The competition for clinical education sites for prelicensure students is becoming increasingly difficult. For some nursing programs, the challenge may result in limited clinical sites. Strategies for overcoming the reduction in clinical sites include decreasing clinical hours in a health care setting, limiting or even eliminating community health clinical experiences in Bachelor of Science in Nursing (BSN) programs, and increasing the use of simulation. Although eliminating community clinicals could solve the immediate problem, this marginal solution does not allow prelicensure students to experience the RN role beyond the acute care setting. A parallel need in prelicensure nursing and health care professional education is to be competent working with others and have interprofessional education experiences (Interprofessional Education Collaborative, 2016). A movement is underway to employ RNs in primary care offices and allow them to work to the full scope of their license (Bodenheimer, Bauer, Syer, & Olayiwola, 2015; Josiah Macy Jr. Foundation, 2016). As health care continues to move into the community, it is important to identify places where RNs are employed in community settings, such as primary care offices. It also is important that prelicensure RN students have educational experiences that allow them to see RNs work to the full scope of their license. Placing a student in a primary care office with an RN preceptor provides a unique prelicensure clinical experience. The primary care office allows the student to see the role of the RN and the working relationship between multiple health care professionals outside of the acute care setting. This article describes an alternative precepted clinical immersion experience in primary care practices for prelicensure RN students with minimal community health clinical experiences. In this project, BSN students were paired with RN case managers (RNCMs) in one of seven nurse-managed primary health clinics. In this environment, students observed and learned primary care, community health, and case management nursing skills.
A literature review examining prelicensure community-based case management education indicated that few studies have examined the preceptor and student experience for senior-level baccalaureate students in nurse-managed primary health clinics serving rural and underserved populations. The literature review initially focused on nursing education in the United States. and was conducted using CINAHL® and the following key words in different combinations: (a) case management, (b) community, (c) nursing education, (d) case management model, (e) ambulatory care, (f) nurse's role, and (g) community or public health nursing. Due to the initially scant results, the search was expanded to nursing education outside of the United States and the time lengthened beyond the traditional 5 years to include 1997 to current. Even with the expanded period, the search yielded minimal articles that provided insight into prelicensure students' opportunities related to case management and the nurse's role in the primary care setting.
One school developed a case management course with a service-learning component for their prelicensure students. The course foundations were rehabilitation and medical–surgical principles of nursing care. The content progressed from care principles to achieving optimal outcomes for clients and their families by maximizing coordination and collaboration, but simultaneously minimizing care fragmentation (Tholcken, Clark, & Tschirch, 2004). The course's clinical component included home visits where a comprehensive assessment was completed to determine an older individual's ability to be safe and functional in their home.
A study that included prelicensure students from associate and baccalaureate degree programs used various community settings to provide nursing clinical sites in the community health environment (Frank, Adams, Edelstein, Speakman, & Shelton, 2005). The sites included public health departments, schools, prisons, and homes. The alternative activities were divided into the following categories: immunizations, surveillance, data collection, patient teaching, treatments, case management, and procedures. The research concluded that alternative learning activities gave students exposure to individual and population-focused care (Frank et al., 2005).
Having effective evaluation tools is important to student instruction and learning. Two separate studies identify evaluating the student's experience in a community health clinical site and case management. The Public Health Nursing Assessment Tool combines social determinants of health, health status, intervention strategies, and self-reflection (Lewenson & Truglio-Landrigan, 2010). The tool was piloted with undergraduate BSN students during their community health clinical course, the results demonstrated the potential use of the tool in community clinical practice with both individual patients and populations (Lewensomn & Truglio-Landigan, 2010). A recent study in England discussed the student qualities, how to evaluate the student experience in a community health clinical experience and the nurse role in the primary care setting. Requirements for student placement included qualities of leadership and decision making with focus placed on the review and coordination of community services available to the patient (Todhunter, 2016). Students were evaluated by reflecting on their experiences by using a narrative framework. The narratives assisted faculty and the assigned matron (nurse preceptor) to evaluate student knowledge regarding their ability to connect the patient's condition with available resources, which is consistent with case management (Todhunter, 2016). The two methods discussed provide faculty with a choice to assess student learning.
The amount of primary care content in nursing programs is limited. Several reasons exist for the limited content, with perhaps the most significant being faculty concerns surrounding skill acquisition, the need to focus on the acute care setting, and NCLEX pass rates (Wojnar & Whelan, 2016). Additional reasons for the scarcity of primary care content are lack of student desire for the content, limited primary care clinical sites, and the low number of RNs in the primary care setting (Wojnar & Whelan, 2016). The primary care setting provides opportunities for the RN to be a RNCM by incorporating the following independent nursing actions into the nursing process: client and family assessment, education, advocacy, coordination, and care evaluation.
Practicing case management is more than making a home visit, having an alternative community clinical site, or providing client education. A competent RNCM addresses coordination, collaboration, and fragmented care for optimal health outcomes for the care recipient and their family (Gallagher & Truglio-Londrigan, 2004; Robinson, 2010; Tholcken et al., 2004). As case management principles, along with care coordination philosophies, are being included in prelicensure curricula, it is important to know how to maximize student learning. Philosophically, care coordination is grounded in case management concepts with both emphasizing accessible, comprehensive, continuous, compassionate, culturally competent and family centered care (Robinson, 2010). The comprehensive nature of care coordination involves a process, which places the patient and family as central members of the multidisciplinary team to assist patients, families, or populations having their health needs met (Robinson, 2010). A multidisciplinary team approach places the RN as an equal with other health care providers. With collaboration, it is paramount that prelicensure RN students receive education that prepares them to practice to the full scope of the RN license. With emphasis on interprofessional collaboration, the holistic practice of the RN makes the nurse the ideal person to address the coordination of care and to assist the client and family reach and maintain health outcomes (Josiah Macy Jr. Foundation, 2016; Salmond & Echevarria, 2017).
Interviewing students could yield more in-depth data on the factors that emerged from the students' evaluations of the clinical experience. Because interviews with individual students or RNCM may be costly in terms of time, energy, and funds, a focus group was considered to be a more economical alternative (Nagle & Williams, 2013). In addition, a focus group is easily integrated into a study design. The investigators convened two focus group sessions and invited all students (N = 23) and RNCM preceptors (N = 8; hereafter referred to as preceptors) to attend. Between the two sessions, five students and four preceptors participated. The low attendance may be attributed to time conflicts and the preceptors' inability to leave the clinical site. Although virtual Web-based technology was present for the focus groups, it was not used.
The purpose of the focus group was to examine concepts or themes affecting students and preceptors that were not captured or sufficiently verified by the project's evaluation tool, which was developed by the primary investigator. The tool focused on case management principles guided by the competencies from the Case Management Society of America's (2016) Standards of Practice and the application of the nursing process by the preceptors in the clinics. The evaluation tool was reviewed by the project team that was composed of faculty, primary care site personnel, and a RNCM consultant. Both faculty and students completed the evaluation tool at the end of the clinical experience. Preceptors evaluated students, and students evaluated the quality of the clinical facility and preceptor, as well as their ability to access experiences that allowed them to accomplish the learning objectives for the clinical experience. The primary investigator and project team identified two prevailing questions that were not addressed by the evaluation tool: (a) What are students' learning needs regarding the case management experience? and (b) What further education do preceptors need to achieve case management competencies and progress toward national case management certification? These two questions were used to prompt the focus group discussion.
The overall focus group procedure (two meetings of the preceptors and BSN students during a 3-month period) was guided by Nagle's and Williams's (2013) qualitative process that includes the following five stages: (a) study purpose, (b) methodology, (c) facilitation, (d) analysis, and (e) reporting. Concept mapping—a strategy commonly employed in nursing education and research (Daley, Morgan, & Berman, 2016)—was used to inform the reduction of the focus group data. Concept mapping and the iterative approach used in qualitative inquiry are similar in their ability to identify the central principles of a set of data.
After each session, the primary investigator and project team immediately compiled a focus group summary using concept mapping principles. Summaries were written and categorized by the team and integrated into a report. Group output consisted of the notes made up of theoretical and personal observations. The investigators developed schematics and identified themes from each of the two groups in keeping with concept mapping processes (Daley et al., 2016).
The focus group results were compiled during the course of two meetings, and the identified issues were delineated and reviewed by the investigators. After careful audit and review of the notes taken by each investigator for the focus group discussions, the investigative team developed concept maps and identified several common and major themes. The responses to the two questions (what are students' learning needs regarding the case management experience and what further education do preceptors need to achieve case management competencies and progress toward national case management certification?) used to guide the students and preceptors were similar and resulted in the identification of three themes: (a) interest in and lack of familiarity with case management, (b) holistic care components, and (c) illness trajectory.
Interest in and Lack of Familiarity With Case Management
The first theme that was delineated was Interest in and Lack of Familiarity With the Case Management Process. Participants reported a lack of preparation in case management that made it difficult to identify what was needed for that process. The preceptors were asked to provide case management services as part of their clinical role. All the preceptors expressed concern about their lack of preparation in case management and having to learn as they went. They knew basic skills but wanted more training. The students wanted more information about the process as well. A subtheme that emerged for both the preceptors and students was surprise at the level of independence of the nursing role in primary care and case management comparted to the acute care environment. Nurses and students both expressed enthusiasm for the teaching component of the RNCM role in the clinic environment and noted that the amount of outreach necessitated additional training and education.
Holistic Care Components
The second theme that emerged was Holistic Care Components. Students and preceptors both expressed wanting to know more about how cultural influences and health literacy affected patient care. Both groups wanted to understand the quality, social, spiritual, and clinical determinants of care. It was also obvious to both groups that rural clients have distinctly different issues regarding health care, such as access to services.
The third theme that emerged was illness trajectory. Both students and preceptors expressed how knowing the trajectory of an illness could help with transitions and care coordination across a variety of settings. Illness transitions must be part of care plans proposed in primary care settings. In addition, illness among rural residents often follows a pattern that culminates in chronic illness because of poor lifestyle choices. Helping clients maximize health motivates the RNCMs to focus on and make the best use of community resources, especially in rural communities.
The major themes that emerged from discussions with the RNCM preceptors and students focused on knowledge that both groups thought they needed to enhance their ability to provide effective case management services. Because the RNCM role at the clinics was relatively new, nursing students' case management experiences were constantly evolving as the preceptors learned to become more comfortable in their role. Teaching the preceptors more about case management will help ensure that they not only acquire the required skills, but also are able to share it students during clinical experiences.
Both groups wanted to know the steps involved in the case management process, as well as how clinical skills and the psychosocial determinants of care affected illness trajectory. The RNCMs were becoming more familiar with the community resources available to help their clients, especially those who were homeless or without health insurance. The students were learning the same information through assigned readings. Students' interactions with the preceptors gave them real-life exposure to strategies for meeting patient needs. Both groups were amazed at the independence of the RNCM role and the resource coordination they needed to learn due to the lack of providers available to handle psychosocial and mental health issues. Role independence highlights the autonomy of the RN in the primary care setting and their ability practice to the full extent of their RN license (Josiah Macy Jr. Foundation, 2016).
The clinics have a diverse population that gave students the ability to learn and apply the principles of cultural diversity, health literacy and to see how people live within the limits of their social determinants of health. Three of the seven clinics are in rural communities. During the session, students and RN preceptors from the three rural clinics identified some concepts of rural nursing theory, including the importance of anonymity and how caring for neighbors and relatives can be challenging (Winters, 2013). The diverse clinic population included several groups: rural men, women, children, and adolescents; individuals experiencing homelessness; college students (some of whom were away from home for the first time, or from other countries); and immigrants (mostly Hispanic migrant farm workers).
The preceptors and the course faculty examined case management standards of practice and reviewed documents related to certification from the various case management organizations. The content identified by the faculty and preceptors establishes a minimum knowledge base for the RN preceptors. This knowledge base includes several case management concepts that also are foundational for providing population-based care to individuals in community practice settings: evidence-based practice, the value of policies and procedures, care processes, and care quality (Quad Council Public Health Nursing Organizations, 2011). All the preceptors involved in providing patient care expressed the importance of and desire to achieve case management certification.
After discussions, clinic leadership agreed to provide the preceptors with the educational materials they need to take the certification examination for ambulatory care case management. The content for the case management certificate program was developed and validated as part of the group sessions with students, RNCM, and project faculty, as well as the clinical administration. In addition to this more formalized content, the group also identified rural health care practice concerns as a thread that would be incorporated throughout the case management curriculum.
The curriculum components agreed on by students and preceptors were case management basics, including how to apply evidence-based practice to this discipline. Specific content deemed important by both groups included examining how to measure outcomes—such as clinical, financial, and patient satisfaction—as part of a quality management process. The curriculum will include content that will be integrated into class assignments for the student and a case management class that RNCMs can take in person or online. Upon completion, the student will be awarded a certificate of completion and RNCMs will be encouraged to pursue certification. Given the type of care coordination and case management services they provide, an ambulatory care certification was thought to be the most appropriate certification for RNCMs. In addition, given that the coordination of care can span acute care, chronic care, health promotion, and disease prevention, as well as rehabilitation and long-term care, the staff determined that care coordinator is a more appropriate title than that of RNCM.
The case management clinical experience gave students access to experiences they would not have had in a traditional community health clinical experience. Having a clinical experience in a primary care setting expands their skill set to include care coordination. This clinical experience also allowed the students to see the potential for RNs to practice to the full scope of their license. Nursing school faculty should consider adding similar case management clinical experiences at primary care sites to their programs to expand students' knowledge of both these areas of practice.
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