Content area
Background:
Structural competency equips nurses to address health disparities by understanding social, political, and economic structures. Despite its significance, nursing education lacks standardized approaches to teaching structural competency, highlighting the need for evidence-based curricula.
Method:
An integrative review followed Whittemore and Knafl's framework and PRISMA 2020 guidelines. A systematic search of CINAHL, PubMed, ERIC, Embase, and Google Scholar identified 17 relevant studies.
Results:
Active learning methods, including simulations, community engagement, and policy advocacy, enhanced learner engagement and competency development.
Conclusion:
Integrating structural competency into nursing curricula through experiential and reflective learning improves awareness of systemic health inequities and strengthens advocacy skills. Future research should refine teaching strategies and develop competency-based assessments to enhance implementation and evaluation in nursing education, recognizing structural competency as both a content area and an advocacy skill.
Full text
Addressing health inequities requires integrating structural competency into nursing education. Today, nurse educators must prepare future nurses to understand how social, economic, and political structures contribute to health inequities and influence health outcomes. Leading organizations such as the National Academy of Medicine, the American Medical Association, and the American Nurses Association's (2005) Code of Ethics emphasize the importance of this competency in transforming nursing education. Nurses need both academic knowledge and practical experience to assess and address determinants of health through collaboration, advocacy, and active engagement (Drevdahl, 2018; National Advisory Council on Nursing Education and Practice [NACNEP], 2019; Robichaux & Sauerland, 2021; Thornton & Persaud, 2018).
Structural competency is the trained ability to recognize, analyze, and respond to health outcomes as products of broader social, economic, and political structures (Metzl & Hansen, 2014). Unlike cultural competency, which centers on individual beliefs and behaviors, structural competency focuses on systemic forces, such as structural racism, income inequality, housing insecurity, and health care access, that shape population health (Metzl et al., 2020; Robichaux & Sauerland, 2021). Nurses, positioned at the intersection of health care and community life, are uniquely equipped to identify and challenge these structural barriers. By cultivating structural awareness and critical thinking, nursing programs can prepare students not only to recognize health inequities but also to advocate for systemic change through both clinical practice and health policy (Drevdahl, 2018; Robichaux & Sauerland, 2021; Thornton & Persaud, 2018). Despite growing interest in structural approaches to health, structural competency remains inconsistently integrated into nursing curricula (Woolsey & Narruhn, 2018). Integrating structural concepts and advocacy training into nursing education is essential for equipping future nurses to challenge inequitable systems and advance health equity.
Despite nursing's long-standing commitment to health equity, few studies have examined structural competency in nursing education. The Future of Nursing 2020–2030 report calls for curricular reforms addressing social determinants of health, health care economics, and systemic inequities to prepare nurses for diverse and complex health care environments (Hassmiller & Wakefield, 2022). Integrating structural competency in both academic and clinical experiences is essential but presents challenges due to a lack of standardized pedagogical strategies (Robichaux & Sauerland, 2021; Scott et al., 2021; Thornton & Persaud, 2018). This integrative review synthesizes current knowledge on structural competency education to guide new application and curriculum development in nursing.
Method
This integrative review followed Whittemore and Knafl's (2005) framework and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) (Page et al., 2021) guidelines to transparently report its purpose, process, and findings. The initial literature search was conducted in February 2024 using four electronic databases: CINAHL®, PubMed®, ERIC™, and Em-base™. Given the evolving nature of structural competency, a supplementary search was performed in Google Scholar, with an updated search in September 2024 ensuring the inclusion of the most recent publications. A medical librarian assisted in developing the search strategy using Medical Subject Headings (MeSH) terms, indexed keywords, and subject headings, including structural competency, structural determinants of health, health care education, and nursing education.
Inclusion criteria targeted experimental and nonexperimental primary research studies published in English between 2013 and 2024, aligning with the initial emergence of structural competency in the literature. Studies were included if they addressed structural competency with an educational focus, teaching strategy, evaluation method, or curricular design. Exclusion criteria were studies that did not align with the concept of structural competency, lacked an educational focus, were conference abstracts, did not address curriculum, or were tools still in development.
Data were imported into Rayyan for systematic screening, with each author independently reviewing studies based on predetermined inclusion and exclusion criteria. The PRISMA flow diagram (Figure 1) outlines the selection process. Study quality was assessed using the Mixed-methods Appraisal Tool (MMAT), which evaluates qualitative, quantitative, and mixed-method designs (Hong et al., 2018). Following MMAT recommendations, overall quality scores were not assigned. Instead, studies were categorized as strong (≥0.80), moderate (0.51 to 0.79), or weak (≤0.50) (Table A; available in the online version of this article). Data analysis followed Whittemore and Knafl's (2005) four-phase approach: (1) data reduction; (2) data display, (3) data comparison, and (4) conclusion drawing and verification. Themes and relationships were identified through constant comparison, categorization, and thematic clustering, refined through author discussions via online meetings.
| Author (Year) | Qualitative | Quantitative Descriptive | Mixed-Methods | Total Points | Score | Quality | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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| Approach appropriate to research question | Sources of data relevant to objectives | Analysis process relevant to objectives | Consideration of findings relate to context | Coherence among data sources, collection, analysis, and interpretation | Sampling strategy relevant to objectives | Sample represent population | Measurements appropriate | Mitigate risk of nonresponse bias | Acceptable response rate | Mixed-methods research design relevant to objectives | Study components effectively integrated to answer objectives | Qualitative and quantitative outputs well interpreted | Discrepancies properly addressed | Components meet quality standards of each method | ||||
| Andress (2020) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Avant (2019) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Bates (2023) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 14/15 | 0.93 | Strong |
| Bromage (2018) | 1 | 1 | 1 | 0 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 4/5 | 0.80 | Strong |
| Burson (2022) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Hayman (2020) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Khazanchi (2021) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Mathis (2019) | 1 | 1 | 1 | 0 | 0 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 3/5 | 0.60 | Moderate |
| Metzl (2018) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 0 | 0 | 12/15 | 0.80 | Strong |
| Mills (2024) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Neff (2020) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Orr (2022) | 1 | 1 | 1 | 1 | 1 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 5/5 | 1.00 | Strong |
| Orr (2020) | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | 5/15 | 0.33 | Weak |
| Rabinowitz (2017) | n/a | n/a | n/a | n/a | n/a | 1 | 1 | 1 | 0 | 1 | n/a | n/a | n/a | n/a | n/a | 4/5 | 0.80 | Strong |
| Ruth (2020) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 15/15 | 1.00 | Strong |
| Woolsey (2018) | 1 | 0 | 0 | 0 | 0 | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | 1/5 | 0.20 | Weak |
| Woolsey (2020) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 14/15 | 0.93 | Strong |
Results
The review included 17 studies: 13 from the United States, two from Israel, one from Canada, and four from Palestine. Most of the studies used qualitative designs (n = 10), followed by mixed-methods designs (n = 5) and quantitative designs (n = 2). Qualitative studies employed constructivist grounded theory, participatory visual and community engagement, descriptive, exploratory, and narrative research. Quantitative designs included pretest-posttest and quasiexperimental studies. All of the studies were published in English between 2017 and 2024. Key details of the included articles are outlined in Table B; available in the online version of this article. Three categorical themes emerged: (1) learner and educational settings; (2) experimental teaching strategies; and (3) evaluation methods and tools.
| Authors (Year) & Country | Purpose | Methods | Key Findings | Critical Appraisal |
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| Andress & Purtill (2020) | To explore teaching strategies to help medical students understand the connection and effects of systemic, institutional, and structural forces that affect health and perceptions of citizens from the community | Design: Qualitative participatory PhotoVoice; quantitative data collection | Students gained a foundational understanding of structural competency and its relevance to health and place, but had difficulty addressing the underlying structural issues. PhotoVoice analysis revealed students gained a basic level of understanding in six of nine domains of the SCA framework, indicating improved ability to connect structural conditions with health disparities. | Strengths: Underpinnings of two models and comprehensive frameworks, triangulation of data |
| Sample size: 36 total (10 medical students; 26 community members) | ||||
| U.S. | Limitations: Small sample size, validity and reliability of the SCA framework, subjectivity to bias, long-term changes may not be able to be completely understand | |||
| Sampling: Purposive; nonprobability | ||||
| Data collection: Community-based PhotoVoice approach including PhotoVoice sessions, group discussions, narrative analysis using the integrated place-health model and SCA framework. | ||||
| Additionally, integrating community-based participatory methods, such as community based PhotoVoice exercises, into medical education can improve students' understanding of the complex factors affecting health. However, many limitations to this teaching were noted by the researchers. | Quality rating: Strong | |||
| Data analysis: Coded interviews, thematic analysis, and evaluation metrics | ||||
| Intervention/teaching strategy: Community-based PhotoVoice | ||||
| Evaluation tool(s) used: SCA framework direct principles | ||||
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| Avant & Gillespie (2019) | To evaluate an elective course designed to expose pharmacy students to the root causes of health disparities and to enhance the understanding of | Design: Qualitative descriptive | Experiential learning activities increased student awareness of structural inequities and expanded knowledge of structural competency concepts. Students demonstrated a proactive approach to addressing health equity and challenging traditional views. | Strengths: Data triangulation, robust data analysis, thick descriptions of findings, and thematic underpinning supported from pedagogical principles for social justice teaching |
| Sample size: 9 | ||||
| Sampling: Purposive | ||||
| Data collection: Weekly reflections | ||||
| U.S. | Data analysis: Thematic analysis; constant comparative method | |||
| structural competency and implicit bias | Intervention/teaching strategy: 3-credit course embedded with experiential learning activities | Additionally, the course emphasized similar courses in pharmacy curricula, highlighting experiential and intergroup learning to bring about meaningful changes in professional practice. | Limitations: Limited information about researcher reflexivity | |
| Evaluation tool(s) used: Qualitative thematic analysis | Quality rating: Strong | |||
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| Bates et al. (2023) | To provide a comprehensive overview of the development and evaluation of two interprofessional educational activities that incorporate structural competency content through common readings, guided by the book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital (Fink, 2016) | Design: Mixed-methods; retrospective pre- and posttest design, and conventional content analysis | Students reported statistically significant | Strengths: Pre- and posttest assessments of learning outcomes. The content of the IPCRE activities contributed to positive reflections on students' ability to deliver health care services equitably. Students enjoyed the activity and were able to positively facilitate meaningful discourse. |
| increase in their confidence discussing | ||||
| structural barriers to care. | ||||
| U.S. | Sample size: More than 250 health professional students across three different universities; 56 students completed the follow-up | Demonstrated enhanced understanding of how structural issues, highlighted in the readings, helped them reflect on practical issues. | ||
| Sampling: Convenience | ||||
| Data collection: Retrospective pre- and posttest of student learning outcomes and open-ended questions | Indicated higher enjoyment of the IPCRE compared with its follow-up. | |||
| Data analysis: Descriptive inferential statistics and conventional content analysis | IPCRE follow-up received higher scores in relation to meeting student needs and interests. | Limitations: Response bias and data were not normally distributed, which hindered the comparison of initial, in-person scores with online follow-up scores. | ||
| Intervention/teaching strategy: IPCRE | ||||
| Evaluation tool(s) used: Pre- and posttest; Interprofessional Attitudes Scale (IPAS); W(e) Learn IP Program Assessment | ||||
| Quality rating: Strong | ||||
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| Bromage et al. (2018) | To explore education of psychiatry residents about the effects of neighborhood structures on health and explore how the environments | Design: Qualitative; experiential intervention | Residents reported improvements in their understanding of structural barriers and community resources. | Strengths: Community and interdisciplinary collaboration, member checking |
| Sample size: 18 second-year psychiatry residents | ||||
| U.S. | ||||
| Sampling: Purposive | The study emphasized and fostered a stronger community-university collaboration, highlighting the importance of engaging with community | Limitations: Significant resources are needed, which may limit feasibility of | ||
| Data collection: Rapid Assessment Approach, focus groups, thematic coding | ||||
| influence health outcomes | Data analysis: Constant comparative method and thematic analysis | members to gain insights into the challenges and resilience within neighborhoods, and connecting the broader context of health disparities. | replicating the study in other settings | |
| Intervention/teaching strategy: Mandatory seminar sessions (3 nonconsecutive days) | Quality rating: Strong | |||
| Evaluation tool(s) used: Formative and qualitative evaluation | ||||
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| Burson et al. (2022) | To analyze the effect of the conceptual framework of structural competency on medical students' and physicians' understanding of societal problems that affect patient health and the practices of health systems to improve their ability to address these issues in practice | Design: Longitudinal qualitative | Six themes emerged and were synthesized. Learners reported improved understanding of structural competency concepts. They described how the curriculum helped conceptualize and apply systemic solutions to societal problems affecting health. However, learners were uncertain about the actions they could perform from their respective positions within the health system. | Strengths: Longitudinal design, comprehensive data collection, and rigorous coding and theme development |
| Sample size: 19 | ||||
| Sampling: Purposive | ||||
| U.S. | Data collection: One-on-one semistructured interviews | |||
| Data analysis: Thematic analysis and strategic coding process | Limitations: Single institution data | |||
| Intervention/teaching strategy: Curricular integration into established medical course titled “Introduction to Medicine in Society” | Quality rating: Strong | |||
| Evaluation tool(s) used: Qualitative content analysis; structural competency framework | ||||
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| Hayman et al. (2020) | To explore and identify specific knowledge and skills required for medical students to effectively engage in policy change and address structural factors that influence social determinants of health | Design: Descriptive qualitative | Learners acknowledged the importance of understanding health and political systems as key factors in effective advocacy. They appropriately referenced facts about SDOH and emphasized the importance of the issue. Learners demonstrated evidence of structural humility and were able to envision how interventions could address structural causes and present potential solutions to barriers. | Strengths: Workshop developed on established framework, comprehensive analysis |
| Sample size: 9 | ||||
| Sampling: Convenience | ||||
| Canada | Data collection: Semistructured focus groups | |||
| Limitations: All participants identified as women, research reflexivity | ||||
| Data analysis: Thematic analysis guided by Metzl and Hansen's (2014) structural competency framework | ||||
| Quality rating: Strong | ||||
| Intervention/teaching strategy: 3-hr workshop | ||||
| Evaluation tool(s) used: Qualitative thematic analysis | ||||
| Khazanchi et al. (2021) | To explore how community-engaged pedagogy can enhance understanding of structural inequities and health disparities, aiming to promote critical awareness and structural competency among participants | Design: Educational design with community-engagement; qualitative | Successfully implemented a community-engaged pedagogy and structural competency framework, designed to scale across an entire first-year class instead of just self-selected students or smaller groups. This initiative fostered a critical understanding of historical structural inequities and current health disparities within the community. Feedback suggested an increased desire for more community engagement elements, particularly emphasizing small-group discussions and extended opportunities for community involvement. The collaborative approach strengthened the relationship between the university and the community. | Strengths: Community-based participatory components |
| Sample size: 132 | ||||
| U.S. | Sampling: Purposive | Limitations: Single institution, short-term post- only evaluations | ||
| Data collection: Anonymous web-based surveys | ||||
| Data analysis: Inductive thematic analysis | Quality rating: Strong | |||
| Intervention/teaching strategy: Community-engaged structural competency curriculum with active learning strategies to enhance existing learning objectives | ||||
| Evaluation tool(s) used: Pre-and postcurriculum surveys | ||||
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| Mathis et al. (2019) | To design an educational teaching strategy to introduce concepts of structural competency to psychiatry residents | Design: Qualitative educational intervention | Learners were able to identify and articulate how social, economic, and political structures affect patient health. Throughout the training and activities, learners identified and articulated how these structures affected patient health. | Strengths: Detailed intervention outline |
| Sample size: 12 | Limitations: Attrition rates | |||
| U.S. | Sampling: Convenience | Quality rating: Moderate | ||
| Data collection: Structured activities including drawings and presentations, and discussions | ||||
| Data analysis: Thematic analysis, comparative analysis | The interactive and experiential nature of the training facilitated deeper engagement and reflection on the material. Preliminary outcomes regarding the effectiveness of the neighborhood drawing activity in enhancing residents' engagement were observed. | |||
| Intervention/teaching strategy: Educational teaching strategy-drawing neighborhood | ||||
| Evaluation tool(s) used: Qualitative feedback; survey-based assessment | ||||
| Metzl et al. (2018) | To incorporate structural competency into medical education through an innovative interdisciplinary pre-health curriculum and assess the effectiveness of the curriculum by evaluating students' understanding of structural factors influencing health | Design: Mixed-methods; comparative analysis | The findings indicate that MHS students were more successful in identifying and analyzing the connections between structural factors and health outcomes compared with premed science majors and freshmen. MHS seniors reported higher levels of preparedness to work with diverse populations compared with premed seniors but not freshmen. | Strengths: Comparative diverse sample across different educational stages and perspectives, and a detailed results section outlining curriculum comparisons |
| Sample size: 339 students: n = 185 MHS majors, n = 63 premed science majors, and n = 91 first-semester freshman | ||||
| U.S. | ||||
| Sampling: Convenience | ||||
| Data collection: Online surveys and thematic coding evaluating the depth of understanding | Limitations: Study means captured data at a single point in time; which may limit the ability to assess changes in understanding over time or the long-term effect of the curriculum in health professional practice | |||
| Data analysis: Descriptive inferential statistics and thematic coding | Additionally, MHS majors demonstrated a deeper understanding of structural and implicit racism, as well as health disparities. The study also revealed MHS seniors were significantly more likely than premed seniors to recognize the importance of structural factors such as neighborhood access and institutional racism in explaining health disparities. | |||
| Intervention/teaching strategy: New interdisciplinary academic major | ||||
| Evaluation tool(s) used: Pre- and postcourse survey; Structural Foundations of Health Survey | ||||
| Quality rating: Moderate | ||||
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| Mills et al. (2024) | To implement a social medicine course in Palestine and provide a critical, reflective, and experiential learning opportunity for students to contribute to structural transformation | Design: Qualitative, participatory action research | The course also presented a model for decolonial education and action, showing how important it is to unite for better health and to potentially change the system through education. Learners encountered challenges and emotional distress when trying to figure out practical next steps to address the underlying factors that affect health. | Strengths: Triangulation with multiple data sources (interviews, focus groups, observations, and journals), participatory action research approach |
| Sample size: 30 | ||||
| Palestine | Sampling: Purposive | |||
| Data collection: Interviews, focus groups, field observation, pre- and postevaluations | ||||
| Limitations: Short duration and limited generalizability | ||||
| Data analysis: Thematic analysis and reflexive journaling | ||||
| Quality rating: Strong | ||||
| Intervention/teaching strategy: 3-week experiential social medicine course | The findings highlight the importance of using context-specific, participatory approaches in health education. | |||
| Evaluation tool(s) used: Pre- and postcourse evaluations | ||||
| Neff et al. (2020) | Develop, implement, and evaluate a curriculum to train health professionals to recognize and respond to the effects of social, economic, and political structural factors on health and health care | Design: Qualitative | Learners found the application valuable for real-world clinical community and policy. Those with clinical experience found that the training helped them rethink how they approach patients. | Strengths: Grounded in theoretical concepts, high response rate, detailed education outline |
| Sample size: 32 distinct instances (275 participants) | ||||
| U.S. | Sampling: Purposive | |||
| Data collection: Open-ended, written-response survey | Limitations: Sample size and scope may limit generalizability to other regions or settings | |||
| Data analysis: Thematic analysis | Learners reported feeling reconnected to their initial motivations for entering the health profession. Medical students discussed their hopes and anxieties for future practice. Experienced providers reflected on past clinical experiences and challenges and found practical strategies for shifting their current practice. | |||
| Intervention/teaching strategy: 3–4-hour trainings with interactive modules and active learning | ||||
| Quality rating: Strong | ||||
| Evaluation tool(s) used: Author-developed qualitative survey | ||||
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| Orr & Unger (2020) | Evaluate the structural competency training model (TOLERance model) developed for nursing students as a proposed methodology that incorporates theory, observations, learning from patients, engagement, and research into nursing curricula | Design: Mixed-methods; empirical ethnography | Increased knowledge and awareness of nursing students' understanding, familiarity, and awareness of the structural determinants of health. The model proposed an essential addition to nursing education programs, bridging individual clinical care and broader sociopolitical structures. The model incorporated key concepts from the Structural Competency Working Group and effectively applied concepts to the nursing curriculum. | Strengths: Connection of theoretical concepts to practical clinical cases, with a detailed description of findings and the study context; potential for broader application across nursing programs in other countries |
| Sample size: Small groups of up to 10 students–not clear on exact sample size | ||||
| Israel | ||||
| Sampling: Not given | ||||
| Data collection: Field observations, interviews, and survey analysis of preintervention and postintervention questionnaires | ||||
| Limitations: Small convenience sample, no integration of qualitative and quantitative data, and limited description of qualitative research; no comparison group for the intervention and likelihood of self-reported measures could introduce bias | ||||
| Data analysis: Content analysis guided by grounded theory and comparative analysis | ||||
| Intervention/teaching strategy: New curriculum model | ||||
| Evaluation tool(s) used: Pre- and postintervention surveys | ||||
| Quality rating: Weak | ||||
| Orr et al. (2022) | Explore how simulation-based learning can be used to improve the structural competency of nurses and nursing students | Design: Quasiexperimental | Students emphasized the strong relevance of structural competency to their daily work. They found that the simulation helped them to strengthen, internalize, and practice this competency. The simulation also helped students conceptualize the factors that create biases. Students reflected that the simulation contributed to their formation of a broader perspective and a deeper understanding. | Strengths: Detailed description of study context, generalizability, and application for various educational settings and health care context |
| Sample size: 87 | ||||
| Sampling: Convenience | ||||
| Israel | Data collection: Pre- and postintervention surveys, qualitative interviews | |||
| Data analysis: Qualitative content analysis and Grounded Theory | Limitations: Resource intense requiring time, financial investment, and trained personnel; single setting | |||
| Intervention/teaching strategy: Standardized simulation sessions (total of 4) | ||||
| Evaluation tool(s) used: Pre- and postsimulation surveys | Quality rating: Strong | |||
| The simulation allowed students to demonstrate how theoretical knowledge has practical manifestations in their work in hospital and community settings. Students reported that a live simulation was more effective than an online simulation. | ||||
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| Rabinowitz et al. (2017) | To evaluate and adapt an existing cultural competency assessment tool to better fir structural competency curricula and to quantify the effectiveness and the effects of the peer-taught structural competency curriculum of first-year medical students' self-perceived knowledge, skills, and attitudes | Design: Quantitative pilot study | Students reported a significant increase in knowledge (p < .01) and higher levels of comfort addressing structural issues in patient care (p < .01). Positive changes in KSAs were observed immediately and persisted 6 months later. | Strengths: Pilot study, detailed description of questionnaire |
| Sample size: 135 | ||||
| Sampling: Convenience | ||||
| Data collection: Same questionnaire administered three different times (pretest, posttest, and 6-month follow-up survey) | Limitations: Lack of a comparison group, reliant on self-reported data, potential biases may have influenced pre- and postcourse evaluation scores. | |||
| U.S. | ||||
| Data analysis: Nonparametric statistical test (Wilcoxon signed rank test) | Additionally, the study concluded that peer-taught structural competency courses can be effective in training medical students to understand and address health disparities using a systems-level approach. | |||
| Quality rating: Strong | ||||
| Intervention/teaching strategy: Peer-taught course | ||||
| Evaluation tool(s) used: Pre- and posttest; Clinical Structural Competency Questionnaire | ||||
| Ruth et al. (2020) | To establish a baseline for measurable and meaningful change structural competency of students between the start and end of a single-semester course | Design: Mixed-methods; pre- and posttest | The study provided focused education on how social and structural factors such as gender, immigration status, and obesity can affect health and lead to stigma. Didactic, observational training, and field work were used to explore these barriers. | Strengths: Using a pre- and post-design allowed for the assessment of the course's effectiveness, providing both quantitative and qualitative findings. The results supported the best practices of experiential learning, indicating a strong theoretical foundation for the course design. |
| Sample size: 27 students | ||||
| U.S. | Sampling: Convenience | |||
| Data collection: Observational transect walks, interviews, pre- and posttest | ||||
| Data analysis: Qualitative comparative techniques through modified constant comparison methods and a coding framework and quantitative statistical analysis of pre- and posttest | The course effectively enhanced structural competency through experiential and didactic learning modules. Significant improvement in students' ability to explain structural reasons for health disparities (p = .007, t = 2.9, CI = 0.39–2.2, SD = 2.28). | |||
| Limitations: Small convenience sample and a single institution (potentially affecting external validity) | ||||
| Intervention/teaching strategy: Single semester-long experiential course design | ||||
| Quality rating: Strong | ||||
| Evaluation tool(s) used: Pre- and posttest; Structural Foundations of Health Survey | ||||
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| Woolsey & Narruhn (2018) | To explore and understand the effect of educational interventions on nursing students' awareness and understanding of social and structural determinants of health, combining two theoretical models (structural competency and bio-power) | Design: Interpretative qualitative | Students reported a shift in how they viewed patients and their situations, and their ability to translate and recognizing systemic factors influencing health inequities. | Strengths: Aligned with institutional mission and strong underpinnings of theoretical tenants. |
| Sample size: ∼72 students (∼36 students/2 sections) | ||||
| Sampling: Not given | ||||
| U.S. | Data collection: Class assessments, focused group discussions, and journal assignments | Limitations: Methodology not well articulated and vague | ||
| Outlined the need for further research to evaluate the effectiveness of curriculum, and adequate amount of time for delivery of content. | ||||
| Data analysis: Details not given; qualitative methods of student evaluations were shared | Quality rating: Weak | |||
| Intervention/teaching strategy: Mandatory course development in graduate nursing programs | ||||
| Evaluation tool(s) used: Qualitative thematic analysis | ||||
| Woolsey & Narruhn (2020) | To integrate structural competency into graduate level nursing education and determine effective content and delivery methods for influencing or changing student perspectives on structural health determinants. | Design: Mixed-methods pilot study; pre- and postsurvey instrument | Students demonstrated improved understanding and application of structural competency principles immediately post-intervention (t(57) = 2.22, p = .031) and in their perceived ability to create change (t(49) = 4.77, p < .001). However, at the 3-month follow-up, scores for these areas had significantly decreased, suggesting a need for ongoing reinforcement. | Strengths: Pilot testing of intervention, mixed-methods approach to comprehensive understanding of the impact of the educational module, longitudinal follow-up |
| Sample size: 60; second-year DNP student | ||||
| U.S. | Sampling: Convenience; single cohort | |||
| Data collection: Combined quantitative and qualitative pretest questionnaire before education module, and posttest immediately following. Three months after education, 29 students responded to a 22-question quantitative survey, and 3 qualitative questions. | ||||
| Limitations: Preliminary findings indicate that the material was taught differently across two class sections, which were later combined, resulting in unintended differences in teaching methods. Coding problems encountered with specific questions, which led to their deletion from the study. Additionally, there were clarity issues with questions, leading to their omission from the analysis. | ||||
| Students requested more practical tools to address structural inequities in clinical settings. | ||||
| Data analysis: Descriptive and inferential statistics; semantic and latent thematic analysis | ||||
| The study highlighted the importance of providing support to students regarding emotional distress that can arise from understanding structural inequities, suggesting trauma-informed care approach in nursing education to assist with these feelings of burnout. | ||||
| Intervention/teaching strategy: 3-hr education module | ||||
| Evaluation tool(s) used: Author developed survey tool, pre- and posttest (author addressed validity) | ||||
| Quality rating: Strong |
Learner and Educational Setting
Structural competency training targeted students and professionals in medicine, nursing, and pre-health fields, with sample sizes ranging from 9 to 339 participants. Most of the studies took place in academic settings, while three of the studies involved practicing health care professionals, faculty, and community members. Five studies focused on medical professionals, four on nursing education, with one examining both undergraduate and graduate nursing programs, and three focused solely on graduate nursing students. The remaining eight studies involved pre-health undergraduate students preparing for professional health programs.
Experiential Teaching Strategies
Studies explored both active and passive learning strategies for integrating structural competency into curricula (Figure 2). Active learning strategies (n = 11) included peer-based learning, group discussions, simulations, service-learning, role-playing, community immersion, PhotoVoice, and legislative participation. Community engagement (n = 3) fostered learner awareness of structural inequities and strengthened university-community partnerships. Passive learning methods (n = 4) included lectures, course readings, and online modules. Additionally, one study introduced curriculum modifications, and another study developed a new educational model.
Evaluation Method and Tools
All of the studies assessed the effectiveness of structural competency training, although approaches varied. Eight studies evaluated the knowledge, skills, and attitudes of learners, while nine studies focused on the quality, perceptions, and overall effectiveness of educational interventions. Pre- and post-test evaluations (n = 9) used the Likert scale and open-ended survey instruments. Some of the studies adapted tools, such as the Structural Foundations of Health Survey Instrument (Metzl et al., 2018) and the Clinical Cultural Competency Questionnaire (Rabinowitz et al., 2017) to include structural competency questions. Bates et al. (2023) incorporated 17 items from the W(e) Learn IP Program Assessment to measure attitudes related to interprofessional collaborative practice and education. Beyond surveys, studies employed qualitative methods, including focus groups (n = 2), ethnographic methods (n = 1), and narrative feedback (n = 2).
Outcomes
All of the studies reported clear learning outcomes. Eleven studies indicated that learners demonstrated increased knowledge of structural factors affecting health and improved attitudes toward recognizing social, economic, and political influences on health disparities. Six studies indicated that learners developed greater competence in addressing underlying structural factors in patient care.
Discussion
This review focuses on bridging the gap in nursing education between theoretical knowledge and the practical application of structural competency, which is essential for preparing future nurses to address broader determinants of health. While existing evidence is high-quality, further development, implementation, and evaluation of teaching strategies that promote structural competency among nursing students remain critical. Unlike previous studies, this review provides specific guidance for nurse educators by outlining pathways for integrating and evaluating structural competency within nursing curricula.
Methodological Considerations and Research Gaps
Methodological approaches in the reviewed studies varied, with most studies employing qualitative methods using thematic analysis. Although robust, these qualitative studies presented limitations, such as potential bias, research reflexivity, and limited generalizability. Several mixed-methods studies offered a more comprehensive evaluation of interventions, while only two studies used quantitative methodologies. The predominance of qualitative research reflects the emerging nature of structural competency education and highlights the need for a stronger evidence base on the effectiveness of these strategies in clinical practice.
While innovative models, such as the TOLERance Model (Orr & Unger, 2020) and simulation-based approaches (Orr et al., 2022), have demonstrated promise in enhancing structural competency, the absence of validated assessment tools limits the ability to systematically measure and validate learning or competency. Addressing this gap requires developing reliable instruments to evaluate changes in knowledge, skills, and attitudes, ultimately strengthening the evidence base for broader implementation of structural competency in nursing curricula.
Challenges in Implementation
Implementing structural competency education in clinical learning environments presents challenges for nurse educators due to its conceptual complexity. First introduced by Metzl and Hansen (2014) as a paradigm shift in medical education, structural competency has since been adopted across health care disciplines, including nursing. The studies in this review illustrate diverse teaching strategies aligning with the American Association of Colleges of Nursing (2021) Essentials, which emphasize competency-based education to advance health equity and structural awareness at systemic, community, and population levels. However, nurse educators often lack experience in teaching these concepts, contributing to a gap in faculty preparedness (Drevdahl, 2018; Orr et al., 2022).
Experiential Learning and Curricular Integration
A key aspect of structural competency involves recognizing that structural factors shaping health are modifiable through targeted interventions (Metzl & Hansen, 2014; Orr & Unger, 2020). Experiential learning approaches, such as community engagement, simulations, and PhotoVoice projects, were frequently used to enhance student engagement and understanding. These strategies promote active learning and critical reflection, areas that have been historically underemphasized in nursing curricula.
While social determinants of health frameworks are widely incorporated into nursing education, they often fail to address the systemic power structures that shape these determinants (Sharma et al., 2018). Only four studies in this review focused exclusively on nursing, underscoring the need to integrate structural elements more intentionally into curricula. The AACN Essentials (2021) calls for nurses and educators to advocate for social justice and dismantle structural inequities within health care. The reviewed studies offer curricular strategies and assessment tools to support this shift, emphasizing experiential and reflective learning as critical methods to help learners address sociopolitical factors influencing health disparities (Robichaux & Sauerland, 2021).
Faculty Development and Pedagogical Approaches
Nurse educators can enhance learners' understanding of structural competency by adapting pedagogical approaches that foster self-reflection, critical consciousness, and diverse perspectives. However, studies in this review noted that many educators have limited expertise in teaching these concepts, creating a barrier to effective instruction. Woolsey and Narruhn (2018) advocate for transformative pedagogies that encourage learners to critically examine structural inequities and engage in meaningful discussions about health disparities. Integrating this approach is essential for embedding structural competency into both clinical education and broader nursing curricula.
Limitations
This review has identified effective educational strategies and evaluation methods for incorporating structural competency into nursing curricula but also presents several limitations. Many studies relied on small, convenience samples, limiting the generalizability of findings. The scarcity of nursing-specific studies highlights a significant gap in the literature, suggesting the need for future research in nursing education. Despite strong efforts to conduct a comprehensive review, potential personal interpretation during data synthesis may have influenced findings. Furthermore, the rapid evolution of structural competency as an educational concept may have led to the exclusion of relevant studies not published in English or indexed in the searched databases. Future reviews should broaden their scope to include grey literature, such as policy briefs, institutional reports, dissertations, and other noncommercially published materials, as well as research conducted in diverse educational and geographic settings to capture a more complete picture of emerging practices.
Future Direction
Future research should explore larger sample sizes and investigate the long-term effects of structural competency education to assess the sustained effects of educational interventions on health care and nursing practice. Studies should refine educational approaches and develop best practices for embedding structural competency into existing courses. Additionally, research should explore integrating structural competency with other nursing competencies, such as cultural competency, implicit bias, and social determinants of health, to assess the synergistic effects of these educational interventions.
Recommendations for nursing faculty include demonstrating intentionality in structural competency education by using transformative frameworks to guide both the design and evaluation of curricula. Evaluation approaches should extend beyond self-reported measures and include competency-based assessments that determine whether learning about structural competency translates into practical application. Developing standardized assessment tools specifically designed to measure structural competency in nursing will provide deeper insights into the effectiveness of related teaching strategies and curricular innovations.
Conclusion
Integrating structural competency into nursing education is essential for preparing nurses to recognize and address systemic health disparities. This review highlights the value of experiential and reflective learning in fostering critical awareness and advocacy skills among nursing students. Nurse educators and institutions play a pivotal role in embedding structural competency into curricula, ensuring future nurses are equipped to navigate complex social and structural determinants of health. By prioritizing competency-based education, nursing programs can cultivate professionals who deliver equitable, patient-centered care and contribute to systemic change within health care.
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The authors thank Dr. M. Shade and Dr. S. Barnason for their thoughtful guidance and support in shaping the foundational ideas and organizational framework of the manuscript.
From College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska (KK), and Des Moines University Medicine and Health Sciences, West Des Moines, Iowa (BC).
Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.
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