Skip to main content
Insights Magazine 2025

Building Systems of Care Around the Whole Person

Building Systems of Care around the whole person

How nurse researchers connect life circumstances with clinical care to improve patient outcomes

BSA

 


What would it take to connect a person’s real- life challenges—like housing, food, or transportation— with the health care they receive? Could it improve patient outcomes?

These questions guided Andrea Wallace, PhD, RN, FAAN, associate dean for research at the University of Utah College of Nursing (CON), during her May 7 lecture for the National Institutes of Health (NIH) Clinical Center Grand Rounds. Hosted by the National Institute of Nursing Research (NINR), the lecture series explores emerging ideas to help researchers and health professionals stay at the forefront of patient care.

This year NINR celebrates its 40th anniversary. And Wallace’s invitation to speak recognized her status as a nationally respected researcher, known for her work in designing and testing practical, evidence-based interventions to improve patient outcomes. in designing and testing practical, evidence-based interventions to improve patient outcomes.

From Asthma to Evidence

Drawing from her experience as a nurse caring for children with asthma in Denver, Colorado, Wallace stated in her address, “I quickly saw that medications and appointments weren’t enough. What really shaped outcomes were the social realities families faced while coping with their child’s chronic illness: healthy housing, time off work, and access to transportation.”

During her lecture, Wallace highlighted her team’s long- standing efforts to integrate social care into fast-paced clinical environments, such as emergency departments and inpatient units. Describing the SINCERE social needs’ screener, which inquires about needs such as transportation, food, utilities or childcare and eldercare and was developed in collaboration with United Way Utah 211, she explained how nurses and care teams have identified critical gaps in access to services that support health and wellbeing.

Since 2017, more than 70,000 patients have been screened through the SINCERE social needs’ screener. “Nearly half of those who complete screening report at least one unmet need, with the most common being for utilities, rent, household items, and food. Still, only 44% made contact with the resource navigator, and fewer than one-third ultimately connected with the community service, showing just how much can be lost between screening and support.”

I quickly saw that medications and appointments weren’t enough. What really shaped outcomes were the social realities families faced while coping with their child’s chronic illness: healthy housing, time off work, [and] access to transportation.
Andrea Wallace PhD, RN

SYSTEMS MATTER: WHAT GETS IN THE WAY

Wallace stressed that screening alone isn’t enough though. Without follow-up systems that ensure appropriate care and a way for health care providers to act on the gathered information, patients’ needs remain unmet.

To help people successfully adopt and benefit from social needs screening, Wallace pointed out, “Systems should be designed to foster relational trust and psychological safety. If staff don’t feel safe raising concerns or deviating from task lists, these relational moments often get skipped.”

Also, systems should be intentionally designed from the start for spread and sustainability. “We need more than just good evidence,” Wallace mentioned. “We need infrastructure to support the transition from promising social needs to real-world practice across systems. When we talk about integrating social needs into care, it’s not just about building a better workflow; it’s about making sure health care meets people where they are and reflects what they actually need to live well.”

Nearing the conclusion of her talk, Wallace underscored the essential role of nursing science in bridging social context and clinical care: “Nurses are uniquely positioned to bridge every layer of care from the patient and family at the center to the broader network of community partners. They’re part of the direct care team. They lead care coordination and serve as the connective tissue across disciplines and settings. They operate across all levels, often simultaneously. That gives them critical insight into what’s working and where systems are breaking down. Nursing science brings the lens we need to move beyond pilots and into sustainable systems that improve health and health care, whether it’s understanding patient context, designing workflows that work in real-world care environments, or building trust within teams. Nursing science isn’t just helpful here. It’s essential.”

BSA

Advancing Solutions that Work

Wallace closed her lecture with a call for deeper investment in nurse scientists and the training that enables them to lead system- level change. She emphasized the growing importance of skills such as community engagement, which fosters trust and ensures interventions are grounded in lived experience; pragmatic trial designs in real-world settings; and fluency in multi-level, cross-sector data, which is essential for evaluating complex interventions that span health and social care. “This work,” she explained, “generates the kind of evidence needed to build health systems that are scalable, sustainable, and responsive to the realities patients face.”

“The journey of nursing science has always been one of depth,” she said. “Persistence and transformation is about noticing what others miss, asking different questions, and designing solutions that reflect the full complexity of people’s lives, not just their conditions, but their communities, their struggles, and their strength.”

LEARN MORE ABOUT RESEARCH AT THE COLLEGE OF NURSING

The College of Nursing is a national leader in nursing research. We are ranked #17 (#12 for public universities) in National institutes of Health (NIH) research funding, and possess a total grant portfolio of $64 million. We are leaders in community and care-based research. Our faculty are training the next generation of nurse scientists to ensure quality care for all. Visit nursing.utah.edu/research to learn more.

PROGRAMS OF RESEARCH

  • Aging
  • Caregiving Across the Lifespan
  • Informatics and Systems Sciences
  • Innovative Care Delivery Models
  • Simulation in Nursing and Interprofessional Education
  • Social and Behavioral Aspects of Chronic Disease
  • Social, Behavioral, and Environmental Determinants of Health and Health Equity Science
  • Symptom experience and Management for Children with Cancer
  • Women’s Health