Web of Causation: What is it and how to incorporate it?

If you’re a nurse or public health educator, you’ve heard about, used, and researched the web of causes. A causal network has many elements and is a key concept in community health – all nursing disciplines should use it in the classroom and in the clinic.

What I would like to explore and promote is the education and use of the Internet in other courses and clinics in addition to community and public health courses – it should be used in paediatrics, newborn mothering, medical/surgical and psychiatric nursing courses. Finding the underlying cause of a health challenge can lead to prevention. Disease prevention is helping to tackle the current healthcare crisis we are facing.

Understanding the web of causality and social determinants

According to the World Health Organization – Environmental Health Sector, children under the age of 5 and adults aged 50-75 are those most affected by the environment – and we as nurses and other health professionals routinely do nothing to assess and address the fact that 80% Our health is directly caused and influenced by where we live, work and play (Magnan, 2017).

A causal web is just that, a web, and it should look like an intricate spider’s web, since all causal factors are interconnected and there is rarely one causal factor in any disease or condition. As nurses, we must aim to change multiple factors in order to see change. Unfortunately, we only focus on changing one factor and consequently don’t see the change we wanted, leading to readmissions, exacerbations and deaths, increasing healthcare costs and distrust of the healthcare system. Unfortunately, we also have this approach in the classroom.

It’s a well-known fact that 80% of our health is directly related to where we live, work and play – since that percentage is staggeringly high, all caregivers should be asking their patients questions about social determinants (regardless of whether it’s about a med-surgeon, pediatrician, OR, or community hospital). All elements should be inquired upon admission and throughout the hospital stay to benefit a patient’s health, and we should also incorporate them into our core nursing courses and clinical settings.

Understanding the web in practice

Let’s break down an example: A patient comes to the emergency room with complaints of shortness of breath, dizziness, and fatigue that have been worsening over the past two weeks. The patient states that he has used his rescue inhaler more often in the last two weeks than in the last two years.

What do we usually ask? Are its vaccines up to date? Has he traveled lately or been sick around anyone? We follow standard protocol and order a 12-lead chest x-ray, maybe a no-contrast CT, CBC/BMP, and finally a swab for flu and now COVID. The patient is taken into the respiratory tray for observation.

What is missing in the assessment?

We don’t ask where they live, work and play. Questions we might ask:

• Have you started a new job? Are they wearing the correct PPE at work and have they encountered a new chemical at home or at work?
• Have you moved to a new house/apartment where there is asbestos, lead paint, smokers/drugs in the building? Do you live near a chemical or paper factory?
• Do you live in a group home/accommodation? Is your car reliable and in good condition?
• Do they have access to healthy food? Were they able to obtain prescribed medication?

This list could go on, but it is crucial to assess the patient’s holistic life experience. What if the root cause of the main health complaint was actually a new apartment a block from a paper mill and the patient left all the windows open for fresh air?

By incorporating direct assessment questions and techniques specific to social determinants of health in all core nursing courses, we can begin to have a new generation of nurses engaging and implementing the results of leading research.