重新排列我们在保健和福祉方面的优先事项

分享智慧

共同成长

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Social environments and connections make a definitive difference in health, wellbeing and longevity. That much we know. Our scientific community, as well as that of Social Work along with other allied disciplines, acknowledges social worlds, environments and connections in science that spans the life course and varied societies. No matter the compelling body of evidence, an almost exclusively biomedical perspective predominates over holistic perspectives on health and wellbeing.

Maintaining health and wellbeing is assumed to require biomedical diagnosis and treatment, necessitating social care only to make such diagnosis and treatment possible and complete as with medical home care. Biomedical dominance is such that we say ‘health and social care’ if we consider social care at all. Policy and practice follow this rule. Care systems and processes are frequently designed in the absence of evidence around social factors in health and despite popularisation of the social determinants of health. An allopathic approach is levelled against health problems—not possibilities for health and wellbeing—from systems design to care provision. Consequently, social care is downplayed most everywhere around the world, in favour of biomedically focused illness care. Illness care adds in limited social care only for those most in need in circumstances where risk and harm loom. The result thwarts salutogenesis—the promotion of health and wellbeing—and hinders healthy aging.

Several major misapprehensions bolster privileging biomedical health care—in the guise of illness care—over social care, even with the latter boasting dual benefits of clear evidence and lower cost.

• First, social care is misunderstood and often proscribed as the professional services provided by a Social Worker. Though Social Workers are experts in social welfare, wellbeing and care, the full scope of social care goes beyond their direct care. Social care is a broad term including ways and means to foster social connections and welfare along with care that bridges gaps in biomedical care such as medical home and supportive care.

• Second, as Gerontological Nurses, we know aging is essentially a life-long human process. Policy and practice continue to define it as the sole domain of older people. Older is typically applied to those aged over 60 or 65 years of age, depending on whose definition you use. Social need and inequity often rise over the life span, with compounded social discrimination, isolation and financial insecurity becoming more common. Thus, adequate social care and support outside the family are difficult for most older people to obtain.

• Third, despite evidence pointing to social care and connections being necessary to launch healthy aging early in life, universal access to social care is absent for many around the world. Indeed, most societies only provide foundational public education through late adolescence. These societies generally limit additional social care to those younger people with extreme need and demonstrated problems. With harm already done, those younger people age against the odds of early damage and inadequate support.

• Fourth, while we know social needs for connection and support transcends all creeds and walks of life, inequities plague scope, access and quality of care to meet those needs. Needs for social care are typically stringently determined based on three factors—economic status, physical function and mental function. Criteria using those three factors are often scaled so that significant damage exists before resources are made available. The result is a proverbial case of too little, too late.

• Finally, almost all social care and much of supportive health care that bridges gaps between health and social domains—think medical home care—relies on high-level functional status. Counterintuitively, users need to be highly functional and often technology savvy to make use of social and supportive health care. In sum, systems and processes for social care are predicated on assumptions of privilege in age, health, capacity and finances, thus implicitly judging those in need.

The extent to which social care, in an encompassing sense, is misunderstood shapes the ways in which programs are developed and funded. Moreover, limited understanding and agreement about social care and who will benefit from it generally proscribe who is eligible and then actually uses the services offered.

The sneaky inequity of opt-in requirements for using social care and supportive health care frustrates would-be users of that care. Many policies at national and institutional levels generally requires individuals to opt into care. Individuals must actively seek out, choose, confirm and reconfirm plans to use a particular service. While the nature of opting into care varies across societies, the premise is universal. If we in the health and social care sector determine you are eligible for some social or supportive health care service, you are then obligated to opt into that service and confirm your availability on the schedule we set out. Our own society—the United States—exemplifies this rule of opting in. For example, increasingly you must opt in if you are eligible for medical home care by contacting agencies, answering frequent telephone calls and confirming email and text messages. We know people who need such care are likely to find getting to the telephone and responding to voice, text and email messages challenging at best and impossible at worst. Requirements to opt in often mean individuals inadvertently miss care they very much need.

Requirements to opt in, as opposed to opting out, of specific services are not new. Indeed, the incongruity of needing to opt into or out of care is the stuff of nursing lore, at least here in the US. We know many nurses who joke they want ‘DNR’ tattooed on their chests. Their satire underscores the startling reality that in many healthcare systems the only form of care out of which you must opt, even when frail and seriously ill, is resuscitation. The mismatch between what care requires opting in and what requires opting out defies the rational. Care that promotes health must be chosen deliberatively and actively. Resuscitation is an illness care procedure that merely remedies the crisis of a moment and does not restore health beyond cardio-pulmonary function. But resuscitation must be rejected repeatedly, even by the frail and seriously ill and in advance if indeed it can be rejected at all. Opt-in social care, when set against opt-out resuscitation, illustrates the detrimental extent to which social care is prioritised in favour of illness care disguised as health care.

Robust science and many clinical initiatives point towards improved health, function and wellbeing over the entire life course when care encompasses both social and supportive health care. Such care also appears to limit risk of premature death, making for longer, better lives. Critically, then, the combination of structural opt-in inequity and misapprehensions about when healthy aging begins and what it requires, who needs social and supportive care, and functional capacity needed to make use of such care represents a costly miscalculation. Privileging the biomedical continues to waste resources, money and human potential.

The fact that we can fix—or try to fix—a health problem should not mean we should be comfortable potentiating it, even through inadvertent neglect. We all easily conjure examples to illustrate this equation. Consider the older person living with chronic obstructive pulmonary disease (COPD) who would benefit from an air conditioning to prevent disease exacerbation and consequent hospitalisation. Few services exist provide that air conditioner and its maintenance to the person living with COPD. Conversely, most health systems provide for hospitalisation to treat COPD exacerbation. No matter the illustrative example, the poignant misalignment evident when we say ‘Health and Social Care’ becomes clear. Social care comes after, and more often as an afterthought, as biomedical health care precedes all else.

Many might argue that ever more prominent attention to the social determinants of health represents marked innovation in biomedicine and a resultant paradigm shift. Here again, the language we use speaks to the reality. Listen as you read the word aloud: Determinants. Factors that decide or cause. This oft cited descriptive model is valuable in calling attention to social factors, but the term ‘determinants’ connotes that health is already determined, past tense. Common representations of the social determinants of health rely on static graphic presentation and phrasing such that the model is devoid of a sense of plan or action. What was a critical innovation nearly two decades ago when the social determinants of health emerged as a framework globally now lacks the dynamic necessary for action to redress health inequities that limits healthy aging and other health inequities today.

The social determinants of health are taught across nursing and the health professions. In most cases, the factors termed ‘determinants of health’ are used to explain a given state of health without a matching model for action. The novice student might well take the determinants as presumed with the connotation that health states are predetermined by the factors listed in the model. Approaches needed to erase inequity and shift the focus on causality in disease management to promoting health and wellbeing are missing. How often do nurses learn techniques to assess and intervene in housing insecurity, food insecurity and personal safety? Not often enough, given the prevalence of homelessness, hunger and violence affecting people of all ages, including the oldest among us around the world. Furthermore, most representations of social determinants of health fail to reflect current concerns and relevant evidence. They miss the climate crisis, healthy aging and understandings of discrimination that highlight pervasively accepted healthism, ableism and ageism. The descriptive utility of the social determinants of health notwithstanding, why not shift our emphasis to a model of social opportunities to improve health by resolving inequities?

Our power, as Gerontological Nurses, to act in service of the wider good lies close at hand. Let us leverage that power now to reorder our priorities to achieve health and wellbeing. The first step we urge is simple to say but difficult to achieve. Let us all begin by always saying ‘Social and Health Care’ and then talking about why that phrasing is important. But know that, though language is powerful, changing what we say is insufficient. Here are some ways in which we can act as Gerontological Nurses in our roles as practitioners, educators, researchers, theorists, administrators, policy shapers and makers and citizens.

• Learn more about social factors beyond the social determinants of health. Focus on inequity and opportunity. Social Workers are perfect partners here. Try discussing your phenomenon of interest with a colleague in Social Work and jointly identifying the social inequities known to contribution to that phenomenon.

• Remember that the planetary climate and local environments are part of the larger social landscape. Our communities and societies cannot exist without a healthy climate. Learn more about the environment and health from the Alliance of Nurses for Healthy Environments (https://envirn.org). The organisation also provides a free-to-read textbook on environment and health that is now in its second edition (https://envirn.org/e-textbook/)

• Educate everyone about common misapprehensions and misconceptions that suppress the value of social welfare, wellbeing and care. Talk with patients, clients, families, students, colleagues, neighbours and friends about how social factors and connections in everyone's lives help us all live longer, better lives, no matter our age.

• Start changing policies that set out opt-in care in favour of opt-out structures that encourage salutogenic care. Advocate for this change in clinical practice, in social and health care administration and in shaping and making policy. As a corollary, work to make resuscitation for people all ages who are frail and seriously ill something they can choose to opt into instead of fighting to opt out of these measures.

• Redefine current interpretations of social determinants of health toward contemporary evidence, true inclusion and engagement and paths to action. Take up the climate crisis, homelessness, hunger, violence and the frequently accepted discrimination of healthism, ableism and ageism in all that we do. That means new conceptual and theoretical models, fresh curricula, innovative policies and inclusive plans for care. It also means voting our nursing values whenever a vote in our institutions, our communities and our nations is called.

• Capitalise on a partnership long undervalued—that between Nurses and Social Workers. Collaborating with our colleagues in Social Work advances so much of what we can do to remake social determinants of health into social opportunities for health and wellbeing, ensuring that social care is guaranteed for people of all ages to live and age healthily. Look for the chance to work together in theory, research, education, care, administration and policy to make this aspiration a reality.

We Gerontological Nurses know so much of what it takes to live long and fulfilling lives. That knowledge is our leverage for action to create greater good at home and all around our shared world. We can imagine no better time, indeed no more urgent moment to cast off the limitations of our disordered priorities for health and wellbeing and envision a far better future. We must all act now to make Social and Health Care for all a global reality. 

全文翻译（仅供参考）

社会环境和联系对健康、福祉和长寿有着决定性的影响。我们知道的就这么多。我们的科学界以及社会工作与其他相关学科的科学界承认跨越生命历程和不同社会的社会世界、环境和科学联系。无论有多少令人信服的证据，几乎完全是生物医学的观点比关于健康和福祉的整体观点占主导地位。

维持健康和福祉被认为需要生物医学诊断和治疗，社会关怀只是为了使这种诊断和治疗成为可能和完成，就像医疗家庭护理一样。生物医学的主导地位是这样的，如果我们考虑社会关怀，我们就会说“健康和社会关怀”。政策和实践遵循此规则。尽管健康的社会决定因素已经普及，但护理系统和流程的设计通常是在缺乏有关健康社会因素的证据的情况下设计的。从系统设计到护理提供，对抗疗法是针对健康问题而不是健康和福祉的可能性。因此，社会护理在世界各地都被低估了，有利于以生物医学为重点的疾病护理。疾病护理仅在风险和伤害迫在眉睫的情况下为最需要的人增加有限的社会护理。结果阻碍了促进健康和福祉的salutogenesis，并阻碍了健康老龄化。

几个主要的误解支持以疾病护理为幌子的生物医学保健优先于社会保健，即使后者拥有明确证据和较低成本的双重好处。

• 首先，社会关怀被误解为由社会工作者提供的专业服务经常被禁止。尽管社会工作者是社会福利、福祉和关怀方面的专家，但社会关怀的全部范围超出了他们的直接关怀。社会关怀是一个广义的术语，包括促进社会联系和福利的方式和方法，以及弥合生物医学护理方面差距的护理，例如医疗之家和支持性护理。

• 其次，作为老年护士，我们知道衰老本质上是一个终生的人类过程。政策和实践继续将其定义为老年人的唯一领域。老年人通常适用于 60 岁或 65 岁以上的人，具体取决于您使用的定义。社会需求和不平等往往在整个生命周期中上升，加剧的社会歧视、孤立和经济不安全变得越来越普遍。因此，大多数老年人很难在家庭之外获得足够的社会关怀和支持。

• 第三，尽管有证据表明社会关怀和联系对于在生命早期启动健康老龄化是必要的，但世界各地的许多人都无法普遍获得社会关怀。事实上，大多数社会只在青春期后期提供基础公共教育。这些社会通常将额外的社会关怀限制在那些有极端需要和明显问题的年轻人身上。伤害已经造成，这些年轻人会因早期伤害和支持不足而变老。

• 第四，虽然我们知道社会对联系和支持的需求超越了所有信条和各行各业，但不平等困扰着满足这些需求的范围、获取和质量。社会关怀的需求通常严格根据三个因素来确定——经济状况、身体机能和心理机能。使用这三个因素的标准通常是按比例缩放的，因此在资源可用之前就存在重大损害。结果是一个众所周知的太少，太晚的例子。

• 最后，几乎所有的社会护理和大部分弥合健康和社会领域之间差距的支持性医疗保健——想想家庭医疗护理——都依赖于高水平的功能状态。与直觉相反，用户需要功能强大且通常精通技术，才能利用社会和支持性医疗保健。总而言之，社会关怀的系统和过程是建立在对年龄、健康、能力和财务方面的特权假设之上的，从而隐含地判断那些需要帮助的人。

从广义上讲，社会关怀被误解的程度影响了项目的开发和资助方式。此外，对社会关怀以及谁将从中受益的理解和协议有限，通常会限制谁有资格并实际使用所提供的服务。

使用社会护理和支持性医疗保健的选择加入要求的偷偷摸摸的不公平让那些想要使用这种护理的人感到沮丧。国家和机构层面的许多政策通常要求个人选择接受护理。个人必须积极寻找、选择、确认和再次确认使用特定服务的计划。虽然选择接受护理的性质因社会而异，但前提是普遍的。如果我们在健康和社会保健部门确定您有资格获得某些社会或支持性保健服务，那么您有义务选择加入该服务并按照我们制定的时间表确认您是否有空。我们自己的社会——美国——体现了这种选择加入的规则。例如，如果您有资格通过联系机构获得家庭医疗护理，您必须越来越多地选择加入，接听频繁的电话并确认电子邮件和短信。我们知道，需要此类护理的人可能会发现打电话和回复语音、文本和电子邮件消息充其量是具有挑战性的，而在最坏的情况下是不可能的。选择加入的要求通常意味着个人无意中错过了他们非常需要的护理。

选择加入而不是退出特定服务的要求并不新鲜。事实上，需要选择加入或退出护理的不协调是护理知识的一部分，至少在美国是这样。我们知道许多护士开玩笑说他们想要在胸前纹上“DNR”。他们的讽刺强调了一个惊人的现实，即在许多医疗保健系统中，您必须选择的唯一护理形式是复苏，即使在身体虚弱和重病时也是如此。什么护理需要选择加入和什么需要选择退出之间的不匹配违背了理性。必须慎重和积极地选择促进健康的护理。复苏是一种疾病护理程序，仅用于补救一时的危机，并不能恢复心肺功能以外的健康。但复苏必须反复拒绝，即使是体弱多病的人，如果确实可以拒绝的话，也可以提前。选择加入社会护理与选择退出复苏相比，说明了优先考虑社会护理以支持伪装成医疗保健的疾病护理的不利程度。

当护理包括社会和支持性医疗保健时，强大的科学和许多临床倡议指向改善整个生命过程中的健康、功能和福祉。这种护理似乎还可以限制过早死亡的风险，从而延长寿命，改善生活。因此，至关重要的是，结构性选择不公平和对健康老龄化何时开始以及它需要什么、谁需要社会和支持性护理以及使用这种护理所需的功能能力的误解相结合，代表了代价高昂的误判。赋予生物医学特权继续浪费资源、金钱和人类潜力。

我们可以修复或尝试修复健康问题的事实不应该意味着我们应该对加强它感到自在，即使是无意的忽视。我们都很容易想出例子来说明这个等式。考虑患有慢性阻塞性肺病 (COPD) 的老年人，他们将从空调中受益，以防止疾病恶化和随之而来的住院治疗。很少有服务向 COPD 患者提供空调及其维护。相反，大多数卫生系统提供住院治疗以治疗 COPD 恶化。无论是说明性的例子，当我们说“健康和社会关怀”时，明显的尖锐错位变得清晰起来。社会关怀紧随其后，而且通常是事后的想法，因为生物医学保健先于其他一切。

许多人可能会争辩说，对健康的社会决定因素的更加突出的关注代表了生物医学的显着创新以及由此产生的范式转变。在这里，我们使用的语言再次说明了现实。大声朗读这个词时听：行列式。决定或导致的因素。这种经常被引用的描述性模型在引起人们对社会因素的关注方面很有价值，但“决定因素”一词意味着健康已经确定，过去时。健康的社会决定因素的常见表示依赖于静态图形表示和措辞，因此该模型缺乏计划或行动感。

健康的社会决定因素在护理和卫生专业中进行教授。在大多数情况下，被称为“健康决定因素”的因素被用来解释给定的健康状况，而没有匹配的行动模型。新手学生很可能会认为决定因素的含义是健康状态是由模型中列出的因素预先确定的。缺少消除不平等和将疾病管理中对因果关系的关注转移到促进健康和福祉所需的方法。护士多久学习一次评估和干预住房不安全、食品不安全和人身安全的技术？鉴于无家可归、饥饿和暴力的盛行，影响了所有年龄段的人，包括我们世界上最年长的人，这还不够频繁。此外，大多数健康问题社会决定因素的表述未能反映当前的关切和相关证据。他们怀念气候危机、健康老龄化和对歧视的理解，这些歧视凸显了普遍接受的健康主义、能力歧视和年龄歧视。尽管健康的社会决定因素具有描述性效用，为什么不将我们的重点转移到通过解决不平等来改善健康的社会机会模型上呢？

作为老年学护士，我们为更广泛的利益服务的力量就在眼前。让我们现在利用这种力量重新排列我们的优先事项，以实现健康和福祉。我们提倡的第一步，说起来简单，做起来难。让我们都从总是说“社会和医疗保健”开始，然后讨论为什么这个措辞很重要。但是要知道，虽然语言很强大，但改变我们所说的话是不够的。这里有一些方法可以让我们扮演老年护士，扮演从业者、教育者、研究人员、理论家、管理者、政策制定者、制定者和公民的角色。

• 了解有关健康的社会决定因素之外的社会因素的更多信息。关注不公平和机会。社会工作者在这里是完美的合作伙伴。尝试与社会工作的同事讨论您感兴趣的现象，并共同确定已知会导致该现象的社会不平等现象。

• 请记住，行星气候和当地环境是更大的社会景观的一部分。没有健康的气候，我们的社区和社会就无法存在。从健康环境护士联盟 ( https://envirn.org )了解有关环境和健康的更多信息。该组织还提供了一本关于环境和健康的免费阅读教科书，现在已经是第二版了（https://envirn.org/e-textbook/）

• 教育每个人了解抑制社会福利、福祉和关怀价值的常见误解和误解。与患者、客户、家人、学生、同事、邻居和朋友讨论每个人生活中的社会因素和联系如何帮助我们所有人活得更长、更好，无论我们的年龄如何。

• 开始改变规定选择加入护理的政策，以支持鼓励健康护理的选择退出结构。倡导在临床实践、社会和医疗保健管理以及制定和制定政策方面进行这种改变。作为推论，努力为所有年龄的体弱和重病患者进行复苏，他们可以选择加入，而不是努力选择退出这些措施。

• 针对当代证据、真正的包容和参与以及行动路径，重新定义当前对健康的社会决定因素的解释。在我们所做的一切中应对气候危机、无家可归、饥饿、暴力以及经常接受的对健康主义、能力歧视和年龄歧视的歧视。这意味着新的概念和理论模型、新的课程、创新的政策和包容性的护理计划。这也意味着每当在我们的机构、我们的社区和我们的国家进行投票时，投票我们的护理价值观。

• 利用长期被低估的伙伴关系——护士和社会工作者之间的伙伴关系。与我们在社会工作领域的同事合作，我们可以做很多事情，将健康的社会决定因素转变为健康和福祉的社会机会，确保所有年龄段的人都能得到社会关怀，从而健康地生活和衰老。寻找在理论、研究、教育、护理、管理和政策方面合作的机会，以实现这一愿望。

我们老年科护士非常了解如何才能过上长寿和充实的生活。这些知识是我们采取行动的杠杆，可以在国内和我们共同的世界创造更大的利益。我们可以想象没有比这更好的时间了，实际上没有比现在更紧迫的时刻来摆脱我们对健康和福祉的无序优先事项的限制，并展望一个更美好的未来。我们现在都必须采取行动，使人人享有社会和医疗保健成为全球现实。

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