Running head: SOCIAL JUSTICE
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Social Justice Advocacy in Gerontological Nursing
Jody M. Dawson
Trent University
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Social Justice Advocacy in Gerontological Nursing
Since the conception of the Canadian Health Act, Canada’s registered nurses
[RNs] have been recognized for their outstanding contributions to protecting public
health care. The leadership of the Canadian Nurse’s Association [CNA] helped to solidify
the five principles that govern Canada’s renowned health care legislation. The CNA
played a pivotal role in ensuring that these principles were founded on the underlying
values of equity and solidarity (Brunskill, 2010). The five principles of the Canada
Health Act affirm that all Canadians have an equal right to accessible, universal,
comprehensive, publicly administered, and portable health care. However, despite these
principles that are enshrined in the Canada Health Act, it is well known that health
inequities exist. Individuals with low levels of income and education with limited access
to health care and support are more at risk for health problems compared to those living
in more advantaged circumstances (National Expert Commission [NEC], 2012).
Older adults are particularly vulnerable to the challenges related to poverty and
health inequities (NEC, 2012). As the number of Canadians over age 65 increases, the
issue of poverty will intensify (Conference Board of Canada, 2013). The best way to
respond to the needs of Canada’s aging population is to first address the issues at the
level of the social determinants of health [SDH] (Reading & Reading, 2012). The focus
of this paper is to use a SDH framework to identify the impact of inequities on the health
of older adults in Canada, and to use the critical social theory to support implications for
social justice advocacy in gerontological nursing. Today, nurses must again use their
strong voice and form a coalition to protect the principles, conditions, integrity, and spirit
of the Canada Health Act.
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SDH Impact on Elderly Individuals
It is a great social injustice that “people who live in the most disadvantaged
circumstances have more illnesses, more disability, and shorter lives that those who are
more affluent” (as cited in Rapheal, 2002, p. 1). A social determinants approach to
healthcare provides a lens to view and address health disparities that are caused by social
unjustices. It allows nurses to uncover the root causes of inequities in health that are
unjust and unacceptable. Increasing awareness of the SDH is the first step to promoting
social justice advocacy and creating change. By addressing issues of income, social
exclusion, education, health literacy, and disability, nurses can unite to remove barriers
and promote emancipation for the elderly population.
Income
In Canada, poverty is the strongest determinant of health (McGibbon, Etowa, &
McPherson, 2008). Poverty leads to cumulative disadvantages across a person’s lifecourse. It confines people to a cycle where poverty causes ill health and in turn, ill health
perpetuates poverty (World Health Organization, 2008). According to the Public Health
Agency of Canada, almost one in five seniors lives near the poverty line (2006).
One of the most common measures of poverty in Canada is the low-income cutoff [LICO] (Touhy & Jett, 2012). The LICO measures the point where a family is
spending 70% or more of their income on necessities (Touhy & Jett, 2012). There is an
alarming rate of seniors with an income just above the LICO. These seniors cannot access
the benefits of income-tested programs and therefore must get by with an extremely small
budget (National Advisory Council on Aging [NACA], 2005). As a result, these seniors
face many of the same challenges as the officially impoverished.
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Low income is linked to social injustices for elderly patients through inequities in
access to home care, medications, food security, and required health care devices, which
leads to negative health outcomes (Public Health Agency of Canada, 2010). Seniors with
low income also experience limitations in terms of affordability of transportation and
access to a doctor, hospital, or specialized community services (Public Health Agency of
Canada, 2010). Issues of physical mobility and chronic illnesses can further complicate
problems related to health care accessibility for seniors.
Social Exclusion
Ageism is a prevalent form of social exclusion that can affect the quality of care
that elderly people receive. R. Butler defines ageism as “the systematic stereotyping and
discrimination against people, simply because of their age” (as cited in Eymard &
Douglas, 2012, p. 26). In a review of ageism among health care providers, Eymard and
Douglas found that ageist stereotypes typically depict older adults as dependent, grumpy,
lonely, crabby, rude, stubborn, in poor physical condition, having impaired memory,
senile, and inactive in social activities (2012). Nurse’s attitudes have been shown to
contribute to the discrimination of elderly patients. Research by Cooper and Coleman
illustrated that mentally intact patients were more popular among nursing staff (2001).
Negative attitudes among physicians have been shown to influence treatment options for
older adults. For example, research by Jacobson highlighted that negative attitudes
towards older adults suffering from hypercholesteremia led to nonprescription of statin
drugs to those who required them (Jacobson, 2006).
Stereotypical attitudes result in lack of full access to competent and
compassionate health care. Negative attitudes towards marginalized populations of
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seniors have the potential to influence treatment options and care (Eymard and Douglas,
2012). It is a great injustice that social exclusion based on age and stereotypical
judgments can lead to neglect, discrimination, oppression, and ultimately poorer
outcomes for elderly patients (McGibbon, Etowa, & McPherson, 2008).
Education
Education is another social determinant of health that can affect seniors’ access to
health care resources and limit their potential for optimal health. Age is associated with
poorer health for elderly individuals who had less opportunity for higher education earlier
in life (PHAC, 2010). Education contributes to a learned appreciation for the importance
of good health behaviours, and individuals with lower education have higher morbidity
rates from acute and chronic diseases (Cutler & Lleras-Muney, 2007). The detrimental
impact of chronic conditions on quality of life is the most pronounced for elderly people
with low economic status (Canadian Academy of Health Sciences, 2010). Low levels of
formal education are also associated with a risk of chronic conditions such as
Alzheimer’s disease, cognitive impairment and dementia (PHAC, 2010). Research also
suggests that older people with lower levels of education are less likely to receive
preventive care such as flu shots (Lu, Singleton, Rangel, Wortley, & Bridges, 2013).
Health Literacy
Health literacy is a social determinant of health that is often unrecognized.
According to the NACA, people who are physically or mentally impaired and people who
have low literacy are the least likely to receive the Canada Pension Plan or the
Guaranteed Income Supplement because they have not applied (2005). It seems unjust
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that lack of awareness or not knowing how to apply prevents these marginalized
populations from receiving financial assistance they are entitled to.
Health literacy not only impacts seniors’ access to resources and their ability to
apply for benefits, but it also impacts their ability to read and interpret labels on
prescriptions and to understand health information and instructions. According to the
Public Health Agency of Canada, only one in eight adults over the age of 65 have
adequate health literacy skills for many basic health related decisions (2010). Age is
associated with lower health literacy, and seniors with lower health literacy are more
likely to report poorer health (PHAC, 2010).
Disability
More than 40% of Canadians over the age of 65 report a disability (Mikkonen &
Raphael, 2010). Having a disability can affect the services that are delivered at point of
care. In an interview with a long-term care home investigator, it was found that residents
who are “the most in need, the most disabled, and the most infirmed have a tendency to
be neglected more than the residents who are able to speak for themselves and request
help” (Touhy & Jett, 2012, p. 369). Neglect of elderly patients as a result of disability
contributes to the sustained oppression of vulnerable members of this population. It is
time to break this cycle of oppression that leads to social injustices.
Applying Critical Social Theory to Gerontological Nursing
The critical social theory “seeks to understand a situation and to alter conditions,
thus leading to emancipation, equality and freedom for individuals (Carnegie and Kiger,
2009). In their research on the advocating role of the nurse, Carnegie and Kiger discuss
the use of the critical social theory as a tool to highlight ethical ways to practice nursing.
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An understanding of the theory is valuable as it allows nurses to recognize that the ability
for people to change their social and economic circumstance is constrained by various
forms of social, cultural and political domination. Nurses who guide their practice with
the philosophical underpinnings of the critical social theory will be able to promote an
unbiased and truly altruistic approach to health care.
The goal of critical nursing scholarship is to be dedicated to work that exposes
oppressions that hinder health potential (Carnegie & Kiger, 2009). In order to protect the
integrity of the nursing profession and the standards that Canada’s health care is founded
upon, registered nurses must become ambassadors for social justice and advocate for
healthcare that is truly equal for everyone. The following is a discussion of the current
knowledge development, policies and research addressing health inequities among
elderly populations. The interventions use the principles of the Ottawa Charter for Health
Promotion to address inequities among elderly populations.
Society: Building Healthy Public Policy
In order to address financial insecurity among older Ontarians, CARP, a national
organization committed to a new vision of aging for Canada, provides recommendations
for the Ontario Government (CARP, 2011). CARP recommends that the Ontario
government work with other provinces to substantially increase the levels of Old Age
Security and Guaranteed Income Supplement payments to at least the LICO. CARP also
recommends that the Ontario Government ensure that its pension reform initiatives to
specifically accommodate the needs of the low wage sector. For those seniors who are
not receiving financial assistance they are eligible for, NACA recommends that the
federal government makes public the number of eligible seniors who have not applied for
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the various program benefits, and that the government increases its efforts to encourage
renewal by sending reminders over a 6-month period before reducing monthly benefits by
10% (2005). Nurses can advocate for these changes to public policy. As the largest
population of health care providers, nurses are well positioned to “build on the
profession’s solid historical roots of advocacy and political action to break the cycle of
oppression” (McGibbon, Etowa, & McPherson, 2008, p. 27).
Institution: Reorienting Health Services
In order to reduce stigmatizing attitudes among health care professionals,
reorienting health services requires attention to changes in professional education and
training. Nursing students who are exposed to positive experiences with older adults early
leads to positive attitudes and an increase in knowledge regarding older adults (Burbank,
Dowling-Castronovo, Crowther, & Capezuti, 2006). Nursing educators play a significant
role in enhancing nursing curriculum to create positive experiences for students. For
practicing RNs, care of older adults requires a specialty skill set which needs to be
recognized. Courtney, Tong, and Walsh recommended that nurses routinely receive
continuing education programs specific to gerontological nursing to increase knowledge,
attitudes, and practice (2000). These educational experiences can help to empower RNs
as leaders in challenging ageism (Eymard & Douglas, 2012).
Community: Strengthening Community Action
Nurses can help to promote empowerment for older adults through advocacy for
strengthening community action in building programs to support older adults. For
example, nurses can help make health literacy part of the community-building strategy
for improving senior’s access to health care. Nurses can raise awareness about health
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literacy to health care professionals so that they can implement interventions to support
seniors with low literacy levels. Interventions include reviewing health information with
patients to ensure they understand, or creating health education groups. Nurses can also
help to strengthen community action by connecting seniors to community programs that
support food security, offer education, or provide transportation, and by providing seniors
with information on financial resources they are entitled to.
Individual: Building Individual Skills
In her research on the relationships between income level, physical health, and
sense of mastery [SOM], Gadalla illustrates the importance of SOM in optimizing older
adult’s physical health and increasing their resilience and chances of recovery (2009).
Gadalla found that low SOM mitigated the effects of low socioeconomic status on
depressive symptoms in older adults and contributed to the relationship between low
education level and psychological distress (2009). Gadalla also found that there was a
negative relationship between SOM and low education and low income (as cited in
Gadalla, 2009). In her study, Gadalla found positive associations between social support
and a greater SOM. Her findings have meaningful implications for nursing practice, as
nurses can design and implement social support programs to improve SOM in older men
and women with low income and/or diminished physical health. This can help older
adults maintain their independence and improve their quality of life.
Conclusion
Tommy Douglas’s original version of the Canada Health Act sought to confront
these social and environmental factors that undermine an individual’s potential for health
(Registered Nurse’s Association of Ontario [RNAO], 2014). Standard five of the
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Canadian Gerontological Nursing Competencies and Standards of Practice specifies that
gerontological nurses are expected to identify barriers in the healthcare system and
advocate for changes to overcome them (Canadian Gerontological Nursing Association,
2010). Whether it is on the political stage in mobilizing change towards an upstream,
social determinants approach to healthcare, or in the compassionate interpersonal
relationships that inspire individual healing and self-actualization, every level of nursing
presents an opportunity to advocate for human rights. By acknowledging that potential
for health is constrained by social, economic, and political systems, nurses can become
agents of change in the contemporary movement towards upstream nursing. Nurses can
use the SDH framework to advocate for social justice that will enhance the quality of life
for all Canadians as they age. As ambassadors for social justice and health equality,
nurses can protect the original values of equity and solidarity in the Canada Health Act.
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References
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Burbank, P.M., Dowling-Castronovo, A., Crowther, M.R., & Capezuti, E.A. (2006).
Improving knowledge and atti- tudes toward older adults through inno- vative
educational strategies. Journal of Professional Nursing, 22, 91-97.
Canadian Academy of Health Sciences. (2010). Transforming care for Canadians with
chronic health conditions. p. 13. Ottawa: Author. Retrieved from
http://www.dfcm.utoronto.ca/Assets/DFCM+Digital+Assets/CAHS+Transformin
g+Care+for+ Canadians+with+Chronic+Health+Conditions.pdf
Canadian Gerontological Nursing Association (2010). Gerontological nursing
competencies and standards of practice. Vancouver: Author.
Carnegie, E., & Kiger, A. (2009). Being and doing politics: an outdated model or 21st
century reality? Journal of Advanced Nursing, 65(9), 1976–1984.
doi:
10.1111/j.1365-2648.2009.05084.x
CARP (2011). Financial insecurity among older Ontarians: CARP Pre-budget submission
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Cooper, S.A., & Coleman, P.G. (2001). Caring for the older person: An exploration of
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perceptions using personal construct theory. Age and Ageing, 30, 399-402.
doi:10.1093/ageing/30.5.399
Courtney, M.D., Tong, S., & Walsh, A.M. (2000). Acute-care nurses’ attitudes toward
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Marking guideline:
Paper Criteria
Below expectations
Meets basic
expectations
 Engages &
prepares reader re.
content & structure
of paper –
More creativity
 5
 Basic
discussion of
significance - 4
Introduction
 Inadequate
orientation to paper
&/or fails to engage
reader - 2
Significance
 Relevance for
aging, the aged,
nursing society
alluded to – 2
Review/analysis
of literature
 Minimal use or
minimal description
of current, relevant,
peer reviewed
literature – 4
 Basic review of
discrete sources
from current,
relevant, peer
reviewed literature
-8
Synthesis of
knowledge
including
implications for
seniors, nursing
practice, policy &
research
 Minimal
demonstration of
integration of
interrelationships of
key ideas – 6
Professional
writing
 Sentence
structure, grammar,
spelling, etc detract
from clarity & flow,
poor adherence to
APA format in
text&/or reference
list – 4
 Evidence of
inter relating of key
ideas &
observations
leading to some
synthesis examples
from clinical or
movie-your own
thoughts would
have strengthened
the paper
 12/ 10
 Clarity and
flow adequate
despite a few errors
in writing &/or
APA –
8
Exceeds basic
expectations
 Clarity &
creativity in
introducing topic &
its treatment – 6
 Discussion of
significance
demonstrates multidimensional thinking
–6
 In depth review of
a breadth of
relevant, sources
including current
peer reviewed
literature –
 More critical
analysis12
 Insightful
integration of key
ideas in creative
expression,
demonstrates
cumulative learning
throughout program
– 14
 Clear, creative,
effective and
accurate writing,
consistent with APA
– 12
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Mark: 47/50=28.2/30
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