The Institute of Medicine's (2011)Future of Nursing report recommended curriculum reform and a paradigm shift in nursing education to connect innovative undergraduate nursing curricula to clinical learning experiences as a means to improve patient outcomes. The Robert Wood Johnson Foundation launched the "culture of health" to find ways for communities to diminish the impact of social determinants of health (SDH; Denham, 2017). Faculty need to ensure SDH are addressed across the nursing curriculum (American Association of Colleges of Nursing, 2008). The National League for Nursing (2019) issued a statement that addressed SDH as necessary inclusions in health professions curricula to better prepare the nursing workforce.
The purpose of this longitudinal, qualitative study was to explore students' knowledge and role perceptions of SDH upon entry and at completion of a Baccalaureate of Science in Nursing (BSN) program by analyzing their abilities to recognize SDH. The aims were: to explore students' perceptions of SDH upon entry into a BSN program and to identify if an evolving awareness of SDH was gained from the curriculum by graduation.
BACKGROUND AND THEORETICAL MODEL
SDH are factors that create health-related barriers, including where people are born, develop, mature, learn, and work. An understanding of SDH is crucial to develop strategies to provide nondiscriminatory opportunities for good health (US Department of Health and Human Services [DHHS], 2019). SDH include factors such as socioeconomic status, education, neighborhood, employment, and social support networks, which are often observed as differences in exposure, vulnerability, and consequences impacting populations creating avoidable variances in health outcomes (Artiga & Hinton, 2018). Racial and ethnic bias, cultural differences, the media and/or politics, living conditions, and geography are SDH that need to be addressed at the root level. With concern that public programs, prevention, and health funding may be reduced, a variety of initiatives address SDH, focusing on broader social and environmental factors. Health initiatives include managed care and identification, screening, and referrals to address SDH-related issues (Artiga & Hinton, 2018).
Health improves by reducing SDH that affect a person's ability to take part in a healthy lifestyle. Members of impoverished communities experience less infrastructure, limited access to public services, and fewer educational opportunities. The cycle of poverty loops over generations. Low-income families may have substandard housing with unsanitary drainage, garbage, and rodents in neighborhoods that lack playgrounds or streetlights (Lee & Willson, 2016).
As the burden of chronic illness contributes to unmet medical needs and health is defined as an outcome of convenience rather than necessity, people seek health care in emergency departments and community clinics rather than making appointments with health care providers (Lee & Willson, 2016). To implement corrective steps, causative factors must be assessed and evaluated (Artiga & Hinton, 2018). Initiatives to address SDH include the availability of public transportation, employment, and affordable food sources. Federal and state initiatives, such as Medicaid-specific programs and managed care plans, identify and address clients' needs (Artiga & Hinton, 2018). A challenge of marginalized communities is to align with World Health Organization initiatives to teach students to recognize deficits, advocate for clients, and address disparities (Rozendo et al., 2017). Services, such as financial support, legal services, childcare, community outreach, preventive screenings, cessation programs, and treatment compliance, should be included in nursing curricula (DHHS, 2019). Little research was found during the literature review, indicating that a knowledge gap exists with regard to SDH in nursing curriculum.
The Social Ecological Model (SEM) provided the framework for categorizing participants' SDH assessment and nurses' responsibilities. In the SEM, individual actions are determined by factors that impact multiple levels, affirming the importance of nurse interventions that impact individual, relationship, community, and societal levels (National Institutes of Health, 2011). Nurse activities can focus on individual and social environmental factors as targets for health promotion interventions. The model suggests that corrections to the social environment will change individuals, and the support of the community is necessary to implement environmental change. An assumption is that nurse health promotion interventions are based on beliefs, understandings, and theories of the determinants of behavior, and an analysis of these four factors reflects the range of strategies available for health promotion.
METHOD
A longitudinal, qualitative study explored the phenomenology of BSN students' knowledge of SDH. Two surveys were used, each with three free-text questions. Two research questions were asked at baseline and program completion: 1) How do you identify poor health contributing [attributed] to SDH? 2) How do you perceive the nurse's role/responsibilities to identify and address change in SDH for clients? An additional question was asked at baseline: What types of actions have you taken to address SDH? At completion, students were asked: How have your perceptions of the nurse's role/responsibilities in addressing SDH changed?
Qualitative methodologies allowed for rich descriptions of students' definitions of components of SDH while phenomenology studied the consciousness of experiences directed toward SDH. The Baseline Survey was delivered at the beginning of the program; the Completion Survey was delivered 21 months later.
Sample
From a convenience sample of 100 BSN students in a South Central urban region of the United States, 91 students volunteered to participate at baseline. Of those, 79 students completed the Completion Survey (86.8 percent). Students ranged in age from 19 to 42 years, with the mode/medium being 21. Students were mostly female (n = 78, 86 percent), single (n = 35, 38 percent), and without dependents. Twenty-one participants (23 percent) had a previous degree. Of the 91 students, ethnicity was self-reported as 59 Caucasian, 18 Hispanic, 3 African American, and 11 other.
Procedure
After obtaining exemption status from the institutional review board, the Principal Investigator explained the purpose of the study to students during orientation, adding that participation was voluntary with no repercussions for not participating. The study was presented as research to evaluate the current nursing education curricula. After answering general questions, participants were given the paper-based Baseline Survey. The Completion Survey was administered during the last week of the final semester. An online survey instrument was used to allow participants to respond at a convenient time in a setting of their choosing; at this point, students were not attending classes on campus.
Data Analysis
Line-by-line survey analysis allowed researchers to code student responses into SDH categories using key phrases and themes, such as childhood experiences, housing, education, social support, family income, employment, communities, and access to health services. The SEM was used to compare baseline and completion surveys to further analyze responses. The researchers identified common themes and SEM categories to establish trustworthiness. Responses initially equated social conditions that affect health with lifestyle choices and individual behaviors (e.g., smoking, exercise, diet). Upon completion of the program, the responses changed to a larger worldview of health-related social conditions and nurses' roles. This change was attributed to students' learning experiences, which included a poverty simulation and community immersion experience with the goal of becoming mindful of others' life experiences. The curriculum included community assessments and the identification of health care access issues, with recommendations for interventions that might bring about change.
RESULTS
Poor Health Attributed to SDH
At baseline, participants responded that SDH that contribute to poor health were communities (n = 38, 42 percent), family income (n = 31, 34 percent), access to health services (n = 23, 25 percent), and education (n = 23, 25 percent). Examples for communities included sedentary lifestyles, unhealthy traditional food, and fast food. Family income was associated with poverty and/or low socioeconomic status. Access to health services included: fear/mistrust/rumors regarding the medical community, lack of insurance, resident status, and prenatal care. At completion, responses were family income (n = 64, 81 percent), education (n = 53, 67 percent), access to health services (n = 31, 39 percent), and communities (n = 28, 35 percent). Examples remained unchanged from the baseline survey for family income, while education expanded to include barriers and lack of resources. Access to health services changed to include illness, disabilities, and mental health. Communities now included geographical barriers, transportation, pollution, crime, food deserts, obesity, and unclean food and water.
The Nurse's Role and Addressing SDH
Regarding the nurse's responsibility to identify and change SDH for clients, students at baseline responded that nurses need to engage in legislative issues, such as universal health care and insurance reform (n = 15, 16 percent), and provide comfort, empathy, compassion, and understanding (n = 11, 12 percent). Some participants (n = 6, 7 percent) thought nurses should volunteer (n = 4, 4 percent) at food banks, health organizations, or in community education, or advocate for safe, affordable conditions (n = 3, 3 percent). By completion, almost three quarters of the participants responded that patient education (n = 57, 72 percent), such as prevention, and resources were the nurse's responsibility in addressing SDH. Additional responsibilities included community assessments and interventions (n = 6, 8 percent); volunteer at health fairs, community clinics, and community events (n = 4, 5 percent); and advocate for better living conditions (n = 3, 4 percent), such as health care, water, and environment.
To establish what participants knew about SDH prior to taking nursing courses, responses at baseline (n = 68, 74.7 percent) centered on self-improvement activities (n = 24, 26 percent) and volunteering (n = 13, 14 percent). A majority of the participants equated SDH with lifestyle choices and individual behaviors. At completion, half said nurses should raise awareness, increase perceptions (n = 36, 46 percent) and advocate for change (n = 30, 38 percent). At baseline, participants gave no examples of contributors to education; at completion, they responded that education was impacted by barriers and lack of resources.
Application of SEM
The first level of the SEM, the individual level, includes age, education, income, and health history. At baseline, participants attributed neglect and overcrowding at home as SDH. At completion, responses included single-parent homes, homelessness, exposure to violence, and dangerous employment without health benefits. The second level, the relationship level, includes friends and family. At baseline, participants acknowledged the importance of support groups (n = 17, 18.6 percent) to address unhealthy relationships, bullying, loneliness, eating disorders, and peer pressure. At completion, responses incorporated culture and traditions related to social support. The third level, the community level, measures impact of social influences on SDH and the settings in which these occur. At baseline, participants reported eating unhealthy or fast food, smoking or drinking alcohol, and unsafe sex as contributors to poor health, with disease presence and risk influenced by media. At completion, geographical barriers, lack of transportation, pollution, crime, food deserts, and unclean food/water were identified. The fourth level, the societal level, includes social norms and policies that create or alter socioeconomic inequalities. At baseline, students responded that use of tax money and government rules influenced health; at completion, students identified government resources and lack of educational resources as influencing health.
IMPLICATIONS AND CONCLUSION
By participating in clinical learning experiences and observing nurses' role modeling, leadership, health promotion, and professional skills were developed. By completion, students were able to identify and process aspects of SDH even though their norms were universally applied, rather than acknowledging differences across cultures and families. This was attributed to the increased complexity in clinical learning experiences that provided a broader view of the nurse's role in public health.
Future studies may replicate this study to strengthen SDH within curricula. Curricular recommendations are to integrate SDH across the curriculum; didactic courses should support clinical learning to raise awareness of SDH (e.g., infection control, wound, diabetes care). Community clinical settings may include urgent care clinics, centers on aging, hospice, school nursing, camps for adults or disabled children, childhood obesity screening, nutrition counseling, and occupational health settings. Leadership, health promotion, and professional skills may be strengthened through participation in legislative days at state capitols; assisting with health care clinics in schools, jails, and homeless shelters; or enacting poverty simulations or community immersion experiences.
A limitation was the difference in data capture, delivered face-to-face initially and online at completion of the program. Data collection methods may bias the results and affect the number of respondents. This study is also limited by its focus on one BSN cohort, yet this framework may guide programs to integrate SDH across the curricula.
It is hoped that identifying and incorporating SDH in nursing education will equip future nurses to consider the impact of SDH when providing patient care. Participants' responses evolved over time with an awareness of SDH supporting the need for clinical experiences that identify an expanded role for nurses and experiential activities that address SDH. Educational advantages that resulted from this study, beyond evaluating students, identified curricular gaps of childhood experiences, employment, housing, and social support that serve as an exemplar for turning questions about SDH into scholarly inquiries. The hope is that more educators become inspired to trace students' progress regarding characteristics described from program beginning to program end to gain insights that inform curricular revisions.
REFERENCES