Over the past two decades, the public health community has experienced a growing appreciation for, and an understanding of, social factors that affect health. These factors are more commonly referred to in the literature as social determinants of health (SDH): “The conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life” (World Health Organization, n.d., para. 1). This movement has been largely influenced by two major phenomena: (a) an understanding that health is not just the absence of disease, and (b) medical care alone cannot adequately improve overall health or reduce health disparities without also addressing where and how people live.
Notable initiatives, both at the global and national levels, have begun to take shape. In March 2005, the World Health Organization established the Commission on the Social Determinants of Health to forge global health partnerships among various countries in addressing the social factors leading to ill health and health inequities. Similarly in the United States, several government agencies have developed initiatives that target SDH. Specifically, the U.S. Department of Health and Human Services instituted SDH as a new topic area within Healthy People 2020, a national initiative to promote health and prevent disease (Koh, Piotrowski, Kumanyika, & Fielding, 2011). Building on these efforts, the Centers for Disease Control and Prevention developed a comprehensive Web portal to provide resources for accessing SDH data, tools for action, programs, and policies ( http://www.cdc.gov/socialdeterminants/index.htm). Together, these major initiatives have produced a large and compelling body of evidence that warrants a better understanding of how health and outcomes are shaped by social factors (e.g., low socioeconomic status, lack of health insurance, and poor education) that lead to disparities in health and health care.
As the population becomes more diverse, cultural competence has emerged as an integral strategy to improve our understanding of SDH and eliminating health disparities (Marmot, Friel, Bell, Houweling, & Taylor, 2008; Shaya & Gbarayor, 2006). Cultural competency in health care is broadly defined as the ability of systems and health care providers within those systems to tailor care to meet social, cultural, and language needs (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). Racial and ethnic diversity in the health care workforce, a type of organizational cultural competence, has been shown to improve the quality of care delivered to minority populations (Betancourt, 2014; Truong, Paradies, & Priest, 2014). Increasing underrepresented groups within the health care workforce will mirror the nation's diverse population and align with federal initiatives, with the goal of reducing health disparities and achieving health equity. However, efforts are still ongoing as to how to promote cultural competence in education and training programs.
Simulation methods may be used to promote cultural awareness and competence among prelicensure nursing students (Bahreman & Swoboda, 2016; Lipson & DeSantis, 2007; Roberts, Warda, Garbutt, & Curry, 2014). The use of simulation in nursing education is growing at a rapid pace, and this teaching modality allows for many nontraditional concepts to be taught in the classroom or laboratory setting, including SDH. By using a simulation modality, nurse educators can replicate many patient situations and give students opportunities to develop and practice their nursing skills in a safe environment (Gore & Thomson, 2016). Simulation can also be used to link theory to practice. Nurse educators are able to use a variety of simulation modes as learning strategies, including demonstration, role-play, and manikin-based education.
In addition, simulation can be used as a learning strategy to challenge students to explore their emotions in relation to SDH. Further, nursing literature supports that the best learning outcomes occur when simulation is integrated across the curriculum (Starkweather & Kardong-Edgren, 2008). Grounded by strong educational pedagogy, SDH should be threaded throughout the curriculum, from beginning to end. Nurse educators are successful when students are engaged in the content. If learning is meaningful, purposeful, contextual, and empowering, students are in a position to engage (Gupta, 2006). Simulation can be a positive impetus for encouraging nursing students to make a difference in the lives of patients who are affected by SDH. In this article, a teaching strategy for increasing the cultural awareness of pre-licensure nursing students using low-fidelity simulations developed by students is described. This strategy can be used to promote cultural awareness and competency in nursing education.
Health Equity Academy Scholars Program
Students who developed and participated in these simulations were part of the Health Equity Academy (HEA). The HEA is a federally funded nursing workforce diversity project committed to the development of minority nurse leaders with an understanding of and commitment to addressing the relationship between SDH and health disparities. The summer 2014, 2015, and 2016 HEA cohorts consisted of 18 minority women ranging in age from 20 to 35 years. All HEA scholars would eventually matriculate into a second-degree accelerated Bachelor of Science in Nursing program. The HEA scholars participated in a 6-week summer Pre-Immersion in Nursing (PIN) program. PIN curriculum objectives included:
- Understanding the impact of SDH on oneself, individuals, and the community.
- Demonstrating the ability to engage in positive team relationships to accomplish tasks and achieve academic excellence.
- Describing and performing processes associated with nursing inquiry and exploration.
- Gaining introspection into the career development of recognized nurse leaders in various practice environments.
- Health care delivery, education, research, and policy.
HEA scholars participated in activities on campus including SDH community assessments, a windshield survey of the local community, multiple SDH seminars, visits to local community organizations that support the underserved, and participation in volunteer projects. Every 2 weeks, the scholars also spent a day in the simulation laboratory with clinical nurse educators who facilitated the development of role-play simulations.
Student-Developed Simulation Scenarios
HEA scholars were tasked to design and then role-play a 15- to 20-minute simulation scenario that incorporated their understanding of SDH. The scholars were also required to: (a) ensure each group member actively participated, (b) incorporate patient and family teaching, (c) display multiple nursing roles, and (d) provide patient-centered nursing care. Students were informed early on that a live audience (i.e., faculty and staff from the school of nursing) might observe. If no objections were made, their simulated experience would be videotaped. A debrief and question-and-answer session would follow their simulations.
A few of the HEA scholars had previously witnessed role-play simulations, but none had designed any scenarios. On arrival to the simulation laboratory for the first time, staff and nurse educators demonstrated several safety nursing concepts by performing an acute care simulation scenario using a high-fidelity patient simulator. A simulation design template was shared and discussed, and the scholars were provided with a journal article about community-based simulations (Distelhorst & Wyss, 2013). On the second visit to the laboratory, videos of two clinic-based simulations from previous HEA scholar cohorts were also shown. During that same session in the laboratory, along with two nurse educators, the scholars were given approximately 2 hours to create a story line, discuss group roles, discuss nursing roles, and identify props that would be needed. During this time, the nurse educators gave feedback and direction on how to develop the scenarios and find appropriate resources. The HEA scholars were given an additional 2 weeks to research and rehearse on their own outside of the laboratory. On the day the simulations were performed, and prior to video recording, each group was given an additional 30 minutes to rehearse with their props, if needed. The HEA scholars then role-played their scenarios.
One scenario involved a non-English–speaking native African woman who came into the clinic after having a nonhealing wound on her foot for several weeks. The students incorporated the use of a nurse, an interpreter, a patient navigator, and a family nurse practitioner while making referrals and providing education for diabetes management.
Another scenario portrayed an immature teenager who continued to smoke, drink alcohol, and party at clubs during her first trimester of pregnancy. The students used a women's health nurse practitioner to educate the soon-to-be mother about how smoking, drinking alcohol, and not getting enough rest affected her unborn baby.
A third scenario included a lesbian couple coming back for a newborn follow-up office visit and facing emotional and financial strain due to a second baby on the way. A pediatric nurse practitioner and a mental health nurse were used to assess the physical and mental well-being of both new moms and the baby.
This scenario included assessing a patient admitted to the emergency department for suspected signs of the Zika virus. The scholars used an interpreter to communicate with a non-English–speaking female patient who was 3 months pregnant and had just returned from Africa.
Another scenario involved patient education and discharge planning for a teenager with diabetes. The scholars assessed the patient's knowledge of his disease process and taught him how to give himself insulin injections.
In summary, in each simulation scenario, students were able to assess the patients' unique needs and offer community-based resources and patient education that addressed their patients' specific socioeconomic, cultural, and environmental conditions.
After each scenario was acted out in front of a live audience, a short debrief followed, which allowed the HEA scholars an opportunity for thoughtful reflection.
Benefits to Student-Developed Learning
The HEA scholars used the teaching strategy of role-play to enhance their critical thinking and communication processes when delivering care to patients from diverse cultural and ethnic backgrounds in various clinical and community-based practice environments. The HEA scholars were highly vested from the beginning, as the simulations were student centered, and they were able to develop a story line and design their own scenarios from start to finish. The entire process was interactive, as the scholars consulted with their team members and nurse educators and later role-played their scenarios in front of a live audience. The student-developed simulations were beneficial for the students meeting objectives, including:
- Students learned about health disparities.
- They were provided an opportunity to practice interpersonal communication skills.
- Their cultural awareness was improved.
- Experience was gained working as part of a team.
- Students learned about specific nursing roles.
- Students learned about community-based resources and education they could offer patients and their families.
At completion of the simulations by the 2016 summer HEA cohort (n = 7), the students assessed their learning by completing a 7-item online survey. The students used a 6-point Likert scale using words instead of numeric options. Options included strongly disagree, disagree, somewhat disagree, somewhat agree, agree, and strongly agree. In response to the objectives of the simulation, students either strongly agreed or agreed that they were able to identify some type of health disparity, improved their cultural awareness, gained valuable experience in working as a team, learned about different nursing roles, had an opportunity to practice their interpersonal communication skills, and learned about patient education and community-based resources to offer patients and their families. Students also strongly agreed (66.7%) and agreed (33.3%) that in the simulations, they were able to identify SDHs that affect the patient's or family's quality of life. From the four open-ended questions included in the survey, all of the students described the value in having the opportunity to choose and develop their own simulation scenario. One student reported, “I enjoyed being able to compose our own simulations to address the social determinants of health that we thought were most important.” Another student stated, “I liked that we were given the option to choose our own topics and showcase what we thought was important in our society today.”
During the debrief, scholars reflected on why they chose a specific disparity or issue. They also discussed group dynamics within their teams. The scholars reported how the simulation experience would affect their future clinical practice. One scholar shared, “It will have a positive impact on my ability to work on an interdisciplinary team. As well, it will allow me to take into consideration how social determinants of health can affect a condition.” Regarding communication with future patients, one student shared, “It also allowed us to actually feel how it is to communicate with patients.” By providing constructive feedback during the debrief, nurse educators were able to address any performance issues or knowledge gaps related to a disease process, SDH, and principles of patient safety.
Implications for Nursing Education
The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2010) highlighted the importance of considering SDH as a basis for health care decision making in nursing, education, research, and health policy. It is critical for nurses to understand the impact of SDH on health outcomes, which in turn inform care plans for the individuals and communities they serve. Educating health professionals in and within communities negatively affected by these determinants will allow opportunities for gaining awareness of social factors that influence health, as well as contributing to the development of effective strategies to improve the health of these communities. The student-developed simulations described in this article offer such opportunities in safe learning environments. To ensure that these critical SDH skills are understood, nurse educators should be intentional in integrating SDH education throughout their curriculum, not only in the classroom, but also in clinical and simulation experiences. In a recent report released by the Institute of Medicine of the National Academies of Science, Engineering, and Medicine (2016), A Framework for Educating Health Professionals to Address the Social Determinants of Health, the committee stated a need for “a holistic, consistent, and coherent framework that can align the education, health and other sectors, in partnership with communities, to educate health professional in the social determinants of health” (p. 1). With the revision of the evaluation tool that was used, higher levels of learning may be more readily assessed or reported by the HEA scholars.
Student-developed simulations are an innovative teaching strategy for improving cultural awareness and learning more about SDH and the many roles nurses play in caring for patients from various backgrounds and circumstances. Students need to be engaged in more experiential learning opportunities, such as student-developed simulations, that will enhance their cultural awareness and incorporate competencies of patient care. By engaging students in simulated learning experiences, the goal is to better understand the SDH and develop culturally sensitive nursing care that will transfer from the simulated environment to the clinical environment. These student-developed simulations can contribute to reducing health disparities for the patients and communities the HEA scholars will soon serve.
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