Structural justice and nursing: Inpatient nurses’ obligation to address social justice needs of patients

Introduction

If one were to name a person with the knowledge about and influence over social justice issues, one would likely think of a politician or a non-profit leader or a policy writer. It is unlikely that one might name a bedside nurse. While justice is widely accepted as an important principle in healthcare ethics, it is rarely a prominent feature of bedside care. Generally, inpatient nurses are only expected to care for their patients while they are acutely ill. Yet, few can understand the impact of inadequate social justice on vulnerable populations and speak to their needs in the way that inpatient nurses can. These professionals witness firsthand the results of social injustices such as food deserts, poor housing, or lack of access to healthcare and how they impact health. Inpatient nurses may gain a deep understanding of their patients’ issues as they work directly at the bedside over long shifts, caring for both patients and their families. Subsequently, these nurses may be able to speak to the results of the structural injustices that impact their patients, as well as their patients’ perspectives and vulnerabilities.

The intention of this article is to argue for reconceptualizing the role of inpatient nurses to include obligatory involvement in social justice issues that impact their patients or potential patients. I discuss the current ethical obligations of nurses outlined in various codes of practices (as they relate to justice), the rationale for an individual social justice obligation, the intersection of hospital care and justice, and how the creation of an obligation to social justice needs might impact inpatient nurses and their actual and potential patients. Because I argue that addressing social justice issues is an obligation of all nurses, I will also discuss how this might be better integrated into the job description and function of inpatient nurses. Furthermore, I offer some initial ideas for what this obligatory involvement might look like and how it could be operationalized, with the aim of generating further discussion and solutions. It should be noted that for this article, the focus of social justice is narrowed to the issues that impact patient hospitalizations. Whether nurses have an obligation to even broader social justice issues of society that go beyond impacting hospitalizations and what that obligation might entail must be left to a future discussion. By the end of this article, I intend to have convinced readers of the following: first, individual nurses have an ethical obligation to address the social structural justice needs of their patients; second, healthcare institutions should revise the job descriptions and roles of bedside nurses to incorporate this obligation; and third, fulfillment of this obligation will benefit patients, nurses, healthcare institutions, and society.

Defining justice

There are many definitions of justice and theories of social justice, and there is no room within the constraints of this article to further the debate on the best definition or theory. It is necessary, though, to stipulate a definition for the purposes of clarity and understanding within this article. Thus, I will use Nussbaum’s ¹ capabilities approach to justice. Her approach seeks to understand and meet the needs of individuals and empower humans to live fully developed lives. Instead of a distributive approach to justice, which attempts to redistribute goods and services to those in need, a capabilities approach can address underlying social structural issues that create injustices and vulnerable populations. Nussbaum ¹ proposes a list of central capabilities, which she contends are necessary to live fully developed lives within a society. Within discussions of justice in healthcare, the most pertinent capabilities are those of life and bodily health, but Nussbaum’s ¹ list of capabilities also include various freedoms and the ability to enjoy multiple aspects of life, which are all relevant to justice as a whole.

In this article, I will consider the question Nussbaum ¹ proposes asking when assessing justice: “What is each person able to do and be?” (p. 18). This question must be asked of patients and populations who are vulnerable to social injustices that lead to poor health and preventable hospital admissions. This question must also be asked of the nurses, who could be better social justice advocates, but may be limited in how much they can or should advance social justice issues that some may argue are outside of their primary roles and basic job requirements.

Ethical obligations of nurses

A reasonable start to the discussion of nurses’ obligation to social justice needs is an examination of professional nursing guidelines. The United Kingdom’s Nursing and Midwifery Council (NMC) ² published a professional code for nurses that offers guidelines on the expectations of how nurses should practice. While their code does not explicitly use the word “justice,” the concept of justice is addressed in the section on ensuring nurses meet people’s physical and psychosocial needs. The code contends that nurses meet this need by fostering well-being, facilitating preventive healthcare, and advocating for vulnerable people, ² all of which are modes of meeting the needs of justice. Thus, one can infer that the NMC’s Code endorses nursing involvement in working toward achievement of justice in healthcare.

The American Nurses Association’s (ANA) ³ Code of Ethics for Nurses’ third provision states, “the nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (p. 9). This provision does not explicitly include the duty to address the underlying social injustices that impact the health of nurses’ patients. Social justice is, however, addressed in the ninth provision, which states, “the profession of nursing, collectively through its professional organizations, must…integrate principles of social justice into nursing and health policy” (p. 35). ³ Interestingly, while most of the provisions of the ANA’s ³ Code of Ethics address the responsibility of nurses as individuals, the ninth provision suggests that meeting social justice needs is a collective responsibility to be achieved through group efforts. I suggest that stipulating an individual responsibility would improve engagement in social justice issues and improve outcomes due to the additional work of a higher number of individual nurses.

Other countries’ nursing codes of ethics do, in fact, place a larger responsibility on individual nurses while also explicitly using the term “social justice.” Both the Code of Ethics of the Canadian Nurses Association (CNA) ⁴ and the Code of Ethics jointly put out by the Australian Nursing and Midwifery Council, the Australian College of Nursing, and the Australian Nursing Federation (ANMC, CAN, and ANF), ⁵ stipulate that social justice issues are both a collective and individual responsibility of all nurses. Each of these organizations’ codes, however, is written as general guides and do not detail how these obligations to social justice needs are to be met. Thus, determination of the obligations of nurses working in an inpatient setting requires further examination.

Proposed obligations of individual nurses

Because of variations in the language in the codes of ethics, clarification is needed regarding whether individual nurses do in fact have an obligation to meet social justice needs. I contend that such an obligation is ethically necessary for individual nurses. A nurse may be meeting some of his or her patient’s justice needs by restoring health and by collaborating with the patient, their family, and other healthcare professionals to make a plan to maintain that patient’s health. However, this does not address the underlying structural problems that lead to a preventable admission. Rather, in order to account for Nussbaum’s broader justice concerns, addressing structural justice should, in fact, be the obligation of all nurses individually.

Mason ⁶ argues that nurses are obligated to address the underlying issues that lead to poor health and asks, “if your profession’s raison d’etre is to promote the health and well-being of individuals, families, and communities, then how can you not address the upstream factors that interfere with this?” (p. S49). She suggests that healthcare’s current focus on acute care rather than preventive care means that poorer and disadvantaged populations are more vulnerable to illness and suffering. ⁶ She further suggests that inpatient nurses who see the results of this inequality and suffering must speak out and become involved in repairing underlying structural injustices. ⁶ Social structure issues such as poor housing, food deserts, and lack of access to preventive care are intricately linked to the upstream factors that Mason ⁶ refers to. At its most fundamental level, nursing is a profession of caring and health promotion. How, then, can a nurse completely meet his or her patients’ health needs without addressing underlying social injustices that preclude optimal health? He or she cannot, which is why the obligation to social justice should belong to nurses both collectively and individually.

In a discussion of practical application of the ANA’s Code of Ethics, Lachman et al. ⁷ suggest that nurses may engage in volunteer work outside of their normal positions in order to address social justice concerns. This is a laudable suggestion, and, indeed, many nurses are engaged in volunteer work in groups that promote social justice. While this volunteering does fulfill the obligation to address social justice concerns, obligating nurses to perform extra duties while “off the clock” is unfair. Nurses should have available ways to meet this obligation during their work days. I agree with Nussbaum’s ¹ contention that individuals should have the ability to choose their own recreational activities and political associations, so creating an obligation of social justice involvement outside of nurses’ place of employment risks violating justice for nurses. Yet, this argument does not absolve nurses of an obligation to social justice within their workplace. Therefore, I would argue that inpatient nurses’ job descriptions should be written to include involvement in discussion of and intervention in the structural injustices that impact their patients. Later in this article, I consider the integration of a social justice obligation into nurses’ roles in more detail.

Healthcare institutions’ mission and vision statements often incorporate language about addressing broader healthcare needs of society. Thus, involvement of staff in social justice concerns is not a novel idea or a huge stretch of imagination. Incorporating front-line staff such as bedside nurses into addressing social justice issues would add diversity and perspective when working toward achieving healthcare institutions’ broader goals.

Many might disagree with inpatient nurses being involved in addressing social justice needs however. Indeed, inpatient nurses have demanding jobs that generate high stress. In discussing the ethical obligations of nurses, Lachman, et al. ⁷ note that compassion fatigue and burnout may inhibit nurses from meeting professional ethical obligations. By demanding that inpatient nurses add social justice projects to their already numerous responsibilities, we must consider that this may increase job-related stress, pull nurses from short-staffed units, and carry the risk that nurses will become overworked or exploited. Thus, to make room for an obligation to address social justice needs and ensure a positive outcome for both nurses and their patients, nurses’ other responsibilities must be lessened or reorganized.

Justice for patients (and potential patients)

First, then, we must ensure that the suggested obligation is reasonably beneficial to patients and important enough to add to the responsibilities of nurses and shift them away from bedside care as part of their normal workflow. Inpatient direct care providers spend much of their time and energy focused on the specific patients under their care and these patients’ individual needs. Because Nussbaum ¹ lists life and bodily health as necessary capabilities, one might argue that direct care providers are providing justice by working toward improving the health and functioning of their patients. Yet, this is an inadequate provision of justice because it is specific to hospitalized patients only, is reactive rather than proactive and preventive, and fails to mitigate underlying causes or exacerbating factors. Surely, the capability of bodily health is better promoted by preventing health problems in the first place rather than treating resultant issues or even preventing recurrences.

The issues of hospitalized patients often stem from social injustices. Patients may become ill because they lack transportation to a primary care provider, because they cannot afford to refill their maintenance prescriptions, because they can only afford housing in a neighborhood with environmental issues, or because of other structural problems beyond their control. Reactive care is problematic on at least three levels. First, certain populations become more vulnerable to poor health necessitating hospitalization. Second, treatment of the health problems that arise from social injustices may be costlier than prevention of the issues in the first place. Third, and most fundamentally, justice requires an infrastructure that meets the capabilities needs of all members of a society, minimizes the need for reactive care, and provides attention to and protection from situations that create vulnerable populations.

Baker ⁸ suggests that healthcare’s current focus on acute needs and patient-centered care detracts from broader social justice needs. She suggests that nurses should become more aware of underlying issues and broaden their concept of their role as advocates to include engagement in promotion of justice and mitigation of structural violence. ⁸ Baker is correct, but it is easy to see why acute needs garner more attention. Acute care needs are pressing and must be addressed promptly. Hospitalized patients require ongoing monitoring and intervention and are often at risk of rapid deterioration. Certainly, these needs must take priority. If your roof began to leak, you would first place a bucket under the leak to catch the water before it could damage your house. However, once the water was contained, you would look into repairing the roof to prevent worsening leaks. Perhaps you do not know how to repair roofs, though, or you are not the owner of the house and merely rent. You would still contact a roofing professional or your landlord to let them know of the leak and even assist in finding the spot needing repair, since you are the one who knows where it is. Similarly, bedside caregivers are close witnesses to poor health that results from social injustices and must be supported to find a way to promote better understanding of these issues so that the metaphorical leak can be better located and repaired.

Balancing competing obligations

An obvious objection to adding obligations to bedside nurses is that this will detract from their ability to provide the acute care that their patients need. However, I am confident that this objection can be addressed and mitigated. As discussed above, inpatient nurses’ primary obligation is to meet the acute care needs of their patients. Nortvedt ⁹ describes how nurses experience dilemmas when they have conflicting obligations to care for individual patients and appropriately allocate healthcare resources, including the distribution of nursing care. He suggests that nurses have a special relationship with and, therefore, a higher obligation to their patients as compared with the general population or even future patients. ⁹ However, he also notes that the patient currently being cared for does not have absolute priority as another patient or individual may have more pressing needs. ⁹ This prioritization shift is common in many areas of the hospital such as in the Intensive Care Unit, where a coding patient may require the attention of more nurses; in the Emergency Department, where acuity of illness takes precedence over arrival time in terms of which patient is treated first; or on general care units, where staff are sometimes asked to expedite discharges if the hospital is nearing capacity.

Perhaps, then, some might argue that a bedside nurse is best utilized by assigning him or her to care for the sickest patients in the hospital and that social justice issues should be left to those who specialize in that area. Indeed, many inpatient units are highly specialized and require nurses with a particular skill set. However, I would argue that to say that inpatient nurses must remain at the bedside at all times, constantly caring for the barrage of patients who enter the unit, treats these nurses as a hospital commodity rather than experienced professionals who can contribute knowledge and insights gained at the bedside to broader health discussions. Like Nortvedt, Olsen ¹⁰ acknowledges that nurses have a special relationship with their patients. He also argues that this does not mean that because nurses care for their patients, they cannot care for humankind as a whole. ¹⁰ He suggests that it is possible to find a balance between caring for one’s patients and caring for all of humankind. ¹⁰ I suggest that to recognize and use the knowledge and insights nurses have, the roles of inpatient nurses and current staffing matrixes should be redesigned. Such changes would allow these nurses time to participate in and contribute their expertise to social justice in a way that meets the needs of their patients, potential patients, and society.

Compassion fatigue and moral distress

Besides the discussion of patients’ needs, though, I am also compelled to address nurses’ needs and examine whether this shift in duties would enhance or limit their capabilities. While it seems evident that bedside nurses’ involvement in social justice benefits their patient population, it is less clear whether creation of this obligation would benefit nurses, exploit nurses, or merely be a neutral shift in duties. Compassion fatigue is a term used when feelings of compassion turn into indifference and one develops a loss of energy in caring for others. Research ¹¹ on compassion fatigue in nurses found that it is related to increasing roles, conflicting demands, and nurses’ perception of their voice not being heard. Adding an obligation to address social justice concerns could be perceived by some as an additional role that conflicts with time spent at the bedside caring for patients. From this perspective, it is possible that nurses would be at risk of compassion fatigue. However, this same research ¹¹ also found that compassion fatigue did not develop if nurses perceived potential triggers as something they could control or challenges they could overcome. These findings lead me to consider that compassion fatigue might be caused or exacerbated by caring for patients while unable to address their underlying social justice issues that triggered the acute care need. Thus, I evaluate that addressing social justice concerns is likely to mitigate compassion fatigue.

Moral distress (MD) can be defined as the negative stress that can arise from conflicts in one’s roles and the inability to take what one evaluates as the ethically correct action. Some might argue that involving inpatient nurses in social justice issues may increase their risk for MD, as they would become more aware of the social injustices that negatively impact their patients. I would remind these objectors that most inpatient nurses are likely already aware of these injustices and experiencing MD due to their inability to mitigate these underlying factors that impact their patients. Research ¹² on MD among nurses found that nurses having a voice, that is, the confidence to speak up and be an agent for change, can reduce MD. Thus, a reasonable conclusion is that giving inpatient nurses the opportunity to address social justice issues will alleviate the MD that may arise from caring for victims of social injustices.

Perhaps inpatient nurses might value having a role in improving social justice and perceive it as a chance to do more good for their patients. Again, research ¹¹ found a negative correlation between compassion fatigue and the sense of control. If a new obligation to social justice needs were presented as a challenge to be conquered, nurses may embrace such a role, experience an enhanced capability to meet their patients’ needs, gain a sense of revitalization in their role as promoter of healthcare, and gain a higher level of job satisfaction.

Integrating and operationalizing a social justice obligation

An obvious question is how this new obligation would be operationalized. Again, the intention of this article is to argue for the need of development and integration of individual nurses’ obligation to social justice into their practice. While I intend to begin a discussion and prompt change, I will not come to detailed conclusions about operizationalizing. However, for a start, care would need to be taken to clarify the role of the nurses. That is, these nurses would not be expected to resolve social justice issues alone but to support and work with policy makers and public health staff. Education would be a necessary component, too, because nurses may be inexperienced in understanding and addressing structural justice issues and because individuals may have varying ideas about what constitutes social justice.

How the nurses’ obligation would be met would be determined by balancing patient needs, institutional needs, and nurses’ skills. Some initial practical ideas are that a nurse might join the institutional ethics committee, participate in meetings regarding the development of a new free clinic, write an article related to his or her experiences, or even simply complete a survey about what social justice issues have the most immediate impact on hospitalizations. By carefully designing ways to meet this obligation and providing institutional and professional support, inpatient nurses could be empowered to add their voices to the discussion and experience satisfaction as advances in social justice are made.

Conclusion

As awareness of how social injustices inhibit optimal health and make preventive care difficult, particularly for certain populations, the urgency of correcting these injustices becomes increasingly obvious. The success of restructuring our healthcare system and preventive care programs will largely depend on policy-makers’ abilities to understand and meet the needs of our population, particularly for groups who are vulnerable to health issues. Few are as keenly aware of the worst-case outcomes that result from social injustices as inpatient nurses, who care for the sickest people in our society. Bringing these nurses’ voices and experience into social justice conversations can lead to better understanding of underlying issues and development of better structural justice. For patients and society, this will lead to better health and lower healthcare costs as preventable admissions are avoided. For the nurses, this will allow them to provide more thorough care for their patients and may simultaneously prevent or alleviate compassion fatigue and MD, though further research and discussion in this area is required.

As a next step, I encourage an institution to research and implement a method of involvement of individual inpatient nurses in social justice issues and then study the impact on the parties involved. Mindful discussion is needed about how to best reformulate the role of inpatient nurses to meet the obligation of involvement in social justice issues that impact their patients. Care must be taken to value their essential insights and include them in discussions without exploiting them or pulling them too far or too frequently from the bedside where they are needed to care for these acutely ill patients. If done with careful consideration and institutional support, obligating inpatient nurses to address the social justice needs of their patients may promote justice and better outcomes for both their patients and the nurses themselves.