The fourth report of the Pew Health Professions Commission (1999) continues to predict more change for the health care system in the United States and refers to the current period of change as only a prelude as to what may come. Additionally, the commission continues to recommend that education of all health professionals needs to expand to include a "broader set of system, organizational, and population skills" (p. 2).
The influence of the current and past Pew reports plus the advent of managed care have caused a number of programs to revise or redesign their curricula. Revision of curricula is a time consuming process, and one that is both intellectually and emotionally challenging. But now, in addition to addressing the health care system changes, nursing education is being continually asked by specialty groups for more content to be added to programs. Chris Tanner's comment about developing a 21-year curriculum is unfortunately quite accurate (Tanner, 1998).
Historically, nursing education has had a reputation of being slow to give up the old, safe, predictable curricula. The discipline has been steeped in a number of traditional educational practices, e.g., "check-offs" for skills, hospital experiences always before community experiences, and medicalsurgical experiences always before specialty experiences, to mention just a few. However, this is an ideal time for nursing to be creative and futuristic in curricula development. It is an opportunity to "think outside of the box" as opposed to rearranging or reinventing the proverbial curriculum.
The Essentials of Baccalaureate Education for Professional Nursing Practice (1998) has defined the three aspects of nursing practice as "care of the sick in and across all environments, health promotion, and population-based health care" (p. 4). To prepare graduates to succeed in the latter two aspects of this practice, health promotion and population-based health care, nursing education has to allocate a significant amount of clinical time outside of acute care settings and in community settings. This paradigm shift has been described as nursing "where the patient or client is." As baccalaureate programs develop and implement more community-based curricula to better meet current and future health care needs, faculty and students alike often have the unrealistic view that life will return to normal when the new curriculum is implemented and the old one has disappeared. However, community-based curricula suffer the same growing pains as traditional ones do. There are always concerns and issues that no one predicted.
The School of Nursing at Wichita State University (WSU) has implemented the first 3 semesters of a 4 semester community-based undergraduate curriculum. Although the curriculum isn't perfect, it is a proactive effort to address the drivers affecting the health care delivery system and also the changes within the higher education environment. However, with implementation of the curriculum, several issues that could affect the success of the new curriculum have been identified. Some issues occurred because it was a new curriculum, but others arose because it was community-based. It is the intent of this article to assist other nursing programs undergoing curriculum revision in addressing these potential issues before they arise.
Lack of Managed Care Penetration
A major impetus to develop a community-based curriculum is because of managed care and the movement away from acute care (Huston & Fox, 1998). The majority of patients are not typically in hospitals or acute care settings, but are seeking health care services within their communities. However, in the urban area of south central Kansas, the penetration of managed care has not reached the proportion that was predicted. Managed care has affected the health care of Kansans, but not as quickly or to the extent previously predicted. Patients continue to be in acute care settings while adequate resources within the community to care for patients have not developed. Additionally, with the changes in Medicare funding, a number of home health agencies in the area have closed. Potential student placement sites in the community are there, but not what was anticipated during the curriculum development stage.
As a result other ideas have been developed. Currently a partnership with the parochial school system has provided significant learning opportunities for nursing students. Projects have involved health teaching and wellness projects for parochial school students and staff members. A popular topic for the younger children has been handwashing and the germ detector machine that junior students built dining the first semester of the new curriculum.
Hands-On Versus Observational Experiences
The proportion of hands-on versus observational experiences for students is a concern for all nursing curricula, but perhaps more so in community-based curricula. With students located at sites throughout the community, the issue often becomes whether the clinical experience is hands-on or observational. Particularly with first semester students, it becomes more difficult to provide hands-on experiences with limited faculty and with students in a number of different settings simultaneously. However, employers are continuing to demand that programs increase hands-on experiences for their students in the community (Hahn, Bryant, Peden, Robinson, & Williams, 1998).
This issue is a continuing one for the WSU School of Nursing. Imperative in all clinical experiences, hands-on or observational, is the development of preceptors who are strong proponents of nursing student education. Although most nursing programs use health care providers as preceptors, other programs have successfully used non-health care providers. Using non-health care providers in a community or neighborhood as preceptors has been a successful model for Northeastern University (Matteson, 1999).
The community-based curriculum at WSU was developed over an 18-month period, used both small and large faculty curriculum work groups, and involved all faculty. However, with implementation of the curriculum, faculty immediately became unsure about what had been developed. Questions arose as to what they had previously committed to and being sure that they hadn't approved "this." Additionally, there was confusion as to the difference between communitybased nursing and community health nursing. A common misunderstanding was that one could just insert community sites into any course and it became a community-based course.
Time was spent reeducating faculty about the curriculum and the goal of community-based nursing in general. It was the intent of the primary curriculum committee of the school of nursing for the new curriculum to espouse the goal of community-based nursing of Zotti, Brown, and Stotts' (1996), "to manage acute or chronic conditions while promoting self-care among individuals and families. . . meeting an acute need, but her/his goal is to enhance the individual or family's capacity for self-care" (p. 212). Pertinent articles (Zotti, Brown, & Stotts, 1996; Barnes et al., 1995; Shoultz & Hatcher, 1997) that were used in curriculum development were again shared with faculty members along with redistributing past curriculum meeting minutes and one-on-one discussions with faculty
State Board of Nursing Unfamiliarity
Although community-based nursing may be a newer concept to faculty, it becomes far more difficult to explain the intent of the curriculum to staff members of state boards of nursing. Junior students in a community setting without benefit of a faculty member being present is an unfathomable concept for most boards of nursing. Generally, the boards of nursing staff backgrounds have been in more traditional acute care settings. Although staff are aware of the changes in health care, its impact may not have affected them to the degree that it has with nursing educators.
The key to acceptance and approval of community-based curricula is education of staff members. Baccalaureate educators, as a group and individually, can be a convincing influence to staff of state boards of nursing.
Appropriate preceptors for a community-based learning experience is an ongoing issue. In addition to preceptors needing education, training, or both, to function in the role, faculty and students need similar education about the preceptor's role. In a community setting, it becomes even more important that competent preceptors are identified and used. Educational workshops for potential preceptors are essential.
STUDENT AND FACULTY SAFETY
Safety issues are increasingly an issue for nursing students and faculty. With the increase of violence in society at large and with nursing students working in community settings that are economically deprived, have high unemployment rates, and suffer from poor environmental health, it may become an issue whether to send students to those communities. Discussions need to be held with all involved- faculty, students and the community leaders- to determine if the benefits of the learning experiences outweigh the risks.
With students at a number of different community sites, faculty travel frequently to observe, guide, and assist students. For ease of communication, cell phones and pagers for faculty become a necessary expense. Although not all nursing programs use these in clinical experiences, each nursing program must do what is most appropriate for the comfort level of administration, faculty, and students.
Although the issues that may arise when developing and implementing a community-based curriculum may seem overwhelming, such issues should not deter programs from continuing their efforts in that direction. Rarely is a new curriculum perfect. Moat come with their inherent problems and issues, and community-based curricula are no exception. Nursing education is being presented with a challenge to design curricula that allows nursing to make a difference in patient outcomes in every setting. As nursing educators we need to welcome that challenge.
- Barnes, D., Eribes, C, Juarbe, T., Nelson, M., Proctor, S., Sawyer, L., Shaul, M., & Meleis, A. (1995). Primary health care and primary care: A confusion of philosophies. Nursing Outlook, 43, 7-16.
- Hahn, E., Bryant, R., Peden, ?., Robinson, K., & Williams, C. (1998). Entry into communitybased nursing practice: Perceptions of prospective employers. Journal of Professional Nursing, 14(5), 305-313.
- Huston, C, & Fox, S. (1998). The changing health care market: Implications for nursing education in the coming decade. Nursing Outlook, 46, 109-114.
- Matteson, P. (1999, April). Educating nursing students in the community: Lessons learned. Paper presented at Concepts-IssuesOutcomes: Community-Based Nursing Curriculum, Cleveland, Ohio.
- Pew Health Professions Commission. (1999). Executive summary of recreating health professional practice for a new century [on-line]. Available:http://www.futurehealth.ucsf.edu/ pubs.
- Shoultz, J., & Hatcher, P. (1997). Looking beyond primary care to primary health care: An approach to community-based action. Nursing Outlook, 45, 23-26.
- Tanner, C. (1998). Curriculum for the 21st tury: Or is it the 21 -year curriculum? Journal of Nursing Education, 37(9), 383384.
- Zotti, M., Brown, P., & Stotts, R. (1996). Community-based nursing versus community health nursing: What does it all mean? Nursing Outlook, 44, 211-217.