If you’re a public health nurse or educator you’ve heard, used, and educated on web of causations. A web of causation has a lot of elements and is a key concept in community health - all nursing specialties should be using it in class and in clinical.
What I want to explore and encourage is educating and using the web in other courses and clinicals in addition to community and public health courses - it should be used in pediatrics, maternal newborn, medical/surgical and psychiatric nursing courses. Finding the underlying cause of a health challenge can lead to prevention. Preventing illness or disease helps address the current healthcare crisis we're facing.
Understanding the web of causation and social determinants
According to the World Health Organization - Environmental Health Sector, children under 5 and adults aged 50-75 are most affected by the environment-and we as nurses and other healthcare professionals, routinely do nothing to assess and address the fact that 80% of our health is directly caused and affected from where we live, work and play (Magnan, 2017).
A web of causation is just that a web, and it should look like an entangled spider web as all causative factors are interconnected and there rarely is one causative factor to any disease or illness. As nurses, we need to aim to change several factors to see a change. Unfortunately, we only focus on changing one factor and consequently do not see the change we wanted, resulting in readmissions, exacerbations and deaths, causing healthcare costs to swell and mistrust in the healthcare system to occur. We, unfortunately, have this approach in the classroom as well.
It's well known that 80% of our health is in direct relation to where we live, work and play - since the percentage is alarmingly high, questions around social determinants of health are something all nurses should be asking of our patients (regardless of if it is a med-surg, peds, OR or community health admission). All elements should be asked at admission and throughout a hospital stay to help promote a client’s health, and we should also be incorporating it in our core nursing classes and clinical settings.
Understanding the web in practice
Let's break down an example, A patient comes to the Emergency Department with complaints of shortness of breath, dizziness, fatigue worsening over the past two weeks. The patient states he has used his rescue inhaler more times in the past two weeks then in the past two years.
What do we normally ask? Are his vaccines up to date? Has he traveled lately, or been around anyone sick? We follow standard protocol and order a chest X-ray, 12-lead, maybe a non-contrast CT, CBC/BMP, and finally swab for flu and now COVID. The patient is admitted to the respiratory floor for observation.
What's missing in the assessment?
We are not asking where they live, work and play. Questions we could start asking:
- Did they start a new job? Do they wear the proper PPE at their job, and have they encountered a new chemical in the home or at work?
- Did they move to a new home/apartment where there is asbestos, lead paint, smokers/drugs in the building? Do they live near a chemical or paper plant?
- Are they residing in group home/shelter? Is their car reliable and in good working condition?
- Do they have access to healthy foods? have they been able to obtain any prescribed medications?
This list could go on but it's crucial to assess the patient's holistic living experience. What if the cause of the chief health complaints were actually caused from a new residence that is one block away from a paper manufacturing plant and the patient has been leaving all windows open for fresh air?
By incorporating direct assessment questions and techniques relating specifically to social determinants of health in all core nursing classes, we can start to have a new generation of nurses addressing and implementing what leading research has concluded.