The Future of Nursing Report 2020-20301 calls for nursing education to integrate the social determinants of health (SDoH) in the curriculum to prepare future nurses to take an active role in identifying and addressing health inequities. Nurse faculty and schools of nursing face multiple challenges that pose as barriers to meet this demand. These challenges include a crowded curriculum, lack of a coherent curricular framework, and a dearth of evidence-based teaching strategies to ensure that concepts on SDoH, health equity, and social justice are seamlessly integrated in the nursing curriculum.

We used Design Thinking (DT) as a framework to prepare prelicensure nursing students to be creative thinkers and problem solvers and to understand how SDoH contribute to health inequities. Design Thinking is a human-centered problem-solving approach to innovation that includes the phases of Empathy, Problem Definition, Ideation, Prototyping, and Testing.2 We received funding from The Rita Hillman and Alex Foundation to integrate DT in the curriculum by weaving the DT phases into select required undergraduate courses over a 4-semester period. This article describes how we integrated SDoH, social justice, and health equity as core components of DT over a 4-semester nursing sequence baccalaureate nursing program.

Integration of SDoH

During the first nursing sequence, all students are required to take the professional nursing course that introduces students to the discipline and profession of nursing. In this course, students learn the professional and ethical comportment expected of a nurse as a clinical leader in a health care system, as well as a nurse's role as patient advocate, clinical problem solver, and leader of innovation in health care delivery. Students are also introduced to DT and its phases and the concepts of SDoH, health equity, and social justice. The course emphasizes the important role of the first phase of DT, Empathy in providing culturally sensitive care especially among the underserved and minoritized populations. The course also adopted the Designing Your Life3 book to help students build and strengthen their ability to empathize through self-reflection and self-assessment using online interactive activities. Faculty use reflection exercises during class to allow students to have a better understanding of self and the importance of empathy in providing fair and equitable care to patients.

For the second nursing sequence, DT is incorporated into the Integrating Evidence into Clinical Practice course, which introduces students to the basic principles of critical appraisal of research for use in professional health care practices. In this course, students learn the basic components of research studies, including theoretical and conceptual grounding of research, critical elements of research design, and how to integrate research into evidence-based practice. Faculty teaching the course redesigned the PICOT (Problem-Intervention-Comparison-Outcomes-Time frame) project to add a "How Might We" component by using the Ideation phase of DT. The goal is to stimulate divergent and convergent thinking and to launch brainstorming to help students develop questions and relevant ideas addressing the SDoH in a population or topic they have identified. Course faculty provided general topics that could facilitate students connecting the SDoH into their chosen topic. As an example, 1 group explored the question: In expectant mothers of color, how does care during midwifery deliveries versus care given during OBGYN/hospital deliveries impact infant mortality? By applying the Ideation phase of DT, the group added the question: How might we improve the midwifery care throughout pregnancies in mothers of color so that we can decrease the incidence of infant mortality?

For the third nursing sequence, DT is integrated into the Contemporary Issues course, which discusses relevant issues that influence nursing practice and health care while exploring the ethical and moral implications associated with heath inequities. Examples of common topics that students explore in their DT project include LGBT (lesbian, gay, bisexual, and transgender) health care, maternal child health, substance use and addiction, and mental health.

For this Contemporary Issues course, students complete activities during the semester addressing the phases of DT. Early in the semester, students complete guided online activities to develop a persona (a patient or patient population) using empathy with an associated health disparity issue or ethical concern and other pertinent SDoH (Empathy and Problem Identification phases). The phases of Ideation, Prototyping, and Testing are completed during a 1-day hackathon event facilitated by course faculty, DT experts, and mentors. During the hackathon, students work as a team in an environment that encourages and welcomes creativity in addressing the needs of the persona with a health disparity or an ethical concern they have previously identified (Ideation phase). As is typical for DT hackathons, each group is provided with a whiteboard, colored markers, Post-its, modeling clay, and other art materials in which to physically create a prototype of their proposed solution(s) (Prototyping phase). At the end of the Prototyping phase, the groups switch to the Testing phase and present their prototypes to other students to obtain feedback about their project. As a course requirement, students develop and present posters about their DT project at the end of the semester where faculty and administrators of the college of nursing and clinical partners are invited to attend.

For the final nursing sequence, DT is integrated into the community/public health nursing (C/PHN) course to address pressing public health issues that are rooted in the SDoH in the community. Students for this course also participate in a 3-hour hackathon later in the semester. The project acronym is DTICH which stands for Design Thinking in Community Health and functions as a summative capstone deliverable for the students. Students form teams of their own choosing consisting of approximately 6 students per team. The students engage in a discussion of our nation's Healthy People 2030 goals and then choose a topic of interest. Each team acts as a public health nursing task force responsible for using DT to develop an innovation (product, policy, program, etc) to address a Healthy People 2030 objective. We have invited students and faculty from other schools within our university such as social work and global public health to participate in the hackathon event. As part of their overall presentation, C/PHN teams critically think about their Healthy People 2030 topic, persona, and problem statement and how these relate to the SDoH. Students identify and describe the linkages that exist between the problem their persona is facing and aspects of the SDoH that are most at play. The fourth sequence C/PHN students apply the concepts and competencies gained not only from their C/PHN course but also from academic work spanning across their previous 3 terms in our undergraduate program and showcase their skills, knowledge, and attitudes honed over the course of their cumulative academic study.

Summary

In fulfillment of the call to action made in the Future of Nursing 2020-2030 Report, the creative teaching and learning strategies integrated in our undergraduate curriculum have equitably offered all students the opportunity to experience the power of innovation using a DT framework with an emphasis on addressing SDoH, social justice, and health inequities. Our graduate nurses bring knowledge and experience to the workplace that contributes to organizational success as systems of care continually evolve to meet complex population health equity needs often driven by SDoH.

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