Monday, August 27, 2018

How do we teach about social determinants of health in nursing education?

Shawna Sisler
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.

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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

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