal structures, power, policies, and politics, including racism, lead to disparities in health.
Contextualize experiential learning opportunities within a structural competency approach that recognizes that what has often been referred to as cultural or ethnic differences are, in fact, structural inequities (Metzl & Hansen, 2014).
Teach students health policy education so they may learn to address the political processes that perpetuate the inequities in health and advance policy solutions to eliminate disparities and improve health.
Students must understand the structural contexts in which people are born, live, learn, work, play, and age. With hope, their understanding will lead to actions that advance health equity, address health disparities, and advocate for just policies that influence health.
Teri A. Murray, PhD, PHNA-BC, RN, FAAN
- American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.
- Centers for Disease Control and Prevention. (2020). Health equity considerations & racial & ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
- Davis, S. & O'Brien, A. M. (2020). Let's talk about racism: Strategies for building structural competency in nursing. Academic Medicine. Advance online publication. https://doi-org.ezp.slu.edu/10.1097/ACM.0000000000003688.
- Fawcett, J. (2019). Thoughts about social justice. Nursing Science Quarterly, 32(3), 250–235 doi:10.1177/0894318419845385 [CrossRef].
- Metzl, J. M. & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126–133 doi:10.1016%2Fj.socscimed.2013.06.032 [CrossRef]
- National Academies of Sciences, Engineering, and Medicine. (2019). Investing in interventions that address non-medical, health-related social needs: Proceedings of a workshop. The National Academies Press. doi:10.17226/25544 [CrossRef]
- Neff, J., Holmes, S. M., Knight, K. R., Strong, S., Thompson-Lastad, A., McGuinness, C., Duncan, L., Saxena, N., Harvey, M. J., Langford, A., Carey-Simms, K. L., Minahan, S. N., Satterwhite, S., Ruppel, C., Lee, S., Walkover, L., De Avila, J., Lewis, B., Matthews, J. & Nelson, N. (2020). Structural competency: Curriculum for medical students, residents, and interprofessional teams on the structural factors that produce health disparities. MedEdPORTAL, 16, 10888 doi:10.15766%2Fmep_2374-8265.10888 [CrossRef]
- Woolsey, C. & Narruhn, R. A. (2018). A pedagogy of social justice for resilient/vulnerable populations: Structural competency and bio-power. Public Health Nursing, 35(6), 587–597 doi:10.1111/phn.12545 [CrossRef]
- World Health Organization. (2019). Social determinants of health. https://www.who.int/social_determinants/en/