The TOLERance Model for Promoting Structural Competency in Nursing Zvika Orr, PhD; and Shifra Unger, MPH, RN I n the past few years, there has been growing recognition of the need to promote “structural competency” among health care professionals and students (Metzl & Hansen, 2014). Structural competency is the trained ability to discern and ac- knowledge how sociopolitical structures, such as public poli- cies, economic systems, and health care delivery systems, have produced and maintained social inequities and health dispari- ties. Structural competency calls on health care professionals to recognize how these structures shape diseases and symptoms. It also encourages them to be aware of how these inequalities are manifested in provider–patient interactions, as well as in the community and policy levels, and to take action on these three levels (Metzl & Hansen, 2014; Neff et al., 2017). Structural competency has become an increasingly known and accepted framework for training and teaching, especially in the United States. However, there are two main gaps in the existing literature on structural competency programs that this article aims to address. First, most of the programs and train- ings have been designed and designated mainly for physicians and resident physicians (Hansen et al., 2018; Neff et al., 2017, 2019), medical students (Rabinowitz et al., 2017) and prehealth students (Metzl et al., 2018; Petty et al., 2017), rather than for nurses and nursing students, even though nurses’ position al- lows them to recognize the bodily harm caused by structural forces (Pine, 2013). This article discusses a unique structural competency training program for undergraduate and graduate nursing students in Israel that specifically addresses nurses’ pro- fessional practices and concerns. In addition, the trainers and teachers at the existing structural competency programs are predominantly physicians and medical students, as well as social scientists and other academics. They usually represent and mediate the voice of the marginalized patients. The program that we discuss in this article integrates patients from disadvantaged groups, such as people with intel- lectual and psychiatric disabilities, as trainers in the structural competency program alongside nurses and social scientists. The following section briefly explains the concept of struc- tural competency. We then discuss the structural competency training model that we have developed for nursing students— the TOLERance model—and its results at the Jerusalem Col- lege of Technology (JCT). ABSTRACT Background: Structural competency is the trained ability to recognize how social, political, economic, and legal structures shape diseases and symptoms. Although structural competency has become an increasingly ac- cepted framework for training and teaching, it usually has not addressed nursing students and has not included marginalized patients as trainers. Method: This article ana- lyzes a structural competency training model for nursing students that includes five components: Theory, Observa- tions, Learning from patients, Engagement, and Research (the TOLERance model). Results: The TOLERance model increases the understanding of the interrelation between the individual clinical level and the sociopolitical structural level. It encourages nursing students to actively engage in social, political, and policy issues that affect their patients’ health and to advocate for policy change. Conclusion: The moral and professional commitment of nurses to their patients demands that they do not ignore the structural forces that are detrimental to their patients’ health. The TOLERance model provides nursing students with skills and competencies that help them to fulfill this commit- ment. [J Nurs Educ. 2020;59(8):425-432.] Dr. Orr is Senior Lecturer, and Ms. Unger is Teacher, Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel. The authors thank the Structural Competency Working Group in the San Francisco Bay Area, and Josh Neff, Seth Holmes, Shirley Strong, Kelly Knight, Eiad Abu Sarah, and Anat Romem for their gen- erous help and inspiration. The authors also thank Daphna Golan, Nancy Scheper-Hughes, Jonathan Metzl, Mark Fleming, and Adrienne Pine for their advice, and Israeli Hope in Academia for their support. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Zvika Orr, PhD, Senior Lecturer, Depart- ment of Nursing, Jerusalem College of Technology, 11 Beit Hadfus Street, Jerusalem 9548311, Israel; email: orr@g.jct.ac.il. Received: January 26, 2020; Accepted: May 20, 2020 doi:10.3928/01484834-20200723-02 Journal of Nursing Education • Vol. 59, No. 8, 2020 425