Here, Professor Ann Hemingway, Public Health and Wellbeing, Faculty of Health and Social Sciences, Bournemouth University

and Joanne Bosanquet, deputy chief nursing officer, Public Health England, explain how nurses must be prepared for their roles as advocates and seek to have influence over local policies which impact on health and the design of healthcare services

Bosanquet, J.

Hemingway, Ann

Bournemouth University Research Online

efforts toward achieving social justice were as important to health as the more immediate downstream direct nursing care they provided.Nursing interventions to prevent illness often focus on the role of educating individuals in relation to their health-related behaviour, such as smoking, exercise, eating habits and sexual health behaviour (Hart and Freeman, 2005). The WHO’s Commission on the Social Determinants of Health (WHO, 2008) recognised that the health There are 20.7 million nurses across the world, which accounts for 50% of the global healthcare workforce (World Health Organization [WHO] 2018a). Nurses also undertake the majority of direct patient contact. This places nursing as a profession in a uniquely powerful position. In 2012, the Royal College of Nursing outlined how nurses can help to reduce inequality by tackling social determinants of health and ‘targeting vulnerable populations to improve health outcomes and access to services’. Health inequalities are systematic differences in the health status of different population groups. These inequities have significant social and economic costs both to individuals and society. However, these differences are preventable and, as such, considered to be unfair and unjust (WHO, 2017).The WHO (2018b) defined social determinants of health as the conditions in which people are born, grow up and live in, their work and age, and states that there is ample evidence that factors including education, employment status, income level, gender, ethnicity, housing and access to health care have a marked influence on how healthy a person is. In all countries, whether low, middle or high income, there are wide disparities in the health status of different social groups. The lower an individual’s socio-economic position, the higher their risk of poor health (WHO, 2017). The WHO (2018b) also recommended that nurses have a significant role in reducing health inequality, stating that, ‘primary health services should be strengthened … with an adequate and well-equipped multidisciplinary health workforce, especially including community health workers and nurses’.Role of nuRsingNursing has a long history of engaging with the social determinants of health. Recently, the International Council of Nurses (ICN, 2017) outlined nursing’s vital role in helping to achieve sustainable development goals. These United Nations goals encompass global issues such as ending poverty and improving health and education (ICN, 2017). Leadership and political activism is seen by the ICN as part of every nurse’s role, a stance illustrated by a quote taken from a case study in their recent document, Nurses: A Voice to Lead (ICN, 2017): What each of these nursing leaders had in common was political activism that grew out of the personal knowledge they gained in providing care for poor, immigrant and otherwise vulnerable populations and understanding that their Role of nurses in tackling  health inequalitiesComment JCN 2016, Vol 30, No 3 278 2 6 ??Here, Professor Ann Hemingway, Public Health and Wellbeing, Faculty of Health and Social Sciences, Bournemouth University and Joanne Bosanquet, deputy chief nursing officer, Public Health England, explain how nurses must be prepared for their roles as advocates and seek to have influence over local policies which impact on health and the design of healthcare services. ▼ Practice pointThe social determinants of health involve the conditions in which people are born, grow up in, live, work and age, which collectively can have an effect on their health status. This article investigates the role of nurses in helping to reduce health inequality by tackling the social determinants of health and targeting vulnerable populations to improve health and access  to services.?? JCN 2018, Vol 32, No 6education role is important; however, it is also vital to consider individuals that nurses care for in their social context, for example, in relation to their economic or housing situation, and for nurses to understand their potential role in influencing these factors. Patterson et al (2012) stated that individually focused interventions must be coupled with initiatives that work to address structural barriers to health, wellbeing, healthy lifestyles or care delivery, such as poor housing and lack of transport for instance. There is a clear message within the WHO (2016) report, Global Strategic Directions for Strengthening Nursing and Midwifery, that nurses need to adopt a practice perspective that considers both individuals and their social determinants of health and wellbeing. One of the key objectives of this report is to empower nurses to ‘contribute to local and national policy development’, to increase the ‘quality of service delivery’ and reduce inequalities in health (WHO, 2016). An example of practice focused on the social determinants of health occurred on the Beacon estate in Cornwall in the 1990s, which had high levels of illness, deprivation, crime and despair. Two health visitors were appointed to work specifically in this area, and their assessment was that the local community had the strengths and assets to make a positive change to their position if local organisations actively helped in this process. The health visitors helped to set up a residents’ association, and worked with the local authority and police and out of this grew a local regeneration project in 1995. By 1999 great improvements had been made, namely: The crime rate was down by 50% 900 properties had been fitted with central heating Unemployment had reduced by 71% Postnatal depression had reduced by 70% Children on the child protection register were down by 60% Childhood asthma rates were down by 50% Boys SATS scores had increased by 100% (RCN 2012). Thus, showing how nurses can be really effective in mobilising local resources and leading change.emPoweRmenTAs witnesses to the negative effects of economic decline on the health and well-being of patients, nurses have a key role in outlining the priorities for policymakers. Furthermore, the more influential the nursing post held, the more to influence or control significant features of their lives (Nyatanga and Dann, 2002). Within nursing however, empowerment is a disputed concept (Suominen et al, 2006). For example, some nursing academics have suggested that nurses and their professional culture may exert a negative influence on patients through the ‘professional ego’, which ensures that the power balance in any intervention rests with the nurse (Hart and Freeman, 2005). This dynamic can disempower vulnerable individuals and prevent them from accessing health care, support and advice. Indeed, assuming that empowering nurses will in turn lead to more empowered patients is naïve, as empowered healthcare professionals do not automatically seek to share power with those they are caring for (Suominen et al, 2006). Other nursing authors have suggested that nurses may be prevented from empowering patients as they themselves may not have power within healthcare services (Christensen and Hewitt-Taylor, 2006). This would imply that, if nurses are to achieve more power and increase their professional standing, they need to be equipped for leadership and engage in political discussion. Patterson et al (2012) viewed empowerment as occurring at both micro and macro points. At the micro point, empowerment occurs between the nurse and an individual patient or community. However, Smith (2014) argues that, as nurses represent the largest work force, this micro-level empowerment with patients cannot be successful without the concurrent macro empowerment of nurses, which focuses on improving health globally. ▼ Practice pointnurses, both collectively and as individual practitioners, should consider the social determinants of health as a priority.‘ ... if nurses are to achieve more power and increase their professional standing, they need to be equipped for leadership and engage in political discussion.’of a priority the area of policy development and influence needs to be for the nurse. A recent All Party Parliamentary Group on Global Health (2016) report stated that developing nursing skills and confidence in the area of policy development will improve health, achieve greater gender equality, and provide stronger economies and communities.The Commission on the Social Determinants of Health (WHO, 2008) outlined three areas of empowerment which are vital to tackling inequities: Material empowerment: to enable people to have the resources they need to live healthily Psychosocial empowerment: to enable people to exert control over how they live and gain support from others Political empowerment: to enable people to influence the circumstances in which they and their community live.Empowerment is defined as an individual’s or group’s ability Empowerment of nurses and nursing is fundamental in relation to: Building their skills, confidence and influence if they are to lead Contributing to the fair provision of health care Helping patients to positively influence the social determinants of health and wellbeing in their local communities (Smith, 2014).The evidence on tackling health inequities is underdeveloped in the nursing literature (Villeneuve, 2008; Swider et al, 2017), and nurses need further evidence to inform practice on how to develop interventions, strategies and skills to prevent or reduce health inequality. As outlined in the example above, an awareness of the health needs and assets within any local area is essential for nursing practice both in hospital and community settings, as are the skills of advocacy, policy influence, activism and community development. Nurses can carry out direct interventions for individuals and families, assess needs and make sure that vulnerable groups are prioritised. They are also in a position to ensure that the right services are commissioned, provide leadership, support community empowerment and advocate for change (RCN, 2012). ConClusionNurses need to engage with individuals and ensure that they focus their practice on the health needs of the communities or groups they serve. Nurses should also help to put power, for example designing and running local services, into the hands of patients and local communities. Globally, nurse leaders must challenge policies on the basis of health equity and nurses, both as a profession and as individual practitioners, should consider the social determinants of health as a priority for improving health and health care and reducing inequities in health outcomes for different groups in society. RefeRenCesAll Party Parliamentary Group on Global Health (2016) Triple Impact: How developing nursing will improve health, promote gender equality and support economic growth. All Party Parliamentary Group on Global Health, LondonChristensen M, Hewitt-Taylor J (2006) Empowerment in nursing: paternalism or maternalism? Br J Nurs 15(13): 695–9Hart A, Freeman M (2005) Health care interventions: making inequalities worse not better. J Adv Nurs 49(5): 502–12International Council of Nurses (2017) Nurses: A Voice to Lead: Achieving the Sustainable Development Goals. ICN, GenevaMalin N, Teasdale K (1991) Caring versus empowerment: consideration for nursing practice. J Adv Nurs 16(6): 657–62Nyatanga L, Dann KL (2002) Empowerment in nursing: the role of philosophical and psychological factors. Nurs Philosophy 3: 234–9Patterson ML, Markey MA, Somers JM (2012) Multiple paths to just ends: using narrative interviews and timelines to explore health equity and homelessness. Int J Qualitative Methods 11(2): 132–51Royal College of Nursing (2012) Health Inequalities and the Social Determinants of Health. RCN, London Smith N (2014) Nursing and change: is it time to revisit empowerment. Int J Nurs Sci 1: 134–6Suominen T, Savikko N, Kukkurainen M, Kuokkanen L, Irvine Doran D (2006) Work-related empowerment at Foundation Hospital. Int J Nurs Pract 12: 94–104Swider SM, Levin PF, Reising V (2017) Evidence of public health nursing effectiveness: a realist review. Public Health Nurs 34(4): 324–34 Villeneuve MJ (2008) Yes we can!: eliminating health disparities as part of the core business of nursing on a global level. Policy Polit Nurs Pract 9: 334–41United Nations (2014) World Urbanization Prospects. United Nations, New YorkUnited Nations Population Fund (2007) State of World Population 2007: Unleashing the Potential of Urban Growth. Available online: www.unfpa.org/publications/state-world-population-2007 (accessed 21 September, 2018)World Health Organization (2008) Final Report on the Commission on the Social Determinants of Health. CSDH, WHO, GenevaWorld Health Organization (2016) Global Strategic Directions for Strengthening Nursing and Midwifery. WHO, GenevaWorld Health Organization (2018a) Factsheet on Nursing and Midwifery. WHO, GenevaWorld Health Organization (2018b) Time to deliver: report of the WHO independent high level commission on non-communicable diseases. WHO, Geneva JCN 2016, Vol 30, No 3 278 2 6 ??JCNKEY POINTS Health inequalities are systematic differences in the health status of different population groups.  The lower an individual’s socio-economic position, the higher their risk of  poor health. Nursing has a long history of engaging with the social determinants of health. Nursing interventions to prevent illness often focus on the role of educating individuals in relation to their health-related behaviour, such as smoking, exercise, eating habits and sexual health behaviour. Nurses can be really effective in mobilising local resources and leading change. Nurses need further evidence to inform practice on how to develop interventions, strategies and skills to prevent or reduce health inequality. Awareness of the health needs and assets within any local area is essential for nursing practice both in hospital and community settings, as are the skills of advocacy, policy influence, activism and community development.

Role of nurses in tackling health inequalities

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Role of nurses in tackling health inequalities

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