Social Work and Nursing Students’ Perceptions of the Social Determinants of Health Based on Practice and Educational Experiences

PURPOSE Although social workers and nurses work together in healthcare settings, there are tensions between their roles. Both professions embrace the concept of the social determinants of health (SDOH), but less is known about how the professions understand SDOH. METHODS Using semi-structured interviews with 25 masters’ level nursing and social work students, this qualitative descriptive study explored the educational and practice experiences relating to the SDOH. RESULTS Both nursing and social work students recognized that socioeconomic, patient/client educational, and access factors contribute to health and healthcare. Subtle differences in emphasis included a broader focus among social work students of the influence of SDOH on vulnerability/disparities and communities. While nursing students focused on vulnerability/disparities, they emphasized the effects of SDOH on specific health conditions. Both groups of students expressed that their exposure to people unlike themselves in their clinical/field educational experiences helped them learn about the SDOH. Nursing students stressed that interprofessional teamwork was vital to addressing SDOH, whereas social work students emphasized cultural awareness and avoiding stereotypes were necessary elements. All students wanted more information about health policies. CONCLUSION The shared understanding of both nursing and social work graduate students have on the effect that SDOH have on health and healthcare can provide a common language. Employing SDOH as a framework for interprofessional education could encourage shared understanding among professions and a purpose for interprofessional educational field opportunities, that would both support learning about the SDOH and collaborative practice with underserved communities. Received: 08/11/2019 Accepted: 11/05/2019 © 2019 Schneiderman, et al. This open access article is distributed under a Creative Commons Attribution License, which allows unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. HIP E & Social Work and Nursing Students’ Perceptions ORIGINAL RESEARCH 3(4):eP1189 | 2 HIP E &


Introduction
Interprofessional practice between social workers and nurses occurs in many healthcare settings, although tension between their roles can also occur (Ambrose-Miller & Ashcroft, 2016;Barbey, 2016). A study in a labor and delivery setting illustrated this role tension (Barbey, 2016). Social workers stated that they were dependent on nurses' referrals and sometimes these referrals occurred too late, thus the social workers felt they could not contribute fully to the patient's care. At the same time nurses voiced that the social workers were not doing enough for their patients. Possible contributing factors to the role tension include professional culture differences, self-identity, lack of role clarity, and decision-making communication and power (Ambrose-Miller & Ashcroft, 2016). Differences in education and training by profession may contribute to these challenges (including terminology and role identity). Lack of knowledge about each professions' skills and training creates further challenges to interprofessional collaboration (Barbey, 2016).
Both nursing and social work take a whole person approach to prevention and practice, with nursing framing this as person-centered care (McCormack & McCance, 2011) and social work using a person-in-environment approach (Karls, Wandrei, & National Association of Social Workers, 1994), although these differences are not mutually exclusive as nursing includes environment in its approach as well. The social determinants of health (SDOH) framework could create an opportunity to have a more clearly defined shared language. As highlighted in Healthy People 2020, addressing the social determinants of health includes creating "social and physical environments that promote good health for all" (U.S Department of Health and Human Services, 2010). As such, the goal of this study was to explore qualitatively the educational and practice experiences of masters' level nursing and social work students, specifically training and understanding of the SDOH, to inform strategies to improve interprofessional collaboration between nursing and social work. The research question was: how do social work and nursing students' understand the SDOH and how has their past educational and practice experiences affected this understanding?

Social Determinants of Health in Nursing
Within the nursing profession, there has been a strong emphasis on SDOH. Olshansky (2017) has called for the nursing profession to: 1) include SDOH in all clinical courses, including assessment for SDOH as a key component of clinical nursing practice; 2) create interprofessional practice to emphasize SDOH (by including social work, public health, city planning, occupational health, police, and firefighters, etc.); 3) emphasize nursing research that focuses on the connection between SDOH and health outcomes; and 4) work to impact

Implications for Interprofessional Practice
• Nursing and social work students recognized that socioeconomic, patient/client educational, and access factors contribute to health and healthcare.
• Nursing and social work students have some subtle differences in how they see the social determinants of health (SDOH) play out in how they care for patients/clients, which need to be addressed as part of interdisciplinary education and practice collaborations.
• Emphasizing the shared language that social work and nursing students have about the SDOH could provide a framework for community-based interprofessional education experiences that would both support learning about the SDOH and collaborative practice with underserved communities.
• Interprofessional health policy classes could meet the needs of nursing and social work students.
health policy decisions that address SDOH. Drevdahl and colleagues (2001) have advocated for the nursing profession to embrace SDOH through a social justice framework that emphasizes social activism in order to correct the inequities in social, economic, and health disparities. This focus on SDOH is not limited to nursing in the United States. Reutter and Kushner (2010) identified SDOH as a critical focus for nurses in Canada in order for them to address inequities in health and healthcare. The major nursing professional organizations, including the American Academy of Nursing, include SDOH in their priorities (Troseth, 2017). A recent article by Tilden and colleagues (2018) very aptly addressed the critical importance of addressing adverse SDOH, recognizing that 60% of health conditions are due to SDOH. Further, Tilden and colleagues (2018) made a forceful argument for the need to collaborate across various health professions.
Although nursing professional organizations are strong proponents of SDOH, some question whether nurses themselves have adopted the SDOH as a guiding approach to care. Reutter and Kushner (2010) note that nursing's traditional individual focus tends to emphasize proximal views of the environment which limit their attention to broader social conditions in the SDOH. They also find that there is an internal division between community nursing's emphasis of inequities inherent in SDOH and acute care nurses' framework of practice with individuals. The Nurse-Family Partnership is one example where the SDOH is an integral part of the standardized interventions provided to disadvantaged families and has proven to be successful in both promoting good health for children and preventing untoward outcomes, such as child maltreatment (Adler, Glymour & Fielding, 2016).

Social Determinants of Health in Social Work
Though now found in the National Association of Social Work (NASW) standards for practice in healthcare settings (NASW, 2016), the terminology "social determinants of health" was adopted within the profession of social work later than other health professions. However, the interplay between social context and the health and wellbeing of populations is foundational to the profession (Rine, 2016). The language in Healthy People 2020 (2010) related to SDOH (specifically equity, disparity and advocacy aimed at oppressed, vulnerable, and disen-franchised populations) aligns closely with social work value of social justice. The SDOH perspective also aligns well with social work's person-in-environment perspective (Karls et al., 1994) and biopsychosocial assessment model. In fact, much of the practice of social work in health settings is attending to social determinants of health, including issues related to services, disability, income, employment, food insecurity, and education (Craig et al., 2013).
Given that social work is already committed to social justice, interventions to improve wellbeing, and advocating for equality (Moniz, 2010), more training in the social determinants framework could support interprofessional collaboration. Andrews et al. (2013) conclude that social workers are a good fit to implement parts of the Affordable Care Act as they are trained to identify and address the SDOH critical to achieving long-term health and well-being for patients. Leichty (2013) argues that social workers join a cadre of other health professionals working to increase health equity, but must transcend disciplinary jargon to fully participate with teams. She specifically addresses social work's role in addressing the obesity epidemic, and questions whether a social justice framework, integral to social work's identity, will help or hinder interprofessional work in obesity prevention.

Social Determinants of Health in Interprofessional Education
The concept of the SDOH is not new in interprofessional education. The University of South Carolina has a course for health professions (including nurses and social workers) which includes SDOH, as well as other relevant topics (e.g. health system improvement, patient safety, cultural competency, and ethics) important for collaborative practice (Addy et al., 2015). A consortium of schools in Florida including medicine, law, nursing, and social work, used a longitudinal service learning opportunity to teach students about the SDOH and provide services to underprivileged communities. (De Los Santos, McFarlin ,& Martin, 2014). Although there are exemplars of creative interprofessional education for healthcare professions, barriers to this type of education exist. A Lancet global independent commission recommended that shared learning opportunities have stringent evaluation and research to build knowledge to assure that innovative interprofessional education strategies are effective (Frenk et al., 2010).

Aims for This Study
Available literature emphasizes that both the professions of nursing and social work identify the SDOH as core to the approach and values of their professions. Yet barriers to effective interprofessional collaboration remain, which may be due to lack of understanding of how each profession views SDOH. Thus, the goal of this study was to understand how students in both professions view social determinants of health. We used semi-structured interviews to understand how SDOH influences their practice, and how it affects the health of their patients/clients. A secondary goal was to explore how students' educational and practice experiences influenced their understanding of the SDOH. To elicit information on the training experiences and current ideas about SDOH, we conducted 25 interviews with nursing and social work graduate students. Findings from this study can inform educational programs on ways to incorporate SDOH into their curricula, which in turn can contribute to use of a shared language that facilitates better interprofessional collaboration between nurses and social workers.

Participants
Graduate student participants were recruited from an on-line social work Masters of Social Work (MSW) program and an on-line graduate nursing Masters of Science in Nursing (MSN) program. Both programs were in the same university and the nursing department is one of four departments that make up the School of Social Work. MSW students were interviewed during the final semester of their master's degree coursework. The researchers asked the field liaison for names of MSW students who were interning in health settings, including mental health settings. All MSW students were part of the Children, Youth, and Families Department within the School of Social Work. All MSN students were part of the Family Nurse Practitioner program (FNP) and students were recruited during the first semester of their master's program. The choice to recruit MSW students later in their educational career and nursing students early in their master's level nursing education was purposeful. Because there is no specified degree needed to enter into a MSW program, most students are socialized into their profession through their educational and field practicum experiences during a masters' program. Fourteen percent of the MSW students in the school had a baccalaureate social work (BSW) degree when entering the MSW program, thus some students in this study could have had undergraduate socialization into the social work profession. Conversely, all FNP students have already been socialized into their profession through the process of completing their baccalaureate nursing education, and through working as nurses for at least one year prior to entering the FNP program. This decision was made because there was a preference for students who had a professional identity established and could reflect on how the SDOH were introduced to them in their educational experience as well as on how SDOH affected their practice.
While students in the same school (different departments), the social work students and nursing students who participated in this study did not have any classes together. In the current model, the FNP curriculum does have nursing students take one class with social work students (human development); nursing students also take an elective from the social work curriculum. Neither of these joint nursing and social work classes occur in the first semester (when the nursing students were recruited). Because the nursing program was new at the time of this study, none of the recruited social work students had classes with nursing students.
For recruitment, the field/clinical administrators at the University provided the principal investigator with a list of eligible students. All 33 students on the social work list were emailed; 12 (36.4 %) agreed to participate. To create a comparable baseline recruitment number, 33 nursing students were randomly selected from the list of 53; 13 (39.4 %) agreed to participate. In total, 25 students agreed to participate in the study. The email sent to students assured them that their participation or refusal to participate would not be known to their faculty and would not affect their grades in any way. An information sheet, approved by the University IRB, was sent to students who emailed back an interest in participating. This information sheet included all required protections for human subjects including, but not limited to, exactly what participation would entail (e.g. recorded interviews), the students' ability to withdraw from the study at any time, and deidentification of recordings and transcriptions from the study. Students were asked to agree (via email) to the conditions outlined in the information sheet prior to setting up a time for an interview. All students who emailed with interest in participation agreed to the IRB conditions. Students received a $30.00 gift certificate for participation.

Interview procedure
Interviews occurred over the phone and were audiorecorded and professionally transcribed as the interviews occurred. At the beginning of the telephone interview, participants were again asked to verbally consent to participate in the study. Once the participant provided consent, the interview commenced. The interviewer was a graduate education student trained by the researchers prior to beginning the study. The two main questions were: (1) What do you know about the SDOH?; and (2) How do you think your education and practice experiences affected what you know about the SDOH? The semi-structured interview guide included written questions and included prompts to elicit more details about the students' ideas (used as needed).
Probes were asked in response to participants' answers to verify understanding of answers provided. The interviews lasted, on average, 45 minutes.

Analysis
Qualitative description (Sandelowski, 2000) guided the data analysis process. Two major broad, open-ended questions, as described above, were developed. The data analysis was guided by these topical areas, while also incorporating any new ideas/concepts generated in the data. The analysis was guided by two topics: (1) students' concept of SDOH and (2) students' past education and practice experience on the SDOH. The goal was to describe the students' meanings of SDOH rather than to develop a more abstract, theoretical explanation for their meanings. Each interview was transcribed verbatim and was de-identified to ensure confidentiality. Each de-identified transcript was read by two of the researchers (JS and EO) individually and a sampling of interviews was read by a third researcher (JC). JS and EO met together three times; the first time they met after reviewing the first 8 interviews, the second after reviewing the second 8 interviews, and finally after reading all the interviews. At each meeting the researchers reviewed the coding of the data, discussed any differ-ences, and came to consensus on the coding decisions. JC reviewed a randomly chosen sample of interviews, as well as the summary of the coding decisions. Finally, all three researchers met to review the themes found in the interviews. The multiple meetings were done to assure rigor in the analysis. Transcripts were read line by line and concepts that seemed to reflect the meaning in the transcripts were generated. While this was not a grounded theory study (i.e. we did not seek to generate theory), we used a key component of grounded theory, that of constant comparative analysis (Glaser & Strauss, 1967). Constant comparison emphasizes the iterative nature of qualitative research in that as data were analyzed, the researchers went back to previous data (within the same transcript or in other transcripts) in order to compare the ongoing data analysis and to develop a more contextual understanding of the data. This methodology also assures rigor in the analysis. Through multiple meetings, combined with individual review/analysis of the data, the research team had the opportunity to compare the interpretation of data by each member of the team, followed by comparative analysis together, integrating the perspectives of each member of the research team. In keeping with qualitative description, the analysis of the data includes presentation of broad categories that reflect an organizational schema to present the results.

Participant Demographics
The participants in the study included 13 nursing students and 12 social work students. The mean age of the nursing students was 35.6 years, consisting of 11 females and 2 males. The self-identified racial/ethnic makeup of the nursing participants included: 7 Asians, 5 Whites, and 1 Latinx. The 12 social work student participants had a mean age of 32.4 years; 10 were females and 2 were males. The self-identified racial/ethnic makeup of the social work participants was 3 Latinx, 3 Blacks, 3 Whites, 2 mixed race, and 1 Asian.

Meaning of the SDOH
The term social determinants of health was not new to the nursing and social work students, although some had greater familiarity with it than did others. Both social work and nursing students were aware of (and seemed to understand) the concept and why it is important in caring for patients/clients, with some difference between these two groups of students. The similarities included awareness of the following broad categories/ themes: socioeconomic factors, patient/client educa-tional factors, and access factors. These categories are not mutually exclusive, and specific descriptors of these categories often included the interrelationship among the categories. Support for these categories is reflected in the interview data. (See table 1

for example quotes.)
Themes Examples of Nurses (N) and Social Work (SW) Students' Interview Quotes

Socioeconomic factors
Economic "There's a lot affected if the money goes to medical bills instead of food or payment for education or payment for rent." N4 "…in spite of knowing what to do but because they cannot afford it. You know, they would opt to do something else…" N5 "It's the socioeconomic level….and its effect on your well-being, your everyday well-being." SW3 "Their economic status. Like with our clients a lot of them are, their economic status would be, like, poverty." SW6 "Those who have more access to higher incomes would have less with their health impacts and more, like, insurance availability." SW7 "Also because they are in poverty, you know, it's hard for them to access these services." SW8 Social "What comes to mind is what aspect of my patient socially..is either like a barrier to health care." N1 "Their ability to socialize with others." N8 "Social aspects in one's life that have either a positive or an adverse effect on a person's well-being." SW3 "It's like social factors or economic factors that contribute to someone's health or a community's overall health." SW1 Patient/Client Educational Factors "Because they couldn't read, go to school…so they don't really know much about how to maintain a good, healthy lifestyle." N4 "If they're not educated they seem to have fewer opportunities in health care because either they don't know about care that's available or they don't realize the impact that it has on their overall health." N6 "We see them later in their disease processes than we would normally see people…who have the education background to seek out care prior to getting very ill." N6 "…the ability to read themselves or have a family member who can read and interpret instruction for administering their medications." N8 "You know having access to health insurance is the difference between life and death (in transplant patients)." N8 "Education and what people know about what's available to them…" SW3 "It's a correlation to lower education and awareness of certain (health-related) topics for example." SW7 Access "I have a client who is a victim of a violent crime. She lives in a not so nice part of town, she also has anxiety and despression and she does not have access to mental health services. First of all, she does't drive and she has a low-income family so she doesn't really have extra money for transportation and what not." SW 3 "Having access to the different locations and also different treatment or whatever it is they need for their health (limited for many patients)." SW 8 "Access to me means that you are able to get in with a clinicians in a timely manner and have somebody who follows your care. To keep healthy you need to be able to monitor your health and you know that's largely through health care providers and having regular check-ups……things like high blood pressure, diabetes…." N6 "If you don't have access to a car and you have to rely on public transportation and for that reason you do not make it to your clinic appointment on time and you lose the ability to continue to see that physi-cian…the ability to follow through on the recommendations of the health care team…" N8

Table 1. Examples of Interview Data Supporting the Themes about the meaning of the Social Determinants of Health (SDOH)
Social work and nursing students generally had a common understanding of SDOH, although there were subtle differences in their descriptions. Social work students emphasized social issues as broadly affecting health, while nursing students made more connections to specific health conditions, such as high blood pressure or diabetes. Another difference between the two groups of students was that social work students had a greater community focus while nursing students focused a bit more on individuals and families. Social work students also focused more on the importance of health policy.

Socioeconomic Factors
Socioeconomic factors comprise a wide array of dimensions. Economic factors, in particular, were described as creating choices that were detrimental because of having to prioritize. For example, because of poverty, many people had to forego healthcare-related services in order to maintain food and shelter. Economic and financial issues created limitations in the ability to make maximum use of healthcare resources. Economic factors were often described in relation to lack of access. Social factors were interrelated with economic factors, but were often described as separate from income levels alone. Sometimes they were referred to in relation to social support from friends and/or family members. Other times they were referred to as social status. Social factors were commonly described by social work students in relation to a community focus.

Patient/Client Educational Factors
Both social work and nursing students commonly noted patient/client educational factors as important factors that contribute to SDOH. Education could be in the form of formal education, but health literacy was also discussed (particularly related to health and healthcare). Students described some people being disadvantaged due to the lack of education in general, but also described people lacking specific education about resources and the need for preventive care.

Access Factors
Access was another category (clearly related to the previous categories described), but was often noted by the students as an important specific area that affects health. Social work students were very aware of the significance of the variety of social services available while also emphasizing that the existence of services does not always equate to use of services, with lack of transportation a particular form of lack of access. They described lack of access as limiting availability of different treatments. Nursing students described lack of access in relation to specific health care resources that normally would facilitate health promotion and illness prevention.

Education on the SDOH
Social work students and nursing students had mostly similar views about how they were educated about the social determinants of health. The most pervasive theme was that exposure to others (people unlike themselves) was the most important element in their education about SDOH. The exposure to others included both caring for different types of clients/patients and being around different types of individuals. Both groups of students found their clinical and field experiences useful to understand how the SDOH affect people's health and healthcare. Additionally, social work and nursing students spoke about how their life experiences outside of school were vital elements in their exposure to others. The second common theme was the need more information about policies and how policies affect their clients' health. The nursing students had some knowledge of hospital policies but needed more information about how community and governmental policies affected the SDOH. Social work students universally felt they needed more information on health policy. The final theme was differences in educational emphasis on SDOH. Social work students stressed how cultural awareness and avoiding stereotypes were vital elements. Nursing students emphasized the tools for incorporation of teamwork and collaboration in healthcare delivery. (See Table 2 for example quotes.)

Exposure to Others
Social work students stressed that their field experiences were varied and exposed them to people with different types of stresses and social problems that affect their health. Nursing students identified that their work in lower income communities and caring for patients whose circumstances were different from their own allowed them a better understanding of barriers to achieving health. Many nursing and social work students noted that their own varied life experiences made them aware of the importance of the SDOH. Although nursing and social work students voiced that exposure to people unlike themselves, rather than specifically classroom experiences, were more helpful in a broad understanding of the SDOH, they did not discount how the classroom was important. Nursing students identified that using case studies and talking to other students could also bring these varied experiences into the classroom. Social work students noted that theoretical knowledge learned in classrooms takes time to be incorporated into practice.

Themes Examples of Nurses (N) and Social Work (SW) Students' Interview Quotes Exposure to others
"..what really did it was the actual experience actually being a clinic and ..seeing how it works" SW 1 "I think probably first and foremost is to have sort of have some life experience behind us." SW5 ".. I think it's truly experiencing different things outside your comfort level are educational experiences. If you've never worked with a senior citizen before and then, all of the sudden you're thrown into a situation where they are your clients .." SW7 "Well, being in that internship that I'm in, it's making me look at a lot of different things and it's making me learn different aspects… of each individual because each individual is different. " SW6 "working in the field…exposed me to different types of people and the different people that are out there because before that I was, you know, like everybody else, living in [my]own bubble." SW11 "Listening to your patients and what their concerns are in regards to their own health" N1 "Helpful to be exposed to different kinds of patients in different socioeconomic status. " N4 "No matter where you're coming from, I think you need to be exposed to people from different backgrounds, different cultures, different ethnicities, and different socioeconomic standings to get to a point where you have a better awareness of the full complexity of the human existence in this world." N7 Classroom Experience "I was able to [use] some of the theories that I learned about and ….a light bulb went off… I was able to apply them." SW5 "I did a lot of case studies about…different communities and different needs of communities." N6 "If there was a class that would talk [only] about social determinants of health…it is such an important part of nursing…treating patient holistically and looking at every factor of their life. "N3 Healthcare Policy "I think… some education on the processes of government and policy and management of patient care… in the community setting is really important. "N6 "I think from a policy standpoint, I'm less well-versed on what actual policies are. I have never actually thought about it." N8 "I think advocating at the local governmental level for funding. So for example, in the geographical area where I work, that would mean working with local government to enact policies that would allow for funding of clinics…. where patients can be seen who would not qualify to be seen other places, for example due to immigration status." N6 "So maybe we should just have a class [on health care policies]" SW 6 "People in this field need to be knowledgeable of health care and what the funding is…As a social worker [we need to know] how these policies impact clients." SW7 "We need to advocate for people in need. I think, for example, for post-partum depression. I think it would help to provide health insurance to mothers after pregnancy." SW8

Differences in Educational Emphasis
Social Work "I think for social work students and social workers in general, we need to have a lot of, like, cultural awareness training, cultural sensitivity training because… [ of the need to] curb their pre-conceived notions of people." SW3 " I think the more culturally competent we are, the healthier we become." SW4 Nursing "I think my training in case management has opened me to understanding that it's not really easy just to discharge someone…Social factors, I think always need to be addressed and, sometimes it can't be done on ..a specific timeframe that most insurance gives us. It all comes down to again, to how skillful the social worker and case manager are in figuring out and fixing the problem." N12 "I think that collaboration, multi-disciplinary collaboration is really important. I don't think any of us as health care professionals operate in a vacuum." N6

Healthcare Policy
Social work and nursing students were aware that their lack of information about healthcare policy made it more difficult for them to affect change for their patients. Both groups of students expressed they were not as prepared as they needed to be in terms of understanding policy in order to help their clients/patients. The nursing and social work students wanted more classroom information to be able to be able to address patients/ clients' access issues in their clinical and field settings. Both groups of students suggested a specific health policy class so they were able to be as informed as possible. The students' roles as advocates for better health care and more access were strongly voiced by both groups of students.

Differences in Educational Emphasis
The final theme in the educational experiences category was differences in educational emphasis by profession. Social work students were sensitive to how SDOH affect different groups of people and how their own sensitivity to differences was an important part of their education as social workers. The social work students were taught to be non-judgmental about differences and how these differences affected their clients' behaviors and attitudes. Nursing students recognized the importance of including SDOH in the classroom and wanted the educational focus about SDOH to include how to work with other professionals to provide the best possible healthcare. The nursing students wanted to know how to direct the patient to access services that they could not provide and how to work with others on the patients' behalf.

Discussion
Recent attention by both nursing and social work to the importance of SDOH is evident in the existing literature as well as in priorities developed within both professions. Nursing and social work clearly share a mutual concern and a focus on SDOH. Historically, however, barriers have existed that prevent optimal interprofessional collaboration; one underlying factor that might explain such barriers is a lack of understanding by each profession of the views of the other on the importance of SDOH. The results of our study elucidate the similarities and differences in views in an effort to contribute to better understanding of each profession by the other.
In general, both nursing and social work students recognized that socioeconomic factors, patient/client educational factors, and access factors contribute to health and healthcare. Differences, while subtle, included a broader focus among social work students of the influence of SDOH on vulnerability and disparities and communities. While nursing students also focused on vulnerability and disparities, they emphasized the effects of SDOH on specific health conditions such as diabetes and hypertension. Social work students included the importance of health policy to a greater extent than did nursing students, though both groups expressed an understanding of the importance of health policy. A particular commonality between the two groups of students is how advocacy is important to address SDOH. Policy advocacy in social work is long-standing (Jansson, 2015) where nursing's role in policy advocacy is more recent (Adams, Dominelli, & Payne, 2009;Spenceley, Reutter & Allen, 2006). Nurses have a history of practicing other types of advocacy including pediatric nurses' advocacy for children and their families, but this advocacy is primarily for individual care needs and listening to the voices of children (McPherson & Thorne, 2000). Nursing educators could learn from social work educators about policy advocacy theories and techniques that would allow nursing to step up their role in making policy changes that address health equity. This study also points to a common need for more information about health policy, which can drive advocacy.
Differences in how social work and nursing students viewed what the focus of their education about SDOH should include was partly due to the types of work and clinical experiences to which the students had been exposed. All the nursing students had previously worked in healthcare settings and these settings are inherently multidisciplinary. Nursing has a long-standing recognition of team approach to care. For example, in The Future of Nursing: Campaign for Action (2015), a collaboration between the Robert Wood Johnson Foundation and the American Association of Retired Persons, interprofessional work is defined as the "cornerstone" of healthcare delivery through a team approach. Although we tried to recruit from the Department of Children, Youth, and Family social work students who were specifically in health settings, some of these students were from social service agencies and may not have had as much exposure to multidisciplinary care.
Thus, the nursing students were more acutely aware of how healthcare is an inter-professional playing field, and in order to be successful each team member needs to work with other team members (Leonard, Graham, & Bonacum, 2004). The social work students in this study were not specifically in a health concentration since the School of Social Work does not have a health concentration, and social work's training on interprofessional collaboration has mainly occurred within health social work courses and practice settings, with little integration of interprofessional training into generalist coursework (Nimmagadda & Murphy, 2014). However, more recent efforts, including the creation of the interprofessional education collaborative by the Council on Social Work Education (2018) has increased educational and training opportunities in interprofessional collaboration in social work.
The importance that students placed on field and clinical experience in understanding the SDOH affects patients' and clients' lives is not surprising. Educators have felt that practice in the field is key to learning and professional competence (Dunn, Ehrich, Mylonas & Hansord, 2000). Although research of the outcomes of practicums is less convincing on practicums' effects on professional student learning (Ryan, Toohey & Hughes, 1996). The participants in the study were convinced that exposure to underserved populations made them see the SDOH in action. Thus, for both social work and nursing students in this study, an important part of their education was their practical experience working with families and communities where the SDOH played a part in decreasing health equity and access.
Interprofessional education experts find that students from health professions in varied educational settings learn from and about each other in innovative curricula, and in real world patient care settings (Earnest & Brandt, 2014). However, Earnest and Brandt (2014) conclude that these types of successful interprofessional educational endeavors are rare. Interprofessional education also affects students' knowledge and opinions about the importance of teamwork (Hood et al., 2014) and could be an important step for social work and nursing to collaboratively address SDOH. An evaluation of an interdisciplinary project with social work and undergraduate nursing students in a middle school found that although the students found value in understanding the others' professional outlook, there was still some confusion on roles and expectations (Alexander, Bashore & Jackson, 2017). The nursing and social work students in the school where this study occurred will have the opportunity to take classes together, but neither of the courses that are required for nursing students address methods for interprofessional work or team building; this might be necessary to address role confusion or perceived inequities. Additionally, since exposure to underserved populations was found to increase social work and nursing students' understanding of SDOH, including joint clinical experiences with underserved populations with a specific emphasis on the two profession's emphasis on SDOH might hold promise. In Canada, voluntary student-run clinics for primarily First Nations individuals included varied health professional students, including social work and nursing, and were found to increase learning in a multi-directional way (i.e. students were mentored by their peers and advanced students, by licensed healthcare professionals, and by the patients themselves; Homqvist et al, 2012).

Limitations
This study's transferability is limited in that the nursing students interviewed in this study chose to enroll in a Department of Nursing, which was within a School of Social Work. Therefore, the nursing students may have been more sensitive to the role of SDOH than students who choose unaffiliated graduate nursing programs. This study recruited students from one university, which limits transferability. We specifically choose to recruit MSW students at the end of their educational program, but we do not know whether the students had a BSW or whether they practiced social work prior to entering their MSW program. Additionally, we do not know how many years the nursing students practiced prior to entering the FNP program. The students' previous practice experience could have affected their understanding of the SDOH. The study only included 25 participants, which also limits transferability.

Conclusions
The findings of this study have implications for exploring strategic ways for social work and nursing to collaborate in an effort to close the health gap that is created due to inequities and disparities in health and healthcare, often explained by adverse SDOH. More research is warranted in this important area in order to meet the challenges in creating a more effective and equitable health system. Nursing and social work professionals are poised to meet these challenges. The students' attention to how access, socioeconomic issues, and patient/ client education are integral to both understanding SDOH and addressing the inequities caused by SDOH is a good starting point for the two professions working together. The subtle differences between how social work students and nursing students view the SDOH were somewhat minor. Interprofessional education that includes the SDOH may be a good place to begin to finding a way to bridge the differences in emphasis on what the SDOH mean, thereby facilitating constructive collaboration between these two professions.