In my years of teaching community health nursing, I have witnessed over and over the change in mentality that students experience from the first day to the last day of class. I have seen many students arrive at class on day one expecting simple content and easy grades. It is my personal challenge each semester to frame community, and population health at-large, as one of the most interesting and critical topics in a nursing curriculum because of the potential nurses possess to positively impact healthcare at a systems-level. When I see a light bulb shine as a student has understood epidemiologic concepts for the first time, when I see the disbelief on a student’s face while interpreting comparative data about global healthcare spending and when students begin to see their professional nursing role as integral to the health of their communities, that is when I know “community health” is no longer just a class. It is a lens through which to better understand and improve healthcare at-large.
How COVID-19 has reinforced the need for a strong community and population health curriculum for undergraduate students
Predating pandemic conditions, there has been a strong call for the US to focus on community and population health to address the reality of exorbitant healthcare spending. Reports by the Centers for Medicare and Medicaid Services (2019) state that the US spends 17.7% gross domestic product, GDP, on healthcare as of 2018. This is nearly double the percent GDP spent on healthcare by the average Organization for Economic Cooperation and Development (OECD) country. For our high healthcare spending in the US, health outcomes are not similarly elevated, “The US has the lowest life expectancy, highest suicide rates, the highest chronic disease burden, and an obesity rate that is twice the OECD average” (Tikkanen, R. & Abram, M., 2020). The need to focus on community-wide preventive care is clear. As a nation, we keep spending on healthcare but are not reclaiming the value of our investment.
The Robert Wood Johnson Foundation, RWJF, the nation’s largest public health philanthropy, has long since recognized the need for a renewed focus on population health. In 2017, the RWJF published Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century. This report propelled the subsequent project, Nursing Education and the Path to Population Health Improvement, which explored nursing education models related to improving population health (“Campaign,” 2019). Recommendations produced through this project stated that population health should be addressed throughout a nursing curriculum and that understanding and assessing social determinants of health should begin early within a nursing program. The following core population health competencies for nurses were recommended:
- Policy – How health policy in this country affects health care and health outcomes.
- Epidemiology/biostatistics – Basic understanding of the distribution and determinants of health and illness across populations.
- Social determinants of health – Identification of SDOH and understanding of interventions and referrals needed to address them.
- Health equity – Using the social determinants of health as a framework, health equity—as a focus of health care—should be discussed throughout the curriculum.
- Interprofessional team-building and skills – Students need to understand the role of health and social service professionals in working together with individuals, families, and communities to improve health.
- Economics of health care – Students need to understand basic payment models for health care and how they affect services delivered and outcomes achieved.
- Systems thinking – Students need to have the ability to understand complex demands, on a large scale, and to develop solutions. They need to know systems theory and systemwide development strategy and have the skills to manage change. (p. 23)
As population health has become a focus of our global narrative in 2020, so too population health must be a cornerstone of our nursing curriculum. The population health competencies identified by the Robert Wood Johnson Foundation provide a guide of where and how to focus our nursing education efforts.
Practical steps forward to support population health within our classrooms and nursing programs include:
Curriculum review
As nurse educators, we can begin at the course-level to evaluate where we can incorporate population health competencies. It is equally important to broaden our scope and ask, at the program level, how are we preparing our nurses to recognize the indelible links between policy, systems, economics, social realities, and health outcomes?
Creating a course-by-course checklist to see when and where health policy, epidemiology, social determinants of health, health equity, interprofessional collaboration, economics, and systems-thinking have been and could be addressed is essential. This will reemphasize the good work we are doing and highlight opportunities for including community and population health in dialogues and clinical experiences with students.
Interprofessional communication
As we collectively look at population health competencies, we should seek guidance from one another, sharing through research and professional collaboration as a community of nurse educators. Learning from the successes of our peers so that we can effectively apply population health competencies in the classroom and in clinical environments will be a win-win for nursing students, nursing faculty, and nursing programs.
Relevant clinical application
We all know that students are busy and that they have many demands on their time and their mental energy. To keep the attention of students, it is important that we demonstrate the value of community and population health by making concepts relevant. This might take the form of fostering community partnerships and inviting community agencies to the classroom. This might include increasing clinical hours spent at local agencies that are focused on addressing social determinants of health. This might include organizing students to attend a policy day at the state capitol. The less abstract and more “real” we make population health, the more frequently students will look beyond a patient’s medical chart to comprehensively understand a patients health status and needs.
As an example of making class concepts relevant, faculty from my university took nursing students across state lines to Clarkson, Georgia, a town named “the most diverse square mile in America” by The New York Times. Clarkston is home to one of the largest populations of resettled refugees in the United States. The day trip included partnering with a local non-profit agency to learn more about refugees and refugee health, having meals and a round table discussion with local refugees, completing a simulation, and taking a tour of the town on foot. Students left with a great appreciation for the needs of this community and the needs of refugees at-large. Students commented that they better-understood concepts from class, such as cultural competency, and that the experience would positively impact their nursing practice. Real-life experiences are a high impact on our students.
Attitude
Passion is contagious. The more that we feel compelled to share with students about the importance of what we teach, the more they will want to learn. So, if teaching introductory epidemiology concepts, let your students know how and why they will benefit from the knowledge. If you are in a Med-Surg simulation lab, why not share with students about the cost of supplies and the economic impact of our healthcare decisions? And if you are in a clinical environment with a student and the patient details a complicated social history with many social barriers, then why not make social determinants of health and health equity key topics during debriefing?
In the wake of the Covid-19 pandemic, the time is now to best prepare our nursing students to be proficient in population health competencies. Whether they need practical skills in emergency and disaster preparedness to triage patients and safely use PPE, whether they need epidemiology and biostatistics to understand emerging research, whether they need to analyze new health policies, or if they need an enhanced focus on systems-level thinking to serve as leaders to address the complex challenges of Covid-19, the reality is that population health competencies are foundational for nurses. A recent survey conducted by the American Nurses Association stated that nurses overwhelmingly felt unprepared for the pandemic (ANA, 2020). While 87% of nurses surveyed said they feared going to work, only 11% felt well-prepared to care for a Covid-19 patient. While Covid-19 is a new disease with a steep learning curve on many fronts, the population health competencies that we foster in our students will be essential for navigating their new nursing roles in the context of a pandemic. As it was pre-pandemic and will always be, nurses who can care for patients AND for populations will pave the way towards a healthier tomorrow.
- American Nurses Association. (2020, April). Covid-19 survey: March 20-April 10. Nursing World. https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/education/innovation/
- Campaign for Action. (2019, March). Nursing education and the path to population health improvement. https://campaignforaction.org/wp-content/uploads/2019/03/NursingEducationPathtoHealthImprovement.pdf
- CMS. (2019, December 17). National health expenditure data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical#:~:text=U.S.%20health%20care%20spending%20grew,spending%20accounted%20for%2017.7%20percent.
- Tikkanen,R. & Abram, M. (2020). U.S. health care from a global perspective, 2019: Higher spending, worse outcomes? Commonwealth Fund. https://doi.org/10.26099/7avy-fc29
