Journal of Nursing Education

Major Article 

Advancing Social Mission in Nursing Education: Recommendations From an Expert Advisory Board

Ashley Darcy Mahoney, PhD, NNP-BC, FAAN; Kristi K. Westphaln, PhD, RN, CPNP-PC; Asefeh Faraz Covelli, PhD, APRN, FNP-BC; Fitzhugh Mullan, MD, FAAN

Abstract

Background:

Social mission refers to a set of concepts and perspectives that promote health equity in health care delivery and within health professions. Little is known about social mission within the context of nursing education. This article clarifies the role of social mission in nursing education, offers current applications, and identifies future opportunities to maximize social mission within nursing to foster a more just culture of health.

Method:

A multidisciplinary advisory board of experts in nursing education convened to review pertinent literature, current case exemplars, and craft a conceptual framework of social mission in nursing education.

Results:

The resulting framework consisted of three action-oriented domains to implement social mission into nursing education: board accreditation, curriculum building and faculty training, and developing institutional culture.

Conclusion:

Successful implementation of social mission into nursing education, and subsequently the nursing workforce, offers the opportunity to further embed equity into health care. [J Nurs Educ. 2020;59(8):433–438.]

Abstract

Background:

Social mission refers to a set of concepts and perspectives that promote health equity in health care delivery and within health professions. Little is known about social mission within the context of nursing education. This article clarifies the role of social mission in nursing education, offers current applications, and identifies future opportunities to maximize social mission within nursing to foster a more just culture of health.

Method:

A multidisciplinary advisory board of experts in nursing education convened to review pertinent literature, current case exemplars, and craft a conceptual framework of social mission in nursing education.

Results:

The resulting framework consisted of three action-oriented domains to implement social mission into nursing education: board accreditation, curriculum building and faculty training, and developing institutional culture.

Conclusion:

Successful implementation of social mission into nursing education, and subsequently the nursing workforce, offers the opportunity to further embed equity into health care. [J Nurs Educ. 2020;59(8):433–438.]

Social mission involves a set of concepts and perspectives that aim to promote health equity in health care. Social determinants of health, access to health care, and attention to the health needs of poor and marginalized people are important themes within social mission, as are addressing implicit bias, racism, and health disparities that negatively affect health outcomes (Agency for Healthcare Research and Quality, 2019; Hall et al., 2015; Williams et al., 2018). Social mission within the context of health professions education refers to enhancing health equity and to addressing the health disparities of the society in which it exists through its mission, programs, leadership, faculty, and graduates (Mullan, 2017). In recent years, social mission has gained momentum both in the health professions and in society (Mullan, 2017; National Academies of Sciences, Engineering, & Medicine, 2016).

However, as in all health professions, there are significant shortfalls in addressing social determinants of health and health equity in nursing. Demographic trends demonstrate a steady rise in population diversity, but minority groups remain under-represented among nursing faculty, nursing students, and the nursing workforce (Phillips & Malone, 2014). There have been calls to action to foster diversity both in nursing education and in the nursing workforce (Olshansky, 2017; Shellenbarger et al., 2019; Thornton & Persaud, 2018). Yet, progress has been slow and characterized by discourse, rather than transformative action. Increasing visible diversity in the nursing workforce is important to improving communication and trust between patient and provider (Murray, 2018), which may lead to improved health outcomes (Williams et al., 2018). This article aims to clarify an actionable framework to implement social mission in nursing education.

Background

Grounded in a rich history of public health, community service, and social justice (Clingerman, 2011; Darcy-Mahoney et al., 2020), social mission is not new to the discipline of nursing but was previously identified as social responsibility. A literature review did not yield a concise definition, metrics, or implementation strategies for social mission in nursing education. However, common themes were identified for nursing education linked to social mission, including social justice, social responsibility, racism, minority health, population health, socioeconomically disadvantaged communities, marginalized groups, and culturally competent care.

It has been suggested that the nursing profession should assume leadership in addressing social determinants of health because nurses have a historical commitment to patient and community advocacy (Williams et al., 2018). According to the Expert Panel on Global Nursing & Health (2010), social justice should guide nursing care and nurses should advocate for social justice policies. Additionally, the holistic model of nursing positions the profession well to analyze and address social determinants of health to improve health outcomes (Olshansky, 2017). If the nursing profession is to fully engage in addressing social determinants of health and in promoting health equity and diversity, nursing education programs must teach and role model social mission in practice (Darcy-Mahoney et al., 2020). To do so, it is imperative for nursing faculty to be culturally competent and teach through a social justice lens (Clingerman, 2011).

Teaching content related to social determinants of health and social justice in all clinical courses and providing service learning opportunities are well recommended across the literature (Bryant-Moore et al., 2018; Clingerman, 2011; Olshansky, 2017; Schmidt & Brown, 2016; Thornton & Persaud, 2018). The Robert Wood Johnson Foundation Culture of Health goals for fostering population health, equity, and well-being is one such framework that may be helpful in guiding nursing students toward a greater awareness of social determinants of health and social mission within the clinical context (Murray, 2017). Although distinct from traditional clinical experiences, service-learning allows students to enhance their clinical learning with intentional community-based experiences (Bryant-Moore et al., 2018; Thornton & Persaud, 2018). This method offers students the opportunity to gain meaningful insights regarding cultural competence, social determinants of health, and health disparities through experiential self-reflection (Bryant-Moore et al., 2018). Importantly, students who participate in a service-learning experience are more likely to participate in similar activities following graduation (Schmidt & Brown, 2016). It is incumbent on nurse educators and leaders to implement opportunities for students to engage in social mission-related experiences to improve health equity. This project constructs and articulates an actionable framework to embed social mission in nursing education.

Method

The process for constructing a framework for social mission in nursing education included a literature review, interviews with key informants, and convocation of an expert advisory board to review the available literature and make evidence-based recommendations.

Phase 1: Exploration

After performing an extensive literature review on social mission in nursing education, we conducted semistructured interviews with a sample of multidisciplinary key informants who possessed expertise in nursing education, social mission, health equity, health workforce, and curriculum development. Table 1 features the interview guide for the semistructured interviews. Thematic saturation was reached after a total of eight interviews. At the conclusion of phase one, a diverse group of experts in nursing and health professions education were invited to join the expert advisory board on social mission in nursing education. Potential participants for the advisory board were purposively selected to cultivate diversity of expertise, geography, and role in nursing and health professions (Table 2). The advisory board consisted of a multidisciplinary panel of 23 leaders in nursing education, health policy, nursing practice, ethics, and social mission.

Key Informant Interview Questions

Table 1:

Key Informant Interview Questions

Social Mission in Nursing Education Advisory Board

Table 2:

Social Mission in Nursing Education Advisory Board

Phase 2: Analysis, Reflection, and Recommendations

The advisory board was tasked with describing an “ideal world” with robust social mission embedded in the nursing workforce, how nursing education could lead the transformation, and strategies to achieve that vision. This process included a literature review and key informant interviews from phase one, presentation of case exemplars, participation in an action-oriented break-out session, continuous critical reflection, and discourse toward a consensus for future recommendations. At the first meeting in August 2018, select members of the advisory board presented examples of institutional commitment to social mission based on case exemplars at their institutions or organizations. One academic leader presented her school's focus on recruitment of and service to “women and families in diverse, rural, and underserved populations.” Another leader discussed her school's mission of “fostering diversity in the classroom and beyond.”

At the second meeting in November 2018, the advisory board participated in action-oriented break-out sessions that continued critical reflection on nursing history through a lens of social mission while beginning to arrive at a consensus for expanding excellence in the nursing workforce through social mission in nursing education. Advisory board members were divided into one of three content-specific work groups to discuss nursing accreditation and board specialty, curriculum and faculty training, and institutional culture within the context of social mission in nursing education. A working operational definition and framework for social mission in nursing education was ultimately derived via an iterative process of brainstorming, narrowing ideas, recognizing patterns and relationships, deriving meanings and themes, and refining and reflecting on definition, attributes, and action items.

Results and Discussion

Recommendations for integrating social mission into nursing education emerged from the literature review, key informant interviews, and the expertise of the multidisciplinary advisory board. Three action-oriented domains were identified by the advisory board: nursing board approval and accreditation, curriculum and faculty training, and developing institutional culture.

Nursing Board Approval and Accreditation Recommendation

The first recommendation to enhance the presence of social mission in nursing education is incorporation of social mission into the nursing board approval and accreditation process. Accreditation is a voluntary, peer-review process that sets the standards for nursing programs across the country. The standards include categories such as institutional and program mission, administrative capacity and governance, curricula, students, faculty, resources, and assessment of student and program outcomes. Inclusion of social mission and the social determinants of health as accreditation standards, particularly related to the standards of mission, curriculum, and outcomes, would prompt nursing programs to embed clear language reflecting these values. In addition, programs are required to show evidence of attainment of the standard. Accreditation site visitors review program documents and question faculty and students to ascertain their level of understanding of key concepts. The leaders of the Accreditation Commission for Nursing Education, the National League for Nursing's Commission for Nursing Education Accreditation, and the Commission on Collegiate Nursing Education should play key roles in discussions about the place of nursing education in promoting the social mission of nursing and addressing health disparities and inequities. The influence of accreditation on the functioning of nursing schools is substantial and offers a vital lever to enhance strategies for teaching and role modeling social mission in nursing education.

Opportunities to bolster social mission in nursing education also exist within the National Council of State Boards of Nursing (NCSBN) and state boards of nursing. The role of board regulatory bodies differs from that of accreditation bodies in that they seek to protect the public's health and welfare by ensuring that safe and competent nursing care is provided by licensed nurses (NCSBN, 2019). State boards of nursing develop and enforce state specific administrative codes of rules defined as nurse practice acts (NPAs). Each state has an NPA, which is the law governing nursing practice, and includes key requirements that nursing program curricula must address to facilitate graduate preparation for entry-level practice. Incorporating requirements within NPAs for knowledge in concepts such as the social determinants of health, cultural competency, unconscious bias, and health disparity reduction hold the capacity to legitimize new areas of competence with important implications for nursing education.

After graduation from a board-accredited school of nursing, the next significant milestone toward becoming a nurse is passing the NCLEX-RN®. Along with representing the portal of entry into the world of professional nursing, the NCLEXRN also evaluates the minimal competencies of nursing graduates. Because every nurse takes the NCLEX-RN, incorporating questions into the examination that reflect key concepts and constructs of social mission represents an opportunity to expand both reach and accountability of including social mission within nursing education. The NCSBN engages in a practice analysis every 3 years to determine examination content, which includes a knowledge survey that is sent to a representative sample of recent graduates, educators from prelicensure programs, and clinical supervisors (NCSBN, 2019). Survey participants rate whether the items reflect knowledge that new graduates should possess and how important the issue is in practice. The NCLEX-RN test plan and the examination questions are, in part, based on the survey results. Suggestions from the advisory board include an analysis of the current language/use of social mission concepts in the NCLEX, collaboration with NCLEX item writers, and partnering with the NCBSN NCLEX practice analysis process. However, for this to happen, clinical agencies that employ new graduates would need to include key aspects of the social determinants of health and the culture of health into everyday nursing practice so that it would be identified as a priority knowledge statement.

The advisory board also recommended working with NCLEX-RN item writers to determine whether language used in currently existing questions could be revised to reflect social mission constructs. Including social mission-relevant questions on the NCLEX-RN licensure examination sends an important message that every nurse should possess knowledge and training in areas such as health disparities and the social determinants of health. Nursing programs include the NCLEX-RN test plan in their curriculum review. If social mission, social determinants, and health disparity items became a part of the NCLEX test plan, this would provide an impetus for inclusion in the curriculum. The current NCLEX-RN test plan (NCSBN, 2019) includes content loosely related to the social determinants of health under the areas of “management of care,” “health promotion and health maintenance,” and “basic care and comfort,” but more explicit language is needed. The feasibility of these strategies was discussed and supported by the chief executive officer of a national nursing board, who also served on the advisory board.

Curriculum and Faculty Training Recommendation

The advisory board recommended curriculum development and faculty preparation as a second strategy toward increasing social mission within nursing education. As part of curriculum development, nursing faculty determine the end-of-program student learning outcomes (SLOs), which are the knowledge, skills, and attitudes that students are expected to demonstrate upon completion of the program (Iwasiw & Goldenberg, 2015). SLOs are based on national guidelines and best practices, accreditation and board of nursing requirements, and the specific mission of the school itself. Nurse educators develop their specific programs with the help of guidelines from a number of nursing organizations (Table 3) (Ard et al., 2019). Standards related to social mission must be developed and receive recognition on a national stage so that the concept is recognized as a key curriculum element. This is beginning to take shape in places such as the National League for Nursing, in their document “A vision for integration of the social determinants of health into nursing education curricula” (Shellenbarger et al., 2019), in which they recommend strengthening nursing's social mission for faculty and curricula. Educating nursing students about social mission provides them with knowledge and ability to better approach the complex social and ethical issues that permeate the health care system. Didactic content could be administered as a separate course or lecture series, or it could be threaded throughout nursing core courses. Innovative clinical experiences in settings such as the justice system, early childhood programs, rural community health clinics, or homeless shelters expose students to the real-world “life lab” versus the more traditional hospital-based lens of health care. There are multiple examples of these types of programs around the country. One can be found in Emory School of Nursing's long-standing Farm Worker Health program, a partnership of over 20 years with the local Ellenton Clinic, in which undergraduate and graduate students from Emory's Nell Hodgson Woodruff School of Nursing, University of Georgia School of Pharmacy, Georgia State University, and Brenau University Departments of Physical Therapy, Clayton State University, and Central Georgia Tech College Departments of Dental Hygiene are placed in an immersive environment for 2 weeks delivering vital health care to farm workers and their children in a farming community in southwest Georgia.

Organizations Providing Guidance for Nursing Curricula

Table 3:

Organizations Providing Guidance for Nursing Curricula

Faculty development is critical for successful integration of social mission into the curriculum. Faculty members are responsible for assessing student learning to determine whether outcomes have been attained. Faculty understanding of and belief in social mission is necessary for the concepts to be firmly entrenched in the curriculum and its related learning activities. Social mission challenges schools of nursing to fully embrace diversity and inclusion. Embedding social mission in nursing education includes recruitment and retention strategies for diverse nursing students and nursing faculty, efforts to foster inclusive environments, creation of centers at universities that support diversity, and directly addressing the consequences of implicit and explicit bias. The Racial Equity Institute at Duke University provides a robust exemplar of success in integrating social mission into nursing education via curriculum development, student support, and faculty training. However, continued research is needed on how to address diversity and inclusion, decrease racism, provide nurse educators with the knowledge and skills to teach social mission, and identify the best methods to deliver social mission content within nursing education.

Developing Institutional Culture Recommendations

A third opportunity to increase social mission within nursing education is to foster an institutional culture that values social mission. Nursing leaders, professional organizations, and community stakeholders have the capacity to champion social mission as a core value of nursing education. Including social mission within the mission statements and values of educational institutions and professional organizations sends a strong message of support and responsibility. For example, promoting institutional activities focused on improving the health of the community would be powerful. In addition, incorporating social mission into the American Association of Colleges of Nursing (2020) Essentials and other nursing education frameworks could create a culture shift that would affect the integration of social mission into the curricula for all levels of nursing education. Increasing social mission aspects that are required for hospital Magnet® designation might also assist in fostering acceptance of social mission as a core value in nursing education.

Creating partnerships that link schools of nursing with community partners (e.g., community health centers, schools, shelters) offers the opportunity to ignite a culture shift via community service and service-learning. Jesuit universities often offer this type of institutional culture within the larger university that then carries over to the health professions schools. For example, Georgetown University is committed to creating students who are “men and women for others” with a focus on care of the whole person (“cura personalis”). This is then exemplified in multiple ways, including value-based endowed chairs, mission-oriented centers, and initiatives in the school of nursing such as the Center for Health Equity and the O'Neill Institute partnership between law and nursing. The Organization for Associate Degree in Nursing (OADN) and the Frontier University are leaders in developing an institutional culture that supports social mission in nursing education. Frontier University innovates with one of the oldest midwifery programs aimed at increasing access to midwives in rural America. Similarly, OADN focuses on diversifying the nursing population by collaborating with colleges and universities in an effort to support academic progression within nursing.

These recommendations offer an actionable process to inform, engage, and invoke change toward a future of enhanced social mission within nursing education. Recognizing the need for social mission in nursing education is a first step, but action is needed to incorporate social mission into the teaching and clinical experiences of students. Embracing social mission as a core value within the context of nursing education offers a transformative opportunity by systematically introducing students to issues of health inequity, racism, and the social determinants of health.

Conclusion

Nurses work on the front lines of health care delivery, directly engaging with patients and the inequities and inequalities that affect them. Embedding social mission in nursing education as a core value offers the potential to bolster excellence in nursing while also fostering a more comprehensive and just culture of health. While some nursing programs may currently address the social determinants of health, diversity, social justice, and inclusion within nursing curricula, a uniform concept of social mission does not currently exist in nursing education.

Rather than representing a competing demand on the curriculum of health professions schools, social mission represents a complementary stream that will enhance excellence via a stronger sense of equity, inclusion, and justice. Not only is social mission important as a core value for the health professions in general, it is also essential in expanding the capacity for excellence within the professions. Excellence in nursing and health care is not possible without social mission. We challenge the nursing profession to consider the benefits of incorporating social mission as a core value. According to Mullan (2018):

Social mission recognizes that there are inequities in the world and, more to the point, in access to health and health care. In ways articulate and inarticulate, many young men and women entering [the health professions] hope to help in this regard. They hope to make the world not only a better place, but also a fairer place. This is social mission.

References

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Key Informant Interview Questions

How does the social mission definition apply to nursing education?

What is unique about social mission in nursing education compared to other professions?

What are the challenges associated with teaching social mission values to nurses?

How do you operationalize social mission concepts in your communities?

What is the potential impact of social mission in nursing education and practice?

How are we training nurses to address social determinants of health?

Social Mission in Nursing Education Advisory Board

Advisor RoleType of School/OrganizationGeographic Location
DeanPublic Research UniversityWest
DeanPublic Research UniversitySouth Central
DeanCommunity CollegeNortheast
DeanCommunity CollegeMid-Atlantic
PresidentGraduate School of NursingMid-Atlantic
Chief Executive OfficerBoard of Nursing/Accrediting BodyNational
Chief Executive OfficerBoard of Nursing/Accrediting BodyNational
Chief Executive OfficerBoard of Nursing/Accrediting BodyNational
Chief Executive OfficerBoard of Nursing/Accrediting BodyNational
President/Chief Executive OfficerBoard of Nursing/Accrediting BodyNational
DirectorBoard of Nursing/Accrediting BodyNational
DirectorStudent Nurse OrganizationNational
Program DirectorCommunity CollegeMidwest
Director of OperationsFederally Qualified Health CenterMidwest
Director of Workforce StudiesPrivate Research UniversityMid-Atlantic
EditorMedical JournalNational
Vice PresidentNursing Professional AssociationNational
Senior Vice PresidentPublic Policy Think TankNortheast
FacultyPublic Research UniversitySouth Central
FacultyPublic Research UniversitySouth Central
FacultyPrivate Research UniversitySoutheast
FacultyPublic Research UniversityMidwest
Program ManagerChildren's HospitalMid-Atlantic

Organizations Providing Guidance for Nursing Curricula

American Association of Colleges of Nursing Essentials of Baccalaureate, Master's, and Doctoral Education
National Association for Practical Nurse Education and Services Education Standards
National League for Nursing Competencies for Graduates of Nursing Education Programs
Nurse Practice Acts, American Association Standards of Professional Practice
Quality and Safety Education for Nurses Competencies
National Council Licensure Examination test plan
Authors

Dr. Darcy Mahoney is Associate Professor and Neonatal Nurse Practitioner, The George Washington University School of Nursing, and Director of Infant Research, Autism Neurodevelopmental Disorders Institute, and Dr. Faraz Covelli is Assistant Professor, The George Washington University School of Nursing, Washington, DC; Dr. Westphaln is Postdoctoral Fellow, Department of Bioethics, Case Western University, School of Medicine, Cleveland, Ohio; and Dr. Mullan was Professor of Health Policy and Management, The George Washington University Milken Institute, School of Public Health, and Professor of Pediatrics, The George Washington University, School of Medicine and Health Sciences, Washington, DC.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Chynna Golding, Kayte Green, Drs. Kenya Beard, Angela Amar, Polly Pittman, Candice Chen, and Katie Gravens, and the Social Mission in Nursing Advisory Board. Support for this work was provided by The Robert Wood Johnson Foundation and the Fitzhugh Mullan Institute for Health Workforce Equity.

Address correspondence to Asefeh Faraz Covelli, PhD, APRN, FNP-BC, Assistant Professor, The George Washington University School of Nursing, 1919 Pennsylvania Avenue NW, Suite 500, Washington, DC 20006; email: afaraz@gwu.edu.

Received: February 10, 2020
Accepted: May 04, 2020

10.3928/01484834-20200723-03

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