May 18, 2021

Transforming nursing education to achieve health equity

Addressing patients’ unmet social needs has always been an aspect of the practice of nursing. But to meet today’s health equity challenges, nursing schools will need to embrace some bold new ideas and uncomfortable conversations. The new report from the National Academy of Medicine, The Future of Nursing 2020-2030: Charting a Path to Health Equity, provides a roadmap all nurse educators should use to begin this urgent transformation.

At first glance, the report’s recommendation on health equity and nursing education sounds simple:

“Recommendation 7: Nursing education programs, including continuing education, and accreditors and the National Council of State Boards of Nursing should ensure that nurses are prepared to address social determinants of health and achieve health equity.”

But as the report’s authors explain in Chapter 7: Educating Nurses for the Future, understanding how to fulfill that mandate is no easy task.

Rejecting the idea that ideas like structural racism and social determinants of health can be addressed in a single course, they call for such concepts to be “integrated throughout the curriculum to give nurses a comprehensive understanding of the social determinants that contribute to health inequities.”

The committee also encourages nurses to lean into difficult conversations around the future of the NCLEX, racism in our profession, and the changes that will be required to develop the next generation of nurses.

Core competencies for health equity

The report details the efforts of our colleagues in several nursing education professional organizations who have identified what all nurses should know about health equity, as well as the competencies required for various degrees. The recommendations of the National League of Nursing and the American Association of Colleges of Nursing feature prominently, as well as the desire to add health equity knowledge and skills to the NCLEX exam. Nurse educators would do well to consider this as they redesign curricula for the future.

Three competencies identified by AACN stood out as particularly important to the NAM committee:

Delivering person-centered care to diverse populations

A major driver in health equity efforts is the changing demographics of the United States, which over the next few decades will become more diverse. In response, nursing schools need to help students learn to address the health needs of populations that are different from their own. This will involve helping students see their own biases and adopt an attitude of cultural humility. The report provides further detail on both topics, differentiating them from approaches to cultural difference that educators have taken in the past.

Collaboration across professions

Most nurses already understand that social determinants of health exist outside the clinical environments where many of us work. What many of us have not yet reckoned with is the many different industries and professions we will need to work with to address these challenges — not just physicians and pharmacists, but engineers, housing and transportation experts, activists, and more.

Continually adapting to new technologies

Nurses’ relationship to technology is complex; many of us would rather be spending time talking to our patients instead of recalibrating our hospital’s latest device. But as the committee makes clear, the judicious use of technologies such as telehealth will be essential to addressing gaps in care in the United States. The authors enjoin nurse educators to help students understand both the “promise and perils” of new technology for health equity, ensuring that nurses can constructively inform these technologies’ design and deployment.

These are some of the key ideas the committee believe will shape future nursing syllabi.  But a nursing school is more than a curriculum. It also consists of the community doing the learning and the ways they are being taught.

Making nursing education more inclusive

It has been clear to our profession for some time that to provide adequate care, the nursing workforce needs to reflect the population it serves. Nurse educators have also been aware that this goal cannot be achieved without cultivating a diverse faculty and student body in our institutions.

But what the new Future of Nursing report makes abundantly clear is that marginal demographic improvements will not be enough to realize the goal of health equity. The authors instead challenge us to reimagine nursing schools as fully inclusive institutions.

“Efforts to recruit and educate prospective nurses to serve a diverse population and advance health equity will be fruitless unless accompanied by efforts to acknowledge and dismantle racism within nursing education and nursing practice,” they write.

Vividly describing the isolation and “loss of self” that many students from underrepresented backgrounds experience in nursing school, they call upon all of us to critically examine the culture of our institutions. For example, they challenge the tendency of nursing school faculty to focus exclusively on white nurses as the sources of innovation and progress in the profession, when many other compelling narratives exist. The report also describes a variety of practical steps that can be taken to more effectively recruit and retain nursing students from underrepresented populations.

An even more daunting challenge described by the report is the need to recruit more diverse faculty for nursing schools. Citing research from AACN, the report explains that nursing faculty are still overwhelmingly female (93 percent) and lag behind the student body and workforce in terms of racial and ethnic diversity, with only 17.3 percent from underrepresented groups.

While this is an improvement from the 11.5 percent from underrepresented groups in 2009, achieving a truly representative nursing faculty on the national level will be a major challenge, since we already face significant shortages of nursing faculty in general. The report rightly calls for further intentional action to ameliorate the problem of who will teach the next generation of nurses.

New pedagogies for new skills

When it comes to how to teach future nurses, however, the report is replete with exciting new solutions.

The committee clearly states that traditional pedagogy is not sufficient for the task. The “domains and competencies” needed to address social determinants of health, they write, “cannot be conveyed to nursing students through traditional lectures alone.” In fact, they cite persuasive evidence that suggests that without real-world experience, classroom discussions of social determinants can actually increase negative attitudes toward affected populations.

Fortunately, nurse educators have developed innovative ways to address this problem. Many of these solutions are far more robust than a visit to a community clinic. The authors describe successful models for long-term partnerships with diverse entities such as “federally qualified health centers (FQHCs), public health departments, homeless shelters, public housing sites, public libraries, and residential addiction programs” where nurses can gain experience and community members can benefit.

Any of these relationships could serve as a first step toward the goal envisioned in the Campaign for Action’s Population Health in Nursing report last year: every nursing school should be a participant in a robust population health partnership.

A few exemplary models go even further in realizing that vision. For example, in its graduate programs the University of Washington supplements a year of work in the community with a year of policy work, raising the social change ambitions of its graduates. Washburn University in Topeka, Kansas has transformed its DNP program to focus on social determinants of health through a groundbreaking collaboration with the Topeka Housing Authority.

The report also highlights simulation as an innovative approach to help students understand the work of health equity in a low-risk environment. One example is the Community Action Poverty Simulation, a role-playing activity where students attempt to access resources impoverished patients might need to address social determinants of health. Research cited by the report claims that these exercises increase empathy and understanding of the situation of poverty — a vital skill set if future nurses are going to help the United States achieve health equity.

Glazer was a member of the Committee on the Future of Nursing 2020-2030. She is also dean of the University of Cincinnati (UC) College of Nursing and vice president for health affairs at UC.