Registered nurses in primary care (RNPC) require working knowledge of social determinants of health (SDOH), levels of prevention (LOP), and resiliency to increase long-term clinical effectiveness and workplace satisfaction. This knowledge gives RNPCs the skills needed to collaborate effectively in care delivery. Such skills, introduced in undergraduate nursing programs, promote a well-prepared primary care workforce that is resilient and retained for the future.
The Robert Wood Johnson Foundation (2017) called for institutions to integrate population-focused competencies that enable nursing students to see the overarching effects of SDOH and address patients' social and financial attributes, including circumstances in a person's environment affecting quality of life and health outcomes (Office of Disease Prevention and Health Promotion, n.d.). These have been identified as economic stability, education, social and community context, health and health care, and neighborhood and the built environment. Understanding SDOH facilitates creation of healthy environments.
Using the LOP theoretical model has proven successful in addressing health issues affecting large numbers of people (Daniels-Witt et al., 2017). This model uses primary, secondary, and tertiary prevention strategies focused on health issues. Primary prevention focuses on disease and injury prevention, secondary prevention aims at reducing the impact of disease or injury, and tertiary prevention is directed toward softening the impact of chronic illness or injury (Institute for Work and Health, 2015). SDOH are pertinent at any level of prevention.
As caring for complex patient populations may prove stressful to nurses across their career, future nurses need to be equipped with self-care strategies that increase resilience, the ability to remain focused in adverse situations with continued optimism about the future (Kester & Wei, 2018). Wildes (2016) emphasized that resiliency can be cultivated in nursing students by teaching stress-reducing strategies such as sleep, proper diet, physical activity, social support, leisure activities, and meditation/mindfulness.
Gamification, the incorporation of game elements into nongame contexts, increases student engagement and motivation and enables learning on a deeper level than passive strategies (Gomez-Ejerique & Lopez-Cantos, 2019). Gamification transforms teaching from the transmission of content to be memorized into learning through inquiry and peer interaction. We created and implemented an interactive board game to review primary care content in an engaging way for an RNPC elective course.
BACKGROUND
Concepts in Primary Care is a grant-supported elective course for a baccalaureate nursing program. The grant's purpose is building a resilient RNPC workforce to enhance access to care, reduce cost of services, and improve health outcomes of medically underserved individuals in Alabama. Students enrolled in the course, RNPC scholars, are immersed in an interprofessional primary care curriculum consisting of didactic, fieldwork, and hands-on telehealth experiences. The Henry Street Settlement, the conceptual model for the course, provides social services, arts, and primary care health care programs to more than 50,000 New Yorkers on Manhattan's Lower East Side. Services offered at the settlement are in direct response to conversations with and requests made by the community (Henry Street Settlement, n.d.).
Our gamification teaching strategy increases awareness of SDOH, LOP, and resiliency, ultimately improving outcomes for chronically ill patients in primary care. The game is played during the first module of the course and provides students with an overview of primary care nursing. It encourages students to consider primary care nursing concepts while developing interventions appropriate for bachelor of science in nursing-prepared RNs. Students work through realistic and complicated patient scenarios, preparing for fieldwork experiences with medically underserved individuals in primary care and reinforcing course content.
THE TEACHING STRATEGY AND REACTIONS
Students roll a die and drive toy cars down the street, navigating roadblocks on their way to healthy people and healthy communities. Squares are marked SDOH, LOP, Resiliency, or Wild (team chooses category). Roadblocks contain 20 different scenario cards. Students crossing roadblocks draw a scenario card, read the card aloud, and discuss their response as related to the patient scenario on the card. Following is one patient scenario: Barbie is a 22-year-old biracial female on SNAP (supplemental nutrition assistance program) with two preschool-aged children. She recently worked hard to earn her General Education Development diploma and was employed full-time with benefits. Her new salary put her earnings $17 above the maximum allowable income for SNAP, and she lost the nutritional assistance. She is struggling to provide meals for her children.
Examples of appropriate responses for this scenario are as follows: 1) SDOH-food insecurity, 2) primary prevention-HPV vaccine, 3) secondary prevention-cervical cancer screening, and 4) resiliency-identify the real challenge. Correct answers result in the team's remaining on the current square; incorrect/incomplete answers require returning to the previous square. Some scenario cards do not require answers, with wording, such as "Congratulations! Your grant proposal is funded, and you have received $1.5 million to screen individuals for health literacy. Move forward two spaces!" or "Too bad! Your community partner has decided to focus their time and attention on retail development. Move backward two spaces." The game can be completed in less than one hour, followed by a short debriefing to reinforce learning outcomes.
Since its conception, Concepts in Primary Care has had 41 students, 5 faculty members, and approximately 10 clinical mentors. The game has been used in a live didactic format and was adapted for use in a virtual learning environment during the COVID-19 pandemic. Anonymous evaluation of the game was completed by students following completion of the in-class activity. The survey consisted of seven questions using a Likert scale (1 = strongly disagree/5 = strongly agree) and focused on confidence and understanding. Overall, students were more confident in their understanding of the role of the RN in primary prevention (4.7) and secondary prevention (4.5), understanding the role of the RN in addressing SDOH (4.5), and understanding of resiliency strategies (4.2). Students noted the game was beneficial to their learning (4.3) and stated that they enjoyed playing the game (4.5). Qualitative feedback included the following: "I enjoyed this learning experience" and "I will use the knowledge by intentionally thinking of SDOH and prevention strategies for every patient to better serve and care for the patient."
USE BY CLINICAL MENTORS
The game was found to be effective as preclinical orientation to common scenarios students will encounter in primary care. The game has also been integrated into the Clinical Mentor Academy, enabling RNs in clinical practice to better serve as preceptors to RNPC scholars. The academy, a one-day orientation, introduces clinical preceptors to their roles, the purpose of the course, and how to support professional growth and development of students. Mentors play the game to obtain an understanding of how to facilitate student learning in the primary care environment. Cards are discussed in a group setting, and the game facilitator emphasizes the complexity embedded in the scenarios, highlighting clinical decision-making skill development. Student and mentor feedback supports the examination of complex issues primary care patients face and how working collaboratively generates solutions translatable to primary care clinical experiences.
FUTURE USE AND CONCLUSION
The game has been successful with undergraduate bachelor of science in nursing students in a primary care elective course, with students and mentors being engaged and providing positive feedback. Scenarios can also be used with students in other population/community/public health nursing courses as an approach to student engagement. Our scenarios focus on women's health, pediatrics, mental health, and adult nursing and highlight specific learning objectives and content, such as health professional shortage area settings, clients facing specific SDOH, primary/secondary prevention, and complex cases requiring the application of resiliency principles.
As promotion of student engagement continues to emerge as best practice, educators will explore gamification as an innovative teaching strategy. Opportunities exist to promote interprofessional collaboration, using our game with interprofessional teams working together to address patient barriers. Our teaching team highly recommends this gamification experience to actively engage undergraduate nursing students in critical thinking and problem solving related to SDOH, LOP, and personal resiliency. The game promotes primary care nursing as a viable career option in which resilient nurses can practice for the future.
REFERENCES