Nursing faculty's realization that a transition in the professional nursing paradigm at the University of Haifa, Israel, was necessary occurred over several years. Nursing faculty first learned about new global economic tendencies, social changes, and health care reform. They then concluded that the nursing profession is facing tremendous changes. For example, nurses are expected to be innovative and accountable for their actions, as well as able to make changes according to client and organization needs. Nurses function as part of a synergistic team and are expected to develop and implement their professional knowledge. Because of these changes, a new professional paradigm was necessary.
Building Blocks of the Nursing Paradigm
The building blocks of the University of Haifa's new professional paradigm include:
* Community and health promotion, which was the leading area of students' clinical experiences and intervention strategies.
* Managerial skills, which made community interventions possible.
* Academic research.
Community and Health Promotion
Current priorities of the University of Haifa include community health care. Hospitals are becoming intensive care centers, and home care is becoming more common for treatment of several illnesses that traditionally required hospitalization. However, with community care, patients can stay in their familiar and supportive environments, and treatment costs are reduced.
Disease and disability prevention improves citizens' quality of life and - allows money to be allocated to other areas (Pew Health Professions Commission, 1995; Spitzer, 1998). Novice nurses should be taught how to use these priorities to patients' and nurses' advantages.
Illnesses and disabilities may cause complex situations for patients, their families, and the health care system. Novice nurses address these situations in their daily work (Merry, 1995; Pew Health Professions Commission, 1995; Waldrop, 1992; Wheatley, 1992). The nursing department at the University of Haifa developed a model that enables students to identify, diagnose, and intervene with patients, regardless of illness or disability complexity. Students are taught several basic managerial skills, including skills for project planning and management, conflict management, and basic budgeting. In addition, as part of their clinical field experiences, students accompany nurses of different clinical expertise to learn about the difficulties they encounter and how they find solutions.
The final building block is academic nursing research. Until recently, most clinically relevant research was hospital based. However, changes in hospitalizaron patterns affect the applicability of the interventions resulting from these studies to clinical practice. The move to community care and focus on health promotion demand development of appropriate research methods and practice (Spitzer, 1998). The University of Haifa offers a research seminar that is essential for novice nurses to acquire basic research skills. Nursing students who take this seminar conduct a community evaluation and then intervene with health promotion tools.
Integrating the Building Blocks into the Baccalaureate Degree Program
The new paradigm is integrated and applied in students' theoretical courses and clinical experiences.
Community and Health Promotion
Students learn about the community during all 4 years of the baccalaureate degree program. They first learn about the concept of community, as well as other basic nursing concepts, in the Nursing Fundamentals course. This course involves a continuous dialogue between students' personal viewpoints regarding the nursing profession and their ongoing establishment of their professional identity. Students are introduced to community care attitudes; community-oriented primary care and health promotion; community health care projects in Israel and the world; and the changing definitions of community, the health care system, and nursing.
At the end of their second year of study, students' first clinical experience occurs in the community, rather than a hospital, which previously had been the norm. The setting was changed because most diseases and illnesses will be treated in community settings in the future. In addition to clinical skills, one of the most important skills nurses will need in community settings is interpersonal skills, such as clinical interviewing and mental and spiritual support. During their clinical experiences, students evaluate patients' illnesses and find treatment resources. Students learn about patients' and their families' perceptions of their illnesses and the influence of illness on patients' daily lives, as well as the cost of the illnesses to the health care system.
During students' third year of study, they take a theoretical course entitled Community. This course has two purposes - to increase students' knowledge of health promotion and its practice and to introduce students to the communities in which they will be involved the following year.
During the final year of the program, students plan, perform, and evaluate an intervention for these communities. The intervention is based on a needs assessment of the community and a joint decision reached by the students and community members regarding the type of intervention. Students practice community care skills, such as community diagnosis and long-term interventions, and use health promotion strategies and interdisciplinary and community collaboration. Students manage the intervention, devise the timetable, and allocate resources primarily by themselves. In addition, the intervention is accompanied by supporting research conducted by the students and their tutors. These tutors are faculty members who specialize in community health nursing. They are experienced in tutoring clinical nursing practice in community settings, and most of them have worked in these settings for many years. Some of these tutors were involved in the development of the new paradigm.
To handle such a project, students learn managerial skills. They are taught complex managerial thinking in the context of the health care world. Students acquire skills related to diagnosis, intervention, and teamwork. Analysis of intrapersonal and interpersonal processes is emphasized. Several values that are central to health care are stressed, including world justice, humanism, ethical decision making, and cost effectiveness. This course includes workshops and a managerial clinical experience, which occurs from the second to final year of study. It also emphasizes clinical experience changes, and the skills students are required to use are broadened.
During the second year of study, students learn about complexities in the health care system and analyze the structure of an organization and its culture, policies, and roles. Students also analyze clients and their environments and try to understand their needs and relationships with different health care subsystems.
During the third year of study, two main issues are addressed - managerial styles and the system or organization experiencing change. These two issues are addressed in conjunction with students' clinical experiences. Students accompany nurses with various expertise and analyze their activity, managerial style, and the combination of both. Students examine the need for change and consider ways of accomplishing it. The basic assumption is that organizations must adjust to the ongoing changes in their immediate and global environments to survive.
During the final year of study, students practice the skills they have learned throughout the community intervention. They select a project manager; manage their resources, including time, people, and finances; resolve conflicts; and make a presentation. One assignment is to design a service addressing the specific needs of the community. Students' plans consider human resources, financial costs, and the marketing campaign.
The community intervention is based on health promotion strategies, is managed primarily by students, and is accompanied by intervention research. Based on a community analysis and needs assessment, students develop their research. They conduct a pretest, establish a baseline, implement the intervention, and conduct an evaluation. Their conclusions are passed on to the community and younger students, thus establishing continuity for the future.
The combination of the three building blocks aims to integrate areas of study and imitate real-life daily work. The authors believe nurses must integrate these skills in their work, and by experiencing this in a protected and guided manner, students will be prepared for their future nursing practice.
Practical Application: Linking the Building Blocke
To demonstrate linking the building blocks, two community interventions are described below. The communities are profoundly different. One community is a closed, cohesive orthodox Jewish community, whereas the other is within a secular junior high school. Despite the differences in customs between the two communities, the fundamentals of the intervention project are the same and are based on health promotion strategies. According to Kaplun (1992), Naido and Wills (1994), and Rainey and Lindsay (1994), they include:
* Facilitating continuous connection with the community.
* Applying health promotion plans adjusted to the specific community's needs.
* Community empowerment through acquisition of knowledge and skills by community representatives to ensure independent continuation of these projects in the future.
* Feasibility of the project for the community and community members' willingness to cooperate throughout the planning, implementation, and evaluation of the intervention.
First Community Intervention
The social structure of the orthodox Jewish community is highly cohesive and is characterized by a hierarchical social system with binding religious values. Voluntary activity within the community is common and ties with the wider secular community are loose. In addition, people within the community do not watch television or listen to secular radio broadcasts. Their lives are guided by both religion and the head of the community, the Admor, along with several other assistants (Levi, 1989). It was a challenge for the nursing department and students to permeate this community. Suspicion and caution from both members of the community and the students accompanied the intervention. The community was interested in health projects but required that each step in the intervention meet their values and beliefs and be authorized by their official leaders. The intervention was conducted, maintaining a separation between men and women due to the religious beliefs of the community.
Intervention Topic. The topic of the intervention was prevention of household accidents. This community is characterized by large families with many children, who live in small, crowded houses. Crowding also occurs outdoors, such as in neighborhood playgrounds where play equipment is limited and inadequate for the large numbers of children using the facilities. Older siblings, especially girls, take care of younger children while their mothers work and their fathers study religion. Because of this situation, accidents occur. For example, children fall or swallow chemicals, especially during preparations for festivals when parents are more distracted and cleaning products and food preparation items are used more frequently.
Community and Health Promotion. The intervention aimed to increase community members' awareness of hazards in the home and ways to prevent accidents and to teach basic lifesupport action. The intervention first was presented to sixth-grade and seventh-grade teachers, then to their students. It consisted of several theoretical sessions, followed by practical applications. The material used throughout this program was adjusted for the community's needs. For example, students, although secular, wore traditional conservative clothing. In addition, the written material was adapted to fit the language and customs of the community.
Managerial Skills. Students used managerial skills throughout the intervention. Initially, they were required to market the intervention, emphasizing their own advantage as health promoters. This strategy was selected because the orthodox community was ready to open itself to the secular world in matters related to health. By establishing cooperation with the community leaders and members, students succeeded in intervening and teaching the necessary skills. Students also were required to budget their project, be creative, and handle conflicts within the community and among interdisciplinary participants.
Academic Research. Students constructed data collection tools and examined them for validity and reliability. After data were collected, they were analyzed using the Statistical Package for the Social Sciences (SPSS). The intervention was based on the results of this analysis, and its effectiveness was assessed several months after project completion.
Success of the Project. Participants learned about and reported successful changes in the homes and community environments in which they worked. Success was verified through student observation, as part of the pretest and posttest. Students learned about marketing their abilities and the project by emphasizing their contribution to the community and managerial skill practice. This was one of the most successful interventions conducted by secular students in this type of community.
Second Community Intervention
The second project occurred in one of the oldest neighborhoods in Haifa. Teachers from one school in the community participated in an advanced study workshop in which they learned about health promotion and conveyed a willingness to engage in this type of project. Seventh-grade students were the target population of this project.
Intervention Topic. According to a needs assessment conducted by the students, one of the most important issues for seventh-grade students is being popular among friends and being part of a group. According to the literature, this is one of the most vital issues for all adolescents (Cotterell, 1996; Montemayor, 1990; Smilansky, 1991). In addition, adolescents who experience difficulties integrating into their peer group suffer from loneliness and social exclusion, which may become a risk factor for suicide attempts. Some adolescents who experience difficulty entering a social group adopt unhealthy behaviors, such as smoking, drinking alcohol, abusing drugs, or being violent, as a way of joining a group, usually a fringe group (Cotterell, 1996; Montemayor, 1990; Smilansky, 1991).
Many immigrants live in Israel, and in the past few years, many immigrant children have joined the educational system. Therefore, they have to adapt rapidly to the language, habits, clothing style, and other attitudes if they want to be part of the "in" crowd. This physical, emotional, and cultural transition is not easy, and gaps between immigrants and native Israeli youth begin to appear. Due to this situation, the Ministry of Education decided, during the year the nursing students were implementing their intervention, that the main topic of the year for education in general was the right for honor and the obligation to respect.
The needs assessment informed students that children who were considered outsiders needed to learn assertiveness skills and ways to become friends with children who were part of the "in" crowd. In addition, the children themselves were divided into three main groups:
* The "ins," who were the main group, primarily native Israelis with few immigrants.
* "Bad guys," who were violent, smoked, and drank alcohol. This group included a mix of native Israeli and immigrant children.
* "Lonely" children, who kept to themselves with a minimal social network. Members of this group were primarily immigrant children.
A sociometric scale, completed by children's peer groups, identified their social rank. The students worked with children in all three groups.
Community and Health Promotion. The intervention had two goals - to strengthen the children's interpersonal and intrapersonal skills, especially those of the "lonely" children, to improve their social popularity; and to encourage children to participate in a Health Day fair held by the municipality. WiUi the help of the nursing students during 10 afternoon meetings, the children built three stands for the fair- healthy food, building physical fitness by walking, and road safety. The children, especially those who were unpopular, were empowered through the working process. Emphasis was placed on working in a group, the right to have differing opinions, democratic decision making, and equal opportunities for all participants.
The children actively participated in the fair by presenting their work. They performed a play about healthy food, took people for a walk under the supervision of a physical education teacher, and managed a stand about road safety in the neighborhood.
Managerial Skills. The students were required to market their intervention to the school's head master, teachers, and students. Connection with the students was difficult to attain because of their suspicion of the nursing students' intentions, and because the three groups of children were not willing to work together. Only after the groups of children were introduced to the Health Day fair and realized its importance, they worked as a team. Each child had a task of his of her own, assigned according to individual capabilities. The "ins" learned from the "lonely" children and shared their own ideas.
Academic Research. The nursing students constructed data collection tools and examined them for validity and reliability. After data were collected, they were analyzing using the SPSS. The intervention was based on this analysis, and its effectiveness was assessed 1 month after project completion.
Success of the Project. The intervention was a success, and one of the popular girls offered her view of what had occurred:
I met children different from me, with whom I wouldn't otherwise have had any relationship. I wouldn't have tried to be their friend. They were good at what they did, and it was nice working with them.
The social network of the unpopular children did not expand significantly, but they became more involved in their peer group activities and could stand up for their ideas more easily, even if they were different.
Project Outcomes for Nursing Students
Several positive outcomes for nursing students were observed, including:
* The students were able to successfully implement theoretical knowledge regarding health promotion, theories, and interventions.
* The students learned that the community is equal in importance to hospitals as clinical experience settings.
* Students managerial skills were strengthened. The students were more confident and independent in using skills such as negotiating and self-marketing and worked successfully on a group project.
* The students successfully built professional and social connections with people of different values, beliefs, and social status.
Project Outcomes for the Communities
Positive outcomes for the communities also were observed, including:
* An increase in knowledge levels and reported health behaviors, and changes in attitudes.
* Community empowerment. For example, in the orthodox Jewish community, the community leaders encouraged each community member to learn first aid and life support, and obtained financial support for the courses from the government. In addition, the leaders ensured that at least one resident of each home participated in the courses.
Complexity and interdisciplinary teamwork characterize the current health care system. Each component of this system must demonstrate its relative advantage and unique contribution. The nursing department of University of Haifa developed a new professional paradigm based on three building blocks - community and health promotion, managerial skills, and academic research. Practical application of linking the building blocks was offered, and two community projects were described. Questions for further research include:
* What is the influence of the curriculum on the professional careers of program graduates?
* What is the influence of the curriculum on nursing student applicants? Why would they favor this nursing program over others in Israel?
* Are this program's graduates and their contributions unique, as perceived by nurses in the field?
* What is the effect of this new professional paradigm on the academic plans of other nursing departments, as well as on clinical practice in Israel?
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