Initial findings of The Future of Nursing 2020–2030 consensus study underscore the critical role of nurses in addressing individual needs, social determinants of health (SDOH), and leading change in health systems approaches to meet both health and social care needs (Campaign for Action, 2019). As the nursing profession continues to grow and develop to meet the evolving health needs of individuals, families, communities, and populations, public health nurses (PHNs) are at the forefront, assessing individual needs and creating interventions to meet health and wellness needs.
PHNs must possess a foundational understanding of the principles and practices of public health nursing to provide effective care to patients, families, communities, and populations. The groundbreaking Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health (2010) examined the needs of future projected populations and how nursing practice, education, and systems will need to evolve to meet their complex health and wellness needs. The report also examined the distribution of undergraduate nursing degrees and found baccalaureate nursing programs emphasized exposure to community and public health competencies across a broader range of settings than are addressed by nonbaccalaureate degree programs (IOM, 2010). In April 2019, the American Association of Colleges of Nursing (2019) reported that only 55% of RNs had obtained a baccalaureate degree or higher in nursing. A need exists to fill the gap in learning and experience by introducing RNs without baccalaureate degrees working in the public health setting to critical concepts vital to meeting the needs of populations using public health services (i.e., patients, families, and communities).
To address this gap, administrative law in one large southeastern state requires that all nonbaccalaureate-prepared RNs working in local governmental public health agencies complete an introductory course about the principles and practices of public health nursing. A module in the course uses scenario-based learning to introduce the learner to vulnerable populations, identifying individual-level social needs (Castrucci & Aurbach, 2019) and PHN interventions that can be provided during individual-level interactions with clients and families. Key concepts for developing PHN interventions, including SDOH (Hsieh & Coates, 2017) and primary, secondary, and tertiary prevention (Stanhope & Lancaster, 2016), are also covered. This article examines the development and integration of the real-world scenarios into the course module and provides example scenarios reflective of situations experienced in local governmental public health clinical programs and the related student worksheet.
When developing training, nurse educators are called to consider theories that promote effective learning (Barbour & Schuessler, 2018). The theory of andragogy, or adult learning, provides the theoretical foundation for the course. Adult learning principles consider that adults are self-directed and are responsible for their own learning; have life experiences that need to be valued and respected; need to be at a place of readiness to learn; want to be able to apply new knowledge immediately; are driven more by internal factors, such as interest in learning; and need to know the reason for learning something (Aliakbari et al., 2015; Merriam & Bierema, 2014). Applying adult learning principles necessitates a student-centered approach where the faculty member provides a facilitation role, and the student provides a more active role in learning (Park & Holtschneider, 2019). Silberman and Bierman (2015) shared that adult learning actively engages students in the content and allows students to acquire knowledge and skills rather than receiving them.
Through a partnership between a state division of public health and a university-based public health institute, nonbaccalaureate-prepared nurses practicing in local governmental public health departments are provided an intensive course on the principles and practices of public health nursing. The genesis of the course was the result of a 1976 ruling leading to administrative code requiring all nonbaccalaureate-educated nurses working in local governmental public health to complete an introductory public health nursing course during the first year of employment (North Carolina Administrative Code, 2016). Completion of the course is also a requirement of the legislatively mandated governmental public health accreditation process in this state (North Carolina Local Health Department Accreditation Program, 2020). The course is provided over 5 weeks and includes two online modules with required reading before attending a 3-day, in-person session. Required coursework covers overarching public health issues, including epidemiology, state public health law, and state-mandated governmental public health services. Public health nursing practice-specific content includes the Public Health Nursing: Scope and Standards of Practice (American Nurses Association, 2013), PHN competencies (Quad Council Coalition Competency Review Task Force, 2018), the nursing process in PHN practice, population health, care management, community health assessment, health promotion, disease prevention, and disaster planning and management. The in-person session culminates with a synthesis module that includes real-world scenarios followed by a mock patient interaction during a home visit where students critique a home visit simulation by applying knowledge learned in the course and recognizing appropriate PHN interventions (Cockroft & Oppewal, 2018).
The course uses a combination of didactic and active learning strategies, including group discussions, case studies, scenarios, and a simulation. In addition to adult learning principles, the course incorporates the principle of memory and transference (Brown et al., 2014). Through simulation scenarios, the participants can connect new knowledge with existing or stored knowledge. Using scenario-based learning allows students to use their experiences in the learning process. It also increases their readiness by using real-life examples that PHNs are likely to experience working in local governmental public health and allows them to build the skills needed to think through real-life situations (Aebersold, 2018).
Integrating Clinical Scenarios
State Division of Public Health PHN consultants, representing various program areas, developed written individual-level intervention scenarios. The scenarios are based on real-world situations faced by PHNs in the local governmental public health department setting (Table 1). The scenarios reflect the variety of clinical programs provided in the state's local governmental public health departments, including sexual health, family planning, breast and cervical care, adult health, and child health clinical services. These scenarios are used in the synthesis module toward the end of the in-person portion of the course.
Examples of Case Scenarios Provided for Small-Group Work
As the synthesis module begins, the students engage in a facilitated large-group discussion identifying vulnerable populations that PHNs care for in the local public health department setting. Then, a review of the three levels of prevention, SDOH, and individual-level social needs occurs before the faculty member provides a communicable disease scenario as a case example. In the example case scenario, “C.L.,” a 35-year-old female, presents to the health department on Monday morning requesting to be seen in the adult health clinic for a “check-up.” The PHN takes routine vital signs, which are all normal. The PHN conducts health history for C.L. and asks C.L. why she has come to the health department today. C.L. states she is concerned about an injury that she received on her right leg on Sunday afternoon. The PHN asks more questions and discovers that C.L. was bitten and scratched while trying to break up a fight between her outdoor cat and a raccoon. C.L. is uncertain about which animal bit and scratched her. She trapped the raccoon in a cage in her yard and wants to domesticate it. In fact, C.L.'s boyfriend is at home watching over the raccoon right now. C.L. shares the cat ran away after the fight but appeared unharmed. C.L. also mentions that her neighbors love to leave food out for stray animals and local wildlife, so they are used to seeing raccoons frequently. The faculty member then reviews individual-level social needs and SDOH that would need to be taken into consideration in this scenario, including:
- Social and Community Context: neighbors practice behaviors that increase the likelihood of exposure to wild animals;
- Neighborhood and Build Environment: lives near a wild animal habitat, safety issues; and
- Health and Health Care: recognizes the need for medical provider attention.
The faculty member then discusses appropriate PHN interventions. Primary prevention interventions would include educating the client about the risk of rabies and rabies transmission, contacting C.L.'s boyfriend immediately to advise no contact with the raccoon, calling animal control for the appropriate handling of the animal, and working with animal control to develop targeted educational campaign in C.L.'s neighborhood about rabies risks and measures to prevent potential exposures. The secondary prevention interventions would include working with animal control related to testing of the raccoon and confinement of the cat and referring the client to an appropriate provider for wound management. If the raccoon tests positive for rabies, then postexposure prophylaxis would be indicated, and the patient would need to be referred to an appropriate medical provider (i.e., emergency department, urgent care, primary care provider) for immune globulin administration and initial rabies vaccine. Plans would need to be made for the client to complete rabies vaccination series at days 3, 7, and 14, and the PHN would need to educate the client on the treatment plan and wound care to prevent secondary infection. Tertiary prevention interventions would include case management of the client to ensure appropriate follow-up and adherence to the vaccination series, monitoring of wound healing, and continued education with C.L. on reducing risks of exposure to wildlife.
The students are then asked to break into small groups of five or six to work on scenarios using the case scenario worksheet (Table 2). The students are given clear instructions on how to complete the worksheet and the time limit for the small-group work. Students are expected to use each other, their course materials, and reliable internet resources to work through each component of the worksheet and for developing PHN interventions at the primary, secondary, and tertiary levels. Students are also encouraged to creatively embellish the scenario to make the small-group work more engaging and meaningful. Each small group then reports their findings to the larger group while the faculty member facilitates discussion and clarifies concepts.
Example of A Case Scenario Worksheet Provided for Small-Group Work During the Synthesis Module
Results from the postcourse evaluations support that the scenario-based learning activity promotes learner engagement through collaboration and problem solving (Pilcher, 2018). Students indicated that sharing in the small and large groups during the module enhanced their learning and that the interactive atmosphere of the module made the content easier to understand (Little et al., 2020).
Although not all learning can be addressed through one theory or strategy, it is crucial to develop nursing education with a theoretical basis that supports learner outcomes. Focusing on adult learning principles and using strategies such as scenario-based learning provides students with the opportunity to apply the course content to situations they may encounter in their nursing work, increasing the relevancy and immediacy of the content. The benefits of using real-world scenarios include exposure to situations typical to the practice setting, high levels of engagement, encouragement of autonomy, and use of problem-solving skills.
Scenario-based learning activities can be generalized to all nursing education environments and nursing specialties. Each problem-centered scenario allows the student to use their critical thinking skills, newly acquired knowledge, and previous nursing experience to derive solutions. Small- and large-group discussions allow the students to learn from and with each other. Scenario-based enhancements, when developed using adult learning principles (Knowles et al., 2014), can be useful for improving the students' knowledge and skills and are an effective way to help students gain the skills necessary to be competent practitioners.
Providing continuing education for PHNs is an investment for all involved: the learner, the employing agency, the organization providing the training, and the community members who use PHN services (Public Health Foundation, 2017). Public health essential service number eight emphasizes the importance of a competent public health workforce to ensure effective care to meet the needs of the public and populations that PHNs serve (Centers for Disease Control and Prevention, 2018). Furthermore, a competent PHN workforce will more consistently address individual social needs and SDOH at every encounter with patients, families, communities, and populations (National Academies of Sciences, Engineering, and Medicine, 2016) when devising appropriate and effective interventions.
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Examples of Case Scenarios Provided for Small-Group Work
|STD Clinic Scenario|
|J.B., a 17-year-old man without insurance, presents to Lake County Health Department for STD screening. The PHN takes the STD history with the following findings: J.B. has been sexually active for approximately 2 months with two different male partners during this time.
J.B. denies any female partners and identifies as “gay.” J.B. states he has performed oral sex on both partners and did not use condoms, since “I can't get any infections that way.” J.B. also states he was a “top” during rectal sex with one partner 2 weeks ago. This was the only time he has engaged in this practice and did use a condom, but it ripped. J.B. states he has some concerns about some bumps that appeared at the base of his penis yesterday, as well as some yellow discharge from his urethra that has been occurring for approximately 1 week. There is no history of J.B. receiving HPV or a Hepatitis A vaccine; however, he did complete his Hepatitis B series and all other recommended childhood vaccinations. J.B. denies ever receiving any STD testing.|
|Family Planning Clinic Scenario|
|L.G., a 16-year-old woman, presents to Metro City Health Department for Family Planning Services. The PHN takes the patient's history with the following findings: L.G.'s BMI is 20. Her blood pressure is 110/60 mmHg. L.G. reports no tobacco use, but states that her mother, father, and brother smoke. L.G. has been sexually active for approximately 12 months with her boyfriend. She denies other partners. Al- though L.G. states she and her boyfriend use condoms, she reports that during their last sexual encounter 2 days ago, the condom broke. She denies other episodes of unprotected sex since her last menstrual period, which started 7 days ago. L.G. is worried about becoming pregnant, and she reports she wants a more effective method of contraception that she doesn't have to think about. When asked about her reproductive life plan, L.G. indicates that she wants to have children “one day,” but plans to finish high school and attend college before she gets pregnant. L.G. is up to date on all her immunizations, except HPV.|
|A 58-year-old woman, B.T., who is eligible under the Federal Poverty Guidelines, presents to the Forest County Health Department for BCCCP services on October 10, 2016. The PHN takes a health history. B.T. is para 3, gravida 3, abortion 0; has had all three living children vaginally and has had no surgeries; has not had a cervical screening in the past 5 years; has had a clinical breast examination and a mam- mogram 3 years ago. B.T. has not received an influenza vaccine this year and has never received a pneumonia vaccine. B.T. has no known allergies to medications or foods and, to her knowledge, has no medical problems per the health history checklist and review of systems.|
Example of A Case Scenario Worksheet Provided for Small-Group Work During the Synthesis Module
|Family Planning Clinic Scenario—28-Year-Old|
|M.W., a 28-year-old uninsured woman, presents to ABC health department for family planning services. The PHN takes the patient's his- tory with the following findings: MW is a gravida 3, parity 2, abortion 1, with 2 living children. M.W. has a family history of diabetes on her mother's side; her mother takes Glucophage ®, and her maternal grandmother is insulin dependent. M.W.'s BMI is 32, and her blood pressure is 148/85 mmHg. She smokes one pack of cigarettes per day. She had a Pap smear last year, which was normal. She is sexually active with her husband and reports their relationship is monogamous. M.W. currently uses oral contraceptive pills, which she has been using for the past 2 years, since the birth of her last child. M.W. does not want to have any more children for at least the next 3 years as she is planning to complete an associate degree program at the local community college. M.W. is up to date on her immunizations. Before M.W. sees the provider, the nurse rechecks M.W.'s blood pressure, and it is 140/85 mmHg.
Other data/information needed:
SDOH and individual social needs that must be taken into consideration: