Journal of Nursing Education

Educational Innovations 

Using Critical Service-Learning Pedagogy to Prepare Graduate Nurses to Promote Health Equity

Kelly M. Bower, PhD, MSN/MPH, RN; Kamila A. Alexander, PhD, MSN/MPH, RN; Mindi B. Levin, MS, CHES®; Keilah A. Jaques, MSW; Joan Kub, PhD, RN

Abstract

Background:

Despite calls from professional organizations to prepare a nursing workforce with the requisite skills to address social determinants of health (SDOH), there is little guidance for nurse educators about how to actively promote student learning of these complex issues.

Method:

We applied a critical service-learning (CSL) pedagogy to enhance graduate public health nursing curriculum and support learner skill building in approaches to combat health disparities by addressing the underlying social conditions.

Results:

Course content and critical reflection activities were built incrementally across four courses and semesters to introduce and apply antioppressive frameworks, encourage students to examine their personal identities of privilege and oppression, and examine historical context and systems of power in public health settings.

Conclusion:

CSL supports student development of structural competence and their understanding of approaches that can dismantle inequitable systems by addressing SDOH that contribute to health disparities. [J Nurs Educ. 2021;60(1):38–43.]

Abstract

Background:

Despite calls from professional organizations to prepare a nursing workforce with the requisite skills to address social determinants of health (SDOH), there is little guidance for nurse educators about how to actively promote student learning of these complex issues.

Method:

We applied a critical service-learning (CSL) pedagogy to enhance graduate public health nursing curriculum and support learner skill building in approaches to combat health disparities by addressing the underlying social conditions.

Results:

Course content and critical reflection activities were built incrementally across four courses and semesters to introduce and apply antioppressive frameworks, encourage students to examine their personal identities of privilege and oppression, and examine historical context and systems of power in public health settings.

Conclusion:

CSL supports student development of structural competence and their understanding of approaches that can dismantle inequitable systems by addressing SDOH that contribute to health disparities. [J Nurs Educ. 2021;60(1):38–43.]

Addressing widespread disparities in health outcomes is both a goal of nursing practice (American Association of Colleges of Nursing [AACN], 2011) and a moral imperative for nurses, nurses-in-training, and nursing faculty. Educating nursing students about the role of social determinants of health (SDOH) as drivers of health disparities and their profound impact on the health of individuals and populations is necessary foundational knowledge (National Academies of Sciences, Engineering, and Medicine, 2016). However, little guidance exists for nurse educators about how to actively promote student understanding of these complex issues and simultaneously develop the requisite skills for nursing practice. Teaching strategies are needed that help students understand the links between the SDOH and health disparities and also provide opportunities to develop skills in the design of effective interventions that promote social justice and health equity (Alexander et al., 2011; National Academies of Sciences, Engineering, 2016; Thompson, 2014). Training strategies are needed to support health professionals in their development of structural competency, which is “the ability to discern how a host of issues defined clinically as symptoms, attitudes, or disease also represent the downstream implications of a number of upstream decisions about matters such as health care and food delivery systems, zoning laws, urban and rural infrastructure, medicalization, or even about the very definition of illness and health” (Metzl & Hansen, 2014, p. 128).

Service-learning (SL), a form of experiential learning, is a central tenet in the National Academies (2016) framework on educating health professionals about the SDOH. SL is “a structured learning experience that combines community service with preparation and reflection” (Seifer, 1998, p. 274) and provides real-world opportunities for students to explore and understand how the SDOH affect populations. In SL, students address community-identified concerns, learn about the larger social context of their service, connect their service to academic coursework, and reflect on better understanding their role as citizens and health practitioners (Seifer, 1998). Critical SL (CSL) builds on the tenets of traditional SL but adds the dimensions of intentionally working toward social change, redistributing power, and developing authentic partnerships (Mitchell, 2008). CSL challenges students to probe even deeper in their reflections, linking their service experiences with academic coursework by exploring the historical, political, and social context of community issues connected to their service activities. Nursing students can then grapple with personal and institutional connections to societal issues. Engaging students in reflection about clinical experiences working alongside community or institutional partners and populations can stimulate conscious thought, laying the groundwork for meaningful discussions about social conditions and how they shape health outcomes in communities. CSL pedagogy can guide nurse educators to integrate foundational knowledge about health inequities in didactic and practicum courses, ensuring social justice is at the forefront of nursing education by examining power structures—the role of positionality and privilege—and exploring strategies to leverage their own change agency (Mitchell, 2008).

SL in Nursing Education

Commonalities between the SL principles and public health nursing (PHN) competencies have been identified (Brown, 2017). Nurse educators used SL to enhance student empathy and positive attitudes toward traditionally stigmatized populations, to promote student cultural competence and cultural consciousness, to develop critical thinking and leadership skills, and to improve student understanding of social justice (Alexander-Ruff & Kinion, 2019; Brown & Schmidt, 2016; Callister & Hobbins-Garbett, 2000; Gardner & Emory, 2018; Gillis & Mac Lellan, 2013; Groh et al., 2011; Jarrell et al., 2014; Loewenson & Hunt, 2011; O'Brien-Larivée, 2011; Taylor et al., 2017). Most nursing education literature describes short-term clinical or elective course SL experiences in a Bachelor of Science in Nursing program (Brown, 2017; Callister & Hobbins-Garbett, 2000; Ezeonwu et al., 2013; O'Brien-Larivée, 2011; Schoon et al., 2012). Few authors describe the application of SL across courses in nursing curricula (Redman & Clark, 2002; Taylor et al., 2017) or in graduate nursing education (Baker et al., 2004; Redman & Clark, 2002). Additionally, CSL as an educational innovation is rarely discussed as a strategy that goes beyond consciousness raising to supporting the development of learner knowledge and skills needed to dismantle structures of inequity (Gillis & Mac Lellan, 2013).

Knowledge about systems of inequality and dismantling structures of injustice can bolster nursing practice, establishing skills and strategies to combat health disparities. The educational frameworks for both baccalaureate and master's education in nursing address the imperative for nurses to be trained to understand the influence of social conditions on health and promote social justice in an effort to address health disparities (AACN, 2008, 2011; Campbell et al., 2020). The Essentials of Master's Education in Nursing states that master's-prepared nurses will have the knowledge and skills to synthesize data about the SDOH to intervene and achieve nursing's goal to eliminate health disparities (AACN, 2011). It also points out that policies and systems “create conditions that promote or impede equity” (AACN, 2011, p. 21), and describes the necessity of master's-prepared nurses to have the knowledge and skills needed to advocate for policies that promote social justice.

This article describes the process to integrate principles of CSL pedagogy into an advanced practice nursing curriculum specializing in PHN. We designed student learning to understand the multilevel roots of social inequities and prioritized development of skills to dismantle unjust systems as a strategic approach to promoting social justice. We also describe the benefits and challenges of implementing CSL in the education of health professionals.

Educational Innovation

Our faculty team applied critical SL pedagogy across four required advanced practice PHN courses in the Master of Science in Nursing (MSN)/Master of Public Health (MPH) joint degree program curriculum. Johns Hopkins University (JHU) School of Nursing faculty who teach in the MSN/MPH program partnered with faculty from SOURCE, the JHU community engagement and SL center for the Schools of Public Health, Nursing, and Medicine. The mission of SOURCE is to engage the JHU health professional schools and Baltimore communities in mutually beneficial partnerships that promote health and social justice ( http://SOURCE.jhu.edu/about/). The involved nursing faculty had previously completed the SOURCE SL Faculty and Community Fellows program in which faculty from JHU nursing and public health, and staff from partnering community-based organizations receive training in CSL pedagogy.

The four advanced PHN courses included one didactic and three practicums offered across four semesters: (a) health promotion and PHN practice, (b) population-based PHN interventions practicum, (c) community assessment practicum, and (d) program evaluation practicum. Course content included five CSL principles: (a) structured experiential learning field experiences, (b) prioritizing community-identified concerns, (c) preparation and preflection, (d) critical reflection and reciprocal learning, and (e) a focus on social justice. Prior to this curricular revision, the three clinical practicum courses already included some elements of SL. They used experiential learning through clinical placements and a requirement of 168 clinical hours in community-based organizations where student projects focused on addressing community-identified concerns. However, before the implementation of this educational innovation, courses lacked a strong emphasis on social justice and intentional conceptualization or implementation of the course content across semesters. The faculty team initiated this curricular revision to enhance student exploration and competency development in social justice promotion. Although practicums had previously included clinical reflection activities, they were not adequate to ensure learning focused on skill-building to promote social justice. Details of the existing content plus addition of new content are outlined in Table 1.

Service-Learning (SL) Principles, Definitions, and Existing and New Applications to Graduate Public Health Nursing Specialty Curriculum

Table 1:

Service-Learning (SL) Principles, Definitions, and Existing and New Applications to Graduate Public Health Nursing Specialty Curriculum

To complement the CSL approach to learning, we introduced antioppressive frameworks to help move students from the simple identification of harmful social conditions to critical analysis of possible solutions to mitigate the social injustices underlying the exposure (Zinga & Styres, 2018). In the classroom, the integration of antioppressive frameworks requires examination of systems, policies, practices, behaviors, and power structures that perpetuate oppression (Zinga & Styres, 2018). It fosters development of critical consciousness or “the ability to intervene in reality in order to change it” (Friene, 1974, p. 7). Several antioppressive frameworks were presented as approaches to counteract power imbalances and included: (a) basic needs centered first (Centers for Disease Control and Prevention, 2016); (b) trauma-informed approach: creating systems that are aware of the impact of trauma, recognize the signs and symptoms of trauma, integrate this knowledge into programs and practices, and take steps to avoid retraumatization (Magruder et al., 2016); (c) harm reduction: a strategy that aims to reduce the harms associated with certain behaviors (Baltzer et al., 2008); (d) restorative justice: a theory of justice that emphasizes repairing the harm done to individuals and communities caused or revealed by criminal behavior, best accomplished through cooperative processes that include all stakeholders (van Ness & Heetderks Strong, 2014); and (e) transformative justice: “transformative change that emphasizes local agency and resources, the prioritization of process rather than preconceived outcomes and the challenging of unequal and intersecting power relationships and structures of exclusion at both the local and the global level” (Gready & Robins, 2014, p. 340).

Faculty taught these antioppressive frameworks in the first semester through lecture and discussion. During practicum courses, students applied the antioppressive frameworks to their community-based projects using discussion-based case studies and written structured reflection activities aimed at deepening student understanding of power, privilege, positionality, intersectionality, and current and historic oppression of populations. In summary, within the revised curriculum, students: (a) examined the historical community–institutional relationships in Baltimore and in practicum sites outside of Baltimore; (b) reflected on responsibilities of ethical community engagement and partnerships; (c) considered one's own power, privilege, and positionality through reflection; and (d) scrutinized power imbalances within organizational and program structures, policies, and practices. Details of the new content and reflection activities are outlined in Table 2.

New Content Developed Using Critical Service-Learning Pedagogy to Enhance Focus on Social Justice Using Critical Reflection and Integrated Into Graduate Public Health Nursing (PHN) Courses Over Four Semesters

Table 2:

New Content Developed Using Critical Service-Learning Pedagogy to Enhance Focus on Social Justice Using Critical Reflection and Integrated Into Graduate Public Health Nursing (PHN) Courses Over Four Semesters

Discussion

Nurses have an ethical obligation to protect and promote social justice and health equity (Fowler, 2008); therefore, they must be able to attend to the multiple determinants of health (Campbell, 2020). However, nursing education provides little pedagogical guidance to help students to develop the skills and competencies needed to uphold this ethical obligation. We applied a CSL pedagogy to four graduate PHN courses in an MSN/MPH joint degree program. For nurses to be able to attend to the multiple determinants of health and engage in systems-level interventions to promote equity, nursing education must go further than training students to understand how structural oppression and values influence health. Nursing education must also train students to be structurally competent, understanding how institutions and social conditions contribute to illness or high-risk behaviors for individuals and health disparities for communities.

Through written reflection, students demonstrated their ability to connect institutional and social conditions with the health of the populations they served in their practicum sites. Students examined structural racism using examples from historical and contemporary policies and practices. For example, students noted evidence and consequences of disinvestment in Black neighborhoods and schools, hypersurveillance by police and subsequent incarceration, as well as food deserts. Examination of redlining maps depicting intentional residential segregation that separated Black families from White families laid bare the intersections of these policies with public health. Students also reflected on policies that influenced the health and well-being of populations. For example, students discussed (a) restrictions on asylum seeking for women who have experienced gender-based violence, (b) deinstitutionalization of support for their needs in outpatient setting, (c) programs and policies to prevent poverty and homelessness, and (d) the role of the Affordable Care Act in meeting population health needs. They identified historical roots of present-day community mistrust of the Johns Hopkins Medical Institution and other systems of care due to persistent mistreatment, discrimination, or racism that affect access to high-quality health care. Students also reflected on their own insecurities, biases, and the challenges of working with populations with whom they do not have a shared identity or lived experience.

The CSL pedagogy and tools, such as antioppressive frameworks, provided students with the opportunity to consider effective policy and systems interventions to dismantle structures of inequity and promote social justice. During case-based discussions, students identified places within public health programs where use of structural competence and other antioppressive frameworks could promote equity and justice. For instance, students identified when program goals and objectives could communicate paternalism and restrict choice for oppressed populations (e.g., increased use of long-acting reversible contraceptives). They also identified how to adjust public health program activities to focus on primary prevention activities that address root causes of inequities (e.g., environmental injustice). They considered examples of programs they have observed or read about that apply an antioppressive framework.

Challenges and Limitations

Although benefits exist to using a CSL pedagogy in nursing education, challenges to implementing this innovation and using the pedagogy also exist. First, developing community partnerships for students to create meaningful and productive experiences is resource and time intensive (Gillis & Mac Lellan, 2013; Schoon et al., 2012; Taylor et al., 2017). Second, it can be difficult to find class time to engage in case studies and reflective discussions. Also, when using an SL approach, there is potential to reinforce stereotypes and deepen the “us” versus “them” dichotomy that is so often present in community–academic partnerships. (Gillis & Mac Lellan, 2013; Jarrell et al., 2014). However, the use of CSL can counter this and increase learners' awareness of the power dynamics that create this dichotomy (Brown & Schmidt, 2016). Further, although CSL can provide students with the opportunity to develop critical consciousness related to factors that underlie SDOH in a clinical practice setting (Brown & Schmidt, 2016), more rigorous evaluation is needed to demonstrate evidence for the overall influence of CSL on students and community health practice. For example, research is needed to strengthen our understanding of how the use of CSL in nursing education affects long-term nursing practice and the ability to establish meaningful relationships with the community.

Finally, this educational innovation did not include any formal evaluation of its implementation or outcomes. It is important to build evidence for this approach, which is generally lacking in the literature describing the implementation of SL in nursing education (Stallwood & Groh, 2011). Despite the lack of formal evaluation, we would do some things differently in the future. For instance, course faculty believed students would benefit from conversations with or presentations from community-based organizations that intentionally apply an antioppressive framework in their work. Alternatively, readings or videos that provide case examples of this work could be used. Faculty also felt that students should have been encouraged to engage in conversation with their clinical preceptors about historical and present-day systems and structures of oppression affecting the populations served at the organizations where they worked.

Conclusion

We took an intentional approach to the development of structural competence in MSN/MPH students by incorporating teaching and learning strategies into four adjacent courses using the principles of CSL and antioppressive frameworks. Using this approach, we bridged curricular components across courses to ensure the students were challenged to incorporate content at higher levels throughout their program of study. Students reported varied levels of opportunity to engage in learning and discussion of these concepts outside of these four courses, depending on the public health elective courses they had taken. Some students reported that these four courses were the only courses in their curriculum where they had these discussions, whereas others indicated that these discussions were common in the elective courses they had taken. This highlights the importance of ensuring that this content is built into required courses. Across the four courses, students expressed appreciation for the opportunity to engage in these learning and reflection activities and they engaged in robust written reflection and class discussions, indicating their appreciation of the structures contributing to social and health inequities within communities. More significantly, it has allowed students the opportunity to gain knowledge and skills necessary for a master's-prepared public health nurse (AACN, 2011; Campbell et al., 2020), particularly when partnering with communities to identify needs and to better understand interventions to address social structural barriers to achieving health equity.

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Service-Learning (SL) Principles, Definitions, and Existing and New Applications to Graduate Public Health Nursing Specialty Curriculum

SL PrincipleDefinitionApplication in Curriculum Integration
Structured Learning ExperienceaProvides students with supervised and intentionally planned actions for service.Existing:

All practicums: One-to-one precepted clinical experiences with community-based organization.

Focus on Community Identified ConcernsaAll service activities are designed and requested by participating community organizations.Existing:

All practicums: Community partner guides practicum project topic and scope-of-work through conversation and sharing about the agency, needs the student could fill, and discussion of course objectives.

Preparation and PreflectionbStudents complete specific guided activities in order to prepare for the service experience, including reflection before service occurs.Existing:

Semester 1: Online module of East Baltimore and Johns Hopkins history.

New:

Semester 1: In-class structured reflection activity after online module.

Critical ReflectioncOpportunities for students to connect their service activities with class content, while examining historical and political context of social problems. This also includes students' self-exploration, and analysis of power and privilege.Existing:

All practicums: Biweekly activity logs to describe work and reflect on progress toward student accomplishment of PHN competencies.

New:

Semester 1: In-class introduction to SL and how to effectively engage in reflection (written and verbal) with activity.

All practicums: Structured in-class reflection activities focused on specific topics.

Reciprocal LearningdBoth the academy (students and faculty) and community partners learn from one another throughout the service experience.Existing:

All practicums: Passive assumption of bidirectional learning—student learns about public health problem, population, and agency from preceptor and preceptor learns about skills, knowledge, and methods student is practicing in the course.

New:

All practicums: Faculty described SL pedagogy to preceptors and students in initial meeting to set-up practicum and encourage intentional and active bidirectional learning and were encouraged to engage with students in critical reflection.

Focus on Social JusticedEngage opportunities to explore and identify systemic and institutional oppression pertaining to social issues and working to dismantle such oppression in order to build communities of justice.Refer to Table 2.

New Content Developed Using Critical Service-Learning Pedagogy to Enhance Focus on Social Justice Using Critical Reflection and Integrated Into Graduate Public Health Nursing (PHN) Courses Over Four Semesters

SemesterSocial Justice ContentCritical Reflection Activities
Semester 1: Health Promotion and PHN Practice Didactic

Online module: Johns Hopkins University & Baltimore: How History Impacts Our Work Community

In-class presentation to define root cause issues: Power, privilege, positionality, intersectionality; and introduction to antioppression frameworks

In-class structured reflection activity focused on historical community-institution relationship; presentation of antioppression frameworks

Semester 2: Population-Based PHN Interventions Practicum

Online module: From Service to Partnership: Principles and Best Practices for Engaging with Community

Online module: Working in a Community Setting: Essential Competencies

In-class structured reflection activity focused on partnership with application of antioppression frameworks

In-class structured reflection activity focused on responsibilities of engagement with application of antioppression frameworks

Written critical reflection question: Consider and reflect on the historical context of the population or public health problem you are working with this semester. What do you know about how racism, power, privilege, and/or intersectionality advantages or disadvantages the health and well-being of this population, historically and/or in present day? (Select those that are most relevant.) What are your gaps in knowledge? How might you go about filling those gaps in knowledge? How might that information inform the work you are doing this semester?

Semester 3: Community Assessment Practicum

In-class presentation to introduce critical consciousness framework for equity-focused community assessment; authentic partnership in context; community expertise, asset, and power mapping; antioppression framework focus on trauma informed approach and harm reduction

In-class structured reflection activity for application of critical consciousness to community assessment, demonstration of PHN competencies, and American Nurses Association code of ethics using antioppression frameworks

Assessment of personal identities of privilege and oppression (students complete prior to class) and in-class structured reflection activity

Written critical reflection question (same as semester 2)

Semester 4: Program Evaluation Practicum

In-class presentation on application of antioppression frameworks to leadership development (servant leadership) and program evaluation

In-class structure reflection activity with case studies that illustrate places of oppression in systems and programs addressing public health problems.

Written critical reflection question 1 (before in-class activity; same as semester 2)

Written critical reflection question 2 (after in-class activity): Consider the mission, vision, goals, objectives, location, and population served (or not served), and personal identities of staff and leaders in the program and/or organization you are working with for your clinical practicum. In what ways does the organization reflect and/or counter antioppressive values? (Note, not every component of the organization has to be addressed, select those that are most relevant.) If you were a leader in the PHN program, how would you intervene to uphold antioppressive values?

Authors

Dr. Bower is Assistant Professor, Dr. Alexander is Assistant Professor, Johns Hopkins University, School of Nursing, Ms. Levin is Director and Assistant Scientist, Ms. Jaques is Assistant Director and Instructor, Johns Hopkins SOURCE, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and Dr. Kub is Adjunct Professor, University of Southern California, School of Social Work, Department of Nursing, Los Angeles, California.

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

The authors thank Lisa DiAndreth, MSN/MPH, RN, for her review of the nursing literature. They also thank the leaders and members of Liberate, Eradicate, Activate for hosting a series of interactive workshops about using antioppressive frameworks in public health education at Johns Hopkins Bloomberg School of Public Health, with a special thanks for the leadership of Anushka Aqil.

Address correspondence to Kelly M. Bower, PhD, MSN/MPH, RN, Assistant Professor, Johns Hopkins University, School of Nursing, 525 North Wolfe Street, Baltimore, MD 21205; email: Kbower1@jhu.edu.

Received: March 19, 2020
Accepted: July 15, 2020

10.3928/01484834-20201217-09

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