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As nurses, we can advocate for health equity and equality for our vulnerable patient populations.

By Mary Atkinson Smith, DNP, FNP-BC, FAANP, FNAP

The promotion of

social justice

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In today’s complex and constantly changing healthcare environment, nurse leaders are focused on patients having adequate access to safe, high-quality ser- vices. They’re also working to decrease hospital readmissions and medical er- rors through the promotion of teamwork and implementation of evidence-based clinical practice guidelines, especially considering the abundant policy changes pertaining to the funding and reimburse- ment of healthcare services. With these topics taking precedence, nurse leaders must remain mindful of the importance of promoting social justice in healthcare.

This article focuses on social justice and its role in improving patient out- comes and enhancing overall population health, particularly among vulnerable populations.

Understanding justice In general, the term justice refers to “a set of universal principles” that “guide people in judging what’s right and what’s wrong, no matter what culture and society they live in,” according to the Center for Economic and Social Jus- tice. Treatment should be fair, equitable, and appropriate, regardless of what an PR

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individual has contributed or earned. Justice is one of the four principal philo- sophical virtues (also referred to as moral or cardinal virtues) that include pru- dence, temperance, and courage. Injustice refers to an individual being deprived, by law or by another individual, of that which he or she is owed.

Justice serves to respect individuals’ rights whether they’re natural or legal in nature. Natural rights don’t depend on cultural or governmental laws; they’re universal and considered to be inalien- able because they can’t be repealed or restrained based on human laws. Natural rights include life and liberty, the pursuit of property and ownership, independent thought and speech, free will and choice, personal beliefs and values, and socializa- tion and relationships.

Legal rights are derived from a spe- cific legal system and differ by state and country. Not a set of universally accepted rights, they can be modified, repealed, or restrained based on human laws. Legal rights include statutes or regulations estab- lished by a legislative body, such as the

dispensing and use of medical marijuana or the Medicaid structure in various states in the US. On an international level, legal rights include the overall structure of each country’s healthcare system, such as the national health insurance model in Canada.

From the standpoint of legal rights, if a healthcare system isn’t structured effectively and fairly, it may promote eas- ily accessible and higher-quality care for the wealthy while poorer citizens become sicker due to the lack of affordability and accessibility.

Social justice in healthcare In healthcare, the term social justice is generally defined as the goodness guid- ing the development of institutions that are social in nature and provide access to beneficial services from the standpoint of health and wellness. When structured in a morally fair fashion, socially organized healthcare institutions work together to provide citizens with resources that are meant to positively advance the health and common good of society. For this to be the case, healthcare institutions must be balanced in a way to avoid monopo- lies that create unfair barriers, leaving vulnerable populations unable to obtain needed health-related services.

Social justice in healthcare may have different meanings to communities, states, and countries; however, it’s widely accepted that good health is needed for individual well-being, which includes seeking comfort, feeling content, and striving for joys in life. Social justice serves to promote the distribution of healthcare resources in a way that benefits marginalized or vulnerable populations while being mindful of more privileged populations. The overall goal of social jus- tice is the promotion of impartiality.

Vulnerable populations A discussion of social justice in health- care isn’t complete without a discussion of vulnerable populations. Geographic

did you know?

Ethics in healthcare

The 1978 Belmont Report, which detailed the egregious ethical issues related to the Tuskegee Syphilis Study, provided a summary of core ethical principles and guidelines related to the process of researching humans. The three core principles identified by the report are respect for persons, beneficence (doing good for oth- ers), and justice, which are still the basis for human research subject protections. In 1979, the textbook Principles of Biomedical Ethics was published, identifying the four principles of biomedical ethics as beneficence, autonomy (right of an individual to decide), nonmalefi- cence (do no harm), and justice.

Sources: Beauchamp T, Childress J. Principles of Biomedical Ethics. New York, NY: Oxford University Press; 1979. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont report: ethi- cal principles for the protection of human subjects of research. 1978. www.hhs.gov/ohrp/regulations-and-policy/belmont- report/index.html.

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region, socioeconomic status, education level, age, and psychosocial or physi- ologic state don’t solely determine vul- nerable populations. The continued rise in healthcare costs, a lack of affordable healthcare, and shortages of healthcare providers all contribute to restricted access to care. The term vulnerable popula- tion may also refer to individuals who are at higher risk for experiencing poor health outcomes regardless of the pres- ence of demographic risk factors. For example, individuals who are uninsured or underinsured may also be considered a vulnerable population because their access to care is limited, contributing to poor health outcomes.

The word vulnerable itself recently came under scrutiny. In December 2017, the US Department of Health and Human Services was instructed to avoid the use of certain words such as “vulnerable” when preparing documents to support budgeting requests for 2019, except when referring to a legal citation or in an exist- ing title. The reason for this terminology change was given by a Department of Justice official as “intended to be more accurate and better reflect Justice Depart- ment priorities.”

This is an example of how influen- tial linguistics can be. Ten US Senators drafted a letter to the acting secretary of the Department of Health and Human Services requesting more clarification on the linguistic restrictions while stating “words matter.” In addition, 315 public health organizations requested an expla- nation, stating that it’s difficult for the CDC to support its mission of advancing health and safety in America when its staff members are encouraged to avoid the use of foundational words.

In general, everyone is at risk for vul- nerability at some point in their lives. No one is immune to unexpected illness, domestic issues, or unemployment, which are all life experiences that can increase vulnerability and negatively influence

health status. Research has shown that individuals who lack sufficient access to healthcare services are more likely to experience negative health outcomes. Various frameworks have emerged that identify similar traits (age, gender, race, and socioeconomic status) and experi- ences (illnesses and traumatic life events) among vulnerable populations that increase the risk of poor health choices and outcomes.

The three factors that have contrib- uted to the growing number of vulner- able populations in the US include an increasing prevalence of chronic medical conditions, such as diabetes and heart disease; a major shift in population demographics pertaining to growing income inequality and aging baby boom- ers; and a decrease in supportive and

key points

Promoting social justice in healthcare

• Identify a specific health disparity or inequity in your practice area.

• Gather evidence-based research about the health disparity/inequity.

• Determine the health disparity/inequity’s economic impact.

• Speak out either verbally or in writing about your findings.

• Collaborate with stakeholders who have an interest in addressing the health disparity/ inequity to determine viable solutions. Keep in mind that stakeholders may be patients who are directly impacted by the health dis- parity/inequity.

• With key stakeholders involved, develop a short- and long-term strategy to address the health disparity/inequity.

• Begin developing and establishing respect- ful relationships with key legislative staff and lawmakers who have an interest in the health disparity/inequity. Keep in mind that they may be on a local, state, or federal level.

• Always keep a positive attitude and an open mind to the thoughts of others while remain- ing persistent and passionate about promot- ing social justice related to health disparities and inequities.

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supplemental resources in lower-income communities.

Health disparities and equity Health disparities are specific differences in population health related to occupation/ income, education, and less representa- tion at higher levels of political office. Disparities may also be seen among indi- viduals with certain demographic factors, such as age, sex or gender, race/ethnicity, sexual orientation, disabilities, immigrant status, and geographic region. Health dis- parities have a specific relevance to social justice because they can develop from in- tentional or unintentional marginalization or discrimination.

Health disparities are increasingly being referred to as health inequalities—the opposite of health equity. Inequalities lead to the development of barriers that limit access to opportunities that promote and support high levels of health. It’s thought

that the term health inequality is better at delineating the differences in health that are due to a lack of social justice rather than general health differences.

Health equity itself is the hallmark of social justice in healthcare because it focuses on reducing health disparities, striving for everyone in society to have the same opportunity when it comes to attaining the greatest level of health. The four overarching goals of Healthy People 2020 serve to minimize health disparities and advocate for health equity in the US: 1. elimination of health disparities and attaining health equity while improving the health of all individuals in society 2. attainment of high-quality healthcare and living longer while avoiding pre- ventable diseases and injuries that lead to disability and premature death 3. creation of social and physical condi- tions that foster desirable health for all individuals

consider this A nurse practicing in a rural clinic notices a common health disparity among patients with chronic obstructive pulmonary disease (COPD) as it relates to their ability to access chronic care management services due to the lack of sufficient and reliable transportation from their homes to the clinic. Most of the COPD patients experiencing this issue are over age 65 and dual eligible beneficiaries, which means that they’re covered by both Medicare and Medicaid due to their age or being disabled and being considered as having a low-income based on state eligibility requirements.

The nurse decides to gather qualitative, sub- jective responses from the patients regarding their access to reliable transportation and finds a common theme among the responses regarding lack of reliability in the designated Medicaid- funded transportation. From this information, the nurse quickly realizes that the lack of reliable transportation is playing a major role in patients missing their clinic appointments. The nurse has also discovered an increase in ED visits and hos- pital admissions among these same patients.

The nurse decides to put her findings and concerns in writing and share them with her local elected officials who serve in the state legislature, in addition to the director of Medicaid, a state-wide advocacy group that focuses on improving the quality of life for older and disabled individuals, and an orga- nization that promotes accessibility of rural healthcare throughout the state. This leads to many of the Medicaid-funded transporta- tion agencies being investigated for quality and reliability, which ultimately leads to the development of a policy that requires Medicaid transportation contractors to meet certain reli- ability and consistency criteria for dual-eligible beneficiaries to attend their health clinic appointments. The nurse is appointed by the governor of the state to oversee a taskforce for addressing health disparities among rural dual-eligible beneficiaries who are older and disabled with a chronic health condition that requires routine assessments for effective management to avoid increased and unneces- sary healthcare spending.

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4. promotion of quality of life with healthy development and behaviors throughout the lifespan.

Highlighting the social determinants of health through a population health model can further highlight the influence of social justice on the health outcomes of different populations.

Social determinants and population health Social determinants of health are “condi- tions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of- life outcomes and risks,” according to HealthyPeople.gov. Population-focused healthcare involves the use of various population-based assessments related to epidemiology and community as the foundation for intervention and preven- tion. The use of a community-based, population-focused model is guided by the specific characteristics and needs of the individual community, which is particularly useful when developing pro- grams to address needs related to shelter, nutrition, healthcare access, or workforce training.

Pairing the social determinants of health with a population health focus isn’t a novel approach to identifying the fac- tors that influence health outcomes. The impact of social determinants of health on the health status of individuals has been consistently researched over the last 40 years and is well established in the population health model. According to the Robert Wood Johnson Foundation, the foundation of health begins in a com- munity’s neighborhoods and schools and in the homes of individuals, which means there are both social and economic factors that impact the health of populations. The population health model addresses the social determinants of health in a collab- orative fashion where multiple disciplines intersect to collect social science data that

can be correlated and integrated with data from the biologic sciences.

Implications for nursing Nurses are well-respected and highly trusted leaders who are in the ideal po- sition to advocate for social justice in healthcare. It’s important that inequalities in access, delivery, and outcomes are con- sidered when developing health policy. The legislative and regulatory aspects of healthcare continue to evolve on all gov- ernmental levels: local, state, federal, and international. One aspect that remains the same is people are what healthcare is about. The basic needs of the people don’t change, including the need for healthcare.

The inclusion of social justice in health- related policy development serves to drive initiatives that are beneficial for all members of society. Health equity and equality are a common byproduct of social justice that offer opportunities of sufficient access to healthcare resources while improving health outcomes. With nurses being the largest group of health- care professionals, it makes sense that we should be advocates for social justice in healthcare. ■

For more on advocacy and policy develop- ment, see our next issue.

REFERENCES

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Braveman PA, Kumanyika S, Fielding J, et al. Health dis- parities and health equity: the issue is justice. Am J Public Health. 2011;101(suppl 1):S149-S155.

Center for Economic and Social Justice. Defining economic justice and social justice. 2017. www.cesj.org/learn/ definitions/defining-economic-justice-and-social-justice.

Eilperin J, Sun LH. Trump administration targets certain words, and the bureaucracy pushes back. The Washington Post. 2017. www.washingtonpost.com/national/ health-science/trump-administration-targets-certain- words-and-the-bureaucracy-pushes-back/2017/12/20/ 3c9bc6c4-e42e-11e7-ab50-621fe0588340_story.html?utm_ term=.38cfcea22c30.

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Garcel J, Ward E, Rodrigues L. Vulnerable populations: a tale of two nations. In: Knickman JR, Kovner AR, eds. Jonas and Kovner’s Health Care Delivery in the United States. 11th ed. New York, NY: Springer Publishing Company; 2015:149-179.

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Mary Atkinson Smith is an NP at Starkville (Miss.) Orthopedic Clinic, a Clinical Associate Professor of Nursing at Sacred Heart University in Fairfield, Conn., Founder of Nurses Lead, and a Master’s in Health Law and Policy Student at Samford University in Birmingham, Ala. Contact her at mary@nurseslead.com.

The author has disclosed no financial relationships related to this article.

DOI-10.1097/01.NME.0000553091.78584.a9