PhD Student
College of Nursing
University of Utah
Social determinants
of health (SDH) has emerged as a critical health care priority over the last
decade due to the increasingly unequal distribution of basic social resources
in our society and its correlation with poor health outcomes (World Health
Organization [WHO], 2017). Federal guidelines from the National Academy of Medicine (NAM) and Centers for Medicare & Medicaid Services
(CMS) assert the importance of screening all patients for their unmet social
needs with the hopes to improve self-management of chronic conditions, reduce
health service utilization, and decrease overall health care costs (Institute
of Medicine [IOM], 2014a; IOM, 2014b; Billioux, Verlander, Anthony, & Alley,
2017). As our health care systems builds the targeted infrastructure to address
these avoidable health inequities in clinical settings, it behooves our nursing
education community to ask ourselves what we are doing, as faculty, to prepare the
next generation of providers to actively engage in SDH-informed clinical
practice.
Dahlgren &
Whitehead, 1993
Nursing education
has a long history of caring for the holistic needs of the patient and their
environment (Theofanidis & Sapountzi-Krepla, 2015); this includes the
screening and intervention on the basic social and ecologic needs of our
families. To date, nursing curricula has yet to come to a formal agreement on
how and what pieces of SDH education should be prioritized in teaching our students.
While there is a national credentialing mandate to educate about vulnerable
populations in graduate nursing programs, the delivery medium is not specified.
This leaves the curriculum focus up to the individual teacher or program. Current
strategies most commonly center around didactic/classroom learning, service-learning,
and community partnerships (Martinez, 2015), but there is little evidence that
this is the best practice. Additionally, with such disparate practices, faculty
lose the ability to formally learn from each other and push the teachings
forward in a methodical fashion.
It may be that nursing
can borrow a page from our medical education colleagues in this case. There is
mounting evidence of an interesting paradigm shift is beginning to occur in
regard to the current landscape for teaching SDH within residency program
hallways. Over the last couple years, there is a growing discontent that SDH
teaching is being reduced to an epidemiology equation, a static perspective
that unintentionally encourages provider disassociation from the patient
experience (Sharma, Pinto & Kumagai, 2018). It attacks the more didactic
formats and prescribed community rotation as a dangerously framing of SDH, likening
it to a “laundry list” of social risk factors and relationships for resident to
know “about” yet neglects the “how” (Sharma, Pinto, & Kumagai, 2018). In my
experience as nursing faculty, this criticism has a great deal of truth. SDH is
not a statistic to be studied, rather it is a dynamic, diverse, bidirectional
ecosystem, one that can vary with patient that walks in our clinic doors.
In reaction, large
portions of the medical education community are choosing to move away from the
pedagogy of stigma and inequality and toward a framework utilizing innovative
models, such as structural competency and critical consciousness (Metzl &
Hansen, 2014; Sharma, Pinto, & Kumagai, 2018). Structural competency, as a
concept, implores providers to take elaborate on the individual’s circumstance
(e.g. symptomatology, self-efficacy, risk factors) and apply their knowledge
about the upstream drivers to hone in on what is influencing the patient’s
downstream behaviors (Metzl & Hansen, 2014). It aims to move the clinical conversation
about health outcomes past that of individual interactions to an interactive
dialogue where the provider uses critical consciousness to integrate additional
interventions at the neighborhood, institutional, and policy levels (Sharma,
Pinto, & Kumagai, 2018).
What does that
mean to nursing, though, and where do we start? The WHO
Commission on Social Determinants of Health (2017) argues that the most
critical to help providers (and trainees) acknowledge the role that targeted interventions
and policies can play in mediating these social determinants. For example, within
an education setting, a structural competency approach would advocate that students
learn to better “recognize the structures that shape clinical interactions” and
help the system develop a standardized language, intervention system, and
cultural humility around our patients’ ecosystems (Metzl
& Hansen, 2014, p. 1). Essentially, we need to seek out and identify how
SDH factors affect our patient population, ask meaningful questions around the
context, and then explicitly and intentionally address these SDH factors in our
treatment plans. In terms of trainee development, this means that we need to help
students learn to sensitively ask the right questions within a clinical
encounter to reveal the humanity and dive deep into the “why” of their
patient’s unmet social needs. We must help them uncover the structures that
create these issues and connect their awareness to the drivers.
United Nations (2018)
This prompt would,
indeed, be a lot to ask of some seasoned clinicians, let alone first-year
graduate students. What I offer below may be an interesting first step in our
nursing curricula that leans us toward the greater goal of SDH fluency:
First off, we need
to start at the beginning – patient trust. Before our trainees go into the room
with a patient, armed with their extensive clinical task lists and
differentials, faculty need to ensure that students actually know how to have
an authentic interaction with their patient, which includes competency in interpersonal
skills, an understanding of the community they serve, and a general comfort
level with patient care. In all likelihood, this is not where our students are
at this point in their education journey. Therefore, we need to help them learn
about it.
By utilizing a
basic simulation experience, faculty can create a lower-stakes clinical situations
with standardized patients (SP) that encourage the trainee to ask more
thoughtful, empathic questions and dig at the humanity of the clinical
encounter. Scripts for the SPs would be preloaded with social ecological
puzzles for the students to elicit within the simulated encounter, and then
students should be asked about why they think such things are happening and
what they can do about it.
While this seems
like a simple exercise, it contains thoughtful, pre-built layers that scaffolds
student learning in a safe yet meaningful way. First, having a frank
conversation about their unmet needs and being able to ask the patient about
how he or she would prefer to be asked/counseled has tremendous value. Second, by
learning about what barriers and protective factors exist for this unique
patient and how the patient would like the social needs addressed, the power
paradigm shifts the providers into learners and the patients into their
teachers.
Call it a
throw-back to the days of Freire
and liberation education, if you will. The more perspectives and active
listening experiences that a trainee has, the more powerful the exchange is. It
is then the job of the faculty to help trainees face head-on any discomfort and
confusion regarding a patient’s sensitive concerns, and they can discuss any
complex care issues that arise.
This small step
may be able to push the conversation of SDH education to a more action-based
solution with structural ramifications (a vast improvement on classroom
learning!). Given its holistic approach to care, nursing is certainly capable
to help lead the way. Once we help our
students understand that patients are more than a MRN or eChart, using
activities like the simulation experience above, we can more dynamically help our
future providers intervene on health inequity and becomes stronger patient
advocates. At that point, the first step of structural humility can be laid and
an emerging empath and provider gains the basic human functioning needs to
better contextual and integrate SDH into his or her everyday practice.
Article links
Website links
References
Billioux,
A., Verlander, K., Anthony, S. & Alley, D. (2017). Standardized Screening for Health-related Social Needs in Clinical
Settings: The Accountable Health Communities Screening Tool. Washington, D.
C.: National Academy of Medicine. Accessed on June 22, 2108 at https://nam.edu/standardized-screening-for-health-related-social-needs-in-clinical-settings-the-accountable-health-communities-screening-tool
Dahlgren, G. & Whitehead, M. (1993). Tackling
inequalities in health: what can we learn from what has been tried? Working
paper prepared for the King’s Fund International Seminar on Tackling
Inequalities in Health. Ditchley Park, Oxfordshire. London, King’s Fund,
accessible in: Dahlgren G, Whitehead M. (2007) European strategies for
tackling social inequities in health: Levelling up Part 2. Copenhagen: WHO
Regional office for Europe. Accessed on June 11, 2018 at: http://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf
Institute
of Medicine (2014a). Capturing Social and Behavioral Domains and Measures in
Electronic Health Records: Phase 1. Washington DC: Institute of Medicine of the
National Academies, Author. Accessed on June 22, 2018 at http://www.nationalacademies.org/hmd/Reports/2014/Capturing-Social-and-Behavioral-Domains-in-Electronic-Health-Records-Phase-1.aspx
Institute
of Medicine (2014b). Capturing Social and Behavioral Domains and Measures in
Electronic Health Records: Phase 2. Washington DC: Institute of Medicine of the
National Academies, Author. Accessed on June 22, 2018 at http://www.nationalacademies.org/hmd/Reports/2014/EHRdomains2.aspx
Martinez,
I. L. (2015). Twelve tips for teaching social determinants of health in
medicine. Medical Teacher, 37(7),
647-652. doi: 10.3109/0142159X.2014.975191
Metzla,
J. M. & Hansen, H. (2014). Structural competency: Theorizing a new medical
engagement with stigma and inequality. Social
Science Medicine, 103, 126–133. doi: 10.1016/j.socscimed.2013.06.032.
Sharma,
M., Pinto, A. & Kumagai, A. K. (2018). Teaching the social determinants of
health: a path to equity or a road to nowhere? Academic Medicine, 93(1), 25-30.
Theofanidis,
D. & Spountzi-Krepla, D. (2015). Nursing and caring: An historical overview
from ancient Greek tradition to modern times. International Journal of Caring Sciences, 8(3), 791-800.
United Nations (2018). Sustainable Development Goals: 17 Goals to
Transform our World. Geneva: United Nations, Author. Accessed on June 22,
2018 at: https://www.un.org/sustainabledevelopment/sustainable-development-goals/
United
Nations General Assembly (2015). Transforming
our world: the 2030 Agenda for Sustainable Development, A/RES/70/1. Geneva: United Nations, Author. Accessed
on June 22, 2017 at: http://www.refworld.org/docid/57b6e3e44.html
World Health Organization (2010).
A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion-
Paper 2 (Policy and Practice). Geneva: World Health Organization, Author.
Accessed on June 22, 2018 at http://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf.
World Health Organization, Commission on Social Determinants
of Health (2017). Closing the gap in a generation: health equity through
action on the social determinants of health. Final Report of the Commission on Social Determinants of Health.
Geneva, World Health Organization. Accessed on June 23, 2018 at http://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf
No comments:
Post a Comment