Throughout the past 5 years, a nursing department has sponsored a community nursing wellness clinic in a small New England city in the United States. This setting provides excellent opportunities for students to work with diverse, underserved, and vulnerable populations. Clinical conferences, reflective journals, and student feedback have led faculty to view this experience as a significant means of curriculum synthesis, yet this had never been assessed formally. This article provides an overview of the wellness clinic and shares results of a qualitative study that assessed the influence of this clinical experience.
Among the challenges faced by nurse educators is the lack of quality clinical sites, recognized as a leading barrier to student learning (Billings & Halstead, 2016; McNelis et al., 2014; National Council of State Boards of Nursing, 2015; Taylor, Angel, Nyanga, & Dickson, 2017). Because nursing care in the community is surging, programs have attempted to keep pace by searching out creative opportunities for students to care for individuals outside of the hospital. Aselton (2011) described a mutually beneficial relationship between a nursing school and a local housing authority. Care was delivered by nursing students in a public housing site in the form of student run clinics, focusing on health education and blood pressure screenings, concluding that these sites can be “an untapped resource for student placements in nursing programs,” and that this kind of “experiential learning has been effective in orientation of nursing students to community-based care” (Aselton, 2011, p. 165). Thompson and Bucher (2013) described how nurse wellness centers located in public housing sites can serve to meet the Association of Community Health Nurse Educator competencies, reporting that the journal reflections of students who participated describe “experiences changed the lens by which they view clients and families” (p. 160).
As competition for community clinical sites increases, universities have also initiated nurse-run wellness clinics as a unique alternative to the more traditional community health sites, such as schools and home care agencies. These sites can potentially meet a variety of important baccalaureate education outcomes. In their study of nurse run wellness clinics in Pennsylvania, Miller et al. (2017) reported anecdotal evidence that nurse wellness clinics meet critical wellness competencies, suggesting that such experiences prepare Bachelor of Science in Nursing (BSN) students for population health and clinical prevention.
The lack of community health sites is not unique to the United States. Faced with increasing numbers of students to place in clinical settings, the University of New England, Australia, established a student-run clinic to serve indigenous Australian families. Researchers found that the clinic was a cost-effective means of delivering care to needy individuals and that the experience was a mutually beneficial one that fostered collaborative learning and respect for human dignity (Stuhlmiller & Tolchard, 2015). Also echoing the challenge of community health placement issues, Babenko-Mould, Ferguson, and Atthill (2016) assessed how a neighborhood wellness clinic in Canada influenced learning on third-year BSN students. Their findings suggest that neighborhood wellness clinics provide a good opportunity for the development of autonomy and leadership skills, as well as enhancing understanding of the social determinants of health. The authors concluded that this unique experience can be a valuable means of student learning.
The autonomy necessary for the patient encounters in the wellness clinic setting is best suited for upper level students, who must synthesize knowledge from a multitude of sources and “think on their feet” to holistically address the health needs of the walk-in patients. Although the findings noted above support the idea that these experiences offer an ideal opportunity for upper level nursing students to practice knowledge synthesis in the community setting, there remains a need to further assess these sites in terms of student learning.
Overview of the Wellness Clinic
The nursing wellness clinic opened in the spring of 2012 in the heart of a city in a space that was made available for use by the university in an effort to increase community presence. The clinic is open 1 day per week during the academic year. It is staffed by nursing faculty at all times, along with advanced practice RN faculty oversight. All individuals are welcome regardless of income level or insurance status. Clients enter the clinic and are greeted and asked to sign in. They complete a waiver explaining the nature of the clinic, in that services provided are purely screening related and not diagnostic. The waiver highlights the fact that there are no records kept, no prescriptions are provided, and referrals are made according to need. Individuals are advised that the focus of the clinic is health promotion and wellness, not curative illness diagnosis and treatment. Clinic services include blood pressure screening, height and weight, nutrition counseling, vision and hearing screening, foot soaks, glucose screening, and stroke screening, among others. The clients are seen by a team of two students. The assessment data collected by the students are reviewed by faculty and a plan is devised. A significant amount of education is provided by the students as each screening is conducted, and individuals are given written material to reinforce learning.
A descriptive qualitative method was used to formally assess the impact of this clinical experience, using focus groups as a means of data generation. Researchers were particularly interested in learning whether an independent nursing wellness clinic provided an opportunity for senior-level students to synthesize knowledge from their BSN curriculum and then use this knowledge to care for members of the community. Senior nursing students in a traditional prelicensure program who were assigned to the wellness center were invited to participate. Eleven students participated: nine women and two men, ranging in age from 21 to 40 years. Approval to conduct the study was granted by the university's institutional review board. An e-mail was sent to all qualified students inviting them to the focus group at the end of the semester. Interested students signed and submitted a consent form.
The students were aware that they were being digitally recorded during the semistructured open forum interview. To minimize influence or coercion, the moderators had no formal academic relationship with the students. Four open-ended questions were asked:
- “To what extent did your nursing coursework prepare you to deliver primary and secondary prevention in this community-based setting?”
- “In what ways, if any, did your nursing courses and your liberal arts education impact your confidence and prepare you to holistically care for clients with diverse backgrounds and age ranges in this setting?”
- “Were there any significant patient encounters you would like to share?”
- “What gaps in knowledge or areas of improvement, if any, have you identified as a result of experience in the clinic?” Recorded responses were then transcribed.
To analyze the data, researchers individually listened to the recordings, then read the transcripts line by line to identify significant statements. The researchers then collectively met to discuss and compare findings. Content analysis of the narrative data was conducted through coding, followed by categorization and analyzation in order to identify emerging themes.
Participants shared specific situations and examples of patient encounters which lent themselves to the following three themes: Competence and Confidence Issues, Frustrations and Rewards of Community Care, and Using “What We Know.”
Competence and Confidence Issues
Although clinical experiences seek to increase competence, they are often intimidating. For some, personal abilities were questioned. For example, several students expressed concerns about abilities and skills that had become rusty:
We have not done manual blood pressures in a while. So you're nervous as you're doing it again, you're [saying], “Okay, and I doing this, am I hearing this right?” I know in come hospitals you still do manuals, but in the ones I've been in we haven't so I haven't done it in two and a half years.
One student did not feel fully prepared when asked a question about a specific diet, and another felt uneasy when asked how to adapt exercise to a disability. Several students expressed confidence about normal laboratory value recall. Despite these issues, delivering care in this setting did serve to increase confidence for several, as they spoke of encounters where they felt very competent and, as a result, felt a boost in confidence:
At first I was really nervous…like I wasn't going to give them the right information or enough information…. I felt like I got into a routine and I felt a lot more confident and able to provide them the education that they needed.
Participants spoke of how they met the challenge of speaking in simple terms and also verbalized recognition of their leap in growth over the years:
This is the perfect semester for it…. Like (providing) quick education to pull out of our heads without resources, without consulting with everybody just to see what we've known since sophomore year.
[It] made us actually realize that we actually know a lot more than we think we do.
Frustrations and Rewards of Community Care
Comments reflected application of key community health nursing concepts that set this apart from traditional hospital-based care. Many voiced frustrations about the challenges of caring in this environment, where lack of control is often perceived:
Not being able to help somebody again, like [we can] in the hospital. They kind of have to listen and do what you say because they're in the hospital, but in the community you can't have that guarantee and think they're going to get it done [accept treatment] and you can't help them the way you want to. I struggle with that a lot.
Students realized that medication compliance and poor chronic disease follow up are common issues in the community. Despite the frustrations, comments also reflected empathy and an enhanced awareness of the struggles faced by others, such as access to healthy food, safe housing, and clean air:
They didn't have clean clothes on, they had holes in their clothes, mismatched clothes, and their hair was not groomed and…knowing what we know from nursing school really helped me to understand where to focus my attention on…. What healthy choices can they make instead of just saying, “Buy fruits and vegetables.” Do they even have access to a store that has [them]?
He also talked about that he lived in a housing development, talked about air quality and some days having ash in the air. It was horrible to know that he wasn't able to do anything for himself.
Students also gleaned appreciation for the good that can come through establishing relationships, despite the obstacles of delivering care in this setting:
A guy come in who had hypertension [and] diabetes, and we were trying to explain the importance of taking his medication and checking his blood pressure and blood sugars. He actually came back for more clarification on what we told him to do.
Using “What We Know”
The final theme related to curriculum synthesis and integration. Many students spoke of how they were able to use knowledge from previous courses to assess patients and properly educate. Knowledge application from the medical–surgical courses was discussed, as well as use of concepts from other nursing courses:
We had growth and development both in nursing and our liberal arts because we had developmental psychology…. You're going to educate a child way differently than you would ever educate an adult…so it's incorporating that and knowing that I know that from my nursing courses and then also, from the beginning I'm thinking about nursing theory where we know the five dimensions of health…. I feel like that's what really makes us different as nurses.
Students appeared to appreciate their knowledge of cultural competence as they interacted with a diverse population. Comments also reflected use of liberal arts courses. For example, one student discussed an encounter with a patient who was in a relationship with a person who served in the Vietnam war, admitting her history course assisted in her understanding of how this affected the relationship. Others noted that public speaking courses enhanced their ability to interact with and educate patients. Finally, students seemed to agree that this clinical was best placed in the last semester of the program and that scaffolding of content prepared them for the experience:
I think we were well prepared. It was a great ending experience—especially on an individual basis to understand that we really know things, you know?
This qualitative study supports the benefits discussed in the literature regarding the potential that nurse-run wellness clinics have as an alternative to more traditional community health experiences. Immersion in the community can serve to link important theoretical concepts to practice. Community health concepts from the classroom portion of the course, such as compliance and control issues, were made real through the one-to-one experiences with community members. The stark contrast of care delivery in the community, as compared with care delivered in the acute care setting, can easily be realized when students spend clinical time in sites such as these. Consistent with other findings in the literature, it appeared that this experience assisted with students' ability to become aware of and empathetic to the struggles faced by others. In addition, autonomy and leadership skills seem to be enhanced by these experiences, aligning well with previous studies. Although faculty supervision is critical as students are required to review the plan of care with faculty, hovering may serve to impede a sense of autonomy. Unobtrusive faculty presence appeared to be appreciated as a source of support and validation.
Because settings such as these are void of advanced assessment and diagnostic technology, students must fall back to the basic health assessment techniques, which is always worthwhile. With electronic blood pressure assessment becoming the norm, concern has been raised about “skill decay,” in that nurses' ability to accurately assess blood pressure levels manually may be in jeopardy (Unsworth, Tucker, & Hindmarsh, 2015). Students insightfully indicated that early-semester refresher sessions may be a way to better prepare them for the experience. As a result, a preparation simulation day will be held to review skills prior to starting in the clinic.
Finally, students were able to reflect on how prior content prepared them for this experience. Important concepts such as evidence-based health education, health literacy, levels of prevention, and cultural competence were mentioned in the focus group, indicating that this opportunity may serve as a means of applying these, with awareness, when caring for others. References to holistic health and the importance of patient-centered care further speak to the impact of this experience on student learning. The last semester seems to be an appropriate placement in the curriculum and appears to be the most effective way of setting students up for success.
Limitations to this study include a single clinic location, a single academic setting, and the convenience sample with a limited number of students. Interview responses may have been affected by the group discussion method. There is the potential for students to remain quiet when they are not in agreement with each other or the potential for students to be too embarrassed to discuss their own inadequacies in front of peers. Although this is the nature of any focus group, the singular incidence of this focus group could add to the effect of the groupthink mentality of the students.
Nurse wellness clinics appear to be a viable alternative to traditional community health clinical sites and can provide a valuable service to underserved populations. Assessment data analysis uncovered unexpected findings that can be used to enhance the student experience. The concern regarding confidence issues of students can be addressed by skill review sessions at the start of the semester. Student frustrations regarding the challenges of providing care outside of the hospital environment can be used to enrich classroom discussion, especially regarding any health disparities they may observe in this setting. Despite these issues, overall data analysis supports use of nurse-run wellness clinics to foster senior nursing students' abilities to employ nursing knowledge in an independent manner, as well as synthesize their baccalaureate nursing education to address myriad patient needs.
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