Our experiences with patients or populations, and the communities in which they live, ought to be the impetus for making our primary responsibility the practice and research that enables healthy policy change and identifies innovative strategies for addressing the social determinants of health. -Betty Bekemeier
Research increasingly suggests that when nursing and other health-related sciences focus their attentions on the social determinants of health, we will achieve improved health status and greater health equity in the populations we serve. This focus requires an “upstream” approach. Upstream approaches refer to an analogy used in the United States for describing efforts focused on primary prevention and addressing root causes of disease and disability. This upstream analogy addresses the underlying issues that cause “downstream” problems rather than going to great lengths to address fully developed and ongoing crises downstream. Many of us in nursing are in downstream positions, researching questions and working with programs that relate to caring for acutely at-risk, vulnerable families or communities and without a focus on activities that would drive a movement from downstream work to upstream measures that change harmful systems instead of responding to their negative outcomes. Our present emphasis on downstream approaches occurs, in part, because of the complexity of addressing social conditions that impact health from upstream and, in part, because of our traditional conceptions of “care.”
Nurses can be natural leaders in addressing the social conditions that impact health, given our holistic perspective on health, our intimate experiences with individuals and communities that provide a unique view of the outcome of social forces such as poverty and failed policies, and our “skills in fostering health protection at the individual and collective level” (Butterfield, 2002). Focusing our research and practice pursuits on the underlying causes of poor health status and health disparities requires an upstream perspective that brings nursing (back) into the realm of policy analysis, social reform, environmental health, sociology, and international health.
Nursing education and research reinforce traditional caring models of service and have dissuaded us from acting to create and support policies that assure “healthy conditions,” from researching root causes of poor health, and from changing the systems that overspend health dollars on illness rather than prevention. Nurses tend to be educated in theoretical models of “service” (not advocacy), thereby focusing practice on caring for individuals in need. A study conducted by Rains and Barton-Kriese (2001) of baccalaureate nursing students nearing graduation found that nursing students “did not see connections between the personal, professional, and political. Nursing seemed grounded in application and service.” Similarly, nursing research generally works to substantiate what is done rather than what could be different and, as a result, reinforces a distance between the tasks of service-oriented nursing work and the complexities of social change. Instead, nursing research could focus on that which challenges political structures that oppress, employing a critical paradigm that is more interested in how data can be used for social change than the extent to which it is scientifically compelling (Ford-Gilboe & Campbell, 1995, p. 22).
Nursing scholarship around the analysis of care cannot be apolitical when contrasted with the politicized systems in which nurses practice today. Thankfully, opportunities do exist to participate in an emerging critical discourse on caring that expands the notion of caring as the “core” of nursing and envisions a more “emancipatory practice” in which nurses participate in communities in a caring paradigm different from that in which we were taught (Stevens 1992). In exercising a practice of caring that joins with vulnerable populations and with each other, we can respond to the complex problems of social inequities through the “collective” action and participatory research, which these problems require (Beauchamp 1975, p. 276). This future could be ours with a collective commitment to social change, political participation, and expanded notions of caring.
While improving the health of the few, we may serve as individuals, as nurses we are complicit in the illness and death of many. Alternatively, our experiences with patients or populations, and the communities in which they live, ought to be the impetus for making our primary responsibility the practice and research that enables healthy policy change and identifies innovative strategies for addressing the social determinants of health. Surely, barriers exist in nursing theory, education, and research that have inhibited support for this expectation of ourselves. For us to be effective, however, in assuring healthy conditions for all populations, the caring practice of nursing necessitates participation in the political process and challenging imbedded social systems and powerful interests (Beauchamp 1975, p. 278). The public should (and perhaps does) expect this of us. We should also expect this of one another.