Learning about the responsibilities of citizenship and engaging in civic action is left to each individual in the United States. However, many Americans believe their participation in solving large and complex social problema is unlikely to make a difference, although they witness homelessness, poverty, lack of health care, and violence on a daily basis. Feeling that one person cannot make a difference has led to learned helplessness and a lack of sodai activism. However, public participation is the "very soul of democratic citizenship" (Loeb, 1999, p. 2).
The challenge for educators is to prepare future citizens who will value civic engagement and responsibility. This is equally true in health professions education where the need to prepare competent clinicians well versed in science competes with the demand to prepare professionals engaged in the type of reforms needed to solve problems of access and equity in the health care delivery system.
One solution to the dilemma of engaging future health care professionals in solving social problems and preparing them to be competent clinicians is the incorporation of service-learning in health science curricula. Service-leajrning as a pedagogy has become well established at all levels of the educational system in the United States and is touted as an effective strategy for preparing civically engaged citizens and professionals. While the models vary, the essential component is a partnership between campuses and communities, with community agencies defining their needs for service and educators providing structured learning experiences for students to meet those needs. Students' critical reflections on the social forces that led to the community need and the student-as-citizen's civic responsibility in addressing that need are characteristic of service-learning modele (Stanton, 1998).
Nursing education, which has always emphasized community-based learning, strengthens community relationships and education through servit^leaxning. The benefits of service-learning develop as students work closely with communities, gain skills and knowledge through their service-learning experiences in those communities, create partnerships with community agencies, and collaboratively develop improvements to benefit the health of those in the communities (Ciaccio & Walker, 1998; Hales, 1997; Logsdon & Ford, 1998; Norbeck, Connolly, & Koerner, 1998).
Often, the goals of service-learning are focused on students' social and academic development and, to a lesser extent, on creating meaningful change in the community. An important component in education is providing students opportunities to examine social problems and evaluate why these problems occur so they, as citizens, will develop a sense of responsibility in handling these social challenges.
Social justice is one framework that can help students examine social problems and reflect on their causes. Social justice is defined in many ways. A core component is the equitable distribution of benefits and burdens in society. Core values include caring, relationships, responsibility, and respect for all regardless of personal characteristics (Wade, 2001).
The critical reflection component of service-learning is especially powerful when integrated with a social justice framework. As students learn and provide service in community agencies, which address, social justice issues, the reflective component requires students to begin to grapple with causes and explanations of the disproportionate share of social and health risks concentrated in particular segments of society. Service-learning related to social justice topics also provides a way for nursing students to experience, rather than just intellectualize, the Code of Ethics for Nurses (American Nurses Association [ANA], 2001). Rooted in nursing's history of advocacy regarding social justice issues, the Code of Ethics for Nurses (ANA, 2001) can be used by students to examine case studies about social justice in health situations and offer guidance to them for addressing social injustices.
This article examines how social justice as a curricular thread has been used by one faculty for undergraduate and graduate nursing education. A required service-learning course for all students provided learning experiences in civic engagement to address communitydefined needs in agencies that address issues of social justice.
Social Justice in the Nursing Curriculum
Faculty from the School of Nursing at the University of Colorado Health Sciences Center have a long-standing commitment to social justice. When a major revision of the school's curriculum and philosophy was undertaken in 1997, social justice and responsibility became one of the core threads of the curricular framework. Faculty defined social justice and responsibility as:
A nursing practice competency characterized by awareness of the multifactorial dimensions influencing the health of individuals, communities, and societies and commitment to accessible and eocioculturally acceptable quality health care for all. It includes sensitivity and advocacy related to underserved, vulnerable individuals and populations and culturally competent nursing practice.
The faculty then designed a curriculum that values social justice and responsibility, as well as several other curricular threads. They decided that service-learning was the ideal pedagogical model for allowing students to immerse themselves in learning experiences related to social justice and responsibility.
Four Aspects of Social Justice
The 1-credit service-learning course, required of students in all four nursing education programs (i.e., BS, MS, ND, PhD), integrates nursing education, connects theory with service-learning, and demonstrates the social justice and responsibility component in the school's philosophy and curriculum framework. Four aspects of social justice were designated as priorities for the service-learning experience, including:
* Minority health.
* Environmental health.
* Medically underserved individuals.
Students who choose to complete their service-learning experiences with a minority health focus participate in heath care services for minority groups, observing the differential health outcomes experienced by ethnic and racial groups being served in their community agency. The following social justice question is posed to students: "Do minorities (ethnic, racial, language, religious, or other) experience a lesser quality, availability, accessibility, or acceptability of health care services?"
Service-learning experiences that focus on poverty provide opportunities for students to examine the health-related outcomes of poor individuals and communities. Students are asked to examine the basic needs of individuals and families who live in poverty and to think about how these individuals' safety, growth, and development are affected through poverty and affiliation with social service organizations. From a social justice perspective, the intent is for students to experience how the distribution of wealth relates to the distribution of health and health potential.
Students who choose a service-learning experience in the domain of en vironmental health participate in community agency efforts to identify and rectify environmental health risks affecting certain populations, especially poor and minority individuals differentially exposed to environmental health hazards. Hazards such as pesticide exposure for migrant workers, leadbased paint in low-income housing, and contaminated water supplies in selected communities provide opportunities for students to examine questions posed from a social justice perspective. Working with agencies involved in environmental health, these students see firsthand how environmental health is a social justice issue.
Experiences with medically underserved individuals allow students to examine the aspects of social justice that are demonstrated by groups such as people with chronic mental illnesses, victime of abuse, people with developmental disabilities, and people with particular differences or disabilities that are considered socially undesirable or unappealing. The social justice issue for students is to reflect on how social prejudices influence health policy to isolate or disempower individuals with particular conditions from meeting their personal health needs.
The learning objectives developed by the faculty to guide the social justice servicelearning experience state that students who complete the couree will be able to:
* Assess and critique social attitudes and structures (e.g., institutional, interpersonal, cultural, sociopolitical, financial) that ameliorate or exaggerate health risks for individuals in poverty, from racial, ethnic, and other minority groups, facing environmental health issues, or belonging to stigmatized or underserved groups.
* Apply social justice and ethical concepts to an understanding of sociopolitical health issues.
* Provide evidence of civic engagement and personal reflection that integrates concepts of social justice, nursing, and service-learning.
The course has the same learning objectives for students in all four degree programs. Because students, regardless of their degree level or background, had not participated previously in these kinds of learning experiences, it was appropriate to have the same learning expectations for all students.
In the course, students are expected to fulfill three major requirements:
* Complete a minimum of 15 to 20 hours of involvement in a service-learning experience. This may vary slightly based on agency requirements, but students work in teams, and teams generally can complete the agency-defined project. Studente are encouraged to select an agency in keeping with their interests and schedule.
* Demonstrate advocacy for an underserved population. Many options are available to students and are reflected in the syllabus. Evidence of civic engagement includes writing letters to newspaper editors; developing brochures or posters to be used by the community agency for future activities; or giving a presentation at a local or state forum on a topic related to health and social justice. The types of evidence for civic engagement are determined, in part, by the agency and the focus of the particular service-learning experience.
* Engage in dialogue with peers and faculty about their experiences during the course and demonstrate reflection on how their experiences address social justice issues and their personal growth as citizens and professional nurses. This is accomplished through participation in a Web-based, on-line forum. In addition, students create a poster or write a personal reflection paper. The reflection and dialogue requires approximately 7 to 10 hours of time during the course.
To achieve these service-learning outcomes and facilitate student experiences, faculty teaching the course build and maintain partnerships with community agencies working for social justice through an agenda related to minority health, environmental health, poverty, or care for medically underserved individuals. Whenever possible, faculty encouraged students to work in groups, with undergraduate and graduate students collaborating to meet their learning needs and the agency's service needs. Sometimes, students from all four programs are able to work on one service-learning team. This provides students with a unique ultraprofessional opportunity, one they seldom have while meeting their individual degree requirements. In addition, the teams composed of students at different degree levels offer agencies a level of service that, at times, is sophisticated. If an agency-defined project requires a longer time frame than one semester, the project is passed to another student team the following semester. An in-depth discussion on partnerships with agencies designed to meet the needs of immigrant communities and the experiences of student teams can be found in Clark, Edick, and Zuk (2001).
Locating Community Agencies
The service-learning requirement is currently in its third year. During that time, faculty, students, and community agencies have learned lessons together in a spirit of continuous improvement. Initially, students were required to find their own agencies. Although faculty had worked to establish relationships with appropriate community agencies, they underestimated the time required to develop working partnerships, frustrating students in their efforts to establish a service-learning relationship with agencies that were either unfamiliar with the service-learning agenda or ill prepared to offer students timely and appropriate experiences. Furthermore, students sometimes were unfamiliar with the idea of social justice and which community agencies were involved in efforts that could be considered social justice in nature. Consequently, studente sometimes selected agencies lacking a social justice agenda.
Considerable time was lost at the beginning of each term while faculty struggled to orient both students and community agencies and while students floundered in their attempts to locate appropriate agencies willing to work in a community-campus partnership and a servicelearning environment. It soon became apparent that the school of nursing needed to invest in the development of several partnerships so an array of agencies was available to students.
A teaching assistant was funded to help faculty develop partnerships with agencies and coordinate the service-learning course. This provided support that was essential in launching and stabilizing the service-learning requirement. During the third year, the teaching assistant funding was lost due to budget constraints. In retrospect, it is evident that having that support was vital for the success experienced to date. Currently, it is challenging for faculty to coordinate and supervise the volume of student service-learning experiences with limited support and infrastructure.
Educating About Service-Learning
Early challenges led faculty to devote considerable time to educating themselves, students, and community representatives about the service-learning model and the course requirements students were expected to complete. Open forums were presented for students and faculty to discuss the course and its requirements. The forums presented information on the definition of service-learning, how it differs from other communitybased learning experiences and clinical courses in the curriculum, and why it was selected as the pedagogical model for learning about social justice and responsibility. With funding granted by Community-Campus Partnerships for Health, a half-day workshop was held for selected faculty, students, and community representatives to determine ways the service-learning model could be implemented most efficiently and how partnerships could be developed to meet the agencies' needs. In the second year of the service-learning course, Community-Campus Partnerships for Health again provided mini-grant funds to host a community fair to solidify the working relationships among students, faculty, and community agencies involved in the course.
Developing an On-Line Version
Simultaneously, faculty realized the course had to become accessible to students participating in on-line distance education. In response, the course was reformulated in a Web-based format, with the syllabus and learning modules available to students anywhere in the world. On-line asynchronous discussion forums were designed to facilitate students' required dialogue with peers and faculty. Descriptions of agencies and their projects were provided on the course Web site so students could match their interests with agency needs more efficiently at the beginning of the term. Distance education students were encouraged to identify similar agencies in their own areas and then obtain instructor permission prior to formalizing service-learning relationships with local agencies. These changes gave students better control of their competing time demands and decreased the frustration they felt in understanding the concepts of service-learning, social justice, and what constituted appropriate community agency and course experiences.
Strengthening Course Content
The course was evaluated by the curriculum committee after it had been offered for 1 year. As a result of this evaluation, the course content was strengthened by adding more content on ethical frameworks to guide the pursuit of social justice by nurses working with community agencies. This included an explication of what an ethical framework is; how it can help one reflect on and interpret experience; and how a framework, such as distributive justice, speaks to the allocation of resources in society, particularly resources that help Ln the attainment of health. The intent was to frame the service-learning experience in an ethical context. Strengthening the ethical component of the course tied the course more securely to the curricular framework and provided a clearer focus for students.
Facilitating Student Transformation
Perhaps the most powerful lessons learned by faculty and students have occurred through the transformations many students experience as they meet their service-learning requirements. Often etudents enter the course reluctantly, viewing it as a "requirement to be met," Many students found that working in community agencies was beyond "their comfort zone" because service-learning differed dramatically from clinical experiences where the setting and client contact was regimented and predictable. For many etudents of relative privilege, working to address social needs was a new and uncomfortable experience, involving close contact with unfamiliar communities and individuals, with whom they had little firsthand experience. Based on student dialogue and reflection, the course typically provided students with opportunities to meet and learn about the people affected directly by social justice issues.
Some etudents reflected in the on-line discussion forums that service-learning introduced a professional transformation, spurring them to conceive of nursing in a broader sense and igniting in them a passion to do more than merely render care to individuals in an institutional setting. Students' reflections have convinced faculty that service-learning has provided students and faculty with unique opportunities to learn about social justice and responsibility. They also demonstrate that students are experiencing civic engagement in a way that offers potential for them to continue with this sense of responsibility in their professional careers.
- American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing.
- Ciaccio, J., & Walker, GC. (1998). Nursing and service-learning; The Kobyashi Maru. Nursing and Health Care Perspectives, 19, 175-177.
- Clark, L" Edick, T., & Zuk, J. (2001). Social justice in immigrant communities: University of Colorado Health Sciences Center School of Nursing and La Clinica Tepeyac team statement. In S. Seifer (Ed.), Partners in caring and community: A team approach to serviceteaming in nursing education (pp. 46-55). San Francisco: Community-Campus Partnerships for Health.
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- Wade, R. (2001). And justice for all: Community service-learning for social justice. Retrieved December 14, 2001 from http://www.ecs.org/ clearinghouse/29/13/2913.htm.