social justice in nursing essay

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

• Hardcopy Version at National Academies Press

5 The Role of Nurses in Improving Health Equity

Being a nurse … in 2020 must mean being aware of social injustices and the systemic racism that exist in much of nursing … and having a personal and professional responsibility to challenge and help end them. —Calvin Moorley, RN, and colleagues, “Dismantling Structural Racism: Nursing Must Not Be Caught on the Wrong Side of History”

Health equity is achieved when everyone has a fair and just opportunity to be as healthy as possible. Nurses are well positioned to play a major role in addressing the underlying causes of poor health by understanding and recognizing the wide range of factors that influence how well and long people live, helping to create individual- and community-targeted solutions, and facilitating and working with interdisciplinary and multisector teams and partners to implement those solutions. Nurses have the potential to reshape the landscape of health equity over the next decade by expanding their roles, working in new settings and in new ways, and markedly expanding efforts to partner with communities and other sectors. But for the United States to make substantial progress in achieving health equity, it will need to devote resources and attention to the conditions that affect people’s health and make expanded investments in building nurse capacity. And nursing schools will need to shift education, training, and mindsets to support nurses’ new and expanded roles.

When this study was envisioned in 2019, it was clear that the future of nursing would look different by 2030; however, no one could predict how rapidly and dramatically circumstances would shift before the end of 2020. Over the coming decade, the nursing profession will continue to be shaped by the pressing health, social, and ethical challenges facing the nation today. Having illuminated many of the health and social inequities affecting communities across the nation, the COVID-19 pandemic, along with other health crises, such as the opioid epidemic ( Abellanoza et al., 2018 ), presents an opportunity to take a critical look at the nursing profession, and society at large, and work collaboratively to enable all individuals to have a fair and just opportunity for health and well-being, reflecting the concept of “social mission” described by Mullan (2017 , p. 122) as “making health not only better but fairer.” This chapter examines health equity and the role of nursing in its advancement in the United States.

As stated previously, health equity is defined as “the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance” ( NASEM, 2017a , p. 32). While access to equitable health care, discussed in Chapter 4 , is an important part of achieving health equity, it is not sufficient. Health is affected by a wide range of other factors, including housing, transportation, nutrition, physical activity, education, income, laws and policies, and discrimination. Chapter 2 presents the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) , in which upstream factors represent the social determinants of health (SDOH) that affect individuals and communities in a broad and, today, inequitable way. Low educational status and opportunity, income disparities, discrimination, and social marginalization are examples of upstream factors that impede good health outcomes. Midstream factors comprise social needs, or the individual factors that may affect a person’s health, such as homelessness, food insecurity, and trauma. Finally, downstream factors include disease treatment and chronic disease management.

Much of the focus on the education and training of nurses and the public perception of their role is on the treatment and management of disease. This chapter shifts that focus to nurses’ role in addressing SDOH and social needs, including their potential future roles and responsibilities in this regard, and describes existing exemplars. First, the chapter provides a brief overview of nurses’ role in addressing health equity. Next, it describes opportunities for nurses to improve health equity through four approaches: addressing social needs in clinical settings, addressing social needs and SDOH in the community, working across disciplines and sectors to meet multiple needs, and advocating for policy change. The chapter then details the opportunities and barriers associated with each of these approaches.

NURSES’ ROLE IN ADDRESSING HEALTH EQUITY

As described in Chapter 1 , the history of nursing is grounded in social justice and community health advocacy ( Donley and Flaherty, 2002 ; Pittman, 2019 ; Rafferty, 2015 ; Tyson et al., 2018 ), and as noted in Chapter 2 , the Code of Ethics for Nurses with Interpretive Statements, reiterated by American Nurses Association (ANA) President Ernest J. Grant in a public statement, “obligates nurses to be allies and to advocate and speak up against racism, discrimination, and injustice” ( ANA, 2020 ).

Addressing social needs across the health system can improve health equity from the individual to the system level. The report Integrating Social Care into the Delivery of Health Care identifies activities in five complementary areas that can facilitate the integration of social care into health care: adjustment, assistance, alignment, advocacy, and awareness ( NASEM, 2019 ) (see Figure 5-1 and Table 5-1 ). In the area of awareness, for example, clinical nurses in a hospital setting can identify the fall risks their patients might face upon discharge and the assets they can incorporate into their lives to improve their health. In the area of adjustment, telehealth and/or home health and home visiting nurses can alter clinical care to reduce the risk of falls by, for example, helping patients to adjust risks in their homes and learn to navigate their environment. And these activities can continue to the high level of system change through advocacy for health policies aimed at altering community infrastructure to help prevent falls.

Areas of activity that strengthen integration of social care into health care. SOURCE: NASEM, 2019.

Definitions of Areas of Activities That Strengthen Integration of Social Care into Health Care.

In short, improving population health entails challenging and changing the factors and institutions that give rise to health inequity through interventions and reforms that influence the institutions, social systems, and public policies that drive health ( Lantz, 2019 ). It is important to note, however, that there are shortcomings in how evaluations of health equity interventions are carried out (see Box 5-1 ).

Shortcomings of Evaluations of Health Equity Interventions.

• ADDRESSING SOCIAL NEEDS IN CLINICAL SETTINGS

Although the provision of clinical care is a downstream determinant of health, the clinical setting presents an opportunity for nurses to address midstream determinants, or social needs, as well. Screening for social needs and making referrals to social services is becoming more commonplace in clinical settings as part of efforts to provide holistic care ( Gottlieb et al., 2016 ; Makelarski et al., 2017 ; Thomas-Henkel and Schulman, 2017 ). Nurses may conduct screenings; review their results; create care plans based on social needs as indicated by those results; refer patients to appropriate professionals and social services; and coordinate care by interfacing with social workers, community health workers, and social services providers. Although the importance of screening people for social needs has led more providers to take on this role, it has yet to become a universal practice ( CMS, 2020 ; NASEM, 2016 ), as most physician practices and hospitals do not perform screenings for the five key domains of social need 1 : food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence ( CMS, 2020 ; Fraze et al., 2019 ). As trusted professionals that spend significant time with patients and families, nurses are well equipped to conduct these screenings ( AHA, 2019 ). Federally qualified health centers (FQHCs)—community-based health centers that receive funds from the Health Resources and Services Administration’s (HRSA’s) Health Center Program—often screen for social needs.

In many clinical settings, however, challenges arise with screening for social needs. Individuals may be hesitant to provide information about such issues as housing or food insecurity, and technology is required to collect social needs data and once obtained, to share these data across settings and incorporate them into nursing practice in a meaningful way. While nurses have an educational foundation for building the skills needed to expand their role from assessing health issues to conducting assessments and incorporating findings related to social needs into care plans, this focus needs to be supported by policies where nurses are employed. As the incorporation of social needs into clinical consideration expands, nurses’ education and training will need to ensure knowledge of the impact of social needs and SDOH on individual and population health (see Chapter 7 ). Communicating appropriately with people about social needs can be difficult, and training is required to ensure that people feel comfortable responding to personal questions related to such issues as housing instability, domestic violence, and financial insecurity ( Thomas-Henkel and Schulman, 2017 ). Finally, the utility of social needs screening depends on networks of agencies that offer services and resources in the community. Without the ability to connect with relevant services, screenings and care plans can have little impact. Consequently, it is important for health care organizations to dedicate resources to ensuring that people are connected to appropriate resources, and to follow up by tracking those connections and offering other options as needed ( Thomas-Henkel and Schulman, 2017 ).

• ADDRESSING SOCIAL NEEDS AND SOCIAL DETERMINANTS OF HEALTH IN THE COMMUNITY

While interest in and action to address social needs in the clinical setting is rapidly expanding, nurse engagement in these issues in community settings has been long-standing. Nurses serving in the community often work directly to address social needs at the individual and family levels, and often work as well to address SDOH at the community and population levels. Public health nurses in particular have broad knowledge of health issues and the associated SDOH, as well as needs and resources, at the community level. Embedded within the community, they also are well positioned to build trust and are respected among community leaders. Also playing important roles in addressing social needs within the community are home visiting nurses. At the individual and family levels, home visiting nurses often represent the first line of health care providers with sustained engagement in addressing social needs for many individuals. They recognize and act on the limitations associated with social needs, such as the inability to afford transportation, or may work with an interdisciplinary team at the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to address food issues and other social needs. By connecting with individuals in their neighborhoods and homes, public health and other community-based nurses promote health and well-being for families within communities and engage in this work with partners from across social, health, and other services.

At the population health level, public health nurses work to achieve health equity within communities through both health promotion and disease prevention and control. They often work in municipal and state health departments and apply nursing, social, epidemiology, and other public health sciences in their contributions to population health ( Bigbee and Issel, 2012 ; IOM, 2011 [see AARP, 2010 ]; Larsen et al., 2018 ). They offer a wide range of services to individuals and community members and are engaged in activities ranging from policy development and coalition building to health teaching and case management ( Minnesota Department of Health, n.d. ). Public health nurses serve populations that include those with complex health and social needs, frail elderly, homeless individuals, teenage mothers, and those at risk for a specific disease ( Kulbok et al., 2012 ). Their interventions may target specific health risks, such as substance use disorder, HIV, and tobacco use, or populations at risk for health problems, such as individuals with complex health and social needs. Specific knowledge and skills they bring to communities include the ability to perform assessments of individual, family, and community health needs; use data and knowledge of environmental factors to plan for and respond to public health issues in their community; provide community and health department input in the development of policies and programs designed to improve the health of the community; implement evidence-based public health programs; and develop and manage program budgets ( Minnesota Department of Health, n.d. ).

Public health nursing roles are characterized by collaboration and partnerships with communities to address SDOH ( Kulbok et al., 2012 ). Core to public health nursing is working across disciplines and sectors to advance the health of populations through community organizing, coalition building, policy analysis, involvement in local city and county meetings, collaboration with state health departments, and social marketing ( Canales et al., 2018 ; Keller et al., 2004 ). Yet, while the work of public health nurses is foundational to the health of communities, their work is rarely visible. Additionally, regarding measurable reductions in health disparities, little research is available that connects directly and explicitly to public health nursing roles ( Davies and Donovan, 2016 ; Schaffer et al., 2015 ; Swider et al., 2017 ).

Recent experiences with H1N1, Ebola, Zika, and COVID-19 underscore the importance of having strong, well-connected, well-resourced social services, public health, and health care systems, matched by an adequate supply of well-educated nurses. A 2017 report from the National Academies of Sciences, Engineering, and Medicine focused on global health notes that when infectious disease outbreaks occur, significant costs are often associated with fear and the worried-well seeking care ( NASEM, 2017b ). In their role as trusted professionals, and given their widespread presence in communities, incorporating public health nurses into community, state, and federal government strategies for health education and dissemination of information can help extend the reach and impact of messaging during infectious disease outbreaks and other public health emergencies. Nurses can serve as expert sources of information (e.g., on preventing infectious disease transmission within their communities) ( Audain and Maher, 2017 ). In the United States, for example, as Zika infections were identified and spreading, one of the strategies used by the U.S. Department of Health and Human Services (HHS) was to work through nursing associations to reach nurses and through them, help reach the public with factual information and minimize unnecessary resource use (Minnesota Department of Health, 2019 ). Given their expertise in community engagement and knowledge of local and state government health and social services assets, public health nurses are well positioned to link to and share health-related information with community partners to help reach underresourced populations, including homeless individuals, non-English-speaking families, and others.

• WORKING ACROSS DISCIPLINES AND SECTORS TO MEET MULTIPLE NEEDS

As nurses work in concert with other sectors and disciplines, interventions that address multiple and complex needs of individuals and communities can have far-reaching impacts on health outcomes and health care utilization. Through partnerships, community-based nurses work to address an array of health-related needs ranging from population-level diabetes management to community-based transportation to enable low-income families to access health care services.

Because multiple factors influence individual and population health, a multidisciplinary, multisectoral approach is necessary to improve health and reduce health inequity. While an approach focusing on only one SDOH may improve one dimension of health, such as food insecurity, intersectional approaches that simultaneously address complex, holistic needs of individuals, families, and communities are often required. Commonly found across underresourced communities are layers of intersecting challenges impacting health, ranging from adverse environmental exposures to food deserts. Health care systems, community-based organizations, government entitities, nurses, and others are increasingly working together to design interventions that reflect this complexity ( NASEM, 2017a , 2019 ). Creative alliances are being built with for-profit and not-for-profit organizations, community groups, federal programs, hospitals, lending institutions, technology companies, and others ( NASEM, 2019 ).

Work to prioritize and address health disparities and achieve health equity is predicated on meaningful, often multidimensional, assessments of community characteristics. One key opportunity to inform multisectoral efforts lies in community health needs assessments. The Patient Protection and Affordable Care Act requires nonprofit hospitals to conduct these assessments every 3 years, with input from local public health agencies. These assessments are then used to identify and prioritize significant health needs of the community served by the hospital while also identifying resources and plans for addressing these needs. Conducting a community health needs assessment is itself a multisectoral collaboration as it requires engaging community-based stakeholders ( Heath, 2018 ). The results of the assessment present opportunities for multiple sectors to work together. For example, a hospital may partner with public health and area food banks to address food insecurity. Or it may partner with a health technology company and a local school board to address digital literacy for underserved youth and their families, and also extend the reach of broadband to support health care access through telehealth technology and strengthen digital literacy. In assessing the community’s health needs, these hospitals are required to obtain and consider community-based input, including input from individuals or organizations with knowledge of or expertise in public health. The reports produced as part of this process are required to be publicly available ( IRS, 2020 ).

These and other community engagement efforts can involve nurses from a variety of clinical and community-based settings in any and all steps of the process, from design to implementation and evaluation of the assessments themselves or the processes and programs established to address identified priorities. For example, the Magnet recognition program of the American Nurses Credentialing Center requires participating hospitals to involve nurses in their community health needs assessments ( ANCC, 2017 ).

A variety of models feature nurses directly addressing health and social needs through multidisciplinary, multisectoral collaboration. Two illustrative programs are described below: the Camden Core Model and Edge Runner.

Camden Core Model

The Camden Coalition, based in Camden, New Jersey, is a multidisciplinary, nonprofit organization that works across sectors to address health and social needs. The Coalition’s formation was based on the recognition that the U.S. health care system far too often fails people with complex health and social needs. These individuals cycle repeatedly through multiple health care, social services, and other systems without realizing lasting improvements in their health or well-being. The Coalition employs multiple approaches that include using faith-based partnerships to deliver health services and encourage healthy choices; sharing data among the criminal justice, health care, and housing sectors to identify points of intervention; and building local and national coalitions to support and educate others interested in implementing this model ( Camden Coalition, n.d. ). One of the Coalition’s best-known programs is the Camden Core Model. This nationally recognized care management intervention is an example of a nurse-led care management program for people with complex medical and social needs. It applies the principles of trauma-informed care and harm reduction with the aim of empowering people with the skills and support they need to avoid preventable hospital use and improve their well-being ( Finkelstein et al., 2020 ; Gawande, 2011 ). The model uses real-time data on hospital admissions to identify “superutilizers,” people with complex health issues who frequently use emergency care. An interprofessional team of registered nurses (RNs) and licensed practical nurses (LPNs), social workers, and community health workers engage in person with these individuals to help them navigate their care by connecting them with medical care, government benefits, and social services ( Camden Coalition, n.d. ; Finkelstein et al., 2020 ). With federal funding, similar versions of the model have been extended to cities outside of Camden (AF4 Q, 2012 ; Crippen and Isasi, 2013 ; Mann, 2013 ).

Camden Coalition partnerships optimize the use of nurses in the community in several ways. An interprofessional team of nurses, social workers, and community health workers visits program participants, helps reconcile their medications, accompanies them to medical visits, and links them to social and legal services. Critical to the model’s success is recruiting nurses who are from the local community, capitalizing on their cultural and systems-level knowledge to facilitate and improve access to and utilization of local health and social services. The culture of the Camden Coalition model has been key to its success. The uniform commitment of nurses, staff, and leadership to addressing people’s complex needs has created a supportive work environment in which each team member’s role is optimized. Care Team members have accompanied people to their meetings and appointments for primary care, helped with applications for such public benefits as food stamps, provided referrals to social services and housing agencies, arranged for medication delivery in partnership with local pharmacies, and coordinated care among providers.

The Camden Coalition focuses on “authentic healing relationships,” defined as secure, genuine, and continuous partnerships between Care Team members and patients. This emphasis has evolved into a framework for patient engagement known as COACH, which stands for C onnect tasks with vision and priorities, O bserve the normal routine, A ssume a coaching style, C reate a backward plan, and H ighlight progress with data. An interprofessional team of nurses, social workers, and community health workers visits participants in the community. Team members are trained to problem solve with patients to achieve the program goals of helping them manage their chronic health conditions and reducing preventable hospital admissions.

Early evidence of the program’s effect in a small sample showed a 56 percent reduction in monthly hospital charges, a roughly 40 percent reduction in monthly visits to hospitals and emergency departments, and an approximately 52 percent increase in rates of reimbursement to care providers ( Green et al., 2010 ), although later evidence from a randomized controlled trial (RCT) indicated that the Camden Core Model did not reduce hospital readmissions ( Finkelstein et al., 2020 ). Other RCTs, conducted in Philadelphia and Chicago, showed that similar social care programs using case management and community health workers can reduce hospital admissions and save money in addition to improving health and quality of health care. Kangovi and colleagues (2018) conducted an RCT in Philadelphia to assess Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention addressing unmet social needs across three health systems ( Kangovi et al., 2018 ). After 6 months, patients in the intervention group compared with controls were more likely to report the highest quality of care and spent fewer total days in the hospital (reduced by about two-thirds), saving $2.47 for each dollar invested by Medicaid annually ( Kangovi et al., 2020 ). The RCT in Chicago assessed the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical conditions and found a 29 percent reduction in hospitalizations and a 24 percent reduction in emergency department visits ( Sadowski et al., 2009 ).

Edge Runner

The American Academy of Nurses’ Edge Runner initiative identifies and promotes nurse-designed models of care and interventions that can improve health, increase health care access and quality, and/or reduce costs ( AAN, n.d.a ). As of February 2020, 59 such programs had been evaluated against a set of criteria and designated as part of this initiative. Many Edge Runner programs are built around the needs of underserved communities and seek to improve health through holistic care that addresses social needs and SDOH, including a range of upstream, midstream, and downstream determinants. Mason and colleagues (2015) assessed 30 Edge Runner models identified as of 2012, finding four main commonalities that illustrate these programs’ broad and encompassing approach to health.

A holistic definition of health. Across the programs, health was defined broadly to include physical, psychological, social, spiritual, functional, quality-of-life, personal happiness, and well-being aspects. Additionally, the definition of health was based on the values of clients and shaped around their preferences. Typically, programs were grounded in SDOH to inform their design of individual- and community-level interventions.

Individual-, family-, and community-centric design. Most programs prioritized individual, family, and community goals over provider-defined goals through a “participant-led care environment” and “meeting people where they are.” Thus, interventions were tailored to the values and culture present at each of these three levels.

Relationship-based care. The programs reflected the importance of building trusting relationships with individuals, families, and communities to help them engage in ways to create and sustain their own health.

Ongoing group and public health approaches to improving the health of underserved populations. The nurses who designed the programs viewed serving underserved populations as a moral imperative. Through peer-to-peer education, support groups, and public health approaches, they sought to empower clients, give them a sense of control, build self-care agency, and increase resilience.

An in-depth study of three Edge Runner programs (the Centering Pregnancy model, INSIGHTS, and the Family Practice and Counseling Network) revealed particular lessons: the essential role of collaboration and leaders who can collaborate with a wide range of stakeholders, the need for plans for scalability and financial sustainability, and the importance of social support and empowerment to help people ( Martsolf et al., 2017 ). In these and other models, the capacity and knowledge associated with building meaningful, sustained partnerships across sectors is a key dimension of nursing practice that impacts health equity. The Edge Runner programs emphasize how, in the pursuit of improving care, lowering costs, and increasing satisfaction for people and families, nurses are actively working to achieve person-centered care that addresses social needs and SDOH and focusing on the needs of underserved populations to promote health equity ( Martsolf et al., 2016 , 2017 ; Mason et al., 2015 ). However, evidence directly linking the programs to decreases in disparities is generally not available. Two examples of Edge Runner programs are described in Box 5-2 .

Examples of Edge Runner Programs.

As models continue to evolve and be disseminated, it is critical to establish an evidence base that can help understand their impact on health and well-being and their contribution to achieving the broader aim of health equity. For care management programs incorporating social care, it is important to consider a broad array of both quantitative and qualitative measures beyond health care utilization ( Noonan, 2020 ). Although RCTs generate the most reliable evidence, this evidence can be limited in scope. For example, the RCTs cited above assessed neither the multidimensional nature of care management/social care models that might be reflected in such outcomes as client self-efficacy, satisfaction, or long-term health outcomes nor their potential social impacts. Also important to note is that care management models incorporating social care are limited by the availability of resources in the community, such as behavioral health services, addiction treatment, housing, and transportation. Programs that connect clients to health and social services are unlikely to work if relevant services are unavailable ( Noonan, 2020 ). Important to underscore in the context of this report is that multisector engagement, as well as health care teams that may involve social workers, community health workers, physicians, and others engaging alongside nurses, all are oriented to a shared agenda focused on improving health and advancing health equity.

• ADVOCATING FOR POLICY CHANGE

Public policies have a major influence on health care providers, systems, and the populations they serve. Accordingly, nurses can help promote health equity by bringing a health lens to bear on public policies and decision making at the community, state, and federal levels. Informing health-related public policy can involve communicating about health disparities and SDOH with the public, policy makers, and organizational leaders, focusing on both challenges and solutions for addressing health through actions targeted to achieving health equity.

When nurses engage with policy change as an upstream determinant of health, they can have a powerful and far-reaching impact on the health of populations. In the National Academy of Medicine’s Vital Directions series, Nancy Adler and colleagues (2016) note that “powerful drivers of health lie outside the conventional medical care delivery system…. Health policies need to expand to address factors outside the medical system that promote or damage health.” Because health inequities and SDOH are based in social structures and policies, efforts to address them upstream as the root of poor health among certain populations and communities need to focus on policy change ( NASEM, 2017a ). Nurses alone cannot solve the problems associated with upstream SDOH that exist outside of health care systems. However, by engaging in efforts aimed at changing local, state, or federal policy with a Health in All Policies approach, 2 they can address SDOH that underlie poor health ( IOM, 2011 ; NASEM, 2017a ; Williams et al., 2018 ). Whether nurses engage in policy making full time or work to inform policy part time as a professional responsibility, their attention to policies that either create or eliminate health inequities can improve the underlying conditions that frame people’s health. Nurses can bring a health and social justice lens to public policies and decision making at the community, state, and federal levels most effectively by serving in public- and private-sector leadership positions. Much of this work is discussed in Chapter 9 on nursing leadership, but it is noted in this chapter given the substantial influence that policy decisions have on health equity. Nurses can and should use their expertise to promote policies that support health equity.

For example, a nurse in Delaware was influential in getting the state’s legislature to pass legislation to implement a colorectal cancer screening program that has increased access to care and reduced disparities in morbidity and mortality from colorectal cancer (see Box 5-3 ). While individual nurses, often through their workplace and professional associations, engage in upstream efforts to impact health equity, there have been repeated calls from within the nursing community for more nurses to engage in informing public policy to improve health outcomes for individuals and populations.

Delaware Cancer Consortium.

• CONCLUSIONS

In the coming decade, the United States will make substantial progress in achieving health equity only if it devotes resources and attention to addressing the adverse effects of SDOH on the health of underresourced populations. As 2030 approaches, numerous initiatives to address health equity are likely to be launched at the local, state, and national levels. Many of these initiatives will focus on health care equity. Yet, while expanding access to quality care is critical to reducing disparities and improving health outcomes, such efforts need to be accompanied by additional efforts to identify and change the social institutions, dynamics, and systems underlying health inequities from the local to the national level. Nurses can contribute to reshaping the landscape of health equity over the coming decade by serving in expanded roles, working in new settings and new ways, and partnering with communities and other sectors beyond health care. Some nurses are already working in roles and settings that support health equity and are engaged in educating about and advocating for health equity through their professional associations. Nonetheless, broader engagement as a core activity of every nurse will help advance health equity nationwide. To achieve this aim will require

• support for and the willingness of the nursing workforce to take on new roles in new settings in the community;
• consistency in nurses’ preparation for engaging in downstream, midstream, and upstream strategies aimed at improving health equity by addressing issues that compromise health, such as geographic disparities, poverty, racism, homelessness, trauma, drug abuse, and behavioral health conditions;
• more experiential learning and opportunities to work in community settings throughout nursing education to ensure that nurses have skills and competencies to address individuals’ complex needs and promote efforts to improve the well-being of communities;
• nursing education that goes beyond teaching the principles of diversity, equity, and inclusion to provide sustained student engagement in hands-on community and clinical experiences with these issues;
• funding to support new models of care and functions that address SDOH, health equity, and population health; and
• evaluation of models to build the evidence needed to scale programs and the policies and resources necessary to sustain them.

These issues are discussed in the chapters that follow. Programs described in this chapter, such as the Camden Coalition and the Edge Runner initiatives, are exemplars of the kind of multidisciplinary, multisector efforts that will be necessary to address the complex needs of individuals and communities and make a lasting impact by eliminating health disparities, with the goal of achieving health equity. Central to these future efforts, however, are parallel efforts that evaluate and provide the evidence base on which to determine the effectiveness of models. One of the greatest challenges this committee faced was finding evidence directly linking the efforts of nurses to address social needs and SDOH to reductions in health disparities that would signal improved population health outcomes and health equity. Such evidence is essential to informing payment policy decisions that can ensure the sustainability of and nurse engagement in these models (discussed further in Chapter 6 ). Through evidence, the nursing profession can leverage its own potential, and the public, other professionals, and other sectors can understand the impact and value of such nursing engagement.

Conclusion 5-1: Nurses are in a position to improve outcomes for the underserved and can work to address the structural and institutional factors that produce health disparities in the first place. Conclusion 5-2: Nurses can use their unique expertise and perspective to help develop and advocate for policies and programs that promote health equity.

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These five domains of social needs are part of the Centers for Medicare & Medicaid Services’ Accountable Health Communities Model ( Fraze et al., 2019 ).

Health in All Policies (HiAP) is a collaborative approach that integrates health considerations into policy making across sectors. It recognizes that health is created by a multitude of factors beyond health care and in many cases, beyond the scope of traditional public health activities. In accordance with HiAP, for example, decision makers in the health care sector should consider transportation, education, housing, commerce, and other sectors impacting communities. HiAP stresses the need to work across government agencies and with private partners from these different sectors to achieve healthy and safe communities. It also encourages partnerships between the health care sector and community developers, for example ( CDC, 2016 ).

• Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 5, The Role of Nurses in Improving Health Equity.
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021)

Chapter: 5 the role of nurses in improving health equity, 5 the role of nurses in improving health equity.

Being a nurse … in 2020 must mean being aware of social injustices and the systemic racism that exist in much of nursing … and having a personal and professional responsibility to challenge and help end them.

—Calvin Moorley, RN, and colleagues, “Dismantling Structural Racism: Nursing Must Not Be Caught on the Wrong Side of History”

When this study was envisioned in 2019, it was clear that the future of nursing would look different by 2030; however, no one could predict how rapidly and dramatically circumstances would shift before the end of 2020. Over the coming decade, the nursing profession will continue to be shaped by the pressing health, social, and ethical challenges facing the nation today. Having illuminated many

of the health and social inequities affecting communities across the nation, the COVID-19 pandemic, along with other health crises, such as the opioid epidemic ( Abellanoza et al., 2018 ), presents an opportunity to take a critical look at the nursing profession, and society at large, and work collaboratively to enable all individuals to have a fair and just opportunity for health and well-being, reflecting the concept of “social mission” described by Mullan (2017, p. 122) as “making health not only better but fairer.” This chapter examines health equity and the role of nursing in its advancement in the United States.

As stated previously, health equity is defined as “the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance” ( NASEM, 2017a , p. 32). While access to equitable health care, discussed in Chapter 4 , is an important part of achieving health equity, it is not sufficient. Health is affected by a wide range of other factors, including housing, transportation, nutrition, physical activity, education, income, laws and policies, and discrimination. Chapter 2 presents the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) , in which upstream factors represent the social determinants of health (SDOH) that affect individuals and communities in a broad and, today, inequitable way. Low educational status and opportunity, income disparities, discrimination, and social marginalization are examples of upstream factors that impede good health outcomes. Midstream factors comprise social needs, or the individual factors that may affect a person’s health, such as homelessness, food insecurity, and trauma. Finally, downstream factors include disease treatment and chronic disease management.

Much of the focus on the education and training of nurses and the public perception of their role is on the treatment and management of disease. This chapter shifts that focus to nurses’ role in addressing SDOH and social needs, including their potential future roles and responsibilities in this regard, and describes existing exemplars. First, the chapter provides a brief overview of nurses’ role in addressing health equity. Next, it describes opportunities for nurses to improve health equity through four approaches: addressing social needs in clinical settings, addressing social needs and SDOH in the community, working across disciplines and sectors to meet multiple needs, and advocating for policy change. The chapter then details the opportunities and barriers associated with each of these approaches.

NURSES’ ROLE IN ADDRESSING HEALTH EQUITY

As described in Chapter 1 , the history of nursing is grounded in social justice and community health advocacy ( Donley and Flaherty, 2002 ; Pittman, 2019 ; Rafferty, 2015 ; Tyson et al., 2018 ), and as noted in Chapter 2 , the Code of Ethics for Nurses with Interpretive Statements, reiterated by American Nurses Association (ANA) President Ernest J. Grant in a public statement, “obligates nurses to be allies and to advocate and speak up against racism, discrimination, and injustice” ( ANA, 2020 ).

Addressing social needs across the health system can improve health equity from the individual to the system level. The report Integrating Social Care into the Delivery of Health Care identifies activities in five complementary areas that can facilitate the integration of social care into health care: adjustment, assistance, alignment, advocacy, and awareness ( NASEM, 2019 ) (see Figure 5-1 and Table 5-1 ). In

TABLE 5-1 Definitions of Areas of Activities That Strengthen Integration of Social Care into Health Care

SOURCE: NASEM, 2019 .

the area of awareness, for example, clinical nurses in a hospital setting can identify the fall risks their patients might face upon discharge and the assets they can incorporate into their lives to improve their health. In the area of adjustment, telehealth and/or home health and home visiting nurses can alter clinical care to reduce the risk of falls by, for example, helping patients to adjust risks in their homes and learn to navigate their environment. And these activities can continue to the high level of system change through advocacy for health policies aimed at altering community infrastructure to help prevent falls.

In short, improving population health entails challenging and changing the factors and institutions that give rise to health inequity through interventions and reforms that influence the institutions, social systems, and public policies that drive health ( Lantz, 2019 ). It is important to note, however, that there are shortcomings in how evaluations of health equity interventions are carried out (see Box 5-1 ).

ADDRESSING SOCIAL NEEDS IN CLINICAL SETTINGS

Although the provision of clinical care is a downstream determinant of health, the clinical setting presents an opportunity for nurses to address midstream determinants, or social needs, as well. Screening for social needs and making referrals to social services is becoming more commonplace in clinical settings as part of efforts to provide holistic care ( Gottlieb et al., 2016 ; Makelarski et al., 2017 ; Thomas-Henkel and Schulman, 2017 ). Nurses may conduct screenings; review their results; create care plans based on social needs as indicated by those results; refer patients to appropriate professionals and social services; and coordinate care by interfacing with social workers, community health workers, and social services providers. Although the importance of screening people for social needs has led more providers to take on this role, it has yet to become a universal practice ( CMS, 2020 ; NASEM, 2016 ), as most physician practices and hospitals do not perform screenings for the five key domains of social need 1 : food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence ( CMS, 2020 ; Fraze et al., 2019 ). As trusted professionals that spend significant time with patients and families, nurses are well equipped to conduct these screenings ( AHA, 2019 ). Federally qualified health centers (FQHCs)—community-based health centers that receive funds from the Health Resources and Services Administration’s (HRSA’s) Health Center Program—often screen for social needs.

In many clinical settings, however, challenges arise with screening for social needs. Individuals may be hesitant to provide information about such issues as housing or food insecurity, and technology is required to collect social needs data and once obtained, to share these data across settings and incorporate them into

___________________

1 These five domains of social needs are part of the Centers for Medicare & Medicaid Services’ Accountable Health Communities Model ( Fraze et al., 2019 ).

nursing practice in a meaningful way. While nurses have an educational foundation for building the skills needed to expand their role from assessing health issues to conducting assessments and incorporating findings related to social needs into care plans, this focus needs to be supported by policies where nurses are employed. As the incorporation of social needs into clinical consideration expands, nurses’ education and training will need to ensure knowledge of the impact of social needs and SDOH on individual and population health (see Chapter 7 ). Communicating appropriately with people about social needs can be difficult, and training is required to ensure that people feel comfortable responding to personal questions related to such issues as housing instability, domestic violence, and financial insecurity ( Thomas-Henkel and Schulman, 2017 ). Finally, the utility of social needs screening depends on networks of agencies that offer services and resources in the community. Without the ability to connect with relevant services, screenings and care plans can have little impact. Consequently, it is important for health care organizations to dedicate resources to ensuring that people are connected to appropriate resources, and to follow up by tracking those connections and offering other options as needed ( Thomas-Henkel and Schulman, 2017 ).

ADDRESSING SOCIAL NEEDS AND SOCIAL DETERMINANTS OF HEALTH IN THE COMMUNITY

While interest in and action to address social needs in the clinical setting is rapidly expanding, nurse engagement in these issues in community settings has been long-standing. Nurses serving in the community often work directly to address social needs at the individual and family levels, and often work as well to address SDOH at the community and population levels. Public health nurses in particular have broad knowledge of health issues and the associated SDOH, as well as needs and resources, at the community level. Embedded within the community, they also are well positioned to build trust and are respected among community leaders. Also playing important roles in addressing social needs within the community are home visiting nurses. At the individual and family levels, home visiting nurses often represent the first line of health care providers with sustained engagement in addressing social needs for many individuals. They recognize and act on the limitations associated with social needs, such as the inability to afford transportation, or may work with an interdisciplinary team at the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to address food issues and other social needs. By connecting with individuals in their neighborhoods and homes, public health and other community-based nurses promote health and well-being for families within communities and engage in this work with partners from across social, health, and other services.

At the population health level, public health nurses work to achieve health equity within communities through both health promotion and disease prevention and control. They often work in municipal and state health departments and apply

nursing, social, epidemiology, and other public health sciences in their contributions to population health ( Bigbee and Issel, 2012 ; IOM, 2011 [see AARP, 2010 ]; Larsen et al., 2018 ). They offer a wide range of services to individuals and community members and are engaged in activities ranging from policy development and coalition building to health teaching and case management ( Minnesota Department of Health, n.d. ). Public health nurses serve populations that include those with complex health and social needs, frail elderly, homeless individuals, teenage mothers, and those at risk for a specific disease ( Kulbok et al., 2012 ). Their interventions may target specific health risks, such as substance use disorder, HIV, and tobacco use, or populations at risk for health problems, such as individuals with complex health and social needs. Specific knowledge and skills they bring to communities include the ability to perform assessments of individual, family, and community health needs; use data and knowledge of environmental factors to plan for and respond to public health issues in their community; provide community and health department input in the development of policies and programs designed to improve the health of the community; implement evidence-based public health programs; and develop and manage program budgets ( Minnesota Department of Health, n.d. ).

Public health nursing roles are characterized by collaboration and partnerships with communities to address SDOH ( Kulbok et al., 2012 ). Core to public health nursing is working across disciplines and sectors to advance the health of populations through community organizing, coalition building, policy analysis, involvement in local city and county meetings, collaboration with state health departments, and social marketing ( Canales et al., 2018 ; Keller et al., 2004 ). Yet, while the work of public health nurses is foundational to the health of communities, their work is rarely visible. Additionally, regarding measurable reductions in health disparities, little research is available that connects directly and explicitly to public health nursing roles ( Davies and Donovan, 2016 ; Schaffer et al., 2015 ; Swider et al., 2017 ).

Recent experiences with H1N1, Ebola, Zika, and COVID-19 underscore the importance of having strong, well-connected, well-resourced social services, public health, and health care systems, matched by an adequate supply of well-educated nurses. A 2017 report from the National Academies of Sciences, Engineering, and Medicine focused on global health notes that when infectious disease outbreaks occur, significant costs are often associated with fear and the worried-well seeking care ( NASEM, 2017b ). In their role as trusted professionals, and given their widespread presence in communities, incorporating public health nurses into community, state, and federal government strategies for health education and dissemination of information can help extend the reach and impact of messaging during infectious disease outbreaks and other public health emergencies. Nurses can serve as expert sources of information (e.g., on preventing infectious disease transmission within their communities) ( Audain and Maher, 2017 ). In the United States, for example, as Zika infections were

identified and spreading, one of the strategies used by the U.S. Department of Health and Human Services (HHS) was to work through nursing associations to reach nurses and through them, help reach the public with factual information and minimize unnecessary resource use ( Minnesota Department of Health, 2019 ). Given their expertise in community engagement and knowledge of local and state government health and social services assets, public health nurses are well positioned to link to and share health-related information with community partners to help reach underresourced populations, including homeless individuals, non-English-speaking families, and others.

WORKING ACROSS DISCIPLINES AND SECTORS TO MEET MULTIPLE NEEDS

As nurses work in concert with other sectors and disciplines, interventions that address multiple and complex needs of individuals and communities can have far-reaching impacts on health outcomes and health care utilization. Through partnerships, community-based nurses work to address an array of health-related needs ranging from population-level diabetes management to community-based transportation to enable low-income families to access health care services.

Because multiple factors influence individual and population health, a multidisciplinary, multisectoral approach is necessary to improve health and reduce health inequity. While an approach focusing on only one SDOH may improve one dimension of health, such as food insecurity, intersectional approaches that simultaneously address complex, holistic needs of individuals, families, and communities are often required. Commonly found across underresourced communities are layers of intersecting challenges impacting health, ranging from adverse environmental exposures to food deserts. Health care systems, community-based organizations, government entitities, nurses, and others are increasingly working together to design interventions that reflect this complexity ( NASEM, 2017a , 2019 ). Creative alliances are being built with for-profit and not-for-profit organizations, community groups, federal programs, hospitals, lending institutions, technology companies, and others ( NASEM, 2019 ).

Work to prioritize and address health disparities and achieve health equity is predicated on meaningful, often multidimensional, assessments of community characteristics. One key opportunity to inform multisectoral efforts lies in community health needs assessments. The Patient Protection and Affordable Care Act requires nonprofit hospitals to conduct these assessments every 3 years, with input from local public health agencies. These assessments are then used to identify and prioritize significant health needs of the community served by the hospital while also identifying resources and plans for addressing these needs. Conducting a community health needs assessment is itself a multisectoral collaboration as it requires engaging community-based stakeholders ( Heath, 2018 ). The results of the assessment present opportunities for multiple sectors to work

together. For example, a hospital may partner with public health and area food banks to address food insecurity. Or it may partner with a health technology company and a local school board to address digital literacy for underserved youth and their families, and also extend the reach of broadband to support health care access through telehealth technology and strengthen digital literacy. In assessing the community’s health needs, these hospitals are required to obtain and consider community-based input, including input from individuals or organizations with knowledge of or expertise in public health. The reports produced as part of this process are required to be publicly available ( IRS, 2020 ).

These and other community engagement efforts can involve nurses from a variety of clinical and community-based settings in any and all steps of the process, from design to implementation and evaluation of the assessments themselves or the processes and programs established to address identified priorities. For example, the Magnet recognition program of the American Nurses Credentialing Center requires participating hospitals to involve nurses in their community health needs assessments ( ANCC, 2017 ).

A variety of models feature nurses directly addressing health and social needs through multidisciplinary, multisectoral collaboration. Two illustrative programs are described below: the Camden Core Model and Edge Runner.

Camden Core Model

The Camden Coalition, based in Camden, New Jersey, is a multidisciplinary, nonprofit organization that works across sectors to address health and social needs. The Coalition’s formation was based on the recognition that the U.S. health care system far too often fails people with complex health and social needs. These individuals cycle repeatedly through multiple health care, social services, and other systems without realizing lasting improvements in their health or well-being. The Coalition employs multiple approaches that include using faith-based partnerships to deliver health services and encourage healthy choices; sharing data among the criminal justice, health care, and housing sectors to identify points of intervention; and building local and national coalitions to support and educate others interested in implementing this model ( Camden Coalition, n.d. ). One of the Coalition’s best-known programs is the Camden Core Model. This nationally recognized care management intervention is an example of a nurse-led care management program for people with complex medical and social needs. It applies the principles of trauma-informed care and harm reduction with the aim of empowering people with the skills and support they need to avoid preventable hospital use and improve their well-being ( Finkelstein et al., 2020 ; Gawande, 2011 ). The model uses real-time data on hospital admissions to identify “superutilizers,” people with complex health issues who frequently use emergency care. An interprofessional team of registered nurses (RNs) and licensed practical nurses (LPNs), social workers, and community health workers engage in person

with these individuals to help them navigate their care by connecting them with medical care, government benefits, and social services ( Camden Coalition, n.d. ; Finkelstein et al., 2020 ). With federal funding, similar versions of the model have been extended to cities outside of Camden ( AF4Q, 2012 ; Crippen and Isasi, 2013 ; Mann, 2013 ).

Camden Coalition partnerships optimize the use of nurses in the community in several ways. An interprofessional team of nurses, social workers, and community health workers visits program participants, helps reconcile their medications, accompanies them to medical visits, and links them to social and legal services. Critical to the model’s success is recruiting nurses who are from the local community, capitalizing on their cultural and systems-level knowledge to facilitate and improve access to and utilization of local health and social services. The culture of the Camden Coalition model has been key to its success. The uniform commitment of nurses, staff, and leadership to addressing people’s complex needs has created a supportive work environment in which each team member’s role is optimized. Care Team members have accompanied people to their meetings and appointments for primary care, helped with applications for such public benefits as food stamps, provided referrals to social services and housing agencies, arranged for medication delivery in partnership with local pharmacies, and coordinated care among providers.

The Camden Coalition focuses on “authentic healing relationships,” defined as secure, genuine, and continuous partnerships between Care Team members and patients. This emphasis has evolved into a framework for patient engagement known as COACH, which stands for C onnect tasks with vision and priorities, O bserve the normal routine, A ssume a coaching style, C reate a backward plan, and H ighlight progress with data. An interprofessional team of nurses, social workers, and community health workers visits participants in the community. Team members are trained to problem solve with patients to achieve the program goals of helping them manage their chronic health conditions and reducing preventable hospital admissions.

Early evidence of the program’s effect in a small sample showed a 56 percent reduction in monthly hospital charges, a roughly 40 percent reduction in monthly visits to hospitals and emergency departments, and an approximately 52 percent increase in rates of reimbursement to care providers ( Green et al., 2010 ), although later evidence from a randomized controlled trial (RCT) indicated that the Camden Core Model did not reduce hospital readmissions ( Finkelstein et al., 2020 ). Other RCTs, conducted in Philadelphia and Chicago, showed that similar social care programs using case management and community health workers can reduce hospital admissions and save money in addition to improving health and quality of health care. Kangovi and colleagues (2018) conducted an RCT in Philadelphia to assess Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention addressing unmet social needs across three health systems ( Kangovi et al., 2018 ). After 6 months, patients

in the intervention group compared with controls were more likely to report the highest quality of care and spent fewer total days in the hospital (reduced by about two-thirds), saving $2.47 for each dollar invested by Medicaid annually ( Kangovi et al., 2020 ). The RCT in Chicago assessed the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical conditions and found a 29 percent reduction in hospitalizations and a 24 percent reduction in emergency department visits ( Sadowski et al., 2009 ).

Edge Runner

The American Academy of Nurses’ Edge Runner initiative identifies and promotes nurse-designed models of care and interventions that can improve health, increase health care access and quality, and/or reduce costs ( AAN, n.d.a ). As of February 2020, 59 such programs had been evaluated against a set of criteria and designated as part of this initiative. Many Edge Runner programs are built around the needs of underserved communities and seek to improve health through holistic care that addresses social needs and SDOH, including a range of upstream, midstream, and downstream determinants. Mason and colleagues (2015) assessed 30 Edge Runner models identified as of 2012, finding four main commonalities that illustrate these programs’ broad and encompassing approach to health.

A holistic definition of health. Across the programs, health was defined broadly to include physical, psychological, social, spiritual, functional, quality-of-life, personal happiness, and well-being aspects. Additionally, the definition of health was based on the values of clients and shaped around their preferences. Typically, programs were grounded in SDOH to inform their design of individual- and community-level interventions.

Individual-, family-, and community-centric design. Most programs prioritized individual, family, and community goals over provider-defined goals through a “participant-led care environment” and “meeting people where they are.” Thus, interventions were tailored to the values and culture present at each of these three levels.

Relationship-based care. The programs reflected the importance of building trusting relationships with individuals, families, and communities to help them engage in ways to create and sustain their own health.

Ongoing group and public health approaches to improving the health of underserved populations. The nurses who designed the programs viewed serving underserved populations as a moral imperative. Through peer-to-peer education, support groups, and public health approaches, they sought to empower clients, give them a sense of control, build self-care agency, and increase resilience.

An in-depth study of three Edge Runner programs (the Centering Pregnancy model, INSIGHTS, and the Family Practice and Counseling Network) revealed particular lessons: the essential role of collaboration and leaders who can col-

laborate with a wide range of stakeholders, the need for plans for scalability and financial sustainability, and the importance of social support and empowerment to help people ( Martsolf et al., 2017 ). In these and other models, the capacity and knowledge associated with building meaningful, sustained partnerships across sectors is a key dimension of nursing practice that impacts health equity. The Edge Runner programs emphasize how, in the pursuit of improving care, lowering costs, and increasing satisfaction for people and families, nurses are actively working to achieve person-centered care that addresses social needs and SDOH and focusing on the needs of underserved populations to promote health equity ( Martsolf et al., 2016 , 2017 ; Mason et al., 2015 ). However, evidence directly linking the programs to decreases in disparities is generally not available. Two examples of Edge Runner programs are described in Box 5-2 .

As models continue to evolve and be disseminated, it is critical to establish an evidence base that can help understand their impact on health and well-being and their contribution to achieving the broader aim of health equity. For care management programs incorporating social care, it is important to consider a broad array of both quantitative and qualitative measures beyond health care utilization ( Noonan, 2020 ). Although RCTs generate the most reliable evidence, this evidence can be limited in scope. For example, the RCTs cited above assessed neither the multidimensional nature of care management/social care models that might be reflected in such outcomes as client self-efficacy, satisfaction, or long-term health outcomes nor their potential social impacts. Also important to note is that care management models incorporating social care are limited by the availability of resources in the community, such as behavioral health services, addiction treatment, housing, and transportation. Programs that connect clients to health and social

services are unlikely to work if relevant services are unavailable ( Noonan, 2020 ). Important to underscore in the context of this report is that multisector engagement, as well as health care teams that may involve social workers, community health workers, physicians, and others engaging alongside nurses, all are oriented to a shared agenda focused on improving health and advancing health equity.

ADVOCATING FOR POLICY CHANGE

Public policies have a major influence on health care providers, systems, and the populations they serve. Accordingly, nurses can help promote health equity by bringing a health lens to bear on public policies and decision making at the community, state, and federal levels. Informing health-related public policy can involve communicating about health disparities and SDOH with the public, policy makers, and organizational leaders, focusing on both challenges and solutions for addressing health through actions targeted to achieving health equity.

When nurses engage with policy change as an upstream determinant of health, they can have a powerful and far-reaching impact on the health of populations. In the National Academy of Medicine’s Vital Directions series, Nancy Adler and colleagues (2016) note that “powerful drivers of health lie outside the conventional medical care delivery system…. Health policies need to expand to address factors outside the medical system that promote or damage health.” Because health inequities and SDOH are based in social structures and policies, efforts to address them upstream as the root of poor health among certain populations and communities need to focus on policy change ( NASEM, 2017a ). Nurses alone cannot solve the problems associated with upstream SDOH that exist outside of health care systems. However, by engaging in efforts aimed at changing local, state, or federal policy with a Health in All Policies approach, 2 they can address SDOH that underlie poor health ( IOM, 2011 ; NASEM, 2017a ; Williams et al., 2018 ). Whether nurses engage in policy making full time or work to inform policy part time as a professional responsibility, their attention to policies that either create or eliminate health inequities can improve the underlying conditions that frame people’s health. Nurses can bring a health and social justice lens to public policies and decision making at the community, state, and federal levels most effectively by serving in public- and private-sector leadership positions. Much of this work is discussed in Chapter 9 on nursing leadership, but it is noted in this chapter given the substantial

2 Health in All Policies (HiAP) is a collaborative approach that integrates health considerations into policy making across sectors. It recognizes that health is created by a multitude of factors beyond health care and in many cases, beyond the scope of traditional public health activities. In accordance with HiAP, for example, decision makers in the health care sector should consider transportation, education, housing, commerce, and other sectors impacting communities. HiAP stresses the need to work across government agencies and with private partners from these different sectors to achieve healthy and safe communities. It also encourages partnerships between the health care sector and community developers, for example ( CDC, 2016 ).

influence that policy decisions have on health equity. Nurses can and should use their expertise to promote policies that support health equity.

For example, a nurse in Delaware was influential in getting the state’s legislature to pass legislation to implement a colorectal cancer screening program that has increased access to care and reduced disparities in morbidity and mortality from colorectal cancer (see Box 5-3 ). While individual nurses, often through their workplace and professional associations, engage in upstream efforts to impact health equity, there have been repeated calls from within the nursing community for more nurses to engage in informing public policy to improve health outcomes for individuals and populations.

CONCLUSIONS

In the coming decade, the United States will make substantial progress in achieving health equity only if it devotes resources and attention to addressing the adverse effects of SDOH on the health of underresourced populations. As 2030 approaches, numerous initiatives to address health equity are likely to be launched at the local, state, and national levels. Many of these initiatives will focus on health care equity. Yet, while expanding access to quality care is critical to reducing disparities and improving health outcomes, such efforts need to be accompanied by additional efforts to identify and change the social institutions, dynamics, and systems underlying health inequities from the local to the national level. Nurses can contribute to reshaping the landscape of health equity over the coming decade by serving in expanded roles, working in new settings and new ways, and partnering with communities and other sectors beyond health care. Some nurses are already working in roles and settings that support health equity and are engaged in educating about and advocating for health equity through their professional associations. Nonetheless, broader engagement as a core activity of every nurse will help advance health equity nationwide. To achieve this aim will require

• support for and the willingness of the nursing workforce to take on new roles in new settings in the community;
• consistency in nurses’ preparation for engaging in downstream, midstream, and upstream strategies aimed at improving health equity by addressing issues that compromise health, such as geographic disparities, poverty, racism, homelessness, trauma, drug abuse, and behavioral health conditions;
• more experiential learning and opportunities to work in community settings throughout nursing education to ensure that nurses have skills and competencies to address individuals’ complex needs and promote efforts to improve the well-being of communities;
• nursing education that goes beyond teaching the principles of diversity, equity, and inclusion to provide sustained student engagement in hands-on community and clinical experiences with these issues;
• funding to support new models of care and functions that address SDOH, health equity, and population health; and
• evaluation of models to build the evidence needed to scale programs and the policies and resources necessary to sustain them.

These issues are discussed in the chapters that follow. Programs described in this chapter, such as the Camden Coalition and the Edge Runner initiatives, are exemplars of the kind of multidisciplinary, multisector efforts that will be necessary to address the complex needs of individuals and communities and make a lasting impact by eliminating health disparities, with the goal of achieving health equity. Central to these future efforts, however, are parallel efforts that evaluate

and provide the evidence base on which to determine the effectiveness of models. One of the greatest challenges this committee faced was finding evidence directly linking the efforts of nurses to address social needs and SDOH to reductions in health disparities that would signal improved population health outcomes and health equity. Such evidence is essential to informing payment policy decisions that can ensure the sustainability of and nurse engagement in these models (discussed further in Chapter 6 ). Through evidence, the nursing profession can leverage its own potential, and the public, other professionals, and other sectors can understand the impact and value of such nursing engagement.

Conclusion 5-1: Nurses are in a position to improve outcomes for the underserved and can work to address the structural and institutional factors that produce health disparities in the first place.

Conclusion 5-2: Nurses can use their unique expertise and perspective to help develop and advocate for policies and programs that promote health equity.

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The decade ahead will test the nation's nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. Nurses work in a wide array of settings and practice at a range of professional levels. They are often the first and most frequent line of contact with people of all backgrounds and experiences seeking care and they represent the largest of the health care professions.

A nation cannot fully thrive until everyone - no matter who they are, where they live, or how much money they make - can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nurses have a critical role to play in achieving the goal of health equity, but they need robust education, supportive work environments, and autonomy. Accordingly, at the request of the Robert Wood Johnson Foundation, on behalf of the National Academy of Medicine, an ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine conducted a study aimed at envisioning and charting a path forward for the nursing profession to help reduce inequities in people's ability to achieve their full health potential. The ultimate goal is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030. This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.

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Thoughts About Social Justice

Affiliation.

• 1 1 Professor, Department of Nursing, University of Massachusetts Boston, Boston, MA, USA.
• PMID: 31203773
• DOI: 10.1177/0894318419845385

This is the second of two essays addressing equity and social justice, which are interrelated concepts of considerable interest to members of our discipline. The purpose of this essay is to define social justice within the context of the conceptual model of nursing and health policy and to link social justice with equity in population health and with practice. An essay about equity appeared in a previous issue of Nursing Science Quarterly.

Keywords: conceptual model of nursing and health policy; nursing; population health equity; social justice.

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How to Develop and Maintain Social Justice in Nursing

October 28, 2021

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Social justice in nursing requires affordable, high-quality health care that is accessible to all people. However, inequalities in the health care system still exist. Emerging nursing leaders are turning these inequalities into opportunities, pursuing advanced education to create a health care system that’s socially just and accessible to all.

What Is Social Justice in Nursing ?

Social justice guides the creation of “social institutions” and the individuals who collaborate with these institutions, according to the Center for Economic and Social Justice. Health care facilities, such as hospitals and private clinics, are examples of social institutions. Created to help people live longer and happier lives, health care facilities provide a positive social service. In turn, individuals such as nurses, patients, community members, and politicians influence change in these institutions. Through their feedback, such as lobbying to lower health care costs, creating custom care plans, and reporting malpractice, the institutions become more accessible for everyone.

Each person has the right to access high-quality health care. Unfortunately, inequality in the health care system remains. African Americans, Hispanics, and Asian Americans are sicker than the rest of the country. And, according to the American Public Health Association (APHA), over a third of the direct medical costs of individuals in these three groups are a result of health inequalities, such as poor access to quality health care or unconscious racial bias.

From a nursing perspective, the goal is to help each patient attain his or her full health potential. However, many health care treatments are cost prohibitive because of high insurance deductibles and medical costs. Other disparities such as lack of access to quality food and technology also can limit the ultimate success of a patient’s health care.

Developing a culturally competent practice is also at the forefront of social justice in nursing. According to the Pew Research Center, between 2015 and 2065, immigrants will account for 88% of U.S. population growth. Nurses must educate themselves on different cultural values and communication styles to create encompassing care plans and promote positive health outcomes.

How Nurses Can Ensure Social Justice in Care Delivery

All nurses uphold a code of ethics set by the American Nurses Association (ANA) that guides decision-making in the nursing profession. One of these ethical obligations identifies the need for nurses to act when there’s social injustice in health care delivery.

With a post-graduate education in nursing such as a master’s-level degree, advanced practice nurses have the knowledge to develop, implement, and oversee policies that ensure social justice in their nursing practice. Acting as primary care providers, nurse practitioners can deliver high-quality care at a comparatively low cost to vulnerable segments of the population that include the following.

• Expecting mothers. Women’s health care nurse practitioners (WHNP) use their specialized and advanced education and certification to help expecting and new mothers who cannot access an obstetrician or gynecologist. WHNPs can lead community outreach programs to educate expecting mothers and conduct home visits to improve the health outcomes of the mother and baby. WHNPs must be certified through boards such as the National Certification Corporation, which ensures expecting mothers are receiving safe, high-quality care.
• Rural residents. Residents in rural areas often have limited access to primary care providers because of physician shortages. Advanced practice registered nurses (APRN) who can operate with full autonomy, such as in diagnosing patients and prescribing medications, can increase access opportunities and health outcomes for rural citizens.
• Patients with chronic conditions. Twenty-five percent of Americans have two or more chronic conditions, such as diabetes and high blood pressure, according to a recent report in Health Affairs . However, managing these conditions is disjointed and accounts for about 75% of health care spending. Using a patient-centered approach to care, nurse practitioners, such as adult-geriatric nurse practitioners (AGNP), can reduce patients’ medical costs and improve health outcomes of patients with multiple conditions.

The Skills of an Advanced Practice Nurse

Each advanced nurse practitioner must possesses a set of key competencies to ensure the promotion of social justice in a clinical setting. APRNs need to have strong communication and critical thinking skills to address health care concerns in their communities. Using a collaborative approach and incorporating feedback from patients, team members, and the community, APRNs can improve the delivery of services in their practices.

These competencies support the essential skill for advanced practice nurses: leadership. Advanced practice nurses need to make consistent, ethical decisions in their practice. Many of these decisions aim to remove health disparities and improve the health outcomes of their community. Advanced practice nurses also may work outside of their practice alongside community members, such as law enforcement or housing development, to address discrepancies in health care and deliver effective programs.

Social Justice and Advanced Nursing Education

Aspiring advanced practice nurses can develop their knowledge and leadership acumen through graduate education such as Regis College’s online Master of Science in Nursing (MSN) program.

Students can pursue one of the following concentrations.

• Adult-Geriatric Primary Care Nurse Practitioner
• Adult Gerontology – Acute Care Nurse Practitioner
• Family Nurse Practitioner
• Pediatric Nurse Practitioner
• Psychiatric Mental Nurse Practitioner
• Women’s Health Nurse Practitioner

Each concentration prepares students to serve the unique needs of a specific population. Students who complete the coursework learn to think critically about the health care system and how they can implement initiatives to improve patient safety and quality.

Influence Social Justice and Change

History records the pulses of social change. Nurses who want to lead change and promote social justice in nursing can benefit from advanced education. Key leadership skills and other competencies are needed to effectively deliver health care in an ethical manner that promotes social justice. Visit Regis College’s online Master of Science in Nursing program to start advocating for positive change in health care.

Recommended Readings

Careers in Nursing: Exploring Nurse Salaries by Specialization What Kind of Nurse Should I Be? Examining Advanced Practice Nursing Paths Using Nursing Skills to Provide Primary Care

American Association of Colleges of Nursing, “The Essentials of Master’s Education in Nursing” </a American Association of Colleges of Nursing, “The Essentials of Doctoral Education for Advanced Nursing Practice” American Nurses Association, “Code of Ethics for Nurses with Interpretive Statements” American Public Health Association, Social Justice and Health Center for Economic and Social Justice, Defining Economic Justice and Social Justice Communities in Action: Pathways to Health Equity , “The State of Health Disparities in the United States” Health Affairs, “Impact of Physicians, Nurse Practitioners, and Physician Assistants on Utilization and Costs for Complex Patients” Healthcare , “Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes” Montana State University, “Nurse Practitioner Patients Less Costly to Medicare Than Physician Patients” National Certification Corporation, Certification Exams The Online Journal of Issues in Nursing , “Implementing the New ANA Standard 8: Culturally Congruent Practice” Orlando Sentinel , “Solving Nurse Shortage Could Help Women’s Health, Infant Mortality Rate” Pew Research Center, “Modern Immigration Wave Brings 59 Million to U.S., Driving Population Growth and Change Through 2065” Regis College, Online Master of Science in Nursing

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How does social justice relate to nursing?

Social justice is practically inherent to nursing. In fact, Provision 8 of the Nursing Code of Ethics declares that “the nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.” 1 From a historical perspective, many of the gains in nursing as a medical field have come out of efforts to improve the health of the community or vulnerable populations. From the 19th century focus on sanitation and hygiene to foster healthier conditions especially in poorer neighborhoods to public health projects during the COVID-19 pandemic to ensure access to care, testing and vaccines for marginalized groups, nursing consistently intersects with social justice topics, typically within the scope of health equity.

Social justice and health equity

Defined by the Encyclopedia Britannica as “the fair treatment and equitable status of all individuals and social groups within a state or society,” the term social justice is also applied to “social, political, and economic institutions, laws, or policies that collectively afford such fairness and equity and is commonly applied to movements that seek fairness, equity, inclusion, self-determination, or other goals for currently or historically oppressed, exploited, or marginalized populations.” 2 Health equity, or, the state in which everyone has a fair and just opportunity to attain their highest level of health, is essentially social justice in action when it comes to health care.

The Department of Health and Human Services explains that achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. 3 These disparities can generally be categorized into the different social determinants of health (SDOHs): economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

Nursing Code of Ethics on social justice

Nursing, like many health care professions, operates by a code of ethics to serve as a moral compass for workers in the field. The Code of Ethics for Nurses with Interpretive Statements (Code of Ethics) was developed in the 1950s and has been amended over time to include technological advances, societal changes and other developments in the field. 4 The Code of Ethics includes clear provisions about caring for patients but it also asks nurses to think beyond the bedside and consider their responsibility to advancing health care and social justice by developing ethical awareness.

The American Nurses Association (ANA) categorizes the principles found in the Code into four groups: autonomy, beneficence, justice and nonmaleficence. These four principles work in concert to treat patients and their choices and values with respect, fairly and impartially treat patients regardless of age, ethnicity, economic status, religion, or sexual orientation and to avoid and minimize harm. 4

Provision 8 of the Nursing Code of Ethics states “The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy and reduce health disparities.” The provision is further divided into four points to hone in on these crucial responsibilities: 1

• Health is a Universal Right: This point aligns with the United Nations, the International Council of Nurses and human rights treaties across the world. It affirms the fundamental human right to access to health care, emergency care, sanitation, health education, treatment, and prevention.
• Collaboration for Health, Human Rights and Health Diplomacy: Acknowledging the unique and essential role of nurses, this point encourages nurses to connect health care with legislation, policies, projects and programs to improve health. As the ANA states, “Ethics, human rights, and nursing converge as a formidable instrument for social justice and health diplomacy that can be amplified by collaboration with other health professionals.”
• Obligation to Advance Health and Human Rights and Reduce Disparities: This point declares, “Nurses should collaborate to create a moral milieu that is sensitive to diverse cultural values and practices.” It encourages innovation in solutions to health disparities and dismantling of unjust structures and processes. It also pushes taking action with health legislation and public education.
• Collaboration for Human Rights in a Complex, Extreme, or Extraordinary Practice Settings: This part of the provision stresses the importance of upholding human rights in all scenarios, even when practicing in extreme settings like war, in pandemics, political turmoil, and environmental or natural disasters. It also encourages nurses to be aware of their moral justifications of all of their actions.

Having an expectation of upholding ethical standards within your profession in the name of social justice can feel like a weighty responsibility. But it also is helpful to have a clearly defined vision for equality that can be used as a guide when determining how to proceed when put into complex situations as a health care professional.

Contemporary social justice efforts in nursing

Today, achieving health equity is at the core of countless not-for-profits, community clinics, public health efforts , and the missions of many large health institutions. Some topics of focus for these efforts include:

• Reducing the rate of Black maternal mortality
• Syringe Services Programs
• Health care for immigrants
• Access to care, especially for minority race populations and lower income neighborhoods and for the LGBTQ+ community
• Ample care and resources for people with disabilities

What nurses can do to further social justice

Like all individuals, nurses can be change agents by responding to racism when they experience or see it occur. There are also many ways both in a clinical context and non-clinical that nurses can take action.

Clinical social justice methods

While working with patients, nurses can screen for social needs and attempt to address determinants of health that might be lacking in a patient’s life. That way they can help connect the patient with social services or create care plans to address their needs. It’s also important for nurses to become educated on the populations they serve and be sure to have an understanding of diverse cultures , how those groups interact with medical personnel and how their beliefs might require different types of treatment or language used and how to foster trust. Of course nurses can also work on or lead the clinical arms of public health efforts like harm reduction, community outreach and more.

Non-clinical social justice methods

As lifelong learners, nurses can also further their understanding of implicit and unconscious bias, as well as cultural competency in health care through continuing education efforts . They can also act as leaders within their own institutions to develop cultures of inclusivity both on the staff and for the patients . Nurses also play a crucial role as educators both professionally and as trusted voices in social settings. Additionally, nurses can advocate for policies at the local, state, and national level that address health equity, which will not only improve well-being now, but also continue to lay the foundation for better health in the future.

Nursing’s history of social justice

Prior to the Civil Rights Movement in the 1960s, discrimination based on race, gender, and more was both legal and accepted as the cultural norm of society. The actions, policies and beliefs from that time have certainly had a hand in the health disparities nurses work against today. But the concept of promoting social justice through nursing is nearly as old as the profession itself. From the early days of nursing, people like Florence Nightingale, Mary Seacole, Clara Barton and Lavinia Dock were advocates for improving the health disadvantaged groups. Two distinct and related examples are how nurses worked to further both the Civil Rights Movement and the social justice efforts of the 2020s.

Nursing and the Civil Rights Movement

Until 1964, hospitals were like most other institutions and were segregated based on race. Even hospitals in the North, although not formally segregated, prevented Black physicians from holding attending privileges at white hospitals and often encouraged Black patients away from the facilities to see Black doctors instead. Even once hospitals became more integrated, Black patients and nurses were often treated poorly. Highly-educated Black nurses were relegated to elementary tasks and Black patients were regarded by white doctors with disrespect. 5

Looking back at the time following the passing of the Civil Rights Act, some people credit nurses with really pushing through change as they acted as vigilant whistleblowers against hospitals and facilities that weren’t complying with integration orders. In an article from Minority Nurse Magazine David Barton Smith, PhD, author of Health Care Divided: Race and Healing a Nation , details the constant struggles to actually enact integration within hospitals: 5

If a hospital tried to circumvent the inspections, nurses would get on the telephone and call either the NAACP, one of its local chapters, the Office of Civil Rights or the Office of Equal Health Opportunity in Washington, Smith explains. In other instances, inspectors would meet secretly with Black nurses the day before inspections to get briefed about floor plans with segregated locations, such as nurses’ changing rooms or lunch rooms. Otherwise, hospital tours could be very selective, he says.

Some facilities tried to get away with what Smith calls “the HEW (Department of Health, Education and Welfare) shuffle.” For example, he says, hospital employees would temporarily integrate infant bassinets so that when inspectors came through the nurseries “they would see little Black faces and white faces next to each other. Then, as soon as the inspectors left, they’d pick them up and separate them again…”

Black nurses also led social justice efforts when it came to desegregating nursing schools (at OCU we have an annual celebration of one of these nurses, Opaline Deveraux Wadkins ) and even the ANA. To be a member of the ANA, nurses also needed to be members of their state nursing association, many of which prohibited Black membership. Efforts by the National Association of Colored Graduate Nurses as well as encouragement from the national level of the ANA eventually led to dissolution of “color bans” in state associations and therefore the organization itself. 5

Nursing and the 2020 social justice movement

After months of stress, uncertainty and fear from the COVID-19 pandemic, the summer of 2020 boiled over with unrest after a series of unjust murders of Black people by police officers in the United States. This marked a critical point in history as Black Lives Matter became a household phrase illustrated by sustained protests, removal of historical monuments considered pillars of racism, and a renewed consideration of police misconduct and systemic racism by individuals and organizations across the globe.

Health care and nursing were not excluded from this reckoning and on August 4, 2020, the American Academy of Nursing (Academy) and the ANA issued a statement on the urgent need for social justice to address prevalent racism and discrimination. Citing Provision 8 from the Nursing Code of Ethics, the Academy and ANA declare that, “The profession’s code exemplifies our promise to advocate for safe and healthy communities. This advocacy extends to all individuals..[and requires that] nurses “practice with compassion and respect for inherent dignity, worth, and unique attributes of every person.” 6 It also acknowledges that health care institutions have historically been a part of the problem and that change has to start with every individual person, “We must remove areas of bias that perpetuate negative behaviors and reinforce harmful stereotypes and stigmas. This extends to those biases held by nurses and other health care providers. Working together, health professionals, public health officials, health care and industry leaders, system administrators, and policy makers, can confront and directly address these behaviors along with the unfair practices that lead to discrimination…” 6

Choose a university that shares your passion for a healthy future

Nursing is a field with tremendous potential to make a difference–both within your own community and across the globe. Make your impact go further when you earn an advanced degree in nursing at a university committed to social justice. Oklahoma City University’s online RN-BSN , RN-MSN and MSN programs are led by faculty with experience in affecting change through efforts to achieve health equity. Talk to an Admissions Advisor to learn more.

• American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. p. 31-33. Silver Spring, MD. Retrieved on May 17, 2023, from nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
• Retrieved on May 17, 2023, from britannica.com/topic/social-justice
• Retrieved on May 17, 2023, from health.gov/healthypeople/priority-areas/health-equity-healthy-people-2030
• Retrieved on May 18, 2023, from nursingworld.org/practice-policy/nursing-excellence/ethics/why-ethics-in-nursing-matters/
• Retrieved on May 18, 2023, from minoritynurse.com/making-history
• Retrieved on May 17, 2023, from nursingworld.org/news/news-releases/2020/the-american-academy-of-nursing-and-the-american-nurses-association-call-for-social-justice-to-address-racism-and-health-equity-in-communities-of-color/

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Career Advice > Professional Development > Upskilling and Promotions > What Is Social Justice in Nursing Practice?

What Is Social Justice in Nursing Practice?

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Nursing is rooted in the foundational belief that every person deserves quality, equitable care. The profession is also shaped by social, health, and ethical challenges . Nurses often work within inequitable systems, yet are tasked with advocating for the best patient outcomes. But what does it mean to practice social justice in nursing? And what is the nurses’ role in promoting social justice and health equity?

Understanding health equity and social justice within nursing practice is the first step to better advocating for your patients . Social justice competence isn’t a hard skill, like inserting IVs or charting medications, but it’s just as essential for patient care. Being a nurse advocate means being curious, thinking critically, and holding compassion for all people — all essential qualities in a professional nurse .

What Is Social Justice in Nursing ?

Practicing social justice as a nurse means advocating for health equity. Every person has the opportunity to live to their fullest health potential . No one should experience disadvantages because of their social position or other circumstances.

When you think of health equity, you might imagine that it means everyone has access to medical care. But health is affected by many factors — housing, economics, education, law, and discrimination, to name a few. In fact, experts estimate that social issues , not medical care, account for up to 90% of health outcomes.

Being a nurse advocate means recognizing these broader determinants of health and understanding their impact on individuals and communities. It means doing your part to address the social, economic, and cultural factors that contribute to health disparities. Nurses play a crucial role in dismantling systemic barriers that hinder access to health — whether it means advocating for large-scale policy change or for a single patient.

Healthcare is a catch-all for a range of social issues. In nursing, you probably witness social justice issues more than you realize. And depending on where you work, you’ll likely see some problems more than others. Examples include:

• A patient is being admitted for diabetic ketoacidosis for the third time in a month because they can’t afford insulin .
• A Black birthing person is at higher risk for birth complications due to systemic racism and disparities.
• A trans patient in a rural area cannot access transitional care because none of the providers in their area understand their medical needs.
• A patient who recently immigrated to the U.S. is admitted with acute sepsis after suffering an injury at their farming job. They would have come to the hospital earlier, but were worried they would be deported.
• A patient is being discharged to a homeless shelter after alcohol detox, where they will likely face barriers to staying alcohol-free.

These problems come from systemic issues, and it isn’t up to you to solve them. As a substance abuse nurse , you can’t address your post-detox patients’ housing problem by inviting them to stay with you. But you can treat them with compassion, give them the sobriety resources they need, and show them that they matter.

Being a nurse advocate doesn’t mean taking on large-scale problems by yourself, although many nurses are involved in social policy change . By understanding how social issues impact your patients and having compassion for the context that people are living in, you can be an advocate in your own way, with every patient, on every shift.

The Importance of Social Justice in Nursing

By practicing social justice as a nurse, you help create healthcare environments that prioritize fairness, inclusivity, and dignity for every individual. You don’t just understand how racism, systemic inequality, and bias affect care, you also work to address it. Social justice not only aligns with ethical nursing principles , but it improves the effectiveness and quality of healthcare delivery.

How to Practice Social Justice in Nursing

If you’re learning about social justice and you’re not sure how to promote health equity, here are some ways to start:

• Take cultural sensitivity training. Cultural competence allows nurses to provide patient-centered care that respects individual values, beliefs, and practices.
• Educate others. Use your platform to educate colleagues, patients, and the community about social justice issues in healthcare. Speak up if you hear coworkers talk negatively about a patient or someone else because of race, financial status, or another social justice issue.
• Be self-reflective. How have you experienced social injustice? Inversely, how have you experienced privilege? Being an advocate means thinking critically about your experiences and how they shape your perceptions.
• Support health literacy. Empower patients with information to make informed decisions about their health. By enhancing health literacy, nurses contribute to a more equitable distribution of healthcare knowledge and resources.
• Commit to continuous learning. Stay informed about emerging social justice issues, healthcare policies, and best practices. Continuous learning enables nurses to adapt their approach and contribute to positive change in the healthcare system and beyond.

Examples of Social Justice in Nursing

What does it mean to advocate for your patients as a nurse? No matter where you work, you can practice social justice in healthcare. Examples include:

• In an ICU , you notice that a Black patient is not receiving the pain management care that he needs. You address this with the medical team, and point out the new plan to the oncoming nurse at shift change.
• In a pediatric clinic , you see a child who is behind on their vaccines. Their parents both work two jobs and have missed several appointments. You make a note to give them an extra reminder call before their next scheduled visit.
• Working in case management , you learn that a female patient is living with an abusive partner. Understanding that abuse is complex, you call them to give them resources about local housing options and to tell them that they have your support should they decide to leave.
• In a med-surg unit , you admit a patient who is having trouble with medication adherence and doesn’t speak much English. By working with an interpreter, you learn that they didn’t understand their medication plan. You alert the medical team to ensure the patient gets the language-appropriate educational materials they need.

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Social Justice in Nursing Practice

Introduction.

Social justice spins around human rights and societal equality ideologies. Social justice is all about giving privileges and fair opportunities to all individuals globally. It aims to readdress the inequalities based on genders, races, disability, ages, religion, or other less vulnerable social characteristics. Social injustice, commonly referred to as discrimination, predominantly affects social justice globally in all sectors, pushing political and influential leaders to create awareness against social injustice, which has become a global threat. Healthcare is not an exception field as matters and issues against the social injustice crisis have been reported.

Social injustice in healthcare pertains to training of nurses to create awareness through advocating the rights and protection of the patients. The roles of a nurse are to act as the intermediaries between the patients and the doctor, providing effective and efficient medical care to the patients. Thus, social justice in health care portrays the delivery of high-quality care per nursing ethics and values without any discrimination to enhance the achievement of social justice and ensure the whole society achieves and maintains a high level of healthy wellbeing.

Fundamentals of Social Justice in Nursing

According to nursing ethics and morals, social justice ideology requires all nursing and medical field practitioners to keenly uphold the legal and human-centred philosophy about health core values. Hence, it is essential to understand social justice as a fundamental nursing practice since it is the foundation of all practical and efficient public health services. In society, fair and just actions are essential as they benefit the given community and the nation. According to the World Health Organization, effective and efficient health care is mandatory for every individual (Artiga et al., 2020). However, with increased demands and global societal discrimination over the last decades, the gap between quality health care has widened between the marginalized and the privileged in society.

The human rights activists support social fairness as a fundamental element since it incorporates the nursing practice and the medical field as a primary, providing holistic health care to a particular individual and a community translating to global. In nursing, social justice deals with the fair allocation of health services effectively to the individual and the opportunity sharing of duties within the facility. During opportunity allocation, a lack of cooperation between the nurses in the facility causes disparity, which transmits poor quality health care to patients (Abu, 2020). The social determinant of health includes food, employment, income, housing, safety, and other fundamental determinants in enhancing social justice in nursing.

The Relationship Between Social and Diversity, Patient- and Family-Centred Care

The patient’s relationships centred care refers to a health care focus on the types of relationships the providers need to address the health care services provided in the facilities. The relations types include; the provider relationship with the patients, the provider relationship with the other providers in the facility, the community of the social connection and finally, the relationship with the family-centred care. These relationship approaches enhance the improvement of healthcare service quality that sees fair service deliverance to all individuals. The patient and family-centred care relationship model enables understanding and analyzing how patients might be treated and handled by the whole health care system when seeking the services. Thus, health services being a core value in any nation, we conclude by comparing social diversity with the patient and family-care preparedness approach.

All the methods advocate improving quality health care for individuals, families, and communities in a diversified manner, translating into a social justice service (Park et al., 2018). Also, during the allocation of employment opportunities in health care services, the social and the diversity approach advocates for free and fair allocation of options, thus creating cooperation, harmony and unity within the health care services hence quality services to all individuals.

During my nursing field experiences, I faced a health care issue, whereas I handled a teenage girl with pregnancy complications as a nurse. Having gotten the pregnancy while in school, she was forced to drop out after family pressure and torture, forcing her to have psychological traumas affecting her pregnancy journey. It posed mandatory healthcare surveillance, whereas it could lead to death or loss of the unborn baby. Coming from such conflicting background, she had no family support during the whole medical care services. It contradicts the FCC arguments that the best way to meet patient safety is through having support from the family.

As healthcare practitioners, we all have the mandate to embrace change, control and support families and society members who have no voice in promoting societal changes. It is essential to understand that maintaining an effective and efficient relationship approach in the health care facility promotes the wellbeing and the health of individuals, families, and whole societies.

The Health Care Disparities

Healthcare disparities refer to the differences in accessing available medical resources and services based on social discrimination, including ages, sex, genders, economic class, ethnicity, and other drawbacks. In nursing practices, barriers such as education, employment, environment, and socioeconomic status can influence patients’ accessibility to health care (McQuaid & Landier, 2018). It promotes the social injustice ideologies in the health care fraternity affecting the less privileged in the society. The WHO should create strict rules that will oversee legal action against the clinicians who portray social injustice to any individual.

The societal inequality leads to increased mortality rates for the less privileged in the society with high depression to the people who cannot access better medical services. Overall, the disparities in health and health care for the people of colour and the less privileged groups have been longstanding challenges. In addition, these health care disparities are driven by the underlying societal and economic injustices. The World Health Organization advocates for equity as a priority to all individuals urging both private and public health care practitioners to wholly put all nursing and medical ethics to put efforts to reduce health disparities.

The healthcare disparity currently includes COVID-19, the ongoing police brutality, societal discrimination, increased psychological health problems, Asian hate crimes, migrant bias, and many others that have openly brought about health care disparities. The humanitarian activist, media house, and influential people have been at the forefront to create awareness against social health disparities. Addressing these health care inequalities would greatly help, especially during the covid-19 pandemic, which has seen many people affected globally, posing societal imbalance.

It is crucial to understand that healthy people goal is always the aim of any nation; thus, curbing the disparities potholes would greatly aid in preventing further widening of these social health care disparities (Artiga et al., 2020). Therefore, narrowing the health disparities is a primary key in improving the overall national growth and development. It also aids in reducing unnecessary health care budgets not only to the government but also to the local citizens.

Recommendations and Conclusion

The demand for effective health care in nursing practices increases with hospitals, patients, and daily global pandemics. Also, this has posed a challenge evidenced by increased social healthy inequalities and health care disparities globally. Hence, calling for the promotion of health care facilities and fair services to society without any discrimination in terms of age, skin colour, sex, nationality, ethnicity, or any societal class. To promote and maintain effective and efficient health care service providence in the society, the following approaches can aid in promoting health care services to all individuals, even less privileged. The health care and the health ministry can build a firm health policy to oversee the service progress rating.

Healthcare should enhance a supportive environment that will aid in creating teamwork thus quality service deliverance. The healthcare service providers should prioritize the community needs and satisfaction in every healthcare sector. Finally, the health personnel should be mentored occasionally to consistently maintain excellent personal skills in the line of duty, keenly adhering to all health ethics and morals.

Abu, V. K. (2020). Let us be unequivocal about social justice in nursing. Nurse Education in Practice, 47 , 102849.

Artiga, S., Orgera, K., & Pham, O. (2020). Disparities in health and health care: Five key questions and answers . Kaiser Family Foundation. Web.

McQuaid, E. L., & Landier, W. (2018). Cultural issues in medication adherence: disparities and directions. Journal of General Internal Medicine,33 (2), 200-206.

Park, M., Lee, M., Jeong, H., Jeong, M., & Go, Y. (2018). Patient-and family-centred care interventions for improving the quality of health care: a review of systematic reviews. International journal of nursing studies, 87 , 69-83.

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• Research article
• Open access
• Published: 12 January 2021

Social justice in health system; a neglected component of academic nursing education: a qualitative study

• Hosein Habibzadeh 1 ,
• Madineh Jasemi 1 &
• Fariba Hosseinzadegan   ORCID: orcid.org/0000-0002-3464-7385 1  

BMC Nursing volume  20 , Article number:  16 ( 2021 ) Cite this article

39k Accesses

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Metrics details

In recent decades, increasing social and health inequalities all over the world has highlighted the importance of social justice as a core nursing value. Therefore, proper education of nursing students is necessary for preparing them to comply with social justice in health systems. This study is aimed to identify the main factors for teaching the concept of social justice in the nursing curriculum.

This is a qualitative study, in which the conventional content analysis approach was employed to analyze a sample of 13 participants selected using purposive sampling method. Semi-structured interviews were conducted to collect and analyze the data.

Analysis of the interviews indicated that insufficient education content, incompetency of educators, and inappropriate education approaches made social justice a neglected component in the academic nursing education. These factors were the main sub-categories of the study and showed the negligence of social justice in academic nursing education.

Research findings revealed the weaknesses in teaching the concept of social justice in the nursing education. Accordingly, it is necessary to modify the content of nursing curriculum and education approaches in order to convey this core value. Since nursing educators act as role models for students, especially in practical and ethical areas, more attention should be paid to competency of nursing educators, specially training in the area of ethical ideology and social justice.

Peer Review reports

Professional values include action standards that are accepted by group members and provide a framework for evaluating beliefs and notions affecting behavior [ 1 ]. Acquisition of professional nursing values is a prerequisite for resolving conflicts; it improves service quality and increases job satisfaction of nurses [ 2 ]. The core values accepted and presented by American Association of Colleges of Nursing (AACN) (1998) include human dignity, integrity, autonomy, altruism, and social justice [ 3 ], out of which social justice has attracted more attention in recent years. Disproportionate burden of diseases and deaths in parts of the society associated with environmental and socioeconomic factors has been recognized for decades; however, the number of documents on these issues has increased dramatically over the past 15 years [ 4 ]. The WHO Commission on Social Determinants of Health attributes these differences to social inequalities in the distribution of power, income, shelter, education, and healthcare as well as climate change, vulnerability, and other life conditions. It also prioritizes social justice as a mechanism for correcting and eliminating inequalities [ 5 ]. Social justice in the health system refers to providing equal healthcare services for all individuals, regardless of their personal characteristics [ 6 ]. The AACN defines social justice as fair treatment, regardless of one’s economic status, race, ethnicity, age, citizenship, disability, or sexual orientation [ 7 ].

Although social justice has been identified as a professional value in documents issued by reputable nursing associations such as International Council of Nurses (ICN), Canadian Nurses Association (CNA), American Nurses Association (ANA), and AACN [ 8 ], the discussion of social justice in nursing profession has always been accompanied by serious doubts and concerns [ 9 ]. In addition, nurses’ responses to social injustice have not always been admirable, and nursing profession’s poor performance originates from various factors such as unawareness [ 10 ].

Development of a professional value such as social justice is a continuous and long-term process that begins with professional nursing education and continues throughout years of nursing practice. Education plays a key role in acquiring professional values [ 11 ]. Students, educators, faculties, clinical and educational experiences, and individual values are among the most important components of learning and development of professional values [ 12 ]. It is very important to train highly skilled and qualified nurses to provide necessary care for heterogeneous populations in today’s ever-changing demographic prospect. Nursing students must understand their responsibility for poplulation health issues and social factors affecting health (eg, world hunger, environmental pollution, lack of access to health care, violation of human rights, and inequitable distribution of health care resources, including nursing services) and in this regard acquire the necessary knowledge and skills [ 13 ].

To institutionalize the concept of social justice in nursing students, especially in developed countries, measures have been taken in the area of education, which include modifications made to nursing curriculum and education approaches [ 14 ]. For instance, simulation is a one of new methods utilized for teaching this concept [ 15 ]. Since the mid-2000s, there has been an increase in tendency towards online learning [ 16 ], co-curricular experiences [ 17 ], and digital storytelling [ 18 ] in order to promote students’ understanding of social justice issues. Nevertheless, some studies have addressed the weaknesses of nursing curriculum in teaching social justice [ 19 , 20 ] and have attributed nurses’ inability in pursuing social justice to their poor scientific and practical competencies [ 21 ]. Although several quantitative and qualitative studies have been conducted in recent decades to institutionalize the concept of social justice among nursing graduates [ 22 , 23 , 24 , 25 ], academic nursing education has unfortunately failed to train competent nurses who seek information and training on social justice. Considering the importance of this subject, a qualitative approach [ 26 ] was adopted to provide an in-depth understanding of social justice based on the realistic results derived from the participants’ real experiences. Therefore, in this study, the experiences of nursing educators and students in identifying the main factors for teaching the concept of social justice in nursing education program were analyzed.

Study design and setting

This qualitative study was conducted using a conventional content analysis method. The participants were recruited from three nursing faculties (Urmia, Tabriz, and Tehran) and two teaching hospitals of Tehran (Motahari Hospital) and Urmia (Talegani Hospital) in Iran. These cities were selected due to their large size and forerun in educational, clinical, and social nursing activities.

Study participants

In view of the objective of the study - identify the main factors for teaching the concept of social justice in the nursing curriculum - we initially selected nursing educators by purposive sampling method. Nursing educators who had more than 5 years of service experience and among the prominent educators with activity in nursing institutions that involved in developing social justice were selected. The data from the study then led us to students and clinical nurses. Among the students, the final year undergraduate students, exemplary and active in social fields, and among the nurses, those with more than 2 years of service experience, accepted by the system professionally and actively in the field of social justice, such as voluntary activities in public health promotion, were selected for the interview.

The participants included 6 men and 9 women with the mean age of 39.07 ± 12.92 years old and mean work experience of 20.00 ± 7.22 years. Out of all the participants, 5 individuals had PhD, whereas 2 had Master’s degrees; the rest had Bachelor’s degrees in nursing. In total, 7 individuals were nursing educators, 2 individuals were clinical nurses, and 4 individuals were nursing students (Table  1 ).

Data collection

The data were collected using in-depth, semi-structured individual interviews conducted at the times and in the places selected by the participants (mainly at nursing faculties). Each interview lasted for 30–90 min; they were audio recorded upon the participants’ permission and transcribed verbatim. All the 13 interviews were conducted by the research team (FH, MJ, and HH) between February and November 2019. The participants were asked questions about their experiences of (learning/teaching) social justice issues. Considering the abstract nature of the research subject, the researchers raised more objective questions. For instance, the educators were asked to “describe their experiences of modification to the curriculum to cover social justice issues”, whereas the students were asked to “describe their experiences of social justice-based practices during internships”. In addition, to better identify factors affecting social justice education in nursing, the educators and students were asked questions such as “Considering your experiences, what factors have affected your engagement in social justice in education?” and “How do you describe education approaches adopted by educators for teaching social justice?”, respectively. (See Additional file  1 for details). The researchers continued the interviews until the data were completely saturated, i.e. when no new idea, concept, or category was derived from the final interviews.

To better relate to the environments of the study and the participants and analyze the data realistically, the researchers also used field notes. Field notes are a brief summary of the observations made while collecting data. This is not limited to a particular type of activity or behavior and assesses the non-verbal behaviors of the participants and their interactions with others. It also depicts a picture of a social position. In this study, field notes also made a detailed presentation of the situation in the right place immediately after the interview and provided the opportunity to confirm the psychological and emotional reactions of the participants. For example, attending the emergency ward of one of the teaching hospitals in Urmia city and observing nursing education in the clinical environment led to a field note focusing the training on the clinical procedures that confirm the insufficient educational content and lack of attention to social justice in nursing education.

Data analysis

After the data were collected, they were analyzed using the conventional content analysis approach. For this purpose, Grundheim and Lundman’s (2004) method was adopted [ 27 ]. In this method, an entire interview is regarded as an analysis unit involving notes that must be analyzed and coded. The researchers listened to the interviews for several times and transcribed the recorded interviews verbatim. The paragraphs, sentences, and words were considered meaning units. A meaning unit is a set of words and sentences that are related to each other in content and are categorized based on their content and context. The texts were reviewed several times to highlight words containing key concepts or meaning units and extract the initial codes. The codes were then reviewed several times in a continuous process from code extraction to labeling. Similar codes were merged, categorized, and labeled and the subcategories were determined. The extracted subcategories were finally compared and merged (if possible) to form the main categories.

Assessing data accuracy and stability

Guba and Lincoln’s (1986) criteria were used to ensure the accuracy and stability of the research data. The credibility of the data was assessed using member-checking and prolonged engagement techniques. For member-checking technique, the participants reviewed the content of the interview and the resulting codes to ensure the accurate meaning and for really reflecting their experiences. The data were also assessed by an external researcher (peer debriefing). To ensure the dependability, data collection methods, interview, taking notes, coding, and data analysis were expressed in detail in order to make judging by the external auditor (external auditing). In order to achieve confirmability, the audit trail method was used, so that all stages of the research, especially the stages of data analysis and the results, were provided to checking of two expert colleagues in the field of qualitative research. The transferability of the findings was also established by providing a rich description of the research report and the content of the interviews was represented by the selected quotations from the participants [ 28 ].

Ethical considerations

The participants were selected after the approval of Ethics Committee of Urmia University of Medical Sciences and the necessary permissions (Code: IR.UMSU.REC.1397.223) were granted. Prior to the interviews, the participants were informed about their anonymity, confidentiality of their information, the research method and objectives, and their right to leave the study at will. The participants also signed informed consent forms.

Classification of the interviews showed that three sub-categories of “insufficient educational content”, “limited competency of nursing educators”, and “inappropriate education approaches” led to the emergence of the main category called “social justice; a neglected component of academic education” (Table  2 ).

Social justice; a neglected component of academic education

Proper education plays a major role in training justice-seeking nurses. Social justice and its importance in healthcare are constituents of the nursing syllabus. Paying more attention to this issue in practical and objective areas of education by educators can influence students’ thoughts, attitudes, and behaviors to pursue justice in health systems. However, Iran’s education system has unfortunately failed to promote justice because of insufficient educational content, limited competency of nursing educators, and inappropriate education approaches.

Insufficient educational content

Development of a comprehensive nursing curriculum, especially on ethical issues such as social justice, could substantially contribute to the preparation of socially and morally conscious nurses who are able to make significant changes in the public health at local, national, and international levels. In this study, the participants highlighted some weaknesses in the content of the existing nursing curriculum such as lack of attention to social justice, discontinuity in presenting courses on ethical values, and allocating most of the nursing courses to medical issues and clinical care.

Lack of attention to social justice in nursing curriculum

Social justice is a core nursing value which plays a significant role in promoting justice by nursing students and nurses. However, according to the participants, it has unfortunately been neglected in the existing nursing curriculum. In this regard, one participant stated,

“In the fourth semester, we studied a course on nursing ethics. I think there was no discussion on social justice because I don’t remember anything about this topic” (Participant No. 7/Nursing Student).

Regarding the importance of teaching social determinants of health, another participant stated,

“I was not aware of the importance of social issues in health until I participated in a workshop called ‘Social Justice in Health’. It really changed my beliefs and broadened my perspective” (Participant No. 10/Clinical Nurse).

Discontinuity in presenting courses on ethical values

Values are major components of the nursing profession. The institutionalization and development of professional values such as social justice contribute significantly to the future of this profession. The few number of courses presented on ethical values and discontinuity in the presented courses (for instance, no course on ethical values is provided for post-graduate students) were major items mentioned by the participants. In this regard, one of the participants stated,

“When students are repeatedly reminded of the importance of a value, they will realize its importance and the value will be institutionalized in them. We partially studied professional values and social justice issues in the fourth semester of our undergraduate courses; however, no similar course was provided for us afterwards during the Master’s program” (Participant No. 5/ Faculty Member).

Or another participant stated:

“We cannot deny that the ethical issues have been institutionalized in our professional graduates to some extent. But, these issues are not worked on in a principled and scientific manner and that there is no constant focus on them. After all, the effect of the hidden curriculum has been more prominent.”(Participant No.1/Faculty Member).

Allocating most of nursing courses to medical issues and clinical care

Diseases and clinical care are among the most fundamental parts of theoretical and practical training provided for nursing students; however, due to the multi-dimensional nature of the nursing profession, special attention should be paid to other dimensions as well. According to the research results, the existing nursing curriculum focuses mainly on transferring knowledge and skills associated with physical and routine care. One participant expressed,

“Most of our courses were related to various diseases and nursing care, and educators rarely talked about ethical and legal issues during their lectures” (Participant No. 6/ Nursing Student).

Another participant stated the reasons for the focus of nursing education on the physical and caring dimensions:

“Well, when we see that our graduates have problems in providing quality clinical care, we also have to do more in the field of clinical care.”(Participant No.3/ Faculty Member).

Limited competency of nursing educators

Educators play an undeniable role in training competent nurses through institutionalizing beliefs and behaviors. Using proper teaching and behavioral approaches, educators can improve students’ critical thinking skills and prepare them to promote justice in health systems. According to the participants, insufficient competency of nursing educators in teaching social justice issues and inappropriate value perspectives of educators in developing social justice were the main properties of this category.

Insufficient capabilities of educators in teaching social justice issues

Educators must be equipped with sufficient scientific, practical, and ethical capacities in order to effectively institutionalize the concept of social justice in students. According to the participants, nursing educators’ insufficient knowledge and experience about social justice issues make it difficult for them to transfer such knowledge to their students. One participant said,

“When I was a student, I once informed my educator about the unjust patient admission procedure in the surgical department. Yet, my educator recommended me to do what the head nurses would say. I did not see the necessary authority in my educator to establish justice” (Participant No. 11/ Clinical Nurse).

Low presence of nursing educators in clinical and community settings is also one of the factors that, according to the participants, has contributed to this problem.

“Unfortunately, our professors are so involved in education and research, especially to promote themselves, that they do not have the opportunity to address social issues.” (Participant No.9/ Faculty Member).

Inappropriate value perspectives of educators in developing social justice

The participants highlighted the important role of nursing educators’ ethical perspectives in promoting the quality of education and training qualified nurses who would provide services tailored to the needs of the society. They also argued that ethical values could help educators establish and expand social justice in health systems. According to the results, most of the educators had undesirable value perspectives on establishing social justice in the area of health. In this respect, participant no. 5 stated,

“When a nurse has no right to make any decisions in a healthcare system, what can I say to the student about social justice?” (Participant No. 5/ Faculty Member).

“My main responsibility is to transfer knowledge in the field of nursing and I think ethics should be taught by educators in medical ethics.” (Participant No.2/ Faculty Member).

Inappropriate education approaches

Education approaches are considered an essential part of the educational structure and play a key role in transferring ethical values such as social justice to students. Given the abstract nature of social justice, choosing the best education approach could help educators resolve complicated problems during teaching in order to institutionalize professional values and beliefs. According to the findings, educators adopt poor education approaches to transfer ethical values such as social justice and self-awareness to students. In this regard, focusing on traditional education approaches and using insufficient affective learning approaches were cited by the participants.

Focusing on traditional education approaches

Undoubtedly, lecturing is one of the most widely used education approaches; however, this traditional method is very ineffective in teaching abstract concepts such as social justice. According to the participants, educators mostly use lecturing approach to teach social justice issues and students are rarely involved in the teaching process. One participant argued that educators mainly use teacher-centered approaches in ethical discussions, stating,

“We (the students) had no active role in the professional ethics class. The educator spoke on relevant topics based on the availed syllabus and provided some examples of clinical ethical issues. However, I think that educators must discuss social justice issues with students to help them visualize and understand cases of injustice and discuss appropriate reactions in such situations” (Participant No. 13/ Nursing Student).

Another participant stated this:

“The predominant teaching method in professional ethics classes has been lecturing. Every now and then, there was some discussions in between, but it was very rare. Other nursing educators were also using the lecture method when talking about ethics” (Participant No. 7/ Nursing Student).

Using insufficient affective learning approaches

The use of affective learning strategies such as reflective activities and simulations leading to emotional responses plays an important role in creating self-reflection and transferring professional knowledge and skills to nursing students. However, based on the participants’ experience, affective learning approaches are not used effectively and systematically in teaching ethical issues such as social justice. In this regard, one participant stated,

“Since there are too many topics on professional ethics, we (educators) can only convey basic issues to students and it is difficult for us to adopt other learning strategies such as the affective approach” (Participant No. 4/ Faculty Member).

The same participant further stated:

“Now, in the professional ethics class, I do my best to teach the content with a combination of methods. For example, we have formed a group for medical students in the cyberspace (WhatsApp) and asked students to express the issues and questions of clinical ethics. They should raise it there because there is no time in the classroom for these issues. However, we have not performed the same for nursing students yet” (Participant No. 4/ Faculty Member).

According to the research findings, social justice in a health system is a neglected component of academic nursing education due to factors including insufficient educational content, limited competency of nursing educators, and inappropriate education approaches. These factors were introduced as the main research subcategories in this study.

Some weaknesses were observed in the content of nursing curriculum, which is an main factor in promoting professional nursing values such as social justice in nursing students. Lack of attention to the issue of social justice in nursing curriculum has also been mentioned in other studies [ 13 , 20 ]. Based on the participants’ experience, most of the nursing courses are allocated to medical issues and clinical care. According to Thurman, clinical specialties have received the main focus of nursing curriculum, whereas little attention has been paid to social justice issues [ 21 ] . This problem can be attributed to the poor performance of nurses in clinical care. The participants also believed that there was discontinuity in presenting courses on ethical values because the professional ethics course was presented only to undergraduate students. This issue disrupts the proper institutionalization of ethical values such as social justice in nursing students. Frenk et al. believe that the preparation of healthcare professionals to address current healthcare inequalities and challenges has been slowed down by obsolete, fragmented, and static curriculum [ 29 ]. In addition, Rozendo et al. highlighted inconsistencies in terms of presenting social justice-related issues in nursing curricula and argued that there was little material on social justice in post-graduate nursing programs [ 14 ].

Nursing educators’ competencies also affect teaching social justice issues. In today’s rapidly-changing world facing numerous crises, experienced educators play a significant role in training qualified nurses equipped with various skills enabling them to create social development. Accordingly, Read et al. highlighted the critical role of nursing educators in institutionalizing fundamental principles of social justice and health equity in students [ 30 ]. According to Ellis, educators should shift nursing students’ learning and thinking attitudes from individualism to community-centered frameworks and from tertiary (reactionary) to primary (preventive) care approaches [ 31 ]. However, unfortunately, the research findings indicated that nursing educators are not sufficiently qualified to teach and institutionalize social justice in students. In this regard, educators’ insufficient knowledge and experience in teaching social justice issues were highlighted by the participants. Borhani et al. found that ethical knowledge of nursing educators determined their students’ professional ethics competencies [ 32 ]. Akbas et al also argued that nursing educators’ knowledge and skills were the first and most important factors affecting their success in teaching issues of professional ethics [ 33 ]. As mentioned by the participants, inappropriate value perspectives of educators in developing social justice was another weakness of nursing educators. The significant impact of educators’ perspectives on teaching ethical values such as social justice has also been emphasized by Parandeh et al. [ 12 ].

Education approaches adopted to present and convey ethical values to students are of high importance. In this regard, Einhellig discussed the ineffectiveness of traditional approaches such as lecturing in institutionalizing social justice in nursing graduates and outlined the benefits of affective learning approaches [ 19 ]. According to the findings, lecturing is the dominant approach used to teach social justice in Iran’s nursing faculties, which is an inefficient teaching approach, as suggested by the research literature. This is probably due to the large number of students and limited time allocated to each academic course. While cognitive learning approaches rely on principles and concepts, affective learning approaches support the integration of knowledge with emotions, attitudes, and personal beliefs [ 34 ]. Neumann found that affective education approaches could enhance students’ understanding and use of ethical values [ 35 ]. Einhellig highlighted that nursing faculties need to use various strategies with a focus on behavior changes in order to successfully institutionalize the concept of social justice in nursing graduates [ 24 ].

Limitations

The findings of the present study were limited to factors affecting education of social justice in the nursing curriculum in the health system in the culture of Iran. Other limitations of this study was the consideration of the three nursing faculties and two teaching hospitals in Iran. As such, it may not be a representative of the experiences of all the nursing profession members in Iran. Limitations of our study proposed the need for conducting further studies with larger and mixed groups and in different cultures.

The research findings provided researchers with an insight into the weaknesses of nursing curricula, educators, and education approaches in social justice development in Iran. It seems that more attention must be paid to professional values and social determinant of health in nursing curricula in order to train justice-seeking nurses with a sense of responsibility. Educators play a prominent role in training competent individuals who are aware of and sensitive to social issues and inequalities. It is necessary to change the education approaches adopted by nursing educators in order to institutionalize the concept of social justice in students. After changing the content of nursing curriculum and applying different education approaches, future studies can focus on the impact of such changes on social development and social justice promotion.

Availability of data and materials

The interview dataset generated and analysed during the current study are not publicly available due to promises of participant anonymity and confidentiality. However, on reasonable request the data could be available from the corresponding author. All applications should be sent to [email protected] . All requests will be answered within a maximum of 1 month by email.

Abbreviations

World Health Organization

American Association of Colleges of Nursing

International Council of Nurses

American Nurses Association

Canadian Nurses Association

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Acknowledgments

This study is a part of a PhD dissertation approved and funded by Vice Chancellor for Research, Urmia University of Medical Sciences. The researchers would like to thank the authorities of School of Nursing and Midwifery, Urmia University of Medical Sciences, as well as the participants for their kind cooperation.

This study was funded by Department of Research, Urmia University of Medical Sciences, which had no role in the design of the study, data collection, analysis, interpretation of data, or writing the manuscript.

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Contributions

The study was designed by HH,MJ and FH. FH participated as the main interviewer. The initial deductive data analysis was done by FH and used as validation of the analysis carried out by HH and MJ. The final data analysis of the interviews was discussed and consented to by all authors. A first draft of the article was developed by FH and MJ. All authors then contributed to this, and finalized it together. FH was responsible for the final draft of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Fariba Hosseinzadegan .

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The participants were selected after the approval of Ethics Committee of Urmia University of Medical Sciences and necessary permissions (Code: IR.UMSU.REC.1397.223) were granted. Prior to the interviews, the participants were informed about their anonymity, confidentiality of their information, the research method and objectives, and their right to leave the study at will. The participants also signed informed consent forms.

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Habibzadeh, H., Jasemi, M. & Hosseinzadegan, F. Social justice in health system; a neglected component of academic nursing education: a qualitative study. BMC Nurs 20 , 16 (2021). https://doi.org/10.1186/s12912-021-00534-1

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DOI : https://doi.org/10.1186/s12912-021-00534-1

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Professional Nursing Values: Taking a Closer Look at Core Values

Introduction

Conceptual explanation of each core value.

There are different reasons why different individual make a choice of taking up nursing as a lifetime career. These reasons may range from financial gains, personal, love for people, professional, or even for job security. Nevertheless, every individual who make that choice of becoming a nurse enters into a lifetime commitment regardless of his or her reasons of becoming a nurse. Consequently, every nurse commits to observe and adhere to the five core values necessary for taking up a career in nursing. These core values include: human dignity, altruism, integrity, social justice, and autonomy each of which is discussed below.

According to the American Heritage Dictionary of The English Language (1992, p. 522), the term “dignity” is defined as the “quality or state of being worthy of esteem or respect” it logically follows that the phrase Human Dignity may be used to denote respect for the inherent worth and uniqueness of individuals and populations. When dignity correlates along with the word “human,” it depicts the concept that each individual man, women, or child (the person) of any race, culture, or ethnic background deserves unconditional respect. The value of human dignity is the ability to have mutual respect for one another as we live together in this world. One would want to remember the “Golden Rule” of treating others as you would want to be treated.

The concept of Altruism is used to depict a genuine concern for the welfare and well-being of others. As defined under the American Dictionary of The English Language, 1992, p. 56 altruism is an unselfish concern for the welfare of others. According to the American Nurses Association (2010), altruism is a core value of every nursing response to provide care to all who are in need regardless of their culture, social, or economic standing” (The American Nurses Association, 2010, p.5).

Altruism is therefore a commitment of every nurse to provide services to others in a selfless way even if it means risking their own safety and health. The welfare of the patient comes first in this line of duty. Chitty & Black (2011) contend that, “practitioners are motivated by service or altruism and consider their work meaningful as oppose to the money made” (Chitty & Black, 2011, p. 66-67). It therefore, follows that health care professionals such as nurses must be dedicated to the ideal of “altruism” to be able to work with the public and the sick patients (some contagious).

Another core value in nursing is the aspect of Integrity. This means acting in accordance with an appropriate code of ethics and accepted standards of practice. The American Heritage Dictionary (1992) defines integrity as the “steadfast adherence to a strict moral or ethical code” (The American Heritage Dictionary of The English Language, 1992, p. 938). Laabs (2011) elaborates that having moral integrity embodies characteristics such as: honesty, trustworthiness, and doing the right thing even when others disagree (Laabs, 2011, p. 433). In addition, a person with integrity “always tries their best to do the right thing, it is not always easy, especially when pressed by time, intimidated by others, not supported in their beliefs, …admitting when one has made a mistake, or has not lived up to one’s moral code and, then doing what one can to make amends” (Laabs, 2011, p. 433).

To put it in a simple way, integrity as a core value of nursing requires that nurses must act and behave ethically, fairly, and honestly in conducting the highest standards of professionalism at all times. Even more important, a nurse commented that, “a person with [moral integrity] will not take short-cuts just because no one else is watching” (Laabs, 2011, p. 434).

The fourth core value of nursing is Autonomy. This term basically means the right to self-determination. The word autonomy is derived from a Greek word Autonomia, which means the condition or quality of being autonomous; independence” (The American Heritage Dictionary of The English Language, 1992, p. 126). According to Varjus, et al. (2011), autonomy may be defined as: The ability to direct one’s own life and to make one’s own decisions… in referring to the profession of nursing, it means the privilege of self-governance and referring to the individual nurses, it means the ability of nurses to make some decisions within their own profession and their right and responsibility to act accordingly to shared standards of that profession.

In addition, Chitty & Black (2011) emphasizes that nursing actions are independent but physicians strongly makes the decisions and supervises many of the nursing activities while nurse practice acts in many states have a role in determining nurses’ actions when authorized by supervising physicians or hospital protocols

Social Justice is the fifth core value in the nursing profession. It means the act of upholding moral, legal, and humanistic principles” Social means “living together in communities, relating to communal living, or relating to society” (The American Heritage Dictionary of The English Language, 1992, p. 1710). Justice on the other hand means upholding of what is just, especially fair treatment and due reward in accordance with honor, standards, or the law (The American Heritage Dictionary of The English Language, 1992, p. 978). In short, social justice is about equality and fairness between human beings.

In a personal communication, January 24, 2012 by Stone a professor at Presbyterian School of Nursing, stated that “as nurses, we are the advocate (fight for patients’ rights, freedom of choice, and equality) for our patients; therefore we question doctors, nurse practitioners, and others about medication dosages etc. when it doesn’t seem right…we speak out for the patients at the bedside when they cannot speak for themselves.” In all, we would build a stronger community and world by “upholding moral, legal, and humanistic principles”.

It therefore goes without saying that at all times; nurses must strive to uphold the aforementioned five core values regardless of the circumstance that they may be faced with. In so doing nurses can be able to treat everyone equally and also be able to put the interest of other before his or hers. This is because the nursing profession is a lifetime commitment to serve others, and all patients as well as their loved ones hold on the commitment of the nurses to adhere to these values. Failure to uphold these values would then result to the public losing faith in the system of healthcare.

Conceptual Explanation of Additional Student Selected Professional Values

It is worth mentioning that nursing is a caring profession. This profession emphasis ices the importance of the caring as it encompasses the connection of nurses with empathy for people. The professional value of caring amongst nurses can only be achieved through the aptitude of nurses to uphold the five core values in the nursing profession; these core values include autonomy, altruism, human dignity, social justice, and integrity. It therefore follows that caring professional nurses have to integrate the aforementioned core values in their day-to-day clinical practice.

Caring as a foundation for relationship is one of the most important professional value as a novice student and as an experienced nurse. Caring is defined as “the provision of what is necessary for the health, welfare, maintenance, and protection of someone or something” (Oxford Dictionaries, 2012). Furthermore, Suliman, et al. (2009) describes caring as a foundation for relationship upon using Watson’s theory on human caring relationships in suggesting that caring is centered on helping the patient in achieving peace within in the mind, body, soul, and through a transpersonal caring relationship.

As Chitty & Black (2011) elaborates on caring, they state that “nurses are encouraged to share their genuine selves with patients while the patients’ spiritual strength is recognized, supported, and encouraged…which leads to development of trusting and accepting relationships which feelings are shared and confidence is inspired ” (Chitty & Black, 2011, p. 309). In all, caring is one of the significant reasons why novice students choose nursing as a career path.

According to Sulimen et al. (2009), there are several caring behaviors which nurses should observe at all times. These behaviors include: appreciating the patient as human beings, showing respect for the patient, being sensitive to the patient, talking with the patient, treating information confidentially, treating patient as an individual, and listening attentively to the patient. (Sulimen et al., 2009, p. 294).

Public Figures Exemplifying Core Values

A public figure who exemplifies these core values of altruism, autonomy, human dignity, integrity, and social justice would be my local pharmacist who dispenses prescription medications to patients. Pharmacists aid the general public in answering questions to medication dosages, over the counter products, and to promote health. Pharmacists work in the healthcare field as well and they collaborate with doctors, nurse practitioners, and other health interdisciplinary for the well-being of the patients.

In comparison with the health profession of nurses, the pharmacist profession embodies their own values and beliefs with similar core values that were established in 1852 (founded by the American Pharmaceutical Association). The American Pharmacist Association (APhA), which is the first and largest association of pharmacist in the United States (American Pharmacists Association, 2012). It is worth noting that even the American pharmacists have some code of ethics which they ought to uphold at all times and they are set out under their preamble. Some of these values include inter alia respect of the relationship between the pharmacist and the patient; the pharmacist must also ensure that patients get the right medication, uphold their trust, and committed to safeguard the welfare of the patients.

• The pharmacist must also ensure that patients get the right medication, uphold their trust, and committed to safeguard the welfare of the patients.
• The pharmacists should also observe patient pharmacist confidentiality
• He must also uphold the dignity and autonomy of the patients.
• In his professional relationship a pharmacist should uphold the core values of integrity as well as honesty.
• Professional proficiency must also be observed at all times.
• They should also show respect to the abilities and values of other health practitioners and fellow pharmacist.
• They must be ready to sever all persons in need of their services at all times
• It is the responsibility of every pharmacist to uphold social justice in his professional services.

The American Pharmacists Association’s (APhA) is very similar to the American Nurse Association’s (ANA) core values of nursing. There are several professional core values that are shared by both the nursing and pharmacists professions such as altruism, autonomy, human dignity, integrity, and social justice. Both work in the health care industry and they work to promote health and well-being of the patient. Often a time, they collaborate with each other to bring all of these five core values together as one.

Life Experience of Core Values (Include Cultural Impact Perceptions)

Autonomy– “the right to self-determination”.

Life experiences of autonomy, as a teenager is a duty and not an option in my culture, especially being the eldest girl. I had the responsibility of making decisions on my own, monitoring my siblings as they do their homework, bathing them, and cooking for them. Being the eldest amongst my siblings, every decision made is always looked at with consequences; therefore, one would have to make decisions wisely. As a daughter, one would have to take care of the younger siblings and to help clean and cook around the house. Housekeeping chores are given to the oldest and to the girls. Boys are considered much more important in the family and so they do not have to do anything.

Additionally, in the Hmong culture, we emphasize a more collective approach to decision making which involves the eldest to the extended family members. For instance, if my parents wanted a divorce, both would have to consult the elders to come together and talk about issues. Decision making in this situation is based on the elder’s ruling. The majority of elders will the parties to reconcile and eliminate the chances of a divorce. In all, autonomy in the Hmong ethnic background particularly in decision making is complicated especially among the young generation which is accustomed to the Western’s way of life and decision makings.

Human Dignity — “respect for the inherent worth and uniqueness of individual care”

There are instances where life experience of human dignity would arise such as an opportunity to feed the poor through a church program. In such instances, the Hmong United Methodist Church youth members have the opportunity to make sandwiches and to feed the less fortunate at the Uptown Shelter. This life experience was an eye-opener for me as a young adult. The act of feeding the poor and to serve those in need is an experience that is geared toward achieving human dignity across all social and cultural status and respect for one another regardless of race, color, and sex. In the end, we are all human beings in search of something-love, respect, shelter, self-esteem (using Maslow’s Basic needs).

Altruism–“a concern for the welfare and well-being of others”

The aspect of altruism cut across all aspects of human life from work place, school, or even in the family. In the Hmong culture, the oldest son in the family is the one who is responsible for looking after the elderly parents but since we live in American where the cultural setting is different, some of these traditional practices are not strictly followed. That notwithstanding the Hmong culture emphasizes the responsibility of the children to their parent or the elderly in the society which is clear indication altruism.

Consequently, care and respect for the elders by the young generation is highly emphasized and practiced in the Hmong culture. Altruism may also be reflected through voluntary work such teaching young children in their elementary education. My work experiences include working as a pharmacy technician, phlebotomist, nursing assistant, and a nursing student (clinical) at Presbyterian School of Nursing. All of the above work experiences involve the core value of altruism.

Clinical Examples of Core Values

Human dignity.

An example of human dignity in nursing is treating all persons with equal respect and giving them adequate care regardless of their social status, race, sex, color or religious and political affiliations. All patients must be treated as one would treat his or her loved ones. Another example of this core value is knocking on the patient’s door before entering the patient’s room. Even when they are not well or cannot answer, one should preserve the patient’s dignity. We have to respect our patient all the time because the space has become their home or their environment.

A clinical example of altruism as a core value of nursing may include nurses putting themselves in the way of patients who may be physically aggressive for purposes of safeguarding the wellbeing and safety of other staff and other patients. It can be also demonstrated through taking care of patients with contagious diseases such as TB, MRSA and others diseases like HIV. In addition, this value may be demonstrated through checking the safety of all patients when the nurse clocks in on duty. The student nurse should make sure that the bed is in the lowest position with the call bell at the patient’s side. The student nurse will evaluate the room to see if there are rugs or clutter in the room to prevent falls or injuries. These are an example of altruism because the patient’s welfare and safety is the priority of the student nurse when she starts her shift for the day.

Some clinical example of integrity in the clinical setting is abiding by the hospital protocols and OSHA regulations. As a student nurse, one would want to follow aseptic technique when inserting a Foley Catheter even when the instructor is not around. A student nurse should wash his or her hands before getting into contact with any patient. This is upholding the core value of integrity. Taking care of patients belonging without misplacing or destroying them is also another clinical example of integrity in the nursing profession.

Nurses have the responsibility to give their patients all the facts and consequences of their health choices and give them the opportunity to decide the procedure they would want to take. This is an indication of autonomy in the nursing profession. As a student nurse in clinical, we are not licensed yet but we are allowed to have some decision making in the order of selecting patients in doing a health assessment and checking patient vitals. One could do it in any order but in a systematic way and chart it in the computer system so that the registered nurse could administer medications to patients accordingly.

Social Justice

An example of this core value in clinical would be when a student nurse stands up for a patient who may not be able to speak fluent in English. That patient may require a translator while the doctor is making his rounds to the unit. As a student nurse, one should immediately call to see if there is a translator available for the next doctor round before the patient is discharge. It is therefore the responsibility of the nurse to arrange for a translator to facilitate decrease the frustration of language barrier and increase a better understanding of the patient as a whole (culturally). Language barrier should therefore not be a reason to deny a patient his or her right to quality health care and that is where the exercise of the core value of social justice comes into play.

Summary and Reflection

Each person in the nursing program has various reasons of becoming a nurse. Some examples such as personal, job security, professional education (science), or just love to be around people. Each one of us has decided to take on this life long journey. In an effort to achieve the mission and vision of the nursing profession, every nurse commits to observe and adhere to the five core values necessary for taking up a career in nursing.

These core values include human dignity, altruism, integrity, social justice, and autonomy. Even though there are many other values that ought to be observed in the nursing profession, the aforementioned values form the basis of this profession and they should be upheld at all time regardless of the circumstances. Indeed, these core values help to guide novice students and practitioners in the nursing profession. It should also be noted that culture has a vital role to play in evaluating personal values and trying to reflect on the five core values of this paper.

The nursing career is a demanding profession and it is forever changing in a time of new technologies, but the core values of altruism, autonomy, caring, human dignity, integrity, and social justice will stand firm. These values cannot be separated from a truly professional nurse.

American heritage dictionary of the English language. (1992). Altruism. Social justice, human dignity, integrity, and autonomy. Boston, MA: Houghton Mifflin Company.

American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Nursebooks. Web.

American Pharmacists Association. (2012). Code of ethics for pharmacist.  Web.

Chitty, K., & Black, B., (2011). Professional nursing: Concepts and challenges . St. Louis, MO: Saunders/Elsevier.

Laabs, C., (2011). Perceptions of moral integrity: Contradictions in need of explanation.  Nursing Ethics, 18(3), 431-440. Web.

Oxford dictionaries. (2012). “ Caring.” Oxford University Press. Web.

Suliman, W., et al., (2009). Applying Watson’s Nursing Theory to Assess Patient Perceptions of Being Cared for in a Multicultural Environment. Journal of Nursing Research (Taiwan Nurses Association), 17(4), 293-300.

Varjus, S., et al., (2011). Professional autonomy of nurses in hospital settings-a review of the literature. Scandinavian Journal of Caring Sciences, 25(1), 201-207. Web.

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