There is a saying, “No man is an island entire of itself; every man is a piece of the continent” (Donne, as cited in Carey, 2000, p. 344). It could also be said that no school of nursing is an island, but rather exists within the whole of the community. Nursing’s roots are grounded in caring for the community, and community-based environments can provide optimal learning experiences if designed in a way that presents a coherent whole for the student. All too often, community-based experiences tend to be snapshots that provide mere observation or fragmented opportunities to learn a skill along with classroom content. Nursing faculty address a number of issues in planning clinical experiences for students. These include limited exposure to healthy populations of children and adolescents, inadequate health assessment and promotion opportunities, and a range of community health nursing roles, including that of the school nurse. From this perspective, today’s nursing faculty must balance the following questions:
- What can we teach students about the expanded role of the nurse in the community?
- Are there services needed by the community that can provide meaningful learning experiences for nursing students?
- What role does nursing faculty have in providing community service opportunities within the clinical realm?
One way of integrating community-based concepts into curricula is to expose students to clinical experiences that focus on specific populations. School-age children have always needed adequate health care, nutrition, education, and support within the community. Although traditional childhood diseases have diminished, new health problems that negatively influence student achievement and success have emerged. Children come to school not only with various medical conditions, but also with diverse social and emotional needs (Wolfe & Selekman, 2002). Many health problems are caused by social conditions and lifestyle behaviors that result in intentional and unintentional injuries, stress, behavioral problems, and depression. An association between a child’s health, general well-being, and academic achievement has been recognized (Fryer, Igoe, & Miyoshi, 1997). In addition, many behaviors that contribute to the greatest morbidity and mortality in adulthood are usually established during childhood. Behaviors such as substance use, dietary patterns, and physical inactivity contribute to preventable chronic health problems such as cardiovascular diseases, cancer, and diabetes (Centers for Disease Control and Prevention, 2001).
Partnering with Schools
The specialty of school nursing is recognized in every state, yet budget cuts and lack of information regarding their effectiveness have influenced school systems to question whether school nurses are needed (Maughan, 2003). Many schools have been forced to reduce the number of school nurses, outsource school nursing services, or cut school nursing positions entirely. This is what happened in 2002 in Douglas County, Nebraska, when the County Commissioners terminated a contract with the Visiting Nurses Association, which had been providing school nursing services to 78 private schools. The board’s rationale for termination was based on cost. Subsequently, schools lost their school health services, leaving them without school nurses, minimal access to health care equipment, and few resources. It also presented schools with the burden of providing state-required screenings, immunization reporting, and mandatory staff education. An overriding concern was that without nurses, preventable problems may go undetected and untreated, thus negatively affecting the health and well-being of children. Schools without nurses can also have a disruption in the care of students with special needs, inadequate care to the student population, and liability and safety risks (Taliaferro, 2005).
Creighton University School of Nursing saw this as a learning opportunity. Although the school of nursing had been using schools for clinical experiences, with the elimination of funding, the program took a more active and independent role in providing basic health services. A partnership between Creighton University School of Nursing and schools was established. This merger provided an opportunity to meet the School of Nursing’s mission by providing service-learning opportunities for students and access to needed health promotion and prevention activities in the community.
Many of these private schools are located in census tracts where the school-age population is living in households with income reported equal to or below state and national poverty levels. Therefore, these schools were unable to afford the cost of nursing services that were once provided by the county. In an effort to help with the needs of these under-served children, Creighton University School of Nursing’s beginning-level students, under the direct supervision of faculty, began to provide school health services. Although advocates recommend a school nurse in every school, the reality is that there are many schools without any school nurse or even a nurse who visits on a weekly basis (Wolfe & Selekman, 2002).
The state of Nebraska and the National Association of School Nurses (NASN) determine which screenings should be performed (Answers 4 Families, 2007; NASN, 2001). Children are screened and rescreened for vision, hearing, height, weight, blood pressure, dental needs, and scoliosis. After the health screenings and rescreenings are completed, each school is provided with a referral log. One individual from each school is responsible for monitoring and follow up. Schools are provided with a Web site address, developed by the nursing students, which lists community resources if there are financial or other constraints that could delay access to health care services. Nursing students also provide services based on specific needs of the individual schools. Examples include analysis of aggregate child health-related data to prepare state-mandated reports, updating student health records, and providing health education to students and staff.
One goal of Healthy People 2010: Understanding and Improving Health is to increase the number of schools providing health education (U.S. Department of Health and Human Services, 2000). Education is key to improving health-related knowledge, attitudes, and behaviors of students (Drott, 2001). Education is presented to school-age students on the basis of needs identified by faculty, students, school administrators, and teachers. Creighton University School of Nursing students developed and implemented teaching plans based on the developmental level of those being taught. Health education topics have focused on health prevention and promotion. Examples include hygiene, nutrition, physical activity, smoking cessation, basic facts related to over-the-counter medications, and the physical and psychological changes associated with puberty. Teaching has also been provided to school personnel. Some of these topics include bloodborne pathogens, asthma awareness and treatment, and medication administration.
School and university partnerships are an important vehicle for innovation and offer unique possibilities for enriching both local and state efforts to improve students’ health (Brown, 1994; Gottlieb et al., 1999; Lieberman, 1992). Using schools as a clinical site for students has resulted in positive outcomes for the nursing students, school personnel, school-age children, families, and community.
One school of nursing faculty member serves as School Health Coordinator. Each school is given a clinical contract outlining all of the services provided. After the contract is signed and before the academic school year begins, a calendar is developed and distributed to all participating schools. The calendar indicates dates for screenings, rescreenings, and immunization reviews. There are also dates available for teaching or other projects that may present themselves during the year. The coordinator is responsible for working with an individual from each school to plan and organize every clinical experience.
Competencies successfully demonstrated by nursing students include understanding the essential concepts of health and illness, providing relevant and appropriate health education, analyzing child health data that may influence the health of the school-age population, identifying strategies to promote and protect the health of the school-age population, and responding to common health problems of the school-age population (American Association of Colleges of Nursing, 1997; NASN, 2001). In addition to these objectives, the nursing students demonstrated the ability to professionally interact and communicate with the school-age population, parents, and school personnel; recognize cultural variations; and provide population-focused prevention within the community. The nursing students have the opportunity to learn the role of the school nurse in the community and come to understand that school nursing is a blend of public health, pediatric, and other nursing specialties that requires unique preparation and skills (Taliaferro, 2005).
In this partnership, nursing is viewed as an active collaborator in the health of the community, which results in positive health outcomes. The health education provided by the nursing students serves to promote the well-being of students, families, and the community by preparing them to make informed choices (Drott, 2001). Faculty believe the school population is healthier and school personnel have increased knowledge of health promotion and health protection strategies. Alegent Health Organization has also recognized the value this program has in the community by awarding Creighton University School of Nursing with a grant to continue to fund some of the services provided.
Since inception of the school health clinical experience, there has been a steady growth in the number of schools participating. During the first year of the project (2002–2003), 15 schools were served. Currently, more than 30 elementary, middle, and secondary schools are receiving some form of school health service from the program, and various services have been requested by other schools, including 28 private and 4 public schools located in rural, urban, and suburban areas. Each year, approximately 9,000 students are screened and, on average, 900 students are referred for identified health problems.
Assessment and evaluation of this project is ongoing. Assessment is performed based on course objectives and student outcomes. Students are evaluated using traditional methods, such as clinical evaluation forms, tests, or quizzes, to determine whether they are efficiently and effectively managing resources when promoting and maintaining the health of the school-age population. One method of evaluation is related to health teaching. After the nursing students complete their educational projects, each teacher is asked to complete a formal evaluation form and return it to the clinical faculty member. Each evaluation is reviewed by the faculty, and feedback is given to the students. Those evaluations are incorporated into the final course summary to improve overall course outcomes.
Indirect measures are also used to evaluate the program. Continued participation and growth in the numbers of schools in the program is one key indicator. No schools have discontinued services since inception of the program and, based on recommendations from participating schools, additional schools have expressed a desire to participate. Each semester, the program receives letters from parents, teachers, administration, and staff expressing satisfaction with the services provided. A principal from one of the schools served stated, in a letter:
Many of the services provided by the Creighton Nursing students may be the only health care contact with professionals (albeit students) many of our students have in any given year. Their recommendations sent home in writing to parents have undoubtedly made some of our parents aware of looming health issues for their children. Such attempts at prevention can make a world of difference in the health of our students. (T. Paladino, personal communication, December 12, 2005)
The school of nursing also hosts an annual principals’ luncheon to receive overall program feedback. Input is obtained from an annual meeting with the Superintendent of Schools for the Archdiocese. Individual school responses are encouraged verbally or in writing. Communication with schools and parents can also be done via the Web site if there are questions or concerns about the program.
Creighton University School of Nursing is working on implementing a formal, comprehensive evaluation plan. Currently, the School Health Coordinator monitors the numbers and kinds of health screenings, rescreenings and referrals. The formal plan would incorporate a 3-month follow-up questionnaire to parents, addressing any concerns or related needs they have regarding their child’s referral. The program will monitor those students who received referral letters but had no reported follow up. An assessment of why action was not taken, barriers encountered, and ways to work with the family to resolve those barriers is planned.
Clinical experiences that serve to educate students while simultaneously helping the community are becoming more widespread in nursing education (Crowley, Bains, & Pellico, 2005). The partnership described in this article has been successful at meeting some of the basic school health needs in vulnerable populations within this community. It has also provided our program with a much needed well child clinical experience while providing the nursing students with skills they need in the future as RNs. Partnering with schools in the community has gone beyond the boundaries of traditional clinical experiences. This collaboration has created unique and meaningful opportunities for nursing students to learn about the expanded role of the nurse within the school and the importance of getting to know and provide service to their community.
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