Post the following:
- An explanation of the importance and value of taking the SDoH into consideration as a DNP-prepared nurse.
- Identify the one SDoH Domain you selected and explain why it is particularly important to you.
- An explanation of why and how you intend to shift your thinking and practice related to the SDoH from the patient-level to the organizational, community, and/or larger field of nursing levels. Be specific, provide examples, and cite the three scholarly resources you identified to support your points.
Note: Your posts should be substantial (500 words minimum), supported with scholarly evidence from your research and/or the Learning Resources, and properly cited using APA Style. Personal anecdotes are acceptable as part of a meaningful post but cannot stand alone as the entire post.
Read a selection of your colleagues' posts.
![Shaping Nursing Healthcare Policy]()
Shaping Nursing Healthcare Policy
A View from the Inside
2022, Pages 91-105
![Shaping Nursing Healthcare Policy]()
7 - The evolving role of social determinants of health to advance health equity
Author links open overlay panelSandra Davis
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Abstract
Efforts are steadily increasing to address social determinants of health (SDH) within healthcare delivery systems. Policies and practices in nonhealth sectors impact health and health equity.
Therefore, the crux of health policies and interventions is a clear and accurate understanding of how and why the social determinants differentially impact health, healthcare, and health outcomes. The fundamental drivers of health inequities are the fundamental drivers of social inequities. The concept that health and health inequities are driven by social determinants is increasingly the focus of nursing articles, conferences, courses, vision statements, toolkits, research, and scholarly projects. Addressing social conditions that impact health is not new to nursing but, an upstream perspective that focuses on (1) systems and structures, (2) policy and politics, (3) historical drivers of disparities, and (4) structural racism as a root cause of health inequities is new. Historical and contemporary policies have created the structures that shape the SDH and have profound and enduring effects on our patients' health, healthcare, and health outcomes. Nurses can lead social change but only with a clear understanding of SDH and its evolving role in advancing health equity.
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Keywords
COVID-19
Health equity
SDH frameworks
Social determinants of health
Social needs
Structural racism
Objectives
Upon completion of this chapter, the learner will be able to:
· •
Recognize the meaning and misunderstanding of the social determinants of health (SDH)
· •
Compare and contrast SDH-related terms and concepts
· •
Explore history as groundwork for current approaches to achieving health equity
· •
Describe structural racism as a structural determinant of health and root cause of health inequities
· •
Examine evolving frameworks to address upstream interventions, policy, systems, and structures
· •
Identify nursing's role in informing policy change
Introduction
The disproportionate impact of the COVID-19 pandemic on racialized groups, the murders of George Floyd, Ahmaud Arbery, Breonna Taylor, and others, and the months of worldwide protests over structural racism have ushered in a new national discourse (Bailey et al., 2021; Lavizzo-Mourey et al., 2021). Attention is being shifted to upstream structural drivers of long-standing injustices, policy, and how inequities are codified and reproduced (Lavizzo-Mourey et al., 2021; Yearby & Mohapatra, 2020). The concept that health and health inequities are driven by social determinants is increasingly the focus of nursing articles, conferences, courses, vision statements, toolkits, research, and scholarly projects (National League for Nursing, 2022). On May 11, 2021, the National Academics of Sciences, Engineering, and Medicine released The Future of Nursing 2020–30: Charting a Path to Achieve Health Equity (National Academies of Sciences, Engineering, and Medicine, 2021) . The report contains an urgent call to action for nurses, over the next decade, to concentrate on the SDH to advance health equity. As the nation's largest healthcare profession , nurses play a vital role in leading change so that every person has an opportunity to live the healthiest life possible ( National Academies of Sciences, Engineering, and Medicine, 2021).
Policies and practices impact health and health equity and efforts are steadily increasing to address SDH in healthcare delivery systems (Ariga & Hinton, 2018; Bailey et al., 2021). Addressing social conditions that impact health is not new to nursing but, an upstream perspective that focuses on (1) systems and structures, (2) policy and politics, (3) historical drivers of disparities, and (4) structural racism as a root cause of health inequities is new ( National Academies of Sciences, Engineering, and Medicine, 2021) .Nurses can lead social change but only if they have a clear understanding of SDH and its important and evolving role in advancing health equity ( National Academies of Sciences, Engineering, and Medicine, 2021) .
The widespread movement for racial justice , along with the stark racial inequities in the impacts of COVID-19, has reinforced the nursing profession's ethical mandate to advocate for racial justice and to help combat the inequities embedded not only in the current healthcare system but across all sectors of society ( National Academies of Sciences, Engineering, and Medicine, 2021, P. 100) . Eliminating persistent, unjust, and avoidable inequities is complex (Braveman, 2006) . It involves social, political, psychosocial, and biological processes that work synergistically and inextricably over the life course, at multiple levels, and through entrenched systems and structures (Braveman et al., 2022) .Despite the inexhaustible efforts of those committed to social justice and social change, eliminating inequities to date has been seemingly unattainable (Yearby, 2020) . There is mounting evidence and an emerging groundswell of thinking that policy change, whether through dismantling existing systems or structures or creating new and innovative policies, is the solution (Braverman, Egerter, et al., 2011; Woolf & Braveman, 2011) .
The same forces that create social inequities also create health inequities and if all policy is health policy, then there is a direct connection between historical and contemporary policy to SDH and its profound and enduring effects on our patients' healthcare, and health outcomes (Bailey et al., 2017; Braveman & Dominquez, 2021; Woolf & Braveman, 2011).
Social determinants of health: the meaning and the misunderstanding
Health inequities, unfair and avoidable differences in health between individuals and groups, result in stark differences in health outcomes for certain communities (Whitehead, 1992). The SDH, commonly taught as the conditions in which people are born, grow, live, work, and age, include factors such as income, education, employment, housing, and neighborhood conditions (Centers for Disease Control and Prevention, 2021). Although it captures many powerful societal factors and societal factors account for up to 80%–90% of health and health outcomes, this definition is incomplete and evasive (Magnan, 2017; Weil, 2021). There is a second part to the definition of SDH that is often omitted, deemed inconsequential, and not discussed (Olayiwola et al., 2020; Weil, 2021).
The World Health Organization (WHO) expands this definition, describing SDH as the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life (World Health Organization, 2022a). This expanded definition adds economic policies, development agendas, cultural and social norms, social policies, and political systems to the SDH construct all of which influence the distribution of money, power, and resources locally, nationally, and globally (World Health Organization, 2022b) .
The WHO's broader definition is critical to recognizing how important historical and contemporary policies, politics, and inequities are to the creation of SDH and health inequity/equity ( Bailey et al., 2017, 2021; Lavizzo-Mourey et al., 2021). It clarifies the forces that gave rise to SDH in the first place, and accounts for how racialized groups are disproportionately burdened by the SDH ( Bailey et al., 2017, 2021; Fleming, 2020; Lavizzo-Mourey et al., 2021). It also lends insight into root causes and conveys the importance of intervening through policy ( Bailey et al., 2017, 2021; Exworthy, 2008; Lavizzo-Mourey et al., 2021). With mounting calls for nurses to lead in advancing health equity, understanding what SDH is not, becomes just as important as understanding what it is ( National Academies of Sciences, Engineering, and Medicine, 2021) .
Social determinants of health and related terms: why clarity matters
Strategies to address SDH are being discussed among the health professions across practice, research, and education (National Academies of Sciences, Engineering, and Medicine, 2016, 2021) . SDH is also being addressed outside healthcare systems by policymakers, health systems administrators, health insurance payors, and across local, state, and federal sectors ( Magnan, 2017) . A clearer understanding of SDH is emerging as multiple stakeholders converge to address concepts related to SDH (Braveman & Gottlieb, 2014; Magnan, 2017) . Clear and standardized definitions are essential to avoid confusion and conflation of terms which is particularly relevant when attempting to forge cross-sector partnerships to collaborate, coordinate, and intervene to resolve SDH issues (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019) .
As described in Healthy People 2020, the SDH are organized around five domains: (1) Economic Stability, (2) Education, (3) Health and Healthcare, (4) Neighborhood and Built Environment, and (5) Social and Community Context (Office of Disease Prevention and Health Promotion (ODPHP), 2022) .
SDH is not population health
SDH is not the same as population health or public health because SDH is just one factor shaping the health of a population (Alderwick & Gottlieb, 2019). Population health refers to health outcomes of a group of individuals to include the distribution of such outcomes within the group. It is also important to recognize that SDH are often taught as negative factors experienced by only some groups, but SDH may confer health benefits and can affect entire populations not just racialized, marginalized, or excluded groups ( Olayiwola et al., 2020). Public health reflects society's desire and effort to improve the health and well-being of the total population, by relying on the role of the government, the private sector , and the public, and by focusing on the determinants of population health which include SDH (Shi & Kao, 2009) .
SDH and social risk factors: closely connected but not the same
Social risk factors are the adverse social conditions associated with poor health, such as food insecurity and housing instability (Alderwick & Gottlieb, 2019). Implementing housing and food insecurity screening tools are needed to address social risk factors but do not address (a) the upstream systemic and structural determinants of health or root causes and (b) how to keep this from happening (Alderwick & Gottlieb, 2019).
SDH and social needs are two different concepts
Social needs are social conditions that individuals identify as most pressing for them (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). This construct is different from the terms above because social needs depend on individual preferences and priorities, highlighting the importance of patient-centered care and shared decision making (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). An example of social needs would be an individuals in transitional housing who cannot afford to travel for healthy food options that are not available in their neighborhood. They would identify healthy food for their family as a pressing social need. Efforts to link them with a farmers market truck that travels through their community does not address the underlying upstream systemic and structural issues that caused food insecurity in the first place.
It's important to understand the difference between upstream and downstream SDH. Upstream social determinants are the root cause of health and health outcomes while downstream social determinants are factors that are temporarily and spatially close to health and health outcomes but are influenced by upstream factors ( Braverman, Egerter, et al., 2011). Addressing SDH involves advocating for policy change that addresses social risk factors and social needs like food and housing stability (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). The upstream policies decrease the downstream social risk factors and social needs. Policymakers are the ones who can best address upstream SDH (Alderwick & Gottlieb, 2019; Chepatis el al., 2021; Green & Zook, 2019). However, without political will important policy change does not happen (Dawes, 2020; Lavizzo-Mourey et al., 2021; Ranit, 2019).
Social determinants of health, health disparities, health inequities, and health equity
The concept of health equity encompasses multiple dimensions including health equity, health inequality, health inequity, and health disparity (Yao et al., 2019). Over time, different ethical, philosophical, political, legal, and cultural perspectives have shaped the definitions of these terms and the definitions have evolved and expanded over time (Braveman et al., 2018). All of the terms are based on human rights and social justice principles and although often used interchangeably they have distinctly different meanings (Braveman, Kumanyika, et al., 2011). Clear definitions are important because these terms are commonly used in teaching, practice, research, leadership, and advocacy domains and shape research outcomes, health systems structures, healthcare delivery, and health outcomes ( Braveman et al., 2018).
Health equity means that everyone has a fair and just opportunity to be as healthy as possible and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances ( Braveman et al., 2018).
Health inequalities is a term that is used more internationally and is defined as avoidable and unjust differences in people's health across the population ( Braveman, 2006; Braveman et al., 2018).
Health inequities are the systematic, unnecessary, and avoidable differences in health between groups of people who have different relative positions in social hierarchies based on wealth , structural racism , power, or prestige, all of which can be shaped by policy ( Braveman et al., 2018; Whitehead, 1992).
Health disparities are the avoidable differences in health caused by structural determinants of health that drive SDH and adversely affect racialized, marginalized, or excluded groups. Health disparities include differences in overall health or unequal burden of disease and/or health outcomes between populations that are attributable to social, political, economic, and environmental factors ( Braveman, 2006; Braveman et al., 2018).
The history of social determinants of health
Minimal attention is given to the history of SDH, and history is important because it provides context from within the United States and internationally ( Yao et al., 2019). History illustrates societal concerns and acknowledgment of structural racism as a root cause of inequities; elucidates inconsistencies in evidence and action; and highlights evolving approaches to achieve health equity ( Bailey et al., 2017, 2021; Yao et al., 2019). Moreover, understanding the history of SDH is foundational to truly understanding the persistence of unjust, unnecessary, and avoidable health inequities, underscoring the meaning of the often-heard phrase, it is going to take political will for action on health equity ( Bailey et al., 2017, 2021; Churchwell et al., 2020).
The concept of SDH gained momentum in the United States in 2010 with the release of Healthy People 2020, which built on earlier work out of Europe and Canada. Initially launched in 1979, the Healthy People 10-year reports have focused on health promotion and disease prevention (Breen, 2017; Shi & Kao, 2009). Although the first report did not specifically highlight equity and disparities as important to health, the second report did. Healthy People 2020 was the first report to use social determinants to frame a conceptual understanding of health, and acknowledge that social, economic, and political factors that influence health ( Breen, 2017). Health inequities are not new, they are centuries old. SDH literature dates back over 100 years (Byrd & Clayton, 2000, 2001; Maxmen, 2021).
1800s: landmark SDH works
Chadwick (1842) published a report on the Sanitary Condition of the Laboring Population of Great Britain ( Chadwick, 1842). This report described variations in life expectancy associated with class ( Chadwick, 1842). Recommendations from this report led to the passing of the Public Health Act of 1848 in the United Kingdom (UK) ( Yao et al., 2019). Virchow (1848), reporting on the Typhus Epidemic in Upper Siesia, emphasized the role of social and environmental factors , documented social inequality as a cause of ill-health, and characterized medicine as a social science ( Virchow, 1848). It is important to note that in 1899 W. E. B. Du Bois identified both social and structural determinants of health in his book The Philadelphia Negro: A Social Study (Du Bois, 1899). Du Bois documented that health disparities of Blacks compared to Whites in the United States were a result of social conditions and not inherent racial traits ( Du Bois, 1899). Further, the social problems experienced by Blacks were rooted in Whites' enforcement of racial discrimination and provision of unequal opportunity ( Du Bois, 1899).
1900s: notable SDH contributions
The Constitution of the World Health Organization, 1946 (World Health Organization, 2022c), defined health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. The preamble declared that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition ( World Health Organization, 2022a). Later in the 1900s, the Whitehall Studies of British civil servants in the mid-1900s investigated SDH and showed an inverse social gradient in mortality from a wide range of diseases (Marmot et al., 1991).
2000s: evolving SDH works
The work of Professor Sir Michael G. Marmot on social determinants of health and health inequities laid the groundwork for establishing the WHO Commission on Social Determinants of Health to support countries in addressing social factors leading to health inequities ( World Health Organization, 2022b). A major focus of the Commission was to turn SDH knowledge into political action (Marmot, 2005). Most recently a growing body of literature is focusing on structural determinants of health ( Bailey et al., 2017, 2021; Braveman et al., 2022; Churchwell et al., 2020; Yearby, 2020). Bailey et al. (2017)published a paper documenting evidence and interventions for structural racism as a root cause of health inequities. Lavizzo-Mourey et al. (2021) and Shah (2021) emphasized that achieving health equity will require dismantling structural racism through upstream policy intervention and political will.
History as a determinant of health
While historical accounts of SDH have traditionally begun with works published in the 1800s, there is now growing acknowledgment that social, economic, and political influences started with the inception of this nation. To this day, they negatively impact the health and well-being of Blacks and other racialized groups1 ( Bailey et al., 2017, 2021; Braveman & Dominquez, 2021; Byrd & Clayton, 2000, 2001; Churchwell et al., 2020).
Healthy People, now in its fifth decade, has made progress in reducing morbidity and mortality and improving health and well-being across the United States but these improvements have not been realized equitably across racialized groups ( Churchwell et al., 2020). Blacks continue to experience higher cardiovascular disease and stroke mortality rates regardless of socioeconomic position , so higher income and access do not appear to protect Black people from the impact of structural racism and its health effects ( Churchwell et al., 2020). Blacks with a college degree are more likely than Whites to experience unemployment and have lower wealth at every level of income ( Churchwell et al., 2020). Health profession's students are taught that infant mortality is more than twice as high in Black than White infants, but faculty often fail to underscore that racism is a toxic prenatal stress for Black mothers at every income and educational level (Krieger et al., 2014).
Structural racism
Structural racism refers to the laws, policies, institutional practices, and entrenched norms that undergird all our systems ( Bailey et al., 2017). It includes the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare, and criminal justice ( Bailey et al., 2017), all of which reinforce discriminatory beliefs, values, and distribution of resources ( Bailey et al., 2017). Although systemic racism and structural racism are very similar and often used interchangeably, there are important differences in the terms ( Bailey et al., 2017). Systemic racism is how discriminatory actions against racialized groups show up in political, legal, economic, healthcare, school, and criminal justice systems, and what structures reinforce or perpetuate racial group inequity ( Braverman et al., 2022). Structural racism takes systemic racism and layers on the historical, cultural, and social constructs beginning with the enslavement and genocide of Blacks and Indigenous people in the United States ( Bailey et al., 2017, 2021).
Race and racism in America
Understanding race and racism in America is foundational to any discourse on health equity ( Bailey et al., 2017, 2021; Braveman & Dominquez, 2021). Yet, many educators, healthcare professionals, policymakers, elected officials, and others responsible for responding to the national discourse on the disparate health outcomes in COVID-19 and racial injustice in America remain resistant to identify structural racism as a root cause of racial health inequities ( Bailey et al., 2017).
Race is a social construct that emerged in the 1600s with the trans-Atlantic slave trade and over the centuries, European settlers sought to maintain an economy with the labor of enslaved African people and their descendants while attempting to uphold the universal rights of man ( Bailey et al., 2017; Braveman & Dominquez, 2021; Byrd & Clayton, 2000; Byrd & Clayton, 2001; Yudell et al., 2016). To reconcile this contradiction legal categories were created on the premise that Blacks were innately different, less than human, and therefore subordinate to whites because they were intellectually, and morally, inferior ( Bailey et al., 2017; Braveman & Dominquez, 2021; Byrd & Clayton, 2000, 2001). Throughout the 17th and 18th centuries scientific racism or pseudoscientific experiments, writings, and teachings reinforced the myth of white superiority and the converse myth of Black inferiority ( Byrd & Clayton, 2000, 2001). These false narrativescontributed to the structural racism in the United States and have resulted in implicit and explicit biases, discrimination, abuse, and neglect of Black patients by generations of healthcare providers ( Byrd & Clayton, 2000, 2001; Reynolds, 2020).
Inequities in the United States include stark and persistent gaps between Blacks and Whites that began over 400 years ago with chattel slavery and Jim Crow law and are ongoing, maintained by policies and practices such as redlining and racial segregation, mass incarceration and police violence, and unequal medical care ( Bailey et al., 2017, 2021). These discriminatory policies and practices share three distinguishing factors (1) they affect multiple overlapping systems, (2) they rely on false racial assumptions and stereotypes, and (3) the harms are historically grounded ( Bailey et al., 2021). In order to dismantle discriminatory/racist ideas and policies, it is critical to first learn how and why they were created and then teach learners about them using important historical context ( Churchwell et al., 2020; Jones, 2018).
Jones (2016) proposed that the attainment of health equity is an ongoing process of assurance that requires three things: (1) valuing all individuals and populations equally, (2) recognizing and rectifying historical injustices, and (3) providing resources according to need ( Jones, 2016).
Nurses have a professional and ethical obligation to dismantle systems that have been structurally designed to harm ( National Academies of Sciences, Engineering, and Medicine, 2021) . They must be taught to recognize SDH and encouraged to find their voice to call out policies and structures that contribute to SDH and acknowledge that structural racism is the root cause of health inequities. Nonmaleficence, or do no harm , is the first of the ethical principles for nurses (American Nurse Association, n.d.; National Academies of Sciences, Engineering, and Medicine, 2021) .
Evolving SDH frameworks
A complete and accurate understanding of the causes, impacts, and extent of racial health inequities is a prerequisite to intervening and evaluating on SDH ( Braverman, Egerter, et al., 2011; Braveman, Kumanyika, et al., 2011; Lavizzo-Mourey et al., 2021) .Several SDH frameworks have been developed to help health professionals, community agencies, researchers, and policymakers organize the multileveled and inextricably complex connections involved in addressing health inequity solutions ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022). Over the past decade Accountable Care Organizations (ACO), value-based payment programs, and Community Based Organizations (CBO) collaborated to reduce cost and improve quality ( Artiga & Hinton, 2018). As a result, several SDH frameworks have been created to promote health equity ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022).
SDH frameworks are evidence-based models designed to help healthcare professionals, community agencies, researchers, academics, and policymakers understand, address, and evaluate the complex, intersecting, and multiple social, economic, and environmental factors that affect health and health outcomes ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022). Several SDH frameworks have been created, applying specific perspectives to an array of contexts including assessing and improving population health, community well-being, rural health, health professions education, reducing health inequities, education and collaboration, and workforce development ( National Academies of Sciences, Engineering, and Medicine, 2016; Rural Health Information Hub (RHIhub), 2022). As our understanding of SDH expands, the frameworks are evolving, but by and large these frameworks are derived from socioecological models or the World Health Organization (WHO) SDOH framework ( Rural Health Information Hub (RHIhub), 2022).
Socioecological models of SDH
A socioecological model broadly conceptualizes health and focuses on multiple interactions between the individual, the group/community, and the physical, social, and political environments that affect health ( Rural Health Information Hub (RHIhub), 2022).
The Dahlgren Whitehead Model developed in 1991 is a widely used socioecological model used to illustrate how economic, environmental, and social factors determine health with individuals placed at the center (Dahlgren & Whitehead, 2021). In a recent paper commemorating the 30-year anniversary of their model, the authors admit a flawed assumption of the model is that lifestyles of different socioeconomic groups are freely chosen when in fact they are structurally determined ( Dahlgren & Whitehead, 2021).
The WHO conceptual social determinant of health framework
The WHO SDOH Framework depicts how social, economic, and political factors such as income, education, occupation, gender, race, and ethnicity impact a person's socioeconomic position which then plays a role in determining health outcomes (Solar & Irwin, 2010). These factors can influence a person's ability to lead a healthy life, impacting things such as quality of housing, opportunities in the built environment that encourage physical activity , and access to healthcare services ( National Academies of Sciences, Engineering, and Medicine, 2021; Solar & Irwin, 2010). In this framework, SDH are categorized into two broad types that work together to impact health and well-being. These determinants are structural determinants, which include socioeconomic and political contexts, class, gender, ethnicity and racism, and intermediary determinants, which include the living and working conditions of people ( Solar & Irwin, 2010).
The social determinants of health and social needs model of Castrucci and Auerbach
The Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) elucidates upstream, midstream and downstream strategies to address SDH ( Castrucci & Auerbach, 2019). The downstream strategies are individual-level interventions that include disease treatent and chronic disease management. The midstream strategies address social needs including housing conditions , employment, and food security ( Castrucci & Auerbach, 2019). While downstream and midstream strategies impact individuals, upstream stretegies impact communities ( Castrucci & Auerbach, 2019; National Academies of Sciences, Engineering, and Medicine, 2021). Upstream interventions influence root causes or sociostructural factors such as policies, economics, discrimination, and racism ( Castrucci & Auerbach, 2019; National Academies of Sciences, Engineering, and Medicine, 2021).
Yearby's revised SDOH framework
Yearby's revised SDOH framework ( Yearby, 2020) is a multilayered model that includes structural racism and law, constructs that have been omitted from other models ( Yearby, 2020). Yearby's model addressed the connection between structural discrimination, law, systems, and racial health disparities and inequities ( Yearby, 2020). Yearby posits that structural racism is the way our systems are structured to advantage Whites and disadvantage racialized groups in the five key areas of the SDH ( Yearby, 2020). Yearby's model also underscores the mounting attention being given to political determinants of health ( Dawes, 2020; Ranit, 2019).
Putting it all together: nurses role in informing policy change
Public health in the United States does not have a broad mandate that addresses the SDH ( Shi & Kao, 2009). Countries vested in improving population health are likely to direct their public health efforts at addressing the SDH ( Shi & Kao, 2009). On the other hand, countries with a narrow public policy goal of treating individuals' illness are likely to direct their public health efforts at meeting immediate social needs and targeting risk factors ( Shi & Kao, 2009).
The United States does not have a national health insurance program run by the government and financed through general taxes ( Shi & Kao, 2009). While the US Department of Health and Human Services (DHHS) and Centers for Disease Control and Prevention (CDC) provide guidance and major funding to state (and sometimes local) health departments, the authority for the health of the public constitutionally resides with state governments ( Shi & Kao, 2009). State health departments craft policy and entrust the operational component to local health departments ( Shi & Kao, 2009). Although DHHS and CDC are two federal lead agencies expected to provide guidance to state and local health departments, local entities carry out essential public health services . In the United States many other agencies such as the Department of Agriculture, the Food and Drug Administration (FDA), the US Department of Labor, the Department of Energy, the Environmental Protection Agency (EPA), and the Department of Transportation are involved, all of which share a widespread agreement on the overall mission of public health. When it comes to intervention, however, there is no consensus as to what constitutes necessary public health services and coordination among and within agencies providing public health services ( Shi & Kao, 2009). No single US entity has overall authority and/or responsibility for creating, maintaining, and overseeing the nation's public health infrastructure. Policymakers across jurisdictions and levels of government do not share a vision of what public health should accomplish and who should be held accountable ( Shi & Kao, 2009).
In the United States, work to address SDH has taken place only in recent years marked notably through the Healthy People 2010, 2020, and 2030 initiatives, which acknowledge that upstream social and economic forces are involved in shaping population health and that a broader policy agenda is needed to successfully improve population health ( Ranit, 2019; Shah, 2021).
With a robust advocacy action center and a strong public policy agenda, the NLN is a leader in making an impact on public policy decisions at the national level. The NLN's objective in the public policy arena is to shape and influence those policies that affect nursing education, workforce, access, and diversity ( National League for Nursing (NLN), 2022).
The NLN's Taking Aim initiative, launched in 2020, is transforming nursing education to address the impact of structural racism and societal inequities ( National League for Nursing (NLN), 2022). The Taking Aim objectives include addressing the impact of structural racism on SDH to enable nurses to become better informed, to create a forum for nurse educators to openly dialogue about bias and racism in nursing education and healthcare, and to offer strategies for classroom and clinical instruction to prepare nurses to encounter and defuse structural racism in clinical practice ( National League for Nursing (NLN), 2022).
The NLN/Walden University College of Nursing Institute for Social Determinants of Health and Social Change was introduced in 2021 ( National League for Nursing (NLN), 2022). This innovative partnership was created to develop leaders and cultivate leadership competencies to integrate a full and complete understanding of SDH and weave social change into nursing curricula and programs. The Institute's SDH and Social Change Leadership Academy is novel to nursing education and will start in 2022. Ten selected nurse educators and interprofessional colleagues with a strong commitment to addressing the SDH and social change will engage in a year-long academy to develop as leaders to transform SDH and social change and engage in research and other scholarly activities with broad dissemination ( National League for Nursing (NLN), 2022).
Leading the future could be ours with a collective commitment to pedagogy, education, and accreditation standards that ensure knowledge of history and political participation for social change. Through education, practice, leadership, and policy the NLN is leading the way in focusing on the SDH to advance health equity.
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Cited by (4)
· Introducing the “Nursing Education Integrating Social Change for Health Equity (NISCHE)” framework for nursing education
2024, Nursing Outlook
Citation Excerpt :
While nursing has long recognized the importance of social conditions on health, a four-dimensional upstream perspect
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Nursing Outlook
Volume 70, Issue 6, Supplement 1, November–December 2022, Pages S1-S9
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The Future of Nursing 2020–2030: Charting a path to achieve health equity
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Highlights
· •
The National Academy of Medicine report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity calls for a series of policy reforms to unleash the potential of nurses to play greater roles in advancing health equity.
· •
The report recommends that the systems that educate, pay and employ nurses: 1) permanently remove barriers to care; 2) value their contributions; 3) prepare nurses to tackle health equity; and 4) diversify the workforce. The need to fully support nurses is interwoven throughout the report.
· •
All nurses should work in partnership with others to advance the nine major report recommendations.
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Keywords
Health disparities
Health equity
Nursing
Leadership
Education
Social determinants of health
The National Academy of Medicine's long-anticipated report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, offers an aspirational vision: the achievement of health equity in the United States built on strengthened nursing capacity, diversity, and expertise (Wakefield et al., 2021). Released in May 2021, the report arrives at a critical moment for the profession. Many nurses are burned out, exhausted, and have experienced moral injury from caring for an unrelenting stream of patients with COVID-19. The pandemic has laid bare and further exacerbated long-existing health inequities. School closings during the pandemic similarly exacerbated educational disparities, and poor treatment of Black, Indigenous, and other people of color by police spotlighted inequities in law enforcement. Collectively, these inequities have resulted in renewed calls to dismantle structural, cultural, and interpersonal racism, including within nursing. This new report provides a roadmap for how the nursing profession can contribute its expertise to create a fairer, more just and healthier world.
Setting the Stage
The report is the second collaboration between the Robert Wood Johnson Foundation (RWJF) and the National Academy of Medicine (NAM) on the future of nursing. The first report, released in 2010, re-conceptualized the role of nurses in transforming the healthcare system (Shalala et al., 2011). RWJF and AARP formed The Future of Nursing: Campaign for Action, a nationwide initiative to advance the report recommendations. Over the past decade, the nursing field strengthened nursing education , advanced practice, promoted leadership, and increased workforce diversity. In doing so, the nursing field has built – and is continuing to build – its capacity to provide high-quality care to more Americans.
As nursing built its capacity and as the evidence increasingly linked inequities to poorer health status , it became clear that nurses could do more to build healthier communities and advance equity. Nurses are the most trusted profession and the first point of contact for most people seeking health care. They are bridge builders and collaborators who engage and connect with people, communities, and organizations to promote health and well-being (Pittman, 2019). Their expertise could be better used to combat the many shortcomings of the U.S. health system. The United States spends $3.5 trillion each year on health care (CMS, 2020) ![single bond]()
more than any other country in the world ![single bond]()
but ranks last compared with other high-income countries on equity, access to care, health care outcomes , and administrative efficiency (Schneider et al., 2021). Life expectancy, infant mortality and maternal mortality are worse in the United States compared with other high-income nations. Disparities in health care access and outcomes related to race, income, geography and other social and environmental factors are also common. RWJF has long believed that nurses have enormous potential for tackling the shortcomings of health and health care in the United States and in 2019 asked the NAM to form a committee tasked with charting a path for the nursing profession to create a culture of health, reduce health disparities , and improve the health and well-being of the nation.
As the committee was well into the process of reviewing evidence and preparing to write the report, the pandemic took hold across the country and shined a light on the nation's rampant health inequities. The committee delayed the report to incorporate the major lessons from the pandemic: its disproportionate and devastating toll on poor and marginalized populations that could largely be attributed to persistent health disparities; the need to fully support nurses; and better prepare the workforce for future disasters. Released in May 2021, the report called for a series of policy reforms to unleash the potential of nurses to play greater roles in advancing health equity.
The Priority Areas
The report recommends that the systems that educate, pay, and employ nurses: (1) permanently remove barriers to care; (2) value their contributions; (3) prepare nurses to tackle health equity; and (4) diversify the workforce. The report underscores that prioritizing nurse well-being is paramount to advancing the recommendations. In addition, the report calls on national nursing organizations to develop a shared agenda for addressing the social determinants of health and achieving health equity. Finally, the committee prioritized research needs to build the evidence base to support nurses in advancing health equity. Each of these areas is discussed below.
Permanently Remove Barriers to Care
Far too often in the United States, people do not see a health care provider when they need one. Nearly 30 million people are uninsured in the United States, and roughly 40 million have health plans that leave them potentially underinsured (Collins, Gunja, & Aboulafia, 2020). In addition, timely access to health care is undermined due to the inability to pay; geographic inaccessibility to services and providers, particularly in rural and underserved urban areas; lack of health literacy; and fundamental mistrust of the health care system and providers. Research demonstrates that delays in obtaining care can lead people to experience worse symptoms and disease progression (Man, Lack, Wyatt, & Murray, 2018). Nurses can help to explicitly address these gaps in access to care. For example, about 70% to 80% of advanced-practice nurses work in primary care , including in pediatrics, adult practice, gerontology, and nurse midwifery . While the primary care nurse practitioner field has grown, the number of physicians entering primary care has stagnated or declined (Barnes et al., 2018; Xue et al., 2016). Care provided by nurse practitioners has been found to be comparable to the care provided by physicians, according to numerous studies (Perloff, Clarke, DesRoches, O'Reilly-Jacob, & Buerhaus, 2019; Yang et al., 2020). They are less expensive to employ than physicians and are more likely to care for vulnerable populations, including those in rural areas (Perloff, DesRoches, & Buerhaus, 2016).
However, the ability of nurses to expand access to care is limited by state and federal laws, institutional barriers, and restrictive health systems policies that prohibit them from working to the full extent of their education and training (Wakefield, Williams, Le Menestrel, & Flaubert, 2021). The report calls for all public and private organizations to remove these regulatory and payment limitations as well as restrictive policies and practices. In fact, during the pandemic, seven states (Kansas, Louisiana, Massachusetts, New Jersey, New York, Virginia, and Wisconsin) temporarily provided full practice authority to nurse practitioners. Evidence is just becoming available about the effect of the temporary waivers to expand scope of practice during the pandemic (Kleinpell, Myers, Schorn, & Likes, 2021; Stucky, Brown, & Stucky, 2021); one study in the Midwest found that states with waivers were able to decrease death rates from COVID-19 (Chung, 2020). The report calls for these temporary restrictions on scope of practice to be made permanent.
This recommendation to remove practice barriers continues the work of the first report, but it discusses in more detail the need to lift barriers that prevent RNs and licensed-practical nurses from practicing to the top of their education and training to increase access to care and help to reduce health care inequities for populations struggling to see a provider when they need one. Barriers that limit the care that RNs and licensed practical nurses provide include restrictions on providing telehealth services and workplace policies that prevent nurses from providing care. Allowing nurses to practice to the full extent of their education and training is an important policy solution to eliminating preventable gaps in access to care.
Value Nurses’ Contributions
As the report notes, the public and private payment systems do little to reduce health inequities. This shortcoming has recently been underscored by the Biden Administration, which has indicated its intent to make health equity a priority consideration in payment policy (Brooks-LaSure, 2021). Because payment drives health care parameters, actions that prioritize health equity can make a profound impact in creating change. The current U.S. payment systems undervalue the care that nurses provide and underestimate the critical role that they can play in addressing obstacles to health equity. For example, acute care nurses can screen patients at discharge to help identify and address social needs like food insecurity. Similarly, community-based nurses can work to advance city or state policies that address the need for accessible housing and safe neighborhoods. But payment systems often only reimburse for physicians’ services while including the services of nurses and other team-based care providers under generic facility charges. With financial support, nurses can markedly expand efforts to advance health equity through their roles in care management and team-based care; preventative care; community nursing , including school nurses ; and providing telehealth services.
School nurses, for example, are a lifeline for 56 million students, particularly children from low-income families, but they are undervalued for the services they provide. They detect illnesses early, help manage chronic conditions, and contact trace outbreaks of infectious disease, including COVID-19. They also provide mental health care. About one-third of student health visits to school nurses before the pandemic were related to mental health (Foster et al., 2005), a need that has grown tremendously during the pandemic. Students of color face more barriers to accessing mental health treatment than others, and structural racism can exacerbate these conditions (Lipson, Kern, Eisenberg, & Breland-Noble, 2018). But 25% of schools do not employ a school nurse, and 35% employ one part-time (Willgerodt, Brock, & Maughan, 2018). School nurses are able to bill Medicaid for services that they provide, but the process is so cumbersome that few schools do so (Ollove, 2019).
Investments that expand, strengthen, and diversify the nursing workforce will help to advance health equity. Specific to the nursing profession , the report calls for public and private payers to provide reimbursement for nursing interventions that address social needs and the social determinants of health in nursing practice and education. Payment systems can enable nurses to make essential contributions to improving care and outcomes for all patients by delivering proven interventions and strategies that can reduce health inequities. Furthermore, the widespread adoption of successful, evidence-based nursing innovations to improve care will remain limited if the organizations that employ nurses are not adequately compensated for these care improvements (Chin & Bisognano, 2021). The report recommends that public and private payment systems be intentionally designed to support and incentivize health care and public health organizations to enable nurses to perform these vital roles. Simply put, the United States spends tremendous amounts of money for health care services, with health outcomes that pale in comparison to countries that spend far less. Recognizing this incongruity, public and private sector efforts are underway to recast payment policy that produces better health outcomes. Nursing input in these payment discussions is critically important, as is payment policy that values the contributions nurses can make to advancing health equity.
Prepare Nurses to Tackle Health Equity
The next generation of nurses needs to be well prepared to promote health equity and improve the health and well-being of everyone. All nurses will need to understand and identify the complex social and environmental factors that affect health, effectively care for an aging and more diverse population, engage in new professional roles, use new technology, collaborate with other professions and sectors around health equity issues, and adapt to a changing policy environment. Meaningful, deep and broad collaboration with partners across the health care and public health systems as well as outside of health care ![single bond]()
with organizations focused on housing, transportation, social isolation, and food insecurity ![single bond]()
will be paramount during the next decade. Yet, the nursing field will face an extraordinary challenge in preparing the next generation as an estimated 1.2 million nurses born during the baby boom generation retire by 2030. This tectonic shift will result in an unprecedented knowledge gap (Buerhaus et al., 2017), even as nursing education strives to produce nurses well prepared to take on contemporary and futures roles and takes action to advance the NAM report recommendations. Specific recommendations to prepare nurses to tackle health equity include:
Revamping Nursing curricula
Too often, content related to the social determinants of health, health inequities, and population health are not well-integrated into undergraduate and graduate nursing education. Academic programs must ensure that nurses are prepared to address the social determinants of health and advance health and healthcare equity. Associated content and competencies should be well-integrated throughout coursework, including through expanded community learning opportunities.
Schools need to evaluate the extent to which they provide substantive education in locations that provide important direct engagement with individuals and families from diverse backgrounds who present with an array of social needs as well as with communities facing challenges associated with the social determinants of health ( Wakefield et al., 2021). Creating learning opportunities across the curriculum, including in public policy venues, accompanied by meaningful reflection on challenging topics such as biases are essential. Much of this learning can occur through active, sustained learning opportunities provided through public health environments such as schools, workplaces, home health care, federally qualified health centers, public health clinics, homeless shelters, public housing sites, public libraries, residential addiction programs, and telework settings. These student experiences, calibrated for educational level, should incorporate opportunities to deeply observe and work collaboratively with other health and non-health professionals to address the social determinants of health. Ultimately, students need active engagement in experiences that prepare them to act on a strong foundation in health equity, care for diverse populations with competence and empathy, and allow them to build the necessary skills and competencies to advance health equity. Nurse educators can find inspiration from exceptional examples of nursing schools that emphasize content and robust engagement around the social determinants of health, population health and community experiential placements. For example, graduate students at the University of Washington spend a year immersed in grassroots work in the community followed by a year immersed in policy. Washburn University in Topeka, Kansas, integrated its DNP academic program with a community clinic that reflects interdisciplinary practice and commitment to ongoing academic improvement informed by both students and faculty.
Increasing the number of nurses with PhDs
More doctorally prepared nurses will be necessary to teach the next generation of nurses and systematically build the evidence base around concepts and issues that connect the social determinants of health, health equity, and health status as well as associated nursing interventions. PhD nursing graduates will need to be able to design and implement research that addresses issues of social justice and equity in education and healthcare, including a focus on informing institutional and public policies. Increasing the number of nurses with PhDs requires financial resources, including scholarship and loan repayment opportunities; sufficient numbers of expert available faculty, including for mentorship; and curriculum revisions that focus on equity. All PhD graduates should have competencies in the use of data on the social determinants of health as context for planning, implementing, and evaluating care and for improving population health through large-scale data application.
Diversify the Workforce
In addition to developing and fielding new knowledge to advance health and healthcare equity, developing a more diverse nursing workforce will be critical. The new report calls on the nursing field to address systemic racism and bias within nursing education and practice, and to prioritize diversity and cultural humility – defined by flexibility, a lifelong approach to learning about diversity, and recognition of the role of individual bias and systemic power in health care interactions (Agner, 2020).
Nursing needs to identify and address structural racism within the profession to address systemic barriers that contribute to the nursing profession remaining overwhelmingly white and female. Despite periodic calls to increase diversity, the nursing field is still roughly 80% white, even though white individuals comprise 60% of the U.S. population. The gap widens further for nurses in leadership positions, including in academia and practice. The American Association of Colleges of Nursing estimated in early 2021 that 10% of nursing faculty and 4% of deans were people of color, while the American Organization of Nurse Leaders said that just under 10 percent of chief nursing officers were people of color (AACN and AONL, 2021). Nurses of color repeatedly report experiencing discrimination and bias within their work settings (Cottingham, Johnson, & Erickson, 2018; Ghazal, Ma, Djukic, & Squires, 2020). Fragmented efforts, while important locally, are wholly insufficient to achieving a nationally diverse workforce. Prioritized support should be directed toward the development of substantive, evidence-based and ultimately scaled efforts to achieve nursing workforce diversity across practice settings, academic institutions and in leadership positions.
Within nursing academic and practice environments, everyone should feel included and welcomed. To achieve this relatively simple-sounding aim, however, requires meaningful and sustained efforts to make sure that nursing students and faculty reflect the diversity of the population and that barriers of structural racism are removed from nursing education, including in the curricula, institutional polices and structures, and the formal and informal distribution of resources and power (Iheduru-Anderson, 2021). Across practice environments, all nurses need to be able to effectively communicate and connect with people of different backgrounds and be capable of self-reflection regarding how their own beliefs and biases may affect their caregiving. Achieving these aims is predicated on a diversified and strengthened academic and practice environment that is inclusive, which requires recruiting and admitting or hiring people from diverse backgrounds, races and ethnicities. Schools of nursing should offer students support and address barriers to their success throughout their academic career and into practice. Implicit and explicit bias training coupled with learning about structural discrimination will be critical for nurses in practice settings. Workplaces should recruit, retain, mentor, and promote nurses from underrepresented backgrounds.
Recommendations to create a diverse, equitable and inclusive workforce
The report includes several recommendations that prioritize actions for nursing educators and academic administrators and that will lead to increased workforce diversity, equity and inclusion. Among the recommendations are to (1) identify and eliminate policies, procedures, curricular content, and clinical experiences that perpetuate structural racism and discrimination among faculty, staff and students; (2) increase academic progression for geographically and socioeconomically disadvantaged students through academic partnerships that include community and tribal colleges located in underserved areas; and (3) recruit diverse faculty with expertise in health equity and use evidence-based and other trainings to develop the health equity skills of faculty.
Disaster preparedness
Disasters and other public health emergencies disproportionately affect people of color, those with low incomes, those experiencing housing insecurity, and those with limited access to health care and transportation (Davis, Wilson, Brock-Martin, Glover, & Svendsen, 2010). Although nurses serve on the frontlines of emergencies and help people and communities to cope and recover, nursing curricula does not consistently and thoroughly teach students about health care emergency preparedness. The report recommends that nursing schools and employers expand disaster preparedness educational and training opportunities for nurses in all sectors and at all levels with particular attention to vulnerable populations.
Fully Supporting Nurses
To unleash the potential of nurses to advance health equity, our country needs to prioritize nurse well-being. The nursing profession has been lauded for its selflessness and caring in delivering care under extremely challenging circumstances during the COVID-19 pandemic. However, this professional engagement, often accompanied by physical and emotional risk to themselves and their families, came with a cost. Even prior to the pandemic, studies showed stress impacting the nursing community , catalyzed by an array of factors ranging from working in understaffed settings, to experiencing bullying and violence in the workplace, to the added pressures of caring for children or elderly relatives outside of work hours (Robert Wood Johnson Foundation [RWJF], 2019; Sauer & McCoy, 2017). Levels of stress and burnout increased during the pandemic, resulting in moral injury and post-traumatic stress disorder for many nurses (Le Beau Lucchesi, 2021; Rushton, Turner, Brock, & Braxton, 2021) and prompting early retirement and departures from the nursing field.
Of the more than 12,000 nurses participating in a December 2020 survey conducted by the American Nurses Foundation, Pulse of the Nation's Nurses, most shared they are currently experiencing a higher likelihood of depression, anxiety, and distress from when they were surveyed in spring 2020. During the spring administration of the survey, 50% of nurses indicated they were overwhelmed. These feelings have intensified as 72% of nurses surveyed last December indicated that they felt exhausted (American Nurses Foundation, 2020).
Nursing students and faculty have also undergone significant changes in expectations related to their roles. During the pandemic, faculty pivoted quickly to adopt new teaching strategies and turned to simulation-based education experiences in lieu of clinical placements. Many programs struggled to find sufficient hours of instruction, training and clinical practice for students. Some students encountered difficulties in submitting their assignments without computers, Internet access, childcare, or a quiet place to study. Nursing students reported feeling stressed, exhausted, and disengaged before the pandemic (Michalec, Diefenbeck, & Mahoney, 2013). Educators have a key role to play in ensuring students’ well-being and providing them with tools and strategies to nurture their well-being throughout their careers. Educators should build and sustain cultures that integrate well-being throughout the curricula in meaningful and visible ways. The Compassionate Care Initiative at the University of Virginia School of Nursing, for example, supports well-being through coursework, resiliency activities, retreats, and workshops classes (Bauer-Wu S, 2015).
At the time of this article's writing, the Delta variant was surging through the South and spreading rapidly throughout the rest of the country, stressing hospital capacity and resulting in hospitalization and death rates not seen since January 2021, mostly among unvaccinated individuals. The U.S. passed the grim milestone of 700,000 deaths from COVID1-19, including more than 1,200 nurses who have died from the virus, a disproportionate number of whom are nurses of color (The Guardian and Kaiser Health News, 2021). The glimmer of hope earlier in the year that widespread vaccination could curb illness and death rates had all but dissipated as this article went to press. The well-documented burnout and stress nurses felt in 2020 and early in 2021 has intensified, accompanied by frustration that too many individuals ignored established, evidence-based public health practices that could mitigate this disease ![single bond]()
with deleterious impact on human and technical resources and the well-being of entire communities. The nursing workforce, often facing staff shortages in the facilities where they work, has been further stretched and fatigued (Jacobs, 2021; Kennedy, 2021).
Beyond adverse impact to nurses themselves, nurses who experience poor physical and mental health are more likely to make medical errors, with resultant harm to patients (Melnyk, 2018). One of the clear imperatives from an ethical, advocacy, and policy standpoint in the next decade is to tackle the systems, structures, and policies that create workplace hazards and stresses that lead to burnout, fatigue, and poor physical and mental health among the nursing workforce. While the long-term impact of this pandemic on recruitment and retention of nurses is still unknown, the circumstances around and expectations of nurses ![single bond]()
from public health departments to critical care units ![single bond]()
are too frequently damaging and wholly inadequate. The report includes several recommendations to create structural and cultural changes to fully support nurses. The primary recommendation squarely lands expectations on education programs, employers, nursing leaders, licensing boards, and nursing organizations to implement structures, systems, and evidence-based interventions that promote nurses’ health and well-being, especially as they take on new roles to advance health equity. This recommendation requires employing organizations’ leadership, governance, and management to monitor and explicitly work to improve nurse well-being. Meaningful efforts will typically require realigning budgets to support these aims and redesigning work so that nurses are supported with adequate staffing levels, appropriate workloads, job control, a healthy physical environment and peer and other support services. Health care organizations can explicitly limit staff time on site or specific shifts to prevent nurses from being overworked. They can implement “see something, say something” programs that encourage nurses and others to report any unsafe workplace conditions, including violence and bullying. Employers can engage their nursing staff directly for ideas and recommendations about the kinds of resources and work structures that they may find most useful in supporting their well-being and that of their nurse colleagues.
One promising practice is peer support groups that enable nurses to talk with other nurses who are or have experienced similar challenges. Another is to increase engagement between managers and nursing staff and thereby communicate value and support for nurses while also obtaining input on process improvement opportunities that can minimize adverse impacts on nurses. For example, the Camden Coalition, which helps to manage the health of people with multiple chronic conditions and social needs, offers 20-minute check-ins each week to create camaraderie among their teams and to support one another, with shorter just-in-time check-ins daily (Coalition, 2021). While self-care has an important role in improving nurse well-being, it is an insufficient solution to challenges that nurses often face, ranging from inadequate staffing, to extremely acute caseloads, lack of equipment, inadequate training, or hostile work environments . Leadership of health and healthcare organizations needs to listen to their frontline staff and prioritize much-needed structural and cultural changes.
Creating a Shared Agenda
To substantially advance health equity across the nation, the report calls on a broad range of stakeholders to support the nursing profession's efforts. Additionally, within nursing itself, there is formidable capacity that, if leveraged, could more quickly and comprehensively advance health equity ![single bond]()
an aim that has the potential to improve health and well-being for millions of Americans. Leveraging the profession's capacity is captured in the report's first recommendation that calls on nursing organizations to work collaboratively, streamlining rather than duplicating efforts to address social needs and the social determinants of health and sharing and capitalizing on key expertise held by particular nursing organizations. This shared response is also relevant because this work encompasses all nurses, regardless of their educational level or work environment . Nursing organizations should join forces to identify priorities for education, practice and policy that address the social determinants of health and advance health equity. The established agenda should include explicit priorities across nursing practice, education, leadership, and health policy engagement, along with associated timelines and metrics for measuring impact. One by one, many nursing organizations have developed educational materials, supported public policy, engaged with media and worked in many other ways to advance health equity. While these individual association efforts are important, the report calls on nursing organizations to collectively share resources, leverage expertise and move together and more expeditiously, prioritizing these focus areas on behalf of the populations we serve.
Building the Evidence
While there is a strong evidence base to build on, more research is needed to advance health equity, including a focus on implementation science that supports broadly scaling evidence-based practice models, education strategies, and public policies. For example, a robust evidence base is essential to efficiently and effectively strengthen and diversify the nursing workforce, foster nurse well-being, and evaluate multisector team approaches to fully address health disparities and advance health equity. The report calls on the major health government agencies, private associations, and foundations to convene representatives from nursing, public health, and health care to develop and support a research agenda and evidence base that describes the impact of nursing interventions, including multi-sector collaboration, on the social determinants of health, environmental health, health equity, and nurses’ health and well-being. Research should focus on using evidence-based educational strategies that clearly result in increases in the number and diversity of students and faculty from disadvantaged and traditionally underrepresented groups; as well as developing evidence-based education strategies that are effective in preparing nurses to eliminate structural racism and implicit bias; and improve the use of advanced information technology to enhance care coordination without creating more inequity.
Call to Action
In setting its sights on positioning the nursing profession to direct its expertise, attention and resources toward achieving health equity, the field is prioritizing a topic that has been anemically addressed for far too long ![single bond]()
with disastrous results. The COVID-19 pandemic shows us that infectious disease on top of compromised social determinants of health can wreak havoc on large swaths of our communities. The past two years have been devastating for low-income individuals, people who live in rural areas, and people of color, who have disproportionately faced adverse economic repercussions and suffered and died from COVID-19. Nurses ![single bond]()
by the tens of thousands ![single bond]()
have stepped into circumstances that put their health and that of their families at risk and are experiencing moral injury , burnout, and stress from being asked to decrease their care level because of a shortage of beds and ventilators. Neither the American population nor the nursing profession should be faced with these circumstances again. By working to advance these recommendations, the nursing field commits to laying the groundwork for creating a healthier and more just America for everyone – the most salient and significant issue of our time.
This work is not and cannot be owned by the nursing profession alone, of course. As the report frequently notes, nursing will need the support and collaboration of everyone whose decisions impact health. New priorities will need to be set and pursued with long-standing partners. New partnerships will need to be forged with social and other sectors that have long worked to advance health equity, including social justice organizations, social services agencies, consumer organizations, and advocacy groups that work on behalf of populations bearing the brunt of health inequities. Health systems, foundations, and broader community partners need to be involved as well (Hassmiller, 2021).
Comprehensive in its contribution, the report contains nine major recommendations and 54 sub-recommendations. Nurses and other stakeholders can download the report at www.nap.edu/nursing2030 and work collaboratively with others in determining particular actions to prioritize. The site also includes recorded webinars, short policy briefs, and a podcast series about the report. In addition, the Future of Nursing: Campaign for Action has an Action Hub available on its website with 54 draft action plans for each sub-recommendation that any organization can use as a starting point to advance health equity.
Nursing has a well-recognized place in mitigating health problems across a wide array of settings. Over the next decade, the report calls on nurses to much more substantively and comprehensively commit to preventing these health problems in the first place by working tenaciously and collaboratively to eliminate the upstream factors that drive health disparities, poor health outcomes and stand in the way of achieving health equity. The report charts a path for all nurses to meaningfully pivot to advancing health equity. With the health status of individuals, families and communities at stake, the clock is running.
Authors' Contributions
Mary Wakefield: Conceptualization, Writing – Reviewing and Editing; Susan B. Hassmiller: Conceptualization, Writing – original draft preparation, Writing – Reviewing and Editing.
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Social Determinants of Health (SDOH)
WHAT TO KNOW
Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, worship, and age. These conditions include a wide set of forces and systems that shape daily life such as economic policies and systems, development agendas, social norms, social policies, and political systems. CDC has adapted this definition from the World Health Organization.
![Thumbnail of CDC's social determinants of health framework]()
Why are SDOH important to CDC?
SDOH are one of three priority areas for Healthy People 2030 , along with health equity and health literacy. Healthy People 2030 sets data-driven national objectives in five key areas of SDOH : healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment. Some examples of SDOH included in Healthy People 2030 are safe housing, transportation, and neighborhoods; polluted air and water; and access to nutritious foods and physical health opportunities.
As the federal government's leading public health agency, CDC has a unique role in contributing to work on SDOH.
Why is addressing SDOH important for CDC and public health?
Addressing differences in SDOH accelerates progress toward health equity , a state in which every person has the opportunity to attain their highest level of health. SDOH have been shown to have a greater influence on health than either genetic factors or access to healthcare services. For example, poverty is highly correlated with poorer health outcomes and higher risk of premature death. A SDOH, including the effects of centuries of racism, are key drivers of health inequities within communities of color. The impact is pervasive and deeply embedded in our society, creating inequities in access to a range of social and economic benefits—such as housing, education, wealth, and employment. These inequities put people at higher risk of poor health.
CDC is coordinating efforts to focus its resources on the areas where federal public health investments can make the most difference. For example, CDC's Racial and Ethnic Approaches to Community Health (REACH) focuses on reducing high rates of chronic diseases for specific racial and ethnic groups in urban, rural, and tribal communities. Since 1999, the program has worked across sectors in racial and ethnic minority communities to reduce tobacco use, improve access to healthy foods, change the built environment to promote physical activity, and connect people to clinical care.
Public health actions that affect SDOH
Public health organizations can:
Convene
Bring together community members and organizations to identify local concerns.
CDC has a long history of convening partners through national conferences, webinars, collaborative publications, and guideline development. CDC also encourages other public health organizations to act as conveners by including coalition-building or community engagement activities as a requirement in some funded projects.
Integrate
Collect and use multiple sources of data, including public health data, to help develop strategies for set direction. For example, public health departments can provide GIS maps of community needs and assets based on CDC PLACES data B and environmental justice data C .
Influence
Lead approaches to develop policies and solutions or leverage funding through various mechanisms to implement and expand priority actions. For example, when CDC Director Rochelle Walensky announced that racism is a public health threat in 2021, it reinforced actions that communities were already taking and supported many others as they took subsequent actions.
Contribute to big changes
Collaborate with others to find innovative solutions and put them into place. For example, an LA County public health initiative resulted in the ban of menthol cigarettes.
Social Determinants of Health resources
Other CDC resources:
National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)
National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)
Public Health Professionals Gateway
Adverse Childhood Experiences at the National Center for Injury Prevention and Control
Additional resources from other organizations:
Healthy People 2030
World Health Organization
White House SDOH Playbook (2023)
HHS SDOH Call to Action (2023)
ON THIS PAGE
· Why are SDOH important to CDC?
· Why is addressing SDOH important for CDC and public health?
· Public health actions that affect SDOH
· Social Determinants of Health resources
RELATED PAGES
· Advancing Science and Health Equity
· Measures of Success
· Social Determinants of Health at CDC
· About Us
· Leadership
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THE SOCIAL DETERMINANTS OF HEALTH
![A person in a lab coat pointing at a diagram AI-generated content may be incorrect.]()
The social determinates of health include factors other than access to health care, such as socioeconomic status, economic stability, access to quality education, physical environment, support networks, employment, etc. Although efforts to improve healthcare within the United States usually point to responsibilities within the healthcare system, there is a growing recognition that these social determinants of health are also critical—from the individual to the population level.
As a DNP-prepared nurse, you will consider and address the social determinants of health when working with patients. Think about the ways in which this will positively impact your patients’ experiences and outcomes, as well as the communities you serve.
RESOURCES
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE:
· Review the Learning Resources that address the importance and value of taking the SDoH into consideration as a DNP-prepared nurse.
· Consider why and how you intend to begin shifting your thinking and practice related to the SDoH from the relatively smaller scope of patient care to the broader perspective of organizations, communities, and the larger field of nursing (e.g., advocating at the policy level, meeting with stakeholders, utilizing esearch and data, etc.).
· Select one SDoH Domain that is of particular interest to you on which to focus for this Discussion.
· Using Walden Library and the internet, search for and identify three scholarly, peer-reviewed articles (within the last 5 years) that address the SDoH Domain you selected from the broader perspective of organizations, communities, and the larger field of nursing.
BY DAY 3 OF WEEK 6
Post the following:
· An explanation of the importance and value of taking the SDoH into consideration as a DNP-prepared nurse.
· Identify the one SDoH Domain you selected and explain why it is particularly important to you.
· An explanation of why and how you intend to shift your thinking and practice related to the SDoH from the patient-level to the organizational, community, and/or larger field of nursing levels. Be specific, provide examples, and cite the three scholarly resources you identified to support your points.
Note: Your posts should be substantial (500 words minimum), supported with scholarly evidence from your research and/or the Learning Resources, and properly cited using APA Style. Personal anecdotes are acceptable as part of a meaningful post but cannot stand alone as the entire post.
Read a selection of your colleagues' posts.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues' postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!
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