Social Determinants of Health: A Longitudinal Study of BSN Students and Nursing Curriculum

Thursday, 19 July 2018: 3:30 PM

Susan K. Lee, PhD, RN, CNE
Nursing Consultant, Austin, TX, USA
Pamela Willson, PhD, RN, FNP-BC, CNE, FAANP, VHF
School of Nursing, Texas State University, School of Nursing, Round Rock, TX, USA

Purpose: The Robert Wood Johnson Foundation and the Culture of Health call for improving population health to improve Social Determinants of Health (SDOH). It is unclear if the components of SDOH are identified, assessed, and discussed within BSN curriculum. Therefore, this longitudinal, qualitative study was designed to better understand a cohort of 100 BSN students' perceptions of their role in identifying and addressing SDOH with their clients. The components of SDOH derive from exclusion, exploitation, humiliation, and an unequal distribution of basic necessities, such as knowledge, food, property, services, and income. When considering the impact of SDOH on the health of vulnerable populations, nursing education initiatives should be designed to align with recommendations from the World Health Organization to address disparities. (Rozendo, Salas, & Cameron, 2017). There may be a need for an increased focus on concepts of culture within nursing education programs to prepare future nurses for culturally congruent practice that has the potential to reduce the negative impact of SDOH. Unfortunately, concepts related to SDOH are not easily identified or tracked across nursing education curriculum (Diaz, Clarke, & Gatua, 2015). As faculty concerned with addressing this potential curricular deficiency, the purpose of this study was to design an inquiry to explore Bachelor of Science in Nursing (BSN) students' knowledge and perceptions of client care as they relate to SDOH. The aims were: 1) to explore students' perceptions of SDOH upon entry into a BSN education program; and 2) to identify if an evolving awareness of social determinants that adversely affect health were gained on a larger scale by program completion.

A literature review was conducted to identify the issues and trends of SDOH in nursing education. The themes identified were used as search terms and included disparity, poverty, inequality, homelessness, nursing curriculum, nursing education, nursing faculty, and nursing students. The literature and research is limited in identifying how SDOH are addressed in existing nursing curriculum. Therefore, to further explore SDOH and their inclusion in nursing curriculum, undergraduate students were surveyed using a longitudinal, qualitative research design spanning the duration of a specified cohorts’ nursing education program.

Methods: After Institutional Review Board (IRB) approval, 90 of the 100 students volunteered to participate, signed the consent form, and responded to the first survey. The first survey consisted of three questions: 1) What social determinants are you aware of that contribute to poor health? 2) What do you imagine is the nurse's responsibility, if any, to identify and address change in social determinants of health for clients? and 3) What have you already done to change social determinants of health? The second survey was administered during the last week of the final semester, prior to graduation. The first two questions were identical to survey one to establish differences in perception of SDOH. An additional third question, “How has your perception of the nurse’s responsibility in addressing social determinants that contribute to poor health changed over the last year?” assessed the students' reflections of change during their program of study.


As a qualitative study, participants were asked to define “social determinants of health.” The results were analyzed line-by-line by each of the researchers to identify common themes and categories. The researchers met to discuss findings, looking for common themes and identifying differences. This process was similarly repeated after the data collection with the second survey. Researchers then compared the findings between the data analyses of both surveys to determine when change in awareness occurred and if this change was related to learning that occurred through the nursing education curriculum. The results from the data analysis suggest that a majority of the students initially equated social conditions with lifestyle choices and individual behaviors, (e.g., smoking, lack of exercise, diet). This cohort of participants indicated that the nurse’s responsibility was to educate and display characteristics like optimism, kindness, open-mindedness, and helpfulness. Their prior activities to change SDOH focused on personal choices, rather than advocating for others, (e.g. moving to a new town, stopped associating with bad influences).

By contrast, a small number of participants identified social determinants that contribute to poor health, such as poverty and lack of education. For these participants, the nurse’s responsibility was believed to be patient advocacy, as in encouraging patient’s to further their education. Prior activities of this cohort of participants included serving in the military, going to war, working with community outreach, volunteering, fund-raising, donating money, and raising awareness with social events. These activities were found to influence an increased awareness of the impact of SDOH and means to lessen the impact on patients.

Conclusion: This longitudinal/qualitative study explored BSN students' perceptions of SDOH. As participants’ responses evolved over time, a narrower, more manageable definition of SDOH was incorporated into nursing care and an expanded role in identifying and addressing SDOH emerged. Clinical student experiences should incorporate experiential activities that raise SDOH awareness. Through identifying and improving nursing education, future nurses will be better equipped to answer the call to consider the impact of SDOH when providing quality, comprehensive patient care. Within the auspices of advocating to improve the lives of client’s affected by SDOH, nurses may take a leadership role in policy development to better healthcare on a larger scale.

Significance: This study stemmed from a desire to better understand BSN students’ perceptions of SDOH; to explore whether students’ awareness of SDOH increases over time; and to study the impact of knowledge gained while in a BSN education program that influences new nurses to address SDOH in clients. There are educational advantages that resulted from this study. Beyond evaluating students, the findings from this study serve as an exemplar for turning Culture of Health questions into scholarly inquiries. The hope is that more educators become inspired to trace students’ progress regarding characteristics described in the Culture of Health from program beginning to program end to gain insights that inform curricular revisions.