Social Justice in Nursing Education: Leap into Action

Objective: Nursing students must be educated on their role in creating a social justice agenda in healthcare; therefore, academia must establish effective methods to teach these essential concepts. The purpose of this study is to explore the impact of an integrated approach to learning social justice. This research provides evidence of the potential efficacy and utility of interactive teaching strategies in the affective domain of nursing students. Methods: The intervention, select affective pedagogical strategies, was designed to integrate content into each semester of the undergraduate nursing curriculum, each were interactive in nature and enhanced the affective learning for the student. The approach aimed at integration of these strategies in a way that decreased further burden for faculty, yet created an environment that enhances the understanding of social justice. Using a pre/posttest design, this study administered the Social Justice Attitudes Scale (SJS), a 24-item questionnaire which is categorized into four sub-scales. A sample of 86 undergraduate nursing students completed the pre-test in the first semester of their nursing program and the post-test in the final semester of their nursing program. Results: The Paired Wilcoxon Rank Sum test was conducted to determine the difference between the pre-test median and the post-test median for each of the four subscales of the SJS; significance set at an alpha of 0.05, all four statistical analyses resulted in a p=<0.001. Conclusion: Reviewing pedagogy in nursing curriculum is an arduous task, but is necessary in order to understand instances in which courses may be lacking in socializing nursing students to the importance of professional nursing values, such as social justice. Integrating affective pedagogical strategies across the continuum of a baccalaureate nursing program has the potential to improve knowledge and intention to act regarding social justice.


Introduction
Although social justice is clearly defined by the American Nurses Association (ANA) and the American Association of Colleges of Nursing (AACN) as an essential nursing value, this definition does not provide direction as to the best pedagogical strategies to foster understanding of the social justice imperative for new graduate nurses. It is not simply enough to understand the meaning of social justice and its importance in health care, but students must be equipped to advocate for change and work toward social equity in all patient care scenarios. Research in the past decade has evaluated the efficacy by which nurse educators have taught professional nursing values, including social justice, and the methods by which academics have attempted to impart these concepts. There remains a dearth of literature identifying didactic methods that can foster social justice thinking and inspire students toward the goal of advocacy and implementing change.

Study Purpose
The purpose of this study is to explore the impact of an integrated approach to learning social justice within undergraduate nursing education. This research will provide evidence of the potential efficacy and utility of interactive teaching strategies in the affective domain of nursing students. The results of this research may provide guidance for school of nursing faculty in future curriculum planning and implementation of pedagogy relative to issues of social justice and diversity competence.

Review of Literature
The AACN [1] definition of social justice as "acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability or sexual orientation" serves as the foundation for this research endeavor. Defined as one of the core nursing values, social justice is a concept that provides the foundation for professionalism within nursing; how nurse educators cultivate this value needs further exploration. Unlike nursing practice skills, which can be measured objectively, professional values are difficult to evaluate as students become socialized in the art and science of nursing. Educators using traditional lecture format are limited in their ability to teach such abstract concepts, but it is essential that students begin to evaluate their moral framework so they are equipped to care and advocate for all patient populations. The uses of affective learning strategies such as reflective activities, and simulations that evoke emotional responses allow nurse educators to create a learning environment in which students begin to engage in self-reflection and develop the knowledge and skills that can create positive change in our society. These approaches elicit feelings that are sometimes uncomfortable for students, but they can also enhance the identification of social inequality from a different viewpoint, creating a new context for understanding the importance of action when presented with social injustice in the health care setting. To successfully disseminate this important concept to graduate nurses, nursing faculty must use a variety of pedagogical strategies which focus on behavior and behavior changes. Jones-Schenk [2] posits "Influencing the affective domain is one of the most complex and difficult teachinglearning aspects. Influencing substantive behavioral changes is some of the most important work educators do".
Affective teaching focuses on values, attitudes, and behaviors, and therefore is an ideal pedagogical strategy when discussing social justice [3,4]. Shown to improve nursing students' understanding as well as application of professional values including social justice [5] affective teaching strategies utilize critical-thinking, self-reflection, emotional response, ethics, personal awareness and attitudes [4]. Affective teaching strategies stimulate humanistic characteristics such as spirituality and diversity, and promote responsibility for therapeutic interventions [6]. Further, Doyle [7] states affective learning has the potential to influence the care students provide to patients.
When implemented, affective teaching strategies have the capacity to influence self-awareness, foster effective self-reflection techniques [8] and integrate academic knowledge with practical application [9]. Using Bloom's Taxonomy of Learning in the Affective Domain, affective learning outcomes can be stratified into five levels of learning: receiving, responding, valuing, organizing, and internalizing [9]. Activities created to increase nursing students' understanding and application of social justice actions aim to advance the student into the highest level of the taxonomy, internalizing, which promotes commitment and incorporation into practice.
There remain gaps in the research literature regarding the concept of social justice, and the best teaching strategies to be used in order to generate knowledge and action by nursing students. Nurse academicians must continue to evaluate curriculum and pedagogy in order to ensure that they fully support the AACN Baccalaureate Essentials recommendations regarding professional nursing values. This research further adds to an original qualitative study evaluating the impact of affective learning strategies on the social justice development of undergraduate nursing students [10]. To further address these gaps, affective interventions were conducted throughout an entire five semester undergraduate nursing program, and statistical measurement including descriptive statistics and nonparametric testing to evaluate student responses was utilized to determine the effects of these interventions on the attitudes of nursing students regarding social justice.

Participants
Information for this research was obtained from a sample of 86 undergraduate nursing students at a public school of nursing in the Rocky Mountain region from August, 2014 to May, 2016. Approval was received from the Institutional Review Board for the Ethical Conduct of Research Committee at the university where the study was conducted. Students were invited to participate in the first semester of the nursing program. These students enter their nursing program after approximately two years of general education requirements. All participants were ensured confidentiality, and were instructed to devise a four digit code to use for both the pre and post-test, so that researchers were not able to discern their identity.

Survey instrument
Permission to use the Social Justice Attitudes Scale (SJS) was obtained from the original author [11]. The 24-item SJS is used to measure constructs that might be predictive of social justice-related behaviors. The SJS ask the participants to indicate how important or how much they value each activity and measures each item with a seven point Likert type scale (ranging from 1-Strongly Disagree to 7-Strongly Agree). Each item in the scale is further broken down into four subscales: social justice attitudes, social justice perceived behavioral control, social justice subjective norms, and social justice behavioral intentions [11]. The SJS tool evidenced good reliability with the original sample, with Cronbach's alphas of the subscales between a=0.82 and a=0.95. See Table 1 for sample questions within the four subscales of the SJS tool.

Subscale Sample Questions
Social Justice Attitudes I believe that it is important to respect and appreciate people's diverse social identities.
I believe that it is important to promote the physical and emotional well-being of individuals and groups.
I believe that it is important to act for social justice.
Perceived Behavioral Control around Social Justice I am certain that I possess an ability to work with individuals and groups in ways that are empowering.
I feel confident in my ability to talk to others about social injustices and the impact of social conditions on health and wellbeing.
I am certain that if I try, I can have a positive impact on my community.
Subjective Norms around Social Justice Other people around me feel that it is important to engage in dialogue around societal injustices.
Other people around me are aware supportive of efforts that promote social justice. Other people around me are aware of issues of social injustices and power inequalities in our society.

Intentions to Engage in Social Justice
In the future, I intend to talk with others about social power inequalities, social injustices, and the impact of social forces on health and well-being.
In the future, I intend to engage in activities that will promote social justice.
In the future, I intend to work collaboratively with others so that they can define their own problems and build their own capacity to solve problems.

Research design
This study was a pre-test post-test intervention design. The SJS survey was disseminated in their first semester nursing foundations course prior to the intervention, and completion of the survey was considered consent for participation in the study. Students participated in foundations courses in which the intervention was employed for the duration of their nursing program, a total of five semesters. The intervention, explained in detail, was a combination of interactive pedagogical strategies, each 30-45 min in length, which were designed to teach students about the concepts of social justice in the affective domain. This set of teaching strategies was used with all nursing students within the undergraduate nursing program during this two year time period, but students were given the option to participate in the research study; they were informed that non-participation would have no impact on their course grades. Students were then asked to complete the SJS survey again in their fifth semester foundations class after the last teaching session had occurred.

Data analysis
The data was analyzed using SPSS 24.0. Data analysis began with computation and analysis of the descriptive statistics and evaluation of the distribution of the data for each demographic variable. Inter-item coefficients were calculated for each subscale to evaluate the extent to which each item related to other items within the survey and the Cronbach alpha was determined. A Type I error of 0.05 was used for all tests of statistical significance. Data distributions were evaluated for excessive non-normality. Parametric or nonparametric statistical methods were used based on standard assumptions [12].

Intervention -Innovative pedagogical strategies
In order to maximize the amount of exposure to the concept of social justice, strategies were developed for integration into every semester of an undergraduate nursing program. Emphasis was placed on the need to minimize didactic lecture and enhance the learning experience through student engagement. Using affective learning strategies, the faculty worked to capture the learners' attention through various experiences. These strategies included challenging students' preconceived notions and compelling students to explore their own raw emotions related to topics of social injustice. The focus of this pedagogy was to foster greater awareness of social injustice and promote the possibility of action in situations of inequality in the healthcare setting. To reach this goal, the acronym LEAP was created to serve as the framework for implementation of social justice teaching strategies. LEAP stands for: Lose the Lecture; Engage the Learner, Affective strategies, and Planning and organization are key to success. Figure 1 is a pictorial representation of the LEAP concept. One of the most basic aspects of this pedagogy is to Lose the lecture, or avoid this traditional teaching method; this is based on historical research that lecture is largely ineffective in teaching abstract concepts such as social justice [13]. This pedagogical perspective is based on the concept analysis of Bernard [14] and the emphasis on student engagement within the classroom. The second element of LEAP highlights the importance of Engaging students, promoting active learning strategies aimed at involving students within the learning process. Research has indicated active learning strategies generate high levels of student engagement; research also indicates that nursing students report perceptions that, compared to other majors, nursing programs are more academically challenging but less engaging in student centered and interactive learning [14]. Next, Affective learning strategies are essential to create an emotional context for learning. Newman and Forsyth [5] demonstrated that affective learning has a greater potential to formulate meaning for the learner of complex social issues. Finally, Planning and implementation are keys to the success of the nursing graduate; once students have developed a greater understanding of social justice issues, they must be coached to engage in such activities and identify ways to personally implement change in healthcare.
To implement the LEAP intervention, the pedagogical strategies were integrated in short time periods (30-45 min) during each semester of the nursing program with the express intent that faculty would be able to conduct these strategies independently in future semesters; ensuring continuation of the emphasis on teaching the core concepts of social justice. Students were given instruction by the lead researchers that the intervention each semester would be conducted in a "safe" environment and that it was essential that students understood their opinions and comments would be respected and they should feel At the beginning of the implementation process, students are just entering the nursing program with varied levels of understanding related to patient relationships and healthcare dynamics. Therefore, it is challenging to find a common experience with which students can relate to the concepts and each other. Pop culture, or the popular visual and auditory media including movies, books, and television, is largely familiar within American society and provides a medium from which to identify situations that exemplify social justice or injustice. The initial strategy, titled Pop Culture Blitz, presents the definition and constructs of social justice and students are asked to recall specific pop culture references that display social justice or injustice. Students work in groups to brainstorm and share their most poignant examples with their peers, and then share the most striking example with the entire class. Groups share why the pop culture reference exemplifies social justice or injustice, and are then asked to reflect how the story's protagonist or antagonist contributes to the resolution of the scenario. Following this activity, movie clips are shown from The Hunger Games and Dallas Buyers Club; scenes are chosen that highlight gross social injustice in a fictional setting followed by a clip regarding the actual injustices that can occur in a health care setting. These scenes are provocative and potentially emotionally charged. Students are asked to reflect on the emotions elicited by these storylines.
The next strategy is implemented after the students have worked within a clinical practicum for several weeks; they are forming an initial understanding of health care environments and the role of the nurse in patient care. Stressing the importance of a safe environment for all involved, students are asked to participate in The "But" Game. This strategy presents the students with introductory statements regarding specific patient populations and scenarios, and then asks students to call out some of the stereotypical, potentially inflammatory remarks that they themselves think of, or remarks students speculate others might say. Statements include: "I know my homeless patient should have the best possible care, but…", "My Spanish-speaking-only patient needs good discharge instructions, but…. ", "My chronic alcoholic patient deserves compassion from caregivers, but…", "My lesbian patient requires assistance with bathing, but…" and "My noncompliant diabetic patient needs education regarding diabetes, but…" Following the call-out session, students are engaged in discussion about self-reflection regarding bias, stereotypes and the potential negative effect these actions can have on social justice in the health care system. Finally, the students are challenged to view patients as individuals instead of as diagnoses and discuss the effect of referring to a patient as "my homeless patient" versus "my patient who is homeless".
The third strategy, titled Tell Me About is a small group exercise; students are assigned one photo of a person and asked, as a small group, to create a story about the person's healthcare needs, including any barriers to care. Groups then share their picture and their story with the rest of the class. Pictures include a young white woman with black hair, black clothes, black make-up and facial piercings; a middleaged, well groomed, African-American man wearing a pink sweater; a middle aged white woman wearing an expensive looking suit; and a young white man, unshaven, wearing ragged, dirty clothing and sitting on the ground in an urban setting. After sharing fabricated stories, the class as a whole discusses if perceived barriers are probable, if they are accurate, and if they are changeable. Students are encouraged to discuss what they, as future nurses, can do to overcome barriers to equitable health care. Finally, an alternate story for each picture is given to the students. For example, the young woman in black contracted malaria during a volunteer mission to South America and had difficulty finding a reputable doctor while overseas; the middleaged African American man wants to discharge early after an orthopedic surgery as he is the sole provider for his wife and children and cannot miss much work; the middle-aged white woman is a stayat-home mom with chronic pain, has a pain contract with her primary care provider but has increased pain, and has dressed up to feel empowered to come to the Emergency Department asking for opioids; and the young white man is a freelance photojournalist who has been diagnosed with idiopathic anemia and he has lost his apartment due to financial stressors from overwhelming medical bills. Students are asked if they feel different about the fabricated patients given a different story, and encouraged to reflect on the complexity and variance of individual patients and patient barriers [10].
Although most strategies take an hour or less and can be inserted into didactic lecture time, the fourth semester LEAP activity is the Missouri Action Poverty Simulation [15], a large scale activity that serves 50-75 students, lasts approximately 4 h and requires a significant amount of faculty or volunteer staffing. Students are placed in mock families and given a description of their lives, incomes, financial responsibilities and community support options. A 15 min block of time represents one simulated week and students attempt to survive for one month by obtaining or keeping jobs to pay bills and financial demands amidst the hardships that often accompany poverty. A debriefing follows the simulation to explore concepts such as student feelings after experiencing financial struggles, the concept of poverty and the hardships involved with escaping economic disparity.
The final strategy, Social Justice Reflection, occurs in the students' last semester in the nursing program while they are in their final extensive clinical practicum. Students write a reflection paper on a situation they have personally encountered in the health care setting in which the health care team provided, or failed to provide, an environment supporting social justice. As a part of this reflection, they are asked to describe how they felt during the situation, and how they feel about it today. This paper also requires students to reflect and write about personal strengths that allow provision of care based on the foundation of social justice and personal limitations that may hinder optimal care. Students bring the papers to class and discuss them in small groups with peers and small groups identify one powerful story to share with the large group. The students are encouraged to share how they might emulate or correct the situation in the future. As this exercise has the potential to bring up societal injustices such as health care disparities of the homeless or federal medical support, a discussion occurs about student's perception of the nurse's role and responsibility in social justice at the bedside, in a healthcare system, in the local community, at the state and national level, and globally. The "But" Game Brainstorm common stereotypes related to populations who are likely to experience injustices in healthcare setting, i.e., "Spanish Speaking patients should get good DC planning, BUT…" Self-reflection and small and large group discussion

Tell Me About
Students fabricate a story based on a photo provided, including barriers to care their "patient" may have.
Self-reflection and group discussion on stereotypes and relation to barriers to care 4 Poverty Simulation Students act out a month of poverty, including budgeting money, managing hardships common for those in poverty.
Simulation: experiential learning of poverty 5 Social Justice Reflection Paper describing a witnessed event of social justice or injustice, and how the student did act or plans to act in such situations in the future to promote social justice for patients.
Self-reflection and contemplation of action on social justice in nursing practice.

Descriptive summary of the sample
The participants for this study totalled 86 undergraduate nursing students, and the average age of the student was 25.7 (SD=7.33). The sample consisted of 74 women (86.0%) and 12 men (14.0%). A majority (61.6%, n=53) of the students reported growing up in suburban neighbourhoods, while 22.1% (n=19) grew up rurally and 15.1% (n=13) were raised in urban environments. The self-reported socioeconomic status of participants was 19.8% (n=17) upper middle class, 61.6% (n=53) middle class, 17.4% (n=15) lower middle class and one participant (1.2%) reported growing up in a poor family. As shown in Table 3, the demographics of the convenience sample were homogenous and representative of the Rocky Mountain region in which the school of nursing is located.  Cronbach's α inter-item coefficients were calculated for each subscale to evaluate the extent to which each item related to the rest of the items on the survey. Cronbach α ranged from α=0.802 to α=0.871 for each of the four subscales within the SJS, demonstrating good inter-item reliability. For the Social Justice Attitudes subscale, the Cronbach α was 0.868; Perceived Behavioral Control around Social Justice had a Cronbach α of 0.819; Societal Norms around Social Justice Cronbach α was 0.802, and Intentions to Engage in Social Justice had a Cronbach α of 0.871. These results are consistent with the original psychometric evaluation of the SJS tool; the internal consistency computed for each subscale was attitudes α=0.95, perceived behavioral control α=0.84, societal norms α=0.82, and intentions to engage α=0.88 [11].
Based on the non-normal distribution of the data, a Paired Wilcoxon Rank Sum test was conducted to determine the difference between the pre-test median and the post-test median for each of the four subscales of the SJS. Significance was set at an alpha of 0.05. For the subscale Social Justice Attitudes, p=<0.001. For the subscale Perceived Behavior Control, p=<0.001. Evaluating the Societal Norms subscale, p=<0.001. Finally, for the subscale, Intent to Engage, p=<0.001. For each subscale of the SJS tool, the researchers were able to reject the null hypothesis. Statistical significance in the subscale of Social Justice Attitudes demonstrates that students specifically endorsed the social justice values, goals and behaviors including empowering patients and facilitating access to resources in order to maximize patient autonomy [11]. The subscale of Perceived Behavioral Control also generated statistically significant results; focusing on student self-perception of the ability to develop specific goals for social justice activities rather than simply articulating self-efficacy in this subscale [11]. Statistical significance in the subscale of Societal Norms emphasizes the self-perceived ability of nursing students to engage in environments that support social justice-related activities [11]. Finally, the subscale of Intent to Engage also generated statistical significance. This subscale accentuates the positive behavior change anticipated by these students as they made individual plans to engage in social justice-related activities in the future [11].

Discussion
The results of this research demonstrate the positive implications of integrating social justice-related content throughout an undergraduate nursing curriculum. Through the progression of this research endeavor, four critical elements surfaced that highlight the potential for greater success in promoting the professional nursing values. First, the use of affective learning strategies is essential to engage the students and create learning that is connected with emotions. These strategies must be integrated throughout the entire curriculum in order to thread these important concepts within every semester of the learning process. Students should also be given the opportunity to reflect on their beliefs and emotions as they proceed through the learning process. This reflective process enables students to bridge any disconnects that they encounter regarding their own thoughts of social justice and promoting their ability to understand inequities in our society and the role they can play in advocating for the marginalized. Finally, social justice cannot simply be taught through traditional lecture; educators are charged with creating environments that challenge the status quo and foster student action. These four elements were also found intertwined within the literature, creating support for this research.

Affective learning strategies
While most educators would agree that social justice thinking is essential for baccalaureate nursing graduates, academia remains uncertain as to the best strategy to teach social justice, and fully understands that knowledge does not necessarily transfer to practice. The results of this research highlight the strong potential for affective learning strategies to influence attitudes promoting social justice; more importantly, these strategies may have the capacity to enhance students' perceptions that they can make a difference in advocating for marginalized patients. This affirms the research conducted by Jones-Schenk [2] and the idea that targeting the affective domain has the opportunity to influence the development of empathy and enhanced social cognition. In order for nurses to act as proponents for social equality, they must be given repeated exposure to social justice concepts, opportunities to reflect on personal values and opinions and guidance on how to anticipate challenges and reaction strategies that promote social justice.

Integration throughout curriculum
This research highlights the necessity of implementing the professional nursing values, such as social justice, across the spectrum of the curriculum. This cannot occur in a haphazard manner, and faculty must be dedicated to the importance of critically examining curriculum, with the focus on identifying deficiencies related to core concepts. Integration of professional nursing values takes time and the effort of multiple faculty members. Betancourt et al. [16] assert that nursing academics are in a "prime position to cultivate leadership for social change through intentional student programs" aimed at understanding the essential nature of social justice and health equity. Yanicki et al. [17] also placed a Call to Action for nursing, stating that a greater emphasis on social justice must be made within nursing curricula. Nurse educators must be able to critically evaluate nursing curriculum, identifying potential deficiencies and shortcomings related to professional nursing values and the emphasis on such core nursing competencies.

Student reflection
One of the poignant elements of these research results also points to the reported ability of reflective strategies to further solidify learning throughout the academic process. Integrated within the pedagogical strategies of this research, there were multiple opportunities for students to reflect on new information and evolving self-perceptions. Reflective activities occurred both for the individual, small groups and large group settings. Using various methodologies for reflection was affirmed in the research by Conte [18] in which she asserted that discussions, verbal and written reflections are all necessary in order to process new understanding of situations. Enforcing the premise that reflections would occur in a safe and judgement-free environment, students were encouraged to share their thoughts and feelings, regardless of the potentially controversial nature of their comments. This further supports the research by Blanchet Garneau [19] which posits that reflection has the potential to improve cultural competence and nursing care. Hopkins and Domingue [20] also discuss the use of group dialogue "to strengthen individual and collective capacities to foster social justice commitments by supporting new ways of thinking about oneself, others and the social structures in which we live".

Promoting action
Knowledge and understanding of social justice concepts are a requisite for nursing professional practice, but there also must be the capability of new graduates to identify situations in which there is social injustice and a steadfast desire to intervene on behalf of those facing those inequities. Adelman et al. [21] discussed the idea of students being moved to act and organize against the persistence of domestic violence within a social justice framework; the assertion of Adelman et al. is that affective pedagogy, specifically educational simulations, are useful in preparing students to not only gain knowledge, but be more prepared to act on behalf of others. This research presents educators' ability to ensure nursing students have this essential framework for practice, as well as the possibility of promoting action on the part of these nursing students or graduates to actively involve themselves in advocacy issues. The final subscale of the SJS tool [11] is the Intentions to Engage in Social Justice. In this element of the tool, participants were asked about their future willingness to engage in activities that promote social justice and work collaboratively with others to define problems and work toward solutions for such problems. Following the interventions of this research, participants' responses were significantly higher in this particular area, creating optimism that knowledge will transfer to practice and that these nurses will enter health care more equipped to work toward a social justice agenda.
Limitations of the current research study are the relative homogeneity of the participants. The demographic make-up of the sample is indicative of the school of nursing relative to gender, ethnic, and socioeconomic distribution, but the data generated from this study sample may not be representative of the general nursing population. Another limitation is the time period over which the interventions were employed; students were actively engaged in additional didactic and clinical experiences, and the change in their social justice attitudes cannot be solely linked to the affective learning strategies conducted in this study.
In combination with previous qualitative research on this topic [10], there is adequate evidence that affective learning strategies have the capacity to change nursing students' perceptions about social justice and their power to act on behalf of others. Future research can further evaluate the integration of professional nursing concepts within undergraduate nursing curriculum; including the development of service learning opportunities that may strengthen the curricular emphasis on social justice. Research conducted with faculty may also shed insight into their perceived challenges of fostering social justice thinking within graduates and the struggles in mentoring this type of behavior.

Conclusion
This research highlights the impact that nursing curricular threads can have on the future nurses and their dedication to the professional nursing values. Reviewing pedagogy in nursing curriculum is an arduous task, but is necessary in order to understand instances in which courses may be lacking in socializing nursing students to the importance of professional nursing values. Without these core concepts as a foundation for practice, educators are simply preparing taskoriented nurses, lacking the understanding of the true art of nursing. Nurses have immense potential to advocate for the marginalized in our society and those skills must be taught and mentored throughout undergraduate nursing programs if there is any hope to change societal norms and create equity. That responsibility lies in the hands of nurse educators; without a consistent focus on nursing professional values, nursing graduates may lack the knowledge and resolve to make a difference.