"Upstream" nursing practice and research.

Nursing practice often brings the nurse into an intimate relationship with suffering individuals and vulnerable communities. To fully and effectively conduct our practice and pursue our scholarship, the socially unjust systems that maintain the vulnerability of whole populations must be addressed through broader political participation and the examination of broken systems (Bekemeier & Butterfield, 2005). Although political action has a poor fit with traditional caring models that were described for nursing practice, theory, and research toward the end of the last century, notions of caring can and should be expanded to include our political responsibilities to respond to social injustices that impact population health. Research increasingly suggests that when nursing and other health-related sciences focus their attentions on the social determinants of health, we will achieve improved health status and greater health equity in the populations we serve (Evans, Whitehead, Diderichsen, Bhuiya, & Wirth, 2001; Labonte, 2003; Raphael, 2003). This focus requires an “upstream” approach. Upstream approaches refer to an analogy used in the United States for describing efforts focused on primary prevention and addressing root causes of disease and disability. This upstream analogy addresses the underlying issues that cause “downstream” problems rather than going to great lengths to address fully developed and ongoing crises downstream. Many of us in nursing are in downstream positions, researching questions and working with programs that relate to caring for acutely at-risk, vulnerable families or communities and without a focus on activities that would drive a movement from downstream work to upstream measures that change harmful systems instead of responding to their negative outcomes. Our present emphasis on downstream approaches occurs, in part, because of the complexity of addressing social conditions