Community health nursing faculty have a well-established history of using clinical sites that provide a broad range of student learning experiences. A survey of Canadian community health clinical education (Cohen & Gregory, 2009) describes three types of placement possibilities: traditional public health, broad community health, and mixed health sector/nonhealth sector sites. Specific sites range from the local public health department to prisons, schools, churches, senior facilities, and a host of other nonhealth-related organizations. However, even with the variety of sites currently reported, nursing programs in specific communities may find themselves in the position of not having an adequate number and type of placements to meet faculty-desired learning outcomes. This situation occurred with the community health faculty at one midwestern college of nursing. The college has a strong and extensive baccalaureate nursing program with both generic and accelerated tracks. Admission occurs three times per year and class size is maintained at 64 students, with a 1:8 faculty-to-student ratio. The community health experience is one of the last rotations in the nursing program and alternates with leadership and transition content. Both rotations are 5 to 7 weeks in duration.
Goals and Principles
Several years ago, the college administrators became concerned about community clinical placements when they were notified that regional public health departments would be unable to sustain clinical opportunities within their agencies. Clinical competition for placements was significant, given that some schools of nursing were preparing to expand enrollment at the same time agencies were preparing to limit placement. As the faculty began to consider this future, several additional issues became evident; specifically, the faculty desired to reach aggregates that were not currently addressed in the program, wanted to expand students’ view of where nursing practice could occur, and hoped to increase access to nursing services for vulnerable groups. These ideas were instrumental in deciding to develop new clinical sites rather than seeking placements at agencies that already were providing nursing services. Four different sites have been established within the past 7 years; these collaborations involve a faith-based community agency, which expanded to include a correction center, a public housing unit, and a local advocacy organization for individuals with disabilities. Development of the faith-based community and the local agency for individuals with disabilities will be discussed further as exemplars.
Two principles were followed when looking into possible clinical sites. First, the college sought academic service partnerships that were the result of authentic collaboration and not simply a matter of appearance. Inherently, this meant that time would be spent in identifying potential partnerships, choosing the best fit, and then working to establish and maintain the relationship. Although this would be a significant commitment by the faculty and college, it was felt to be time well spent. Second, both the university and the college were strongly committed to the concepts of service-learning. The concept is embedded in the value statements of the university and supported by grants and developmental educational offerings. The college of nursing, as with most nursing schools, has consistently incorporated service-learning in a number of courses. Perhaps the best articulation of the faculty vision of the partnership was made by Seifer (2002), who said of such relationships that “community agencies are not just ‘placement sites’ for students but are genuine partners” (p. 431). To integrate both principles, faculty agreed to seek sites that had the potential to develop reciprocal learning in an equal partnership and were addressing community concerns and incorporating opportunities to broaden professional growth by experiencing poverty, homelessness, social justice, and reflection.
Initially, the college of nursing targeted a geographical area in close proximity to the cluster of health care agencies known as the Medical Mile and the college’s Center for Health Sciences. The neighborhood selected was impoverished and known to have limited access to health care services and resources. To begin the selection of potential partners, community health faculty scanned health care and nonhealth care agencies within the geographical area. A number of agencies were visited to explore their current services and potential fit with the college’s academic needs.
The first agency was faith based and identified as the lead community agency with an established relationship with community residents, who often were members of underserved vulnerable populations. This agency provides a full spectrum of spiritual, economic, and relational services to its neighbors, empowering them to make change. The trust residents have in the agency contributes to the development of nurse–client relationships.
The second geographical area targeted extended county-level services. The selected agency is a nonprofit advocacy and service organization that is part of the independent living movement. The agency serves all county residents and provides care coordination and referral, occupational therapy, policy consultation, and community advocacy. A key aspect of the agency is that many staff members are themselves individuals with disabilities.
After partner agencies were identified, initial fit was assessed. Initial fit means that both the college and the agency would benefit from the partnership and there was a positive, harmonious connection between the individuals who would be working together. With a good initial fit, the focus shifted to defining the specifics of the relationship. As Frank (2008) noted, it is important for all partners to have shared visions and goals without competing with each other. In the initial discussions with agencies, the partners felt that the relationship could expand capacity and outreach to clients in areas where nursing services were not available. The faculty identified opportunities in the context of meeting baccalaureate nursing program educational goals, expanding clinical sites, and focusing on health promotion and disease prevention. Nursing interventions, such as individual and group education, case management, screenings, and community referrals, were proposed. Agencies evaluated how such nursing services could be integrated with services already provided.
Although the agencies had distinct missions and worked with different vulnerable groups (i.e., low income, urban neighborhoods, and individuals with disabilities), the two partnerships had common goals. These were, first, to build on the developing capacity among clients to access coordinated appropriate primary care; second, to develop health programs to meet the needs of the disenfranchised and underserved individuals and families; and third, to educate future health care providers in culturally competent care of vulnerable populations. In short, the college agreed to provide nursing services within a home provided by the agency. For the college, these services came under the purview of the Academic Nurse Managed Center. This center is a source of clinical placements for students and has the ability to provide primary care services, which might be needed as backup for the immediate needs of clients.
At this point in the development of the partnerships, both sides were excited about the possibilities envisioned, and specific activities for the first experiences were identified. The focus of nursing care would be case management, health promotion, and advocacy. Clients were referred by agencies, other providers, or current clients. Services were provided in the home or at the agency, with home visits being conducted by pairs of students. Students were educated on safety issues, and the assessment and referral process itself helped to avoid violent environments. Students were encouraged to not make or terminate visits if they had any sense of danger. Faculty were available for immediate problem resolution by telephone and would accompany students as needed. Thus, student safety was assured. Nursing students had access to the Academic Nurse Managed Center for immediate consultation–referral. Thus, client safety was also ensured.
Typical activities for community health nursing were differentiated to ensure understanding between partners and students. Population-level health screening opportunities and aggregate-level health educational sessions were included in the partnerships. In addition, research opportunities to complete the practice, education, and research triangle desired by the college were sought. Faculty structured the research and students functioned within the project. In one such project, both neighborhood and county areas were targeted to reduce lead exposure (Gordon, Datema, Slager, Martin, & Vander Werf, 2009).
One sign of a strong partnership is the willingness to contribute resources, as well as provide input into activities (Bleich, Hewlett, Miller, & Bender, 2004). Agencies agreed to provide space for students, computers, health records (if available), and educational support, as well as some supplies needed to maintain the activities. Depending on the partner, the college provided printing supplies and screening equipment and supplies, as well as other miscellaneous items. All partners provided human resources, with time provided by various faculty, staff, and volunteers. Contracts between parties helped to document these arrangements.
As noted previously, the college has nurtured these partnerships over the past 5 to 7 years. In a recent term, students evaluated 1-year program outputs and outcomes under faculty supervision. Each site provides services for approximately 35 to 40 clients concurrently and six student rotations during the year. For individual client activities, students carried a load of approximately four clients each, who were seen on an individualized need basis for a maximum of two times per week. During a 14-week semester, the mean number of visits was 8.6, although the range varied from 1 to 18. A significant portion of students’ time was spent coordinating care and finding resources. Thus, in addition to home visits, students made an average of 8.11 telephone calls regarding client care. It is important to note that a substantial number of neighborhood clients did not have telephones; therefore, brief stops at the client’s home and written communications were also used by the students. In reviewing the records for the previous year, students found that the top nursing diagnoses were readiness for enhanced knowledge, impaired mobility, ineffective health maintenance, and health-seeking behaviors. The types of nursing interventions varied considerably, with most focused on education. Screening events occurred regularly (i.e., weekly or biweekly), either at the site or at a related event. Finally, students completed group health education during each rotation; therefore, approximately six additional sessions per year were made available for the community.
Consistent with the focus on education, the most common client outcome involved changes in knowledge. Increases in mobility, changes in health behaviors and beliefs, adherence to regimens, pain control, coping, self-esteem, and motivation were also noted, as well as alterations in the environment. Although the established nurse–client relationship was mutually beneficial, some relationships were stronger than others. Faculty assumed the stabilizing position within the client relationship, but it was difficult to capture the extent of loss experienced by the client when a valued student completed the rotation and another resumed the care provision.
Student outcomes are consistent with the educational objectives of the course, and evaluations document satisfaction with the partners. Students value the clinical sites for the unique socioenvironmental client situations they encounter. For many students, it was their first opportunity to see poverty and disability up close and personal through real-life experiences, which helped to challenge their personal perspectives and increased their understanding of barriers to health care. It is not unusual to hear from students several semesters later, after their first experiences in a professional nurse role, supporting what was learned.
At the organizational level, the partnerships have other benefits. In addition to meeting the college’s need for high quality community placements, the arrangements have demonstrated responsiveness to the university’s mission, vision, and goals. The collaborative relationships were highlighted in the recent North Central Association Accreditation Report and the positive media releases, which helped to balance the recent negative press that focused on the university’s tuition increases. In addition, the college’s community health nursing model was nominated for two national awards. For the agencies, in addition to expanding client care capacity, the relationships allowed them to demonstrate collaboration with a different part of the nonprofit community, broaden their services toward health promotion, and provide care without reimbursement constraints. Finally, validating the contributions nursing students make to their communities can be helpful not only within an academic service partnership but also to the nursing profession at large (Schrader, 2008). Partnering agencies routinely use this information for reports to the community and for grant applications.
As would be expected, challenges are to be found. From the academic perspective, faculty must add provider-administrator to their instructor roles. They are, in effect, the CEO of a small nursing service. Additional adaptations occur because students visit client homes alone, and faculty case-coordinate from a distance. Leadership for the partnerships lies with tenure track faculty, but the clinical sites are managed intermittently by adjunct clinical instructors. Faculty can be more or less comfortable with these situations, which is a consideration during faculty recruitment.
Students often have difficulty keeping client care in the broader perspective. As with other community experiences, students may not see any change in health status or behavior during their rotation. Correspondingly, faculty have found they must repeatedly address the placement of the client in their care continuum. Instead of a single focus of where the client is now, faculty must constantly keep in mind where the client has been and where he or she is going.
Agencies may experience difficulties regarding the academic calendar. Working with weeks rather than months and the intermittent nature of student placement puts additional stressors on the agency. Staff are involved in a variety of activities with students, and these activities are often repeated during each rotation. In addition to orientations, sites work with the students individually or in a group to help them understand the particular aggregate. Challenges also exist for clients who have to cope with the loss of their student every 7 weeks. The college can minimize these challenges by proactively addressing them. Maintaining consistent faculty placement, communicating the academic calendar in advance, strong faculty leadership, and clear expectations for clients are important strategies. For all parties, the willingness to be flexible and change as needed is essential. Despite these difficulties, satisfaction with the program has been expressed consistently by all of the partner agencies, clients, faculty, and students.
With success comes the desire to sustain the partnerships over time. According to experts (Hewlett & Bleich, 2004), resources that are shared in a mutually beneficial way can be a key element in sustaining a relationship over time. This requires staying aware of the changing environment for the clinical partner, as well as for academe. Specific agency activities have shifted over the years to consider changing missions, standards, and economic realities. For example, one of the agencies advocated for expansion of the community health nursing program partnership to include a corrections center and a low income senior housing unit. From the educational perspective, sustainability concerns revolve around implementing a new curriculum, maintaining the client base at a manageable level, and insuring clients are appropriate for the program. In the long run, keeping students placed in the agency, and thus its web of services, facilitates the sustainability of the partnership.
Casey (2008) identified key success factors in educational service partnerships. These include trusting and valuing the partner, a shared framework, leadership, management of changes, strong communication, equity and involvement in decision making, power, and a coordinator for the partnership. All of these factors have come into play between the college of nursing and its partners. Overall, the two partnerships have helped to not only ensure high quality clinical placements for students, but also to expand nursing services into the community; vulnerable populations, not always included in outreach programs, have greater access to nursing services. In this way, the college adds to the growing movement to reduce health care disparities.
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- Cohen, B.E. & Gregory, D. (2009). Community health clinical education in Canada: Part 2—Developing competencies to address social justice, equity, and the social determinants of health. International Journal of Nursing Education Scholarship, 6, Article 2.
- Frank, B. (2008). Enhancing nursing education through effective academic-service partnerships. In Oermann, M.H. (Ed.), Annual review of nursing education (pp. 25–43). New York, NY: Springer.
- Gordon, B.A., Datema, M., Slager, D., Martin, J.T. & Vander Werf, M.C. (2009). Community participatory research: Student nurses collaborate to reduce lead exposure by educating paint retailers. Nurse Educator, 34, 43–46. doi:10.1097/01.NNE.0000343401.11448.f9 [CrossRef]
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