As graduates of the University of Washington School of Nursing, we read with interest Young, Bakewell-Sachs, and Sarna's 2017 commentary "Nursing Practice, Research and Education in the West: The Best Is Yet to Come." Our time at the University of Washington instilled in us a passion for recognizing and addressing structural factors affecting health, particularly population health. Although Young et al. (2017) touched on many health challenges and the priorities that funding and professional organizations have established to meet these challenges, their emphasis on-and call for-eliminating health disparities was clear. Consistent with the empirical evidence, they specifically identified social determinants of health (SDH) as important causative factors that generate and perpetuate health disparities.
From our perspective, however, the discussion of the SDH and the links to improving population health fell short-particularly in the recommendations made for advancing nursing practice, research, and education. Despite Young et al. (2017) identifying poverty and education as two of many SDH, their text primarily focused on efforts to modify the individual rather than the contextual and structural conditions that have been shown to drive select within-individual factors (including behavioral and biological processes). The authors referred to concepts at the individual level (i.e., "person," "self-management," "personalized;" p. 264) despite noting that the future is being shaped by the larger socioecological environment. The vision for nursing practice centered on advanced practice registered nurses providing primary care to patient populations and procuring full practice authority-practices occurring largely with individual patients. In the section on nursing research, Young et al. (2017) underscored symptom science, wellness, self-management, and end-of-life and palliative care as priority funding areas, all of which again transpire at the individual level. Finally, in their vision of nursing education, the authors recommended that nurse educators prepare nurses who can tackle "population health priorities" (p. 267). We strongly agree with this statement but question how this recommendation can be met when nurse educators reinforce individualized, evidence-based practice while continuing to focus student learning at the individual level.
It is not "population and [emphasis added] health issues" (p. 266) that are confronting today's nurses, but rather population health issues. The patterning of disparate health outcomes at the population level necessitates interventions at structural and systems levels. Much like Young et al. (2017), we too are eager to be part of solutions that will contribute to eliminating health disparities. Bassett (2015, p. 1087)-in calling for critical research, institutional reformation, and public advocacy-exhorts health professionals not to "sit on the sidelines" with respect to differences in health outcomes. We echo this counsel and encourage our colleagues to be active participants in achieving health equity through crafting solutions that tackle structural determinants of health.
Denise J. Drevdahl, RN, PhD
University of Washington Tacoma
Shawn M. Kneipp, PhD, RN, ANP-BC, APHN-BC, FAANP
University of North Carolina at Chapel Hill
RESPONSE FROM THE AUTHORS
When asked to write this paper (Young, Bakewell-Sachs, & Sarna, 2017) marking a major milestone for the Western Institute of Nursing (WIN), the opportunity sparked rich conversation among us as authors, and we hoped that our paper would spark further conversation among readers. Thank you to the respondents for adding their thoughts and perspective to the dialogue. The readers are referred to the more comprehensive papers on the topics of practice, research, and education that formed the backdrop for this article, available on the WIN website (see https://www.winursing.org/2017-state-of-the-science-presentations/).
Our paper provided a regional perspective for approaching the past, present, and future of the WIN region (Western United States). We believe that a focus on both populations and health issues in the West is appropriate as population health occurs at many levels, from the local to global communities. Although there are some commonalities, there are also important differences across the 13 states due to differences in demographics, economics, history, community resources, and predominant health issues. Providing a regional perspective is rare in discussions of nursing scholarship. An awareness of regional health issues and healthcare challenges is important for scholars as they address the structural barriers requiring policy change.
We appreciate the respondents' emphasis on the importance of SDH and population health in addressing health and healthcare in the United States. We agree that the paper could have gone further in emphasizing larger societal issues that would mitigate SDH and potentially support and help to define population health, yet we disagree that our focus was on "modifying the individual." Opportunities for individual and societal intervention abound at all levels, including the individual, the family, the community, the region, the nation, and globally. Nursing is relevant at all these levels, and-within our profession-scholars, educators, and practitioners have their respective impacts. Improving or modifying current healthcare delivery is vitally important to transforming our systems of care. Continuity of care, for example, where individuals remain connected throughout a system of care, could lead to progress toward improved population health. Comprehensive primary care offered through evidence-based standards of practice with advanced practice and registered nurses would support individuals within the context of their circumstances and could explicitly address SDH. Furthermore, our education should be designed within a framework of inclusion and an understanding of SDH using interprofessional guidelines for such an approach (National Academies of Sciences, Engineering, and Medicine, 2016).
We agree that nurses can contribute significant advocacy to address the contextual and structure conditions affecting health equity, including racism, ageism, sexism, and homophobia. Some of our nursing colleagues in the West, identified as Edgerunners by the American Academy of Nursing, have been addressing these SDH through policy efforts for many years (see http://www.aannet.org/initiatives/edge-runners).
We urge all our nursing colleagues to accelerate their efforts to achieve health equity and to recognize the importance of their collective impact in creating the future that we prefer in practice, research and education.
Heather M. Young, PhD, RN, FAAN
University of California, Davis
Susan Bakewell-Sachs, PhD, RN, FAAN
Oregon Health & Science University, Portland
Linda Sarna, PhD, RN, FAAN
University of California, Los Angeles
REFERENCES