How can students learn and use the principles of Public Health in a brief 15-week semester? Even more importantly how can they actively study and assimilate the public health philosophy which is essential to their political position as service professionals, regardless of the actual setting of their practice? Whatever can be done to integrate public health premises and theory with clinical experience will allow students more time to experiment with this alternative approach in health care. This in turn will aid their future work.
I hypothesize that providing a superior base in public health concepts requires the BSN program's broader use of liberal studies. Both a general education and Public Health are essential to imaginative, substantive thought which brings about critical study, research, and relevant change in health care. Acquiring new information is not enough for the student. An essay in the Phi Beta Kappa bulletin, Key Reporter by Jaroslav Pelikan (1979-1980, p. 2), addresses the "difference between ordinary research and significant research [which] is frequently the result not of still more concentration of the scholar's own discipline but of the insights that come from liberal studies." The same need exists in Public Health, namely to get the students, the future professionals, to extend their concept of health care beyond the traditional medical model. This is essential in Public Health because it is a system of generalists who act with a total approach in assisting families and groups to achieve both physical and mental health goals. Students need, therefore, to move simultaneously toward expansion and specificity in their work with clients in the community.
In Teaching the Universe of Discourse, James Moffett (1968, p. 57) develops the relationship between thought, speech, and writing. By learning to write better, students improve their ability to express themselves extensively and complexly in any of the communication modes appropriate to the topic and to the audience. This improved skill affects other student competencies. Success increases the confidence needed by students to explore other new means of expression. Then they can risk considering other options for their learning. More importantly, the processes of skillful writers show that writing leads to further thinking, clarification, and generalizing. Writing necessitates significant revision to aid another's understanding of the author's words. During the process of reflecting on others' perceptions, "decentering" occurs. The student begins "seeing alternatives, . . .standing in others' shoes, . . .knowing that one has a private or local point of view and knowledge structure." Critical thinking processes expand as it becomes essential to analyze different perspectives and their consequences and to compare them to and change personal views.
Janet Emig (1977, p. 124) recalls Jerome Bruner's assertion that we learn "by doing," by depiction in image, and "by restatement in words." Writing uses hand, eye, and brain to communicate. It also demands the "fullest functioning of the brain," the emotive, intuitive, relational right side and the processing action of the left (p 125). Emig stresses that writing requires connections not only to be made but to be declared, thus involving the student actively in the act of learning. Because of the time involved in writing, reflection and passage between present, past, and future occur, further reinforcing the relationships that people actually search for in the real world. Indeed, as with learning, writing is "multi-representational and integrative,'' physical evidence to students of their own "evolution of thought (p. 128). Reader response to the product aids the connective engaging qualities of writing. Moffett and Emig show writing as a process that is critical to the act of thinking and therefore invaluable to the work of Public Health.
A sophisticated narrative public health journal was used for two complete, 15- week semesters, 1979-1980, with 70 senior students. Twenty-four students' performances could be studied thoroughly during that time. A spin-off from the basically reflexive tool used in English classes, the journal was to provide a non-threatening, confidence-building writing and thinking experience. It was assumed that the designed experiment of the journal would result in writing which would produce changes, at least to some degree, in students' attitude toward the hither-to unknown public health concepts. The goals of the project included:
1. increasing the rate and effectiveness of integrating public health theory and practice. This includes an earlier acceptance of the Public Health model.
SLATER SCALE RATING - % STUDENTS WITH 3.8+ SCORE (MAX. - 4.0)
MID TERM GRADES - % STUDENTS WITH 80%+ ON OVERALL TEST
2. increasing the ease and effectiveness of writing in the narrative mode.
3. increasing use of creative thought.
4. increasing direct personal exchange with faculty each week, an important objective when 10-13 students make up each clinical group with each student having five to seven cases and other community group projects.
The guidelines for the journal needed to be flexible enough to promote experimentation and exploration in thought, expression, and writing technique yet specific enough to provide a sense of direction and significance for students. With this in mind, it was determined that the process for working with the journal should be:
1. students would select their own individual topics. There would be no right or wrong topic or comment. Students would keep in mind, though:
* the new range of ideas they were being exposed to and considering.
* the relationships drawn between theory and practice and between the political and health systems.
* the significant awarenesses they had come to.
2. teachers would concentrate on guiding the student toward further exploration through written feedback. They would positively confront students about contradictions in the journals by encouraging additional query and further investigation into the consequences of decisions.
3. students and teacher would invest energy in their respective parts of this communication process. Students would write in a book they chose so continuity of the process would be maintained, and they would determine the length of the entry. Journals were submitted on the last clinical day each week. Faculty wrote responses and gave back the journals on the first day of the next week's clinical experience. At the end of the semester, students would provide a narrative assessment and grade evaluation of their work in this process, 5% of their grade for Public Health being derived from this project.
Outcomes related specifically to three key objectives (Figure 1).
Clinical Practice, Exam Scores, and Other Student ftpers
A comparison of Slater scores (Figure 2) reveals 45% of the students in the fall of 1978-1979, when the journal was not being used, received ratings of 3.8-4.0 grade point conversion, while 100% in the winter did. In the 1979-1980 fall semester, 69% of the students got a rating of 3.8-4.0, and 91% in the winter did. Grades in mid term exams show change also (Figure 3), none of the 1978-1979 fall students achieving a score in the 80s and above; 12.5% of the winter group did. The 1979-1980 fall students had 38% in the 80s range, and the winter group had 73% in the 80s and above. Grades in narrative papers across both years remained essentially the same, in the 80s and 90s; this area did not seem to be affected much, possibly because one paper was a narrative of the nursing process for a family, a process familiar to the student, though the style of writing required in Public Health was more sophisticated. The other paper was a community analysis done in groups of two to three students, which allowed students to collectively smooth out the presentation.
VALUES ABOUT HEALTH CAHE - % STUDENTS EXPLORING IDEAS
ESSAY PORTION ON EXAMS (FOR EXPERIMENTAL GROUP ONLU) -% STUDNETS WITH 80%+
Values About Health Care
Non-gradable measures of progress were also noted in the experimental group, which are the most significant indicators of progress in the overall goal of increasing student integration of public health theory with practice. This is a key objective because Public Health is critical to nurses' development of a population-focussed health care system. A third of the students in the fall 1978-1979 demonstrated significant or continuing exploration of the values involved in health care delivery (Figure 4). Thirty-seven percent of the winter group did. Though these students did not use a journal, their ideas and struggles became apparent in individual and group conferences. In the 1979-1980 group, 69% of the fall students made such changes, and 55% did in the winter. Students began to question some faculty's lecture statements about the myth of the culture of poverty, for example, since other teachers had emphasized the influence of society and environment on self-expectations. Having to look at theoretical questioning of why this occurred in society prevented students from being able to apply the simplistic cliches and rationale that are offered as explanations in the society. Students shared in their journals that not only was Public Health forcing them to see new ideas for that experience but that the questions made them look at themselves and how they, as everyone, are conditioned toward certain views. They explored and grew through their journal presentations until they saw that it was not inevitable they retain their old ideas. Change could occur personally once they became aware of the reality and contradictions of their original views, of the consequences for nursing practice and for the population's health needs in their outlook, and of the ability to change professional behavior and attitude through external and internal dialogue.
Student comments about the journals, essay writing on exams, and journal interaction with the teacher show the positive value students felt, at times begrudgingly, toward the process. Faculty stated the purpose of the journal was to increase student comfort and effectiveness in writing at the beginning of each semester in which it was used. Faculty, therefore, showed that effective, clear, noteworthy narrative writing was a desirable and necessary skill for senior students to work on and possess. The fact that students did not have to be fearful about what they wrote in the journal, but that they did have to write and think allowed them a safe but definite place to do this in. The teachers, furthermore, emphasized the appropriateness of narrative writing by having the essay become a part also of examinations, previously only set up with multiple-choice questions.
The physical exchange of the journals between student and teacher reflected the significance the process began to take on. Students handed in their journals weekly. If they were delayed they made a point of saying when they would be in, and delivered them in time to get written response for the next week. Each entry could become, and often was, a further development of important ideas and new awakenings for the student from prior weeks- Some students, in fact, would turn in ajournai entry because they wanted to and found it of special value, even if another paper was due that week which meant a journal was not requested by the teacher. They stated they found it made ideas clearer in their minds when they had to write them down. They needed the feedback to have their thoughts validated and supported in the new endeavors they were being asked to take on in Public Health. It was critical to read and think with each student's entry and to give written feedback to them each Monday. This would take about three hours each weekend - the reading, analysis, reflection, and writing. The energy put into the reply reinforced for the student that the teacher also valued writing as a thought and communication process, because it was done regularly and directly to the student.
Students continued to express dislike over essay questions on exams. They had been conditioned toward this through their relatively little experience in writing during their four years at the University, even in some of their liberal arts classes. However they improved in their writing on exams, which faculty continually pointed out to them (Figure 5). In the fall of 1979-1980, 69% of the students in the group that were studied got at least 80% credit for the 23-point essay segment of the mid term exam and 54% got at least 80% credit for the 20-point essay portion of the final. In the winter of 1979-1980, 73% of the students got 80% or better on the mid-term exam which consisted entirely of a takehome exam. Students chose three out of six questions from it to write on. There were no essay questions on the final exam for that semester. The previous year, 1978-1979, students had one or two essay questions for 10-14 points on the mid term and final. Scores were not kept separately on those portions of the exam, but the students complained bitterly and long about having to write essays even when they did them satisfactorily. They were not used to writing an exam this way and did not want to have to do that.
Students exhibited increased creativity in both the journals and the narrative paper assignment in 1979-1980. The form of journal entries revealed this especially. As students got more into their investigation of significant issues in their journals, they began to look at such questions as: Why does poverty exist? How and why does the society devalue positive health behaviors? Writing at times began to resemble stream of consciousness prose. In other places, students were asked if they had considered writing poetry. They had and applied that skill to this exploration. They had not known before, not received permission for, and not opened themselves to seeing that various forme of discourse could well be used more effectively for working out ideas and expressing them more sharply to others. One student with fine artistic skills began to sketch not only in journal entries but to create illustrations to hang in the agency. Her talent could be used in nursing. Students and staff alike responded to her pictorial challenge which said: "I wondered why somebody didn't do something, then I realized I am somebody."
Narrative papers showed improvement, not through grades, but in the broader topic range selected for discussion and the application made to the larger community. Students examined the isolation of older persons in several of their cases for the nursing process paper, instead of choosing a topic that involved one family only in their caseload. The problem of continued education for young teen-age mothers was explored in another paper. For community analyses, students selected more significant problems of sub-communities and studied possible agency assistance, such as the powerlessness of public assistance recipients and the work of the Welfare Rights Organization; the institutional racism in the health care of poor blacks located in a generally more affluent county and the role of the Health Department in addressing the problems. The integration of Public Health, nursing, social science, and political theories in public health work demands and allows the increased integration of the Public Health worker, in this case the senior student in nursing. The form of the journal aided that process for the students in Public Health, 1979-1980.
The experimental use of the Public Health journal is of value for several reasons. It demonstrates, again, that we may create more positive environments for learning in nursing. We can use techniques from various disciplines in order to get students to use more of their faculties and senses in thinking, problem solving, and communicating. The writing project arose out of the problem students have in assimilating Public Health values, in considering a wider range of alternatives for health care, and in feeling Ul at ease with narrative writing and exploration. Since skills in cognition, thought, and writing are interrelated and affect each other, it is appropriate to apply writing methods and examine the outcomes in nursing students' work.
The findings support the value of the narrative journal process. Although it does not operate alone in changing student overall response to Public Health in any given semester, it does affect who the students are and what their political-social values are. The students, in general, have been exposed to only traditional, conservative ideas regarding health care delivery and the state's social responsibilities. It is in experimenting with alternative ways to deal with the problems students have in approaching the Public Health model that we further aid them in their struggle to become professional nurse practitioners, who can effectively help people achieve "physical, mental, and social well being," health as defined by the World Health Organization. This is the objective we, as nursing faculty, need to keep before ourselves as a guiding principle at all times.
- Emig J. (1977). Writing as a mode of learning. College composition and communication, 27(2), 124-128.
- Moifett, S. (1968X Teaching the universe of discourse. New York: Houghton Mifflin
- Pelikan, J. (1977-1980). A gentleman and a scholar. The Key Reporter, 45(2), 2.