Cultural competence has been extensively studied in nursing education and is a dynamic process that involves understanding and acknowledgment of different cultural and ethnic beliefs and practices. The importance of cultural competence should not be negated, yet as disparities in health outcomes across diverse patient groups persist, nursing education must look beyond understanding of cultural and ethnic beliefs.

Nursing practice is founded upon a holistic model of health care and positions nurses to play an important role in addressing social determinants of health (Olshansky, 2017). The American Nurses Association's (2015)Code of Ethics for Nurses emphasizes principles of social justice and the need to include social needs and concerns in nursing and health policy. In recognizing that health is determined by social and economic opportunity, the National League for Nursing (NLN, 2019) released A Vision for Integration of the Social Determinants of Health Into Nursing Education Curricula, which calls for nurse educators to integrate social determinants education at all levels of nursing education. The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, [AACN] 2008) underscore the importance of BSN-prepared nurses having the ability to engage in holistic care of individuals and populations. Student engagement in health policy is imperative, with students educated to advocate for their profession and patients to ensure access, equity, social justice, and affordability in health care.

The AACN Baccalaureate Essentials (2008) further delineated cultural competencies for undergraduate and graduate nurses. At the undergraduate level, four essentials describe key elements for baccalaureate nursing graduates to provide culturally competent care in collaboration with interprofessional teams. The seventh essential addresses advocacy and social justice, with a commitment to vulnerable populations and eliminating health disparities. The Essentials provide a framework for building undergraduate curriculum and emphasize cultural competence as well as advocacy and social justice.

BACKGROUND

Structural competency is the ability to identify how a patient's presenting symptoms and disease processes are influenced not only by cultural practices but also by structural factors such as inequalities and stigmas that may put them at risk for certain diseases or even lead to "noncompliance" (Metzl & Hansen, 2014). Metzl and Hansen's (2014) framework of structural competency proposes that, rather than teaching health disparities from a theoretical perspective, medical education should focus on how the structure of an environment can influence population health. Clinicians should be able to recognize that many inequities are influenced via institutions and policies, and thus, clinical interactions should focus not only on the individual but also on institutions and policies - or lack thereof - that have brought the patient to them in the first place.

Structural competency is described in preprofessional health education and aims to describe how societal structures can contribute to health disparities (Metzl & Hansen, 2014; Metzl & Petty, 2017). Structural competency may be conflated with the social determinants of health. Metzl and Petty (2014) emphasize that a pedagogical movement is needed to shift away from cross-cultural understandings of individuals toward structures and policies that influence population health outcomes. Structural competency is an approach that consists of education in five core competencies: recognizing structures that shape clinical interactions, developing a language of structure, rearticulating cultural formations in structural terms, observing and imagining structural interventions, and developing structural humility (Metzl & Petty, 2014). Promoting an awareness of personal biases about structural factors that may produce health inequities is a first step toward advancing structural competency. As the United States becomes a more diverse nation, it is important to develop cultural competence in order to provide individualized care. However, as a profession dedicated to the advocacy of others, nurses must also be able to understand how societal structures influence health outcomes.

PURPOSE

Assessment of nursing students can be used to shape and drive curricular innovations that build on the calls to integrate social determinants of health (National League for Nursing, 2019) and more purposefully integrate the social sciences in understanding and addressing health disparities to inform action. The researchers sought to describe baccalaureate nursing students' attributions of the effects of structural factors on health. The research question guiding this study was whether attributions of structural factors on health differed at different points across the curriculum.

METHOD

The design was descriptive and cross-sectional, using a validated tool to assess student attributions of health inequities, the Attribution of Racial/Ethnic Health Disparities (AREHD) Scale, which assesses the attribution theory or what people believe are causes of health outcomes (Price et al., 2014). The AREHD was validated in a sample of 423 undergraduate students across four Midwestern universities and assesses two facets of attribution theory: individual responsibility and social determinants. The AREHD was found to be a reliable assessment of individual responsibility ([alpha] = .87) and social determinants ([alpha] = .90). BSN students were invited to participate after a brief presentation of the study was provided in class. The survey was developed in Qualtrics XM(R), and IP address tracking was disabled to anonymize the responses. A secure link to the Quatrics XM survey was deployed via James Madison University (JMU) online course management system, and an email was sent to all potential participants. Institutional review board approval was obtained prior to the start of the study. Students had the opportunity to open the link and review the informed consent document prior to beginning the survey.

RESULTS

Of 450 eligible students, 157 participated in the study (34.8 percent response rate). Response rates varied by academic level in the program: newly admitted (20.4 percent), first semester (13.4 percent), second semester (38.2 percent), third semester (17.2 percent), fourth semester (10.8 percent). The students ranged from 18 to 27 years old (M = 20 years) and were predominantly female (96.2 percent) and Caucasian (91.1 percent). Students from the following racial/ethnic groups were also represented: African American (1.3 percent), Asian (3.8 percent), and Hispanic/Latino (7 percent).

Participants were aggregated by academic level (semester in the program) to assess trends in attributions and perceptions of the curriculum addressing domains of competence as they progressed through the nursing program. Participant responses on the AREHD were similar across most questions, and participants rated overall social and individual attributions as having an impact on health behaviors in racial/ethnic minorities (1 = high relevance, 4 = no relevance). Participant responses did vary on four AREHD questions. Testing was conducted to assess for differences between the academic levels on the AREHD. There was a statistically significant difference between the academic levels as determined by one-way analysis of variance on two of the AREHD social determinants questions: the lack of low-cost public transportation available for low-income racial/ethnic minorities, F(4, 153) = 3.677, p = .007, and the level of environmental stressors affecting racial/ethnic minorities, F(4, 143) = 2.616, p = .038. Two additional questions approached statistical significance: the high rate of criminal activity in which low-income racial/ethnic minorities are involved, F(4, 153) = 2.294, p = .062, and the lack of adequate low-cost housing for low-income racial/ethnic minorities, F(4, 153) = 2.224, p = .069. A Tukey post hoc test revealed differences between first- and third-semester students; first-semester students (M = 2.31, SD = 0.884) were less likely to rate transportation as being relevant to health disparities when compared to third-semester students (M = 1.57, SD = 0.662, p = .01). In addition, the difference between first-semester students and fourth-semester students approached significance (M = 1.65, SD = 0.702, p = .56).

DISCUSSION

Self-reported attributions of social determinants of racial/ethnic health and individual responsibility, as assessed by the AREHD Scale, were favorable; participants reported that social and individual contexts were related to racial/ethnic health. Previous research (Price et al., 2014) described demographic and biological factors that affect attribution of concepts to racial and ethnic health when examining health policies. These include political affiliation, gender, and ethnicity, indicating that certain personal beliefs tend to focus more on individual responsibility rather than socially and structurally determined external factors. The impact of specific educational and personal experiences that may influence student attributions toward racial/ethnic health was beyond the scope of this study. This study focused specifically on academic level within a traditional baccalaureate nursing program and found that students in the fourth and final semester of the nursing program associated one structural factor, transportation, as being attributed to health disparities. Of note, students in the fourth-semester level have completed coursework in a population health course. Two structural factors (housing, environment) and one individual factor (criminal activity) approached significance.

The Association of American Colleges & Universities states that students will increasingly require "wide-ranging and cross-disciplinary knowledge, higher-level skills, an active sense of personal and social responsibility, and a demonstrated ability to apply knowledge to complex problems" (Association of American Colleges & Universities, 2007, p. 45). JMU is a liberal arts university with a robust general education program. General education courses include those that focus on the human community to create informed global citizens. Favorable attribution scores could be due to concepts addressed in courses throughout the general education program, which is completed before beginning nursing coursework in upper division admission programs, as well as throughout the BSN courses themselves. In addition, favorable attribution scores in the early semesters of the program, particularly Semesters 0 and 1, show that general education coursework could contribute to students' awareness of structural inequities.

LIMITATIONS

This study was conducted at a single site within a university setting that lacks diversity across its student population. The predominantly Caucasian, female sample may limit generalizability of the findings. The participants' exposure in general education coursework may limit the interpretation of findings.

This study consisted of nursing students, and there is little comparative data on differences in attributions of health disparities across colleges campuses. Nursing has been ranked the "most honest and ethical" profession on Gallup's ethics poll for 17 years in a row (Brenan, 2018). The questions that were posed on the survey could simply show that nursing students are, in general, morally and ethically "good" people and may have answered these questions based on their values rather than based on topics that were specifically discussed or taught during their nursing education. Although this may speak to the ethics and values of nursing students, it does limit the ability to evaluate whether the School of Nursing is teaching these concepts to students or if these questions simply lacked moral ambiguity to students whose future career is heavily based in ethical behavior (Sharma et al., 2018). The quantitative design limited researcher follow-up with participants to further assess their experience and perceptions of structural competency in their education.

CONCLUSION AND IMPLICATIONS FOR FUTURE RESEARCH

As the nation's largest health profession, nurses have the ability to advocate for both patients and populations. Understanding how structural inequalities are affecting patients as well as what could be done to help those who are left behind in the growing, changing, ever more political world of health care policy would allow nurses to better advocate for structurally competent policies, agencies, and programs at the local, state, and even national level. Although the students surveyed did score favorably on the AREHD survey, it is difficult to determine whether this understanding leads to action. Further research is needed to help link knowledge of structural and social determinants of health to advocacy as a professional nurse. Furthermore, it would be beneficial to assess experienced nurses' attributions of health disparities and their engagement in advocacy to address structural inequities.

Nurses must be educated not only to provide holistic care for diverse groups but also to advocate for the health and well-being of their patients. This will require nurse educators to encourage students to think beyond the nurse-patient encounter to look comprehensively at social and structural issues that create health inequities. Further research is needed to assess the development of student awareness and competence in addressing structural determinants of health.

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