Community health nursing educators are challenged with shaping clinical courses that provide students with direct clinical care experience in the community setting while also fulfilling the imperative to develop baccalaureate nursing (BSN) students’ skills in assessment and care of communities on a population health level. To meet these challenges, educators not only must secure community clinical experiences that provide opportunities for direct patient and population-based care, but also must grapple with the development of methods for consistently meeting a broad range of community health student learning outcomes.
This article presents a model that uses conceptual pillars and a hybrid constructivist learning approach to facilitate consistent opportunity for achievement of student learning in both population care and direct care to individuals across a diverse range of community clinical sites. In addition, by supporting students in construction of knowledge, the model is designed to further the development of skills for lifelong learning. The model may be of particular interest to programs that use a large number of community clinical sites and wish to keep consistency in ultimate student learning outcomes.
Chronic illness and infectious disease are major contributors to the status of health in the United States. For health promotion and disease prevention to be broadly effective, it is necessary to address determinants of health on a population, as well as an individual, level. The U.S. Department of Health and Human Services, in its Healthy People 2020: Framework (n.d.), has placed an increased emphasis on addressing population-level determinants of health. This is reflected in a commitment to an “ecological and determinants approach to health promotion and disease prevention” (p. 2) and in the designation of a new inclusion in the overarching goals to “create social and physical environments that promote health for all” (p. 1).
Leading bodies in nursing education have charged nurse educators with ensuring that future baccalaureate-educated nurses are prepared and disposed to address population health concerns, including determinants of health. The American Association of Colleges of Nursing’s The Essentials of Baccalaureate Education for Professional Nursing Practice (2008) holds in Essential VII that “health promotion and disease prevention at the individual and population level are necessary to improve population health and are important components of baccalaureate generalist nursing practice” (p. 4). Outcomes for Essential VII include, “Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources and the range of activities that contribute to health and the prevention of illness, injury, disability, and premature death” and “participate in clinical prevention and population-focused interventions” (American Association of Colleges of Nursing, 2008, p. 25).
The Association of Community Health Nursing Educators has outlined a framework for community health nursing education in Essentials of Baccalaureate Nursing Education for Entry Level Community/Public Health Nursing. This guide identifies the following highly valued core professional values: community/population as client, prevention, health promotion, partnership, health environment, and diversity (Callen et al., 2009).
Benner, Sutphen, Leonard, and Day (2010), in the Carnegie Foundation report entitled Educating Nurses: A Call for Radical Transformation (2010), suggested that nursing educators place greater emphasis on situated learning and cognition (understood as the acquisition of comprehension through exposure to knowledge and concept application in the relevant practice environment). One implication of this recommendation is that future nurses will have greater capacity to implement population health concepts (such as epidemiology and addressing determinants of health) if, as students, they are able to apply population health concepts in clinical learning environments. How then, do nurse educators best design community clinical experiences that facilitate the development of competency in population health while at the same time preserving aspects of education focused on direct care of the individual in community settings? The model described in this article represents a promising approach to this challenge, a model that also provides for consistency in learning foci and that supports development of skills for lifelong professional learning.
Many nursing programs have shifted the community clinical experience from a sole focus on home health care to community-based direct patient care in diverse settings and incorporation of care on a population level. Multiple approaches were found in a literature review, and some of the salient examples are highlighted.
One approach is that of service–learning, in which the creation of a health service for the community (by the educational institution) is aligned with the creation of learning opportunities for nursing students. For example, Culley (2010) described the development of a university-based Medical Reserve Corps that served as a clinical learning context. Participating nursing students had opportunities to develop population care skills through building strength in community systems for emergency preparedness. Richards, O’Neil, Jones, Davis, and Krebs (2011) described a direct care service–learning approach in which BSN students occupy specific provision of care roles while working with RNs as well as nurse practitioner clinicians and faculty at one of two rural, nurse-managed, federally qualified health clinics opened by the school of nursing.
Many BSN programs, particularly in Canada, have seen a significant shift from the traditional clinical placements in which students are mentored by RNs to nontraditional placements in which students are placed in nonmedical agencies that do not employ RNs (Pijl-Zieber & Kalischuk, 2011). Examples of nontraditional placements given by Pijl-Zieber and Kalischuk include homeless shelters, police departments, correctional facilities, shopping malls, and churches or synagogues. Reasons cited by the authors for this switch included the shortage of traditional clinical placements, an increase in demand for community clinical sites, a decrease in community and public health nurses within community health settings, and an increased focus, for many schools of nursing, on community-based and population-focused nursing. The authors developed the point that the use of nontraditional sites supports teaching of population health and engagement with community development and that, although these skills currently may not be the focus of the majority of public health nursing positions, these skills are the foundations for the realization of the vision of public health nursing that has been articulated by major nursing organizations.
As community nursing faculty consider distribution of students into diverse community clinical sites, the nature of faculty involvement and the role of on-site clinicians as educators becomes prominent. Mallette, Loury, Engelke, and Andrews (2005) developed the Integrative Clinical Preceptor Model. This model is based on a reciprocal relationship between nursing students, preceptors, and faculty. The students take on an active role in setting their goals, the preceptors are valued as clinical teachers, and the faculty members serve as a resource for both students and preceptors. The authors described an implementation of the model in which faculty members stayed in communication with preceptors and engaged students throughout the semester using a series of assignments that highlighted the clinical experience.
In a different approach to faculty involvement and clinical mentorship, Sims-Giddens, Helton, and Hope (2010) described a student-to-student peer mentoring arrangement in which graduate nursing students were linked with undergraduate community health nursing students in a setting that delivered health care to an at-risk community-based population. Nursing faculty and the agency directly communicated with the graduate students, who then in turn mentored and directed the undergraduate nurses’ projects that were developed and implemented based on the specific community health needs.
Carter, Kaiser, O’Hare, and Callister (2006) discussed the imperative to evolve best practices in community and public health nursing education. The authors maintained that there is a rich underpinning for such education in the guiding principles, competencies, and essentials established by leading organizations in public health nursing education, and they stressed the importance of the development of evidence-based best practices that will allow students to acquire these competencies through application. The authors then offered their own contribution to the development of best practices: a collection of potential learning activities that are specifically linked to and organized by the framework of the Association of Community Health Nursing Educators’ Essentials of Baccalaureate Nursing Education for Entry Level Community/Public Health Nursing and the Quad Council of Public Health Nursing Organizations’ Scope and Standards of Public Health Nursing Practice (as cited in Carter et al., 2006). The article also discussed the paucity of research on public health nursing education outcomes and called for further research so that teaching practices may truly be evidence based.
Within the literature reviewed, several compelling themes emerged. Pijl-Zieber and Kalischuk (2011) and Culley (2010) discussed ways in which particular types of clinical sites facilitate growth in population health skills and knowledge acquisition. The role structuring of faculty and clinical teachers for community nursing education becomes of particular importance when students are distributed in the field, and the articles by Sims-Giddens et al. (2010), Richards et al. (2011), and Mallette et al. (2005) all offered insight into potential ways of addressing this issue. The challenge of pedagogical design was approached by Mallette et al. (2005) and Carter et al. (2006). Carter et al. offered specific learning activities grounded in national recognized competency and essentials; Mallette et al. reported standardized preceptor training and described faculty-evaluated learning activities that all students participated in regardless of clinical site assignment.
A model that would provide a unifying structure for consistent pedagogical foci and learning outcomes in population health and direct patient care in the community across a wide range of community clinical experiences has not been reported in the literature. The Pillars Constructivist model described in this article provides such a model.
Conceptual Pillars for Learning Outcomes
The authors’ initial community clinical placement modification was devised out of immediate need due to the inability to meet the demands of increasing numbers of students and decreasing commitments from home care agencies. At the same time that these logistical limits were encountered, there was a growing interest in providing students with the opportunity to apply population health principles in a clinical experience. In addition, there was a desire to expose students to a wider perspective of nursing roles in the community. Through the development and ongoing nurturance of clinical partnerships with nurse leaders in a variety of public health settings, the faculty came to understand the value of a diverse combination of home care and other learning opportunities—the distributive experience. After the distributive experience was implemented for three semesters, rotating more than 100 senior-level BSN students, the nursing faculty as a whole voted to adopt this approach to community health as the program transitioned into a concept-based curriculum.
In working toward providing a formal structure and methodology for this new curriculum community clinical course, the faculty identified aspects of the traditional home health-based clinical experience they wanted to preserve and nourish. Specifically, the team identified that the home health experience, particularly when students were held accountable for providing the nursing assessment, care, and planning for a home visit, was an exceptional practice for bringing to light the autonomous responsibility of the nursing role. Although the impact and inherent responsibility of nursing action is present in all clinical settings, the experience of home health nursing often lifted the veil of this reality. Also identified as salient in the home health experience was students’ exposure to the lived experience of illness in the individual’s own home setting. In this direct exposure, students were stimulated to integrate an assessment of the individual’s immediate environment, as well as family dynamics in most instances, into nursing care. In exposing students to the autonomy of caring for a patient in the home environment, there was often an extension of understanding and compassion for the day-to-day impact of health challenges. In addition, the team wanted to preserve the focus that the previous home health-based course maintained on accessing and integrating evidence for best clinical practices.
While considering what the program might have lacked previously in the existing home health only experience, the team was inspired to build experiences that would provide opportunities for the application of population health concepts and would broaden the understanding of nursing roles in public health. The team envisioned an outcome in which nursing students would grow in their understanding and disposition to act as advocates and catalysts in the shaping of determinants of health—both individual and population based.
In the team’s aspiration to maintain the strengths of the home health experience, to build nursing role performance in public health, and to provide opportunity for clinical application of population health principles, four conceptual pillars were developed. These pillars, and the subobjectives that fell under the pillars, would serve as the structural elements (and the meta learning outcomes) by which the faculty would design and guide the community clinical experiences. The pillars also would provide the structural elements with which students engage in a constructivist approach to learning experiences.
The four pillars are:
- I. Incorporate determinants of health in nursing care of population aggregates and communities.
- II. Provide direct care based on evidence and best practices in community settings.
- III. Integrate sensitivity to and appreciation of the lived experience of health and illness into nursing practice.
- IV. Align comprehension of public health nursing roles with one’s own ethical and professional formation.
A fifth pillar was added secondary to suggestion and agreement at a general faculty meeting:
- V. Demonstrate the ability to collaborate as a member of a multidisciplinary team within the health care system to develop, implement, and evaluate health care provided to clients across the age span.
A Concept-Based Hybrid Constructivist Method
This model took inspiration from work conducted in the area of concept-based learning activities (CBLAs) as discussed by Nielsen and Lasater (2010). CBLA focuses student assessment, intervention planning, reflection, and group discussion around a specific clinical concept. In doing this, as opposed to a total patient care approach, the student experience is altered from that of being task focused to a facilitation of deeper focused learning within a specific clinical conceptual area. The CBLA approach, as Nielsen and Lasater proposed, may be used as the sole model or may be integrated with other clinical learning approaches during the course of a semester.
The Pillars Constructivist model borrows from CBLA the approach of intentional focus on a specified concept in clinical education, with explicit student awareness of concept as focus and with design of learning approaches to support growth in the specified conceptual area. The Pillars Constructivist model draws on these significant aspects of CBLAs and integrates this with a hybrid constructivist approach so that students might self-direct and coordinate learning in specific conceptual areas, the pillars, across a diverse range of community clinical experiences (and be supported in this process). Clinical experiences might include multiple home health agencies (with student experiences differing in amount of student autonomy, patient care responsibility, and type of clinical supervision), as well as a diversity of sites in the community that differ in focus on direct care of individuals or population care and also in direct student clinical application versus shadowing.
In designing the course methodology, the authors were inspired by the description of a constructivist approach to learning in the context of online nursing education (Moran, 2005). Constructivist theory in pedagogy is characterized by the facilitation of independent thought for engagement in conceptual learning. One of the leading thinkers in Radical Constructivism, Ernst von Glasersfeld (2001), noted:
From the constructivist point of view, creating concepts is a form of construction and, whatever the circumstances, construction involves reflection, i.e. a recognition of the connections that can be made by co-ordinating sensory elements or mental operations. (p. 165)
von Glasersfeld acknowledges the importance of direct teaching for imparting established knowledge but points to the utility of using a constructivist pedagogy to build the ability of the mind to develop intellectual skills of reflection, independent thinking, and conceptual synthesis. If future nurses are to become change agents in the redesign of health care (Institute of Medicine, 2011, p. 32) and in the shaping of our nation’s determinants of health, they will need these intellectual skills and the experience of applying them in the context of public health.
Common in discussions of constructivist approaches to education of health professionals is the relationship of constructivist learning to the ability to address complexities of practice particularly, in areas that are not easily knowable. As expressed by Hodges (2011) in an article on complexity science and problem-based learning in community nursing clinical education:
Constructivist pedagogy fosters inquiry to solve unstructured problems, bridge current and future health needs, and develop habits of exploring complex adaptive systems contextually as a necessary foundation for professional practice resilience in a complex health care environment. (p. 7)
The method described in this article uses a hybrid constructivist approach in that there will be some direct teaching of established knowledge but the overall structure of the course will be that of student-navigated construction of knowledge (in the community health conceptual realms represented in the pillars). Constructivist approaches to health professional education have been described with differing emphases: on construction through group process, through scaffolding of knowledge, and through experiential construction of knowledge (Gleeson, 2010; Hodges, 2011; Hunter & Krantz, 2010; Moran, 2005; Rolloff, 2010). In the current model, the locus of constructivist approach is the individual experiential and self-directed learning that emerges around the conceptual pillars.
Overview of the Pillars Constructivist Model
The pillars offer a conceptual basis for construction of knowledge (Table). Assignment of meaning, conceptual synthesis, and conceptual organization of each student’s clinical experience is sought after, interpreted, and constructed by each student through the clinical experience and supporting course reading and exercises. Figure 1 represents one student’s engagement with the model. Students are assigned to various clinical sites at which they will have experiences (four of the five sites available to a clinical group for the student represented in Figure 1). Students will identify and engage resources and experiences at each clinical site through which knowledge and conceptual understanding (represented in the specific pillars) is built. Assigned readings and faculty-generated, concept-based exercises aid in facilitating this work. The process of knowledge construction is represented in Figure 1, in the variously patterned lines that extend from the student through clinical sites to reach the pillars (the difference in line pattern serves only to designate specificity to conceptual pillar). The faculty are seen in the diagram in a support and facilitator role. Figure 1 reflects student discernment in matching the clinical experience opportunities to construction of knowledge; given the same site assignment, individual students might develop different alignments between clinical sites and focus of conceptual work (Figure 1 shows just one possibility).
Example of student engagement with the model.
Figure 2 represents the larger picture of the way that the model provides for pedagogical consistency for a large group of students (in this case 40 students, but the number could vary) around the concepts represented in the pillars. Although each cohort of 10 students will work with a different faculty member and a different array of clinical sites (and individuals within cohorts may have different site distributions), all students will use a hybrid of faculty support and constructivist learning to engage their own set of clinical experiences to build knowledge in the conceptual domains represented by the pillars.
Overview of student distribution in the model using multiple diverse community sites.
In the employment of this model, it will be essential that students are given the opportunity to achieve success and that they receive sufficient support from faculty and preceptors throughout the process. In providing opportunity and support for success, it is necessary that clinical sites are developed and assignments are created that will allow students to engage and show progress in the desired conceptual pillars (i.e., learning outcomes). For a program with many clinical sites, this may be accomplished by coordination in mapping the areas of learning that may occur at each clinical site, then designing student assignments and rotations so that all students have the opportunity to work toward achieving the learning outcomes in each pillar. It remains the work of students to search for, engage, and analyze the information, observations, and experiences within these assignments that will allow them to construct knowledge. The pillars, the constructivist methodology, and instructor support are the guides.
To succeed in this model, students must engage in active learning. They must assess their learning needs and learning opportunities, develop an evolving plan to achieve these outcomes, and engage in formative self-evaluation. These are intellectual skills and habits of mind that should be encouraged.
Implementation of the Model
In the initial implementation of this model, students’ experience consisted of 50% of the clinical time spent in the traditional home health care experiences combined with 50% of the clinical time spent in experiences with clinical partners who specialize in providing public nursing care in settings such as public health divisions, domestic violence centers, schools, day care centers, a variety of outpatient clinics, a nurse family partnership home visitor program, wound care centers, long-term care facilities, and assisted living facilities. Faculty, together with clinical partners in the community, devise a schedule in which students rotate through clinical experiences. Students spend one day per week in the home care setting and one day per week in a rotation through various community sites, with 2 to 5 days at each setting. Any given student is likely to have experiences at one home health agency and three to four other sites in the community. Because conceptual learning is constructed across clinical experiences, rotation to multiple clinical sites provides synergy in reaching conceptual outcomes. In the implementation of this model, it is important to note there is flexibility in the specific distribution of clinical experiences.
Faculty visit the diverse community rotation sites to intermittently observe students in the setting, provide feedback to students, and obtain written and verbal feedback from preceptors. In the home health experience, faculty instructors are present with students each day of that experience so that instructors may choose to build learning opportunities through regular face-to-face preclinical and postclinical sessions. The ideal is that one faculty member works with a cohort of students in both the home health and community rotation experiences as this broadens the opportunity to share experiences and perspectives. This support and facilitation of constructivist learning may be accomplished through preconferences and postconferences, online sharing of assignments, and various meeting times designed for this purpose.
In the diverse community rotations, students complete graded written assignments before and after each clinical rotation. Although there are some assignments required of all students across cohorts, most of the preassignments and postassignments are designed by individual course instructors and are specific to the clinical sites. This balance in assignments is a flexible aspect of this model. All assignments are designed to provide the opportunity to construct knowledge in the conceptual pillars as students prepare for, integrate, and reflect on the clinical experience. The opportunity to do this work is paired with an understanding that students are responsible for a self-awareness of progression in the pillars and for purposeful initiative in attainment of the pillars.
Assignments facilitate constructivist learning by using a combination of approaches: assigned readings, questions that ask students to delve into the assigned literature to prepare themselves with content for the clinical experience, and open questions that ask students to look for connections between clinical experience, assigned readings, acquired knowledge base, and conceptual pillars. As part of the preparation for specific clinical site experiences, students are prompted to develop a plan to pursue learning needs (e.g., what will you focus on and what questions will you probe?). Students may also be asked to formulate their own questions related to the clinical experience and to explore these questions through a literature search.
Students are given an initial orientation to the concept of constructivist learning prior to the start of the clinical experiences. Exercises are used that help students see several different correct answers to simple logistic questions or pictures. The first few exercises are pictures that have the appearance of several figures, depending on how one looks at the graphic. The students are then given a logic scenario and asked to come up with several different solutions to a problem. From these simple exercises that encourage intellectual initiative and flexibility, students are segued into application of the constructivist learning model for the semester. The constructivist model is made explicit so that students understand the nature of their role in finding different ways of advancing in the pillar concepts through various clinical sites throughout the semester. There is emphasis placed on the process of developing constructivist learning as a valued learning experience in and of itself.
Formative evaluation is ongoing throughout the semester. The students are encouraged to engage in this process, discuss this assessment with faculty, and receive faculty evaluation and feedback. The pillars provide the framework for the formative and summative evaluations. A pass/fail approach to grading is used in the clinical course, although this model could just as well accommodate numerical grading. Students are expected to reach 75% achievement of each pillar, as measured by passable achievement of 75% of the subobjectives under each pillar. Alternatively, subobjectives could be used solely as guides, and instructors could grade students based on the larger gestalt of progress in that conceptual pillar. (The specific subobjectives used by the authors can be obtained by writing to the authors.) Although a standard numerical rating was used to evaluate progress in the first implementation of this model, the authors recommend adaptation of a progressive pie chart method to better represent progression in attainment of subobjectives and pillars. For example, it would be expected that a student would be at 50% attainment of all pillars at midpoint in the semester. This pie chart could promote student engagement in planning and navigating construction of knowledge in each pillar.
Students have provided feedback on the experience. One student wrote:
During this rotation, I was able to incorporate determinants of health in nursing care of population aggregates and communities. Within this vulnerable population, I was also able to identify the many different determinants of health such as income, education, and environment. I was also able to evaluate the ability and limitations of agencies to deliver health care services, and/or affect determinants of health within communities.
A second student wrote about her experience working with a county-level sexual assault response team nurse. She stated:
…all in all, my learning need for practice in this community setting was to learn and acknowledge the reality of the situation in its entirety and be able to work within the system to help as many people as possible.
A mixed-method evaluation of the Pillars Constructivist model has been undertaken. Preliminary findings, across the majority of measures used, indicate the model’s effectiveness. A manuscript is under development that will include a report of outcome data and a discussion of implications for nursing education.
By providing a conceptual structure in the pillars and by facilitating a method for active student engagement and responsibility in achieving learning outcomes, this model was developed to give unifying direction to a cohort of students across diverse community clinical sites. The student learning foci in this model are relevant to population health as well as to provision of direct care in community settings. The approach supports the development of skills and habits for independent, lifelong learning.
The pillars are the structural and conceptual elements by which the faculty design and guide the community clinical experiences and by which students guide their learning process. The pillars were constructed to embody the most promising aspects of what community health clinical education might offer. These aspects include incorporating determinants of health in nursing care of population aggregates and communities; providing direct care based on evidence and best practices in community settings; integrating sensitivity to and appreciation of lived experience of health and illness into nursing practice; aligning comprehension of public health nursing roles with one’s own ethical and professional formation; and demonstrating the ability to collaborate as a member of a multidisciplinary team within the health care system to develop, implement, and evaluate health care provided to clients across the age span.
The pillars are not based on one specific guiding document of community and public health nursing competencies or essentials. However, the authors believe most of the competencies or essentials that are suggested by leading organizations in public health nursing relate to the pillars in this model. If a program wanted to use this model and incorporate a specific set of public health nursing educational competencies or assessments, these might be included as subobjectives within a relevant pillar.
As many nurse academics face the constraints of limited home health agency clinical placements and the reality that many other types of community clinical sites are able to accept only small numbers of students at a time, faculty are challenged to create new community health learning experiences. These challenges open windows of opportunity for the development of learning opportunities that support the clinical application of population health concepts. Some nursing programs have developed service–learning models in which provision of community clinical services are provided through the learning institution, thereby serving the community and creating clinical learning opportunities for students. The amount of student clinical learning experiences in this approach will partially depend on the number of people served by the programs. For institutions like the authors’ institution that are not yet at the point of supporting community clinical services of scale, another option is to use a multitude of diverse clinical sites in the community. The model presented in this article may be of benefit to a service–learning environment, but it is particularly suited to programs that use a number of diverse clinical sites. One of the advantages of using a diversity of community sites is that students have exposure to diverse role opportunities in community health. The initial implementation of the model used community health sites that were nursing and medically oriented. However, use of nontraditional sites could be integrated into this model. Although the specific arrangement of clinical experiences may vary greatly in the use of this model depending on institutional and community resources, it is necessary to ensure that students have the opportunity for construction of learning within all five pillars.
As this model was in the process of being developed, one of the major concerns raised by the larger faculty body, and shared within the course development group, was that of accountability: how would faculty ensure that students were actively engaged in learning if there was no faculty member present for some of the experiences and if there was no immediate responsibility for direct clinical care in some of the experiences? This model puts student accountability at the core of the experience by facilitating a self-navigated method of knowledge construction (with support and monitoring).
The dynamic and autonomous constructivist learning environment described in this article provides students with the ability to take ownership of the clinical experience, foster critical thinking through active learning, and develop skills for lifelong learning. This intellectual development is in the context of both direct care and population health.
Community health nurse faculty hold the challenge of ensuring students adequate exposure to today’s public health nursing environment and preparing future nurses to participate in and shape health and health care in the United States. Carter et al. (2006) have called for the development of best practices in community and public health nursing education; the authors of the current article hope that the model presented herein will be a useful contribution to those ends.
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||Public Health Concept or Capacity
||Incorporate determinants of health in nursing care of population aggregates and communities
||Provide direct care based on evidence and best practices in community settings
||Integrate sensitivity to and appreciation of lived experience of health and illness into nursing practice
||Align comprehension of public health nursing role with one’s own ethical and professional formation
||Demonstrate the ability to collaborate as amember of a multidisciplinary team within the health care system to develop, implement, and evaluate health care provided to clients across the age span