*The text is not the final, published version of the white paper. The published version can be accessed at the Sage Journals website, Journal of Transcultural Nursing: https://journals.sagepub.com/doi/abs/10.1177/10436596231163878.
Integration of population health, social determinants and social justice in Transcultural Nursing and culturally competent care
White Paper by the Scholars Education Interest Group
Dula F. Pacquiao, EdD, RN, CTN-A, FTNSS, FNYAM Corresponding author
School of Nursing, Rutgers, the State University of NJ
Joanna Basuray Maxwell, Ph.D., RN, FTNSS
School of Nursing, Towson University
Patti Ludwig-Beymer, PhD, RN, CTN-A, FTNSS, FAAN
Purdue University College of Nursing
Alessandro Stievano, PhD, MNursSci, MSoc, MEd, BNurs, FEANS, FAAN, FFNMRCSI, FTNSS
Research Coordinator, Centre of Excellence for Nursing Scholarship
Appointed Professor, Unicamillus University, Rome Italy
Priscilla L. Sagar, EdD, RN, CTN-A, FTNSS, FAAN
Professor Emerita of Nursing
Mount Saint Mary College
Larry Purnell, PhD, RN, FTNSS, FAAN, DHumL
Professor Emeritus, University of Delaware, Newark, DE
Professor Emeritus, Excelsior University, Albany, NY
Katharyn F. Daub, EdD, MNEd, CTN-A, FTNSS
Professor of Nursing
Co-Coordinator DNP program
University of Hawaii at Hilo
Jehad O. Halabi, PhD, RN, FTNSS
Professor of Nursing
Qatar University, Doha, Qatar
As part of its mission to advance Transcultural Nursing worldwide, the Transcultural Nursing Society Scholars upholds the central role of the discipline and cultural competence in advocacy, empowerment and transformation of the life conditions of disadvantaged populations. This White Paper affirms the Scholars’ core belief in the value of Transcultural Nursing and culturally competent care in addressing social determinants to promote health equity. The Scholars Education Interest Group propose recommendations for changes in education, practice and research undergirding the discipline and expand cultural competence to directly address social structural and historical forces that perpetuate health vulnerability in diverse populations.
Integration of population health, social determinants and social justice in Transcultural Nursing and culturally competent care – White Paper by the Scholars Education Interest Group
The mission of the Transcultural Nursing Scholars is to advance worldwide the discipline through generation and dissemination of knowledge, practice and research in Transcultural Nursing. The current state of global health disparities has affirmed the major impact of social structural and historical factors on longstanding health vulnerability across population groups. In 2020, the Scholars identified the need to refocus Transcultural Nursing to address social and environmental factors that create cumulative disadvantages in population groups that are more likely to be culturally diverse from the dominant sectors of society. The Scholars further identified the need to reconceptualize culturally competent care to include knowledge, skills and values directly addressing social determinants to promote equitable health outcomes.
A subgroup of the Scholars, the Scholars Education Interest Group (SEIG) took leadership to develop a White Paper to identify the issues and develop appropriate recommendations for change in Transcultural Nursing and Culturally Competent Care, serving as guidelines for education, practice and research to promote health equity.
In 2008, the World Health Organization’s (WHO) Commission on Social Determinants of Health published synthesized evidence on the causes of health inequities that set in motion generation of new knowledge and theories on the social determinants of health (Solar et al., 2022). The ongoing COVID-19 pandemic has exemplified how structural determinants of health inequity have real impacts on differences in infection rates, access to treatment and mortality (WHO, 2021). According to WHO (2023) social determinants of health (SDOH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems. SDOH account for 30-55% of health outcomes. Health disparities are the differential consequences in health across population groups linked with social disadvantages, hence actions should be directed at the social structural and systems level.
In 2021, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (National Academies of Sciences, Engineering, and Medicine, 2021) and The Essentials: Core Competencies for Professional Nursing Education (AACN, 2021) emphasized the role of nurses in promoting health equity through incorporation of population health, social determinants and social justice in professional nursing education, research, and practice. In particular, the American Association of Colleges of Nursing’s Essentials emphasized the sub-competencies of diversity, equity, and inclusion as integral to addressing SDOH. Nursing education, practice, leadership, policy, and research need to integrate SDOH to reduce health disparities and foster health equity (USDHHS-NACNEP, 2020).
The International Council of Nurses (ICN) code of ethics calls on nurses to advocate for equity and social justice in resource allocation, access to health care, and other socioeconomic services. The Code of Ethics for Nurses by the American Nurses Association (ANA) underscores the nurse’s role to promote, advocate for, and protect the rights, health, and safety of the patient. Social justice is addressed explicitly in its ninth provision, which states that the profession of nursing, collectively through its professional organizations, must integrate principles of social justice into nursing and health policy. Social justice promotes health equity through fairness in the distribution of material resources based upon a compassionate understanding of the needs of others and the compelling motivation to act on their behalf (Alacovska, 2020).
The Scholars Education Interest Group underscores the central role of Transcultural Nursing in the design and implementation of culturally competent care upholding diversity, inclusion and beneficial care for individuals, communities, and populations. Transcultural nursing has a tradition built upon years of research and theory development by Leininger and other transcultural nurses to generate patterns of care that are meaningful, supportive, and respectful of peoples’ diverse values and lifeways. Aligned with our long-held tradition of universality and diversity in caring (McFarland & Wehbe-Alamah (2019), the challenge is achieving the universal value of health equity by combating the potential disadvantages of diversity in populations lacking power and influence in mainstream society. Culturally competent care should comprise actions that transform the lives of disadvantaged populations enabling their capacity to achieve health. Cultural competence encompasses culturally congruent and linguistically appropriate care with specific, measurable outcomes at certain points within its developmental pattern of growth (Pacquiao, et al., 2020).
We need to retool culturally competent care to address social inequities embedded in SDOH that create cumulative disadvantages and health vulnerability in populations. While we recognize the significance of salient values and ways of being inherent in diversity, there is a more pressing need to address social, economic, political and historical structures and policies that impact health outcomes of populations often marginalized by being different from powerful groups in society. Health equity is possible when culturally competent care enables diverse populations to transform their life conditions and improve their capacity for health.
While individual-based and disease-focused interventions are important, equitable health outcomes are possible when actions are directed towards elimination of social inequalities that create disadvantages and limit the life chances including health of certain population groups (Pacquiao & Douglas, 2019). The dominant ethos of individualism underlying the belief that individuals can be relied upon to act on their behalf, creates an impossible expectation for population groups with multiple social vulnerabilities to tackle systemic societal structures and policies that limit their ability for self-agency (Krieger, 2021). Actions on social determinants necessitate broad-based multisectoral collaboration to create high impact solutions and theories of change to dismantle unfair policies, laws and regulations that limit the potential including health of vulnerable groups (Solar, et al, 2022).
Integration of population health, social determinants and social justice in transcultural nursing and culturally competent care are fundamental to advocacy for health equity particularly for disadvantaged minority populations that have suffered excess burden of poor health and death. To this end, the Scholars Education Interest Group advocate for the following changes to be implemented under the collaborative leadership of TCNS and the Scholars:
- Refine, modify, and augment current TCN conceptual models, principles and theories to incorporate insights from the growing body of evidence and explanations for health disparities.
- Promote awareness of how societal structures and policies create disadvantaged social and physical environments resulting in poor health of population groups.
- Analyze large data sets and other sources to establish evidence linking SDOH and population health outcomes.
- Design models of practice with potential to address SDOH and its impact on population health.
- Develop research protocols to generate new theory and solutions to mitigate impact of SDOH.
- Strengthen community capacity through development of social capital and effective social networks.
- Promote engagement of students and professionals in disadvantaged communities to discover SDOH and generate multisectoral partnerships and collaboration for change.
- Enhance participation of students, professionals, organizations and communities in policy development, implementation, and evaluation.
- Promote internalization of social justice consciousness among students and health professionals.
Transcultural nurses have a rich tradition in working with diverse communities around the world to discover their unique patterns of caring and health promotion. They have longstanding knowledge and skills in working with diversity, advocacy for cultural differences and respect for unique ways of life of the people. The current challenge of health equity is to advocate and work with diverse populations by forging multisectoral and multidisciplinary coalitions to mitigate the negative effects of social determinants stemming from the societal arrangements of power, privilege and prestige. Transcultural nursing must be cognizant of the impact of historical and continuing oppression, discrimination, and marginalization of populations because of their position within the social hierarchy. Cultural competence should create empowerment of vulnerable groups to minimize the negative health impact of their social place in society.
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Reviewed and endorsed by the Transcultural Nursing Society Board of Trustees February 2023.
The Transcultural Nursing Society (TCNS) remains committed to the values and beliefs reflected in the White Paper.