The American Association of Colleges of Nursing Essentials for Doctoral Education in clinical practice require that Doctor of Nursing Practice (DNP) students are able to understand and apply population health principles in their roles as systems leaders (American Association of Colleges of Nursing, 2006). However, the conceptual transition from individual care to population health is challenging for many learners (Babenko-Mould, Ferguson, & Atthill, 2016; Mezirow, 2000). Students often hold strong beliefs about individual determinants and personal responsibility for health, while underestimating influences of education, neighborhood, home, zip code, ethnicity, and others (Fawcett & Ellenbecker, 2015). These beliefs insulate them from confronting their own mental models. To expand their perspectives on the concept of health, we created an online course using transformative learning (TL) principles. The purpose of this article is to describe the integration of TL principles into an online DNP population health course and report on student learning outcomes.
TL is the process of using a priori interpretation to construct a new or revised interpretation of the meaning of one's experience in order to guide future action (Mezirow, 2000). TL uses strategies to encourage students' self-examination of their beliefs and assumptions. These beliefs create barriers to acceptance of population concepts, especially social determinants of health. TL approaches are used sporadically throughout health professions curricula (Brooks, Magee, & Ryan, 2018). However, effecting changes in learners' perspectives to result in meaningful changes in health professionals' behaviors and ultimately in health disparities requires leveraging critical curriculum content with transformative strategies (Brooks et al., 2018; Thibault, 2015).
The DNP population course is a priority course to work toward culturally safe, appropriate, quality care and reduction of health disparities through increased awareness of potential personal bias and implicit system discrimination. Mezirow (2000) proposed 10 phases of TL, five of which were appropriate for the DNP population health course format. These TL phases were (a) disorienting dilemmas, (b) self-examination of values and feelings of fear, anger, guilt, or shame, (c) critical assessment of sociocultural assumptions, (d) recognition that one's discontent and the transformative process are shared and that others have negotiated a similar change, and (e) exploration of options to gain concordance with new perspectives.
During the first 10 weeks of the online population health course, faculty introduced foundational population health concepts. Students completed the Institute for Healthcare Improvement (2015) Triple Aim for Populations health lessons. Students read Healthy People 2020 (U.S. Department of Health and Human Services & Office of Disease Prevention and Health Promotion, 2015), the World Health Organization (2015) health inequalities, Social Determinants of Health: A Comparative Approach (Davidson, 2015), and the United States v. Organisation for Economic Co-operation and Development countries in health outcomes (Organisation for Economic Co-operation and Development, 2015). The remainder of the course built on these concepts using TL principles and reflection surveys to promote learners from microsystem experts into macrosystem thinkers.
Disorienting Dilemmas in Population Health Content
TL disorienting dilemmas were created through provocative, real-life patient stories through videos and articles about disparities in care, differential exposure to health insults, disparate life opportunities, and health outcomes. Students chose a population of practice interest and wrote iterative analyses of that population's health determinants based on the weekly learning topics. Four student surveys were deployed at 2 to 3 week intervals throughout the course.
Prior to completing survey one, students were presented with a disorienting dilemma (Mezirow, 1996). Disorienting dilemmas inspire students to gradually recognize a disconnect between their internal mental models and their environments. Students listened to a recorded address by Dr. Donald Berwick describing a “sign-post” patient named Isaiah (Berwick, 2012). Isaiah was a “tough looking, inner city, 15 year old” (Berwick, 2012) who presented to a clinic with acute lymphoblastic leukemia. Through the years of grueling treatments, remissions, transplants, and eventual cure, Dr. Berwick developed affection and respect for Isaiah. However, Isaiah came from a life of poverty. He smoked marijuana at age 5, owned a gun at age 9, was using crack cocaine at age 14, dropped out of school, and became homeless, living on the streets. At 37 years of age, he was found on a city sidewalk, brain dead from uncontrolled diabetes. Berwick emphasized the paradox between the effectiveness of stellar biomedical care and the complete failure of a society that permits poverty, homelessness, hunger, and despair for millions of Americans. In fact, Isaiah's life and death were disorienting dilemmas for Berwick and demonstrated the power of social environments to kill. In survey one, students were asked to describe their healer's compass, personal values, and political leanings, as well as a similar patient from their own experiences. These provocative questions created internal dissonance and confusion, promoting students' self-examination of values and truths (Mezirow, 2000).
In survey week 2, students viewed Unnatural Causes (National Minority Consortia of Public Television & Joint Center Health Policy Institute, 2008), a video that presented the science undergirding increased cortisol levels as a biological, disease-producing response to social subordination and stress. Students read supporting texts and articles about disparities in morbidity and premature mortality in populations (Davidson, 2015). Survey two asked students to identify the most impactful action they could take in their current practice communities to positively influence the social determinants of population health. These questions required students to consider the differences between their existing mental models and alternate explanations of illness and death. Students were encouraged to critically assess their epistemology about morbidity and review its validity in the context of stress science.
Assignments for survey week 3 included the essential article by Eisenberg and Power (2000), “Transforming Insurance Coverage Into Quality Health Care: Voltage Drops From Potential to Delivered Quality.” The article described the complexities in obtaining health care that is affordable, timely, appropriate, accessible, and of high quality. Survey three asked students to identify the voltage drop concepts operating the most potently in their population of interest. Students were prompted to recognize their own biased judgments about access to care and consider whether bias was shared among clinicians.
Survey four built on student readings from the (a) Kaiser Family Foundation about care access and insurance coverage of lesbian, gay, bisexual, transsexual, and queer (LGBTQ) individuals (Kates, Ranji, Beamesderfer, Salganicoff, & Dawson, 2018), (b) the Institute for Healthcare Improvement's (2015), Triple Aim for Populations, and (c) the Obergefell v. Hodges decision on marriage equality (Supreme Court of the United States, 2015). Survey four asked students if they received content in school about the unique concerns of patients who identify as LGBTQ and the level of stigma in their communities. Students were challenged to recognize any faulty assumptions they had about LGBTQ health care and to explore options to address the problem.
Student anonymity and online learning methods encouraged honest responses to sensitive questions. Faculty posted reflective questions each week using the Blackboard® survey feature. The survey feature creates an anonymous report of the students' responses. Students read, viewed, and considered the learning materials prior to survey completion.
Evaluation of Student Learning
Eleven students completed the Advanced Practice Nursing Population Health course. Ten were women, 10 were Caucasian, and one student was African American. Students' ages ranged from 26 to 61 years, with a mean age of 38 years. The course faculty member and one senior PhD student individually performed line-by-line and deductive content analysis (Elo & Kyngäs, 2008) of the students' surveys (N = 44). Evaluators searched the texts for evidence of TL using the a priori codes of disorienting dilemmas, self-examination, critical assessment, recognition, exploration of options, (Mezirow, 2000) and then compared and reconciled coding. Coded quotations were revised after discussions and achievement of consensus. New codes were developed when the content did not align with TL concepts. Faculty–learner longitudinal engagement, immersion in the course experience, and dialogue with learners established credibility of the work (Elo & Kyngäs, 2008). To ensure reflexivity, evaluators' personal reactions were recorded with the data.
Student Learning in Transformative Phases
Investigators identified eight TL themes from students' survey responses. Five of the themes were the first five themes of Mezirow's TL learning concepts. The three emergent themes were Trust, Concordance, and System Analysis. TL phases as defined by Mezirow occurred in the data, but not to equal degree across surveys one through four.
There were eight instances of students perceiving TL disorienting dilemmas, with four accounts emerging from Berwick's address in survey one. One of the students wrote:
This class is helping me to adjust my “[healer's] compass” somewhat in realizing that correcting issues within this population has a trickle-down effect that later reduces problems for others as well. As reflected in all of these quotes, disorienting dilemmas were relevant to population health learning.
According to Mezirow (2000), the self-examination phase of TL results in examination of oneself, considering differences, and acknowledging that one's expectations may be unrealistic. Eleven quotes were related to self-examination. Seven of the 11 quotes came from responses to survey one. This quote affirmed examination of self:
Earlier in our course I read about different opinions on careers and social status being based on luck or hard work. I have pondered on this debate. I have worked very hard to get where I am, so at first I thought: hard work. Then I thought about children who grow up in poverty. Even if they work extremely hard, they are not given the same tools or opportunities. Many patients who are undereducated are often poor, working long hours, and make poor decisions. Before I furthered my education, I ignorantly focused on their noncompliance. Classes like this present the big picture, giving me the ah-ha feelings and sorrow towards my old views.
Students experienced discomfort with their epistemology and reviewed its validity given their experiences as nurse practitioners. Eight quotations were related to TL critical assessment from survey one and three quotations from survey four. One student wrote:
…Once unable to work, she became homeless, couldn't live without dialysis, and couldn't afford hospice.… I know there are many patients like her, especially in the west and southwest regions, where “charity” dialysis is actually common. This patient stands out for me because it was really the first time I have looked at the bigger picture. I am ashamed for things I have not caused too.
Twelve student quotations demonstrated the TL recognition phase through acknowledgment of bias and recollecting their unique discovery experiences. One student said:
I told them everything I had learned over the past hour. I again told my story to a group of residents. I told my family. I told my boyfriend. I felt that people needed to understand what is going on. Honestly, even though I am a registered nurse with a Bachelor's degree, I once viewed the health care system through a narrow spectrum. Education has opened my eyes to the bigger picture.
Fifteen quotations described students' exploration of ways to improve the problems they encountered in practice. Seven of the exploration quotes were from survey one, and eight quotes came from survey two. One student wrote:
Though I am ashamed to say, I have not been involved in politics prior to graduate school. Now I can see why it is mandatory that I am involved to work toward healing my patients. My patient was a sign-post of the need for change. I have the responsibility of assessing disparities, lack of policies, and lack of support systems. I am voice to the victims and I plan to be part of the change.
Concordance was an emergent and contrasting theme to disorienting dilemmas. In concordance, students' discovered alignment between personal and professional beliefs, values, and actions. The learners who perceived this internal consonance believed that health care should be a human right, and the provocative survey only strengthened that belief. In survey one, a learner wrote:
My healer compass falls in line with my political and party platforms. I believe health care is a basic human right and no one should go without it.
In response to the surveys, students not only critically examined themselves but also society and systems. Twenty-six quotations described the emergent theme of System Analysis. One student wrote:
I was sad at the broken system and mad at the complexity of attempting to receive support.
The role of trust in health care was explicitly questioned in survey one. Student responses were strong and plentiful. They found distrust to be a common barrier to the patient–provider relationship, patients' treatment adherence, and disclosure about lifestyle and health behaviors. One student wrote:
Past experiences, lack of trust in the system, lack of trust in others of different races- I believe it does interfere with [patient] outcomes
TL techniques may be a successful teaching strategy for online DNP population health courses. Disorienting dilemmas evoked learner analysis of their own beliefs and the society and health system structures where disparities persist. Social determinants of health were novel for most students. Learners linked the multimedia course content to their own lives, resulting in meaningful narratives about human vulnerability, resilience, and justice. DNP graduates will search for their moral compass in the crosshairs of rapid-paced health care, ethical challenges, and advocacy opportunities. TL methods appear to prepare graduates for this affective and cognitive work and sets the stage for lifelong professional learning and action (American Association of Colleges of Nursing, 2006; Benner, 1982). As such, the TL-DNP population health course may be the most important offering in the curriculum.
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