Recent national events have highlighted the consequences of systemic racism on our nation. As a result, nursing organizations have challenged health care professions educators across the United States to include in their curriculum the relationship between systemic and structural racism and its impact on social determinants of health (SDOH) and, ultimately, patient outcomes. The call demanded nurse educators to reflect on current practices, identify gaps, and develop a plan.1 At the same time, students have escalated concerns that faculty are not addressing real-time current events in relevant ways within classroom instruction. Thus, 2 equally problematic conditions emerged: lack of faculty-led discussion on current civic events and lack of intentional curriculum efforts to address systemic and structural racism and the downstream effects on health and health outcomes.
In response, our school leadership recognized this as a critical issue and charged the curriculum committee with intentionally addressing structural racism and SDOH throughout the prelicensure and postlicensure nursing curriculum while considering how SDOH intersect with current events, defining these as high-priority topics. A SDOH faculty lead was designated to facilitate the process, and several subgroups were convened. The first goal was to ensure high-priority topics were identified and appropriately integrated throughout the curriculum using the Emory University Nell Hodgson Woodruff School of Nursing (NHWSN) SDOH framework that focuses on policy, cultural, environmental, and social concepts (Hamilton, 2019, unpublished). The second goal was to ensure faculty were being supported/developed throughout the process. Third, curriculum mapping would be completed beginning within the prelicensure curriculum as the pilot. Finally, a program evaluation plan was developed to track the short- and long-term effects of curriculum changes and faculty development on students and faculty, respectively.
This foundational approach was subdivided into 4 components; the first was the development of broad overarching SDOH course objectives that would be included in every syllabus in the prelicensure program followed by the identification of high-priority topics and learner objectives specific to each course. Faculty training and development were constructed and guided by the Office of Education. Finally, evaluation was led by a core group of researchers and the Office of Diversity, Equity and Inclusion (DEI). This article describes the first critical component of identifying high-priority topics and inclusion in nursing curriculum using an SDOH framework.
The Imperative
Social determinants of health refers to the environments in which people are born, live, work, learn, play, and worship that affect their health, functioning, quality of life, risks, and health outcomes.2 Although nursing education in the United States has historically been acute care centric, there is a growing shift toward continuity of care and the community's impact on health. An important consideration is the degree to which acute care systems impact a patient's health. Currently, acute care settings are only responsible for 20% of a patient's heath, whereas the remaining 80% is largely impacted by a patient's health-related behaviors, socioeconomic factors, and environmental factors (ie, SDOH).3 Although the need to integrate SDOH and priority topics into nursing curricula is clear, nursing schools often lack structure and support to do so. Faculty often report constraints within prelicensure and postlicensure nursing programs that prohibit adequate time and ability to address SDOH and priority topics in real time.
Methods
Experienced faculty from prelicensure and postlicensure programs, active clinicians, curriculum specialists, curriculum committee leadership, and students serving on the curriculum committee developed a list of high-priority topics relevant to the students' experiences outside of class and to the greater community at large. An anonymous survey was sent to the curriculum committee to rank order the high-priority topics and choose which ones they deemed most relevant for the upcoming calendar year. These items were tabulated, discussed, and categorized by school leadership and curriculum committee members.
High-priority topics were thematically grouped into 4 overarching themes: power and privilege, world health disruptions, societal influences, and physical, mental, and behavioral health (Supplemental Digital Content, Figure, http://links.lww.com/NE/B7). Each high-priority topic was framed through the NHWSN SDOH framework to ensure the dynamic nature of these topics were considered in a multifaceted approach. In addition, consideration was given to the prelicensure and postlicensure curricula to scaffold items based on students' competency level.
Because of the complexity of mapping leveled content in both programs simultaneously, explicit mapping was piloted within the first semester of an accelerated master's level entry to practice nursing program that was also an academic-practice partnership. As part of this partnership, an existing advisory board composed of faculty and practice partners was consulted to garner feedback of high-priority topics with regard to relevance and priority. High-priority topics were shared with first-semester nursing faculty who selected topics most closely aligned with their respective courses.
An SDOH subgroup of the curriculum committee, composed of a prelicensure student representative and faculty, constructed weekly learning objectives to address the high-priority topics. Objectives were provided to course faculty, and feedback was elicited to determine overall fit of objectives to specific courses, modifications needed, linkages across courses in the semester, and faculty support required to feel confident in addressing objectives. In addition, the mode of teaching (eg, lecture, simulation, clinical practice) and associated assignments were also captured. Faculty objectives were merged with curriculum committee objectives. The SDOH curriculum subgroup, to eliminate redundancy, then further refined objectives, and topics were scaffolded across the curriculum. For instance, vaccines were covered in the pathophysiology and pharmacology courses in the usual scientific fashion. However, they were addressed in the population health and pediatric courses, through the social and cultural aspects of the NHWSN SDOH framework, whereas the nursing professional development course addressed vaccines through the environmental and policy lens. Although all courses addressed vaccines, the aspect within the SDOH framework (ie, social, cultural, policy, environment) varied. This approach helped to alleviate concern from faculty that they could not cover all the dimensions of a high-priority topic within the SDOH framework in their course.
To aid in curriculum mapping, faculty were given a comprehensive spreadsheet with the high-priority topics, associated objectives, and the courses in which the topic would be addressed. Faculty documented the method for addressing their objectives, estimated hours devoted to the topic, and aspect of the SDOH framework they addressed. Faculty team huddles were convened to unite first-semester faculty members with the nursing program director to review progress toward addressing objectives and reinforced the need to document course activities.
Results
The high-priority topic list included 25 high-priority topics; 9 were chosen to be addressed in the first semester and are depicted in red on the Supplemental Digital Content 1, Table, http://links.lww.com/NE/B7. A total of 69 unique learner objectives were created across 5 first-semester prelicensure courses, including didactic and clinical/skills laboratory courses. An example of how select high-priority topics were integrated across several courses can be found in the Supplemental Digital Content 2, Table, http://links.lww.com/NE/B8. Currently, the first semester is in the process of concluding, and therefore, curricular outcomes are pending. The Office of DEI alongside a core group of research faculty are evaluating student and faculty outcomes with results pending.
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