Dr. Northrup-Snyder is Assistant Professor, and Ms. McDaniel is Instructor/Faculty Team Leader, Oregon Health & Sciences University, School of Nursing, Baccalaureate Completion Program, Portland, Oregon. Dr. Van Son is Assistant Professor, Washington State University, College of Nursing-Spokane, Spokane, Washington. Dr. Van Son was affiliated with Oregon Health & Sciences University, Portland, Oregon, at the time of this research.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Larra A. Snyder for research assistant contributions that maintained the confidential nature of the research and allowed exploration of the demographics.
Address correspondence to Kathlynn Northrup-Snyder, PhD, CNS, RN, Assistant Professor, Oregon Health & Sciences University, School of Nursing, Baccalaureate Completion Program, 1243 SE Jefferson Street, Dallas, OR 97338; e-mail: email@example.com.
A critical need exists to facilitate better transitions between health care settings. Nurses play a significant role in facilitating effective transitions between acute and community-based care settings (Coleman, Smith, Frank, Min, Parry, & Kramer, 2004). To be effective in this role, nurses must have a solid understanding of different health care settings along the health–illness continuum. In particular, an awareness of public and community health and local community resources is necessary to facilitate positive outcomes related to health care setting transitions, particularly post-acute care (Boling, 2009). However, community-based clinical experiences are rarely part of an associate degree nursing program and, as a result, students from associate degree programs lack competence in population-based care (Rosen, 2000).
The baccalaureate nursing (BSN) degree continues to be the minimal recommended educational preparation to work in public and community health nursing (Association of Community Health Nursing Educators, 2009), yet less than 40% of those working in public and community health nursing meet this criterion (Bureau of Health Professions, 2006). National nursing organizations recommend that nursing preparation must include practice within the community and public health venues if current and future health system needs are to be met (Lichveld et al., 2001; National League for Nursing, 2001).
Public health, community health, and population-based care are required in baccalaureate level nursing programs; however, the degree of understanding about aggregate health care, the role of public and community health nurses, and community resources available to the population continues to be lacking by most nursing professionals (Bryan, Bayley, Grindel, Kingston, Tuck, & Wood, 1997; Murray, 1998). This became apparent for the faculty teaching several terms of a community health nursing course for a postlicensure online RN-to-BSN program. The online course used a constructivist approach to build a learning community designed to increase reflective thinking, shared solutions, and expanded knowledge of population-focused concepts (Lee, Carter-Wells, Glaeser, Ivers, & Street, 2006; Legg, Adelman, Mueller, & Levitt, 2009).
During the last week of the course, students were provided an optional set of discussion forum questions related to their insights gained in the course. The questions asked were:
- What are the three most important things you have learned in this course?
- What has surprised you the most?
- How will you apply what you learned in your professional practice?
The purpose of this study was to describe the nursing students’ online discussions about their perceptions and understandings of the public and community health nursing role and practice after participating in a community health clinical course within an RN-to-BSN program.
Retrospective analyses of online course discussions were conducted over a period of five terms in a 2.5-year period. Qualitative research of online narratives is relatively new and content analysis can be an effective method of exploration (Marra, Moore, & Klimczak, 2004). Using weekly online discussion threads, students shared their community clinical experience, assessments, health education projects, and understanding of the assigned public and community health nursing role and population. Course discussion threads were designed to facilitate student interaction with minimal faculty feedback or opinions to promote problem solving and sharing by the students. Weekly discussions were designed, with open-ended questions used to facilitate an organized method of reflective journaling on community-focused clinical experiences. As distance students, each student was in a different clinical setting. Thus, discussion postings not only provided personal reflections for each student, but also provided insights for other students who were having a different community-based clinical experience. This strategy served to increase the length and responsiveness of the discussion postings by each student (Mazzolini & Maddison, 2003). Narratives written in an online discussion forum not only captured individual student impressions and opinions, but also provided a focus group synergy as a result of peer responses and reflections on postings. The discussions for each term were unique and allowed researchers to retrospectively analyze each term’s responses for themes.
Using inductive content analysis (Elo & Kyngas, 2007), themes related to students’ perceptions, understanding, knowledge, and perceptual changes of the public and community health nursing role were coded, grouped into content categories, and abstracted into main categories. Institutional review board approval was obtained.
The participants (N = 145) in the community health nursing practicum are RNs returning to school to obtain BSN degrees at a Pacific northwest university. The students participate at a distance, conducting their community and public health clinical experience close to their homes, and course-related topics are discussed online. Course concepts, assignment submissions, and grading were conducted using an online course platform. The clinical experiences placed students in a variety of public and community health nursing roles where the preceptor is the student’s primary role model. Assignments supported learning about a clinical agency and the population served, the public and community health nurse role, effective health education, and community assessment leading to intervention projects.
In the first week’s online discussion, students shared information about themselves, including their current practice, clinical assignment, and general perceptions about the course. Most of the student population was Caucasian (87.5%), Asian (3.5%), Latino (2.2%), and African American (1.3%). The age of students ranged from 22 to 60 years (mean: 38.7; mode: 34.4), and 85.5% were women.
Students reported from 0 to 31 years of practice post-associate’s degree, with less than one third practicing 2 years or less (28.3%). The majority had been in nursing for 2 to 10 years (41.4%), and approximately one quarter had practiced more than 10 years (15.8% = 11 to 20 years; 5.5% = more than 20 years). Nine percent did not mention the number of years of nursing practice. Nurses either were new to nursing and had little experience (3.5%) or had worked only in the hospital (49.6%); thus, most students entered the course sharing they had little familiarity with public health nursing. Twenty-seven percent had had jobs that were primarily hospital based. Approximately 12% of the nursing students had some community health experiences either through a previous job or community volunteerism (3.5%) or as a public or community health nurse (8.2%). Some students did not describe their experience or job and could not be categorized (8.2%).
Discussions were coded with each term and year and unique identifiers were substituted for each student, creating anonymity. Final discussions were analyzed using each student’s posted discussion comment as the narrative unit of analysis. Student response rate was 75% (n = 109). Each narrative was coded and then analyzed for similar words and phrases, which were grouped into themes. The first two authors (K.N.-S. and C.R.S.) assessed these narratives independently, identifying primary codes and categories, which were compared for similarity. Further clarification and agreement of theme wording was determined through discussions of the coded documents. Electronic records of the coding decisions created an audit trail. Credibility (Polit & Hungler, 1999) was augmented with the first (K.N.-S.) and third (C.M.) authors remaining engaged with the course thoughout the five terms. This engagement provided time to observe the general culture of the RN student taking a community health clinical course and to assess the responses provided over several student groups and terms.
Findings and Discussion
Two overarching themes, Awareness: Community and Context of Public and Community Health Nursing Role and Understanding: Home–Hospital–Home Patient Transitions, were obtained from coded narratives. These themes were shared across the different student groups. Some of the subcodes may have been found in only one course or may have been described in all five student terms analyzed.
Awareness: Community and Context of Public and Community Health Nursing Role
Changing Perspectives of Public and Community Health Nurses. Content within this category was captured within each class and across class terms. Perhaps the most intriguing statements shared were those of students reflecting surprise at public and community health nurses being “real nurses”:
A nurse in the community is just as much of a nurse as those who practice in acute care settings. This was not how I believed or felt before this class, but I can see now that in many cases, they are more autonomous and use more critical thinking skills than [do] acute care nurses.
Students shared their individual clinical agency experiences throughout the course, gaining a foundation based on the variety of nursing positions available in a community. One student said, “I was amazed at how many different agencies and opportunities exist for nurses in the community.” Students connected this variety to the recognition of nursing being a much larger profession than they had been exposed to in previous settings. As the students discussed their understanding of the roles of the public and community health nurse, they frequently commented on the awareness of the nurse’s role as critical to population health and the larger health care system.
Public and Community Health Nurses’ Roles and Characteristics. Students’ discussion demonstrated an expected understanding of the nursing roles they were exposed to and explored within the course. However, the amount of narrative data provided on the characteristics students observed in their preceptor or the public and community health nurses’ role in general was surprising. Autonomy was a universally described characteristic: “I was surprised by the amount of autonomy these home health nurses had been given. It also opened my eyes to the amount of responsibility these nurses assume.”
Nurses’ Voice. Advocacy was specifically mentioned in several discussions:
The thing that most surprised me was discovering all the needs of the community I have lived in my whole life. I feel much more compelled to volunteer and advocate for my [community’s] needs.
This depth of feeling about the desire to be an agent of change at a variety of levels in the community is summarized in this succinct statement: “[I] can no longer be a bystander.” Other students shared their desire to make a difference by being more politically involved within health care systems as leaders and advocates at local, national, and global levels. A significant amount of time was spent within each course group discussion focused on the degree of power the public and community health nurses demonstrated in the community. The concept of the nurse having power both as an individual and as a member of a powerful profession was repeated frequently. This quote captures an overview of these concepts:
My whole focus on nursing has begun to change.... I no longer see nursing as a profession that is forced to operate within the confines of a hospital. We can truly impact the health of our neighborhoods, our churches, our cities, our nation, and our world.
Exploring the Lack of Knowledge of the Public and Community Health Nurses’ Role in the Profession. This theme combines the students’ comments on issues related to the negative impressions and misunderstandings of the role of public and community health nursing they held as acute care nurses prior to taking a community health course. One student commented, “I had no idea that community health nurses make up such a large percentage of nurses as a whole.” This lack of knowledge about community and the public and community health nurses’ role was discussed in three of the five class terms and included concepts of “not advertising nursing” to consumers, “a need for more information to be presented in the associate degree programs,” and “tooting our own horn,” suggesting the need to promote the impact of public and community health nursing on the health of the community.
As noted in a previous theme, once the nurses became aware of the effect a nurse could have by working in the community, many were interested in exploring work in this area. Two students described a public and community health nursing role as their “ideal job,” and a few of the students accepted positions within the community after the completion of their clinical rotations. Others, although interested in community health nursing, were concerned about the lower salary and longer hours of many of the public and community health nurse positions. A final theme, discussed in two of the five terms, was whether the public and community health nurses required special training beyond acute care or required time needed in the acute care setting that would prepare for them for a public and community health nursing role.
Understanding: Home–Hospital–Home Patient Transitions
Context of Care. Student discussions indicated that they embraced population health concepts during their community practicums while simultaneously finding ways to apply these concepts to their current jobs in acute care. These thoughts are expressed in the following statement:
I will think beyond “from the wheelchair to the car” as I discharge patients. I will...have the big picture of the client’s home environment, neighborhood, state, nation and world.
A second statement elaborates further:
While assessing, [I’m] always thinking about the community they live in and how that affects their health, [and this] will be taken into consideration. Discharge planning will be looked at dramatically different due [to] my experiences in this course.
In addition to the initial surprise expressed by students about the role of the public health nurse, students also commented on their lack of knowledge about the many resources within their community. Many were surprised by what they considered “the hidden populations.” One student said, “I learned how my patients really live and it was very enlightening.” Nurses now felt a new responsibility toward connecting patients with the resources found in the community. They had an expanded connection to the local community, the population that lives within them, and the professionals serving the community outside the hospital. Also reflected was confusion about the best methods for accomplishing the task of communication between acute care nurses and public and community health nurses:
I think discharge planners are a link between the entities. But, as an acute care nurse, or as a community nurse, how could you create a line of communication with each other?
Patient-Centered Approach. The application of holistic and patient-centered care in their acute care practice was the focus of this theme. Nurses discussed the challenges of how to apply patient-centered care to their acute care practice: “I really envied them [the public and community health nurses] their ability to really know, see, and care for the patient.” Many of the nurses gained an understanding of the importance of listening and being nonjudgmental as opposed to intervening as the nurse expert: “We truly are invited guests into our clients’ lives, and I find more and more wisdom in exploring what they want for their health. That makes the difference.” Students also discussed skills learned within the course, including community assessment, health teaching strategies, and structured interventions.
The narratives from RN-to-BSN students in this study provide a snapshot of how acute care nurses benefit from knowledge of community-based care and services. These students provided unique insights into the value of learning about the public and community health nurses’ role and the affect on patient transitions from post-acute care. Based on these findings. some recommendations can be made. First, research is needed to assess the nurse graduates’ knowledge in population-focused care and the best educational strategies to prepare nurses to work across acute and public and community health nurse roles. Nurses, patients, and their families will all benefit from nurses in acute care having an understanding of community services and resources. This knowledge and understanding enables the acute care nurse to facilitate a smoother transition for patients returning home (Parrish, O’Malley, Adams, Adams, & Coleman, 2009). Smoother transitions are critical to the reduction of readmission rates, decreased inappropriate use of emergency rooms, and improved health promotion activities (Boling, 2009; Naylor & Keating, 2008).
Second, research is needed to explore the acute care nurses’ awareness of the public and community health nurses’ role. Why is there a gap between the acute care nurses’ knowledge and understanding of the community setting, and what can be done to address this gap? The creation of staff development curricula to increase the knowledge and experience of the public and community health nurses’ role in the community must go beyond the idea of just introducing nursing students to this concept.
Finally, as curricula become more creative and technically oriented to meet the needs of adult learners and distant students, online learning opportunities are expanding. Online discussion forums provide a narrative in which students and faculty can explore and synthesize course concepts (Marra et al., 2004). As a result, as this study suggests, discussion forums provide a rich source of data for researchers and educators to analyze student learning and evaluate curriculum outcomes.
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