Thinking Upstream: Preparing Students to Champion Health Equity

Editorial freeThinking Upstream: Preparing Students to Champion Health Equity Teri A. Murray, PhD, PHNA-BC, RN, ANEF, FADLN, FAAN, , PhD, PHNA-BC, RN, ANEF, FADLN, FAAN Teri A. Murray, PhD, PHNA-BC, RN, ANEF, FADLN, FAAN E-mail Address: email protected Journal of Nursing Education, 2025;64(10):611–612Cite this articlePublished Online:October 01, 2025https://doi.org/10.3928/01484834-20250910-01 PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookxLinkedInRedditEmailBluesky SectionsMoreIntroductionIt is essential that students recognize their ethical responsibility to engage in health advocacy and civic and political engagement as a means of advancing health equity. While nursing faculty have long excelled at preparing students to advocate for individual patients, the next step should be to prepare them for "upstream" advocacy—shifting from a solely individual focus to a systems-level approach that can target structural and long-term change to champion health equity. One way to conceptualize this expanded view of advocacy is through McKinlay's (1979) upstream-downstream metaphor.McMahon (2022) retells McKinlay's (1979) compelling upstream-downstream metaphor, which illustrates the need for a broadened view of advocacy that extends beyond individual rescue efforts. In this metaphor, the act of repeatedly rescuing drowning victims, without ever attending to what is "upstream," pushing them into the water, underscores the importance of addressing the structural determinants, the broader social, economic, and policy-level influences, including laws, systems, and institutional practices that create and sustain inequities. Simply put, the metaphor shows how inequities begin upstream, with structural causes and flow downstream to produce poor health outcomes. While downstream clinical interventions and midstream social needs actions can alleviate harm, inequities will persist without addressing those upstream determinants, the root causes that drive the disparities commonly seen across populations.Understanding the metaphor is the first step; the next step is equipping students to apply upstream thinking through advocacy and civic and political engagement. Nursing faculty can guide students to focus on broader social, economic, and policy-level influences, including laws, systems, and institutional practices that shape the social determinants of health. Teaching students to think upstream means shifting their gaze from an individual patient to the sources of ill health. As McMahon's metaphor suggests, students must look beyond rescuing drowning victims to understand why they are falling in the river, addressing the structural drivers of disparity. By teaching students' advocacy and political engagement skills, faculty can empower students to become civically engaged, recognize when policies cause harm, and support action-oriented policies that enhance health. Health advocacy is a professional responsibility, and understanding policy is a critical first step in fulfilling that responsibility.Applying upstream thinking is particularly relevant and pressing in the context of current federal policy proposals that could have a profound impact on nursing and health. Proposed federal actions such as the elimination of the National Institute of Nursing Research ( https://www.ninr.nih.gov/), the defunding of Title VIII Nursing Workforce Development programs, and cuts to Medicaid, if enacted, would have significant implications for nursing science, workforce sustainability, and access to care for vulnerable populations. The proposed elimination of these federal policies represents a structural determinant that can shape the distribution of resources available to communities and to the nursing profession. Faculty must prepare students to recognize these upstream drivers and to respond through advocacy, policy engagement, coalition-building, and political action. Without this preparation, nurses risk being reactive rather than proactive, potentially being sidelined in critical policymaking conversations.The role of nursing in advocacy and action has deep historical roots. Lilian Wald, founder of the Henry Street Settlement House in the Lower East Side of Manhattan, engaged directly with policymakers to address poverty, child labor, housing, and public health infrastructures (Snyder-Grenier, 2020). Wald's vision expanded nursing practice beyond care delivery of individuals and families to a broader policy reform agenda in health, labor, education, recreation, and housing. Her actions were directed at the structural determinants of health. Wald's legacy as a pioneer exemplifies the deep roots of nursing's social contract with the public.This tradition of advocacy continues today, as reflected in the American Nurses Association (ANA) Code of Ethics (2025), Provision 9, "Nurses and their professional organizations work to enact and resource practices, policies, and legislation to promote social justice, eliminate health inequities, and facilitate human flourishing (p.37)." Inherent in this statement is the expectation that nurses should belong to professional organizations. Faculty should encourage students to join and participate in nursing organizations at local and national levels, engage them in legislative days through state nurse associations, and use the ANA Code of Ethics to emphasize that advocacy is both a moral and professional responsibility.The ANA Code of Ethics provides concrete guidance for nurses' civic and political engagement. Provision 9.2 highlights that nurses' engagement in civic and political life reflects the profession's social contract, highlighting the reciprocal responsibilities between nurses and the broader society. Provision 9.5 further underscores that nurses have an ethical responsibility to engage in the political process, particularly in shaping legislation and regulations that affect the public's health (ANA, 2025). For example, contemporary issues such as the shortage of primary care physicians, the scope of practice for advanced practice nurses, and policies governing collaborative practice agreements illustrate how these structural factors directly influence health care outcomes. Engaging students in these relevant real-world policy issues provides opportunities for them to be involved in both advocacy and civic and political engagement, while preparing them to influence the systems that determine individual and population health outcomes.The ANA Code of Ethics, Provision 5 (2025) emphasizes that nurses have a professional responsibility to engage at every level of the democratic process. This includes participating in elections, considering leadership roles, advocating against barriers to voting, and collaborating with elected officials to advance health and social policy. Faculty can model this engagement and highlight its importance in the curriculum. They can mentor students in advocacy and connect students with organizations to demonstrate how collective action strengthens nursing's voice. Teaching students that coalition-building and collaboration with both governmental and nongovernmental organizations are key to addressing the social and structural determinants of health and promoting overall societal well-being. This will prepare them for an active life of advocacy, political and civic engagement, and professional participation.Call to ActionThe nursing profession cannot afford to produce a generation of graduates who are unprepared to navigate the political forces that shape health. Faculty must intentionally integrate advocacy, political engagement, and the structural determinants within the curriculum, clinical experiences, and scholarly projects. This means that faculty model civic and professional engagement, mentor students in coalition-building and policy advocacy, while providing real-world involvement in legislative and organizational leadership. By doing so, the graduates are prepared not only to care for individuals but to champion equitable, evidence-informed policies. They can influence systemic changes that safeguard the health of communities and strengthen the profession.Teri A. Murray, PhD, PHNA-BC, RN,ANEF, FADLN, FAANSaint Louis University, TrudyBusch Valentine School of Nursing,St. Louis, MissouriPresident, National Institute ofNursing ResearchAssociate Editor, Journal ofNursing Education teri.murray@slu.eduAmerican Nurses Association. (2025). Code of Ethics for Nurses. https://codeofethics.ana.org/home > Google ScholarMcKinlay J. (1979). A case for refocusing upstream: The political economy of illness. In Jaco E. G. (Ed.), Patients, physicians, and illness (3rd ed., pp. 9–25). Free Press. > Google ScholarMcMahon N. E. (2022). Framing action to reduce health inequalities: What is argued for through use of the 'upstream-downstream' metaphor? Journal of Public Health (Oxford, England), 44(3), 671–678. 10.1093/pubmed/fdab157 PMID:34056659 > Crossref MedlineGoogle ScholarSnyder-Grenier E. M. (2020). The house on Henry Street: The enduring life of a Lower East Side settlement. Washington Mews Books. 10.18574/nyu/9781479801381.001.0001 > CrossrefGoogle Scholar Next article FiguresReferencesRelatedDetails Request Permissions InformationCopyright 2025, SLACK IncorporatedPDF download • 147.5 KBteri.murray@slu.eduDisclosure: The author has disclosed no potential conflicts of interest, financial or otherwise. Published online10/01/25