Colleges of nursing have traditionally relied on partnerships with local public health departments as a means to provide community health clinical experiences for undergraduates (Anderson, Richmond, & Stanhope, 2004; Barger & Crumpton, 1991; Hall-Long, 2004). As funding for public and community health services diminish across the United States, the discipline will be faced with unique challenges. Fewer opportunities and resources (e.g., public health nurse preceptors) will require institutional reconceptualization of how the community health clinical experience is implemented while concurrently meeting course objectives. The decline in essential health services is anticipated to worsen as the United States struggles to restructure an ailing health care system (American College of Occupational and Environmental Medicine, 2009; Molyneux, 2008).
The likely upheaval in health care presents an ideal opportunity to unravel and redefine how colleges of nursing engage students in community health clinical learning. Riner (2008) describes principles of successful community engagement with respect to public health nursing as:
- Being knowledgeable about the community and its history.
- Creating and maintaining trusting relationships.
- Working in partnership.
- Valuing diversity.
- Using assets within the community.
- Remaining flexible.
- Assuring a long-term commitment to the community.
Incorporating these tenets through service-learning and community engagement activities could potentially improve the quality and comprehension of community health nursing didactic, address the pressing need to reform how the clinical experience is achieved, and be instrumental in helping meet projected demands for community health services. The goal of this article is to advocate a pedagogical shift in thinking about what constitutes and qualifies as community health clinical experiences. Service-learning and community engagement activities intended as part of the clinical curriculum are discussed.
Service-learning as a theoretical framework to enrich academic learning and fulfill community stated needs has long been a component of higher education in the United States (National Service-Learning Clearinghouse, 2008; W.K. Kellogg Foundation, 2007). By definition, it includes elements of merging educational skills and knowledge to provide a needed service identified by the community. This experiential learning should be a reciprocal relationship in which both student and community alternate between the role of teacher and learner while meeting course objectives. Opportunity and time allotted for student reflection is also an essential feature of the experience (Bringle & Hatcher, 1996).
Although service-learning has experienced a renaissance at universities across the United States, research describing its use in undergraduate nursing education remains limited. Within the discipline of nursing, service-learning has been used in varying degrees to facilitate personal and professional development, address health care disparities, and augment understanding of theoretical concepts.
Professional formation and identity are developmental issues that can be difficult for undergraduate students to absorb and comprehend. Involvement in service-learning has been described as a mechanism that facilitated greater understanding of the nursing profession and the self as a professional (Hunt & Swiggum, 2007; Laplante, 2009). Civic engagement has also been argued to have merit as a fundamental component of nursing education. Increasing community involvement can be instrumental in fostering professional development and shaping of the sociopolitical self beyond the realm of academia (Gehrke, 2008).
Vulnerable populations are most often challenged with issues of equity and access to health services. Nursing education that incorporates service-learning into the curriculum can be beneficial to the community in this regard. Community engagement through service-learning activities has demonstrated outcomes of increased access to care and a decrease in health disparities among at-risk groups (Hamner, Wildner, & Byrd, 2007; Lashley, 2007).
In a study measuring outcomes of service-learning in nursing education, Reising et al. (2008) found that students achieved a better understanding of community health theory and practice, as well as professional and civic development. The community increased health care knowledge about diabetes and heart disease, which were prevalent illnesses within the population. Others have found integrating service-learning into nursing courses improved students’ understanding of vulnerable populations, diversity, providing health care service to communities, professional development, and civic responsibility (Bentley & Ellison, 2005).
Although the literature is sparse, the benefit of service-learning in community health education is a compelling rationale for incorporating it into the curriculum. The following conceptual approach was designed to improve quality and comprehension of community health didactic, address the need to restructure community health clinical experiences, and meet projected demands for community health nursing services in partnership with communities.
The Bucket List: A Service-Learning Approach to the Community Health Clinical Experience
Qualitative responses on final course evaluations indicated that undergraduate students experienced greater difficulty transitioning from a circumscribed hospital-based model of illness and the individual to a more independent role centered on health promotion and the community. Students often struggled to make connections between theoretical knowledge and practice. This issue, coupled with a decrease in clinical sites and resources, prompted an evaluation of integrating a service-learning framework into the clinical curriculum. This model was preferred because key elements are largely congruent with principles of community engagement, community health nursing, and the nursing profession.
Applying the major tenets of effective community engagement and partnership, the Bucket List was developed to provide a rich learning experience while meeting community-defined health goals. The syllabus statement and sample list are shown in the Table.
Table: Bucket List of Community Health Clinical Service-Learning and Engagement Activities
Activities on the Bucket List were chosen specifically to deepen community engagement and understanding. It was also important to include opportunities for students to work with established institutions that provide services to the community. Using familiar organizations enhances the functioning of partnerships and builds trust among the university, community, and selected institutions.
A final requisite was to appoint a consistent faculty member at each clinical site. Maintaining a stable and consistent faculty shows a long-term commitment to the community, which further strengthens relationships and trust.
To gain a better understanding of overarching health and wellness, students conduct a windshield survey (i.e., environmental assessment) and research the history of the community before initiating service-learning experiences. Students are then responsible for choosing long- and short-term activities, and are encouraged toward those that serve aggregates they are most passionate about.
A health-related project is concomitantly developed, negotiated, and refined in partnership with the community and faculty. The project is implemented near the end of the term. From the Bucket List activities, project development, implementation, and evaluation, students acquire a better understanding of community functioning, community-defined health needs, theoretic concepts, and the autonomous function of public and community health nurses.
The following exemplar demonstrates a Bucket List service-learning activity and resulting project that was particularly rewarding for students and the community.
Students assigned to York Hill community organized into subgroups of two to three according to their aggregate of interest. The maternal-child group chose a term-long commitment with a nonprofit organization, St. Francis Mother and Baby, that accepts financial donations and essential items for economically disadvantaged mothers and infants.
Interactions with key informants, which included community and public health nurses, social workers, the founder of St. Francis Mother and Baby, community leaders, community residents, and faculty, revealed a basic community need for newborn thermometers with instruction in languages reflective of immigrant groups. Research into the extent and outcome of the problem suggested lack of thermometers or knowledge about how and when to use them resulted in prolonged hospitalization, severe injury, or death of a newborn.
Working in collaboration with community leaders, the students developed a simple to read and easy to follow instruction sheet on newborn temperature taking in 15 languages (Arabic, Cambodian, traditional Chinese, Farsi, French, Korean, Lao, Polish, Russian, Spanish, Vietnamese, Somali, Hebrew, and Amharic) represented in the community. Pictures were included to address literacy and those who rely on visual learning.
Resources donated to the project included several hundred digital thermometers that were supplied to those who did not receive thermometer during postpartum hospitalization and translation for the pamphlets. The instruction sheets and thermometers are currently supplied through St. Francis Mother and Baby to community health nurses who request them for clients. Students in subsequent cohorts are compiling data and evaluating usefulness of the Bucket List tool. The founder of the center is working on copyrighting the pamphlets for use beyond the York Hill community.
This example illustrates service-learning and project development based on principles of effective community engagement. Through windshield survey and research, students became knowledgeable about historical and present-day aspects of the community prior to starting the clinical experience. Active involvement at the grassroots level with St. Francis Mother and Baby gave students a greater understanding of community function, strengths, assets, and health concerns, and also created trusting relationships. Identifying the need for newborn temperature-taking instruction in 15 languages was accomplished through a collaborative process and working in partnership with the community. Developing pamphlets in residents’ native language with visual aids acknowledged the rich diversity of members and respect for those who are not literate.
Using this approach to the community health clinical experience, students expressed improvement in didactic comprehension, ability to apply theoretical concepts, a solid grasp of independent nursing practice, and better understanding of community as client. Traditional clinical work with a local health department may not have had the same impact or produced these results.
The students in York Hill were able to spend a day shadowing a public health nurse in the community. However, during the experience, they became focused on the skill being performed and the individual, rather than health promotion and the whole of the community. From the students’ perspective, the care given to clients in the community was difficult to distinguish from that provided in the hospital setting. Subsequent conversations between students and faculty during postclinical reflection meetings helped make connections among their observations, principles of community health theory, and practice.
The service-learning approach to the community health clinical experience immerses students in the community in ways that are unique and meaningful to both students and the community. When given the opportunity to work with an aggregate of interest, students radiated a genuine enthusiasm and concern for the community. They became trusted and valued members of the group, and they often continued voluntary service in the community after graduation.
Reconceptualization of the community health nursing clinical experience at the undergraduate level has become a necessity, particularly during these uncertain economic times. The reality of dwindling public health resources has made this an urgent priority. By incorporating service-learning and community engagement activities into coursework, faculty and students can improve quality of learning and comprehension, address the need to reform implementation of clinical experiences, and meet anticipated demands for community health nursing service in partnership with communities.
Inevitable changes in the current public health care system can be viewed as an opportunity to construct a more effective way of providing nursing education and care directed toward the promotion of health and well-being among vulnerable and at-risk groups. Nurses and nurse educators should be at the forefront shaping how education and practice occurs within the community.
- American College of Occupational and Environmental Medicine. (2009). Healthy workforce/healthy economy: The role of health, productivity, and disability management in addressing the nation’s health care crisis: Why an emphasis on the health of the workforce is vital to the health of the economy. Journal of Occupational and Environmental Medicine, 51, 114–119.
- Anderson, D.G., Richmond, C. & Stanhope, M. (2004). Enhanced undergraduate public health nursing experience: A collaborative experience with the Kentucky Department for Public Health. Family & Community Health, 27, 291–297.
- Barger, S.E. & Crumpton, R.B. (1991). Public health nursing partnership: Agencies and academe. Nurse Educator, 16, 16–19. doi:10.1097/00006223-199107000-00010 [CrossRef]
- Bentley, R. & Ellison, K.J. (2005). Impact of a service-learning project on nursing students. Nursing Education Perspectives, 26, 287–290.
- Bringle, R.G. & Hatcher, J.A. (1996). Implementing service learning in higher education. The Journal of Higher Education, 67, 221–239. doi:10.2307/2943981 [CrossRef]
- Broussard, B. (2009). Promoting wellness in communities theory. Unpublished manuscript, Seattle University.
- Gehrke, P.M. (2008). Civic engagement and nursing education. Advances in Nursing Science, 31, 52–66.
- Hall-Long, B. (2004). Partners in action: A public health program for baccalaureate nursing students. Family & Community Health, 27, 338–345.
- Hamner, J.B., Wilder, B. & Byrd, L. (2007). Lessons learned: Integrating a service learning community-based partnership into the curriculum. Nursing Outlook, 55, 106–110. doi:10.1016/j.outlook.2007.01.008 [CrossRef]
- Hunt, R.J. & Swiggum, P. (2007). Being in another world: Transcultural student experiences using service learning with families who are homeless. Journal of Transcultural Nursing, 18, 167–174. doi:10.1177/1043659606298614 [CrossRef]
- Laplante, N. (2009). Discovering the meaning of reciprocity for students engaged in service-learning. Nurse Educator, 34, 6–8. doi:10.1097/01.NNE.0000343398.26695.6d [CrossRef]
- Lashley, M. (2007). Nurses on a mission: A professional service learning experience with inner-city homeless. Nursing Education Perspectives, 28, 24–26.
- Molyneux, J. (2008). The top health care news story of 2008: The ailing economy. American Journal of Nursing, 109(1), 19.
- National Service-Learning Clearinghouse. (2008). History of service-learning in higher education. Retrieved from http://www.servicelearning.org/what_is_service-learning/history_hesl
- Reising, D.L., Shea, R.A., Allen, P.N., Laux, M.M., Hensel, D. & Watts, P.A. (2008). Using service-learning to develop health promotion and research skills in nursing students. International Journal of Nursing Education Scholarship, 5(1), Article 29. doi:10.2202/1548-923X.1590 [CrossRef]
- Riner, M.E. (2008). Health promotion through healthy communities and cities. In Stanhope, M. & Lancaster, J. (Eds.), Public health nursing: Population-centered health care in the community (7th ed., pp. 394–408). St. Louis, MO: Mosby Elsevier.
- W.K. Kellogg Foundation. (2007). History of service-learning. Retrieved from http://www.service-learningpartnership.org/site/PageServer?pagename=sl_history
Bucket List of Community Health Clinical Service-Learning and Engagement Activities
|The following syllabus excerpt includes explicit introductory information, explanation of service-learning, and brief examples of potential opportunities:
|Until this point, your nursing education has largely focused on the medical model of diagnosis, treatment, and care directed toward individuals and/or the extended family. During this quarter, the context of care will shift and expand to incorporate aggregates (groups, populations, communities, etc.) with emphasis on health promotion and disease prevention. Health care activities will take place in a community setting rather than traditional hospital institutions. You will engage in a variety of service-learning activities intended to increase your engagement, understanding, and appreciation of your assigned community. This component of the clinical experience is essential, as you will discover in theory and subsequently through community interactions that nursing practice in this venue is more effective when: (1) viewed as working in partnership with the community and (2) rapport, trust, and commitment are established through providing needed health services as defined by the community.
|The following “Bucket List of Possible Community Health Clinical Service-Learning and Engagement Activities” is a compilation of potential clinical activities. Some are short-term interactions (one or two times), whereas others are long-term and will continue throughout the quarter. From the opportunities provided below, select those of interest that will maximize involvement with your assigned community. This list is not exhaustive. If you discover community meetings or conferences regarding public or community health, please share the information with your clinical faculty.
|Bucket List of Possible Community Health Clinical Service-Learning and Engagement Activities:
| Attend Nurse Legislative Day
| Present a health talk at the schools located in your assigned community
| Spend the day with a community or public health nurse in your assigned community
| Identify social and environmental justice issues in your community and pose possible solutions for discussion during clinical seminar
| Visit the Northwest African American Museum and discuss relevant historical perspectives of the community during clinical seminar
| Volunteer at a HeadStart program in your assigned community on a weekly basis
| Set-up weekly blood pressure screenings at a food bank in your assigned community
| Provide health services at a shelter in your assigned community on a weekly basis
| Work with the local YMCA/YWCA on a weekly basis concerning health issues that affect your assigned community