3.1: Teaching SDOH Across the Curriculum

The nursing profession is most capable of assessing social determinants of health (SDOH) and positively addressing health inequities in the nation and worldwide. Exploring and integrating SDOH and cultural aptitude into nursing curricula is essential to healthcare today. Traditionally, content related to SDOH in nursing curricula has been isolated into community and public health nursing courses, and graduate-level programs have varied depending on the program's focus. Consequently, isolating concepts of SDOH within curricula does not enable students or nurses to see the wide-ranging influence of SDOH and its impact on clients, communities, and aggregates (Thornton & Persaud, 2018). Merely integrating SDOH into didactic components of the nursing curriculum has yet to be effective when preparing nurses for the workforce. Therefore, influencing future engagement and advocacy through the integration of SDOH content into nursing curricula through transformative learning strategies is preferred. Allowing student perspectives to move beyond gaining knowledge and allowing students to understand, reflect, analyze, apply, and create content and experiences will increase their awareness of SDOH and its impact on health outcomes.

Teaching SDOH to students as only academic content rather than through clinical or active experiences does not provide the students with adequate knowledge, skills, or abilities to equip them to take necessary social and/or political actions required to help society achieve health equity and eliminate disparities (NACNEP, 2019). Curricular integration opportunities must focus on purposeful education for students and nurses to understand the connections between SDOH and clients' challenges (Thornton & Persaud, 2018). Providing opportunities for students to connect didactic material with meaningful clinical experiences in a variety of settings will lead to improved learning outcomes. A curriculum that is committed to addressing SDOH will allow students to develop an understanding of and ability to screen for SDOH so they can intervene and advocate as needed. Integrating SDOH concepts into the curriculum serves as the foundation; however, for students to thoroughly gain competence and confidence in serving as advocates in addressing SDOH, experiential learning scattered across the curriculum is essential for student growth and competence. Strategies may include interprofessional education and collaboration, case studies, motivational interviewing, empathic inquiry education, simulation, advocacy/policy, and mindful service-learning experiences. Each of these is briefly described below.

Interprofessional Education

In 2010, the Institute of Medicine highlighted the benefits of interprofessional education (IPE). Since then, healthcare has significantly transformed, and the concept of IPE has been essential in improving healthcare delivery and health outcomes. The nursing profession plays a vital role in collaborative practice amongst health care professionals both in acute and community settings. Interprofessional collaboration is often an untapped student experience and can provide exceptional opportunities to gain perspectives and insights. Nurse educators can integrate content related to SDOH (legal, economic, social, and political implications) into existing nursing curricula through interprofessional experiences. IPE can profoundly impact students’ knowledge and attitudes toward such practice issues. Students will gain collaboration skills, teamwork, leadership, and diversity of thoughts when addressing complex issues within healthcare (Thornton & Persaud, 2018). Adopting IPE experiences through live activities or simulation across undergraduate and postgraduate curricula supports the future evolution in nursing (Buckley et al., 2012).

Case Studies

Case studies are one method to teach critical thinking and clinical reasoning by allowing students to purposefully understand and interpret information in the delivery of care. Specifically, unfolding case studies align with nursing practice as they progress gradually in real time (Hekel, 2023). Incorporating unfolding case studies into nursing curricula allows for active engagement of students and can evolve throughout the individual course or multiple courses throughout a program. Unfolding a case study across multiple courses allows students to holistically assess their client and incorporate previous learnings with the client through repetitive exposure.

Illustrating Healthy People 2030’s five SDOH domains allows for a multitude of cases to be developed. For example, a case study could focus on economic stability as the client encounters poverty, homelessness, lack of access to care, and food insecurities. An additional emphasis on social justice and care inequities can be introduced through case studies as an innovative teaching strategy to introduce such concepts. Unfolding case studies have a unique ability to provide sequential snapshots of changes clients, families, and communities experience and can be tailored to emphasize a focus on client care and the impact of SDOH. Students build fundamental thought processes through the presentation of realistic, real-world scenarios occurring over a period of time. Furthermore, it provides fundamental thought processes, enhances clinical judgment, and prepares students to enter the workforce or advance their knowledge within the nursing profession (Hekel, 2023).

Motivational Interviewing / Empathic Inquiry

SDOH screening and inquiry may require the nurse to ask potentially sensitive questions. Encouraging an interview method that is less data-driven and more relationship-driven may result in a better nurse-client relationship and improved health outcomes. Motivational interviewing and empathic inquiry encourage participants to further explore reasons for their health and provide a structure for collaboration and conversations related to health behavior changes. When conducting SDOH interviewing, empathic inquiry is an effective method based on motivational interviewing and trauma-informed care. This method of inquiry emphasizes engaging, empathizing, supporting, summarizing, action planning, and collaborating with the healthcare team (Thornton & Persaud, 2018). Incorporating motivational interviewing and empathic inquiry across nursing curricula in didactic content in the classroom and simulation can provide students the opportunities to master such interviewing and inquiry skills, further stimulating information regarding SDOH.

Simulation

Simulation is used as both a teaching strategy and an evaluation method in nursing education (Thornton & Persaud, 2018). Simulation is 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). Healthcare Simulation Standards of Best Practice^TM are outlined and maintained through the International Nursing Association for Clinical Simulation and Learning (INACSL) and are designed to advance the science of simulation, provide evidence-based guidelines, and share best practices. Additionally, it provides a detailed process for evaluating and improving simulation procedures and delivery methods that students, facilitators, and faculty benefit from. The adoption of these standards demonstrates a commitment of an organization to quality and implementation of evidence-based practices within healthcare and improving client care across all aspects of healthcare and healthcare professionals. Incorporating SDOH case scenarios through simulation is an effective and resourceful way for students to gain experiential knowledge and insights into a variety of care settings, populations, and aggregates.

Policy

Identifying SDOH in health inequities often requires a social justice perspective (Thornton & Persaud, 2018). Social justice refers to the fair and equal treatment of individuals, where their rights are protected, and there is an equitable distribution of resources and unbiased decisions. Often, healthcare outlines this in terms of health equity, which is the work of reducing health disparities and allowing all individuals to achieve their highest level of health. Nurses are uniquely positioned to drive social justice and equity in healthcare. To do so, holistic training and adherence to ethical principles must occur. The American Nurses Association (ANA) provides a statement on Ethics and Human Rights, calling for nurses to advocate, protect, and amplify human rights and social justice concerns (Timmons, 2021). Additionally, the American Association of Colleges of Nursing (AACN) states, “…nursing must address structural racism, systemic inequity, and discrimination in how nurses are prepared” (American Association of Colleges of Nursing, 2021, p.6).

Further guidance suggests providing students opportunities to engage in ongoing personal development toward understanding their own conscious and unconscious biases. The foundations of professional nursing practice and values in nursing include altruism, autonomy, human dignity, integrity, and social justice. Incorporating these values while threading SDOH across the curricula will enable students to identify SDOH's significance to the overall health of individuals, families, and communities. Furthering their ability to contribute to the greater purpose of the nursing profession (Thornton & Persaud, 2018).

Service-learning Experiences

Service-learning experiences work directly with vulnerable and marginalized populations most affected by SDOH (AACN, 2008). Such experiences are valuable and critical components of nursing education. Nurse educators must consider the importance of service-learning experiences and develop innovative opportunities for students to gain insights and understand the barriers these groups face. Service-learning experiences are not the same as volunteerism or clinical experiences. Instead, service-learning experiences are based on a collaboration between academic institutions and community partners that allow students to interact and utilize reflective exercises. Particularly, reflective exercises could include journaling, artwork, storytelling, or portfolios. These strategies allow students and faculty to explore difficult SDOH issues uncovered through the service-learning experience (Thornton & Persaud, 2018).

Service-learning experiences should be incorporated into all realms of nursing education. Every student moves into areas of practice that require an understanding of how SDOH impacts the health of individuals and communities (Thornton & Persaud, 2018). Incorporating structured content focused on introducing service-learning concepts, gaining knowledge, developing compassion for others, and purposefully reflecting on experiences will allow students to increase their knowledge related to SDOH and build confidence in their own practice.

In nursing education, transformative changes are needed to adequately prepare nurses when assessing and addressing the SDOH of individuals and communities they serve. Nurse educators are uniquely positioned to proactively develop curricula addressing SDOH by incorporating interprofessional education, teaching new skills and communication methods, and forming new community partnerships. Thornton & Persaud (2018) established clear recommendations for incorporating SDOH into nursing curricula; review Table 3.2 below for an overview of recommendations.

TABLE 3.2 Recommendations to Incorporate SDOH in Nursing Curricula (Table Source: Thornton & Persaud, 2018)

1. Commit to the integration of content related to SDOH throughout curricula.

2. Expand clinical education experiences outside of the acute care setting.

3. Develop interprofessional education initiatives that encourage collaboration.

4. Focus on assessment skills such as motivational interviewing and empathic inquiry.

5. Increase curricular content related to social justice and advocacy.

6. Create intentional programs of service learning

7. Require faculty education programs related to SDOH and curricular content.

8. Focus on improving workforce, student, and faculty diversity.