In 2020, enormous cultural and health events created fissures and tensions in the United States. Through this strenuous time, nursing has been recognized as an essential profession. Despite challenges and pressures, nursing has and will continue to have a pivotal role in addressing the nation's health.
Recent progress has been noted by nurse leaders working on a consensus report on the Future of Nursing 2020-2030. The goal is to “chart a path for the nursing profession to help our nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century” (National Academy of Medicine, 2020, p. 1). Due to the need to incorporate more information on the COVID-19 pandemic's influence on nursing, the complete report has been delayed until spring 2021 (National Academy of Medicine, 2020).
TOWARD A CULTURE OF EQUITY
There is strong potential to improve health and reduce health disparity outcomes. In the last similar study in 2010, the Institute of Medicine (now named National Academy of Medicine) partnered with the Robert Wood Johnson Foundation to produce The Future of Nursing: Leading Change, Advancing Health report (Institute of Medicine, 2011). Among other goals, the report called for advancing educational attainment in nursing. A leading recommendation from the study has largely been realized; in 2019, 64.2% of the nursing workforce held a Bachelor of Science in Nursing (BSN) degree as compared with 37% in 2008 (American Association of Colleges of Nursing, 2019). Progress in nursing education was made.
Further overall progress will not be easy. Thousands who work in nursing today support a culture of acute complex care. For today's nurse, it is all we have ever known. We are drawn to the high energy and rich learning experience found in complex hospital-based nursing care. We are fascinated with emerging medical science and real-time critical thinking and problem solving. Nurses are drawn to empowerment through responsibility, the deep sense of accomplishment in work, and the sense of calling to rescue people.
I recall a particularly troubling 3 p.m. to 11 p.m. surgical intensive care shift early in my work in critical care. I was caring for a patient who was a victim of what we now call a social determinant of health; he was being treated for an infected gunshot wound inflicted in an unsafe neighborhood. Back then, I was only focused on rescuing my young patient from systemic infection. Now I think more about rescuing him from the effects of his preventable circumstance. Such effects include violence and crime, the breakdown of families, financial crises, sexual abuse and trafficking, isolation caused by social media, and online gaming. These circumstances have led to significant behavioral and mental health challenges, and thus, an opioid crisis (Cantu et al., 2020). Inherent in all these effects is a concern for health overall and concern for the health of a growing number of people.
UPSTREAM: A WAY FORWARD
Solutions must go beyond complex care rescue to examine and address the root causes of problems which are often based in social circumstances and environmental factors. New frameworks, sometimes described as upstream social determinants of health, have emerged over the past 20 years, linking societal factors to health disparities (Ratcliffe, 2017). The University of Chicago's Center for Interdisciplinary Health Disparities Research (CIHDR) described a “downward causal chain from the population (social) level to the disease (genetic) level” (Gehlert et al., 2008, pp. 3-4). The CIHDR model starts with “race, poverty, disruption and neighborhood crime; moves to isolation, acquired vigilance, and depression; then to stress-hormone dynamics; and finally to cell survival and tumor development” (Gehlert et al., p. 4).
In contrast, upstream care may be understood through this parable:
A man and a woman were fishing on the riverbank when they saw a woman struggling in the current. They rescued her. Soon, they saw a man struggling. They rescued him, too. This continued all afternoon.
Finally, the exhausted pair decided to go upstream to find out where and why so many people were falling in. They discovered a beautiful overlook along the river's edge without any warning signs or protective barriers. The couple went to community leaders to report the number of victims they had rescued and explain the connection to the unprotected overlook.
Community leaders agreed to install a protective guard and post warning signs. Preventing the problem saves resources, energy, and lives.
This parable shifts focus from downstream (individual treatment) to upstream (prevention strategies for the whole community (Merck, 2018).
That's where the culture of nursing should be going: upstream. This generates hope. The National Academy of Medicine's Future of Nursing 2020-2030 consensus study can give us hope and an opportunity to consider with fresh eyes and eager anticipation our own work in a culture of health and health equity.
A CHRISTIAN PERSPECTIVE
Addressing the difficulties of inequality, poverty, loneliness, and fear resonates with the Christian imperative in the second part of the Great Commandment, which are Jesus' words about our neighbor:
“‘Love the Lord your God with all your heart and with all your soul and with all your mind and with all your strength.’ The second is this: ‘Love your neighbor as yourself.’ There is no commandment greater than these” (Mark 12:30-31, NIV).
The account of the Good Samaritan in the New Testament is a story about compassion, neighbors, and reconciliation. In this parable, the Samaritan first rescued a half-dead man by treating his wounds. He then went further, addressing the man's social needs for safety and stability in partnership with an innkeeper, a member of his community who he engaged in his neighbor's care.
“And who is my neighbor?” Jesus replied, “A man was going down from Jerusalem to Jericho, and he fell among robbers, who stripped him and beat him and departed, leaving him half dead. Now by chance a priest was going down that road, and when he saw him he passed by on the other side. So likewise a Levite, when he came to the place and saw him, passed by on the other side. But a Samaritan, as he journeyed, came to where he was, and when he saw him, he had compassion. He went to him and bound up his wounds, pouring on oil and wine. Then he set him on his own animal and brought him to an inn and took care of him. And the next day he took out two denarii and gave them to the innkeeper, saying, ‘Take care of him, and whatever more you spend, I will repay you when I come back.’ Which of these three, do you think, proved to be a neighbor to the man who fell among the robbers?” He said, “The one who showed him mercy.” And Jesus said to him, “You go, and do likewise.” Luke 10:29-37, ESV.
Jesus made it clear in this parable that his followers are to care about and act upon the needs of people who are in our path. For nurses, this relates to our patients and clients and their families and communities. This example stretches beyond the immediatehealth need of a person to the person's social, economic, and familial needs.
In applying Jesus' mandate to care for our neighbors, there is a lot of work to do in “making things right” in today's healthcare system, as can be found in these select Future of Nursing 2020-2030 aims:
- addressing social determinants of health;
- providing effective, efficient, equitable, and accessible care for all across the care continuum;
- identifying the system facilitators and barriers to achieving this goal;
- assuring that the voices of individuals, families, and communities are incorporated into design and operations of clinical and community health systems;
- creating systems that bridge the delivery of healthcare and social needs care in the community;
- eliminating gaps and disparities in healthcare; and,
- 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 (National Academies of Science, Engineering, and Medicine, 2020).
Christian nurses are entrusted with the Good News that God, in his great love, looked down on the sins of humanity and provided for us a Savior, his son, Jesus Christ. Jesus made things right for humankind in the eyes of God. We are likewise entrusted with the love of Christ who makes things right.
The Gospel of Jesus Christ is not about healthcare; it is Good News about a love relationship with the one true living God. Only from there can we begin to explore our contribution to the health equity goals of our profession.
We are called to advance the work of reconciliation and renewal in the world. Paul describes this in 1 Thessalonians 2:4: “We speak as those approved by God to be entrusted with the gospel. We are not trying to please people but God, who tests our hearts” (NIV).
A COMPELLING EXAMPLE
A most encouraging contribution to health and health equity is happening in Memphis, Tennessee, listed as the second poorest city in the United States (Stark, 2018). The Congregational Health Network has received national attention for caring for the poorest individuals in that city. The model is driven by Black church congregations who are committed to improving the health of their communities, working through church members who serve as liaisons, some of whom are nurses.
The Congregational Health Network (CHN) joined in partnership with the 7-hospital Methodist Le Bonheur Healthcare system and 604 churches in Memphis (Cutts et al., 2017). More than two dozen clergy in the CHN devised five care pathways that support the hospital-to-home transition for church members focused on a person-centered journey of health. Clergy and other church workers partner with the hospital staff, “promoting better health by serving as role models, helping individuals adopt healthier lifestyles, encouraging use of community-based programs, and serving as links between congregants and the health care system” (Cutts et al., p. 267).
This partnership serves the population that often lacks the ability to navigate the healthcare system and arrange appropriate postdischarge care, thus leading to frequent readmissions. Outcomes of the model include a reduced mortality rate among CHN participants of nearly one-half of the rate for nonenrolled patients with similar characteristics. Other outcomes include a reduction of healthcare charges, lower inpatient admissions, and higher patient satisfaction with the healthcare (Cutts & Baker, 2014). This partnership illustrates how faith communities and faith community nurses can invest in the upstream work of reducing the effects of health inequities.
Similar faith-based models exist across the United States. These are connections and lessons from compelling faith and health examples that can propel a national health and health equity movement.
A NEW EDUCATIONAL MODEL
Population health, as a specialty in graduate nursing education, is built on three pillars: public health systems, clinical healthcare systems, and public policy. This specialty advances the concept of social determinants of health, as described in Healthy People 2030 (2020):
- economic stability (employment, food insecurity, housing instability, poverty)
- education (early childhood education and development, enrollment in higher education, high school graduation, language, and literacy)
- social and community context (civic participation, discrimination, incarceration, social cohesion)
- health and healthcare (access to healthcare, access to primary care, health literacy)
- neighborhood and built environment (access to foods that support healthy eating patterns, crime and violence, environmental conditions, quality of housing).
This list represents myriad complex drivers and underlying factors impacting health, each with separate and sometimes competing interventional models. The work to bring about health and health equity will take place against a backdrop of partisanship, fragmentation, and collective national mistrust. The effort will take place in the community and will require reconciliation among divergent ways of thinking through trust and commitment to common goals.
Christians face complex change as we engage in the hard work of reconciliation with Christ-like love as our example. In his book, Renewing Minds, author and Christian leader David Dockery (2008) frames a Romans 12 way for building community—authenticity, discernment, devotion to one another, honoring one another, enthusiasm, meaning “filled with God” (p. 95), patience, faithfulness, generosity, hospitality, blessing others, living peaceably, identifying with one another, harmony with others, genuine humility. Christian nurses take the example of Christ into their workplaces—from bedside to classroom to homeless shelter to board room.
People of a faith community often covenant with one another as one body of Christ. On a recent Sunday following a Future of Nursing 2030 Town Hall event, as I recited the words of my church's covenant written in 1837, I was struck by the relevance of those aged words to our present-day context. The covenant begins:
Thanking God for the light we have received, and for the revelation of Jesus which we now enjoy . . .
I pledge to walk circumspectly in the world; to be honest, just, and faithful . . .
Always ready for reconciliation . . .
To use our gifts for the common good; to visit the sick; to pray for each other and the world; to aid the poor and needy; and to perform other such kind offices as may be well pleasing in the sight of God. (First Baptist Church, 1837)
Let us pray for this hopeful moment in nursing's history and for those leaders charting nursing's path toward 2030. Pray that the light we have received will illuminate our way so that we may act circumspectly as strong agents of reconciliation in making things right for the health of all people. Let brotherly love abound in us. May we act boldly in the wonder of God's mighty love, knowing that God cares more and loves more deeply than we do. And may we keep our eyes fixed on God, delighting in his statutes with faith in his excellent Word.
May we journey with our profession in a most honorable culture change, continuing in hopefulness and guided by the example of our Lord, Jesus the Christ.
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