Nursing Implications of Social Determinants of Health

Abstract:
A transformation is occurring in health care that recognizes non-medical factors, or social determinants of health (SDOH), significantly impact health and health care outcomes. SDOH include economic, societal and environmental situations and influences. It has been found that health disparities and inequities for patients and patient populations are often due to SDOH. It is important for nurses and all members of the health care team to be knowledgeable of and able to identify and address SDOH in practice. Education for health care providers is necessary to enhance SDOH awareness and best practice. Nurses are integral to the transformation of SDOH into patient care and improving health of individuals and patient populations for a culture of health.

Introduction:
Factors impacting health are numerous, complex, intertwined, and include biological, psychosocial and sociological domains. With the goal of improving the health of individuals, families and populations, health care is undergoing a transformation that recognizes there are conditions and circumstances beyond the health care arena that have a significant impact on health status, equity and outcomes. Examples of these conditions include housing, income, access to food, and other social parameters, referred to as social determinants of health (SDOH) (Murray, 2018).  Studies demonstrate that addressing “upstream” SDOH, or the root causes that impact health, can be instrumental in preventing or decreasing the progression to “downstream” affects such as a decline in health condition or negative health outcomes (Schroeder et al, 2018). A critical element in this transformative process is for nurses, physicians and members of the interprofessional health care team to identify and address SDOH as an integral component of caring for patients. Education is essential to enhance knowledge and understanding of the effects of SDOH and implications in care. Nurses are in a key role to integrate SDOH into practice and advance this transformation for improved health of individuals, families and patient populations.

Nurses are essential in identifying and addressing issues impacting the overall health of individuals. Through use of the Nursing Process, nurses assess, plan, implement and evaluate care to optimize health for patients. In caring for individuals, it is important to consider factors impacting patients’ current health status and supports for improving and maintaining health and wellness. Identifying and addressing SDOH is essential to improving the health status of patients and populations. Nurses are vital in ensuring SDOH are included in the assessment, planning and delivery of patient- centered care.

Definition:
SDOH are forces that include social norms, economic and social policies, agendas and systems, the distribution of power, money, and resources locally, nationally, and worldwide (World Health Organization, 2020). The five major areas of SDOH are economic stability, education, health care, society and community, and neighborhood and environment (Healthy People 2020). The importance of addressing SDOH is recognizing that non-medical factors impact health, wellness, and medical concerns. It is estimated that SDOH are leading determinants in up to 75% of health outcomes (Schroeder et al, 2019). Addressing SDOH may prevent or lessen the impact of illnesses or health conditions before they lead to negative health effects. As described by Schroeder (2019), managing an upstream SDOH issue can decrease a downstream issue such as an acute hospitalization.

Economic stability is the ability to access resources necessary to live a healthy life, and is impacted by situations such as poverty, employment, income, housing and food insecurity. Among the complexities of housing are the ability to afford and secure safe, quality housing, as this is imperative to healthy living. Safe housing depends on many factors, such as exposure to lead paint, safe drinking water, and environmental safety. Considerations of neighborhoods and environments include access to green space, safety for walking, risk of violent crimes and discrimination, and the quality of local schools for families with children. The Alliance for Health Policy (2017) cites one in five Americans live in a neighborhood with high rates of crime, pollution, inadequate housing, lack of jobs, or limited access to nutritious food. Another important factor of economic stability is food insecurity, or a person’s ability to afford and access food, the availability of healthy food options, and assistance with shopping and food preparation.

Access to health care is essential to managing urgent and chronic conditions, with primary care being the foundation for effective and efficient patient-centered care, including referrals to specialty care when needed. Barriers exist in the logistics of accessing care, and patients may need assistance with finding and scheduling appointments with health care providers. Lack of transportation may impede the patient’s ability to keep scheduled appointments, and employment and insurance status may affect access and affordability of medications and equipment to assist with medical needs (Healthy People 2020). Language barriers, education level, health literacy, and the availability of caregiver supports are important considerations in assisting patients to understand and participate in their plan of care (Alliance for Health Policy, 2017; Healthy People 2020).

Health literacy, or the ability of an individual to obtain, process, understand, and communicate basic health information and services so appropriate decisions can be made, is an important component of SDOH. Studies have shown more than one third of adults in the U.S. demonstrate low health literacy, with approximately 77 million have difficulty following instructions on a prescription (Barton et al, 2018). People at risk for low health literacy include older adults, individuals with cognitive decline, people with low education levels and low socioeconomic status, and people with limited English proficiency. Anxiety and the use of medical terminology and jargon can also impact heath literacy. Committing to improving health literacy assists in eliminating barriers to understanding information so improved health can be achieved by all (Barton et al, 2018).

Nurses are in a pivotal role for enhancing health literacy, improving quality and safety outcomes, patient experience, and the cost of health care. Strategies to enhance health literacy include asking patients their preferred language for health care information, speaking slowly and clearly, asking “what questions do you have?” as opposed to “do you have any questions?”, validating understanding of information by using methods of learning verification such as teach back, and utilizing language interpreters as needed (Barton et al, 2018).

Resources needed for health are not limited to medical care; they also include promoting physical and social conditions in homes, neighborhoods and workplaces. Differences in health outcomes are closely connected to social disadvantages, which results in health disparities (Murray, 2018). Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health. Disparities in health status and health outcomes are rooted in environments and conditions in which people live and are often shaped by structures such as distribution of wealth, power, social mores, cultural norms, and economic and political forces (Murray, 2018). These are largely attributed to the unequal distribution of resources based on factors such as socioeconomic status but can impact everyone. Contributors to health disparities include socioeconomic position, residential location, environmental living conditions, occupational risks and exposures, health risk and health seeking behaviors, and limited access to medical care (Murray, 2018). 

Health Equity, the attainment of the highest level of health for all people, is the overarching goal of identifying and addressing SDOH. Achieving health equity involves valuing everyone equally with continuous societal efforts to address preventable inequalities, past and present injustices, and the elimination of health care discrepancies (Healthy People 2020). The rationale for focusing on this is that achieving health requires more than just controlling disease, it includes ensuring all members of society benefit from the same basic rights, security and opportunities (Healthy People 2020). 

The impact of SDOH on outcomes and health equity is recognized on a global and national level. The Word Health Organization has identified SDOH as one of six priorities and has stated education on SDOH is necessary for the health care work force to understand and implement strategies to address social inequities (NLN, 2019). The Robert Wood Johnson Foundation (RWJF) has developed a national agenda to build a culture of health where everyone has a fair and just opportunity for health and wellbeing. Healthy People 2020 selected SDOH as a leading health topic, recognizing the critical role of home, school, workplace, neighborhood and community in improving health. The American Hospital Association released a white paper in 2019 examining SDOH in Medicare and Medicaid programs, and the Center for Medicare and Medicaid Services has funding opportunities for programs addressing SDOH and for increasing awareness of policy makers in the significance of SDOH in influencing health and health status (NLN, 2019).

The Triple Aim:
The Triple Aim of the Affordable Care Act has established three goals for health care: Better Care, Smarter Spending, and Healthier People (Rhode Island EOHHS, 2017). Better Care is focused on providing patient-centered, accessible, culturally competent care, delivered by practitioners working to the full extent of their licensure, and is focused on keeping people well. The second aim, Smarter Spending, includes improved efficiency in the use of health care resources through paying for value rather than volume of services, or value-based care. Smarter Spending includes encouraging prevention and other primary care measures, and rebalancing care from costly hospital or nursing home stays to home and community-based care. The third aim, Healthier People, includes enhancing the overall health of the population while coordinating the care of specific populations with chronic disease or multiple health conditions, and addressing SDOH (Rhode Island EOHHS, 2017).

Through interaction with patients and identifying individual patient needs, nurses are in a key role to improve health by addressing SDOH. Collaboration with nursing and interprofessional colleagues and aligning resources with patient needs relative to SDOH enhances patient care and health outcomes. Including SDOH as a parameter of care decreases health disparities for individuals and patient populations, and potentially reduces health care costs.

The responsibility and commitment of the nursing profession to providing safe, quality care for individuals, families, communities, and populations is addressed by the American Nurses Association in the Nursing Social Statement and Code of Ethics, and in state Nurse Practice Acts (American Nurses Association, 2019). Nurses’ membership on unit based, departmental and hospital committees facilitates SDOH policy development and implementation of evidence based best practices. Through participation in professional nursing organizations and on boards, nurses contribute to improvements in SDOH issues affecting health care.

Vision for a Culture of Health:
The impact of SDOH on outcomes and disparities is a major challenge across all areas of health care, and a focused approach is required toward improving health equity. The Robert Wood Johnson Foundation has developed a Vision for a Culture of Health to meet this 21st century challenge. The Vision for a Culture of Health is comprised of four interconnected areas:  making health a shared value; fostering cross-sectional collaboration to improve wellbeing; creating healthier and more equitable communities; and strengthening integration of health services and systems (Robert Wood Johnson Foundation, 2019). Building this culture of equity includes the following changes, goals, and understandings:

• Good health flourishes across geographic, demographic, and social sectors.
• Attaining the best health possible is valued by our entire society.
• Individuals and families have the means and opportunities to make choices that lead to the healthiest lives possible.
• Businesses, the government, individuals and organizations work together to build healthy communities and lifestyles.
• No one is excluded.
• Everyone has access to affordable, quality health care because it is essential to maintain, or reclaim health.
• Health care is efficient and equitable.
• The economy is less burdened by excessive and unwarranted health care spending.
• Keeping everyone as healthy as possible guides public and private decision making.
• Americans understand that we are all in this together
     (Robert Wood Johnson Foundation in Billings, 2016).

Nursing Implications:
The Robert Wood Johnson Foundation (2019) recognizes the nursing profession as integral to implementing and achieving the Culture of Health. Through practice across the spectrum of settings with focus on patient-centered care, nurses are essential to meeting current and emerging health care issues and are pivotal to the implementation of this vision (National Academy of Medicine, 2019). In 2009, the Robert Wood Johnson Foundation partnered with the Institute of Medicine to advance nursing practice through the Campaign for Action: Future of Nursing. The Campaign for Action included goals for nursing education, such as increasing the number of baccalaureate and doctoral prepared nurses, ensuring nurses practice to the full extent of their education, enhancing nursing leadership opportunities, and improving data collection for policy making and workforce planning (Robert Wood Johnson Foundation, 2019).

The outcomes and lessons learned from the Campaign for Action: Future of Nursing report will be used to inform development of the Future of Nursing 2020-2030 framework (National Academy of Medicine, 2019). Expert analysis, research, and current science and technology are being utilized to build the framework for advancing the nursing profession to meet social and health care needs from 2020-2030. Evidence-based models of care addressing SDOH nationally and globally will be considered in building and sustaining a culture of health (National Academy of Medicine, 2019).  Although the specific goals are in development, the areas of focus for the Future of Nursing 2020-2030 include:

• The role of nurses in improving the health of individuals, families, and communities by addressing SDOH and providing effective, efficient, equitable, and accessible care for all across the care continuum, as well as identifying system facilitators and barriers to achieving this goal;
• The current and future deployment of all levels of nurses across the care continuum, including collaborative practice models, to address the challenges of building a culture of health;
• System facilitators and barriers to achieving a workforce that is diverse, including gender, race, and ethnicity, across all levels of nursing education.
• The role of the nursing profession in assuring that the voice of individuals, families and communities are incorporated into design and operations of clinical and community health systems.
• The training and competency-development needed to prepare nurses, including advanced practice nurses, to work outside of acute care settings and to lead efforts to build a culture of health and health equity, and the extent to which current curriculum meets these needs.
• The ability of nurses to serve as change agents in creating systems that bridge the delivery of health care and social needs care in the community.
• The research needed to identify or develop effective nursing practices for eliminating gaps and disparities in health care.
• The importance of nurse well-being and resilience in ensuring the delivery of high-quality care and improving community health.
           (Murray, 2019; National Academy of Medicine, 2019)

Strategies to assist nursing and the interdisciplinary health care team to identify and address SDOH are needed in academic and practice settings. As a foundation, concepts of SDOH need to be integrated into nursing and health care education curriculum (Murray, T., 2017). Including these concepts through clinical experiences and simulation to enhance learning will create confidence and competence in assessing and addressing SDOH in various setting (Thornton and Persaud, 2018). Traditionally these concepts have been focused on in community and public health courses, however they are applicable to all health care settings and therefore are important to include across academic health care programs. The National League for Nursing (NLN) has issued a Call for Action with an intentional approach to integrate SDOH education throughout the nursing curriculum. This Call to Action aligns with the nursing profession’s social mission, advocacy, social justice and health equity (NLN, 2019). The NLN advocates for assessment of SDOH as an essential competency, stating “health is inextricably linked to the social, economic, environmental, political and cultural forces that shape the world around us” (NLN, 2019). Inclusion of SDOH in nursing education facilitates preparation for emerging roles in population health such as patient navigator and nurse case manager. Experiential learning through collaboration between academic programs and community-based partners supports preparation of the future health care workforce through innovative preceptorship programs. 

The Nursing Process provides the framework for integrating SDOH into patient care. Screening questions in the nursing assessment focused on SDOH serve as a guide to identifying social issues impacting patient health. Components of the nursing assessment include questions related to employment, housing, availability of nutritious food, access to health care including mental health, and caregiver or social support. To ensure members of the interdisciplinary team are competent and comfortable in speaking with and screening patients for SDOH, they must first be educated in the importance and relevance of these questions to a person’s health. By educating the health care workforce on screening tools and the significant impact SDOH have on health, interdisciplinary team members will be better prepared to explain to their patients the importance of these screenings, answer patients’ questions and develop their interdisciplinary care plans. For a health care organization to provide comprehensive, patient-centered care and identification of resources to assist with meeting a patient’s SDOH needs, it is important for the health care team to utilize standardized, consistent screening questions when evaluating SDOH. The American Academy of Nursing has called for standardization of SDOH assessment measures that are accessible across the continuum of care to various systems and health care providers (Billioux et al, 2017). Documentation in the electronic medical record by nursing and the interprofessional care team is necessary to ensure an accurate record, tracking and communication of the patient assessment, goals, progress and outcomes, with updates as required or needed based on the patient’s condition (Daniel et al, 2018). 

Interdisciplinary Team Strategies:
Communication with the interdisciplinary care team is essential to patient-centered care. In developing the nursing care plan, it is important for the nurse to ensure assessment findings and patient care problems are documented appropriately and communicated with the care team. Strategies for communication include direct discussion with medical providers and members of the interdisciplinary health care team. Daily team huddles provide an opportunity for all members of the team to review each patient’s needs, progress, referrals, and update the care plan. Nurses are an essential part of this team and may be the leader of the team huddle. In addition to providing information to the team for discussion, the nurse serves as a patient advocate to ensure patient needs identified by nursing are addressed. An outcome of the team huddle may be that a patient care conference is needed to address complex patient care issues. 

Utilizing a consistent communication strategy among the health care team supports collaboration, teamwork and best practice. An example is SBAR- Situation, Background, Assessment and Recommendation- which provides a consistent method of communication among all health care team members in all patient care situations (Institute for Healthcare Improvement, 2020). TeamSTEPPS® provides concepts and techniques for clarification and follow-through, such as closed loop communication and check-back confirmation (Agency for Healthcare Research and Quality, 2020). Communicating with patients and families, and ensuring they understand and participate in the plan of care is an integral component of patient-centered care. The use of teach-back has demonstrated verification and enhancement of patient understanding and education, leading to improved patient outcomes. Health care language interpreters may be needed when communicating with the patient and their family to ensure information is conveyed accurately. Privacy and telephone etiquette are also important considerations when communicating with patients and families. 

With the emergence of SDOH as a parameter of health and wellbeing across the spectrum of patient care, education for the health care team is needed to enhance knowledge, understanding and address this aspect of care in practice. Educational content would include a description of SDOH and its impact on health, assessment, accessing resources, documentation in the electronic medical record, and patient follow-up. Fostering patient-centered care, focusing on individual needs to optimize patient outcomes, and decreasing health disparities are important aspects of SDOH education. Strategies to support communication and patient engagement include topics such as learning to ask patients potentially sensitive questions, listening without judgment, awareness of the environment in which the inquiry takes place, and empathic interviewing. (Thornton and Persaud, 2018).

The process of functioning as an interprofessional team and knowledge of roles and resources of each discipline is enhanced through education and practice. Interprofessional education and collaboration using case studies, simulation, and debriefing provide an interactive learning opportunity to enhance knowledge of SDOH and strengthen team communication and collaboration (Cantey et al, 2017; Thornton and Persaud, 2018). Interprofessional education enhances knowledge of the roles within each discipline and how to work together to meet patient needs as an interactive team. The role of the nurse as a patient advocate can be included in simulation activities. Reflection on and debriefing of the interprofessional education experience may raise awareness of SDOH as well as previously unrecognized implicit biases.

Recommendations published by the American College of Physicians in 2018 supports the use of interprofessional education to encourage a team approach to treating patients negatively impacted by SDOH and toward reducing health disparities and advancing health equity. Recommendations include developing best practices for use of electronic health records to improve individual and population health, increasing research and policy development related to SDOH, and advocating for the funding of programs to reduce health disparities (Daniel et al, 2018).

Conclusion:
Nurses are in a position to advance knowledge and best practice regarding SDOH in patient care. Through participation on committees, boards, and professional organizations, nurses have a voice in shaping policies, procedures and processes. Utilization of nursing research findings, best practice recommendations, and guidelines foster advancements in knowledge and evidence-based practice. Examples of informational resources on SDOH include current literature and professional organizations such as the American Nurses Association, National Academy of Medicine website, Robert Wood Johnson Foundation website, and Agency for Healthcare Research and Quality website. Nursing research is needed to advance knowledge and best practice of the implications of SDOH on patient care. There is a wide array of areas for research, including screening, assessment and interventions to address SDOH, documentation in the electronic health record, and linking SDOH education of nurses and the interdisciplinary care team to patient and population health outcomes (Olshansky, 2017; Wetta, 2017).  Nursing implications of SDOH is an emerging and expanding area of practice and nursing research provides the foundation for innovative advancement in the delivery of patient-centered, quality patient care.

Click here to take the post-test, evaluation, and receive your credit for reading this article!   

 References

1.     Agency for Healthcare Research and Quality (2020).  TeamSTEPPS®  Retrieved From https://www.ahrq.gov/teamstepps/index.html

2.     Alliance for Health Policy (2017). Social determinants of health.  Retrieved from http://www.allhealthpolicy.org/sourcebook/social-determinants-of-health

3.     American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Association.

4.     American Nurses Association. (2016). Guide to Nursing’s Social Policy Statement: Understanding the Profession from Social Contract to Social Covenant. Silver Spring, MD: American Nurses Association.

5.     Barton, A., Allen, P., Boyle, D., Loan, L., Stichler, J and Parnell, T. (2018). Health literacy: Essential for a culture of health.  The Journal of Continuing Education in Nursing. 49(2): 73-78

6.     Billings, D. (2016). Building a culture of health: Implications for nurse educators.  The Journal of Continuing Education in Nursing. 47(5):210-211.

7.     Billioux, A.,Verlander, K., Anthony, S. and Alley, D. (2017).  Standardized screening for health-related social needs in clinical settings.  National Academy of Medicine. Retrieved from https://nam.edu/standardized-screening-for-health-related-social-needs-in-clinical-settings-the-accountable-health-communities-screening-tool/ 

8.     Cantey, D., Randolph, S., Molloy, M., Carter, B. and Cary, M. (2017).  Student-developed simulations: Enhancing cultural awareness and understanding social determinants of health.  Journal of Nursing Education. 56(4):243-246.

9.     Daniel, H., Bornstein, S., Kane, G. (2018). Addressing social determinants to improve patient care and promote health equity:  An American College of Physicians position paper. Annals in Internal Medicine. Retrieved from https://www.acpjournals.org/doi/10.7326/M17-2441

10.  Healthy People 2020. Social determinants of health.  Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

11.  Institute for Healthcare Improvement (2020).SBAR tool: Situation-Background-Assessment-Recommendation. Retrieved from http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx

12.   Murray, T. (2019). The future of nursing 2020-2030: Educating the workforce.  Journal of Nursing Education.  58(9): 499-500.

13.  Murray, T. (2018). Overview and summary: Addressing Social Determinants of health: Progress and opportunities.  OJIN: Journal of Issues in Nursing; 23(3).

14.  Murray, T. (2017).  Outside the hospital walls: Social determinants and population health.  Journal of Nursing Education. 56(6):319- 320.

15.  National Academy of Medicine (2019).  The future of nursing 2020-2030.  Retrieved from https://nam.edu/publications/the-future-of-nursing-2020-2030/

16.  National League for Nursing (2019).  A vision for integration of the social determinants of health into nursing education curricula. Retrieved from http://www.nln.org/docs/default-source/default-document-library/social-determinants-of-health.

17.  Olshansky, E. (2017). Social determinants of health: The role of nursing. American Journal of Nursing. 117(12):11.

18.  Pittman, P. (2019). Activating nursing to address unmet needs in the 21st century.  Robert Wood Johnson Foundation.  Princeton, NJ.  March 12, 2019.

19.  Rhode Island Executive Office of Health and Human Services (2017). Healthcare Workforce Transformation Report. Retrieved from http://www.eohhs.ri.gov

20.  Robert Wood Johnson Foundation (2020). Building a Culture of Health. Retrieved from https://www.rwjf.org/content/rwjf/en/cultureofhealth/about/how-we-got-here.html#ten-underlying-principles

21.  Robert Wood Johnson Foundation (2019).  Future of nursing: Campaign for action. Retrieved from https://www.rwjf.org/content/rwjf/en/how-we-work/grants-explorer/featured-programs

22.  Schroeder, K., Garcia, B., Snyder, S. and Lipman,T. (2019). Addressing social determinants of health through community engagement: An undergraduate nursing course.  Journal of Nursing Education. 58(7):423-426.

23.  Schroeder.  K., Malone, S., McCabe, E. and Lipman, T. (2018). Addressing the social determinants of health: A call to action for school nurses.  The Journal of School Nursing. 34(3);182-191

24.  Thornton, M. and Persaud, S. (2018). Preparing today’s nurses: Social determinants of health and nursing education. OJIN: The Online Journal of Nursing.23(3).

25.  Wetta, R. (2017). Nurses poised to address social determinants of health.  Retrieved from https://www.cerner.com/blog/nurses-address-social-determinants-of                               

26.  World Health Organization (2020). About social determinants of health. Retrieved from https://www.who.int/social_determinants/sdh_definition/en/