Nurse educators struggle to provide community health clinical placements for nursing students that cultivate refined assessment opportunities for assessment of culturally diverse populations. Current challenges identified by nursing faculty who teach in community health include the paucity of clinical sites, economic constraints related to travel, and limited exposure to culturally diverse communities. According to Critchley et al. (2009), “The need for culturally competent nursing care services amidst increasing population diversity has intensified the call to increase cultural competence among healthcare professionals to more closely reflect the demographic changes in the world” (p. 69). Currently, travel-abroad courses are commonly used to provide cultural immersion experiences to satisfy this need (Critchley et al., 2009; Ramal, 2009); however, given the current economy, many students cannot afford the time or the cost of study-abroad experiences. Economically feasible approaches must be explored that address access to diverse communities and fulfill the requirements of community health nursing education.
During the third Annual Linking Education and Practice for Excellence in Public Health Nursing (LEAP) Community/Public Health Nursing Faculty Development Conference breakout session in 2009, faculty and public health nurses identified challenges that existed in providing community health clinical experiences for nursing students. Community health nursing faculty identified multiple barriers regarding obtaining community health clinical sites, including controlling costs, reducing travel time to clinical sites, locating settings that can accommodate large numbers of students, and providing culturally diverse clinical experiences within the time constraints of a one-semester course.
The community health faculty members discussed their individual school’s community health curriculum and clinical settings. Through this discussion, faculty discovered their mutual struggle in providing clinical experiences that were geographically and demographically different from their own nursing school’s immediate community.
From the public health practice perspective, nurses shared their observations that current graduate nurses entering the public health workforce lacked the knowledge, skills, and affective behaviors needed to work with culturally diverse populations. The public health nurses postulated one cause of this cultural naivety could be the often homogenous clinical experiences provided in nursing school.
The LEAP conference provided the opportunity for faculty and public health nurses to network and strategize possible solutions to the aforementioned concerns. As a result, two schools of nursing in different states, Alverno College and Winona State University, volunteered to participate in a collaborative project in which community health nursing students could exchange community health assessments to enhance their community assessment skills in an economical manner. The students selected from Alverno College (n = 9) were in their sophomore year of the nursing program, whereas the students from Winona State University (n = 9) were in their senior year. Although faculty realized that comparing students at different stages in their program was not ideal, it was unavoidable because the community content of the participating schools was placed in different years within their curriculum matrix. Two regional directors of the LEAP project offered to facilitate the faculty communications between the two schools of nursing and provide the public health nurses’ perspective. E-mails and phone conferences were used to communicate between all stakeholders to develop the project. Institutional review board approval was not required because the community health assessment was already part of the course requirements at both schools. The deans of nursing supported and provided written permission for the project, as well as school resources (technology department) to support faculty and student involvement. All participating students provided written consent for photography, videotaping, and the use of statements in publications. Faculty from each school of nursing selected two diverse communities for their students’ assessment.
The paucity of clinical sites and the lack of access to diverse populations for community health clinicals is a common concern voiced by nursing faculty. Community health nursing faculty use traditional (e.g., health departments) and nontraditional clinical sites, such as “senior apartment complexes, children’s camps or day centers, museums, fire departments, community centers, correctional institutions, churches” (Harwood, Reimer-Kirkham, Sawatzky, Terblanche, & Van Hofwegen, 2009, p. 2) as learning environments. Other clinical settings used by faculty include community health nursing experiences in other countries (Critchley et al., 2009; Ramal, 2009). However, sending students abroad can be costly in both time and money.
Falk-Rafael, Ward-Griffin, Loforet-Fliesser, and Beynon (2004) suggested building partnerships between groups (e.g., academic institutions, faculty, students, and other groups) is a critical skill that is necessary for students to acquire to be effective in community health nursing practice. The authors identified face-to-face meetings and written communications to strengthen these partnerships. Another way to facilitate communication between partnerships is through the use of video-conferencing. Zalon (2008) stated that “cyber meetings using videoconferencing and teleconferencing can bring individuals from distant locations together to focus on projects needing collective wisdom” (p. 237).
Project Purpose and Objectives
The purpose of this pilot project was to provide nursing students with a low-cost, culturally diverse clinical experience within their community health course. The windshield survey (Nies & McEwen, 2006) and videoconferencing were selected as the teaching strategies to accomplish this goal. The windshield survey technique is a method whereby one collects data about a community by driving in a car and writing down objective observations; no inferences or judgments are made. Various forms of documentation can be used when performing a windshield survey, including note taking, still photography, hand-held tape recorder, or video recording. The windshield survey technique was used to obtain data for each of the eight dimensions of the Community-as-Partner model.
The rural and urban exchange project had several objectives:
- Provide an opportunity for nursing students to experience community health in both rural and urban settings by exchanging windshield surveys.
- Use videoconferencing as a medium for students to share experiences and receive faculty feedback in real time.
- Evaluate the effectiveness of the use of videoconferencing as a teaching strategy for community health education to provide recommendations for replication of the project.
Partnership Development and Demographics
Two schools of nursing were selected for this demonstration project. Alverno College is a women’s Catholic college located in Milwaukee, Wisconsin, with an enrollment of approximately 2,800 students. The student body is culturally diverse, consisting of approximately 65% Caucasian, 17% African American, 12% Hispanic, 5% Asian American students, and 1% other/unknown in 2009 (Alverno College, 2009). Winona State University is a co-ed public university located in Winona, Minnesota, with an enrollment of approximately 7,824 students. The student body composition is 88% Caucasian, 2% African American, 1% Hispanic, 2% Asian American, 4% Unknown, and 3% International in 2008 (Winona State University Databook, 2010).
Description of Urban Communities Studied
Alverno College selected two community sites proximal to their location that would be representative of urban settings. Both sites were within Milwaukee, Wisconsin, which has a population density of 3,892.1 per square mile in 2000 (U.S. Census Bureau, 2010). Each urban setting was located within a school community, which was further delineated and described by zip code.
The first population assessed was a predominately African American public high school within a Caucasian community. According to the U.S. Census Bureau (2010), 3.8% of this community’s population fell below the national poverty level; the median household income for this community was $47,224.
The other school selected for this project was a Hispanic, private, girls’ middle school located within a primarily Hispanic community. The neighborhood surrounding this school was 30% to 40% below the national poverty level in 1999 (2-1-1@Impact, 2005, p. 40). The median household income was $32,216 in 2000 (U.S. Census Bureau, 2010).
Description of Rural Communities Studied
The rural communities studied by Winona State University nursing students were within Houston County in Minnesota, with a population density of 35.3 per square mile in 2000 (U.S. Census Bureau, 2010). Houston County has a total population of 19,718, with a median household income of $40,680; 6.5% of this population was below the national poverty level (MnGeo: Minnesota Geospatial Information Office, 2000).
The first rural community assessed by the Winona State University was La Crescent, Minnesota. This was a predominantly Caucasian community with a population of 4,923; the median household income was $45,433, with 3.9% of the population living below the national poverty level (MnGeo: Minnesota Geospatial Information Office, 2000). Similarly, Spring Grove, Minnesota, the second community, was predominantly Caucasian, with a population of 1,304 and a median household income of $29, 643; 11% of Spring Grove’ population live below the national poverty level (MnGeo: Minnesota Geospatial Information Office, 2000).
Application of Models
Anderson’s and McFarlane’s (as cited in Nies & McEwen, 2006) Community-as-Partner model provides a format for data collection using a systems approach to survey a community using eight dimensions: health and social services, safety and transportation, education, communication, politics and government, recreation, economics, and physical environment.
The students were instructed to investigate their assigned communities and find supportive cinematography in all eight dimensions of the Community-as-Partner model using the windshield survey. During the process of cinematography, no individual images were captured to protect the identity of the residents.
Expanding Cultural Awareness
The Process of Cultural Competence in the Delivery of Healthcare Services (Campinha-Bacote, 2002) model describes a process nurses use to become culturally competent. The constructs within this integrated model (cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire) are interdependent and equally necessary for the journey toward cultural competence. This project afforded an opportunity for students to explore their biases, prejudices, and assumptions when assessing and researching their assigned communities using the components within the Community-as-Partner model (Anderson & McFarlane, 2011).
Project Design Planning and Implementation
To provide a unique clinical experience that could be shared by Alverno College and Winona State University nursing students, the strategy of exchanging completed windshield surveys and discussing community findings using videoconferencing was used. Students had the ability to review the corresponding school’s windshield surveys prior to the videoconference. During the videoconference, students were able to compare and contrast the results of their observations and make inferences regarding the four communities represented in this project (Table 1).
Table 1: Pilot Videoconferencing Teaching Strategy Project Process
Evaluation of the Project
At the conclusion of the project, students were asked to fill out a short survey regarding their experience (N = 17). It consisted of three questions using a 5-point Likert scale (strongly disagree to strongly agree) to assess their perceptions of the teaching strategy:
- This was a good experience to learn more about the similarities and differences between rural and urban communities (88% strongly agree; 12% agree).
- The windshield survey provided a good method for me to compare rural and urban communities (69% strongly agree; 31% agree).
- Videoconferencing was an effective means to share the information between the schools of nursing (81% strongly agree; 19% neutral).
The narrative responses touched on the students’ prior assumptions regarding rural and urban communities, lessons learned from the experience, suggestions for project improvement, and their favorite aspect of the project (Table 2).
Table 2: Highlights of Nursing Students’ Narrative Responses Regarding Videoconferencing (N = 17)
The student feedback revealed that the experience influenced their perceptions of communities. General statements demonstrated that students gained a better understanding of the complexities of community health and appreciation for the role of the public health nurse. Students enjoyed using different types of media for an assignment, especially teleconferencing, to interact with other students and to share their work and perspectives.
Faculty thought the project provided the students with an opportunity to experience different approaches in meeting the criteria for a clinical experience. For example, one student group used storytelling within their DVD, whereas the other group used stakeholder interviews to obtain data of their individual community. It also allowed the students to compare and contrast communities they would otherwise not have access to within their local geographical area. Finally, using technology to facilitate the collaborative exchange of ideas allowed them to interact with nursing students in another state.
Suggestions for Replication
Technology and Environment
Students noted that access to the Internet would have been beneficial during the question-and-answer session during the videoconference because it would have allowed them the ability to search for data requested. In addition, faculty stated that the quality of the audio and visual reception could have been improved to facilitate the social interaction between the groups; it was difficult hearing and seeing students not near the microphone or camera. After the conference, it was realized that a recording of the conference would have assisted in the debriefing and evaluation and could have assisted the faculty in guiding the students in the reflective process of learning.
Student and Faculty Recommendations
Upon completion of the project, it was identified that the survey tool developed needed improvement because it did not capture the intense learning experience expressed by the students in their feedback. It was suggested that it would have been useful to have the students write a short paragraph summarizing their perceptions of their own community, as well as the other communities studied, after the project commenced to capture deeper insights through a more qualitative approach. This would have allowed the students to look back to see whether their perceptions of the communities changed after participating in the videoconference. In addition, had a recording been available after the videoconference, a formal debriefing session could have been conducted to allow the students to more effectively compare and contrast their individual and group analyses of the communities.
Faculty noted that using four communities (two urban and two rural sites) caused some confusion when performing comparisons and stated it would have been easier to compare just one rural and one urban community, especially when time was a factor. The students verbalized that they felt “rushed” during the videoconference, given that the data for discussion included all eight dimensions of the Community-as-Partner model used for this pilot. Another time constraint encountered during the pilot was the additional challenge of working around two diverse academic schedules that had discrepant timing related to examinations and student personal commitments.
Faculty identified that having student participants at the same stage in their academic program would have provided for a balance reflective experience. In this pilot project, the students from Alverno College were at the sophomore level and in the early stages of their program, whereas the Winona State University students were in their final semester of nursing school. This created some differences in the quality of media, reflection, and content analysis of the communities. In addition, because the students were at different stages in their subsequent programs, faculty participation in the actual windshield survey and videoconference varied. Finally, the distance between the nursing schools and response time to e-mails added an additional burden.
Two unforeseen bonuses of the project were realized at the completion of the pilot. Faculty provided individual copies of the windshield survey in DVD format and in PowerPoint®, as well as feedback for students’ personal academic files. These materials can be used by the students to develop their portfolios for future employment. The other benefit was that students witnessed faculty collaborating and modeling professional communication behaviors.
Community health nursing faculty members struggle to provide their nursing students with valuable and culturally sensitive experiences in clinical settings. Many challenges exist, including the difficulty of establishing culturally diverse clinical sites in areas that have homogenous populations, as well as the cost and time needed to travel to distant locations. It is important for faculty to remember to provide multiple opportunities that expose students to diverse populations within clinical settings. In addition, faculty must be comfortable with the community assessment process and developing contacts with a community. This pilot project, which combined a windshield survey with an interactive videoconference exchange, was found to be an effective, low-cost teaching strategy to meet these challenges for the two nursing schools involved in this project. Further replication of this project is needed to evaluate the validity of its use by other schools. Appropriate evaluation instruments should be used to measure nursing student progress toward cultural sensitivity.
Preparation of students for public and community health nursing may be improved by using interactive teaching strategies that connect classroom theory to clinical experiences. Using videoconferencing as a teaching strategy may assist in reaching this goal within baccalaureate nursing programs. The authors encourage other schools of nursing to consider alternative methods of technology to provide better access to culturally diverse populations and community health clinical experiences for nursing students.
- Alverno College. (2009). Facts 2009–2010 [Brochure]. Milwaukee, WI: Author.
- Anderson, E. & McFarlane, J. (2011). Community as partner: Theory and practice in nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
- Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 11, 199–203. doi:
- Critchley, K.A., Richardson, E., Aarts, C., Campbell, B., Hemmingway, A., Koskinen, L. & Nordstrom, P. (2009). Student experiences with an international public health exchange project. Nurse Educator, 34, 69–74. doi:10.1097/NNE.0b013e3181990ed4 [CrossRef]
- Falk-Rafael, A., Ward-Griffin, C., Loforet-Fliesser, Y. & Beynon, C. (2004). Teaching nursing students to promote the health of communities: A partnership approach. Nurse Educator, 29, 63–67. doi:10.1097/00006223-200403000-00007 [CrossRef]
- Harwood, C.H., Reimer-Kirkham, S., Sawatzky, R., Terblanche, L. & Van Hofwegen, L. (2009). Innovation in community clinical placements: A Canadian survey. International Journal of Nursing Education Scholarship, 6(1), 1–19. doi:
- MnGeo: Minnesota Geospatial Information Office. (2000). 2000 Census and mapping and report additions. Retrieved from http://www.lmic.state.mn.us/datanetweb/php/census2000/c2000.html
- Nies, M. & McEwen, M. (2006). Community/public health nursing: Promoting the health of populations (4th ed.). St. Louis, MO: Elsevier.
- Ramal, E. (2009). Integrating caring scholarship, and community engagement in Mexico. Nurse Educator, 34, 34–37. doi:10.1097/01.NNE.0000343396.19071.21 [CrossRef]
- 2-1-1@Impact. (2005). Report card to the community. Retrieved April 10, 2010, from http://www.impactinc.org/PDF/impactreport.pdf
- U.S. Census Bureau. (2010). State & county quickfacts [1999–2000]. Retrieved February 19, 2010, from http://quickfacts.cencus.gov/qfd/index.html
- Winona State University Databook. (2010). Fall opening enrollment undergraduate ethnicity counts . Retrieved February 19, 2010, from http://www.winona.edu/air/IR/databook/default.htm
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Pilot Videoconferencing Teaching Strategy Project Process
Faculty from two schools of nursing selected diverse communities, developed a timeline, and selected methods of communication (e.g., e-mail, telephone, teleconference, and mail).
Community health nursing students were selected to participate in the project and were provided with an orientation to the community assessment project.
Consent for photography and participation in the project were obtained from all stakeholders (e.g., students, faculty, and schools of nursing administration).
A standardized windshield survey instrument and specific community locations were selected by the faculty for inclusion in the formatted media—PowerPoint® presentations and DVDs.
Media personnel were contacted to assist with the videotaping of the windshield survey and coordinate the day, time, and location of videoconference.
Students performed their windshield survey and obtained supporting data regarding their assigned communities using evidence-based resources.
Students were given time to create media (i.e., PowerPoint presentations and DVDs) and send it to the corresponding school of nursing.
Structured discussion questions were composed by faculty to facilitate the videoconference.
An evaluation tool was created and administered to the nursing students to capture their feedback of the experience.
Faculty reviewed student feedback and provided recommendations for improvement and replication.
Highlights of Nursing Students’ Narrative Responses Regarding Videoconferencing (N = 17)a
Before I participated in this experience, I thought the following about the rural/urban environments:
Rural: “spread out, not as many resources.” Urban: “everything available within minutes, diverse.”
“I knew that there would be major differences, but learned that there were so many similarities [poverty, low income, and health care issues].”
“I felt I knew everything there was to know about my own community; however, this experience really opened my eyes.”
“I thought that the rural community would have better opportunities for access to healthcare, when really they had to travel a long distance to get to a hospital. In the urban setting I always thought that we were not able to be seen for certain health conditions, when it really is easier to get to a hospital and we also have free clinics available for those that are low income.”
I learned the following as a result of this experience:
“Being a public health nurse is a lot of work. I thought they worked at the health department and gave immunizations to children. I think their work goes unrecognized and [is] sometimes unrewarded.”
“There were positives and negatives in each community.”
“Just because an area shares the same zip code does not mean that they share the same problems.”
“What strategies can we implement as nurses to better our communities?”
“I learned that public health nurses must know a lot about the communities and people they serve.”
I would suggest these changes:
“Decide ahead of time [initial preconference] what exactly the other groups want—meet with them at the start of the project.”
“Next time [I suggest] we would be allowed water and a computer.”
“I think that both groups would have the same understanding of the assignment.” [One person should explain the project to both groups in order to make the interpretation of the project more uniform].
“I believe it [the teleconference] could have been longer; we did not have enough time to touch on every area.”
I liked this part of the rural/urban experience best because:
“The comparison between the two [perspectives of the students for this assignment] different approaches of the assignment” [for the media presentation].
“I think the interaction with Winona State really put the whole experience together. The visuals helped, but ultimately the interaction with them was the best part of the experience, exchanging stories and facts.”
“I liked the teleconference the best because it was informative; I was able to see the level of commitment and importance of this project to community nursing. It has only enhanced my desire to work in the field [of community health nursing].”