Healthy People 2010: Understanding and Improving Health, second edition, (U.S. Department of Health and Human Services, 2000) challenges clinicians and educators to revolutionize the health care system to achieve an optimum level of health for all people. Healthy People 2010 objectives identify many diverse problems of community health (e.g., chronic heart and lung disease, HIV/AIDS, abusive behavior, mental disorders, obesity, adolescent smoking). Advanced practice nurses (APNs) should be part of the solution to these problems. The nature of the interventions needed to achieve Healthy People 2010 objectives mandates that academia and community agencies develop partnerships to solve issues and improve community health. Community-based care is essential to nursing in the 21st century.
Master's-prepared APNs continue to develop independent practice that promotes quality health care and cost-effective care delivery and meets consumer demands (Ketefian et al., 2001). Master's of science in nursing programs prepare four types of APNs- nurse practitioners (NPs), nurse midwives, nurse anesthetists, and clinical nurse specialists (CNSs). Currently, almost all the clinical specialties in graduate nursing education programs focus on meeting individual patient needs in traditional settings, rather than on community-based care. Service-learning projects broaden the perspectives of MSN graduate students, while helping community agencies that struggle to meet their expanding needs.
As the phrase service-learning suggests, there are two interrelated parts inherent in the activity - students' active engagement in community service linked with academic study. The authors' community engagement through servicelearning (CETSL) demonstration project, funded by the Helene FuId Health Trust, provided graduate nursing students with an opportunity to link nursing theory and clinical experience with the social environment (i.e., to serve and learn in the "real world"). The health care needs of Cleveland's inner-city community were the primary focus of service. In Cleveland, minorities have been overrepresented in infant mortality rates, cases of lead poisoning in children, and deaths due to heart disease, AIDS, and breast cancer (Community Research Partners, 2001).
The Ohio Department of Health (2000) Usted more than 100 city of Cleveland census tracts as primary care health professions shortage areas. On the other hand, Cleveland is rich in institutional and human resources available to provide services to these areas and willing to facilitate the implementation of this servicelearning project. Faculty and students, partnering with community agencies, designed assignments consistent with the course objectives. Students engaged in activities to help the agencies better serve their constituencies.
Not only did the community agencies benefit from the students' service, but student reflections on the service-learning experience documented their heightened sensitivity to the needs of patients and their families. Graduates of the MSN program increased their understanding of their role as resources to the community, and faculty had the opportunity to connect their expertise to the community. In addition, curricular reform supported an ongoing community-based care model.
The first step was to form a planning committee of faculty, the MSN program director, staff from the Office of Campus Community Service, graduate students, and community partners, who met monthly to answer the following questions:
* What needs exist in the community?
* What needs can be addressed using the expertise of APNs?
* Is the CETSL educational program inclusive?
* Are its outcomes and goals feasible?
* Are desired outcomes and goals suitably addressed?
* How do program objectives and the assessment plan compare?
By planning for evaluation before beginning implementation, faculty and agency partners were clear about expectations. The committee also developed an orientation manual for faculty, students, and agency partners.
Faculty support was critical to integrating service-learning because students reflect the level of commitment they see in faculty. As students learned APN roles, faculty provided not only knowledge in flinipnl practice, but also a venue for learning (Davies, 1993). Faculty closed the gap between theory and clinical practice and created direct efficacy in reality. As faculty facilitated unique learning opportunities in service-learning, the graduate program provided opportunities for education and research, not only to students but also to community members.
Developing faculty expertise in servicelearning as a method of instruction began by increasing their knowledge about potential benefits of CETSL and providing texts, supportive materials, newsletters, and Weh site access related to servicelearning. Institutional membership in Community-Campus Partnerships for Health (CCPHI, a national service-learning organization, was key to faculty orientation. A CCPH consultant with experience mentoring the development of community-based service-learning in graduate nursing education presented workshops for faculty, students, and community partners. Core faculty prepared the first curricular integration, taking advantage of opportunities to attend service-learning conferences and obtain small grants supporting the innovative components of their individual courses.
Administrative support included inkind grants of tame for the MSN director and faculty assistance with implementation and program evaluation, as well as use of the graduate program facilities for meetings. The Helene FuId Health Trust grant supported a project manager to monitor the curricular integration, faculty development to implement the curricula (with in-kind support by the Frances Payne Bolton School of Nursing), a graduate assistant support staff, computer resources for evaluation data input and analysis, and a dissemination conference in May 2002. The Center for Healthy Communities (CHC) (Canfield, 2002) also provided Faculty Curricular Development Mini-Grants awarded directly to three faculty members for their course projects. The CHC evaluation process served as a model for developing the evaluation tools used in this project. Development of and integration of service-learning into all CNS and NP graduate programs was a gradual process with opportunities for formative and summative evaluation. Each community agency offered different opportunities and challenges.
This article provides the evaluation of results as graduate nursing students participated in CETSL. Agencies evaluated the effect on their individual clients and the agency itself. Students, faculty, and agency partners signed an informed consent, approved by the University Review Board, allowing the authors to disseminate the results of the evaluation.
Master's of science in nursing etudents (N = 79) in summer and fall courses completed pretests and posttests that measured expected outcomes of the CETSL program. The CETSL projects had been planned and initiated as partial fulfillment of course objectives. The geriatric and adult nurse practitioner (GNP/ANP) courses, the Primary Care of the Older Adult course, and the Common and Acute Problems of the Adult U course initiated separate community service-learning projects. A CNS course, Collaboration and Administration in Health Care Delivery Systems; an acute care nurse practitioner (ACNP) course, Advanced Management of Acutely 111 Adults; and a core MSN course, Health Promotion Through the Life Span, also implemented CETSL projects. Courses substituted community engagement activities for an assignment (e.g., paper, quiz, test) in the traditional course and assigned credit to the CETSL activity. Learning goals in each course required between 8 and 24 contact hours for service projects, with faculty defining the meaning of contact hours.
The plan for implementation included orientation of graduate students by community partners and faculty at the beginning of the projects, either onsite or at the university, to describe community issues. Then, needed projects were assigned or selected by each group of students. Although not all students received an orientation by agency personnel, student consents and plan forms, including descriptions of the projects and time frames, were completed after at least minimal orientation by faculty. Implementation varied with each project but always involved community site contact and engagement. At the end of the CETSL program, graded projects were presented in public forums.
Examples of Projects
Three groups of students in the ANP program worked with a diabetes association in a setting that served homeless and indigent individuals. The agency needed an evaluation tool to be used as the basis for a diabetes education program they were developing. Students developed a carbohydrate counting educational packet for diabetes education, an educational pamphlet relating to hyperglycemia and hypoglycemia, and an educational sheet about diabetic foot care. Students interviewed clients with diabetes at the community site to obtain a baseline of patient knowledge and worked with clients to obtain cholesterol levels and blood glucose levels and provide education on the increased risk of elevated cholesterol in people with diabetes.
Twelve students in a GNP class were divided into three groups and assigned to two senior centers. Each center was in a different geographic, economic, and cultural area of the city. The agency needed staff education on evaluating and improving functional health of older adults. The two sites afforded students the opportunity to vary their proposals for evaluating the functioned health of these older adults. At one site, students developed three projects, including "Hands of Time," "Who Wants To Be a Millionaire,'' and "The Memory Game." The "Who Wants to Be a Millionaire" game can be used by staff to assess participants' cognitive function and reaction time.
The other site needed to assess participants' functional ability to determine whether individuals were eligible for special transportation. Faculty and community partners guided project development to assure accuracy. Materials and equipment (e.g., audiotapes for the exercises, exercise bands, health information brochures, posters) were donated to the community sites. Detailed descriptions of all the programs were copied, bound, and donated to the centers so the projects could be replicated there or at other sites as appropriate. Like Schneidennan, Jordan Marsh, and Bates-Jensen (1998), the authors found that student paradigms of care for older adults were changed and enhanced by their service-learning experience.
One project in the CNS management course met a city public school system's need to analyze data on children's medications. The analysis was completed, the data were shared with the school system administrators, and a poster was prepared for the school nurses to use in presenting the findings at a national conference.
The ACNP students helped a hospice agency implement a continuing education program for staff orientation that focused on respiratory and cardiac assessment. Students first spent time with the hospice nurses to provide a realistic continuing education program that would address their needs.
The core health promotion course, the largest course to date, involved student groups in meeting the needs of a health museum. Students prepared and taught modular programs on health topics for all ages, planned and helped staff at health fairs, and completed community planning surveys.
Evaluation Tools and Data Analysis
Both qualitative and quantitative tools for formative (e.g., journaling, midcourse focus groups) and summative (e.g., surveys, focus groups) methods were used to evaluate the effects of the CETSL activities, providing objective data, supported by student reflections at the end of the learning experience. At the beginning of the courses, students completed pretest questionnaires designed by the Division of Health Professions Education of the Center for Healthy Communities (2001) and, after the service-learning activities, completed two posttests (one from the CETSL program and one from the CHC).
At the middle and end of the courses, themes of service-learning in graduate education were identified through analyses of transcripts of focus groups and reflection responses from a Web-based educational discussion board. The CETSL faculty and community partners also shared their feedback regarding what they had gained through the projects and provided suggestions for improvements. Demographic and survey data from students were analyzed using the Statistical Package for the Social Sciences 11.1 for Windows. Demographic characteristics were described, and paired t tests compared the relationship of the students' responses before and after the CETSL projects. Significance level was set at ? < .05.
Respondents for whom complete pretest and posttest data were available included 70 female (88.6%) and 9 (11.4%) male students. The average ages were 34 for female students and 31 for male students. Most respondents were White (73.4%), although 9 were international students from Asian and African countries. The qualitative evaluation data are from 65% of respondents who used journaling for reflection activities and 35% who engaged in Web-based discussions. Almost half of the students (47%) received a formal orientation by the community agency partners, CETSL program directors, or faculty before the service started.
As with most new initiatives, approximately 1 in 6 (17.6%) of the students did not think they had acquired or enhanced skills. Most students agreed they had learned new skills (e.g., assessment), especially with individuals who were underprivileged and minimally educated, and how to deliver needed health care or information to these populations. The majority of students (72.5%) thought they had gained unique knowledge through the CETSL experience. Students said this learning experience "was great." Within the project period, students kept diaries to facilitate reflection. Through the diaries, it was clear the students met the objectives. They commented on the differences, as well as the similarities, in the populations. One student wrote, "We often do not realize how healthy the public/elderly population really is until we see them in the community." Another noted, "I definitely learned things that I wouldn't have learned in a classroom."
Faculty involved were somewhat surprised at the students' lack of familiarity with individuals from very low and no income populations. It was apparent from faculty's conversations with them that students had spent the majority of their nursing careers in hospital settings and suburban offices where there were few very lowincome clients. For example, although students understood the pathophysiology of diabetes and its effect on individuals, they had little understanding of how to help clients with diabetes in the real world. The students reported they gained a better understanding of how difficult it is for clients with diabetes to rely on community meals and food banks to follow a diabetic diet. Interestingly, students also indicated they initially had "felt sorry" for the clients with low or no incomes but, at the end of the project, admired these people who were making the best of their situations.
The student feedback form documented students who felt they met the goals of learning and service (71.5% in learning; 66.7% in service). Approximately 90% of students would be willing to complete CETSL activities again. Eighty-six percent of students described the service goal as providing a needed education and health service to the community. Students (25%) who reported having difficulty completing their service-learning projects were frustrated when their agency contact left for another position and the person "assigned" as the project liaison was not supportive (i.e., used the students as free labor on other projects, rather than the agreed service needs). Faculty addressed this situation with the agency partner, redirecting the new director toward meeting agency needs with experiences appropriate to the APN students' abilities, but it was not possible to completely eliminate the negative feelings. Nevertheless, 75% of all students reported learning as much or more than they did with the "usual methods."
Agency partners reported that many of the accomplished projects had been on their planning agendas for 2 to 8 years, without sufficient staff to complete them. They documented that 90 to 1,200 hours of service had been provided to their agencies and received anecdotal reports from thente who were pleased with the direct service provided. One agency partner who had students design and implement an outreach program to the Hispanic community, thus supporting the agency's Welfare to Work initiative, summarized it as "The whole service-learning concept.. .seeing what the impact of the students' projects are/can be [changed] the care in thie community."
The statistical analysis of the pretest and posttest quantitative evaluation demonstrates significant learning after the CETSL activities (p < .0001). A Cronbach's alpha coefficient of scale reliability was .87 for the pretest and .91 for the posttest. Student means (1 = low to 5 = high) attested to a higher level of understanding of their role as community resources in providing health service in the community. Significant Ip < .0001) changes were noted in the following areas:
* Know the typee of community resources available for the population with whom I worked (pretest = 2.75; poettest = 3.45; 91.4% above moderate change).
* Understand how health care delivery système affect my work in the community (pretest = 2.73; poettest = 3.21; 81.1% above moderate change).
* Know the health care needs of the community in which I served (pretest = 2.81; poettest = 3.52; 94.4% above moderate change).
* Understand the responsibilities of other professionals in a multidisciplinary team (pretest = 3.24; posttest = 3.65; 95.7% above moderate change).
* Know the barriers to receiving health care in the community that I served (pretest = 2.81; poettest = 3.51; 91.5% above moderate change).
* Understand the effect of socioeconomic status on health and illness (pretest = 3.26; poettest = 3.76; 92.9% above moderate change).
* Understand how my placement site is perceived in the community (pretest = 2.43; posttest = 3.15; 69.7% above moderate change).
* Know how to work with clients who have various levels of health care knowledge (pretest = 3.10; postteet = 3.68; 92.8% above moderate change).
Overall, students developed more extensive knowledge of the needs and barriers of community populations and how to work with these often underserved individuals and groups.
It is poseible to adapt service-learning to engage graduate nursing students in the community using a variety of course curricula. Community-baBed health care activities supported attainment of concrete course objectives. The procese of developing and completing projects improved relationships of faculty with community partners and revised the community's perception of an "elitist" university as committed to community service. The majority of students benefited from this out-of-claesroom learning. Individualizing course plans reflected the spirit of service-learning, not just to meet students' needs but to meet the community partners' needs. From students' perspectives, the projects were creative and fun. For example, one GNP student group used a creative approach to the functional reach test and the Get-Up-and Go to assess risk for falls. The residents placed their handprints on fabric and created two quilts that were framed and given to the sites. A third GNP group developed a game that allowed residents to test their memory and health knowledge. Questione were asked, and when they answered correctly, residents were able to unwrap a gift. An exercise class accompanied thie game.
Service-learning in community settings helped graduate nursing students to learn but, equally important, promoted the health status of underserved populations. The assignments that were positively evaluated challenged students' creative abilities. Graduate nursing students who already have developed their roles as generalist nurses value being and feeling needed. Through service-learning, the students, with faculty expertise and guidance, made a difference in the community. Both faculty and students have had opportunities for professional service. One unplanned outcome has been the opportunity for NP faculty to develop a practice site that will provide health care to homeless individuals, going beyond the etudent projects to meet faculty members' need to maintain NP certification. In this win-win situation, individuals with limited resources receive quality care froni excellent practitioners.
These findings agree with Martin (1995), specifically that promoting better nursing skills involves creating learning opportunities for students in which they gain knowledge in the context of the changing environment in nursing and the health care system- a mandate for the future of nursing education. Progressive nursing education is not limited to classroom teaching and hospital practice. Providing creative opportunities to collaborate with communities and serve unhealthy populations will contribute to the development of a healthier society.
The experience and process of CETSL for students was valuable for the majority. This result corresponds to the collaborative, community-baaed projects at the University of Lethhridge, Canada (Kulig & Wilde, 1996). From the faculty's perspective, the service-learning assignment solved a concern about GNPs focusing on health-challenged older adults without working with older adults in the community who are functioning with their challenges. Getting to know the vulnerable population helps students see the possibilities that exist for living at home, even with serious health problems and functional deficits. Keeping older adults independent and community dwelling as long as possible can be considered a realistic goal for GNPe. The interactions with senior centers were a valuable teaching tool, although somewhat different than the faculty's original expectations.
Two areas that will be addressed as the CETSL program evolves are aligning individual student objectives with their past experiences and providing orientation based on these experiences. Because of graduate students' varied past clinical experiences, community projects selected for each course need to be appropriate to students' experience levels. Further consideration of past experiences when planning the assigned activities is warranted to improve the effect of service-learning projects. As faculty and community agencies continue to work together each year, projects potentially can be targeted more accurately. As with other educators (Miller & Swansea, 2002; Simoni & McKinney, 1998), a need was identified to continually assess the benefits of interventions not only to students but also the community agencies and the constituents served.
Overall, the authors demonstrated that service-learning projects at the graduate level can help students explore and successfully meet relevant community health needs and problems in areas with traditionally underserved populations. The authors also were able to motivate the majority of students to focus on the effect of meeting holistic integrated health and community needs, rather than limiting practice to individual client health needs. In addition, the authors agree with Reinhard and Moulton (1995) that:
Advanced practice. nursing U enhanced if the nurse ib able to identify, create, and use data to support nursing [in] communities and to manage and evaluate community health programs (p. 151).
By involving students in developing projects that "left something with the agency" and in evaluating their projects using graded criteria, benefits went beyond the 15week semesters. Finally, through graduate nursing education, this CETSL experience provided a benchmark for students to realign their thinking about their clients' barriers and opportunities, the resources available in the community to serve clients, and their role as resources to the community.
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