Community health service agencies need BSN graduates who have a sound knowledge of both public health sciences and community nursing. One of the major challenges nursing educators face is finding appropriate clinical experiences to prepare students for work in community health. Providing opportunities for the application of theory in real settings with real groups can be particularly enriching for registered nursing students whose learning needs and motivations differ from those of the non-RN undergraduate. As adult learners, RN students are typically self-directed, experienced, desirous of learning material consistent with adult roles, and interested in immediate applicability of material (Cross, 1981). Socially relevant experiences that build on an RN1S previous knowledge are a particular challenge to educators.
This article presents an innovative clinical alternative for RNs in a BSN completion program in rural North Carolina using a clinical group experience that emphasized the community as a client and focused interventions on aggregate populations. The goal was to integrate public health science and nursing practice to reinforce nursings commitment to provide care as established by the ANA standards of Community Health Nursing practice (ANA, 1986).
The outreach program was offered through the Area Health Education Center in Fayetteville, NC. Thirty-six students enrolled in the course on community health concepts in Summer 1984 and in the clinical practice course the following fall.
The students represented a broad geographic area. They ranged in age from 26 to 57, with a mean age of 38. The class members were almost evenly divided in their basic educational preparation between ADN and diploma programs; two students had attended a college program that had not conferred a BSN degree.
Group members had significant clinical experience in nursing, ranging from 3 to 37 years, with a mean of 13.8. Clinical settings in which students previously had practiced covered an array of intensive and rehabilitative services for all age ranges: 23 students were employed at the time in a hospital setting, 4 worked in health departments, 2 in home health, 1 in a nursing home, and 2 in occupational health. Three students taught at the high school or technical college level; only one class member was not employed.
Students developed community-based projects during the summer concepts course and implemented them in the fall clinical course. Concepts and skills that students were expected to use in implementing their projects included leadership, group process, community assessment and intervention, change theory, collaborative decision making, and self, group and program evaluation. In the concepts course, students carried out a community assessment and used that information to identify community health needs and problems as well as target populations. Students then designed projects based on that data and a literature review. In the clinical course, students revised, implemented, and evaluated the projects. Eleven project groups with two to five members each were formed. Students were grouped according to agency assignment and home community in order to facilitate program development and minimize time and travel requirements.
Ib enhance communication between faculty and students, data sheets were completed by each student group with information on group membership, a group contact person, project title and description, implementation settings, community resources to be contacted, and times and location to meet with faculty. Each project group then met weekly with faculty to discuss activities and progress, ideas, and concerns. Students also used logs to detail activities, discuss theory, and communicate with faculty.
Students were responsible for contacting and negotiating with community resource people and target populations. Faculty were available for resource negotiation and also visited sites to provide input, support, and evaluation during the implementation phase and to meet with community personnel. Faculty also served as consultants, offering input and guidance throughout the projects.
Of the 11 projects, six focused on primary prevention, two on secondary prevention and three on tertiary prevention. Target populations ranged from teenagers to the elderly and methods used varied, depending on each groups needs.
Primary prevention programs focused on safety education for parents of infants and pre-school age children, advanced planning of funeral and burial arrangements for senior citizens, industrial employee safety education, basic life support skills for high school occupational health students, stress management techniques for first-year ADN nursing students, and prenatal care for pregnant teens. Sites for these activities included local hospitals and industries, public schools and colleges, nutrition centers, and health departments.
Secondary prevention activities included a screening, education, and vaccination program for hospital employees following a rubella outbreak and breast self-exam classes offered at multiple sites for professional and public audiences. Tertiary prevention programs included the formation of a local chapter of the American Diabetic Association, participation in a hospice development, and classes for hospitalized chronic obstructive pulmonary disease patients and their families on home-care management .
With the implementation of their projects, some groups found they needed to modify their plans or change their target populations. The group targeting pregnant teens for a prenatal education awareness program found few willing participants. The target population was therefore expanded to include non-pregnant teens in selected school classes and educators and community leaders who had contact with teens. The hospice education group found that a new hospice program had not yet begun a public awareness effort regarding the role and benefits of hospice care. The project group, therefore, redirected its efforts to health professionals in the community who might refer clients to a hospice and/or volunteer their own services to the hospice effort.
Community support and collaboration were important components of many projects. To help students implement a rubella screening program, the local health department furnished rubella vaccine, provided mailing containers for blood samples, and coordinated and processed employee information and vaccine records. Community health professionals in the private sector participated by screening their own clients. Cooperation of key community health and lay leaders was integral to another groups project, a county based diabetic support group. The community leaders served as resource persons, steering committee members, membership recruiters, and contact persons.
Several project groups faced values held by businesses and the community. One project group was challenged to provide pregnancy-related information to teens while making it acceptable to parents, teachers, and community elders. Another group found that implementing a health education program at the work site needed to demonstrate benefits to both employees and management. Individuals* improved health status was only one objective to be met; cost effectiveness for industry, demonstrated by increased safety hours and/or decreased missed work time, was another.
Group process and professional collaboration were used by all groups to varying degrees. Professional collaboration was important in developing and implementing a breast self-exam project and the rubella screening project. Support groups were a specific strategy used in the stress management project. Critiquing of the group process of each project team was an expectation.
Once the projects were implemented, students evaluated the effectiveness of their interventions and shared the evaluations and suggestions for continuation or related work with their communities. Some communities were very receptive to the idea of continuing some aspects of the projects. The stress management project team was asked to return to work with future groups, and planning to continue health programs at the work site was in progress when the project ended. It was also expected that the prenatal education started by one project group would be continued by another resource in the community.
A final paper describing the project was submitted by each group after the project's completion. The paper outlined the goals, objectives, and methods used in the project and provided an in-depth literature review and evaluation. At the end of the clinical experience, each group also presented an overview of their project to faculty and other students. These presentations provided an opportunity to recognize the efforts and abilities of each group and examine the impact on target communities.
At the end of the semester, all students evaluated the group projects' value as learning experiences. Ninety percent or more of the students agreed that they had experienced a significant growth in community assessment (96.8%) and intervention skills (93.6%), as well as skill in initiating change (90.5%), group process dynamics (90.6%), and evaluation (90.5%). Improvements in decision making (87.4%), self and program evaluation (87.4%), and leadership skills (81.1%) were rated somewhat lower.
Nearly all the students (93.7%) agreed that the project increased their knowledge and skills; 90.6% felt the project exposed them to up-to-date information and perspectives and 90.5% felt it increased their ability to think and evaluate. Also, 90.5% felt faculty support and guidance were sufficient during the implementation phase and that the diaries and group process evaluation tools were sufficient to assist them in understanding the group dynamics.
Thirteen students estimated that the project took 8 to 10 hours per week, eight students said it took 6 to 7 hours, and four felt they had spent 15 hours or more per week on the project. The average per pupil expenditure on the project was approximately $43.50. Another expense came with the average of 40 miles per week each student drove during the project.
Students noted that the major advantages of the project were the opportunity to be self-directing, the demand for flexibility and the use of skills and knowledge, the fact that the project was done in their hometowns at a time of their choosing, and the project's pertinence to real-world problems in their communities. Students listed only distances between group members and constraints on time as disadvantages.
The two faculty members who coordinated the projects were initially concerned that students would have difficulty establishing contacts with local agencies, traveling the required distances, and maintaining the complex communication necessary. These problems, however, failed to materialize. Students assumed a large share of the responsibility. Faculty maintained phone contact with students, read students' logs each week, and visited each group on site every 1 to 2 weeks.
Ae the faculty developed confidence in the students and their projects, they encouraged greater independence among the students. Faculty were particularly pleased to see the positive, continuing community support for the students' efforts.
In January 1987, students who had participated in the course were mailed an open-ended questionnaire asking them to describe how the community health experience had influenced their present practice, the lasting effects the projects had on their community, and suggestions for managing the experience in the future. Thirty-six questionnaires were sent, and the response rate was 55.6% (N = 20).
Many respondents reported hard work and extensive time involved in planning projects. Students felt the projects increased their evaluative and research skills, demonstrated the importance of identifying goals and objectives, and heightened their awareness that implementation requires a feasible, pragmatic design and hard work. Two students said they had used the same process to carry out new projects in their present work settings.
When asked about continuing community effects from the projects, nine projects (82%) were cited as having some level of activity still present. Several projects, such as the breast self-exam program, infant/child safety teaching, and industrial safety measures were incorporated into existing agency activities. Activities with the hospice and American Diabetic Association chapter still continue. The high school program for pregnant teens offered an entree to the public school system and has now been expanded to include pregnancy prevention.
Suggestions for future efforts of this kind included more specific guidance early in the project development phase, reimbursement for gas, and more attention to and assistance with group process during implementation. Two respondents identified the need to provide advanced or different clinical assignments for students with previous public health learning and experience.
The success of this alternative clinical experience in community health nursing reinforces the view that adult RN learners predominantly experienced in acute care can successfully transfer previous knowledge to a new arena of practice, integrate the knowledge with new theoretical concepts, and apply this knowledge in a semistructured, population-focused practicum. Furthermore, such educational programs in community health nursing can be an asset to participating communities.
- American Nurses Association (1986). Standards afcommunity health nursing practice. Kansas City, MO.
- Croes, P. (1981). Adults as learners. San Francisco, Ca: Jossey-Bass.