Dr. Kruger is Associate Professor and Community Coordinator, Dr. Roush is Assistant Professor, Dr. Olinzock is Associate Professor, and Dr. Bloom is Professor and Associate Director of Undergraduate Studies, School of Nursing, University of North Florida, Jacksonville, Florida.
The manuscript was presented in part at the Association of Community Health Nursing Educators Annual Institute, Kansas City, Missouri, June 2007, and the Sigma Theta Tau 18th International Nursing Research Congress Focusing on Evidence-Based Practice, Vienna, Austria, July 2007. The authors thank the University of North Florida administration, faculty, and students of the School of Nursing and community partners for their commitment and support to making the Home-base model an integral component of nursing education at the University.
Address correspondence to Barbara J. Kruger, PhD, MPH, RN, Associate Professor and Community Coordinator, School of Nursing, University of North Florida, 1 UNF Drive, Jacksonville, FL 32224; e-mail: firstname.lastname@example.org.
The University of North Florida School of Nursing Home-base model was the result of the vision to prepare students for successful interdisciplinary practice across the continuum of care, with diverse populations in a broad range of settings. This is accomplished through continuous student engagement in one community practice setting across the nursing curriculum. The school refined its undergraduate baccalaureate curriculum in 2001 to respond to potential changes in the health care system, to respond to the national movement to implement community-based nursing education (American Association of Colleges of Nursing, 1993, 1997, 2002; National League for Nursing, 1993) and to address 21st century competencies (Pew Health Professions Commission, 1993, 1998). The school sought to integrate community health concepts and experiences across the curriculum while retaining an emphasis on the knowledge and skills needed by graduates in acute care settings. The goal was to incorporate strategies identified by local public health nurse leaders and faculty that were similar to those identified in a study of prospective employers (Hahn, Bryant, Peden, Robinson, & Williams, 1998) as a way to teach students to swim in the ocean (i.e., community) as well as in a pool (i.e., hospital). These strategies emphasized the development of skills in decision making, collaboration, and communication, as well as technical competencies, while helping students gain comfort in working with individuals with different worldviews. The focus in the home-base is on health promotion and exploration of the ecological factors that influence the health of individuals, families, and communities.
The Home-Base Model
Development of the Home-base model was influenced by Linderman’s (2000) recommendations for future changes in nursing education and the community-based curriculum models from Northeastern University (Matteson, 1995, 2000) and the University of Central Florida (Kiehl & Wink, 2000). Among Linderman’s (2000) seven curriculum changes, the “increased use of projects that require months to complete thereby providing an understanding of the complexity and nonlinearity of the real world” (p. 11) was a challenge that the Home-base model sought to address. Home-base development also incorporated a service-learning pedagogy (Gelmon, Holland, Shinnamon, & Morris, 1998; Norbeck, Connolly, & Koerner, 1998; Seifer, 1998; Zlotkowski, 1998).
The University of North Florida School of Nursing’s innovative model, although influenced by other academic models of educating nursing students in the community, has its own distinctive features. Three core concepts characterize the uniqueness of the model, including the continuity of the student’s clinical practice across time and place, the inclusion of students as partners, and the gradual transition to population-focused care. The concept of maintaining nursing students in one home-base over the entire course of their studies is now considered a key component of the curriculum.
Community organizing principles (Minkler & Wallerstein, 2002; Walter, 2005) provided three guiding concepts for the development and implementation of the Home-base model:
- Integrate students and faculty into existing community initiatives to increase capacity.
- Work in a participatory approach to address community issues.
- Engage in continuous, long-term initiatives to build sustainability.
Integrating faculty and students into existing community initiatives was an important philosophical approach, as a well as practical one. The University is located within a large urban and rural area, rich with resources to meet the health and social needs of residents. Rather than carve out a niche to address unmet needs and risk competing for scarce resources, we chose to bolster what the community was already doing and support their capacity. At a practical level, as a small school of nursing, we did not have the resources to sustain an academic nurse-managed center (Wink, 2000), particularly with the fiscal challenges facing well-established centers (King, 2008). Consequently, we internalized the mindset and placed the community at the center of our practice where we interact in relationship with each other (Walter, 2005). Faculty who were already practicing introduced students to their community partners, whereas other faculty created practice opportunities by engaging new community partners.
Partnering with communities to respond to their issues and agendas was the second guiding concept. The idea of the community generating their issues and solutions and “starting where the people are” (Nyswander, 1956, as cited in Minkler & Wallerstein, 2002, p. 280) is thought to result in ownership and authentic change. Although this principle is embedded in community and public health nursing theory and practice, it may not be a customary paradigm across nursing specialties. Students may underestimate the amount of time it takes to develop relationships, the restraint it takes to listen to the community, and the skill it takes to work as a partner in a participatory manner. Community practice is predicated on working with the community and is a competency that is transferable to any nursing practice setting or specialty area. Partnering with the community to improve population health and reduce disparities emerged in the 1970s was advanced globally in the 1986 World Health Organization Healthy Cities/Healthy Communities movement (Minkler & Wallerstein, 2002) and more recently reinforced by the Institute of Medicine (2002). Community and public health nursing practice and education have consistently emphasized community partnering as an essential nursing competency (American Nurses Association, 2007; Association of Community Health Nursing Educators, 2000; Council on Linkages Between Academia and Public Health Practice, 2001; Quad Council of Public Health Nursing Organizations, 2004).
Contributing to the community through continuous, long-term engagement was the third principle that guided the development of the Home-base model. The extended time in one community allows students to discover community strengths and assets (Kretzmann & McKnight, 1997), to be realistic about planning and implementing health promotion programs, and to think on their feet. One semester is an artificial time frame within which to teach community health concepts that, in practice, may require months and years to learn. In the home-base, students, faculty, and community partners engage with each other over time, beyond one course or one semester. The initiatives and programs that result from partnering together build on each other and become integrated in the fabric of the community.
A home base, whether a geographic location or comprehensive agency, is constant for each student during each semester throughout the nursing program. The University of North Florida School of Nursing currently has six home bases (Table 1). Twenty-four to 48 students are assigned to each home base, in which they engage in 16 hours of service-learning activities during each of their first four semesters, concluding with a 90-hour capstone project in their final semester. Two to three faculty members coordinate and maintain multiple partnerships within each of these communities (Kruger et al., 2008). In total, 14 faculty members—70% of our undergraduate faculty—maintain relationships with 50 community partners. Faculty members hold nursing specialties in community and public health, psychiatric and mental health, adult health, pediatrics, and women’s health and comprises a committee within the school that monitors the refinement of the Home-base model.
Table 1: School of Nursing Community Home-Base Description
Students are assigned to a home-base upon entry into the nursing program on the basis of proximity to their residence. They remain in their home-base for the entire length of their nursing program. Students work with faculty, community partners, and residents to plan and implement activities that meet community-identified needs. Students visit their home-base any time of day or day of the week, balancing planned activities and emerging opportunities with their class and personal schedules.
Four of the home-bases are geographic in nature (i.e., they are specific neighborhoods or regions in Northeast Florida). For example, Pine Forest is a small, well-established urban neighborhood comprised primarily of African Americans with new immigrants from Eastern Europe and Southeast Asia. The Pine Forest partners promote the health of residents across the lifespan through programs such as lead poisoning prevention, hurricane preparedness, injury prevention, neighborhood revitalization, and integration of multicultural immigrant families.
The other two home bases are program focused, residing in agencies serving a wide geographical area. One is the Northeast Florida Chapter of the American Red Cross and the other is a city agency called the Jacksonville Children’s Commission, both of which have several programs and serve thousands of residents. At the Red Cross, students participate in disaster training and preparedness and a global measles prevention initiative, shelter nurse recruitment, and teach health and safety courses. The Children’s Commission’s focus is on maximizing the health and well-being of children and families. Students participate in several programs, including literacy programs, home visits, consults at childcare centers, developmental screenings, and parenting and injury prevention classes.
Faculty and community partners sustain long-term relationships in each home-base through joint planning and project oversight, regular meetings, partnership development workshops sponsored by the University of North Florida school of nursing, professional development opportunities in the community, and joint presentations with students at conferences.
The knowledge and skills necessary for participation in home-base activities are provided within two distinct didactic courses, one in the first semester and one in the final semester of the program. The first-semester Family and Community Assessment course (4 credits) introduces students to the basic concepts and tools for participation in health promotion and illness prevention activities in the community. The final-semester Community Partnerships course (5 credits) emphasizes population-focused public health concepts and theories and is accompanied by a 90-hour clinical practice course. The topical content (Table 2) in the first-semester and final-semester community courses is consistent with the knowledge and skills recommended for generalist community and public health nursing curricula and public health nursing competencies (Association of Community Health Nursing Educators, 2000; Ferren Carter, Laux Kaiser, O’Hare, & Callister, 2006; Quad Council, 2004).
Table 2: Topical Content Covered in Didactic Community Courses
The Pine Forest Neighborhood Home-Base
The students’ paths to partnership vary among the home-bases. The Pine Forest experience is described in the following case report. These students work within the Pine Forest home-base for 5 semesters.
Semester One: Getting to Know Pine Forest
New students are welcomed into the fold of Pine Forest by all partners, community, faculty, and peers. A community resident or activist organizes and serves as a guide for the initial tour in a local church bus that has become a rite of passage. As students tour, they are told the stories of Pine Forest, visit landmarks, and view murals depicting historical events in the community. They attend a local church service, a neighborhood association meeting, and a city government-supported citizens advisory committee meeting to expose them to the broader social, cultural, economic, environmental, and political influences on health in the community. Students also participate in screening activities, after-school programs, and summer camps.
Community engagement is supported by learning activities in their first-semester Family and Community Assessment course. As students learn about community assessment in class, they apply the content in their home-base by conducting a mini community assessment including a windshield survey, interviews with key informants, and a review of demographic and health statistics. Students reflect on their experiences using an online journal to which faculty, other students, and community partners may respond. Journals serve as a vehicle for students to reflect and critically think through the fear and discomfort that often accompany a new experience. At the end of the semester, all students meet to debrief, share stories, and discuss service-learning opportunities for the following semester.
Semesters Two Through Four: Getting Involved in Pine Forest
During semesters two through four, students are simultaneously taking didactic and clinical courses in nursing specialties. In the home-base, they learn to engage residents, plan small interventions, and practice implementing and evaluating them. For example, a group of students worked with the director of the after-school program to promote better hygiene with elementary school children, a priority identified by the community. In their second semester, they spent time building relationships with the children through after-school activities such as homework assistance and fitness games. In the third semester, students engaged the children in interactive activities such as the shower dance and, with guidance from the program director, developed an incentive program to encourage behavior change. Drawing on pediatric course work in their fourth semester, students tailored their teaching methods to the developmental level and abilities of the children.
As the educational program continues, some students may move on to other interests, as newer students become invested. Senior students mentor the newer students and bring them in on their shirttails to the trusting relationships and successful teaching strategies that have been established. Health promotion projects have expanded beyond hygiene and include an ongoing Youth Power fitness project and the Open Airways program from the American Lung Association.
Semester Five: Working as Partners in Pine Forest
In the final semester, students spend 90 hours working in teams to plan, implement, and evaluate service-learning projects. Community, faculty, and student partners focus on an issue of concern to stakeholders. At this stage in their program, students function autonomously and work in a collegial manner with community and faculty partners. Clinical practice is supported by didactic content taught in the Community Partnerships class, which emphasizes joint program planning, theory-guided and evidence-based interventions, integration with existing initiatives, and beginning exposure to a population focus.
For example, continuing on the groundwork of prior semesters related to the hygiene project, a small group of seniors collaborated with the community center director and summer camp counselors to design, implement, and evaluate a 6-week health promotion curriculum. Students combined evidence-based practice from their formal education with their situational knowledge developed during their 2 years of experience with these children to design a program tailored to the specific ages, stages, needs, and behaviors of this population of Pine Forest children. The project is sustainable by the Pine Forest community center staff and has the potential for customization for other community center camps with similar populations.
Preliminary Student Outcomes of the Home-Base Model
Formative evaluation was an integral component of Home-base model implementation and is continuing into its sixth year. Initial student feedback was obtained through focus groups and analysis of student reflective journals, which evolved into an annual exit survey that combined structured and open-ended questions that were deemed exempt by institutional review board. During the first 2 years of home-base implementation (2002 through 2004), students addressed the structure and quality of the educational experience and partnership formation and recommended more interdisciplinary opportunities. Initial student reaction was mixed. Students commented that the clinical objectives were not always clear and did not always relate to course content, and that faculty teaching sections of the course were not always consistent with expectations. At the same time, students indicated that their work in the community gave them a “broader perspective,” allowed them to interact with diverse populations, was prevention oriented, taught them about community resources, and allowed them to build relationships and work independently. Curriculum adjustments were made in response to student feedback.
By 2006, graduating seniors (n = 97, 71% response rate) consistently indicated they were able to “see the big picture” (88%), “make a difference” in the health of their community (78%), gain an appreciation for the health promotion role of the nurse (85%), and “shed underlying prejudices” (80%). They frequently expressed an appreciation for “upstream approaches” before it gets “to the point where people have to go to the hospital…. [The students] really gained an appreciation for prevention over just fixing existing health problems.” One student who taught women about breast self-examinations, domestic violence, stroke, diabetes, and hypertension noted that:
[The women] were implementing changes in their lives. They [were] speaking to neighbors, friends, and family concerning the information we gave them. In fact, at our gatherings they now refuse to eat fried chicken!
These students, and many others, left their home-base “feeling a sense of responsibility and pride” and increased self-confidence. In addition, students reported learning about community resources (81%), working with other disciplines (66%), and practicing skills such as communication (78%), teaching (70%), and advocacy (57%). These indicators, derived from initial qualitative data, have increased in frequency over the first 4 years.
Students also wrote about getting past their fears and misconceptions about new and different places and reported that the experience “opened my eyes” and “broadened my horizons.” One student described her experience of working with homeless individuals as the:
challenge…to mellow to the level of the community nurse. Working with this population, you have to slow down or you will miss what they need. You have to stop and take the time to be with them to find out what you can do.
This student comment resonates with Zerwekh’s (1991) description of the promotion of client readiness to change through “Timing and Detecting,” (p. 215) a nursing activity that requires a balance of listening, being present, building trust, and being patient. Many of these preliminary outcomes are consistent with the findings in national studies of service learning (Eyler & Giles, 1999). Although nursing community-based programs use service-learning pedagogy, the challenge is to compare outcomes from across anecdotal reports (Champagne, 2006).
Implications for Nursing Education
Several community-based academic nursing curricula with some kind of continuous experience across courses or semesters have been reported in the literature over the past 5 years (Hall-Long, 2004; Hamner, Wilder, & Byrd, 2007; Thies & Ayers, 2004; Ward et al., 2007; Williams-Barnard, Sweatt, Harkness, & DiNapoli, 2004; Wink, 2003). However, there is no reported evaluation of continuity as it relates to community clinical experiences. In fact, the only evaluation of continuity found in the literature was of a geriatric curriculum embedded in four clinical courses across 1.5 years in a nursing program (Davis, Beel-Bates, & Jensen, 2008). The investigators reported significant differences among geriatric assessment competencies by students who participated in the longitudinal clinical experience, compared with students who did not. The need to document outcomes and engage in pedagogical research is essential to articulate an evidence base for nursing education (National League for Nursing, 2005).
The attitudes, knowledge, and skills that students learn through a continuous, long-term experience in a home-base have implications for community and public health nursing and for general nursing education. In most schools of nursing, community health content is still being taught in a single course at the end of the curriculum (Chappy & Stewart, 2004). There is little research about how to influence student interest in careers in community health (Hayes et al., 2006). On the basis of our 2007 exit survey, 53% of the respondents (n = 87) indicated that they were very likely to somewhat likely to consider a career in community and public health nursing—an increase of 10% from when we first asked this question in 2003. This suggests that continuity in a practice setting and collaborative relationships such as that found in a longitudinal, interdisciplinary academic experience in rural health may be essential ingredients to positively influence future career choices (Florence, Goodrow, Wachs, Grover, & Olive, 2007).
The gradual progression of community experiences within the curriculum is necessary for students to engage residents, develop relationships that move them toward grasping the big picture, appreciate the influence of community context on health, and develop a population approach to practice. This is consistent with qualitative analyses of the development of expertise in public health nurses (Diekemper, SmithBattle, & Drake, 1999a, 1999b; SmithBattle, Diekemper, & Leander, 2004a, 2004b). As the concept of population health, however it is defined among nursing specialties, gains popularity among advanced practice nurses (Radzyminski, 2007), nursing programs should consider clinical practice experiences that allow students to gradually widen their perspective from individual to population-focused care.
The Home-base model allows students to move beyond the biomedical focus on disease and cure, conceptualize their practice within a holistic and inclusive model of health, and appreciate the effects of sociocultural, environmental, and political determinants of health (Evans, Barer, & Marmor, 1994; Marmot & Wilkinson, 1999). The Environments of Care Model proposed by Ervin, Bickes, and Schim (2006) addressed this need to focus on:
care concepts…across settings, in ways that honor the complexities of nursing practice and provide directions for adaptation, growth, and lifelong learning. (p. 78)
In this kind of broad curriculum model, the usual divide separating community health and acute care nursing education can be merged into a holistic perspective.
The University of North Florida School of Nursing re-fined curriculum, encompassing the Home-base model, is accomplished within the same number of credit hours, while maintaining NCLEX-RN® pass rates that consistently match or exceed state and national averages. Annual evaluation has allowed us to continually refine the Home-base model and to generate indicators for an assessment tool that is being psychometrically tested for use in outcome evaluations. A longitudinal multicohort study is in process. Measuring outcomes of the Home-base model, from the combined perspective of students, faculty, and community partners, will be a future contribution to nursing pedagogical evidence and will help to determine the significance of clinical continuity in nursing education.
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School of Nursing Community Home-Base Description
|Home base||Home-base Focus||No. of Studentsa|
|Neighborhoods & regions||Geographic based|
| Northwest Jacksonville & Urban Core||Substance abuse recovery center; homeless shelters; clinics for underinsured and uninsured; low-income housing project; Healthy Start and Infant Mortality Coalition||24 to 48|
| Pine Forest Neighborhood||Historically African American neighborhood with immigrants from Asia and Eastern Europe addressing health promotion across the life span in collaboration with multiple local partners||24 to 48|
| The Beaches||Senior citizen community centers; school and afterschool programs; homeless shelter; health clinic for individuals who are uninsured||24 to 48|
| North Jacksonville & Rural Areas||Cardiovascular risk reduction among school children; social model assisted living for older adults and individuals diagnosed with Alzheimer’s disease; street medicine (i.e., delivery of health care and related services directly to individuals who are homeless and live and sleep on the street, along riverbanks, and in abandoned buildings among other places); inner city primary care clinic; occupational health||24 to 48|
|Program focused||Agency based; serving large areas|
| Jacksonville Children’s Commission and Services for Children with Special Needs||Child development, subsidized child care, and family support services; residential summer camp for children with diabetes; case management for children with special health care needs and families in urban homeless shelters||18|
| American Red Cross||Disaster preparedness; shelter volunteer recruitment; and University Red Cross Club||18|
Topical Content Covered in Didactic Community Courses
|First Semester||Final Semester|
|Community and public health nursing history||National and international health care systems|
|Introduction to nursing roles in public health||Economics, policy, and social justice|
|Community health assets-based assessment||Public health core functions|
|Community database use||Partnerships and coalition development|
|Family health theory||Theoretical foundations for health promotion at individual, group, and community levels|
|Introduction to epidemiology||Community health planning, quality assurance, and evaluation|
|Health promotion and risk reduction|
|Teaching and learning theories||Nursing care of vulnerable populations|
|Cultural diversity||Diseases of major public health importance in the United States and the world|
|Family health risks|
|Child, older adult, and intimate partner violence||Epidemiology|
|Environmental health||Bioterrorism and disaster preparedness|
|Home environment||Public health nursing interventions|
|Local disaster preparedness||Subspecialty nursing practice across settings|