Social Justice, Social Determinants of Health, Interprofessional Practice and Community Engagement as Formative Elements of a Nurse Practitioner Managed Health Center

Aim: This paper presents four key elements for developing infrastructure to address health disparities which are social justice, social determinants of health, interprofessional practice, and community engagement. Method: These elements are then illustrated within a nurse-led interprofessional practice exemplar. Conclusion: Using these key elements, there is great potential for developing and carrying out a community-based participatory research agenda to address health inequity within a nurse-led interprofessional practice setting. Social Justice, Social Determinants of Health, Interprofessional Practice and Community Engagement as Formative Elements of a Nurse Practitioner Managed Health Center Publication History: Received: November 17, 2016 Accepted: January 23, 2017 Published: January 25, 2017

What this paper adds: This paper discusses social injustice, interprofessional practice and development of community partnership as it relates to the development of a sustainable health disparities research agenda and it application in a nurse-led health care center.
Implications of this paper: This paper provides both theoretical underpinning and a real world exemplar of a strategy to develop a community based participatory research agenda to address health inequity within a designated community.
Nursing as a profession has consistently focused on the mental and physical well-being of others -individuals, families, communities and populations. As nurses strive to support this wellbeing, they must be knowledgeable of those complex factors that affect an individual's ability to experience optimal health. Globally, nursing literature has broadened to increasingly focus on social and environmental factors on health and assist nurses to enhance how we view, and practice, nursing to address health disparities among underserved populations. Within the last 10 years, the health disparities literature has consistently identified key elements which can support knowledge development and change in nursing practice. These key elements are social justice, social determinants of health, interprofessional practice and community engagement.

Social Justice and Nursing
Social justice as a construct has been explored by a vast array of professions. The concept has been found in the literature as far back as the writings of Plato. Theologians Thomas Aquinas (1225-1274) and John Locke (1632-1704) as well philosopher Immanuel Kant (1724-1804) are widely seen as key contributors to the early underpinnings of current social justice ideals. The contemporary concept of social justice is generally associated with the work of John Rawls (1921Rawls ( -2002. In Rawls' A Theory of Justice [1] he proposes, "Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override. For this reason, justice denies that the loss of freedom for some is made right by a greater good shared by others"(p3-4). Rawls [2] states "justice is the first virtue of social institutions" (p 113). This philosophy is based on the two moral powers 1) a of sense of justice and 2) conception of the good.
Social justice principles, whether implicit or explicit have been incorporated into nursing practice since its inception. Many of Florence Nightingale's writings address the need to consider the influence of social issues on health. In a synthesis of Nightingale's writings, Selanders and Crane [3] identified that Nightingale set forth the premise that thework of nursing should not be limited by gender, spiritual beliefs or values of those they serve. Lillian Wald, viewed as the founder of modern public health nursing, established the Henry Street Settlement House, in New York City in the late 1800's where the poor could receive medical care and access to social services. Wald grounded her efforts "in the belief that the world was simply an expanded version of a culturally diverse neighborhood" [4].
Overtime, nursing education has demonstrated the importance of mandating the inclusion of social justice concepts at every level of instruction and as part of the American Nurses Association Code Special Issue: Community-Based Participatory Research Practices of Ethics. The American Association of Colleges of Nursing (AACN) Essentials guidelines identify the need to address social justice concepts in bachelor's programs [5], master's education [6], and in doctoral preparation for advanced practice [7]. The AACN mandate for this content validates nursing's commitment to assisting our students in preparing to meet the challenge of addressing social justice issues and recognizing their relationship to health.
The American Nurses Association [ANA] Code of Ethics with Interpretative Statements [8] addresses the role of the nurse as part of collaborative practice and collaborative research. In addition, it included specific language focused on the responsibility of the nurse to address social injustice with an understanding if its relationship to health disparities. Provisions 7-9 of the Code provides support for nurses in the development and leadership of interprofessional practice, to hold a greater understanding and application of the social determinants of health model, and the expectation for nursing research and scholarship that best addresses the complex needs of populations especially those that are underserved and experiences health disparities due to social and economic disadvantage.

Social Determinants of Health and Health Inequity
The World Health Organization [9] defines Social Determinants of Health (SDH) as "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" [9]. These contextual factors affect people's exposure to environmental risks, vulnerability to illness, access to care, and ability to undertake healthy behaviors or manage health conditions within their home settings. Social determinants are often the foundation of poor health and are critical to understanding health disparities.
The complex interaction of social and economic conditions that affect health include education, income, employment, neighborhood characteristics, and social conditions and contexts as well as culture and beliefs about health. Individuals with low education and income are more likely than better-educated, higher-income individuals to lack a stable job, safe housing, food security and adequate income to meet health needs. Inequity in resources result in increased morbidity and mortality and these interactions have a cumulative effect over the life course for individuals, families and communities [10][11][12][13][14][15][16].

Interprofessional Education, Practice and Research
The ability to address health needs with a social justice perspective cannot be accomplished by nursing or other disciplines in silos. Therefore, addressing the social justice imperative necessitates collaborative, interprofessional practice, education and research. Interprofessional education (IPE) is becoming an essential element in the preparation of healthcare professionals for interprofessional collaborative practice(IPP) and research. IPE has been shown to improve healthcare delivery and health outcomes with the Institute of Medicine [17] urging interprofessional collaboration in healthcare to improve the quality of care. Socialization into health professions roles involves mutual learning through interactions with professionals from other disciplines to understand their roles, values, attitudes, skills, behaviors, and norms [18]. Although the IPE and collaborative practice movement began about 40 years ago, high quality evaluation research remains critical to show their effectiveness [19]. Healthy People 2020 [20] recognized the importance of interprofessional education and practice in meeting community health needs, specifically stating in Educational and Communitybased Program Objective 19 (Office of Disease Prevention & Health Promotion [ODPHP], n.d.) that the goal is to, "Increase the proportion of academic institutions with health professions education programs whose prevention curricula include interprofessional educational experiences" [21]. Deutschlander et al. [22], in their systematic review of the literature, concluded that "offering these types of IPE experiences has also shown to influence student's first place of employment at graduation, especially in rural and urban primary care specialties involving underserved populations" (p.1). Settings such as these experience significant health disparities, and inequity in health care access and service availability. Increasing providers committed to underserved populations directly impacts inequities in access and service availability.
The importance of a clear research agenda surrounding IPE and IPP cannot be overstated. However, there is considerable discussion on the manner in which this can be done(i.e. what actually can be measured and what is the most appropriate methodology). The work of Brandt et al. [19] and Goldman et al. [23] identify that previous research has focused on three types of impact (of IPE/IPP). These are short-term changes on the learner; practice-based processes and organizational level policy change. The Institute of Medicine published Measuring the Impact of Interprofessional Education (IPE) on Collaborative Practice on Patient Outcomes [24] to aid in clarifying how IPE/IPP might be studied. The report offers extensive guidance related to study design and identifying types of outcomes that could realistically be measured. In addition, the report discusses a key element that had not been fully explored previously which was the recommendation for inclusion of patient, family and caregiver experiences with the goal of improved alignment between education and practice as well as improved person-centered and community-centered outcomes. The report states that, "Addressing these gaps will entail giving IPE (and IPP) greater priority by forming partnerships among the education, practice, and research communities to design studies that are relevant to patient, population, and health system outcomes. Engaging accreditors, policy makers, and funders in the process could provide additional resources for establishing more robust partnerships. Only by bringing all these constituencies together will a series of well-designed studies emerge. " (Institute of Medicine [24]) This document supports engagement of patient and community as important partners in this area of research as providers strive to be better equipped and thereby improve health outcomes and address health disparities.

Community Engagement, Partnership and Health Equity
Health practitioners and researchers have increasingly used community engagement in the context of health promotion and disease prevention. The Centers for Disease Control and Prevention (CDC, 1997) has defined community engagement as "the process of working collaboratively with, and through, groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people"(p 9). The Principles of Community Engagement [25] document identifies that "community engagement is grounded in the principles of community organization: fairness, justice, empowerment, participation, and self-determination" (p 4). A growing body of research has clearly identified that ecological factors support health or influence the development of disease. Because health is socially determined to a great extent, then health issues are best addressed by engaging community partners who bring their own understanding, concerns, values and priorities. Through this approach, trust is built, coalitions are formed and innovative solutions are identified which are culturally and socially congruent. These solutions are more sustainable because community partners are invested in those solutions and they are tailored to the needs of those being served. Also of importance in community engagement is the focus on the underlying principles of equity and justice which is enacted through the bidirectional partnership between practitioners and/or researchers and the identified communities.
Key characteristics of community engagement are the critical nature of building trust, supporting empowerment, role definition and collaborative decision-making among partners. Even as this process is occurring, interprofessional team building is also occurring. Both require time, resource development (human and financial) and relationship cultivation as essential infrastructure that supports innovation, improved outcomes, outcome measurement and the development of a community based participatory research agenda in collaboration with community stakeholders.
The Principles of Community Engagement [24] identify that the community based participatory research model includes clear delineation of 1) contexts, 2) group dynamics and equitable partnerships, 3) collaboratively developed intervention strategies and 4) outcomes that are focused on system change to address inequality in health and health care.

Methods
The following is an exemplar of a unique clinical setting that has systematically applied the elements of social justice, social determinants of health, interprofessional practice, and community engagement to build an infrastructure that is well suited to address health disparities, develop educational approaches and CBPR research.

Kentucky Racing Health Services Center
Established in 2007 as a nurse practitioner managed health center, the Kentucky Racing Health Services Center (KRHSC) provides a full range of health care services to the un-and under-insured workers in the Kentucky thoroughbred horse racing industry. The KRHSC is located at the Churchill Downs racetrack which is a horse racing setting in Louisville Kentucky, USA and the home of the worldrenown, annual Kentucky Derby. The KRHSC is a collaborative program between the Kentucky Racing Health and Welfare Fund, Churchill Downs and the University of Louisville School of Nursing.
The Kentucky Racing Health and Welfare Fund consists of money allocated by the Commonwealth of Kentucky which comes from unclaimed winnings generated from bets placed at Churchill Downs during the racing season. If winning, horse racing tickets are not cashed by their owners, a portion of that money goes into the Kentucky Racing Health and Welfare Fund as determined by the state. The University of Louisville School of Nursing identified the unmet health care need of the racetrack workers as a result of their clinical experience, the School of Nursing developed a service proposal and a collaboration was formed with Churchill Downs using Racing Health and Welfare Funds to provide the needed care.
The KRHSC serves a primarily Spanish-speaking population with scheduled office visits and same day visits, and there is no charge for the provided services. The individuals that are served migrate across the United States as part of their work in the horse racing industry. Horse racing tracks have meets or sessions at different times of the year and workers follow this schedule. Following this schedule can mean traveling thousands of miles several times per year to continue their employment. Horse racing tracks in states such as New York, Louisiana, Florida, Arkansas and others provide what health services they can for workers, but care is fragmented and not always available. The migratory nature of this work makes delivering quality, sustainable health care challenging at best.
Along with physical health services, the program has recently expanded to include mental health services based on the identified needs of the population being served. There is an interprofessional provider team including advanced practice and registered nurses, physicians, dentists, and translation/culturally tailored services. Since its inception, the KRHSC averages approximately 2,000 office visits per year. Nurse practitioner faculty from the University of Louisville School of Nursing see patients 2 ½ days per week and adjust the schedule to meet the needs of this migratory population. KRHSC services primarily occur May-December annually and most patients leave the area January through April to work at racetracks in the warmer climates.
Beyond the services provided to this diverse community, the Center is an invaluable service learning clinical site for students studying nursing (BSN, MSN and PhD), Latin American and Latino Studies and for undergraduates interested in considering a career in medicine. Undergraduate community nursing students routinely provide educational offerings at the clinic that have a prevention focus. The Center has provided the opportunity for several students to complete pilot studies as a foundation for their master's thesis and doctoral dissertations. Outcomes from the service learning programs and student projects are measured through identified student learning outcomes and educational research. Clinical research is also undertaken. Currently, research data is being collected to examine Latino women's perceptions regarding access to the KRHSC health care services to better meet cultural and social needs of this population.
Because of the migratory nature of the patient population, health care follow up is challenging with many patients ceasing to take their medication when they are away from the Center. As part of KRHSC outcome improvement efforts, factors associated with medication nonadherence are under investigation to address barriers to self-care behaviors using the contextual knowledge about this population. Efforts to better understand center patients and the community's needs necessitate creative research strategies that require a true partnership between the KRHSC, the university and the horseracing community that experience disparity in health. Table 1 identifies the four key elements and how they were enacted within the KRHSC setting (Table 1).

Conclusion
This exemplar provides a picture of the focus on social justice, building community infrastructure for clinical services, professional education and research in partnership with community funders, health and non-health care professionals and the underserved population themselves. A CBPR research agenda is underway resulting in an