Social determinants of health (SDOH) are the conditions in which individuals are born, grow, live, work or attend school, and age (Healthy People 2020, 2019; World Health Organization, n.d.). They comprise factors relating to neighborhood and built environment (e.g., access to green space, risk of violent crime), health and health care (e.g., health insurance status, access to specialty care), social and community context (e.g., community cohesion, language proficiency), education (e.g., quality of local schools, literacy levels), and economic stability (e.g., food insecurity, ability to afford safe housing) (Healthy People 2020, 2019). SDOH have a direct impact on well-being and are estimated to lead to 75% of population health outcomes (Centers for Disease Control and Prevention, 2014; Dignan, 2001; McGovern, 2014).
Given nursing's holistic focus on the interaction between patient, environment, and health, nurses can play an important role as leaders in understanding and addressing SDOH in various clinical populations and settings (Deatrick, 2017; Lathrop, 2013; Schroeder, Malone, McCabe, & Lipman, 2018). An understanding of SDOH also improves nurses' ability to practice with cultural humility. Cultural humility entails practicing in a way that prioritizes the aspects of cultural identity most important to the patient. It is other-oriented, requires ongoing self-reflection, and considers the power imbalances of the nurse–patient relationship (Foronda, Baptiste, Reinholdt, & Ousman, 2016; Hook, Davis, Owen, Worthington, & Utsey, 2013; Tervalon & Murray-García, 1998). Further, nurses must understand the SDOH in order to understand the causes of heath disparities and advance health equity (LaVeist & Pierre, 2014; Reutter & Kushner, 2010; Villarruel, Bigelow, & Alvarez, 2014). Baccalaureate training is an important time to learn about the SDOH because it allows for an influence on all future practice encounters.
Service-learning and community engagement are promising approaches for increasing health professional students' understanding of the SDOH. By spending prolonged time in a community and engaging in service-learning, students can collaborate with a community, learn from community members, and gain a better understanding of a population's day-to-day lived experiences (Harkavy & Benson, 1998; Harkavy & Hartley, 2010; Knecht & Fischer, 2015; Martinez, Artze-Vega, Wells, Mora, & Gillis, 2015). Community-based experiential learning, when coupled with critical inquiry and reflection, can support students' abilities to understand and address SDOH as clinicians (Brown & Schmidt, 2016; Sharma, Pinto, & Kumagai, 2018). It is important to note that the most beneficial type of community immersion entails spending time where patients are actually born, grow, live, work or attend school, and age. Primary care and outpatient clinics do not serve this purpose because they are the components of health care system. Optimal sites for gaining a deeper understanding of SDOH will vary among communities based on where individuals spend their time; this could include schools, emergency housing shelters, recreation centers, public libraries, parks, or transitional housing.
Given the need for nursing students to understand and address SDOH in their future clinical practice, a course was developed at University of Pennsylvania titled Addressing Social Determinants of Health: Community Engagement Immersion. The purpose of this article is to present the development, structure, and outcomes of this course for junior and senior BSN students and to share insight, lessons learned, and guidance for baccalaureate programs that are hoping to incorporate a similar course.
The setting for this course was a school of nursing in a private, research-intensive university in West Philadelphia, an underresourced community that experiences poverty rates among the highest in the nation, high chronic disease burden, and many health disparities (Philadelphia Department of Public Health, 2018). The course was an elective for junior and senior BSN-level students. Course content was grounded in an approach that builds on the strengths of communities and emphasized techniques to develop effective, collaborative, and health-focused interventions for underresourced populations. The course was first piloted in the spring of 2017.
The course structure was structured as a flipped classroom. A flipped classroom approach entails delivery of course content outside the classroom (often online) with in-class time being spent on participatory, learner-focused activities. This technique reverses the traditional learning environment by having students first process didactic material outside of the classroom, with in-class time focused on a deeper and interactive exploration of course content (Bergmann & Sams, 2012; Betihavas, Bridgman, Kornhaber, & Cross, 2016; Lage, Platt, & Treglia, 2000). The flipped classroom approach was chosen to provide the majority of course time for community engagement, promote self-motivated learning of course content, and prevent scheduling conflicts that would preclude interested students from enrolling in the course. In-class sessions were once at the beginning and once at the end of the semester. The first class served as a course orientation and introduction to SDOH. (Of note, all students had already taken a course titled Psychological and Social Diversity in Health and Wellness as part of their core curriculum.) During the semester, students were required to spend 2 to 4 hours per week at their community site. Students were assigned to sites individually or in small groups based on interest and availability of community sites that included schools, the public library, emergency housing shelters, and community/recreation centers. Students were assigned both a faculty mentor and a community site mentor. Community site mentors were individuals with established formal relationships with the community site and informal relationships with the community; their professions were diverse and included nurses, nonprofit leaders, teachers, and public health professionals. They were chosen for their knowledge of the community, the community site needs and resources, and their willingness and ability to be a mentor for the course. Before the third week of the semester, students worked with their community site mentor, course faculty, and community members to develop a community site contract that detailed the students' final course deliverable—a health promotion project that was developed fully in collaboration with the community site and met a community-defined need. Funds of up to $100 per community site, obtained through philanthropy, were available to support the course deliverables (e.g., purchasing necessary supplies).
In addition to the time at the community site and final course deliverable, students were required to contribute to weekly online discussion boards and attend one in-person discussion session related to SDOH. Online discussion boards and sessions helped students to develop a broader understanding of SDOH, contemplate upstream approaches to improving health in various clinical settings, and consider issues to their specific community site and population. Online discussion board topics were related to current events, such as the opioid epidemic. Discussion sessions were designed to allow for deeper conversation around key issues related to SDOH, such as racism.
At the final in-class session, each student presented a poster detailing the health promotion project they developed as their course deliverable. The session was held in the evening and included a dinner to which community site mentors were invited. At the conclusion of the semester, each community site mentor was contacted to provide optional feedback on the student's grade. In addition, anonymous positive quotes related to the evaluation of the course were taken from the students' final weekly discussion boards and shared with the community site mentors via a thank you e-mail.
Students completed anonymous precourse and postcourse evaluations that focused on SDOH-related knowledge, skills for understanding and addressing SDOH in clinical practice, course satisfaction, and impact of the course on future clinical practice. Evaluations included items such as:
- The current clinical skills I have to assess for social determinants of health are: excellent, very good, good, fair, poor.
- Overall I feel confident that I can recognize the social determinants of health and apply them to my assessment of patients with diverse racial and ethnic backgrounds: very confident, confident, average confidence, somewhat confident, not confident.
- Overall I feel confident that I can improve my cultural sensitivity and awareness of diverse patient's health needs as I develop management plans: very confident, confident, average confidence, somewhat confident, not confident.
Evaluations were completed via paper and pencil during the first and last in-class sessions. Students had the option of providing an indicator to allow for linking of their pre- and postcourse evaluations. The evaluations included both multiple choice (knowledge assessment), ordinal scale (self-rated knowledge and confidence), and open-ended questions (course satisfaction). The evaluations were developed by the course director (T.H.L.), an experienced faculty member and expert in SDOH and nursing care of underresourced populations. Responses to the self-rate knowledge and clinical skills questions were summarized using basic descriptive statistics in SAS® 9.4 software. McNemer's Test was used to examine changes from precourse to postcourse with a significance level of p < .05.
A total of 36 students enrolled in the class in the spring of 2017 (n = 16) and spring of 2018 (N = 20), combined. Most students identified as female (n = 35, 97%) and were between ages 18 to 24 years (n = 29, 80%), with six students between ages 25 to 34 years(17%) and one student between ages 35 to 44 years (3%). Four of the 36 (11%) students were of Latinx ethnicity. Students identified as American Indian/Alaskan Native (n = 1, 3%), Asian (n = 6, 17%), Black or African American (n = 2, 6%), White (n = 25, 69%), and White and Middle Eastern (n = 1, 3%) (n = 1 missing, 3%). Students worked across 18 community sites. All students who enrolled completed the course. Thirty-six students completed precourse evaluations and 35 completed postcourse evaluations; of those, 27 evaluations included the optional indicator and thus were able to be linked for examination of precourse to postcourse changes in self-rated knowledge and confidence.
Course Evaluation: Knowledge About SDOH
Compared with precourse evaluations, postcourse evaluations demonstrated a greater percentage of students who rated their knowledge about “recognizing social determinants of health and understanding their effect on health outcomes and wellness” as very good or excellent compared to good, fair, or poor (32% to 68%, p ≤ .01). “Current clinical skills to assess for social determinants of health” (11% to 89%, p = .99), “skills and knowledge to incorporate cultural preferences/sensitivity in the care of patients from diverse racial and ethnic backgrounds” (22% to 78%, p = .10), and “current skills and knowledge to effectively communicate with patients from diverse backgrounds” (20% to 80%, p = .32) demonstrated increases that were not statistically significant.
Course Evaluation: Course Satisfaction
When asked about the positive aspects of the course, students most commonly reported enjoying and learning a great deal from time at their community site, with comments such as:
- [Engaging with the community] really opened my eyes to how SDOH can impact communities.
- I enjoyed my site work the most and feel fortunate to have worked for an organization that provides such excellent service to the community.
Students also included positive comments about the online discussion boards and in-person discussion sessions, reporting that they were though provoking and complemented their community-based learning. For example, one student noted that the “discussion posts were very thought provoking, allowing us an outlet to debrief our engagement and experiences while challenging our comprehension of SDOH.” Regarding areas for improvement, student feedback varied. A few students mentioned they did not find the online video class to be engaging or thought that weekly discussion board became repetitive.
Course Evaluation: Confidence in Clinical Skills for Addressing SDOH
Compared to precourse evaluations, postcourse evaluations demonstrated a greater percentage of students who rated themselves as confident or very confident (compared to somewhat confident, average confidence, or not confident) in “recognizing the social determinants of health and applying them to assessment of patients with diverse racial and ethnic backgrounds” (46% versus 54%, p < .01), “applying and incorporating culturally sensitive knowledge in care of patients with diverse backgrounds” (35% to 65%, p < .01), “improving cultural sensitivity and awareness of diverse patient's health needs to develop management plans” (46% to 54%, p < .01), and “improving communication skills and developing effective relationships with patients from diverse racial and ethnic backgrounds” (43% to 57%, p < .01).
This article reports the development and evaluation of a BSN course that used a flipped classroom approach to deepen students' ability to address SDOH in nursing practice. This course was novel in that it focused on weekly hours in the community rather than a classroom or traditional clinical site. Students' knowledge about and confidence in addressing SDOH increased after the course, with many feeling particularly positive about the community engagement and discussion boards and sessions. Given the positive course feedback and increase in self-reported knowledge, the course was considered a success and is planned for continued implementation.
It is important to note that this course differs from traditional community nursing courses that focus on development of clinical skills for practice sites based in the community, such as primary care or school nursing. In this course, the community sites were eclectic and not clinical settings; they included the public library, dance classes, emergency housing shelters, early literacy programs, and science-focused charter high schools. In addition, each student's primary contact was a site mentor—not a faculty member—allowing for much of the education to be provided by someone immersed in the community who was often not a clinician. In addition, the focus of the course was on the final course deliverable being driven by the community site needs. For deliverables, students were encouraged to think beyond health behavior education, consider upstream approaches, and ensure sustainability and feasibility in limited resource settings. The primary learning outcomes were related to understanding a community's experience and interacting with individuals whose daily experiences often substantially differ from their own. Thus, this elective course allowed students to deepen their understanding of community health in a broad way that differs from a community nursing course that is focused on developing clinical skills for practice sites based in the community. Importantly, nurses that understand SDOH may be better poised to deliver care in a manner of cultural humility and in a way that can advance health equity in all settings (LaVeist & Pierre, 2014; Reutter & Kushner, 2010; Villarruel et al., 2014).
The data presented in this article have several limitations. The experiences of our students might not translate to other programs. In addition, students' clinical comfort and skills were self-reported as part of a course evaluations—skills were not assessed independently or measured using a validated tool. Also, although community site mentors' feedback was regularly sought through both formal and informal routes, their feedback was not part of the course evaluation reported here. Further, this course included $100 per community site to support the course deliverable; this may limit generalizability as not all courses will have this resource available. However, many of the deliverables the students created required minimal resources because they were designed to be sustainable and feasible in underresourced settings. For example, deliverables such as a packet of information on health topics of interest to the community or a binder with health-focused game ideas for youth required no more resources than a student's typical course project. Finally, this article reports on the experience of only two semesters of the course and might not reflect the findings that would occur with longer implementation.
For two years, a one-semester elective BSN course used community engagement to advance students' ability to understand and address SDOH. The course, which entailed experiential learning and a strengths-based approach to population health, allowed students to spend the majority of their class time at community sites. As part of the course, students developed partnerships with community members and mentors, resulting in the creation of a deliverable that could meet a need identified by their community site. Complementary in-class and online discussions deepened conceptual understanding and allowed for reflection and debriefing. The course increased students' knowledge and confidence in addressing the SDOH. Importantly, courses such as this that focus on SDOH may advance nursing students' abilities to provide care with cultural humility, advocate for patients, and reduce health disparities.
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