History has shown that the nursing profession has done much to enhance population wellbeing through the understanding of social determinants of health (SDoH) (Stewart-Fahs, 2017). SDoH are defined by the World Health Organization (WHO) (2019a) as:
‘The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.’
As nurses witness the poor health associated with SDoH, they are uniquely placed to recognise the growing causative factors. In doing so, nurses play a significant role in reducing the impact of social injustice by becoming actively involved in ensuring that appropriate services are commissioned (Royal College of Nursing (RCN), 2012). This can be achieved, for example, through the process of shared decision making, an approach that allows patients and health professionals to work collaboratively to decide the most appropriate care provision based on the best available researched evidence and the patients informed preferences—a process ultimately linked to improved health outcomes (Coulter and Collins, 2011).
By prioritising nursing research and understanding the impact of the SDoH, the nursing profession is in a strong position to recommend health policy and develop collaborative learning opportunities with a variety of professionals, including police services, social workers, public health strategists and fire fighters, in a combined effort to address the significant harm caused by SDoH (Olshansky, 2017). However, this requires nurses to be knowledgeable of wider SDoH, an understanding which should be integrated into all clinical courses (Olshansky, 2017). It is clear that the nursing profession is considered an influential component of healthcare delivery—one which is also able to positively affect national economic growth (International Council of Nurses (ICN), 2017). Nurses, argues Hughes (2017), also have the potential to be influential ‘change agents’ and innovators for societal health and wellbeing; furthermore, by becoming increasingly politically active and ‘professionally assertive’ they are leading the way towards health system improvements.
Nursing on a global scale
Contemporary nursing practice is now the focus of global governments, as evidenced in the Nursing Now Campaign (Crisp and Iro, 2018), and as 2020 is the Year of the Nurse and the Midwife (WHO, 2019b), this can be the time when nurses become global influencers. This will require collective action to challenge the inequality, exclusion and injustice embedded in oppressed societies (Millward and Takhar, 2019). Nurses undertaking collective action are in a strong position to drive forward the global covenant: to promote and maintain quality patient care and holistic healing (Watson, 2018).
History has shown that the nursing profession has done much to enhance population wellbeing through understanding of social determinants of health
However, nurses must shake off their role as ‘functional doers’—those who act on the instructions of others—and instead become ‘thoughtful strategists’—those whose independent actions are based on education, evidence, and experience (Institute of Medicine, 2011). It has been argued that nurses need to actively commit to renewing the vigour of those who are burnt out and dispirited (Watson, 2018), a scenario that, as Cañadas-De la Fuente et al (2015) argued, is becoming a global concern. Nurses and the public need to connect with and energise their enthusiasm (Watson, 2018), and subsequently create an optimism for results and ingenuity.
According to WHO (2018), nurses and midwives constitute 50% of the global healthcare labour force. Furthermore, as nurses undertake the majority of direct patient care, nursing is in a uniquely strong and powerful position (Hemingway and Bosanquet, 2018) to influence leadership, empower communities and inspire change (RCN, 2012). From this standpoint, nurses can develop leadership and political activism—both are considered important aspects of every nurse's role, and this is a stance taken by the ICN (2017).
However, many nurses do not see themselves as leaders and political activists—a position that is often considered too far removed from everyday working life (Rouse, 2007). Nevertheless, this is an essential skill which all nurses must develop in order to protect their practice and the nursing profession as a whole (Rouse, 2007). This is supported by Barbara Stilwell, executive director of the Nursing Now Campaign, who said that nurses must see beyond their roles, but towards self-advocacy; otherwise they are likely to become trapped in their self-generated bubble (Agnew, 2018).
One way this could be achieved is through policy development, but nurses are severely underrepresented in this area (Nelson, 2016). It is with this in mind that nurses seek to understand and become engaged with collaborative policy work (Burke, 2016). Despite advances in healthcare delivery and technology, significantly less advancement has been made in addressing the impact of wider SDoH (Olshansky, 2017).
It's time to change the rhetoric
A recent report by the UK Government (Public Health England (PHE), 2018) sought to create a better understanding of the social, environmental, and cultural influences on health and wellbeing. Supporting the WHO (2019a) definition of SDoH, the nursing profession is in a strong position to lead on health improvements by linking SDoH outcomes with analysis and action in order to bring about desperately needed changes in policy (Olshansky, 2017). Such actions, argue Chinn and Kramer (2018), require a praxis approach, which they opine occurs on both an individual level—an understanding of the conditions that unfairly restrict personal capacity and involvement— and as a collective endeavour—requiring reflection and action in collaboration with others involved in bringing about both social and political change.
At a singular level, this is a process through which nurses can recognise, reflect and act on circumstances that unfairly limit their own and others capacities, and take action to change the circumstances that lead to social injustice. As a collective undertaking, this requires reflection combined with action, and working with others who seek to bring about both political and social change (Chinn and Kramer, 2019).
Historically, nurses and midwives have supported the most vulnerable communities in society (Mitchell, 2012). However, rather than nurses demonstrating the strong leadership skills so desperately needed to bring about sustained positive change, Thorne (2018) suggested that nursing systems, both nationally and internationally, are ‘breaking down and need urgent attention’—this stance being ‘reflected in a number of recent calls for strengthening the collective capacity of nursing’.
Nurses in senior positions should act to support fellow nurses to become politically motivated, actively involved in health law and to access leadership roles, all of which can ensure that the voices of nurses are heard, especially by those in influential positions (Woodward et al, 2016). The importance of these actions should not be underestimated, and a collective voice is a central tenet of public trust (Thorne, 2018). All nurses are considered to have a vital role to play in creating a global nursing voice at every level (ICN, 2017). A further way in which this could be achieved is through nurses becoming ‘thought leaders’ (Shattell and Darmoc, 2017).
Public thought leaders and social media
Through the use of social media, nurses are in a strong position to influence both policy and the public using their authority, credentials and professional roles (Shattell and Darmoc, 2017). In doing so, they should consider becoming public thought leaders. Although this may sound like something unfamiliar, becoming a thought leader simply means to harness expertise and appreciate its value to a wider audience (Shattell and Darmoc, 2017).
One potential means of accomplishing this is for nurses to create alliances outside of nursing and reach out to those who are champions of healthcare delivery, for example younger physicians and other health professionals. The nursing profession must seek to maintain professional associations—those connections where nurses’ opinions on health and public policy are expressed with vigour and determination (Thorne, 2018). This could be achieved through the development and use of social media. Social media is now well entrenched in our culture, as well as in knowledge gathering and information sharing strategies. It has transformed the way in which our society communicates, and its advent has precipitated an increase in activism (Barry and Hardiker, 2012; Kende et al, 2016).
The use of social media therefore can empower nurses to develop conversations and create networking opportunities, and as a result the possibilities for creating support and solidarity have increased significantly (Traynor, 2017). It is important to note, however, that there are some valid concerns around so-called ‘clicktivism’ not being a form of authentic activism (Lawless, 2015). However, clicktivism can be defined as the use of the internet and social media to create, for example, petitions or to organise protests, all with the intention to achieve a political aim (Cambridge Dictionary, 2019). This type of perceived activism has raised many questions about whether the use of social media can in fact lead to meaningful change (Sormanen and Dutton, 2015). Nevertheless, what can begin as a local action with a few actively taking responsibility has the potential to result in change (Dodgson, 2019). It is important to note that E-professionalism (Cain and Romanelli, 2009) is an essential element of social media use. Nurses in particular must be aware of the importance of using social media safely and professionally (Nursing and Midwifery Council, 2019).
Social media platforms have the capacity for mass collaboration, through which people can become a source of new ideas and innovations (Loader and Mercea, 2012). In the nursing profession, this can encourage nurses to reflect and act on new knowledge, and it can become an invaluable communication tool in developing nursing leadership (Flury, 2017).
‘Through the use of social media, nurses are in a strong position to influence both policy and the public using their authority, credentials and professional roles.’
Nursing work is often dictated or controlled by those who are far removed from everyday practice. Encouragingly, ‘social media is acting as a democratising force empowering nurses to overcome these oppressive structures through community action’ and by using social media wisely, nurses can strengthen opportunities for increased democracy and voice, ensuring productive and effective change becomes a reality (Traynor, 2017: 140).
Conclusion
Through their collective actions, nurses have the potential to reduce or even eliminate the impact of SDoH, although it is evident that this requires a considered and global collaborative approach. However, while the nursing profession continues to be failed by archaic, oppressive policies—an example of this is the continued reluctance to ensure the role of the ward leader (within the NHS) is a supervisory one (RCN, 2016), a cause previously championed by Robert Francis (2013)—it could be argued that the nursing profession cannot adequately prepare nurses for leadership early in their professional roles, and therefore it could be particularly difficult to make significant inroads into tackling the challenges that face the nursing profession. Therefore, nurses must seek to change the rhetoric, and one way to do this, as Taylor (2010) argues, is for nurses to recognise the importance of adopting an emancipatory reflective approach to change, a process through which, nurses can, by undertaking a profound and structured analysis of their work, free themselves from assumptions and oppressive forces which limit professional practice, allowing transformative action to take place (Taylor, 2010).
KEY POINTS
- Nursing is considered a global profession and the focus of many governments regarding healthcare reform
- The negative impact of the social determinants of health continue to exist and perpetuate health inequalities
- The nursing profession can take positive action to reduce this impact
- A global covenant is needed to capture the impact of nursing actions
- Through collective action, nurses can and do achieve great things