The expansion of nursing programs in Saskatchewan, Canada, has challenged educators to find sufficient numbers of quality practice education experiences in urban settings. The Saskatchewan provincial government earmarked funding to assist nursing education programs to develop alternate strategies that would increase the number (capacity) of high-quality practice education settings for nursing students, examine innovative practice education models to prepare graduates, and better use existing resources. In response to this funding opportunity, a team of nursing education administrators invited the Saskatchewan Institute of Applied Science and Technology (SIAST) Nursing Division faculty to submit innovative ideas for pilot projects that met four essential criteria. Each pilot project was required to (a) deliver the experience in a rural or remote setting, (b) apply an innovative instructional strategy, (c) demonstrate evidence of community-based education, and (d) include interprofessional and intraprofessional learning opportunities. With its demonstrated innovation for a unique intraprofessional practice education (IPE) component where three different SIAST prelicensure programs shared their community-based experience concurrently in a rural First Nations community, the IPE project was approved for funding. The intraprofessional component of the project was informed by research examining three categories of nurses in western Canada (Besner et al., 2005). Besner et al. (2005) identified substantial challenges to collaborative practice among licensed practical nurses (LPNs), registered nurses (RNs), and registered psychiatric nurses (RPNs), such as role confusion, role overlap, and ambiguity that contribute to tension, rivalry, and underuse of human resources. Nurse educators are uniquely positioned to help students understand the different roles of nurses and other health care providers. As an applied research project with ethical approval from the University of Regina, the IPE pilot project aimed to address these challenges.
IPE Project Planning and Coordination
The Partnership Model for Community Health Nursing Education (PMCHNE) (Falk-Rafael, Ward-Griffin, Laforet-Fliesser, & Benyon, 2004) helped to operationalize the IPE pilot project. A key feature of this model is the triad partnership—a symbiotic relationship that exists between faculty advisors, community advisors, and students. The model exposes students to features of successful partnerships, such as communication, commitment, negotiation, and mutual respect, on several levels. Health promotion is a basic tenet of the model, and students have the opportunity to experience how the determinants of health (Mikkonen & Raphael, 2010) affect individuals, families, aggregates, communities, and society, as they participate in community projects to improve health outcomes.
The PMCHNE is a four-stage model designed to ensure the success of a community partnership and includes (a) building the foundation through selection processes of community partners, community and faculty advisors, and nursing students that ensure high quality at all junctures and sharing a philosophy of community health and of learning between practice and education; (b) launching the placement of nursing students in practice education settings by offering orientation sessions to all involved and establishing a team charter and a learning plan; (c) implementing the placement for faculty and community advisors and students and providing ongoing monitoring for quality experiences and early resolution of issues; and (d) evaluating the quality of the placement, determining satisfaction with the participation, and identifying the lessons learned. Integral to the success of each stage is an environment that is supportive, where each partner works collaboratively to simultaneously achieve the outcomes for nursing education and the health of the community (Falk-Rafael et al., 2004).
Initially, the three faculty advisors participated in regularly scheduled meetings to outline the tasks and steps needed to build the foundation and launch the project (Falk-Rafael et al., 2004). Project planning focused on nine main areas: community consultation, partnership development, identification of common competencies, construction of a practice education guide, selection of an instructional strategy, student evaluation, communication and integration of technology, student selection, and creation of faculty and student schedules.
Coteaching (Crow & Smith, 2003) was the instructional strategy selected for the project, whereby faculty advisors from the LPN, RN, and RPN programs shared in the planning and coordination of students’ practice education experiences, as well as sharing teaching and the evaluation of student performance. This strategy was challenging because even though students were from the same educational institution, they were at various stages in their respective programs and the number of required practice hours varied. The LPN students were in their final year, the RN students were at the end of their second year, and the RPN students were at the end of their first year. Student and faculty schedules were staggered to ensure that students had the opportunity to participate in the various learning experiences and that faculty were available to teach and evaluate student performance. After the project was launched, faculty advisors, in partnership with the community advisors, shared the coordination and delivery of the students’ experiences.
As outlined in the PMCHNE (Falk-Rafael et al., 2004), community advisors, consisting of agency administrators, department managers, and nursing staff who were directly involved in the planning of students’ learning, were consulted throughout the pilot project. Faculty advisors and their program heads met with community advisors to explain the PMCHNE, describe the pilot project, and determine the health needs of the community. The students’ learning experiences were selected in consultation with and support of the community advisors and the students. Faculty advisors conducted an orientation for the managers and nursing staff to introduce them to the IPE project framework, the concept of community-based education, and the practice education guide. This guide was a valuable reference used to introduce the project, outline roles and responsibilities, and describe student competencies and learning outcomes.
Student Selection and Orientation
Students were provided with a synopsis of the pilot project and were invited to participate. Inclusion criteria consisted of being of Aboriginal descent, being a current resident of the First Nations community, having an interest in working with Aboriginal people, having an interest in rural nursing, and a willingness to commute to the community. Thirty students expressed interest in participating in the project, and each program head selected three students from the pool of interested individuals who, in addition to meeting inclusion criteria, demonstrated success in previous practice education experiences. An information session was held to introduce students to one another and to the faculty advisors, to describe the salient characteristics of the project, to outline possible learning opportunities, and to explain the PMCHNE. Consent and risk management forms were signed, and practice education guides and orientation manuals were distributed.
Student Learning and Evaluation
Each of the three SIAST nursing programs involved in the project prepare students for a specific professional nurse designation; therefore, a primary task was to identify common competencies between the three nursing programs. On review, it became apparent that the programs shared similar, although differently labeled, competencies in their respective curricula. To elucidate the commonalities, similar competencies were grouped and color coded to the respective programs and then were relabeled as learning pathways. These common learning pathways included holistic health, professional and ethical practice, cultural safety, therapeutic relationship, critical thinking, and clinical judgment. Students used the learning pathways to develop their learning plans. These plans plotted students’ learning throughout their experience and were the basis of information shared during debriefing sessions between the triad of students, community, and faculty advisors.
Faculty advisors provided daily performance feedback to the students, and each faculty advisor was responsible for evaluating students’ performance using the respective program’s evaluation tool. Feedback from the other faculty and community advisors was considered to formulate the student evaluation. This evaluation method provided the students with consistent and ongoing feedback and a fair final evaluation. Faculty advisors changed each week; therefore, to provide continuity and facilitate student progress, a secure, shared drive on SIAST’s server enabled faculty to document anecdotal notes on student performance and learning activities, which was essential to create learning opportunities and formulate student evaluations.
Technology, through the use of cell phones, computer lap-tops, personal digital assistants, and voice recognition software, was further used to enhance communication and facilitate learning. An electronic learning management system provided a platform where students could e-mail each other, receive announcements from faculty, and access course-related materials and resources.
IPE Project Implementation
The start dates for the three student groups were staggered across an 8-week time frame. Prior to beginning clinical practice, all students attended a common orientation day to introduce them to rural nursing and to the First Nations community and its population’s health assets and needs. This was followed by a tour of the integrated health service facility, an introduction to community advisors, and a review of the schedules and evaluative tools. Cultural norms were introduced at the outset, as an elder from the community prayed for successful project outcomes. For each week after orientation, the students and faculty attended a 4-hour scheduling, sharing, and supporting meeting. Students met as a cohort to discuss the scheduling of the learning experiences available, the sharing of the learning experiences from the previous week, and the supporting of each other as they journeyed on through the project. These meetings helped the students connect and bond as a cohort.
Students had standard learning opportunities, which were similar to their urban counterparts, such as experience on an acute care unit and in emergency and outpatient departments. In contrast to their urban counterparts, students were exposed to many other health care providers and programs housed in the integrated health service facility and community. Health services were provided by a nurse practitioner, a wellness support nurse, a health educator, home care nurses, a youth leadership coordinator, and by the maternal–child health program, the environmental health program, and the First Nations healing and counseling center. Students worked with the dietician, the diabetic nurse educator, and mental health workers, and they participated in community education and health promotion sessions, such as healthy cooking, diabetic testing, and support groups for fetal alcohol disorders. These experiences allowed students to observe the health team working collaboratively to meet the holistic health needs of the community.
A valuable cultural experience involved student engagement in health promotion activities during Treaty Day celebrations (Treaty Day honors the treaties between Aboriginal people and the provincial governments). Students created interactive poster presentations on topics related to mental health, dental hygiene, diabetes, and cigarette smoking. Students joined the health team and offered interested Treaty Day participants the opportunity to have their cholesterol and blood glucose tested and provided preventative health teaching. Students and faculty attended a First Nations Pow Wow as part of the community celebration. Other cultural learning activities included attending an Aboriginal awareness session (whereby the nursing students became familiar with the history of Aboriginal people and the current issues and challenges facing the Aboriginal people in Canada), touring the addictions treatment and counseling center, listening to a presentation from a women’s healer, attending a session with traditional healers, and participating in a ceremonial sweat (intended to purify the body, mind, spirit, and heart) and a nature walk with a medicine man. Overall, it was an experiential journey for the faculty advisors and students, and they felt compelled to share their experiences with their peers and colleagues to enlighten them about the rewards of nursing in a rural First Nations community. Student participants were proud to be pioneer participants in the IPE project and hoped other students would have the same opportunity in the future.
Results and Discussion
All IPE project participants were invited to complete an online survey designed to determine the community’s potential to build capacity by providing high quality practice education settings for nursing practice education and to evaluate the utility of the PMCHNE, the effectiveness of coteaching, and the value of the intraprofessional learning component. Highlights from the survey were compiled and disseminated to nursing administrators and project participants.
The project’s main goal was to build capacity. Building capacity is more than finding placements; it also involves the quality of the learning process. Building the foundation (Falk-Rafael et al., 2004) through preparative processes, such as establishing contact with the community, building partnerships, providing orientation, defining roles, and ongoing communication and review of the PMCHNE model, contributed to the high quality of the IPE project and cannot be overemphasized. Students and faculty advisors repeatedly indicated that they felt welcomed in the First Nation community, and the interactions, interconnections, and feelings of inclusivity they experienced with the nurses, other health care providers, elders, and the community contributed to a quality learning environment.
Another significant feature that contributed to quality was the cultural experience associated with learning in a rural First Nations community. Although student learning was not quantified, the students reported a better understanding of primary health care; the determinants of health, cultural diversity, interprofessional and intraprofessional collaboration; holism; the continuum of care; and rural nursing as a result of this experience.
Acute care community advisors indicated that it was too taxing to accommodate nine students at one time, as they reported that reorientation of each student group was too resource intensive. The students also indicated that there were too many students in the group at times, resulting in competition for experiences. Thus, the nursing division was challenged to determine how to continue the project in a way that would build cost-effective capacity, as well as to ensure a high-quality learning environment. Students and faculty advisors concluded that three to six students per program could be accommodated in the community by organizing the students into six teams of three members (one student from each program per team) and rotating them through different learning experiences. This would address the community advisors’ concerns, allow the project to continue in the future, and help the program be more cost effective.
The majority of students confirmed that the PMCHNE facilitated the linking of theory with practice and safe and appropriate learning activities, participation in a team project, collaboration between education and the community, achievement of required competencies, and identification of the community’s health assets and needs. Faculty advisors found that the model was useful in guiding community-based practice education in a First Nations community. Survey results also indicated that the community advisors would require ongoing dialogue about the model and its application to become more familiar with it and to appreciate its merit.
Coteaching as a teaching strategy received mixed reviews from the students. Although some students identified that coteaching modeled the competencies of intraprofessional collaboration, others felt it was difficult and stressful to work with three separate faculty advisors because of the need to prove oneself to each advisor. Faculty advisors viewed coteaching positively and appreciated each other’s contribution to student learning and evaluation. One faculty advisor indicated that the greatest challenge was managing three sets of students who were at different levels of skills, understanding, and experience.
Faculty advisors, community advisors, and students saw value in the intraprofessional experience, particularly because it developed students’ awareness of common competencies within the three nursing occupations. Students felt comfortable in a shared learning environment and indicated they would be more effective with intraprofessional collaboration in the future. They indicated they had a better understanding of how the various roles come together to improve the health of the client, family, and community and valued the interdependence of the roles.
Nursing education has been challenged to build capacity and prepare graduates to work collaboratively with other health care providers and the community. This pilot project was successful in meeting that challenge by incorporating the PMCHNE to help guide the process of community-based education in a rural First Nations community. Integration of three nursing programs resulted in students’ developing an early understanding of the various roles of nurses and other health care providers and an appreciation of how they come together to improve the health of the client and the community. The evaluation of the IPE project provided useful feedback for refining the innovation. Significantly, 70% of the students identified they would be interested in pursuing a career in rural nursing after graduation, thus faculty advisors recommended that future nursing students should have this opportunity for an IPE experience. Overall, the IPE proved to be successful in providing an innovative practice education model to prepare nursing graduates for their professional role, to increase their capacity, and to better use existing resources.
- Besner, J., Doran, D., McGillis Hall, L., Giovannetti, P., Girard, F., Hill, W. & Watson, L. (2005). A systematic approach to maximizing nurses’ scopes of practice. Ottawa, Ontario, Canada: Canadian Institute of Health Research.
- Crow, J. & Smith, L. (2003). Using co-teaching as a means of facilitating interprofessional collaboration in health and social care. Journal of Interprofessional Care, 17, 45–55. doi:10.1080/1356182021000044139 [CrossRef]
- Falk-Rafael, A.R., Ward-Griffin, C., Laforet-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]
- Mikkonen, J. & Raphael, D. (2010). Social determinants of health: The Canadian facts. Toronto, Ontario, Canada: York University School of Health Policy and Management. Retrieved from http://www.thecanadianfacts.org/The_Canadian_Facts.pdf