Social Justice For Health Equity In Nursing Essay

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In the US and around the world there are increasing concerns about inequity and a lack of fairness for many members in our society. What do you think the professional role of a nurse is when it comes to addressing equity in health care?Social Justice For Health Equity In Nursing Essay

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The Liaison Committee on Medical Education recommends that US medical school
curricula “appropriately address” cultural competence and health disparities, and build solutions
to reduce health disparities (Liaison Committee on Medical Education, 2015). However, the
current reality of deeply entrenched structural inequities across race, class, gender, and social
privilege makes it a challenge for students to grasp health equity solutions. Can health
professional education truly create educational and training opportunities for students to explore
health equity solutions that reduce health disparities? Classroom lectures about social justice can
send the message that these values are mere platitudes without practical meaning and concrete
examples that actually promote and improve the health of socially disadvantaged groups.
This paper illustrates how social justice principles and values can be integrated into
professional graduate education through self-reflection, self-direction, advocacy, and
collaborative learning opportunities. We are all ethics educators in various disciplines at Loyola
University Chicago. First, we discuss the social justice foundations of health equity. Then we
share lessons learned from incorporating social justice concepts in our courses in bioethics,
medicine, nursing and law. Our hope is that our educational innovations can help foster greater
recognition of the importance of social justice education and how it can be successfully
integrated in various professional educational settings.
Social Justice and Health Equity Concepts
Health equity, defined simply as the elimination of health disparities, can be
conceptualized as two separate parts: 1) the principle of health equity as a vision to aspire
towards, and 2) the practice of health equity as the action needed for current structural change to
occur (Stone, 2013). The principle of health equity is built upon the justice as fairness principle
and is widely accepted. John Rawls’ “justice as fairness” theory has been one of the most
influential views of social justice over the past 40 years (Daniels, 2001). The theory states that
human beings possess certain basic rights, and in order for society to function effectively
members should have equal access to opportunities, and inequalities should be limited. Although
Rawls’s justice as fairness theory does not specifically address health, it has been highly
influential among thinkers and policymakers in democratic societies (Rawls, 1985).Social Justice For Health Equity In Nursing Essay
The practice of health equity is frequently debated in recent works focusing on global
perspectives of justice and health. Amartya Sen takes a practical approach to justice and
describes justice in terms of capabilities. He suggests that the ability to achieve good health must
include an evaluation of the freedom a person may have to function (Sen, 2005). Moreover
Beauchamp and Childress have re-invigorated the contested debate on social justice by adding
more recent content on allocation of goods and services, rationing and setting priorities, with US
examples from the Oregon Health Service plan in more recent editions of their venerable book
Principles of Biomedical Ethics (Beauchamp & Childress, 2008). Political and public
stakeholders disagree on the specific aspects of fair allocation of health care resources compared
to other vital interests, such as education, housing, and defense. Despite these disagreements, the
basic concept of social justice is seen as critical to ethical decisions in healthcare and plays a key
role in resource allocation across health care debates.
In its simplest form, the process of justice means to act to promote fairness and equality.
According to Beauchamp and Childress, “[d]istributive justice refers broadly to the distribution
of all rights and responsibilities in society including civil and political rights” (Beauchamp &
Childress, 2008). Retributive justice refers to what is merited or deserved. Social justice
incorporates both of the above components and might be explained as “all groups and individuals
[being] entitled equally to important rights . . .” (Levy & Sidel, 2006).
Social justice processes might also encompass the notion of equity. Levy and Sidel
(2006) define equity as follows:
Equity in health can be defined as the absence of systematic disparities in health (or in the
major social determinants of health) between social groups that have different levels of
underlying social advantage or disadvantage.
The Loyola Model for Integrating Social Justice in Graduate Education
Consistent with our Jesuit mission, “…a diverse community seeking God in all things and
working to expand knowledge in the service of humanity through learning, justice and faith,” the
Loyola University Chicago balances social justice principles and practice through self-reflection,
self-direction, advocacy, and collaborative learning opportunities in many courses. We will share
a few examples of lessons learned from curricular and elective courses in bioethics, medicine,
nursing, and law (see Table 1).Social Justice For Health Equity In Nursing Essay
Table 1: Course Program and Description
Course Name Type Length
Learning Opportunity *
Justice and Bioethics Bioethics/Cur
15 SR
Patient Centered Medicine Medicine/Cur
48 SR
Cultural Competence in Health
8 SR, SD, A, C
Bioethics and Professionalism Bioethics/Elec
36 SD, SR, A, C
Social Justice Elective Bioethics/Elec
8 SR, SD, A, C
Medical Legal Partnerships Law/Elective 15 SR, SD, A, C
Clinical Nursing Nursing/Curri
15 A
*self-reflection (SR), self-direction (SD), advocacy (A), collaboration (C)
Social Justice through Self-Reflection Learning Opportunities
The Loyola Justice and Health Care course allows students to use self-reflection to explore
global and local social justice issues. This online course evolved over time. Initially, it focused
solely on health care and justice issues in the US. The instructor of this course (KP) decided to
expand this course and make it more cosmopolitan in its scope. This change occurred after the
instructor took an immersion trip to East Africa where he was confronted with many serious
health disparities. These disparities were sharply illustrated by the HIV/AIDS epidemic which
had left numbers of orphaned children in East Africa. Thus, he added more readings by authors
who address global health injustices (e.g. Paul Farmer). Students in the course were required to
interview an individual who was working toward greater justice in health care, locally,
regionally, nationally or globally. Lastly, guest speakers were invited to speak about issues
related to justice and healthcare. These assignments and structural changes to the course
encouraged students to reflect on the theoretical issues of social justice in a more accessible way
and the presentations show students how key leaders in medicine start and sustain health equity
solutions. It builds on the notion of doing, reflecting and contextualizing, as described by our
colleagues Mark Kuczewski, et al. (Parsi & Sheehan, 2006), with regard to how justice is taught
to medical students at Loyola University Chicago Stritch School of Medicine.Social Justice For Health Equity In Nursing Essay
Efforts to integrate social justice in the medical school curriculum are not entirely novel.
For instance, schools such as the University of Michigan Medical School (Kumagai & Lypson,
2009), Geisel School of Medicine at Dartmouth (Coria, et al, 2013), and the John A. Burns
School of Medicine at the University of Hawaii (Schiff, 2012), have all reported on their
individual efforts to integrate the concept of social justice in the medical school curriculum. Here
at Stritch, we have integrated social justice issues in our curriculum within our Patient Centered
Medicine course (PCM) through self-reflection learning opportunities. This is a three-year
longitudinal course that equips students with many basic competencies in clinical care. In PCM1, students are introduced to the basics of taking a complete medical history. In addition, they are
given lectures on professionalism, clinical bioethics, and the US health care system. There are
also lectures and small group discussion to reflect on health disparities, cultural humility and
global health. In our small group exercise for this session, we quote a physician who gave an
ethics grand rounds at Stritch several years ago:
Physicians play a key role in eliminating health care disparities. One of the ways they can
prevent disparities is to be more aware of cultural barriers to health care. Each patient has a
unique story, culture, value system, language, experiences, phobias, interests, habits, etc. that
will determine how they view and participate in their well-being. The patient may also have
experienced a history of oppression which could have physical and psychological
consequences, such as depression, anger, or a sense of fatalism. These are other factors that
may influence approaches to healthcare. (Boyd 2009)
We also integrate social justice in the third year of PCM (PCM-3). In fact, two of the
learning objectives of this course relate to issues of social justice:
 Analyze the obligation of the medical profession to promote the health and well- being
of the public.(O1)
 Define social justice and analyze its role in medical professionalism. (O2)
PCM-3 is structured a bit differently from PCM-1 in that the students gather every 6
weeks to reflect on their experiences as third year medical students. These reflection exercises
allow students to make greater meaning of issues related to health disparities, health equity, and
social injustice. As our colleagues have written elsewhere, our “students need an opportunity to
integrate this sense of justice both cognitively and affectively” (Parsi & Sheehan, 2006). Thus,
the process of integrating a sense of social justice requires doing, reflecting and contextualizing,
something our students do routinely within PCM.
Social Justice through Advocacy
The Loyola Cultural Competence in Health Care course is an 8-week blended course with
online and in-class learning activities that promotes social justice values through self-reflection,
leadership, and advocacy learning opportunities towards health equity solutions. In the course, a
culturally competent health care system is defined as “[a system] that acknowledges and
incorporates—at all levels—the importance of culture, assessment of cross-cultural relations,
vigilance toward the dynamics that result from cultural differences, expansion of cultural
knowledge, and adaptation of services to meet culturally unique needs” (Betancourt, et al. 2003).Social Justice For Health Equity In Nursing Essay
The course allows students to reflect on the individual, organizational, and structural factors that
could promote culturally competent health care systems. The topics cover the ethical challenges
of recognizing unconscious bias and implementing solutions to reduce racial and economic
health disparities. Students work in small groups to practice cross-cultural communication skills
and evaluate institutional change strategies presented by health system administrators. For the
final project, students prepare a multi-media proposal to reduce health disparities that is shared
with relevant stakeholders. For example, a student proposed an education and enrollment
program for Hispanic families to increase awareness and enrollment in health care coverage
under the Affordable Care Act. This project was designed in partnership with Hispanic
undergraduate students. Overall, the course reflects the Jesuit concept of social justice that
advocates for the well-being of all by promoting student advocacy. Cultural competence is a
practical concept that can be used effectively to promote the Jesuit concept of social justice by
training competent health care professionals to reduce health disparities and promote health
The final project challenges students to identify current health disparities and develop
actionable health equity solutions. For example, a student working full time in an outpatient
setting was concerned that she was not in a leadership position, and therefore did not have
enough influence to bring about meaningful change in the institution with regard to reduction of
health disparities. Through the course she developed a proposal illustrating how language was a
barrier for some patients and that bilingual materials and signage in key locations could reduce
or eliminate this barrier for some. This proposal made the organization aware of the problem
posed by language, improved the language services provided to non-English speakers, and
opened the door for future cultural and language standards, through policy or organizational
change. The final project allows students to practice advocacy skills built on justice principles.
Social justice in nursing education has long been embedded in the general commitment of
nurses to the practice of caring for people, advocating for patients, and seeking to meet the
holistic care needs of those they serve. Florence Nightingale (1859) wrote about such ideals in
her “Notes on Nursing: What it is and What it is Not.” The American Nurses Association (ANA,
2001) in their Code of Ethics for Nurses preface list nine provisions with the view that “Nursing
has a distinguished history of concern for the welfare of the sick, injured, and vulnerable and for
social justice. This concern is embodied in the provision of nursing care to individuals and the
community.” The first provision in this code emphasizes that nurses practice “with compassion
and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by
considerations of social or economic status, personal attributes, or the nature of health problems”
(ANA, 2001). In addition, the National League for Nursing (NLN, 2015), one of the national
accrediting bodies for colleges of nursing, notes that “[in] nursing education, the majority of
sources regarding justice focus on the clinical preparation of undergraduate students to meet the
needs of culturally diverse populations.“ As such, cultural competency is closely associated with
social justice in nursing education. The American Association of Colleges of Nursing (AACN,
2008) defines cultural competence in nursing education as “the attitudes, knowledge, and skills
necessary for providing quality care to diverse populations.”
Although accrediting bodies, colleges of nursing, nursing students, and professional nurses
alike may agree on the need to practice nursing in a way that is ‘just’ using a broad philosophical
definition of providing non-judgmental care, nursing educators are not always clear on how
social justice should be taught in a way that it will become integral to practice. In the article
‘Challenging the Coherence of Social Justice as a Shared Nursing Value,’ M. Lipscomb (2010,
p. 4) argues that perhaps there is not one particular definition that is shared by the nursing
profession. He states that (nurses) should not “assume that social justice describes a clearly
understood, self-evident, and irrefutable good” and that it is false to accept “social justice as a
shared nursing value produces a uniform set of practical actions or outcomes.” These debates
reflect the challenge between social justice principles and practice in nursing education.Social Justice For Health Equity In Nursing Essay
Despite the fact that nursing education and practice may not have a consensus definition for
what the term social justice means and how it is translated into the care of patients, there has
always been a foundational belief that nurses advocate for those they take care of. This
advocacy role should not be interpreted as an exclusive one for nurses –– all health professionals
are called to do this. Nurses, however, often spend more time with the patient and their loved
ones at the bedside, in the clinic and in follow up care activities. As a result, nurses may have
knowledge beyond the medical facts of a patient’s history, appreciating the social, cultural,
economic, and spiritual aspects that can influence patient care (Fisher, et al, 2007). For example,
a patient may tell the nurse during an admission assessment to the hospital that she has no help at
home to assist in her care at discharge and has little money to pay for help and thus is afraid to
go home. Because the nurse is aware of this information early in her hospital stay, referrals for
home care services, transportation and such can be arranged and the patient may have less
anxiety about discharge. This provides advocacy for patient care needs for discharge as well as
social justice aspects of care related to resource allocation and cultural competence.
With regards to our pedagogical approach with nursing students, the undergraduate nursing
students at Loyola have a 6 credit hour leadership course that helps them develop critical
thinking skills as well as global health issues that impact on patient care. At the graduate level,
there is a 3 credit hour bioethics course as well as research and policy classes that are designed to
integrate social justice education for the various specialties. The graduate nursing program at
Loyola includes a mandatory 2 credit hour bioethics course as well as a 1 credit hour health
policy course that includes discussions about cultural, religious, and social/public policy in the
context of professional conduct and patient care. These classes are both offered online or inperson and the vast experience of the students makes the topic discussions very meaningful.
The overall awareness and application of social justice in nursing practice at both
undergraduate and graduate levels is best taught during clinical rotations when the student is
providing care to individual patients. For example, the clinical instructor can review with each
student their assigned patient and point out specific social needs that might need to be explored
in order to provide the best plan for care, discharge, and follow up needs of that patient.
Social Justice through Self-directed Learning
In addition to integrating social justice within the formal curriculum, we also integrate justice
into our extracurricular offerings through self-directed learning opportunities. The Bioethics and
Professionalism Honors Program at Stritch aims to encourage and enhance the development of
the character and intellect of its students outside of the traditional curriculum. Stritch has a large
number of students who are active in a largely self-directed curriculum related to bioethics,
service to the underserved, leadership, and professionalism. The Bioethics and Professionalism
Honors Program requires students to document and reflect upon this self-directed curriculum
systematically. The program provides a formal structure for students to enhance their
knowledge and awareness of bioethics and professionalism issues while undertaking a range of
activities in these areas.
Students enter this extracurricular program in January of their first year and complete it in
June of their third year. They are paired with a faculty advisor who provides feedback on their
work. The requirements of the program include the following: setting annual goals related to
their bioethics and professionalism activities and knowledge, reflecting on those activities in
the student’s online portfolio, attending seminars, and completing a capstone proposal and
project. Some of the topical seminars focus on issues of social justice, social health
determinants and disparities, and service to the underserved. Students spend 1-2 years
planning, undertaking and completing their capstone project which may be empirical/clinical,
pedagogical, service-oriented, or conceptual in nature. Many of these projects involve issues of
social justice and focus on underserved communities and groups. Students present their project
as an academic resource, primarily posters, at the end of their third year and are evaluated by
faculty. Students who complete this program are eligible for a fourth year elective designed to
write up and submit their capstone project for publication.
We also offer an elective course on social justice and underserved minorities for students
from first year to fourth year. This course addresses the role of race in medicine, particularly
structural inequities that perpetuate disparities (e.g. access to health care, education, and
income). Medical students create a health care conference in partnership with a local high
school to learn about the barriers to healthy living in an underserved community. Students
explore the intersection of social structures of power and privilege and the practice of medicine
in this course and practice creating culturally tailored solutions to improve community health
in partnership with high school students.
Social Justice through Collaborative Learning Opportunities
As educators, we are expected to translate ethical principles into meaningful action for
our students. One way to accomplish this is through collaborative and experience-based learning
that represents the health professionals providing care, as well as the communities in need of
care. Collaborative partnerships are well recognized as a best practice to reduce health disparities
while linking social justice principles to practical actions (Fisher, et al, 2007). A medical-legal
partnership (MLP) is an ideal method to operationalize the academic experiences in nursing,
medicine, law as well as other health care professional programs. According to the National
Center for Medical-Legal Partnerships, an MLP
aims to help vulnerable populations navigate the complex legal systems that hold
solutions to many problems associated with social determinants of health. By integrating
legal assistance into the medical setting, MLP helps . . . communities mitigate the social
stressors that affect their health so that they can get and stay healthy (Health Justice
Project, 2015).Social Justice For Health Equity In Nursing Essay


This partnership offers something different:
The medical-legal partnership model is unique because it bridges patient to population
level interventions and also adds a level of institutional systems change. Health and legal
services are integrated, rather than operating as a referral mechanism, leading to longterm, sustainable, more effective solutions to health – and legal – problems (Health
Justice Project, 2015).
This approach is increasingly relevant given the systemic nature of healthcare delivery
challenges. No longer can communities and professionals accomplish their goals by taking a
siloed approach, but rather all must work together sharing resources, avoiding duplicative or
unnecessary services, and ultimately improving the health of those whom they serve. Loyola’s
Law School, in partnership with the Erie community clinic, offers a medical-legal partnership
clinic for students from social work, public health and medicine. They learn collaboratively to
tackle housing, homelessness, and environmental policy cases (National Center for Medical
Legal Partnership (2014).
The approach of an MLP is intended to be preventive to avoid an urgent legal crisis in the
future. In fact, one of the core components of an MLP, according to MLP experts Megan Sandel,
et al., is to provide “legal advice and assistance to patients, with a focus on the early detection of
legal problems and the prevention of legal crises and health consequences” (Sandel, et al, 2010).
This is integral to promote social justice in health care. According to Sandel, et al. (2010),
“medical-legal partnerships can work with government agencies to change laws and policies
affecting low-income populations.…they can encourage the enactment or amendment of laws
and regulations to benefit vulnerable populations.”
Both the American Medical Association (2009, p. 4) and the American Bar Association
(2007, p. 2) passed resolutions supporting these partnerships. Through teaching the foundations
of social justice in our academic programs we can prepare our students to apply this knowledge
in a concrete way to not only understand social justice but to effectuate it as well. Graduate
education programs in bioethics, public health, nursing and medicine are all uniquely positioned
to partner with community legal resources or may even have the benefit of a law school with a
legal clinic within their university. Social Justice For Health Equity In Nursing Essay
In order for health equity solutions to flourish and be sustained, the role of social justice
must be incorporated into the education and development of bioethics, nursing, medical, and
legal professionals. By bringing these professional groups, all of whom are committed to social
justice, to act in the classroom and outside of the classroom through self-reflection, selfdirection, advocacy and collaborative learning promotes social justice in a meaningful and
tangible way. Below is a list of resources for integrating social justice in health professional
graduate education (Table 2). We hope that the educational examples we have described here
will foster greater attention to health equity solutions to reduce racial and economic health

What Is Social Justice in Nursing?
Social justice guides the creation of “social institutions” and the individuals who collaborate with these institutions, according to the Center for Economic and Social Justice. Health care facilities, such as hospitals and private clinics, are examples of social institutions. Created to help people live longer and happier lives, health care facilities provide a positive social service. In turn, individuals such as nurses, patients, community members, and politicians influence change in these institutions. Through their feedback, such as lobbying to lower health care costs, creating custom care plans, and reporting malpractice, the institutions become more accessible for everyone.Social Justice For Health Equity In Nursing Essay

Each person has the right to access high-quality health care. Unfortunately, inequality in the health care system remains. African Americans, Hispanics, and Asian Americans are sicker than the rest of the country. And, according to the American Public Health Association (APHA), over a third of the direct medical costs of individuals in these three groups are a result of health inequalities, such as poor access to quality health care or unconscious racial bias.

From a nursing perspective, the goal is to help each patient attain his or her full health potential. However, many health care treatments are cost prohibitive because of high insurance deductibles and medical costs. Other disparities such as lack of access to quality food and technology also can limit the ultimate success of a patient’s health care.Social Justice For Health Equity In Nursing Essay

Developing a culturally competent practice is also at the forefront of social justice in nursing. According to the Pew Research Center, between 2015 and 2065, immigrants will account for 88% of U.S. population growth. Nurses must educate themselves on different cultural values and communication styles to create encompassing care plans and promote positive health outcomes.

How Nurses Can Ensure Social Justice in Care Delivery
All nurses uphold a code of ethics set by the American Nurses Association (ANA) that guides decision-making in the nursing profession. One of these ethical obligations identifies the need for nurses to act when there’s social injustice in health care delivery.

With a post-graduate education in nursing such as a master’s-level degree, advanced practice nurses have the knowledge to develop, implement, and oversee policies that ensure social justice in their nursing practice. Acting as primary care providers, nurse practitioners can deliver high-quality care at a comparatively low cost to vulnerable segments of the population that include the following.Social Justice For Health Equity In Nursing Essay

Expecting mothers. Women’s health care nurse practitioners (WHNP) use their specialized and advanced education and certification to help expecting and new mothers who cannot access an obstetrician or gynecologist. WHNPs can lead community outreach programs to educate expecting mothers and conduct home visits to improve the health outcomes of the mother and baby. WHNPs must be certified through boards such as the National Certification Corporation, which ensures expecting mothers are receiving safe, high-quality care.
Rural residents. Residents in rural areas often have limited access to primary care providers because of physician shortages. Advanced practice registered nurses (APRN) who can operate with full autonomy, such as in diagnosing patients and prescribing medications, can increase access opportunities and health outcomes for rural citizens.
Patients with chronic conditions. Twenty-five percent of Americans have two or more chronic conditions, such as diabetes and high blood pressure, according to a recent report in Health Affairs. However, managing these conditions is disjointed and accounts for about 75% of health care spending. Using a patient-centered approach to care, nurse practitioners, such as adult-geriatric nurse practitioners (AGNP), can reduce patients’ medical costs and improve health outcomes of patients with multiple conditions.Social Justice For Health Equity In Nursing Essay
The Skills of an Advanced Practice Nurse
Each advanced nurse practitioner must possesses a set of key competencies to ensure the promotion of social justice in a clinical setting. APRNs need to have strong communication and critical thinking skills to address health care concerns in their communities. Using a collaborative approach and incorporating feedback from patients, team members, and the community, APRNs can improve the delivery of services in their practices.

These competencies support the essential skill for advanced practice nurses: leadership. Advanced practice nurses need to make consistent, ethical decisions in their practice. Many of these decisions aim to remove health disparities and improve the health outcomes of their community. Advanced practice nurses also may work outside of their practice alongside community members, such as law enforcement or housing development, to address discrepancies in health care and deliver effective programs.

Social Justice and Advanced Nursing Education
Aspiring advanced practice nurses can develop their knowledge and leadership acumen through graduate education such as Regis College’s online Master of Science in Nursing (MSN) program.Social Justice For Health Equity In Nursing Essay

Students can pursue one of the following concentrations.

Adult-Geriatric Nurse Practitioner
Family Nurse Practitioner
Pediatric Nurse Practitioner
Psychiatric Mental Nurse Practitioner
Women’s Health Nurse Practitioner
Each concentration prepares students to serve the unique needs of a specific population. Students who complete the coursework learn to think critically about the health care system and how they can implement initiatives to improve patient safety and quality.

Influence Social Justice and Change
History records the pulses of social change. Nurses who want to lead change and promote social justice in nursing can benefit from advanced education. Key leadership skills and other competencies are needed to effectively deliver health care in an ethical manner that promotes social justice. Visit Regis College’s online Master of Science in Nursing program to start advocating for positive change in health care. Social Justice For Health Equity In Nursing Essay

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