Nurse educators are engaged in active dialogue about the processes by which undergraduate nursing students can best gain clinical knowledge and caring skills (Tanner, 1990). This dialogue is not new but is even more relevant in view of the turbulence in health care today and potential changes in nurses' roles. As emphasis is shifting from acute care settings to communities (Moccia, 1993) and as efforts are intensifying to reach marginalized segments of the population who have been underserved (Hall, Stevens, & Meleis, 1994), nurse educators are pressed to design culturally competent curricula (American Academy of Nursing, 1992) enlivened by community participation. Nursing students need experiential - Iy based education to comprehend and foster processes of caring. Concrete, emotionally compelling experiences that resonate with here-and-now situations in the real world stimulate learning of a useful and enduring nature. The purposes of this article are to describe and analyze such an experience: a critical experiential teaching strategy situated in the community that was implemented over a three-year period, 1991-1993. Specifically, the learning activity was undergraduate nursing student and faculty participation in an annual HIV/AIDS walkathon- held in a Midwestern city.
The AIDS Walk in which students and faculty participated is modeled after similar AIDS Walks that have been organized annually in many metropolitan areas since the beginning of the HIV/AIDS epidemic. AIDS Walks are events where multiple efforts converge to prevent the spread of HIV, insure the provision of care and resources for those who are infected, inform the public, and bring political pressure to prompt research and governmental actions to end the epidemic. AIDS Walks have grown to involve thousands of participante who gather on one Saturday or Sunday each year to walk together several miles across their city to demonstrate solidarity in the fight against AIDS, educate the citizenry, and raise money for local community-based organizations serving people with HIV/AIDS. Joining the ranks of these walkers are people with HTV7AIDS; their families, friends, caregivers, and supporters; health care providers; public officials; corporate supporters; and increasingly diverse segments of the public who want to learn more about HTV/ AIDS, show their support for those who are living with HIV/AIDS, and contribute to efforts toward preventing the disease.
Participants may walk as individuals or join as teams who walk together. Fundraising is accomplished through the generation of pledges, although this is not a requirement for participation. Walkers usually secure sponsors who pledge to contribute a monetary amount of their choice for every mile completed. This mechanism is not only effective in raising financial support but spreads news of the AIDS Walk and its purposes to countless others who do not directly participate in the e-vent. Generally, the AIDS Walk itself includes opening and closing ceremonies with speakers, entertainment, refreshments, food, and information and vending booths. The atmosphere of the day is ordinarily quite celebratory.
Theoretical Perspective and Educational Goals
The decision to situate a teaching/' learning experience for undergraduate nursing students in AIDS Walk participation was informed by critical perspectives on education, including feminist pedagogy (Crowley, 1989; Hedin, 1989; Ruffing-Rahal, 1992), "connected teaching" (Belenky, CIinchy, Goldberger, & Tarule, 1986), anti-racist educational praxis (Maxwell & Buck, 1992), and pedagogy of the oppressed (Freire, 1970). These critical perspectives share several basic principles: a) respect for the knowledge, interpretations, and life experiences of students, b) rejection of the "banking concept" of education in which students are thought to be empty containers to be "filled" by deposits of the teacher's knowledge, c) belief in the mutual dialogical process of teaching and learning, d) critique of objective, decontextualized teaching strategies, and e) value on situated knowledge-building that connects students to everyday life and practice in communities. With a critical stance toward education, innovative strategies that provide social and political grounding for teaching and learning are necessary (Hartman, 1991).
Applying a critical approach to nursing education gives nurse educators the opportunity to interact with students in a way that facilitates students' critical awareness of themselves and the contexts of clients' lives. Critical experiential teaching strategies also potentiate: a) appreciation of diversity, b) increased understanding of social, political, economic, and cultural influences on the health of individuals, families, and communities, c) questioning of oppressive conditions, and d) transformative nursing practice wherein consumers of health care are fully empowered participants (Clare, 1993; Stevens & Hall, 1992).
The central objective for incorporating AIDS Walk participation as part of undergraduates' clinical learning experiences was to create the atmosphere for students to encounter themselves as caring persons and examine racist, classisi, heterosexist, and gender-biased structures in society that distance professional caregivers from marginalized populations like those who are living with HIV/AIDS. The overall goal in designing this educational strategy was to facilitate student discovery of their competencies for empathy. Through connection and collaborative involvement in the community, it was anticipated that students would be able to recognize their own agency as they altered their attitudes and took actions that had significance for members of a disenfranchised group who were at health risk.
Implementation of a Critical Experiential Teaching Strategy
Procedures- From 1991 to 1993, undergraduate nursing students, faculty, and staff at the University of WisconsinMilwaukee School of Nursing organized and entered a team in the annual Wisconsin AIDS Walk. Each year, 7 to 10 students who were enrolled in a junior-level acute care clinical course participated in AIDS Walk activities. AIDS Walk team participation was offered as an optional course activity. Students were informed that their grades in the course would not be influenced by their participation or non-participation in the Walk or by the value of financial pledgee they might secure should they deride to participate. Over the three years, a total of 26 students were involved in AIDS Walk activities. All students enrolled in the course each year voluntarily elected to participate.
A variety of teaching/learning activities were involved in AIDS Walk participation. During the week preceding the Walk, the recommended reading assignment included selections about HIV/AIDS from books and journals (e.g., Cohen & Durham, 1993; Durham & Cohen, 1991; Kelly & Holman, 1993). During course discussion times, students viewed videotapes about HJV/AIDS (e.g., Larson & Lehman, 1990; Willeneon & Elliott, 1992) and heard presentations by faculty involved in ongoing HfWAIDS research. Students were also encouraged to interact with family, friends, neighbors, fellow students, and co-workers about their upcoming participation in the AIDS Walk and enlist pledge sponsors if they wished, The teaching/learning activities during the Walk itself included attendance at the opening ceremony where persons with AIDS and their family members spoke to the crowd about their experiences. There were also speeches by celebrities, politicians, and event organizers about the meaning and significance of the AIDS Walk. Then the team joined the other 5,000 to 8,000 people to walk the 10 kilometers across the city of Milwaukee. Along the way, there were countless opportunities to socialize with other walkers, read the placards and banners displayed, pick up written information, and take in the entertainment. At the end of the Walk, there were closing ceremonies with additional speeches about HIV prevention, health needs of people with HIV/AIDS, community efforts to provide service to infected persons, and the need for community mobilization to combat the disease. A postWalk barbecue for the team was also held each year to provide the opportunity for informal student-faculty-staff discussions about their experiences at the AIDS Walk. During the week following the Walk, students shared their observations and synthesized their experiences in the context of a formal class discussion. They also submitted a written assignment.
The written assignment varied each year. In 1991, students wrote entries in their weekly clinical journals. In 1992, students were given the option of participating in the AIDS Walk as fulfillment of a "professional development" course assignment that would ordinarily require attendance at a professional conference or lecture series. Students wrote a brief summary of events and an evaluation of what they gained toward improving their professional practice. In 1993, students participated in the AIDS Walk as an option for fulfilling a "philosophy of nursing practice" course assignment. Rather than write a standard philosophy of nursing term paper, they wrote an initial philosophy statement about the nursing care of persone with HIV/AIDS which they submitted during the week prior to the Walk. Following their participation, they were asked to reflect upon their original philosophical statement and revise it as necessary based on their observations and experiences at the AIDS Walk, analyzing how health care practices and policies might be changed in view of the needs of people who are living with HIV/AIDS.
Outcomes - The content of informal and formal discussions, journal entries, and papers from all three years indicated the value of participation in the AIDS Walk as a critical experiential teaching strategy. It was a "real-life" clinical experience that students found both exciting and consciousness-raising. Many of the students described how for the first time they personally "felt" the stigma associated with AIDS. One student wrote:
When I asked my father to sponsor me with a pledge for the AIDS Walk, he told me he'd give me money for cancer, heart disease, multiple sclerosis - anything else, but not AIDS.
Another student wrote about having to deal face-to-face with a loved one's fears and stereotypes:
My boyfriend warned me not to go to the AIDS Walk. He said there might be fights because of all the queers and drug users that would be there. I told him that if he was worried about me, he was welcome to come with me and join our team. He said, "Not on my life! Just make sure you stay away from any TV cameras.'
Students also discovered firsthand the niisiriformation that circulates about HIV/AIDS:
I was so excited that I got to shake hands with Magic Johnson at the ADDS Walk. But when I told my friends, several of them asked me, 'Did you wash your hand afterwards?' These friends are college students. I was shocked by their ignorance about HIV transmission.
Students not only encountered others' attitudes about people with HIV/AIDS; but they (also) confronted their own beliefs and sentiments. They reported feeling supported and respected by the faculty and other students as they struggled with fears and discomforts. Participating in the AIDS Walk activities as a group in an atmosphere where open discussion was welcomed helped students feel safe in expressing their feelings and incorporating new experiences:
I always thought of AIDS as something 'out there'. But seeing all those people and talking about it, now I think of ADDS in terms of real live people's faces and their stories.
At first, I thought of AIDS as a disease of gays, drug users, and prostitutes. Then from our readings and discussions, I came to learn that AIDS is increasing most rapidly among women and children. But I thought it was still pretty much focused in minority populations, so I wasn't part of it. At the Walk, to meet and hear stories of so many different types of people, including young white women like myself, who are HIVinfected - it brought this epidemic closer to home.
Several students described how their actual experiences of participating in the AIDS Walk ran counter to their expectations, allowing them to better understand the perspectives of affected communities and empathize with individuals and families as they grappled with HIV/AIDS:
I expected the AIDS Walk to be a somber event. But it really was a celebration of life with all the decorations, festivities, and music. I was particularly impressed by the young man who spoke about how AIDS gave him a second chance at life. I was also amazed by that guy who talked about living with HIV/AIDS for more than 10 years. He looked great and seemed to be living his life to the fullest.
I think what hit me most was hearing the speeches of the mothers, fathers, sisters, and brothers. For every person that is infected, there are so many others who are affected by this disease. I always thought of persons with ADDS as living out their lives and dying alone - and I know that some still unfortunately do. But it was great to see so much family involvement and support.
In response to what they observed at the AIDS Walk, students began identifying and questioning inadequacies in policies and procedures, gaps in access to health care, and less than competent and compassionate delivery of services to people with HIV/AIDS. Their critiques included the following:
I think it's criminal that women often can't get an AIDS diagnosis and associated disability benefits just because they present with different symptoms than men or don't develop male manifestations of the disease.
The stories that people with AIDS told about hospitals and health care providers were outrageous. Like the young man who ate only cold meals because his tray was left out in the hall until his partner could arrive and bring it in. The nurses were too scared or too prejudiced to get close to him. That is not right. I also can't believe hospitals still put warning labels on the doors, charts, and Kardexes of patients with AIDS. That shouldn't be necessary with universal precautions.
I was interested to hear the State Representative speak about the difficulties he had getting his brother who had AIDS into a nursing home. If he had problems with all his clout and money, what's happening to those less fortunate? I wonder if ADDS would be on his political agenda if it hadn't hit in his own family. And how many politicians will need to lose a loved one to ADDS before more money is allocated to AIDS care and research?
Some students became interested in working with people with HIV/AIDS, in part due to their experiences participating in the AIDS Walk:
I always thought that when I graduate, I'd like to work in the operating room or the recovery room. But I began to get interested in HIV nursing through the class discussions we had about AIDS. And then the ADDS Walk..I might like to work on an AIDS unit." [Upon graduation, this alumna did secure a full-time position on an AIDS inpatient unit in a large inner-city hospital.]
Walking with the School of Nursing Team in the AIDS Walk reinforced my desire to work with women and children with ADDS, especially the children who are all too often "left out" when their mother is ill. [This alumna is now a volunteer with the Milwaukee AIDS Project.]
Staff and faculty also benefitted from their AIDS Walk participation with the students, as their reflections suggest:
Participating in the Wisconsin AIDS Walk for the past three years has given me a renewed spirit of community service. I plan to continue to participate in future events to help with the fight against AIDS.
As much as students learn about AIDS from hearing the stories of diverse individuals and witnessing the community response, faculty learn from the students - their questions and reactions provide fertile ground for planning curricula. And the team spirit is wonderful - students, staff, and faculty coming together for a common cause.
Problems did not occur in the use of this particular experiential teaching strategy with these students during the three years reported here. Overall, students evaluated the experience very positively. It might be anticipated, however, that some difficulties could arise. When cultural values are challenged and oppressive conditions caused by racism, classism, sexism, and/or homophobia are exposed in the teaching/learning situation, students may experience some emotional distress. Sensitivity on the part of faculty is essential. The debriefing period provided by an informal barbecue gathering following the AIDS Walk was crucial in this regard. Additional educational resources and emotional support services may be necessary for some students.
AIDS Walk participation is but one possible means of immersing undergraduate nursing students in community situations that are conducive to experiential learning, In this case, it presented chances for "dialogue across differences" (Ellsworth, 1990, p. 12) and "situated learning" (Harding, 1991, p. 101) as students took active roles in building the knowledge, skills, and empathy they will need to care for and work effectively with individuale, families, and communities infected and affected by HIV/ADDS. Use of this teaching strategy demonstrated that when students believe that learning activities are realistic and important, they bring an enthusiasm that fuels engaged participation. Rather than passively accepting a set of didactically presented principles of caring, these students learned about caring by facing their own emotions and beliefs, experiencing stigma close at hand, and becoming critically aware of how that stigma can affect clinical practice. Their evaluations of the ADDS Walk experience suggest that when students feel supported and positively regarded as they try new behaviors, enter unfamiliar social worlds, and interact with people culturally different from themselves, the conditions are created for understanding what is competent caring in nursing.
As undergraduate nursing students interact with populations outside the familiar settings of clinics and hospitals and participate in events orchestrated primarily by community groups themselves, they learn the important skills of perspective-taking and coalition-building and are able to see the process of empowerment that these skills can engender. Good basic hands-on clinical skills training will always be a key to quality nursing care, but teaching/learning experiences that raise consciousness (Fisher, 1987) about caring in community contexts will become increasingly vital as more and more sites for health services provision move outside acute care settings. Just as practice in psychomotor skills in the clinical laboratory prepares students to provide competent physical care to individuala, practice in encountering emotional biases and cultural stereotypes, developing critical insights, and discovering their empathie capacities in the community prepares students to provide culturally competent physical and psychosocial care to individuals and aggregates.
- American Academy of Nursing. (1992). Expert panel report: Culturally competent health care. Nursing Outlook, 40, 277-283.
- Belenky, M.F., Clinchy, B.M., Goldberger, N.R., & Tarale, J.M. (1986). women'* ways of knowing: The development of self, voice, and mind. New York, NY: Basic Books.
- Clare, J. (1993). A challenge to the rhetoric of emancipation: Recreating a professional culture. Journal of Advanced Nursing, 18, 1033-1038.
- Cohen, F.L., & Durham, J.D. (Eds) (1993). Women, children, and HIV/AIDS. New York, NY: Springer.
- Crowley, M.A. (1989). Feminist pedagogy: Nurturing the ethical ideal. Advances in Nursing Science, 11(3), 53-61.
- Durham, J.D., & Cohen, F.L. (Eds.) (1991). The person with AIDS: Nursing perspectives (2nd ed.). New York, NY: Springer.
- Ellsworth, E. (1990). Educational films against critical pedagogy. In E. Ellsworth (Ed.), The ideology of images in educational media (pp. 10-26). New York, NY: Teachers College Press.
- Fisher, B. (1987). The heart has its reasons: Feeling, thinking, and community-building in feminist education. Women's Studies Quarterly, 15(3-4), 47-73.
- Freire, P. (1970), Pedagogy of the oppressed (M.B. Ramos, Trane.). New York, NY: Seabury.
- Hall, J.M., Stevens, P.E., & Meleis, AJ. (1994). Marginalisation: A guiding concept for valuing diversity in nursing knowledge development. Advances in Nursing Science, 16(4), 23-41.
- Harding, S. (1991). Who knows? Identities and feminist epistemology. In J. Hartman & E. Messer-Davidow (Eds.), (En)Gendering knowledge: Feminists in academe (pp. 100-115). Knorville, TN: University of Tennessee Press.
- Hartman, J.F. (1991). Telling stories: The construction of women's agency. In J. Hartman & E. Messer-Davidow (Eds.), (En)Gendering knowledge: Feminists in academe (pp. 11-34). Knoxville, TN: University of Tennessee Press.
- Hedin, B.A. (1989). Nursing, education, and sterile ethical fields. Advances in Nursing Science, 11(3), 43-62.
- Kelly, P.J., & Holman, S. (1993). The new face of AIDS. American Journal of Nursing, 93(3), 26-34.
- Larson, C. (Producer), & Lehman, N. (Director) (1990). Coming out about AIDS [Film]. Milwaukee, WI: Wisconsin Educational Communication Board, Wisconsin Public Television.
- Maxwell, A.H., & Buck, P.D. (Eds.). (1992). Teaching as praxis: Decolonizing media representations of race, ethnicity, and gender in the new world order (Special issue] . Transforming Anthropology, 3(1).
- Moccia, P. (1993). Nursing education in the public's trust: A faculty of the community. Nursing & Health Care, i4(9), 472-474.
- Ruffing-Rahal, MA. (1992). Incorporating feminism into the graduate curriculum. Journal of Nursing Education, 31, 247-252.
- Stevens, P.E., & Hall, J.M, (1992). Applying critical theories to nursing in communities. Public Health Nursing, 9(1), 2-9.
- Tanner, C.A. (1990). Caring as a value in nursing education. Nursing Outlook, 38(2), 70-72.
- Willenson, N. (Producer), & Elliott, B. (Director) (1992). One more day: A family living with AIDS [Film]. Milwaukee, WI: American Warehouse.