Reducing health inequity in the United States is a social mandate for nursing in the 21st century. The World Health Organization and others have defined and identified multiple social determinants of health (SDOH) that may negatively impact patient health and contribute to health inequity. Nurses, on the frontlines of healthcare, are uniquely positioned to assess for social determinants of health and positively address health equity. The purpose of this article is to explore social determinants of health and nursing education, including clinical and classroom opportunities. We also discuss faculty development and diversity as a strategy of impact, and conclude with a call to action and recommendations for nurse educators working to include SDOH in nursing program curricula.
Key Words: Social determinants of health, nursing education, diversity, interprofessional education, health equity, simulation, service learning
The levels of health inequity that currently exist within the United States will not be relieved by one healthcare profession alone, yet nursing holds the greatest capacity to address this major challenge of the 21st century. With approximately 2.9 million nurses currently employed within the United States (United States Department of Labor, 2018), the role of the nurse in addressing health equity and the social determinants of health [SDOH] must be strengthened. The World Health Organization ([WHO], 2018) defines the SDOH as, “the conditions in which people are born, grow, live, work and age that impact their health” (para. 1). The WHO website lists several key concepts related to these determinants, such as employment conditions; social exclusion; public health programs and social determinants; women and gender equity; early child development; globalization; health systems; measurement and evidence; and urbanization.
Reducing health inequity is a clear social mandate for nursing in the 21st century, and will require nursing care that is more acutely focused on the SDOH. The ability to address specific SDOH that may impact patients and then connect them with specified services has the potential to reduce healthcare costs (Pruitt, Emechebe, Quast, Pamme, & Kristopher, 2018). More than ever before, nursing must be ethically obligated to promote health equity in the 21st century and will require nursing care that is more acutely focused on the SDOH. The purpose of this article is to explore social determinants of health and nursing education, including clinical and classroom opportunities. We also discuss faculty development and diversity as a strategy of impact, and conclude with a call to action and recommendations for nurse educators working to include SDOH in nursing program curricula.
Social Determinants of Health and Nursing Education
Community and public health nursing courses have been the traditional place for content related to SDOH... Recent calls to better prepare nurses for practice outside the acute care environment provide initial support for an emphasis on the integration of the SDOH in nursing curricula (Josiah Macy Jr. Foundation, 2016; National Advisory Council, 2016). However, there will continue to be a need for nurses in the acute care environment who understand and assess for SDOH. Social determinants of health have not traditionally been integrated as a thread throughout most nursing education curricula, and this has prevented nurses from acquiring knowledge necessary to assess and address key drivers of health. These include, but are not limited to, an understanding of the more complex and less obvious drivers of health such as neighborhood safety, discrimination based on sexual orientation and gender identity, and job security. The situation is similar throughout other health professions. For example, Siegel, Coleman, and James (2018) recently noted that medical schools provide training related to the SDOH in an irregular and often unintentional manner.
Isolating key concepts within curricula does not enable students or nurses to see the wide-ranging influence of SDOH. Community and public health nursing courses have been the traditional place for content related to SDOH within undergraduate nursing curricula. Graduate level program content has varied depending on the focus of the program. Isolating key concepts within curricula does not enable students or nurses to see the wide-ranging influence of SDOH. The Robert Wood Johnson Foundation (2017) recently called for academic institutions to integrate population-focused competencies to better prepare nurses for emerging population-focused roles. This call has prompted more nursing programs to thread this information throughout curricula, as opposed to confining SDOH concepts to select coursework, and thus may increase opportunities for broader study of this important content.
Clinical and Classroom Opportunities
Solely integrating SDOH into the didactic components of a curriculum has not been effective in influencing future engagement and advocacy among students in the health professions. Solely integrating SDOH into the didactic components of a curriculum has not been effective in influencing future engagement and advocacy among students in the health professions. For example, medical students who learned about SDOH from a didactic (i.e., non-experiential) approach have shown an increase in negative attitudes toward the medically underserved as they progress through a program (Schmidt, George, & Bussey-Jones, 2016). Integration of SDOH content into nursing curricula is preferably approached from a transformative learning standpoint. This perspective moves beyond gaining knowledge and encourages students to understand, reflect, analyze, and apply content to potential future experiences and encounters. “In addition to inclusion in didactic coursework, experiential learning experiences are considered an effective teaching methodology for increasing awareness of SD[O]H” (Sabato et al, 2018, p 241).
Opportunities for curricular integration must focus on how to better educate nurses to understand the connections between SDOH and the challenges patients face. Opportunities for curricular integration must focus on how to better educate nurses to understand the connections between SDOH and the challenges patients face. Nursing students need opportunities to connect didactic material with meaningful clinical experiences in a variety of settings. For example, the Maternal and Child Health Bureau funds a Leadership Education in Neurodevelopmental and related Disabilities (LEND) program. Following an extensive pilot, six content areas with corresponding content themes, in addition to instructional strategies, were developed to guide curriculum integration (Edwards, Towle, & Levitz, 2014). While not created solely for nursing education, nurses are a target population for the LEND program. One of the content areas, protective factors related to child development, includes content about safe neighborhoods, economic security, nurturing family, and environmental influences.
Providing clinical experiences in nursing education related to this content requires moving some clinical experiences from the acute care setting to work with organizations that provide care for pregnant mothers and young families. This may also include clinical experiences outside of courses focused solely on maternal and child health. Working with agencies that utilize the Nurse Family Partnership (2018), Healthy Families America Program, (2015) or similar programs, allows students to examine and learn first-hand about these content areas in an environment where both positive and negative outcomes can be witnessed. Opportunities for students to reflect on the variables impacting a child’s health would be an essential component of the learning experience.
An effective curriculum should include multiple SDOH experiences, community engagement, and student reflection. Clinical experiences within the acute care setting constitute the majority of clinical hours a pre-licensure nursing student completes. Reconsideration of both curricular content and traditional acute care clinical experiences is necessary to prepare new nurses for future practice (Murray, 2017). An effective curriculum should include multiple SDOH experiences, community engagement, and student reflection (Sabato et al, 2018). Nursing faculty should design learning opportunities that occur in a variety of locations. Nontraditional clinical placements such as a free clinic, public schools, or non-governmental organizations provide nursing students with an opportunity to gain insight not only into the healthcare needs of population, but also to consider how interprofessional collaboration can be used to provide health services (Cheshire, Montgomery, & Johnson, 2017). Faculty should consider these settings for all nursing courses, even those that have traditionally used the acute care setting to provide clinical education.
Before a major shift in clinical placements can occur, some consideration must first be paid to the commitment of the organization to address the SDOH, and then to accessibility, safety, and sustainability. Limiting content on the SDOH to community/public health and/or elective courses further encourages a divide between where it is and is not appropriate to assess or address SDOH. Providing clinical placements outside of the acute care setting in courses other than community/public health can help students see the role of nurses in assessing for and addressing SDOH in various practice settings. Nursing students need to develop an understanding of and ability to screen for SDOH so that they can intervene as nurses on behalf of patients.
... it is through the experiential learning experiences across the curriculum that increases competence and confidence of students to serve as advocates in addressing SDOH. Integrating SDOH into the curriculum as either content or concept serves as the foundation. However, it is through the experiential learning experiences across the curriculum that increases competence and confidence of students to serve as advocates in addressing SDOH. Other specific examples of how SDOH can be integrated throughout nursing curricula include: the use of interprofessional education and collaboration; the use of simulation to improve assessment skills and communication related to the SDOH; education about motivational interviewing/empathic inquiry; curricular content on advocacy and policy closely related to improving SDOH and health equity; and service learning. Each of these is briefly reviewed below.
Interprofessional Education and Collaboration
Interprofessional collaboration is an often-untapped experience that provides an interesting opportunity for educators to integrate content related to SDOH into existing curricula. The Institute of Medicine (2010) has highlighted the benefits of interprofessional education (IPE) and called for its use to improve healthcare delivery and health outcomes. For nurses to be prepared for interprofessional collaborative practice, they must first be socialized to this role. Interprofessional collaboration is an often-untapped experience that provides an interesting opportunity for educators to integrate content related to SDOH into existing curricula. IPE has been shown to have a profound impact on student knowledge and attitudes on practice issues (Buckley et al., 2012).
IPE experiences among health professionals that do not tend to collaborate in actual practice can also be beneficial. For example, Sabato et al. (2018) found success in a formal IPE program, Team Up. During this two-year program, students from both dentistry and nursing participated in a number of activities as they collaboratively worked through case studies. Each team member applied discipline-specific knowledge as the group analyzed and managed the cases. During the first year, students focused on the critical skills needed to address SDOH on an interprofessional team. They learned about the experience of receiving care, reaching health goals, access to resources, and motivational interviewing. In year two, the cases progressed to include issues related to physical and/or cognitive disabilities, substance use disorders, oral cancer, and obesity. Participants demonstrated an overall increase in the perceived value of interprofessional teamwork as well as ability to engage patients in issues related to SDOH (Sabato et al., 2018).
IPE experiences among health professionals that do not tend to collaborate in actual practice can also be beneficial. Challenges that SDOH present for those in our care require a close examination of legal, economic, social, and political implications. Additionally, the skills of collaboration, teamwork, leadership, and diversity of thoughts are required to plan, intervene, and evaluate interventions that address these complex issues (Benfer, Gold, & Schweitzer, 2012). Partnerships between professions vested in health equity can address the needs of the community while enhancing the student learning experience. For example, an interprofessional education opportunity to complete a community needs assessment can be provided for nursing and education students, or nursing and law students. Collaboration develops interventions that move beyond a single discipline and address SDOH from a higher level. Interprofessional education and collaboration can occur throughout nursing education programs, including the use of simulated scenarios.
Simulation can provide students with first-hand experiences that increase awareness and support the need to reconsider individual biases. Simulation is utilized as both a teaching strategy and method of evaluation within nursing education. For this purpose, simulation is defined as a “...technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” (Gaba, 2004, p. i2). A recent longitudinal study explored baccalaureate nursing students’ knowledge and perceptions of client care as they relate to SDOH (Lee, Wilson, & Armstrong, 2018). The majority of students related social conditions to lifestyle choices, rather than circumstances, during the initial exploration early in their program. Overcoming these biases is necessary to properly address SDOH. Simulation can provide students with first-hand experiences that increase awareness and support the need to reconsider individual biases.
Income is one of the most important determinants of health and several tools exist to simulate poverty conditions and enhance student understanding of and attitudes toward working with the poor and life in poverty (Reid & Evanson, 2016). These simulation experiences can help nursing students identify life circumstances and SDOH that influence overall health.
Nurse educators using poverty simulations must be careful not to perpetuate stereotypes or assumptions about poverty. Nurse educators using poverty simulations must be careful not to perpetuate stereotypes or assumptions about poverty. This requires careful planning and tool consideration in addition to structured debriefing. For example, the Community Action Poverty Simulation by the Missouri Association for Community Action (2012) has produced significant changes in knowledge and attitudes about poverty among undergraduate students (Reid & Evanson, 2016). This simulation provides participants with the opportunity to address food, shelter, and other basic needs while playing the role of families living with low income, coping with real-life scenarios, and interacting with community resources.
Simulation can also be used to enhance student understanding of literacy, culture, transportation, availability of food, and access to healthcare. A key component to addressing SDOH is screening; the skills needed to properly screen can be practiced and evaluated within simulation to better prepare students to integrate screening for SDOH into their assessments.
Motivational Interviewing and Empathic Inquiry
Screening for SDOH requires skills that allow the nurse to ask potentially sensitive questions... Screening for SDOH requires skills that allow the nurse to ask potentially sensitive questions, and encourage an interview that is less data driven and more relationship driven. Motivational interviewing and empathic inquiry can support this process and should be included in nursing curricula. Motivational interviewing encourages participants to explore the reasons for their health and provides structure for collaborative conversations related to health behavior change (Stanhope, Tennille, Bohrman, & Hamovitch, 2016).
The motivational interview strategy is useful to elicit intrinsic motivation for behavior change and strengthen an individual’s own self-efficacy and capacities to change (Appiah-Brempong, Okyere, Cross, & Adjei, 2013). Empathic inquiry is an approach to conducting SDOH interviewing that is based in motivational interviewing and trauma-informed care. The focus is on collaboration and emotional support, while addressing patient priorities and planning (Oregon Primary Care Association, 2018). This method of inquiry emphasizes engaging, empathizing, supporting, summarizing/action planning, and collaborating with the team. Empathic inquiry requires listening without judgement and understanding the importance of the environment in which the inquiry takes place.
Didactic content in both the classroom and simulation can provide opportunities for students to master interviewing and inquiry skills that can better elicit information regarding SDOH. While motivational interviewing and empathic inquiry are seemingly focused on the individual, this is also an important area of health promotion at the community level. The overall health of a community is determined by the health of its members. Developing self-efficacy and self-awareness enables community members to improve the overall health of their communities through sustainable actions. Strong communities are necessary to address SDOH through social action and advocacy (Appiah-Brempong et al., 2013).
Social Justice and Advocacy
Social determinants of health result in health inequities that often require a social justice perspective. Social determinants of health result in health inequities that often require a social justice perspective. Social justice is built on the concept that there is a need for fair and just relationships between individuals and society. The American Nurses Association (ANA, 2015) defines social justice as “the analysis, critique, and change of social structures, policies, laws, customs, power, and privilege that disadvantage or harm vulnerable social groups through marginalization, exclusion, exploitation, and voicelessness” (p. 63). The guidelines set forth by American Association of Colleges of Nursing (AACN) Essentials documents call for the inclusion of social justice concepts across bachelor’s, master’s, and doctoral programs in nursing (2006, 2008, 2011). This mandate affirms the need to prepare nurses to understand the need to address social justice issues in a manner that acknowledges their relationships to health. The ANA Code of Ethics (2015) affirms this need in Provision 9, calling for nursing education programs to “anchor students in nursing’s professional responsibility to address unjust systems and structures, modeling the profession’s commitment to social justice and health through content, clinical and field experiences, and critical thought” (p.36).
The foundations of professional practice and values in nursing, including altruism, autonomy, human dignity, integrity, and social justice, should be addressed not just at the beginning or end of program coursework but as threads throughout curricula (AACN, 2008). These threads can be easily tied to those related to SDOH. This strategy enables students and nurses to identify how SDOH relate to the overall health of individuals and communities, and also identify how seemingly individual parts of nursing practice contribute to the greater purpose of nursing as a whole. Influence of nurse leaders at all levels on the development and implementation of health policy must address SDOH to improve health equity by specifically addressing upstream, or larger systematic, factors. These include policies that address topics like economics, education, criminal justice and transportation (Adler et al., 2016). These connections can further assist students in their understanding of health policy. Service learning opportunities can also help solidify these connections within nursing education.
Service learning is one of the most common educational approaches to address SDOH. Service learning is one of the most common educational approaches to address SDOH (National Academy of Sciences, Engineering, & Medicine, 2016). Working directly with vulnerable and marginalized populations most affected by SDOH is an essential component of nursing education (AACN, 2008). Nurse educators must consider innovative opportunities for students at all levels to develop a deep understanding of the issues that these groups face.
Service learning is a structured experience that combines community-based service with specific learning objectives, preparation, and reflection (Schmidt & Brown, 2016). It is important to distinguish service learning from volunteerism and clinical experiences. Service learning is based on collaboration between the academic institution and the community partner. These experiences can range from screening clients in a health clinic for the homeless to health education in elementary schools. A key factor that distinguishes service learning from other similar experiences is the use of reflective exercises that connect specific course objectives to the service experience (Rooks & Rael, 2013).
Social responsibility, awareness, and understanding of social justice among students increases after participation in a service learning experience (Bach & Weinzimmer, 2011; Long et al., 2011). Additionally, students who participate in service learning are likely to participate in similar activities after they enter practice (Schmidt & Brown, 2016). However, it has been noted that one service learning course may not be enough to observe a significant change in these areas. In fact, a decrease in these areas has been noted in some cases (Rooks & Rael, 2013; Villanueva, Hovinga, & Cass, 2011).
... reflection offers an opportunity for both students and faculty to explore the difficult issues related to SDOH... Reasons for this decrease included unrealistic expectations of the student and community-based organization (CBO); incompatible interest between the student and CBO; lack of student understanding about the CBO; and lack of attention to reflection. All of these reasons can be addressed by a thoughtfully developed service learning thread within a nursing education program. In particular, reflection offers an opportunity for both students and faculty to explore the difficult issues related to SDOH that can be uncovered through the service learning experience. It is important for faculty to consider multiple ways of reflection, such as journaling, artwork, storytelling, and portfolios.
Traditionally, service learning has been incorporated into undergraduate nursing education. However, graduate nursing students are moving into areas of practice that require understanding about how SDOH impact the health of individuals and populations. For example, the Growing Our Own in the Delta (GOOD) program based in Arkansas supports master’s degree students’ participation in collaborative projects that enrich their understanding of SDOH (Bryant-Moore et al., 2018). Though direct engagement with the community, students broadened their understanding of the healthcare needs of the population they will serve (Bryant-Moore et al, 2018). Similarly, DeBonis (2015) reported an increase in graduate nursing students’ knowledge and understanding of SDOH and also a desire to continue in an advocacy role due to service learning.
Service learning can also successfully be integrated into nontraditional models, such as a post-licensure, online RN-BSN program. Barnes (2017) found a significant increase in students’ sense of responsibility to serve the community after integrating service learning into an 8-week online RN-BSN course. Students self-selected a population based on their geography, personal interest, and goals. Workshops were integrated throughout the course to guide students through the experience and ensure that the outcomes were being addressed. The workshops focused on introducing service learning concepts, gaining knowledge, developing compassion for others, and reflecting on the experiences. These students also showed a significant increase in their belief that they can have influence in the community. This is critical as nurses must not only have the knowledge related to SDOH, but also the confidence to influence change.
Faculty Development and Diversity
Threading content related to SDOH throughout an entire nursing curriculum requires that all faculty are adequately prepared to teach this content within the context of their individual course(s). Faculty development is essential for those interested in integrating SDOH into nursing programs through the various strategies discussed. Graduates of nursing programs must be equipped with the knowledge and skills needed to effectively address SDOH. Program leaders must commit resources needed for both faculty and student development. Possessing the skills to offer transformative learning opportunities is essential not only for full time faculty, but also for clinical instructors, mentors, and preceptors,
Nursing education leaders at all levels must consider innovative ways to cultivate diverse graduates who sincerely desire to address SDOH. A diverse workforce is a precursor to reducing health disparities and achieving health equity (LaViest & Pierre, 2014; Williams, et al., 2014). Nursing education leaders at all levels must consider innovative ways to cultivate diverse graduates who sincerely desire to address SDOH. Diversity in nursing includes representation from racial/ethnic minority groups, men, people with disabilities, and the educationally and economically disadvantaged. To create a diverse workforce, a diverse and inclusive faculty is also necessary to serve as role models for students, and mentors with similar experiences (Phillips & Malone, 2014).
A Call to Action for Nursing Education
Transformative changes are needed in nursing education to prepare nurses to adequately address SDOH and improve health equity. Literature that supports the abilities of practicing registered nurses to address SDOH is very limited. Transformative changes are needed in nursing education to prepare nurses to adequately address SDOH and improve health equity. Nurses are uniquely positioned on the frontlines of healthcare to address SDOH that impact health inequities; therefore, nurse educators must proactively develop curricula to include the use of interprofessional education, teaching new skills, utilizing new teaching methods, and forming new partnerships. To this end, we offer several recommendations.
Summary and Recommendations
Preparing nurses to address SDOH in the acute care environment and beyond is essential in today’s complex healthcare environment (Josiah Macy Jr. Foundation, 2016; National Advisory Council, 2016). The Table presents recommendations for nursing education programs to consider related to addressing SDOH. This may be helpful for program leaders to evaluate what is currently in place and where improvement is most needed.
Table. Recommendations to Incorporate SDOH in Nursing Curricula
There will always be a need for nurses in every care setting to understand and assess for SDOH. There will always be a need for nurses in every care setting to understand and assess for SDOH. Intentional effort is essential to educate faculty and improve diversity. Leaders in the profession of nursing, and other health-related professions, must assure that appropriate content and meaningful experiences for interprofessional collaboration are incorporated into curricula to address the challenges to well-being that these multifaceted determinants present for so many.
Marleen Thornton, PhD, RN
Dr. Marleen Thornton is an Associate Professor and serves as the RN to BSN Online Program Director in the School of Nursing at Notre Dame of Maryland University. She teaches across the undergraduate and graduate nursing curricula, focusing on healthy aging and nursing theory. Throughout her professional and academic career, Dr. Thornton has focused on health promotion, the oldest older population, and community health. She is currently engaged in projects focused on the social determinants of health and the related role of the nursing profession. Dr. Thornton obtained a Bachelor of Science in Nursing and Master of Science in Nursing from Kent State University in Kent, OH, and a PhD in Nursing from the University of Colorado in Denver.
Sabita Persaud, PhD, RN, APHN-BC
Dr. Sabita Persaud is currently the Associate Dean for Graduate Studies at Notre Dame of Maryland University School of Nursing, where she has worked since 2012. She specializes in community/public health nursing with a specific focus on vulnerable populations. Throughout her professional career, Dr. Persaud has focused on health promotion, vulnerable populations, and engaged learning. Currently, Dr. Persaud is involved in research projects focusing on nurses’ knowledge, attitudes, and behaviors related to the social determinants of health. She received a Bachelor of Science in Nursing and Master of Science in Nursing – Community Health from the University of Maryland at Baltimore, and a PhD in Health Services from Walden University.
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