Identify the ethical challenge in nursing you selected. Explain why you selected this ethical challenge and why you think it is important. Describe the

Abstract 

Abstract: Determinants of health (DOH) are key predictors of health, wellness, morbidity, and mortality. The more familiar  social DOH are not the only DOH. By themselves, the social DOH do not adequately explain how individuals and populations achieve and maintain  health equity or  inequity. Other DOH also exert political, economic, and institutional forces at all levels of the socioecological systems in which humans interact with their environment.

According to the American Nurses Association, the  Nursing Code of Ethics is a "non-negotiable moral standard for the profession" (Fowler, 2015a, p. viii). Provision 9 of the  Code of Ethics states that social justice is of primary concern for social ethics (p. 159) and that professional nurses are obligated to advocate for and integrate principles of social justice into nursing practice and health policy (p. 151).

In search of conceptual explanations for these phenomena, and to locate health equity/inequity within a wide array of upstream DOH, a comprehensive review of the interdisciplinary professional literature and conceptual analysis were conducted. A new conceptual framework that acknowledges nursing's collective responsibility for ethical action for transformative change was developed. The framework addresses both "further upstream" antioppression efforts and "farther downstream" efforts to remediate the impacts of health inequity.

The purpose of this Policy Watch column was to introduce a new "Expanded Conceptual Framework for Ethical Action by Nurses on the 'Further Upstream and Farther Downstream' Determinants of Health Equity" (Fornili, 2022).

INTRODUCTION

The World Health Organization ( WHO, 2022a ) defines  health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (para. 2). Note the similarities between this definition of health and the Substance Abuse and Mental Health Services Administration working definition of recovery, the primary goal of behavioral health care (for mental health and/or substance use disorders).  Recovery is not merely abstinence from substance use but rather "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential" ( Substance Abuse and Mental Health Services Administration, 2012 , p. 3). According to the American Nurses Association (ANA), health is a specific social need and  nursing was created to address that need. The ANA refers to this relationship between the nursing profession and society as  nursing's social contract; it explains expectations about what society and governments expect from nursing and what nursing should expect from them ( Fowler, 2015b , p. xi).

Determinants of health (DOH), including  determinants of substance use and recovery, refer to a wide range of factors that influence health status. Sometimes, the determinants are described using an  upstream,  downstream metaphor, with the determinants referred to as upstream causal factors, and good or poor health being the resulting downstream outcomes. Numerous determinants are responsible for health outcomes (National Academies of Sciences, Engineering, and Medicine [ NASEM], 2017 , p. 2). Many people are familiar with the term  social determinants of health (SDOH). The SDOH are defined as "the conditions in the environments in which people live, learn, work, play, worship and age that affect a wide arrange of health, functioning, and quality-of-life outcomes and risks" (p. xxiv). The SDOH include education, employment, health systems and services, housing, income and wealth, the physical environment, public safety, the social environment, and transportation (p. xxiv).

Although the SDOH are key predictors of health, wellness, morbidity, and mortality, by themselves, they do not adequately explain how individuals and populations achieve and maintain health equity or health inequity. Other DOH also exert  oppressive political, economic, and institutional forces at all levels of the socioecological systems ( Bronfenbrenner, 1977 ) in which humans interact with each other and their environment ( Hofrichter, 2003 ;  McGibbon, 2021a, 2021b ;  Schoon & Krumwiede, 2022 ).  Systematic oppression and  structural power are "further upstream" antecedents of the structural societal and social determinants.

Health equity refers to the absence of avoidable, preventable, or remediable differences in health among groups of people ( Dawes, 2020 , p. 19;  WHO, 2021 )-the state in which the unjust burdens of disease and the just benefits of good health are equitably distributed ( NASEM, 2017 , p. 1). As  equity is closely related to "what is considered fair and just,"  inequity exists when differences in health determinants and outcomes are "systematic, unfair and avoidable" ( Penman-Aguilar et al., 2016 , p. S35). Health inequities are "systemic political obstacles" that are "baked into our systems" by discriminatory standards, practices, and beliefs ( Dawes, 2020 , p. 19).

Critical theory illustrates the often-hidden processes by which dominant power structures create inequities and maintain oppressive forms of injustice ( Chinn & Kramer, 2015 , p. 247).  Critical consciousness involves  awareness of and action against forces that limit or promote opportunities for certain groups ( Freire, 2000 ;  <a rel='nofollow' target='_blank' href='https://ovidsp.dc2.ovid.com/ovid-new-a/ovidweb.cgi?QS2=434f4e1a73d37e8c9f7c7fcc4d5af0f524405b7eb001fa8b7e0a0024433f1d40a1cca41740221cc853d17797a

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