Calling all nurses to action! Everyone keeps saying that the healthcare system is broken, and I would agree. We have huge disparities between clients in the care they receive. These disparities are often based on race, ethnicity, socioeconomic status, and zip code (Ritchie, 2013). It has been estimated that 80% of the factors that contribute to health happen outside the walls of healthcare. We have clients struggling with food insecurity, housing insecurity, and huge deductibles on their healthcare plans. These clients are forced to make impossible choices. These are "individuals who lack the economic resources to purchase goods and services; who reside in neighborhoods with high concentrations of poverty and crime, along with limited green space and available neighborhood grocery stores; and who are at risk for adverse health outcomes" (Murray, paragraph 1, 2018).
Resources needed for health are not limited to access for medical care, but include health-promoting physical and social conditions in homes, neighborhoods, and workplaces (Murray, 2018). As Islam has noted, "social determinants of health are the conditions or circumstances in which people are born, grow, live, work, and age. These conditions are shaped by political, social, and economic forces" (Islam, paragraph 2, 2019). There continues to be a growing recognition of the relationship between neighborhoods and health, with one's zip code understood to be a stronger predictor of health than genetic code. More initiatives, from a variety of sources, focus on implementing coordinated strategies across different sectors in neighborhoods having social, economic, and environmental barriers that lead to poor health outcomes and health disparities (Artiga & Hinton, 2018). It is time that we nurses return to our nursing roots and take back health in our care settings!
It is no longer acceptable to roll one's eyes at clients who go to the Emergency Department (ED) for primary care, because the reality is that they have nowhere else to go. We have millions of Americans covered by Medicaid and next-to-no healthcare providers taking new Medicaid clients. Some providers list on their websites that they participate in Medicaid; yet when one makes a few calls, one discovers that these providers are rarely are accepting new clients. Additionally, clients with complex social needs will require more than a 15-minute appointment. We, as providers, need to advocate for a payment structure that reimburses us for delving into concerns of these complex clients. We need to get paid for the time and energy it takes to help clients with struggles they face, rather than being paid only for procedures.
We can no longer give people a packet of discharge instructions written in medical jargon, instructions that they may or may not be able to read, even though these instructions are, supposedly, written at the sixth-grade level. Such situations cause me to ask: when did they start teaching medical terminology in the sixth grade? Our clients often do not understand our instructions.
Additionally, we frequently fail to ask whether or not they have transportation to see the specialist that we have recommended; whether they have food to take with their medication; and whether they have to choose between putting a meal on the table for their children or taking these medications. Nor do we generally let them know how much money the specialist is going to require at the time of their visit. Far too often, when the client, who did not have the ability to do what we recommended, comes back, we label the client as non-compliant and the client receives marginal care. We have to stop judging people and begin to partner with them to bring about the change in healthcare they want to achieve.
We have nurses employed in traditional and nontraditional environments, acute care settings, outpatient settings, and the community; and we ALL have the opportunity to make an impact on a client’s health. We need motivation to be the change that we know needs to happen. We need to fight for equality in healthcare and make our payers and providers accountable for the value clients receive from their healthcare. It is no longer acceptable for clients who have experienced adverse childhood events not to be screened for chronic health conditions, such as lung cancer or chronic obstructive pulmonary disease, knowing they are more likely to have these conditions due to the toxic stress they experienced as a child.
People are not coming to the ED simply because it is convenient. Often, the provider who knows them could not see them, or they do not even have a care provider who knows them. Camden Coalition found that 1% of clients use 30% of the healthcare dollars spent in their area (Noonan & Craig, 2019). As providers we should be working overtime to impact the health of this 1%, to save healthcare dollars that could be better spent elsewhere. If we had a healthcare system that advocated for health, rather than focusing on illness and disease, and one that addressed social determinants of health, we could save healthcare money.
As healthcare providers, we need to begin to care about clients’ basic needs and to ask whether they have adequate food and housing, and if they experience personal violence. We need to help them make necessary connections to local resources to improve their situation. Participation in the above care activities is not only the responsibility of social workers. It is also our responsibility, as professional nurses, to improve their health. If health is determined by all of these environmental factors, why are we not asking about living situations? We need to be active in our communities and know if there are enough homeless shelters and food pantries to service the number of clients who need these resources. Nurses need to take the reins and lead the charge to care for our most vulnerable populations, and to advocate for these, our clients. I encourage you to explore your community resources and make the connections that your clients need.
There are so many creative and wonderful solutions to this broken system. The future of nursing requires us as nurses to have the vision to impact these clients in their living environments. Each of us could reach out to a local food pantry, and/or have emergency food available in our care settings. Each of us could screen for social needs, and/or start a community coalition to address issues, such as homelessness. There are innovative people all across the country taking such initiatives. Organizations, such as the Camden Coalition (ref), Health Leads (ref), Promedica (ref), or the Root Cause Coalition (ref) are great examples to help you get started.
Do some research, get energized and be the change you want to see.
Darris Bohman, MSN, RN, CEN
Darris Bohman is a certified Emergency Department nurse with 26 years of experience. She is passionate about the socially complex clients that she treats, and she has created many new processes and interventions to ensure these clients are treated with the dignity and care they deserve. Darris is a trainer in Trauma-Informed Care. She has presented at the Beehive, for the “Putting Care at the Center” conference in Los Angeles, CA, the Ohio Hospital Association, the National Emergency Nurses Conference, and the National Conference for the Root Cause Coalition. Darris and a co-worker prepared, and were awarded, a grant to explore access to primary care in their geographic area as well as interventions to address social determinants of health in these areas. Darris has expertise on the subject of social issues and is working in her organization to design and implement interventions to address these issues. Darris has won the Director’s Award from TriHealth for her work in this area. As an adjunct nursing professor for Miami University, she feels strongly that we nurses must impart knowledge of these social issues, along with the interventions that can address these issues, to the next generation of nurses.
Artiga, S. & Hinton, E. (2018, May 10). Beyond health care: The role of social determinants in promoting health and health equity. Washington DC: Henry J. Kaiser Family Foundation. Retrieved from https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/.
Camden Coalition, https://camdenhealth.org/.
Health Leads https://healthleadsusa.org/
Islam, M. (2019). Social determinants of health and related inequalities: Confusion and implications.” Frontiers in Public Health, 7(11). doi:10.3389%2Ffpubh.2019.00011
Murray, T. A. (2018, September 30). Overview and summary: Addressing social determinants of health: Progress and opportunities. The Online Journal of Issues in Nursing, 23(3). doi: 10.3912/OJIN.Vol23No03ManOS
Noonan, K. & Craig, K. (2019, July 16). “From siloed systems to ecosystem: The evolutions of the Camden Coalition’s complex care model.” The Hotspot Blog: Camden Coalition of Healthcare Providers. Retrieved from https://www.camdenhealth.org/from-siloed-systems-to-ecosystem-the-evolution-of-the-camden-coalitions-complex-care-model/.
“ProMedica: Our Mission Is to Improve Your Health and Well-Being.” ProMedica.org. Retrieved from www.promedica.org/pages/home.aspx
Ritchie, D. (2013, July). Our zip code may be more important than our genetic code. Rhode Island Medical Journal, p 14. Retrieved from: http://www.rimed.org/rimedicaljournal/2013/07/2013-07-14-sdh-complete.pdf.
“The Root Cause Coalition.” Root Cause Coalition, Retrieved from www.rootcausecoalition.org/