Journal of Nursing Education


Undergraduate Community Health in the First Semester: Opportunities and Challenges

Barbara J Speck, PhD, RN



In the current health care environment, there is a trend for care to move from acute hospital settings to community settings. The Pew Health Professions Commission and the American Association of Colleges of Nursing identified a need to modify health care professional education to meet the needs of the changing health care system and diverse demographics in the United States. In traditional baccalaureate nursing programs, the community health nursing course typically is taken in the last year, after students have completed medical-surgical nursing courses. This article describes a curriculum that begins with the community health nursing course. Many opportunities and challenges related to this placement are described.



In the current health care environment, there is a trend for care to move from acute hospital settings to community settings. The Pew Health Professions Commission and the American Association of Colleges of Nursing identified a need to modify health care professional education to meet the needs of the changing health care system and diverse demographics in the United States. In traditional baccalaureate nursing programs, the community health nursing course typically is taken in the last year, after students have completed medical-surgical nursing courses. This article describes a curriculum that begins with the community health nursing course. Many opportunities and challenges related to this placement are described.

Several nursing schools have reported changes in their curriculum based on predictions that health care will continue to move from acute care to the community. These changes have ranged from expanding community content to redesigning entire curricula. Oneha, Magnussen, and Feletti (1998) described a cooperative community clinical experience with a community health center where students were immersed in the community and community partnerships. Thomas (1995) developed an occupational community health clinical experience that included aggregate assessment, environmental health assessment, and opportunities to plan and develop health promotion programs. Both of these examples describe community clinical experiences at the senior nursing student level. Conversely, Conger, Baldwin, Abegglen, and Canister (1999) described an integrated curriculum with community health concepts included throughout the curriculum, beginning in the first semester. Wherever changes occur, the intent is to better prepare students to practice in the changing health care environment. This article discusses the opportunities and challenges of presenting an aggregate community health nursing course in the first semester of a redesigned undergraduate baccalaureate nursing program.

Description of Undergraduate Program and Community Health Course

The University of Louisville School of Nursing implemented a major curricular revision in 1998, which had been developed by faculty members during the previous 2 years. The revised curriculum has been described previously (Freeman, Voignier, & Scott, 2002) and will be described briefly in this article. A framework was developed for the curriculum that identified assessment, intervention, evaluation, communication, systems management, and professional behavior as life skills. Facilitators of these skills are critical thinking and technology.

The sequence of courses begins in the junior and senior years with four consecutive courses of 15 credit hours each. The first course, Lifeskills for Nursing I, includes aggregate community health nursing, communication, systems management, and professional behavior. Lifeskills for Nursing II, III, and IV each include increasing levels of communication, systems management, and professional behavior. Lifeskills for Nursing II and III focus on chronic and acute care with individuals and families, and Lifeskills for Nursing IV is a synthesis course, focusing on preparing students for the transition to practicing nurses.

Learning outcomes critical for professional nurses in the 21st century were identified. The learning outcomes of the curriculum are:

* Effectively communicate both orally and in writing with peers, clients and families, and other health care providers.

* Demonstrate critical-thinking cognitive skills and affective disposition.

* Work effectively and cooperatively with groups.

* Select, use, and evaluate nursing interventions for clients, families, and groups (i.e., communities).

* Demonstrate personal and professional life skills and commitment to lifelong learning and service to the profession and community.

* Use technology effectively in nursing practice.

Successful students demonstrate progress toward achievement in each of these outcomes after completing the first 15-credit course, Lifeskills for Nursing I.

Seven of the 15 credits of Lifeskills for Nursing I focus on community aggregate content, while the other eight credits focus on communication, systems management, and professional behavior life skills. The community health didactic content includes typical content in most community health courses, regardless when it is taught. Content includes community health concepts (i.e., aggregate care, health promotion, levels of prevention), community health assessment, cultural diversity, health education, epidemiology, communicable diseases, and aggregates issues. The primary focus of the community health clinical experience is a community health assessment of an aggregate, such as a small community, nursing home, senior center, or school. Groups of four or five students complete an assessment of the aggregate, analyze the data, identify strengths, develop a prioritized problem list, develop and implement one intervention based on the problem list, and evaluate tibe intervention.


The opportunities provided by the revised curriculum are that critical concepts and aggregate skills are introduced early in the curriculum, communication and technology skills are used immediately and consistently, research is introduced, and group process is a major experience. Student groups complete a community health assessment and, thus, are intimately involved in the difficult concept of aggregate care in the first semester, before exposure to individual care. Individual care is the most easily understood concept for nursing students and the general public because most models of nursing and images of nurses present hospital nurses caring for individual patients. By focusing on aggregate care early in the curriculum, students are exposed to the importance of clients, their families, and their communities beyond the hospital walls. The concept of aggregate care is not easy to grasp, but class and clinical assignments reinforce the didactic content. In addition, community health assessment and the nursing process frequently are compared and contrasted.

Another important concept introduced early is cultural diversity. As the general population becomes more diverse, nursing students continue to be primarily White women from middle class backgrounds. Only 10% of nurses are from minorities, compared to 28% the U.S. population being from minorities (Pew Health Professions Commission, 1998). In addition, less than 6% of nurses are men (Pew Health Professions Commission, 1998). Although national efforts are under way to increase the diversity of all health care professionals, including students, faculty members, and practitioners, the reality is that this goal has not yet been met. It is critical that nursing students are exposed early and often to concepts of diversity, including ethnocentrism, stereotypes, prejudice, and diverse cultural health philosophies and health care practices. This is typical content in community health courses, so when taught in the first semester, studente have the advantage of processing this information early in the curriculum and applying it in all subsequent clinical experiences.

Students also learn early how to identify community resources. As a part of their community health assessment project, students identify the myriad community resources available to their aggregate. Because student groups assess a variety of aggregates, the resources may be specific to one aggregate. However, an important learning objective is the presentation of each project, so students from all other groups learn about an aggregate, including the community resources available in this community. Students can use this information throughout the curriculum when they encounter a situation where, for example, a hospitalized patient requires a community resource. Students typically are amazed to learn the breadth and depth of resources available in the communities in which many of them live.

The skills to which students are introduced in the communication content are reinforced by many activities during the community section of Lifeskills for Nursing I. In the didactic content, students present a variety of content to their classmates. In the history segment, students first view a short videotape on public - health history and read the chapter on history in their textbook. Historical eras are divided in broad categories, and student groups present public health events from specific eras. The variety of content and selection of unique material keep the students' interest far longer than an instructor lecturing on this topic. Culture presentations feature characteristics of specific cultures and incorporate the assignment on research with individuals from many cultural groups.

Another enjoyable presentation for students is the presentation of the community health assessment projects. Student groups are required to complete a PowerPoint presentation and dress in professional attire, as if they were presenting the information at a professional conference. Faculty members from the school of nursing are invited to attend the presentations. This reinforces the professional behavior content, provides students with experience in presenting to a group, and completes the community assessment project by disseminating the results. In addition, students provide a summary of the project to the community (e.g., school principal, city mayor, nursing home director).

Students also have many opportunities to use computer skills. At the beginning of Lifeekills for Nursing I, all students are assigned an e-mail account and are made part of an email list for undergraduate nursing students. This provides a mechanism for efficient communication among peers, faculty members, and administrators. In addition to assignments in professional behavior, systems management, and communication content, many community health assignments require computer skills. Students learn how to use PowerPoint for presentations, which is a skill they use throughout the Lifeskills for Nursing courses and then in their professional careers. Specific assignments require literature searches, and students become proficient in this skill in a short time. The community health assessment requires students to access national, state, and local databases for information about their specific aggregates. In addition, the courses include Internet assignments related to epidemiology case studies, creating rates from an actual state database, and environmental health issues.

Primary and secondary prevention interventions are the major nursing technology skills used by students in the clinical experience. Students implement one intervention based on their community health assessment. The identified intervention may be an educational presentation, health fair, or screening. Some unique interventions have been:

* Organization of a "kick-off" community walk to highlight the need for cardiovascular risk reduction through regular physical activity.

* Development of a community resource manual in Spanish for a school with a large Spanish-speaking population.

* Identification of families without working smoke alarms, with the help of the fire department in a small community.

In addition to the intervention for their aggregate, each student clinical group plans health education presentations for public school classes. A small needs assessment is conducted with the teachers in a specified school(s) to identify pertinent topics. Students then prepare an educational plan, including objectives, content, methods, and evaluation plan. After the presentation, they complete an evaluation of the presentation.

A second activity in which all students participate is scoliosis screening of mid&e school students in public schools. This activity provides students with an opportunity to reinforce the concepts of screening (e.g., screening procedure, identification of at-risk aggregates, criteria and procedure for referral). Therefore, all students have opportunities to make health education presentations in the community and participate in screening and other primary or secondary prevention activities.

Students learn the basic types of research and the research process in the first semester, and then research content is threaded throughout the curriculum. Assignments require reading research articles with a beginning understanding. For exampie, when students are learning about different cultures, one assignment is for each student to find an article of a research study with participants of various cultures. Students read the article, report the results to their classmates, and lead a class discussion of the basic research method and the findings related to the cultural group.

Finally, students have ample opportunities to work in groups. A group of four or five students completes a community health assessment of a small aggregate. Group members use information learned in the communications content to identil~ group process, function, and roles in their own group. Not all groups run smoothly, but students then have the opportunity to use their problemsolving and critical-thinking skills to resolve issues. Student groups generally solve their own problems, but if necessary, a faculty facilitator is assigned to the group. This is an important learning outcome because working in groups as effective team leaders and members has been identified as an important professional skill (American Association of Colleges of Nursing, 1998; Shugars, O'Neil, & Bader, 1991).


The challenges provided by the revised curriculum are related to nontraditional placement of the community content, students* lack of medical-surgical knowledge, and the fact that clinical instructors may not be community health faculty. The nontraditional placement of the community content presents several difficulties. It hinders students in this program from transferring to another program and receiving credit for content. Although the community content can be identified, it does not include all of the traditional community health content, primarily home health. In addition, students who wish to transfer into this program must begin with Lifeskills for Nursing I, although they already may have completed one semester in a traditional program. Pharmacology and pathophysiology courses are not integrated into the Lifeskills for Nursing courses, so these could be transferred if equivalent.

The second challenge is that students have not yet completed medical-surgical nursing courses. Students are capable of learning and implementing primary and secondary prevention interventions for aggregate care, and although the philosophy is not unusual for public health students, nursing students have preconceived ideas of the nature of nursing school - primarily taking care of sick patients in hospitals. Theoretically, nursing students who begin with public health could be more focused on the content than senior nursing students who are focused on hospital nursing, and want as much experience as possible as students before beginning their careers in hospitals. Anecdotally, from the author's experience, teaching both the traditional placement of community health and the placement of community health in the first semester, no difference in student interest regarding being in the hospital setting has been demonstrated.

Finally, some clinical faculty members may not be community health faculty. There are several reasons for this. One is that the nontraditional sequencing makes it difficult to hire clinical faculty. The community health clinical experience is scheduled during a 7-week block of the semester. Other Lifeskills in Nursing courses also have block clinical experiences and require faculty for several days per week only certain weeks of the semester. This has presented the administration with a difficult schedule for hiring clinical faculty. When clinical faculty members are not community health faculty, the course coordinator is responsible for working with the faculty in understanding aggregate care and preparing for the clinical experience and student assignments. Use of experienced clinical faculty members has decreased the difficulties in this respect.


The Pew Health Professions Commission reports (O1NeU, 1993; Pew Health Professions Commission, 1995, 1998; Shugars et al., 1991) consistently call for changes in health professions education to match the needs of the changing health care system, as health care shifts to the community. Oennann (1994) specifically called on nursing faculty to reexamine their existing curricula. Some specific suggestions were greater emphasis on traditional community health concepts of health promotion, levels of prevention, and atrisk populations. The community health nursing curriculum described in this article is an effort of one nursing program to meet these challenges. Although major change is extremely uncomfortable for faculty members, students, and administrators, change is inevitable as less hospital beds are needed and health care is provided in clinics, schools, workplaces, and homes.


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