The purpose of this activity is to engage in a volunteer experience with a safety net project or community program. The historical roots of the nursing profession originate from the work of Flo

251

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CHAPTER

13 COMPETENCY #11 Shows Evidence of Commitment to Social Justice, the Greater Good, and the Public Health Principles

n  Patricia M. Schoon  with Noreen Kleinfehn-Wald and Colleen B. Clark

Erica is a new public health nurse (PHN) in a large urban county where 40% of the children live in pov- erty. During Erica’s home visit to a young family, the mother states that the 2- and 3-year-old children have become “slow to get things and were tripping and falling more than usual.” A year ago, the family had moved from a newer apartment building into a 70-year-old building when the husband lost his job. Erica notices paint chips on the floor and is concerned that they are from lead-based paint. She advises the mother to have her children’s blood lead levels checked. The mother says she does not have health insurance and cannot afford a trip to the doctor. Erica tells the mother the paint should be replaced, but the mother is concerned that the landlord will not listen to her. Erica consults with her public health nursing supervisor about what else can be done.

ERICA’S NOTEBOOK COMPETENCY #11 Shows Evidence of Commitment to Social Justice, the Greater Good, and the   Public Health Principles

A. Applies principles of social justice to promote and maintain the health and well-being of populations

B. Understands the impact of the social determinants of health on vulnerable and at-risk populations

C. Advocates for the disadvantaged and underserved

D. Participates in collaborative social actions to reduce health disparities and inequities

Source: Henry Street Consortium, 2017

USEFUL DEFINITIONS

Advocacy: Actions to ensure that individuals or populations have basic human rights and justice: “Advocacy pleads someone’s cause or acts on someone’s behalf, with a focus on developing the community, system, individual, or family’s capacity to plead their own cause or act on their own behalf” (Minnesota Department of Health [MDH], 2001, p. 263).

Charity: Giving of oneself (volunteering) or of one’s resources to those in need.

Civic Engagement: Working with community members to improve the civic life of the community through social and political actions based on an understanding of the community, its diversity, assets, and problems (Gehrke, 2008).

Ethnicity: A collective group of individuals with presumed common ancestry sharing cultural symbol and prac- tices. Individual identification of ethnicity may be voluntary and self-defined (Ford & Harawa, 2010; Lee, 2009).

(continues)

C o p y r i g h t 2 0 1 8 . S i g m a .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Collection (EBSCOhost) – printed on 2/4/2023 12:47 AM via MINNESOTA STATE UNIVERSITY – MANKATO AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model for Nurses Account: s4200124.main.ehost

252 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Health Disparities: Preventable, population-specific differences in health and disease (incidence and preva- lence), health outcomes, or access to care that place some populations at greater risk than others and that are primarily the result of the social determinants of health.

Health Equity: “When every person has the opportunity to realize their health potential—the highest level of health possible for that person—without limits imposed by structural inequities. Health equity means achieving the conditions in which all people have the opportunity to attain their highest possible level of health” (MDH, 2014, p. 11).

Human Rights: Individual and family rights to live an independent, fulfilling, healthy life and earn a living wage for food, clothing, housing, and a safe environment; self-determination and autonomy. Human rights are rights inherent to all human beings. They are universal and inalienable, interdependent and indivisible, equal and non- discriminatory, entailing both rights and obligations (Office of the High Commissioner for Human Rights, n.d.).

Institutionalized Racism: Historical and systematic discrimination that results in normalization and acceptance of differences in how minority populations of race and ethnicity are perceived and treated that results in edu- cational, social, economic, and health inequities (Blodern, O’Brien, Cheryan, & Vick, 2016; Feagin & Bennefield, 2014; Gordon-Burns & Walker, 2015).

Market Justice: Personal resources and choices provide the basis for use and distribution of healthcare services based on concepts of individualism, self-interest, and individual effort; no collective obligation of society or government exists to provide for healthcare (Budetti, 2008).

Race: A social construct rather than a biological construct that is consistent with historical racial and ethnic population histories as opposed to specific genetic differences; different from ethnicity although frequently combined in healthcare practice; may be considered part of ancestral background (Frank, 2008; Jaja, Gibson, & Quaries, 2013; Lee, 2009).

Racialization: A process in which racial, ethnic, and cultural descriptions of groups of people in combination with statistical data combines to create distinct and different categories of people who are identified as having common risk factors and behaviors. This process leads to stereotyping groups of people with the tendency to see people as part of a specific group rather than as individuals (Cloos, 2015; Smedley & Smedley, 2005). This phenomenon is part of institutionalized racism.

Social Determinants of Health: The social determinants of health are the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics (World Health Organization [WHO], n.d.).

Social Justice (syn., distributive justice): The concept that individuals have the right to receive resources based on their needs and that a collective social obligation exists to provide for basic human needs, including health services (Budetti, 2008).

ERICA’S NOTEBOOK COMPETENCY #11 (continued)

Taking Action for What Is Right— Applying Principles of Social Justice Professional nurses have a social contract with their clients and the public to ensure that the healthcare needs of indi- viduals, families, populations, and communities are met in a caring, nonjudgmental, just, and equitable manner. Nurses as professionals and as private citizens are guided by the rule of law that protects basic human rights and by ethical principles that undergird basic human rights and social justice, a core principle of public health. Nurses in

public health are confronted with ethical issues or moral challenges surrounding human rights and social justice on a daily basis. Moral challenges are situations in which a nurse’s ethical beliefs are challenged and require critical thinking to arrive at a solution that protects the rights of individuals, families, and communities. The integration of caring (a core component of nursing) and social justice (a core component of public health), in conjunction with the moral challenge resulting when PHNs witness their clients experiencing health disparities and social injustice, propel PHNs to become involved in social and political advocacy (Falk-Rafael & Betker, 2012).

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253CHAPTER 13  n  Competency #11

Article 25 also speaks to many of the social determinants of health that have both societal and individual origins (see Table 13.1).

Respect for human rights is a basic tenet of ethical nurs- ing practice (American Nurses Association [ANA], 2015, 2016; Fowler, 2015). The International Council of Nurses (ICN, 2011) views healthcare as a basic right for all individ- uals; they state that nurses are obligated to provide fair and equal treatment and have a responsibility to safeguard client rights at all times and are held accountable for both their actions and their inactions. The ANA Code of Ethics identi- fies the obligations of nurses to support both human rights and principles of social justice for all:

A fundamental principle that underlies all nursing practice is respect for the inherent dignity, worth, unique attributes, and human rights of all individu- als. The need for and right to health care is universal, transcending all individual differences. Nurses con- sider the needs and respect the values of each person in every professional relationship and setting; they provide leadership in the development and implemen- tation of changes in public and health policies that support this duty (ANA, 2015, p. 1).

In addition, the ANA code stipulates that nurses are obligated as individuals and as a profession to act at the community and systems levels of practice to reduce health disparities. n Provision 8: “The nurse collaborates with other

health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (p. 31).

n Provision 9: “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy” (p. 35).

As students, you will be challenged and at times conflicted by the decisions you face that require choosing between two important and good things. For example, do you decide to respect individual autonomy and confidentiality, or do you find it necessary to enforce a public health law? This chapter provides guiding principles for social justice, information about population health disparities that confront PHNs, and a framework for public health advocacy interventions to help prepare you for the difficult situations you may encounter as a student and as a professional nurse.

Guiding Principles for Taking Actions for What Is Right Matwick and Woodgate (2016) report that social justice is considered a core value of nursing present since the late 19th century and evident in the actions of public health nursing leaders such as Nightingale and Wald. It is central to the practice of public health nursing. The two key attributes of social justice in nursing practice are equitable distribu- tion of resources and helping relationships that occur when those with social advantage and power help those with less social advantage and power. Matwick and Woodgate believe that in order to practice social justice, nurses need to rec- ognize and acknowledge social oppression and inequities, which then lead nurses to take caring actions toward social reform. They propose the following definition of social jus- tice (p. 182):

Social justice in nursing is a state of health equity characterized by both the equitable distribution of services affecting health and helping relationships.

Principles of social justice and human rights provide a framework for the ethical principles of public health prac- tice. The principles of social justice that are key to the health and well-being of populations include: n Collective social responsibility for community members n Responsibility of government to ensure the basic human

rights and healthcare needs of its citizens n Equitable allocation of healthcare resources based

on need n Protection of the rights of individuals and families to

live safe, healthy, and fulfilling lives

The United Nations published The Universal Declara- tion of Human Rights detailing 30 articles defining human rights (UN, 1948). The Preamble states, “Whereas inherent recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice, and peace in the world… a common understanding of these rights and freedoms is of the greatest importance.” Articles 1 and 25 provide an international standard for health as a basic human right.

TABLE 13.1 Selected Human Rights From the UN’s Universal Declaration of Human Rights

Article 1. All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 25. (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Source: United Nations, 1948

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254 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

For example, at the individual/family level of practice, a PHN would arrange to have an interpreter present when providing health education and counseling to an immigrant family who cannot speak English. At the community level, PHNs could create a social marketing campaign to help the community understand and respond to the challenges English language learners have in understanding English language signage posted throughout the community. At the systems level, PHNs could work with interprofessional teams to improve access to healthcare services for immi- grants and English language learners. Figure 13.1 depicts the three levels of practice.

Nurses have a social contract with the public. The Ameri- can Nurses Association Guide to Nursing Social Policy State- ment (Fowler, 2015) outlines the social contract that nurses have with the public. The contract involves 16 elements of reciprocal expectations between nursing and the public (p. 19). The ninth expectation, Promotion of the Health of the Public, stipulates that nurses have a social responsibility to address health disparities at all levels of society:

Promotion of the Health of the Public: It is expected that nurses will address the problems faced by indi- vidual patients including issues of health disparities and that nursing will be involved with and lead in health-related issues important to society. In some instances, nursing will be in the vanguard of emerging health-related issues. Nursing will participate in the promulgation of healthcare policy at regional, state, national, and global levels. Protection of the public through advocacy also includes whistleblowing (p. 21).

The World Health Organization (WHO) considers the human right to healthcare from a very holistic perspective (2015).

The right to the highest attainable standard of health requires a set of social criteria that is conducive to the health of all people, including the availability of health services, safe working conditions, adequate housing, and nutritious foods (WHO, 2015, para. 1). Achieving the right to health is closely related to that of other human rights, including the right to food, housing, work, education, non discrimination, access to information, and participation. The right to health includes both freedoms and entitlements. n Freedoms include the right to control one’s health and

body (e.g., sexual and reproductive rights) and to be free from interference (e.g., free from torture and from non- consensual medical treatment and experimentation).

n Entitlements include the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health.

WHO also identifies principles and standards of human rights that provide guidance to address the causes of human

rights inequities. These principles and standards are out- lined in Table 13.2 (2015, para 7).

These human rights, especially those emphasizing access to living conditions that encourage health, guide much of the work that PHNs do. Sometimes advocating for the human rights of individuals and concurrently advocating for social justice for vulnerable individuals, families, or populations results in ethical conflicts. Nurses have ethical responsibil- ities to protect the rights of individuals and to protect the health and welfare of the community. Consequently, some actions, such as mandated reporting of specific communi- cable disease incidents, require nurses to identify an ethical rationale for whether they choose to protect the individual or the community when protecting both simultaneously is not possible. Public health professionals have a code of ethics (Public Health Leadership Society, 2002) that directs them to act to protect vulnerable and at-risk populations and to work to eliminate health disparities. (See Table 13.3 for principles and examples of PHN actions.)

FIGURE 13.1 How a PHN Can Practice at All Three Levels

Individual/Family Arrange to have an interpreter present when providing health education and counseling to an immigrant family who cannot speak English

Community Create a social marketing campaign to help the community understand and respond to the challenges English language learners have in understanding English language signage posted throughout the community

System Work with interprofessional teams to improve access to health care services for immigrants and English language learners

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255CHAPTER 13  n  Competency #11

PHNs have both a moral and a legal obligation based on human rights to secure and provide public health services to those who need them. However, because resources are finite, PHNs are faced with the difficult situation of setting priori- ties to determine which at-risk populations and who among these populations will receive services. PHNs employed by governmental agencies work with community partners to identify need, available resources, and service gaps. A human rights approach presented by Gruskin and Daniels (2008, p. 1573) provides a framework for these decisions:

n Direct concern with equity in the utilization of resources.

n Examination of the factors that may constrain or sup- port planned interventions, including the legal, policy, economic, social, and cultural context.

n Participation and negotiation between all stakeholders, even as primary responsibility rests with government officials to facilitate these processes and to determine which interventions may have the biggest impact on health.

n Government responsibility and accountability for the manner in which decisions are made, resources are allo- cated, and programs are implemented and evaluated, including the impact on these decisions on health and well-being.

TABLE 13.2 Human Rights–Based Approaches

Nondiscrimination: The principle of nondiscrimination seeks “…to guarantee that human rights are exercised without discrimination of any kind based on race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status such as disability, age, marital and family status, sexual orientation and gender identity, health status, place of residence, economic and social situation.”

Availability: A sufficient quantity of functioning public health and healthcare facilities, goods and services, as well as programs.

Accessibility: Health facilities, goods, and services should be accessible to everyone. Accessibility has four overlapping dimensions: nondiscrimination; physical accessibility; eco- nomic accessibility (affordability); information accessibility.

Acceptability: All health facilities, goods, and services must be respectful of medical ethics and culturally appropriate as well as sensitive to gender and life-cycle requirements.

Quality: Health facilities, goods, and services must be scientifically and medically appropriate and of good quality.

Accountability: States and other duty-bearers are answerable for the observance of human rights.

Universality: Human rights are universal and inalienable. All people everywhere in the world are entitled to them.

Source: WHO, 2015

TABLE 13.3 Ethical Principles That Guide Public Health Professionals in Confronting Health Disparities

Principles PHN Practice Examples

Public health should address principally the fun- damental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

n Focusing on primary prevention with individuals, families, and communities

n Assessing the social determinants of health as part of the community assessment process

n Sharing the data on the social determinants of health that adversely affect the health of community members

Public health should advocate and work for the empowerment of disenfranchised community mem- bers, aiming to ensure that the basic resources and conditions necessary for health are accessible for all.

n Targeting services to vulnerable and at-risk populations experiencing the greatest levels of health disparities

n Advocating through the political process for funding and services for vulnerable and at-risk populations

n Using an assets-based approach to collaborate with community members to empower them to manage their own healthcare needs

Public health programs and policies should be implemented in a manner that most enhances the physical and social environments.

n Providing services to the uninsured and underinsured in homes and in community and mobile clinics

n Creating and providing culturally sensitive services n Collaborating with community organizations that provide safety-net

services

Source: Public Health Leadership Society, 2002

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256 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

EVIDENCE EXAMPLE 13.1 Social Justice and Human Rights Issues Identified by Practicing PHNs

A focus-group process was used to identify social justice and human rights issues that cause staff PHNs to confront ethi- cal dilemmas on a daily basis. Sixteen nurses working in a suburban-rural county public health agency used storytelling to draw out examples of the social justice issues and human rights principles that were being violated which resulted in neg- ative health outcomes. All four examples identified resulted in reduced health outcomes for individuals and families.   Right to self-determination (human right)—Clients are in need of services but do not qualify for existing programs. For example, an elderly person may need personal care attendant services but does not qualify for medical assistance, so the client remains at risk for placement in a long-term care facility.   Right to a standard of living adequate for the health and  well-being  of  individuals  and  families  (human  right)—The working poor often work in entry-level jobs and earn salaries

that make them ineligible for public services, even though their income is not enough to adequately support their families.   Autonomy  (human  right)  versus  greater  good  (social  justice)—A client with a communicable disease chooses to break home isolation and exposes many people by going out in public. Parents choose not to vaccinate their child, who then becomes ill with pertussis and exposes an entire classroom of children, including one child who is immune-compromised.   Inequitable  distribution  of  power,  money,  and  resources  (social  justice)—Legal immigrants arriving in the state have received no health examination in their home country and are not provided with a health screening upon arrival in the United States. Other foreigners seeking admission to the country as refugees have a health examination and have a health screen- ing upon arrival in their county of residence.

Source: Kleinfehn-Wald, 2010

Market Justice Versus Social Justice Globally, healthcare systems vary but are generally based on principles of market justice, social justice, or a combination of the two. The U.S. healthcare system, like the rest of the U.S. economy, is based on free enterprise and the principles of market justice. An alternative healthcare system, based on social justice, is embodied in the nonprofit and govern- mental healthcare systems. See Chapter 7 for a discussion of the U.S. healthcare system. Advocates of social justice believe that the government has a role to play in the provi- sion of and assurance of basic health services to its citizens. Advocates of market justice believe that individuals and the private sectors are better prepared to meet the healthcare needs of private citizens. Social justice requires that the gov- ernment be responsible and accountable for the health and well-being of its citizens. Market justice requires that indi- viduals be responsible for their own health and well- being. Table 13.4 compares the concepts of market and social jus- tice relative to healthcare.

The United States has a dominant and enduring cul- tural value of individualism—a belief that individuals are able to create their own destiny and that individual rights are more important than society’s rights (Ludwick & Silva, 2000). This cultural belief presents a significant barrier to the development of a social justice model of healthcare. It is important for nurses in the United States to understand the cultural values of our society to determine how health equity might be achieved.

Social Determinants of Health Social determinants of health are the conditions and cir- cumstances that vulnerable populations experience over their life span in their homes, neighborhoods, work places, schools, and the larger community. The social determinants of health include access to healthcare and the systems put in place to deal with their ongoing health status and illness. These circumstances are in turn shaped by a wider set of economic, social, and political forces at the local, national, and global levels (WHO, n.d.). These social determinants of health have a significant impact on the health status of populations—often a negative one. Research has shown that interventions that address social determinants of health well in advance of identified health problems or concur- rently with medical care improve health and reduce health disparities (Williams, Costa, Oduniami, & Mohammed, 2008). The social determinants of health (social and eco- nomic factors and physical environment) account for 40% of the health determinants that influence health outcomes, as illustrated in Figure 13.2.

Examples of social determinants of health identified by Healthy People 2020 are outlined in Table 13.5. Both the cat- egories of social determinants and physical determinants in the table are considered social determinants of health.

Healthy People 2020 has identified objectives for the social determinants of health in the following categories: economic stability, education, neighborhood and built environment, and social and community context (Healthy- People.gov, n.d.).

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257CHAPTER 13  n  Competency #11

TABLE 13.4 Market Justice Versus Social Justice in the United States

Market Justice Social Justice

People are entitled only to those valued ends, such as status, income, and happiness, that they acquire by individual efforts, actions, or abilities. The focus and beliefs include:

n Individual rights and responsibility n Death and disability as individual responsibilities and

problems n

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