Learner Response to an Activity Introducing Adverse Childhood Experiences as a Social Determinant of Health

Abstract

Background:

Threading content on the social determinants of health into the nursing curricula is a best practice recommended by certifying bodies; however, introducing content on social determinants of health can overwhelm learners, who may have difficulty relating the information to their nursing practice.

Method:

This article describes a learning strategy that used film and an experiential activity to introduce content on adverse childhood experiences, a “social determinant of health”, and resilience into nursing coursework. One hundred and thirty first-semester nursing students viewed the film in class and participated in a focused debrief and subsequent clinical exercise.

Results:

Participants (97%) agreed that the film appropriately introduced the content. Learners reported that the debrief was helpful in relieving distress, and 95% found the content relevant to their future nursing practice.

Conclusion:

Early introduction of key concepts related to adverse childhood experiences may assist prelicensure nursing students in developing a trauma-informed professional practice.

Introduction

The updated American Association of Colleges of Nursing core competencies for nursing education (2021) call for threading content related to the social determinants of health into curricula. “Social determinants of health” are defined as the conditions in the environments in which a person works, lives, plays, and ages (Office of Disease Prevention and Health Promotion, n.d.). Because inequities in social determinants of health contribute to inequities in health and health care, it is critical that nursing students are familiar with social determinants of health and learn to develop care strategies to address their influence. However, introducing social determinants of health content can be difficult and may leave students questioning how to incorporate this knowledge into their clinical practice. This article describes a learning activity that used film and a practical exercise to introduce content on adverse childhood experiences and resilience into coursework for first-semester nursing students.

Background

Adverse childhood experiences (also known as ACEs) are an example of a social determinant of health (Braveman et al., 2011). Examples of adverse childhood experiences include child abuse, parental mental illness, addiction, incarceration, and any intimate violence that may alter the body’s respones to stress and increase the risk for physical and mental health conditions. Depression, suicide, addiction, diabetes, cardiovascular disease, and cancer are examples of health conditions associated with adverse childhood experiences (Felitti et al., 1998; Gilbert et al., 2015; Jakubowski et al., 2018).

Data from large population-representative studies suggest that adverse childhood experiences are common, with at least 50% of the population experiencing at least one (Gilbert et al., 2015; Jakubowski et al., 2018). As front-line health professionals who provide care in nearly every setting, nurses should be aware of how these experiences may affect health and wellness (Gill et al., 2019; Girouard & Bailey, 2017; McKee-Lopez et al., 2019; Oral et al., 2016) and should understand that experiences in health care settings can retraumatize individuals with a history of adverse childhood experiences (Reeves, 2015). New nurses should begin their career practicing trauma-informed care that is supported by awareness of the pervasiveness of adverse childhood experiences and other traumas. Gill and colleagues (2019) recommend introducing this important topic in the first-semester curricula; however, specific instructional techniques and strategies are needed. Our team (a) considered how best to present content on adverse childhood experiences to nursing students, and (b) created a clinical learning opportunity to allow application of the learned content. The decision was made to use a film to enhance students’ affective learning experience.

Use of Film in Nursing Education

Film and film clips have been used successfully in nursing education to discuss growth and development, mental health, and end-of-life care (DiBartolo & Seldomridge, 2009; Hyde & Fife, 2005; Kerber et al., 2004; Oh & Steefel, 2016). A recent review of teaching strategies for using film with prelicensure nursing students identified three common types of useful activities: reflective, practical, and evaluative (Oh et al., 2013). Reflective activities (e.g., postfilm discussion, role-playing, writing exercises) are commonly used to stimulate critical thinking and help students understand complicated human behavior and experiences. Practical activities allow learners to apply new knowledge, a critical step in knowledge retention and mastery. Evaluative activities are necessary to gauge the effectiveness of learning methods and may consist of class evaluation or attitudinal surveys if the goal is to shift students’ attitudes about a subject.

Implementing the Learning Activity

The learning activity was divided into two parts: Students (1) watched and discussed the Resilience film to learn about the impact of adverse childhood experiences, and (2) created a wellness fair for four local elementary schools. The institutional review board determined that this educational activity was exempt from IRB approval. Learners in the nursing course were informed that knowledge gained from this learning activity would be shared with other educators. Learners provided written consent for their evaluation and feedback to be shared in aggregate form.

Part 1: Viewing the Resilience Film and Related Student Outcomes

“Resilience” is a 60-minute film produced by KPJR films (Redford, 2016) that examines the physiological consequences of toxic stress caused by adverse childhood experiences with an emphasis on efforts by education and health care professionals to identify protective factors that promote resilience. After reflecting on our past experiences of having asked students to view the film outside the classroom, the decision was made to hold an in-class viewing. Showing the video in class met two objectives: (1) all learners viewed the film, and (2) it was possible to tap the immediacy of learners’ emotions after watching the film.

An essential part of using film in education is providing an opportunity to process what has been seen and heard collectively (Oh et al., 2013). Discussion prompts derived from the facilitator’s guide that accompanies the film were supplemented with material based on the most recent literature on adverse childhood experiences and resilience. Introducing the concept of trauma-informed care during the debrief helped the students to connect the film with their future nursing practice. Understanding the health effects of trauma constitutes a foundational part of the trauma-informed care pyramid (Raja et al., 2015) and prepares future nurses to address social determinants of health.

Acceptability of the Film and Student Comments

Almost all of the 130 nursing students (97%) approved of the use of the film to introduce this content. In the evaluation survey, 91% of the nursing students indicated that the post-film discussion was an essential part of their learning process. The majority of the students (95%) identified the content as beneficial for their personal or professional life and future nursing practice. A word cloud was used to gauge student perception prior to and immediately following the learning activity. The pre-class word cloud included many negative words, such as crying, drowning, crippling, and loneliness, but none that alluded to resilience or compassion. The post-class word cloud was very different; several high frequency words emerged: “exponential,” “chronic,” “systemic,” “misunderstood,” and “support.” “Exponential” and “systemic” reflected a new awareness of the prevalence of adverse childhood experiences, but words like “misunderstood,” “support,” and “buffers” added aspects of resilience and compassion that were absent in the pre-class word cloud.

Part 2: The Wellness Fairs

To support efforts to build resiliency in the local community, we partnered with four after-school programs at local public elementary schools to present a series of wellness fairs. Based on the resiliency literature, the nursing faculty selected six themes for presentation at the fairs: physical activity, relationship building (e.g., friendships), nutrition, expressing emotions, sleep, and mindfulness. The nursing students considered the developmental age of the public-school students in the after-school programs and created 10-minute interactive experiences representing each assigned resilience theme. The course faculty reviewed and approved the suitability of their lesson plan, SMART objectives, and the clarity of their descriptions of the planned activities. The wellness fair after-school student participants rotated through each of the six thematic stations, which were run by the nursing students.

The course faculty observed that the nursing students incorporated learned material about themes in the film into their interactions with the elementary school children. For example, faculty noticed that the nursing students encouraged after-school students to “speak up when things are not OK,” and asked what they already knew about each topic before beginning their teaching. Immediately following the wellness fairs, nursing students completed a verbal debrief with course faculty. Two themes that emerged were (a) increased appreciation of the children’s awareness of stress and (b) improved interpersonal skills related to flexibility and teamwork. Nursing students frequently expressed surprise that children are aware of stress in the home and community. Discussions of the learning activities about sleep sometimes elicited comments regarding environmental challenges to sleep, such as shared beds and bedrooms, and neighborhood noise. During discussions of health fair activities related to stress and relaxation, participants occasionally commented on financial worries in the children’s homes. For some prelicensure nursing students, the discussion provided a unique insight into the stress and adversity that begins early in life for some children. The debrief provided space for learners to reflect on their feelings after having heard difficult information from children and to appreciate the potential affect and importance of providing them with developmentally appropriate education on stress reduction techniques to promote resilience. The learners identified intersections between social determinants (e.g., poverty and adverse childhood experiences) and articulated the impact of social determinants of health on the elementary students.

Somewhat unexpected themes that emerged during the wellness fair debrief were group cohesion and the development of essential interpersonal skills for future nurses. The learners applauded one another for engaging fully with the learning activity, remaining flexible, and rearranging responsibilities intuitively in response to changes in participants’ plans and needs. One group provided a specific example of adaptiveness and flexibility: When it became evident that a child was having a hard time finding a partner for a group activity, three nursing students rearranged the plan so that one of them could partner with the child while the other two carried on with facilitating the activity. In addition, students commented that teamwork is an essential interpersonal skill for nurses and reflected on how they had demonstrated compassion in their responses to the children and one another.

Discussion

This experiential learning activity aimed to introduce first-semester nursing students to the effects of social determinants of health on health outcomes. By utilizing the film, “Resilience”, and school wellness fairs that had a thematic emphasis on promoting resilience, the students were able to experience “real life” applications of social determinants of health in clinical practice. Learners found the use of the Resilience film and the post-film debrief suitable for navigating the difficult topic of toxic stress and adverse childhood experiences. They also recognized the relevance of these topics to their future nursing practice. The description of this learning activity provides a template that nursing educators can integrate into existing courses to address topics related to social determinants of health and/or prepare nursing students to build a trauma-informed practice.

The evaluation of the learning activity showed that viewing the film caused distress for some learners, but this distress did not persist during the post-film debrief. Learners were provided with examples of self-care activities and were reminded of available counseling resources on campus. Almost all learners agreed that the use of the film and debrief was an appropriate strategy for introducing this content. Timing of this content during the semester was an important consideration as well. Implementing adverse childhood experiences education into the first semester prepares nursing students to build on this knowledge in subsequent courses; however, this content was intentionally scheduled towards the end of the first semester to permit the class to build cohesiveness and trust before addressing a topic that can be emotionally difficult. Due to the potential for the activity to cause distress, having learners view the film together in class was considered better than assigning it to be viewed independently. The evaluation from learners suggested that the in-class format was appropriate, and one learner commented, “[students are] too likely to skip presentations offered outside of class, and this is too important [to skip].” In addition, the post-discussion word cloud provided a rough measure of the knowledge that learners had gained during the activity and was a tool to identify any overall distress.

The post-film discussion and debrief were essential components of the learning activity because they allowed learners to (a) process emotions, (b) identify knowledge gained, and (c) close any gaps in knowledge regarding adverse childhood experiences and resilience. In leading the discussion, it was important for faculty to recognize each learner’s autonomy and respect that some learners might avoid engaging in the discussion as a self-protective action (Carello & Butler, 2015). Preparing and teaching classes about toxic stress can trigger educators who have personally experienced trauma; therefore, it is critical, both for learners and educators, that the class discussion and debrief emphasize concepts related to resilience and plasticity (i.e., the ability for the nervous system to grow and adapt) in order to counter erroneous notions that childhood adversities are deterministic (Shonkoff & Garner, 2012).

Incorporating after-school wellness fairs added an active learning aspect that demonstrated the effect of social determinants of health and provided an intervention for nursing students to support improved health outcomes for the students. Experiential learning activities allow learners to apply classroom education in the real world, further cementing knowledge gained; however, it is often during the process of reflection on the experience that significant learning occurs (Brackenreg, 2004). In the community health fairs debrief, the nursing students began to synthesize their understanding of the amount of development that occurs during childhood as well as the extent to which stress and adversity early in life can disrupt the typical process of child development. Learners discussed skills such as their ability to work as a nursing team, to innovate learning activities in the moment, and to remain flexible during the organized chaos of an after-school health fair, although these topics were not a primary focus of the learning activity. Experiential learning can be transformative for nursing students (Kear, 2013); several students expressed their intent to explore trauma-informed nursing care in greater depth independently, which suggests that the activity prompted a possibly transformative curiosity and openness to further learning.

Conclusion

Social determinants of health, including exposure to adverse childhood experiences and toxic stress, have a significant impact on health and wellness, a finding that is prompting an increasing number of health care environments to embrace trauma-informed care (Oral et al., 2016). Using film as a pedagogical tool to expose first-semester nursing students to the concepts of adverse childhood experiences and resilience is acceptable to learners, feasible for educators to implement, and lays the foundation for students to gain confidence in implementing trauma-informed approaches. Integrating activities that help students to understand the impact of social determinants of health is vital to addressing health inequities and ensuring that graduate nurses are prepared to deliver quality nursing care in the 21^st century.