This article describes a servicelearning experience developed and implemented by strengthening an existing partnership among a baccalaureate school of nursing, a federally qualified community primary health care clinic, and senior baccalaureate nursing studente. Following participation in team-building experiences at a Partners in Caring and Community Institute, representatives of the three partners collaboratively designed a service-learning experience for senior undergraduate nursing students and agency professional staff. This partnership enabled clients with diabetes from the clinic to receive enhanced self-management support.
The Pew Health Professions Commission (1995) described the future landscape of health care for the 21st century and called for schools of nursing to develop new models for "the integration between education and the highly managed and integrated systems of care" (p. 7). These future educational models were to provide opportunities for relevant clinical education in a system where acute care hospitals would no longer be the center of the health care network. The Pew Health Professions Commission (1995) farther proposed that these new models include "...flexible work rules that encourage continual improvement, innovation and healthcare work re-design" (p. 7).
The recommendations from the Pew Health Professions Commission (1995) represented a change from traditional models of nursing education that had created a dominant value for the direct care of clients in hospital settings. Historically, nursing clinical instruction consisted of relieving the responsibilities of hospital staff nurses for a period of time while students and their clinical instructors managed the acute care of assigned clients. This level of engagement by students and nursing faculty created immediate benefits for the professional staff who were temporarily relieved of care duties to focus on other important responsibilities of their roles.
As health care shifted from acute care settings to community-based systems of care, and further, to clients themselves (Fagin, 1998), professional nurses also needed to reconceptualize the focus and nature of their care. Early reports indicated that the professional nursing staff in this emerging system of community care were ill prepared to understand and manage the changing demands of their roles (Meyer, 1997; Murray, 1998). Gebbie and Hwang (2000) noted that nursing also "...may be affected by organizational and economic shifts most quickly and severely" (p. 716) of all the public health disciplines. Many nurses in community-based settings were educated or socialized into the profession in acute care settings. Nursing faculty were challenged to identify engaging and accountable learning experiences for students in these community-based settings where direct care to clients was not the primary focus of their role. It was unclear how etudents would fit in, learn, contribute, and help shape this new health care environment.
At the same time, community primary health care settings were challenged to redesign high-quality, efficient care to underserved clients with chronic illnesses within a financially unstable environment. Collaborative, evidence-based approaches to chronic disease management evolved in community health centers across the United States to efficiently reduce health disparities (Bureau of Primary Health Care, 1998). Diabetes was one of the six diseases targeted for collaborative intervention, and client self-management support was one of the key elements of this new integrated system of care (Smith, 2000).
Mintz and Hesser (1996) suggested that service-learning involved "working in a creative tension marked by collaboration, reciprocity, and diversity.. .within the context of the interrelationships among three domains, or partners" (p. 34). The three partners cited were academia, the students, and the community. Servicelearning was identified as having the "potential for promise as a curricular strategy" to engage students of the health professions in meaningful, emerging roles in the community (Seifer, 1998, p. 275). The Health Professions Schools in Service to the Nation (Gelmon, Holland, & Shinnamon, 1998) concluded in their final evaluation report that service-learning is "clearly a relevant pedagogy in health professione education" (p. 74). Therefore, the conditions presented by the need for change in nursing education, combined with the need to develop new skills among professional community-based nursing staff within a changing health care environment proved to be an ideal arrangement for a service-learning experience in this Partners in Caring and Community project.
The Community Health Improvement Center and senior undergraduate students of a small, private baccalaureate school of nursing partnered to enhance services to clinic clients with diabetes mellitus. The clinic participates in a national collaborative initiative designed to provide more equitable care to underserved clients with diabetes. Services of the Community Health Improvement Center are targeted to low-income individuals who are uninsured or underinsured and, therefore, have no access to private health care. Clients of the publicly funded clinic are members of at-risk populations. Many are developmental^ disabled, have few literacy skills, and experience numerous significant barriers to effective self-management of diabetes. The nursing students enhanced the clinical services for these clients by case finding clients with diabetes who did not have regular contact with the clinic providers and case managing clients who required more intensive educational intervention, support, and reinforcement.
The partners created the diabetes project because it seemed to blend a diverse set of motives. The community partner was motivated by the desire to contribute to the development of future professional nurses in a way that would expand students' conceptions of professional nursing practice. Making a difference in clients' lives in a knowledgeable, confident way was a primary motive for the students. The faculty wanted to engage students in learning the course content in meaningful, productive ways that would contribute to the quality of clients' lives, as well as relieve some of the workload of the clinic's professional staff. Underlying each partner's participation was a shared mission to provide quality services to individuals with diabetes who required a higher intensity of services, but who could not afford them.
Clinic staff provided three formal inservice sessions for students on topics such as clinical practice standards for management of diabetes mellitus, nutritional management of diabetes mellitus, and practical management of clients with diabetes. Clinical practice guidelines from the American Diabetes Association (1999) were used as the basis for these workshops. At the end of each morning, students participated in group reflection activities and submitted a critical incident journal that was reviewed by the instructor at the end of each week. The executive director of the clinic also conducted group reflection activities with the students. In addition, the students entered diabetic outcome data associated with the collaborative project into a computerized registry.
The overall goal of the experience was to strengthen an existing partnership. There also were two major objectives developed by the team. The first objective was to create the beginning of a learning community, one that incorporated knowledge and perspectives from students and the fields of nursing, medicine, sociology, and nutrition. The second objective was to create a shared value among all partners that involved caring for and supporting this underserved population.
This service-learning activity was a value-added activity to the services the nurse practitioners and physicians already were providing for clients of the clinic. The providers identified clients who would benefit from additional reinforcement of positive health strategies, and student nurses visited these clients biweekly. The students assumed a coaching/advocate role with clients. Much of the student work involved helping clients develop positive health strategies designed to remove medication acquisition barriers, educational barriers, and perceptual barriers. Students provided individualized patient teaching on topics ranging from nutrition for diabetes management to individually tailored exercise regimens to help with diabetic control.
This service-learning activity was different from typical student clinical experiences because it was deliberately planned and implemented by the partnership. The project team, consisting of the executive director of the clinic, a nursing faculty member, and a senior nursing student, shared responsibilities for implementing the project. The faculty member of the team coordinated the experience, facilitated daily group reflection, and provided feedback to students in their journals. The student acted as a peer coordinator/leader for the project. The executive director made the inservice workshops possible and facilitated group reflection activities.
The goal to strengthen the partnership was met. The Partners in Caring and Community Institute enabled the participants to share their vision with one another and provided support and structure to facilitate a common starting point. The diabetic project was an important facultativo activity for improved communication and collaboration between the students and the health care providers, which led to critical reflection regarding problem solving and overcoming barriers for the selected clients with diabetes.
In addition, the project provided a meaningful context for student activities and, to a large extent, was an excellent motivator for student engagement. The knowledge component contributed by the faculty member and health care providers from three disciplines of nursing, medicine, and therapeutic nutrition, and the fresh perspectives of the nursing students facilitated the conscientious planning for effective self-management for the clients with diabetes. At the conclusion of the project, all three members of the project team reported they were able to be more straightforward with one another and better able to communicate their goals as a result of the experience.
Skills Knowledge and Insight
The individual and group reflection activities helped the students connect social conditions to issues related to clients* self-management. The student journals reflected many of the barriera thente encounter when trying to make the major lifestyle changes associated with successful diabetes control, as well as strategies used by students and health care providers to help clients overcome those barriers. The students began to realize the relative nature of many of the health decisions made by clients. Finally, the students reported this service-learnmg project was a hands-on experience with health care and social justice issues.
Cultural differences between the students and cliente or between the students and staff were more likely to be bridged because of the project. There were many moments when the advocacy and enthusiasm of the student helped an experienced health care provider consider a problem from an alternative viewpoint. Conversely, there were many moments when the knowledge and wisdom of the health care provider helped a student be more effective when working with clients.
The faculty and the community partner believed the service-learning experience taught a portion of the course content in a more powerful way than the usual reading assignments in a textbook, lecture, or hypothetical care map. The students who truly engaged in the process gained knowledge and understanding of what nursing potentially could be, and the health care providers were able to connect to that emerging ideal and were energized by it.
Students initially believed they were not using their time wisely by spending it inputting outcome data into a computerized database. They felt data management was the responsibility of a clerk. However, they were persuaded to continue the activity because it forced them to think about the desired outcomes of their activities with clients. The faculty believed this data management activity ultimately would affect how students spent their time with clients. The executive director of the clinic agreed but for different reasons. She maintained that data management was a realistic responsibility for a nursing professional in a public primary health care setting and that working with outcome data sets is a valuable experience. Therefore, the activity was maintained, and although a few students did not appreciate the experience, most reported a feeling of pride when they noted an improved outcome for one of their assigned clients.
Finally, the nursing students had an opportunity to engage with clients and a variety of health care professionals in this new, redesigned, and integrated approach to diabetes care. This service-learning activity provided an opportunity for all involved to learn how to work with one another and to build on each other's strengths and assets to improve care to this underserved and vulnerable population, who so richly deserves support with this complex disease.
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