The World Health Organization (2017) defined social determinants of health (SDOH) as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (p. 1). These SDOH can be as influential as medical care in determining health outcomes (Braveman & Gottlieb, 2014). Although the importance of addressing SDOH in the health care system is increasingly being recognized, very little literature reports on implementing SDOH education into nursing curricula. More specifically, although some baccalaureate nursing programs are finding evidence that students develop an appreciation for the importance of SDOH after doing work on this topic (Evans-Agnew, Reyes, Primomo, Meyer, & Matlock-Hightower, 2017), no documented assignments implement SDOH training into clinical coursework for graduate-level nursing students. The purpose of the project described below is to increase family nurse practitioner (FNP) students' knowledge and acceptance of the SDOH concept and to increase their competency to integrate SDOH screening and referral processes into clinical care.
The Social Determinants of Health Project
Faculty in the FNP track of the Master of Science in Nursing (MSN) program at the The University of Alabama at Birmingham have been implementing an assignment to assess SDOH with the patients the students are treating during their clinical rotation, in which students complete 600 clinical hours. The project is simply called “The Social Determinants of Health Project” and is implemented in three phases corresponding with the fall, spring, and summer semesters. In phase 1, students are given an overview of SDOH and the opportunity to ask questions in a 1 hour webinar and a subsequent faculty-monitored discussion board. They are then required to complete a three- to five-page literature review on SDOH, with a minimum of five to seven peer-reviewed sources. One article introducing the concept of SDOH screening and an established SDOH screening tool for use in a clinical setting (Page-Reeves et al., 2016) is assigned, and the other articles are selected by the students after completing a review of the literature on SDOH. Articles may be chosen according to students' interest areas. Screening questions in the established questionnaire are focused on food insecurity, housing, utilities, income, employment, transportation, education, substance abuse, child care, safety, and abuse. In phase 1, students are evaluated on writing quality and their demonstration of a cohesive understanding of SDOH.
In phase 2, students interview the preceptor (physicians or nurse practitioners) about their preceptor's understanding of SDOH and their role in health and health care. Students also prepare the screening tool in the study by Page-Reeves et al. (2016) for use in their third semester clinical rotations. Because it is not ethical or productive to screen patients without addressing their needs (Garg, Boynton-Jarrett, & Dworkin, 2016), students develop referral toolkits that are synergistic with their screening questions. Students identify appropriate resources in the geographic area surrounding their respective clinical sites. They compile detailed information about each resource and develop a referral sheet to provide to patients who screen positive for any SDOH deficiency. They work with their clinical preceptors to ensure the screening questions and referral sites are most appropriate for their patient population. If there is not a referral source for a specific SDOH screening question, students are instructed to remove or adapt that question for a better fit.
Students review the final screening tool and referral sheet as well as the appropriate ICD-10 codes with their preceptors for addressing SDOH. Students submit their screening tools and referral sheets to their instructor for review and evaluation.
In phase 3, students implement the SDOH screening and referral process. They are required to complete 100 screenings and attempt to make at least 50 referrals to services. Instructions include that they should begin screening at the start of their rotation and continue until they reach either 100 screenings or 50 referrals. At the end of the semester, students complete a final three- to five-page paper describing their experience; the numbers of screenings and referrals conducted; the reception of the project of their preceptors, clinic staff, and patients; and their reflection on the overall experience. They also prepare a poster formatted as if it were to be delivered at an academic conference. They present their posters in 3- to 5-minute segments at the final on-campus session of the MSN program. Students are evaluated by their instructors on their paper, poster, and presentation.
Results and Reactions from SDOH Project Implementation
Preliminary findings from final assignments associated with phase 3 reports and from course evaluations suggest that students increased their knowledge of SDOH and their attitudes about the importance of SDOH screening and referrals in clinical practice. The majority of the participating students stated they have the intention to integrate SDOH screenings and referrals into their future clinical practice. In summary, of the 170 students in the 2016–2017 MSN-FNP year-two cohort, 169 students completed the project, and one student did not receive approval from the clinical site to implement it. Many students reported that their clinical sites put their logo and branding on the referral sheets, indicating significant buy-in. Some preceptors wanted to avoid questions related to abuse or safety, and those questions were removed. Others wanted students to add social questions related to desire for help with tobacco cessation or help with nutrition. These adaptations were allowed, as students are guests in the clinical sites. Several students also reported that before the project, their preceptors said they would ask about social issues if a patient specifically mentioned one, but that they were not doing a comprehensive screening with all patients. Most students reported that their preceptors were previously not aware that they could be reimbursed for addressing SDOH and found the ICD information to be very valuable. Students' appreciation for the assignment grew over the three semesters. Course evaluations suggested in semester 1/ phase 1 that students thought this was busy work and unrelated to their training as nurse practitioners. In semester 2/ phase 2, students were more receptive to the project. In their final reports in semester 3/ phase 3, they were overwhelmingly pleased with the impact this assignment had on them and their understanding of how social determinants of health are associated with more typical goals of care in a clinical setting.
The project is providing a valuable learning opportunity for MSN-FNP students and seems to be providing important, new information to preceptors. Future evaluation will consider the outputs and the objective proximal and distal learning outcomes associated with this project beyond those identified for the course. Instructors interested in integrating this activity into their curriculum may contact the corresponding author to request the full assignment.
Katie Crawford Buys, DNP, MPH, FNP-C
D'Ann Somerall, DNP, MAEd, CRNP, FNP-BC
University of Alabama at Birmingham
- Braveman, P. & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes [Supplemental material]. Public Health Reports, 129(2), 19–31. doi:10.1177/00333549141291S206 [CrossRef]
- Evans-Agnew, R., Reyes, D., Primomo, J., Meyer, K. & Matlock-Hightower, C. (2017). Community health needs assessments: Expanding the boundaries of nursing education in population health. Public Health Nursing, 34, 69–77. doi:10.1111/phn.12298 [CrossRef]
- Garg, A., Boynton-Jarrett, R. & Dworkin, P.H. (2016). Avoiding the unintended consequences of screening for social determinants of health. Journal of the American Medical Association, 316, 813–814. doi:10.1001/jama.2016.9282 [CrossRef]
- Page-Reeves, J., Kaufman, W., Bleecker, M., Norris, J., McCalmont, K., Ianakieva, V. & Kaufman, A. (2016). Addressing social determinants of health in a clinic setting: The WellRx pilot in Albuquerque, New Mexico. Journal of the American Board of Family Medicine, 29, 414–418. doi:10.3122/jabfm.2016.03.150272 [CrossRef]
- World Health Organization. (2017). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/