Abstract
Nurses can play a substantial role in addressing social determinants of health (SDOH) through patient interactions and care; however, limited training opportunities exist for professional nurses on SDOH. The purpose of this project was to develop free online learning modules related to addressing SDOH in patient care and evaluate changes in competency levels. On average, professional nurses reported a 0.55-point increase in competency scores across SDOH topics encouraging the development of additional trainings related to SDOH.
Objectives
Describe the challenges related to training opportunities for nurses on the social and economic factors that impact patients’ health.
Explore the impact of free online learning modules related to addressing social determinants of health in nursing.
Identify the role of training and educational interventions available to professional nurses to increase knowledge and competence related to providing high-quality, person-centered care.
Introduction
Social determinants of health (SDOH) are the many social and economic factors that shape the conditions and places in which people live, work, learn, worship, play, and age.1,2 These determinants of health work together to impact health status. Nurses can play a substantial role in addressing SDOH through patient interactions and care. However, nurses encounter several barriers that impede their ability to address SDOH with their patients.
Perhaps one of the largest barriers to addressing SDOH in patient care is lack of training on how to communicate and address health-related social needs in patient interactions.3 -6 Some nurses report that they don’t know how to have these conversations with their patients due to a lack of knowledge on the SDOH, how to address them, and how to refer patients to appropriate resources.3,4,7 Other factors that also influence nurses from talking about SDOH-related health concerns such as time, competing care priorities, and lack of support from other healthcare workers.3,4
An SDOH competency survey of 690 practicing nurses identified the lowest self-reported competencies in addressing civic engagement, climate change, immigration status, interpersonal violence, and environmental health. 6 To address these gaps, we developed targeted educational interventions to improve nurses’ confidence in addressing SDOH.
This project aims to measure the change in self-reported competency among nurses in addressing SDOH in patient care following the completion of online continuing educational (CE) modules designed to train nurses on various social factors determining health outcomes.
Methods
This educational project was reviewed by the University’s Institutional Review Board (IRB) and deemed exempt. Participation in the online CE learning modules and evaluation survey was voluntary.
In Spring 2023, a team from a private university located in the Southeastern United States developed a self-assessment questionnaire to evaluate nursing professionals’ self-reported competency in addressing SDOH. 6 The SDOH competency survey was then distributed electronically via email listservs of nursing professionals primarily composed of contacts from an academic hospital, as well as from other listservs and practicing RNs who have participated in previous projects within our institution. The findings from the SDOH competency survey informed the development of a free online educational intervention designed to provide training on various SDOH topics. The responses were used to tailor the content of the CE modules to provide education on the SDOH topics that nurses reported having the lowest competency in addressing with patients. 6
The team that created the online CE learning modules included experts in SDOH, nursing, and nursing education, an instructional designer, and a team of evaluation experts. Using the results of the SDOH competency survey, 6 the team identified 5 SDOH topics RNs felt they were least competent in addressing in their clinical practice. These topics were: Civic Engagement, Climate Change, Immigration status, Interpersonal Violence, and Environmental Health. To ensure a comprehensive learning experience for continuing education, the team created 2 introductory modules that provided a complete overview of SDOH and Health Literacy as a primer for deeper learning in these 5 areas for a total of 8 modules in the educational intervention.
In response to recent bans on gender-affirming care, the team developed a web-based module to highlight the role of SDOH in healthcare access and to equip nurses with the knowledge and competencies to address the SDOH affecting LGBTQIA+ patients, it is essential that nurses understand the unique and intersecting SDOH that impact the health of LGBTQIA+ individuals and recognize the complex factors that must be considered when providing gender-affirming care and developing treatment plans. This module serves as a practical application of how SDOH intersect in gender-affirming care, and provides practice-based examples to guide clinicians in delivering equitable, affirming care.
Following the completion of each module, learners took a module-level knowledge check consisting of 5 to 8 questions. Learners must score 90% or higher on this knowledge check to move on to the evaluation survey and the next module in the learning program.
Learners’ perceived competency in addressing specific SDOH factors before and after completing the module was assessed retrospectively. 8 The evaluation survey also assessed participant satisfaction with the module using Net Promoter Score. 9 All responses were anonymous and confidential and used only for the purpose of improving the relevance and efficacy of these educational modules for nursing professionals.
Following completion of each module, respondents completed an evaluation survey using retrospective pre-post questions to reflect on their competency before and after taking the module. 8 For each assessed SDOH topic, participants ranked themselves along a 5-point scale (1 – Novice, 2 – Advanced beginner, 3 – Competent, 4 – Proficient and 5 – Expert). 10 This scale was adapted from Benner’s Novice to Expert scale. 10 The evaluation survey also assessed participant satisfaction with the modules using a Net Promoter Score, a measure to indicate if participants would recommend the CE modules to a friend or colleague. Scores range from −100 to 100 with a score of 50 being considered excellent. 9
Evaluation survey responses were cleaned for duplicate responses and analyzed using Excel and SPSS. Responses without corresponding demographic data were removed from the dataset as we could not confirm if they were a student or professional nurse (n = 326). This left us with a sample size of 913 evaluation survey responses representing 210 unique nurses. Responses on the Novice-Expert scale were weighed 1 to 5 and averaged across module and SDOH topic. One-tailed T-tests were conducted to compare the mean pre- and post-module competency scores of topics where they appeared in more than 1 module. T-tests were conducted in Excel for the 9 SDOH topics that occurred in more than 1 module. With a hypothesis that competency scores would only increase following completion of the educational intervention, a 1-tailed T-test was justified. Respondents were asked if they would recommend the module to peers and responses were converted to an aggregate Net Promoter Score.
Results
This study consists of 913 evaluation surveys submitted between August 2023 and March 2025 by professional nurses (n = 210). On average, each professional nurse completed 4.3 evaluation surveys. Among those who completed the evaluation surveys, the average age was 48.3 years old and 91% of respondents were female (Table 1). The majority of respondents identified as white (61%). Forty-four percent of professional nurses were registered nurses (RN) and 21% were nurse educators. Among respondents, professional nurses worked in academia, acute care, ambulatory care and other settings.
Respondent Demographics.
Professional nurses consistently ranked their competency with SDOH topics higher after completing the modules. On average, professional nurses saw a 0.59-point increase in competency scores (Table 2). Difference of means testing revealed that there was a significant difference in average competency scores following completion of the modules for language barriers (P-value .0002), access to primary health care (P-value .0003), health literacy (P-value .0001), access to nutritious foods (P-value .0435), income (P-value .0163), discrimination (P-value .0010), immigration status (P-value .0053), environmental conditions (P-value .0093), and housing situation (P-value .0033). The average pre-module competency scores for all SDOH topics fell within the competent range (3), while post-module average scores showed that 68% (13 out of 19) of the SDOH topic competencies reached the proficient range (4).
Average SDOH Topic Competency Scores Pre- and Post-Module.
Participants saw the highest increase in competency score after taking Module 3: Civic Engagement as a Social Determinant of Health: Empowering Registered Nurses (+0.84) and the lowest increase in competency score after taking Module 1: Bridging the gap: Assessing and Addressing SDOH in Your Nursing Practice (+0.50; Table 3). Difference of means testing revealed that 5 modules had a statistically significant increase in competency scores after taking the module.
Average Module Competency Scores and Net Promoter Scores.
Five of the 7 modules received a Net Promoter Score of ≥50: SDOH overview, health literacy, immigration, interpersonal violence, and environmental health (Table 3). Additionally, the self-paced, online format of the modules was well received, with nurses praising the content as clear, engaging, and directly applicable.
Discussion
SDOH competencies consistently improved by half a point following module completion. All SDOH topics had a pre-module competency score in between competent (3) and proficient (4) with 68% of topics (13 out of 19) having a post-module competency score above 4 meaning respondents were proficient in their understanding and ability to discuss SDOH topics. A score of 4 or higher indicates that the learner understands the full scope of the situation and can anticipate potential challenges while planning accordingly. This suggests the nurse is well prepared to address the patient’s needs. A score of 5 reflects an expert-level nurse with a profound understanding of the situation and the necessary skills to navigate it and provide high-quality care.
After completion of the online modules, only 5 respondents self-identified as ‘novice’ across all 23 SDOH topics. In fact, most RNs ranked themselves as proficient (4) for almost every SDOH topic pre-module and post-module.
Of the 6 modules with more than 1 SDOH topic, the difference in mean competency scores pre- and post-module was significant across all 6 modules, indicating that the modules were effective in increasing RN competency in the addressed SDOH topics. Furthermore, of the 9 SDOH topics that were addressed in more than 1 module, all had a statistically significant increase in mean competency score. Where nurses felt they had the lowest competencies, these modules were exceptionally successful at increasing their competencies.
The project builds on earlier work in which nurses reported low levels of confidence in addressing Civic Engagement, Climate Change, Immigration status, Interpersonal Violence, and Environmental Health. 6 This project found that all educational modules were successful in improving nurses’ competency in the addressed SDOH topics. Although the Civic Engagement and the Climate Change modules received the lowest pre-module competency scores, participants showed the greatest improvement in perceived competence following the Civic Engagement module. In contrast, the Climate Change module had the lowest post-module competency score. This underscores the importance of assessing gaps in competency and providing timely educational interventions to increase the confidence and competence of nurses in addressing social factors.
Low levels of knowledge and confidence have been reported as important barriers to practicing nurses’ ability to deliver high-quality, person-centered care that integrates assessments and interventions for SDOH.3,4 While schools of nursing have begun to incorporate SDOH competencies into prelicensure and graduate program curriculum, 11 practicing nurses may not have access to the educational resources needed to increase their competency for SDOH in the care of their patients. Continuing professional development is needed to strengthen nurses’ confidence and competence with the social factors affecting health. Nurses need to be better equipped with strategies and resources to address the complex social and societal issues faced by patients and communities.
Despite the promising results of this assessment, there are limitations to consider in evaluating results. The potential for response bias in self-reported survey data is a major limitation as several factors may bias responses. Response bias influenced by recall, personal and professional experience, and social desirability may have impacted these results. The first limitation that must be acknowledged is the self-report bias inherent in the respondents’ post-module competency scores. To mitigate potential response bias, this study utilized a retrospective pretest design asking participants to rate both their pre- and post-intervention status after the intervention. 8 Professional nurses competency scores reflect respondents’ perception, rather than an assessment of their interactions with patients before and after completion of the online modules. Furthermore, this score reflects an immediate reflection on skills, rather than allowing respondents to work with patients for a few months and then following up on how the module may or may not have influenced their practice. Thus, the post-module competency scores could be viewed as inflated.
Another potential limitation is that the knowledge check at the end of each module may limit the number of nurses who completed the evaluation survey. If professional nurses did not score 90% or higher on the knowledge check, they did not receive the evaluation survey for that module. This may lead to response bias, as we are not capturing evaluation data from nurses that did not pass the knowledge check therefore inflating the post-module competency scores.
Conclusion
Online self-paced learning is easily accessible by nurses. By providing free, online educational modules on Civic Engagement, Climate Change, Immigration status, LBGTQIA+ patient care, Interpersonal Violence, and Environmental Health, this project addressed topics identified as significant gaps in nurses’ knowledge on SDOH. 6 The results of this project suggest that the educational modules evaluated are effective for increasing RN knowledge and confidence to address SDOH. Efforts in the future should look to strengthen the educational interventions available to professional nurses. Increasing exposure to complex topics in more than 1 educational module, designing education consistent with nurses’ learning needs, and incorporating experiential learning, will improve professional nurses’ abilities to address SDOH factors in practice.
Footnotes
Acknowledgements
The project team would like to acknowledge the expertise and support from the subject matter experts who were responsible for developing the content for the training modules – Autherine Abiri, DNP, FNP-C, ENP-C, Dr. Lori Modley, DNP, RN, CPNP-PC, Rebekah Chance-Revels, RN, DNP, MPH, Jessica Mengistab, BSN, RN, Polyanna Heng, MN, Surafail Ambaye, MN, Crista Irwin, PhD, RN, Ashley Ruiz, PhD, RN, and Abby Mutic, PhD, CNM.
Ethical Considerations
This educational project was reviewed by Emory University’s Institutional Review Board (IRB) and deemed exempt.
Consent to Participate
Participation in the online CE learning modules and evaluation survey was voluntary.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $945,776.00 with 0% funded from non-governmental resources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Raw evaluation data were generated at Emory University. Deidentified data supporting the findings of this study are available from the corresponding author (JMP) on request.