The United States reportedly spends over $8,000 per person on healthcare annually. This amount is two-and-a-half times greater than any other developed country in the world (Kane, 2012). However, this is not reflected statistically in the morbidity and mortality rates of its citizens. Many may ask why and what are we missing. To answer these questions, one may need to look no further than their own town and community.
In 2013, the Center for Disease Control (CDC) reported health disparities as a causative factor for the unchanging morbidity and mortality rates in the United States. The World Health Organization defines social determinants of health as “conditions in which people are born, grow, live, work, and age”, and also identify them as the main cause for health inequalities worldwide (WHO, 2013). Health disparities affect people of all ages. The risk of dying before the age of 65 is over three times greater for citizens at the socioeconomic bottom of society than those at the top (Alder & Stewart, 2007). The youngest citizens are not immune to these facts. Infants born to mothers with less than 12 years of education are twice as likely to die during their first year of life compared to those born to mothers with 16 or more years of education (Robert Wood Johnson Foundation, 2008).Order now
Healthcare is a continually evolving and changing with aims of improving patient care, cost containment, and research that advances medications and procedures beyond expectations. The majority of focus is on disease processes and treatments. Therefore, the effects of lower economic status on personal health may not be receiving the attention it deserves. The nursing profession is in a unique position to assist in providing the advocacy, education, caring, and community involvement required to both look for causative factors and to identify possible solutions of social inequality of health (Lathrop, 2013). Nurses such as Florence Nightingale and Loretta Ford long ago worked tirelessly to lay the groundwork for correlating health and socioeconomic status (Lathrop, 2013).
Health Reform Goal and Cost Reduction
The idea of improving social determinants by expanding the role of nurses coincides with one major goal of health care reform, which is preventative care. Addressing social determinants through education provided to the community outside of an acute care setting along with the expansion of preventive care in the health reform policy both have the common goal of increasing the wellbeing of the community. Also, to increase access to healthcare and preventative care, “The Patient Protection and Affordable Care Act will bring substantial changes to the U.S Health care system over the next several years including a new emphasis on prevention and expanding coverage to 32 million currently uninsured Americans.” (Lathrop, 2013)
The Patient Protection and Affordable Care Act (ACA) will also allow for a federal investment in a variety of preventative services and public health. Specifically, “A grant program will support community-based prevention services focused on reducing rates of chronic diseases and addressing health disparities” (Baker Institute Policy Report, 2012, p.3). While focusing on social determinants to health status through increased educational programs and community-based programs can decrease the cost of Medicare and Medicaid within the acute care setting, it can also increase the cost of Medicare and Medicaid in the community based setting (Baker Institute Policy Report, 2012, p.3). The ACA increases Medicare and Medicaid with an expansion of preventative services in hope of improving overall health. Improvement of overall health will in turn decrease the need for acute care facilities and therefore decrease the need to utilize Medicare and Medicaid coverage within an acute care setting. The expansion of preventative care will increase access to community-based programs and also increase job opportunities for health care workers.
The increasing focus to decrease social influences makes this proposal specific to the population affected by lower income and lower levels of education. According to Lathrop (2013), “Those higher up along the gradient have access to better foods, more education, safer neighborhoods, recreation, higher paying jobs and health care. These serve as protective barriers against chronic disease, injury, and mortality.”
Limitations and Barriers
Social determinants have long been identified as a barrier for access to healthcare. While increased access is possible for many through the ACA, there is still work to be done. In an effort to lessen the influence of disparities on the health of the individual, Dahlgren and Whitehead (2007) developed multilevel strategies to address economic, education, living and working conditions, community support and individual lifestyle changes (Lathrop, 2013). The implementation of these strategies will require role expansion for the Advanced Practice Registered Nurse (APRN). The APRN is particularly suited for the leadership, teaching, and advocacy roles it will require. However, this will also serve as a major barrier to implementation. This barrier will not only affect the patients, but also the providers and facilities involved.
The nursing profession is currently experiencing a critical shortage in staff. The Bureau of Labor Statistic (2014) projects the demand for nurse practitioners will increase by 34 percent over the next ten years, that is 20 percent more than all other occupations. To complicate matters further, physicians are also in the midst of a critical provider shortage. Therefore, it is predicted that the Nurse Practitioner will be vital in caring for the increasing number of aging, chronically ill, and the newly insured patients (Domrose, 2014). Implementation of the strategies to alleviate health inequalities will require personnel, thereby placing an increased strain on an already strained profession. Essentially, this will take qualified APRN’s away from direct patient care, in a time when primary care providers are needed the most.
Role of the Advance Practice Registered Nurse
According to the American Nurses Association Code of Ethics, “the nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.” (Mahony & Jones, 2013). With this in mind, the nursing profession strives to provide unbiased access to healthcare. This can be achieved by providing targeted care to those experiencing inequalities. Also, we must simultaneously work to eliminate the social conditions that result in and perpetuate the status quo. The APRN, by immersing themselves into the social, political, economic, and historical framework of the communities they serve, can achieve this goal in a variety of ways.
The APRN can also serve as facilitators to advocate for policy changes aimed at overhauling the health administrative architecture. This intervention ideally would target the ease of access to healthcare for people. The ACA, which passed in 2010, set the stage for realization of this concept providing a major focus on preventive healthcare. In order for the APRN to achieve this goal they must take a more holistic approach to healthcare practice within the community to neutralize ongoing health disparities.
In 2013, Mahony and Jones also noted, “policymakers and practitioners support the movement to allow APRNs to practice to the extent of their educational level and training”. This is due, in part, to the shortage of primary care physicians, specifically in rural settings. Legislation is currently underway to achieve these goals. If passed, APRNs will become full participants in achieving the goal of preventive healthcare for everyone.
Exploring the causative factors for social determinants of health is a vital part of improving health care in the United States. Seeking out the factors that increase health care disparity is pertinent to developing strategies to overcome inequality in health among social classes (Mogford, Gould, & DeVoght, 2011). A review of the ACA by the Baker Institute Policy Report (2012) describes the expansion of Medicaid and reports the planned increase in funding to public health centers. However, simply making health care access more readily available will not eradicate the multifactorial and complex problem of social inequality in healthcare (Lathrop, 2013).
To alleviate health disparity, APRNs must go beyond traditional patient care and health promotion roles. Expanding scope of practice is essential to discover both where the inequities arise and how also to diminish these disparities (Williams et al., 2014). APRNs must become involved in community outreach and education to discover where services fall short for. This will also allow the APRN to know where to begin to advocate for changes in policies that create inequality among social ranks. According to the Dakota Nurse Connection (2012), collaboration with homeless shelters, social workers, and government benefits experts can also broaden the knowledge base of health care workers and aid in directing care. We must also become experts in local resources to direct our patients to available services. To ensure positive change, APRNs must familiarize themselves with the legal process and lobby for laws that will ease the burdens of lower income families in hopes of diminishing life stressors that cause an increase in health problems. We must also advocate for equality in public school quality for all children, and champion legislation that enables lower income students to achieve higher education (Lathrop, 2013).
To provide quality care to all patients we must recognize that social status has a direct correlation with health. As APRNs, we will need to evolve and expand our scope beyond direct patient interaction to better advocate for our low income patients to ensure equity in care (Lathrop, 2013).
Adler, N., & Stewart, J. (2007). Reaching for a healthier life: Facts on socioeconomic status and health in the U.S. The John D and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health. Retrieved from http://www.macses.ucsf.edu/downloads/Reaching_for_a_Healthier_Life.pdf
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Bureau of Labor Statistics. U.S. Department of Labor. Occupational Outlook Handbook. (2014). Nurse anesthetists, nurse midwives, and nurse practitioners. Retrieved from http://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm on January 15, 2014.
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Mahoney, D., & Jones, E. (2013). Social Determinants of Health in Nursing, Research, and Health Policy. Nursing Science Quarterly, 26:280.
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Robert Wood Johnson Foundation. (RWJF, 2008). Overcoming obstacles to health: Report from the Robert Wood Johnson Foundation to the commission to build a healthier America. Retrieved from http://www.commissiononhealth.org/PDF/ObstaclesToHealth-Report.pdf
Williams, S. D., Hansen, K., Smithey, M., Burnley, J., Koplitz, M., Koyama, K., & … Bakos, A. (2014). Using Social Determinants of Health to Link Health Workforce Diversity, Care Quality and Access, and Health Disparities to Achieve Health Equity in Nursing. Public Health Reports, 12932-36.
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