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According to the Robert Wood Johnson Foundation, “Health equity means increasing opportunities for everyone to live the healthiest life possible, no matter who we are, where we live, or how much money we make.”
Health equity is of vital concern to nurses, whose daily work as patient educators and healthcare practitioners is influenced by interrelated factors such as:
- Health Disparities
- Social Determinants of Health
- Cultural Competence
- Social Justice
With the help of Drs. Janice Phillips (PhD, RN, FAAN) and Margaret Moss (PhD, RN, JN, FAAN), editors of the upcoming book Health Equity and Nursing, DailyNurse is looking at these basic concepts and exploring the role of health equity considerations in the day-to-day work of nursing.
“Health disparities” refers to the inequalities in health and health care between different population groups. There are widespread inequalities that impinge upon public and individual health and well-being. Among the patients most directly affected are members of ethnic minorities, immigrant and low-income families, and people living in areas far from accessible care. According to a 2018 study, the US spends an estimated $93 billion in excess medical costs per year due to racial disparities alone.
DailyNurse: Can nurses help to overcome health disparities that affect their patients?
Janice Phillips: “It’s been over a decade since nurse leader Dr. Gloria Smith wrote a commentary “Health Disparities: What Can Nursing Do?’ In her commentary, Dr. Smith encouraged nurses to promote nurse managed primary care and focus on changing local, state and national policies to help address health disparities.
In recent years however, we have expanded our efforts to reduce health disparities to include an emphasis on achieving health equity. Healthy People 2020 defines health disparities as a type of particular difference in health status that is closely linked with economic, social, or environmental disadvantages. Populations that experience greater social and economic hardships are more likely to experience health disparities.
In contrast, health equity is a principle that underscores a commitment to reducing and ultimately eliminating health disparities. Health equity occurs when all populations (especially vulnerable, less advantaged socioeconomic populations) experience their highest level of health. Efforts to achieve health equity are intertwined with our ability to effectively eradicate health disparities. In our daily practice, nurses can be mindful to assess for these and other conditions that may adversely impact health outcomes and make appropriate referrals to members of the health care team such as social workers and case managers who are skillful in addressing identified social needs and can make appropriate referrals for additional services.
On a higher level of intervention, nurses must become skillful in advocating for social policies that can positively impact the myriad of social and economic conditions (inadequate housing, lack of employment and education opportunities) that adversely impact the health and well-being of those we serve.”
Health Equity and Social Determinants of Health (SDOH)
Social determinants of health (SDOHs) are factors apart from medical care and genetics that account for roughly 80 percent of overall individual health outcomes, according to the National Academy of Medicine. SDOHs are factors such as socio-economic status, availability of nutritious food, air and water quality, housing, education, transportation, racial segregation, and exposure to racism and violence. SDOHs can include a patient’s neighborhood and environment, access to health care (including insurance); social, cultural, and community context; level of education; and economic stability—all of which play a role in a nurse’s assessment of a patient’s wellbeing and risks to the same.
DN: In what ways can a nurse incorporate SDOH considerations into treatment?
Janice Phillips: “As they are working on the frontlines providing direct care to patients, it is important for nurses to be mindful of the many social and economic factors that may impact the health and well-being of patients and communities at large. In recent years hospitals have started screening patients for social needs that may have some bearing on a patient’s health and health outcomes. Factors such as access to stable housing, primary care, nutritious foods and transportation have emerged as significant factors impacting health status and health outcomes. Thus nurses are pivotal to integrating these factors when conducting patient assessments and making referrals that can help address the identified social needs. Other factors such as structural racism, income, education, poverty also impact health status and outcomes.
As patient advocates, nurses are well positioned to relay important information to social workers, case managers and other members of the interprofessional health care team who have the expertise to refer patients to needed resources. Nurses are valued collaborators in this regard and are encouraged to familiarize themselves with how their respective hospitals and health care systems are assessing and addressing the identified needs of patients. According to the American Hospital Association, by 2023, 48% of health care organizations will have a standardized means for collecting data on the social determinants of health, making this an important opportunity for nursing practice. Knowing where one’s organization stands with these efforts is an important first step.
Public policies that address the root causes of poor health status and longevity are central to any effort devoted to addressing the social determinants of health. Nurses are encouraged to get involved with their professional organizations, home institutions or other stakeholders who can work together to advance a policy agenda aimed at addressing the myriad of social and economic factors that impact health.”
According to Dr Jasmin Whitfield (RN, MSN, MPH, DNP), “culturally competent care is not just acquiring information on a particular group of people but rather developing a respect for and understanding that the beliefs, attitudes, behaviors, language, and rituals of that group all play a role.” The epidemiology, manifestation of disease, and effects of medications vary among different ethnic and cultural minorities, so nurses need to make themselves aware of matters such as ethnicity and culture, sexual preferences, and other points of identity as part of their patient dialogue, as all of these matters have specific health connotations.
DN: How can a nurse deal with topics such as patients’ ethnicity, language, culture, sexual orientation, and gender identity in a sensitive, yet direct manner?
Margaret Moss: “It may be of help for the practicing nurse to know of other care modalities recognizing a cultural component. There is Cultural Safety, defined by Williams (1999), “as an environment that is spiritually, socially and emotionally safe, as well as physically safe for people”. This includes being safe to tell your nurse how you identify, relay your spiritual and other needs without fear of retribution etc. Especially when there is patient-provider racial, gender or ethnic discordance, there can be a tentativeness on either side to communicate effectively and fully.
There is Cultural Humility and Cultural Respect as well. So, a big tip is just ask…very simple. With humility, state you are unaware of any special needs or care they may have and ask. Ask, how do you identify? Instead of guessing and then go from there. Whereas Cultural Competency can be seen as useful for the dominant culture caring for the ‘other’. As an Indigenous nurse, no one offered me a Cultural Competency course or workshop as I cared for dominant culture patients. However, safety, humility and respect always serve to increase a patient’s comfort and optimize results.”
Health Equity and Social Justice in Nursing
Social justice is a key aspect of health equity and is a core concept of nursing ethics. The American Nurses Association (ANA) states that nursing has a “professional responsibility to address unjust systems and structures.” Adhering to this ethic can lead to involvement in some divisive issues, but nurses have been advocates for social justice and human rights since the days of Florence Nightingale.
DN: In your view, what role do today’s nurses have in working towards social justice?
Margaret Moss: “Social Justice (from the Oxford Dictionary at Lexico) is justice in terms of the distribution of wealth, opportunities, and privileges within a society. It is well known, published, proved, that minorities in the US suffer, daily and out of proportion to non-minority peoples, at the lower end of these distributions. Other groups such as the poor, working poor, chronically ill and disabled, and LGBTQQ2+ suffer as well. To help even out these disparities in the health realm, nurses must advocate. At times, they are the only thing standing between a patient and health or death.
Similarly, nurses are and must be advocates beyond the individual. Nursing programs at the bachelor’s level and above incorporate Community Health, Population Health, Leadership and often Health Policy into the curriculum. I sought a law degree after my PhD in nursing, as both have at their base-advocacy. I have worked my career in advocating for more just American Indian Health. Social Justice Issues face every nurse every day and they are deep and wide. They hit ethics; policy and procedures that may be seen as detrimental but are, “always done that way”; unpotable water such as in Flint, MI; or Uranium on American Indian reservations; lack of available medicines; unfunded programing, and the massive leading edge of aging care; autism; and a host of other issues.”
DN: Finally, what actions can nurses take to further social justice and health equity in healthcare?
Margaret Moss: “Nurses at 3 million strong have the collective and individual power to help change these imbalances, by showing up (legislatures); speaking up (comment on proposed rules); and participating (in practice and advocacy associations).”