COMMUNITY-DRIVEN NURSING: TRANSFORMING Nursing Curricula and Instruction
Nehls, Nadine, Vandermause, Roxanne, Nursing Education Perspectives
The nursing literature is replete with references to the changing health care environment. In response to recommendations from the PEW Health Professtons Commission (1,2), accrediting and regulating bodies have mandated new directions for nursing education (3,4). One clear direction being taken is toward community-based nursing education.
Background Over time, notions of what constitutes education in community care have changed. Historically, public health was synonymous with nursing in the community. Public health and, later, community health nursing were distinguished by attention to aggregates, prevention, promotion, and protection (5-8). Given these foci, it was argued that community health nursing was not interchangeable with the broader definitions of community-focused and community-based nursing.
The thrust of community-focused nursing education was to bring the knowledge and expertise of students and faculty to the community. It did not extend to changes in ideology. By contrast, community-based care was conceptualized as not only providing care in the community, but also altering the power structure in the provider-receiver dyad. A new term, community-driven, was introduced to identify more clearly the ideological commitment to health care driven by the needs of the community.
Community-driven education (9) shifts the relative focus from learning in the community to learning with the community. Most recently, service-learning has become part of the discourse as disciplines in higher education reclaim the practice of community service as essential to higher learning (10-13). Some nurse scholars (14-21) have embraced the term service-learning; others (22) have argued that clinical education in nursing is, by nature, service-learning.
ABSTRACT The aim of this study was to evaluate an innovative approach to teaching and learning community-based nursing. A hermeneutic research procedure was used to analyze data from individual interviews with undergraduate nursing students, faculty, and community preceptors. Two themes, or common meanings, of participation were identified: I) Forming new partnerships: Experiencing community-driven nursing, and 2) Creating new visions:Thinking about community-driven nursing. By describing and interpreting these themes, the authors show how nursing curricula and instruction should be transformed regardless of clinical setting.
Key Words Community-Based Nursing Education - Community-Driven Nursing - Curriculum Revision - Hermeneutic Research
Notwithstanding disagreement over terminology, there exists a common and sustained interest in providing care to persons in varying locations, as well as a growing mindfulness to form partnerships with those served. Around the globe, innovative nursing education programs are being developed to reflect new directions in health care. For example, nurse educators in South Africa used a reflective process to design and implement a curriculum concurrent with the country's initiative to embrace democracy (23). Likewise, at the University of Haifa and the Technion in Israel, a paradigm shift occurred through a rigorous analysis of traditional assumptions and processes in nursing education (24).
In the United States, efforts to improve community-based practice and education are numerous. Students in Ohio immersed themselves in the cultures of migrant farm workers, families needing respite care, and medically uninsured African Americans (25). Collaboration is key in an education-service partnership in northern Wisconsin, where university faculty and neighboring clinical staff share planning, responsibility, and decision making in a participatory teaching-learning endeavor (26). In a public-private partnership in Massachusetts, a model of community-based primary care education for nursing and medical students is purported to have "radically transformed health professions education..." (27, p. 38).
Despite documented innovations in community-based nursing education, numerous challenges remain. First, there continues to be confusion about what constitutes community-based nursing education - presently, the term is vague. The assumptions and goals of community-based education, therefore, must be carefully described and examined. Second, undergraduate nursing students continue to favor inpatient, not community-based, settings, challenging educators with helping students see the need for and rewards of community-based nursing. Third, there is a growing awareness that a fundamental shift in power between providers and consumers of health care has emerged. Thus, nurse educators are confronted with a new challenge of identifying teaching and learning strategies that prepare students for the shift toward not only community-based but also consumer-oriented care.
With these challenges in mind, a pilot project funded by the Helene Fuld Health Trust (HSBC Bank USA, Trustee) was initiated at a large American university. The pilot project was based on the assumption that nursing education must reclaim service as central to all clinical learning experiences. In other words, undergraduate nursing students should be schooled in understanding the needs and desires of consumers, regardless of where care occurs. To convey this philosophy, the term community-driven, rather than community-based, was chosen to describe and guide this demonstration project.
The new curriculum was designed to be substantively different from the existing curriculum in the following ways:
* Each student was paired with one of the pilot project faculty members who served as a mentor throughout the project.
* The student participants and mentors met regularly as a group.
* Students in the pilot project were able to choose a clinical setting as opposed to receiving an assignment available at the time of registration.
* Students in the pilot project spent more time in community-based settings than their classmates.
* Regardless of the clinical setting, the philosophy of community-driven nursing was taught.
* Project faculty and students developed partnerships with community stakeholders including clergy, nurses, housing experts, social service workers, and citizens (22).
Evaluation was an integral part of this project. Several methods of evaluation were used, including interviews with students, faculty, and community preceptors about their experiences. The interview findings are the focus of this article.
Method The authors used a hermeneutic research approach (28-31) to evaluate this demonstration project. Hermeneutics, grounded in the interpretive phenomenological thinking of Martin Heidegger, assumes that humans exist hermeneutically, that is, humans lind significance and meaning in their day-to-day existence (32). Given this philosophical perspective, the task of the researcher is to uncover common meanings, or themes, that have previously gone unrecognized.
Sample Given that the goal of this research was to understand the perspective of all stakeholders, the sample included students, university faculty, and community preceptors. Fourteen undergraduate nursing students, six university faculty, and 11 community preceptors consented to participate. The students were primarily white females with varying interests in community-based care. The faculty participants were experienced teachers with specialty areas in community health, psychiatric, or medical/surgical nursing. The community nurse and non-nurse preceptors had varying degrees of experience in teaching and practiced in a variety of community-based settings.
Data Collection Individual, private interviews were conducted to obtain data about the experience of participating in the project. Each participant was asked to respond to the following statement: "We are, interested in learning about what it has meant to you to participate in the Fuld Project. Can you tell me about an experience that stands out for you?" Subsequent conversation elicited further elaboration on what it meant to be a student, faculty, or community preceptor in the project.
A research associate facilitated the interviews at a designated time and place. The interviews, which lasted approximately 60 minutes, were audiotaped and transcribed verbatim. All identifying information was deleted from the transcriptions.
Data Analysis The researchers analyzed the transcribed interviews using the multistage data analysis described by Benner (29) and outlined in a frequently cited study (30). First, texts were read to obtain an overall understanding of each text. Next, each researcher prepared a written summary of the text, including identification of common meanings or possible themes, excerpts from the text to support themes, and interpretation of the themes. The researchers met, read their summaries aloud, and listened for discrepancies in themes. When discrepancies occurred, the researchers returned to the interview texts to seek clarification. Then, relevant literature was used to clarify, support, or extend the identified themes.
Although the hermeneutic research tradition assumes that no single correct interpretation of the texts exists, efforts are made to confirm, extend, or challenge the researcher's interpretations. The multiple stages of data analysis are attempts to keep the interpretive report corresponding to the texts. Ultimately, the validity of interpretive phenomenological studies is evaluated by each reader, who must ask himself or herself whether the interpretations are plausible based on the data provided.
Findings Findings revealed that the meaning of participation for teachers, students, and community preceptors was grounded in the experience of new partnerships and new visions of nursing. The identified themes - Forming New Partnerships: Experiencing Community-Driven Nursing and Creating New Visions: Thinking About Community-Driven Nursing - underscore the need to embrace new approaches to teaching and learning that transcend clinical settings.
Forming New Partnerships: Experiencing Community-Driven Nursing In all of the interviews, participants discussed the experience of forming new partnerships. The new partnerships were described as connecting with others through a common mission. The driving concept, community-driven nursing, provided a focal point around which to gather and an opportunity to experience community-driven nursing firsthand.
For example, when faculty members were asked about the Fuld Project, their initial reactions revealed a renewed feeling of importance in working with other teachers for the good of students. One teacher explained:
"For me, the Fuld Project really means having an opportunity to be connected with other teachers. It's probably the first time I've ever worked consistently with other teachers in this school...it's different, being involved in something new and exciting that we all sort of feel passionate about. I think it's the idea of having a common mission....It reminds me of what it was like working as clinician where everyone was working for some common good - better good - that was really outside of ourselves. That's harder to find in a setting like this where a lot of what one does is more closely monitored in terms of what one is producing. For me, there's a constant script in my head: 'How's this going to look? What is this going to do? Where are you going with this? Frankly, is it good for your case [promotion]?' When I meet with the other people involved in this project, it just doesn't matter. I don't think about that. So, not only does this project mean working with other people, but people are coming together. We're on a common course....we're offering the students something different, which really has to do with connecting with other people."
This faculty person, aware of the demands of both teaching and research, recognized the risk of losing what had brought her to nursing initially - a concern for others. Being reminded of "some common good - better good" renewed her belief in nursing and nursing education as service to others.
For students, the shift from a teacher-centered to student-centered curriculum provided opportunities to experience community-driven nursing first as students and then as nurses. Allowing students to choose where they wanted to learn communicated a concern not only for who the learner is, but also for who the learner may become (33). In other words, the practice of expanding ownership of the curricula communicated a belief in the student's future as a nurse. For example, this student was certain that she would be a nurse in the community:
"It [the pilot project] was more satisfying for me. It's definitely more of what I've wanted to learn. I'm not planning to do a lot of hospital-type nursing. I really appreciate the chance to cater my education to what I'm going to use it for."
Teacher-directed curricula are problematic when students' interests are disregarded, and the underlying philosophy of community-driven nursing is not experienced or taught. The student explained what is self-evident: If educators wish to cultivate or maintain an interest in community-based nursing, there must be ample and early opportunities to experience this form of practice.
Like faculty and students, community preceptors also experienced the significance of new partnerships. A preceptor identified the collaboration and support from faculty as key factors to effective teaching and learning of community-based nursing:
"Prior to this project, I said to people, 'I really don't think that undergraduate students are appropriate for this environment.' The Fuld Project worked because of the support, the collaboration ....I'm facilitating the learning here, and she [the university instructor] has more familiarity with what we expect of this group....I'm very excited about the collaboration between what students learn in terms of their content and then what I can facilitate here....I guess it's satisfying for me because I'm part of a learning community."
Although the concept of learning communities is not new to nursing education, the results of this study reveal an innovative approach to creating learning communities. By shifting attention away from teaching and toward learning (34), a common goal is established. Learning is reclaimed as central, achievable, and sustaining for all members of the learning community.
Creating New Visions: Thinking About Community-Driven Nursing In all of the interviews, there existed descriptions of thinking about nursing differently. Fueled by a responsibility to others, new visions were created that challenged conventional ways of thinking about teaching, learning, and practicing nursing.
For university faculty, the use of multiple, distant, and new clinical sites necessitated a reexamination of conventional teaching ideas. Most notable was the need to extend the preceptor model of clinical education beyond its use with senior-level students, making it applicable to beginning students. As this shift occurred, the roles and responsibilities of both nurse educators and nurses changed. University teachers experienced a sense of "unsettledness" as they began to turn over teaching tasks to community preceptors. An experienced university clinical instructor reflected on the practice of "letting go":
"I've gotten positive feedback from preceptors that the students have just taken responsibility for their own learning....There's still a part of me that says, 'Oh gosh,' because in the traditional sense, we were so used to being there and evaluating students. Although, when you've got eight students and they're off in different rooms, it's not [like] being there and actually being the one evaluating. Trusting colleagues in the field, really, the clinical experts, to be able to say, this student is doing very well....So it's just, letting go."
While difficult, this university instructor recognizes that in a community-driven curricula, the assumptions and practices of university teachers cannot be privileged. Community preceptors must be welcomed as partners in nursing education. In this new vision of teaching nursing, university faculty members are challenged to both expand their role through collaboration and limit their role through curtailment in performance evaluation.
For preceptors, to be welcomed as partners in nursing education created a vision of leaching as learning. As learning became the focus, paradoxically, the monitoring of goals and outcome objectives took less precedence. A preceptor described the emergence of the new vision of teaching as learning nursing thinking:
"I set up with the instructor that we would meet periodically through the semester...[to] make sure that we were organizing things in the way that would meet the goals and objectives of the clinical experience. But when I met with the instructor, it was clear to me that the way this project has been set up, and probably the influence of the primary instructor, that nursing can be taught in many different settings....that's the way the students are being taught. And that's why this undergraduate student is successful here versus other undergraduate students who didn't have the benefit of somebody helping them understand they're learning a process of thinking. They're using knowledge, they're gaining knowledge, but they're also learning a process of approaching problems and health concerns...."
By challenging the self-evident assumptions that nursing knowledge is site-specific and learned through monitoring goals and objectives, a different perspective on nursing education emerged. The preceptor credited the university instructor with helping the student view nursing as earlier findings (35) have determined - a way of thinking. This vision liberated the preceptors from the conventional practice of regularly scheduled meetings to monitor prescribed goals and objectives.
For students, participation in this project also meant experiencing new visions of nursing practice. By having opportunities to think about the patient-nurse relationship in a new context, conventional views of nursing practice were challenged. One student attributed her decision to remain in the profession to an opportunity to implement the principles of community-driven nursing:
"I don't think I would have stayed in nursing if my experience was always brief. I was repelled by that whole process. It was just the antipathy of what I wanted. And if that had been my only picture of nursing, I might have gotten out of it....There was such an objectification of the patient in the hospital. And no matter what people said or how hard they try, it still happens...the neat thing about seeing someone in the community is that you're building trust as the patient can allow it....I think nursing is nurturing and, well, establishing a trusting relationship that's reciprocal where you're not imposing or violating, directing, controlling....So, nursing is building that foundation, and then responding in a helpful, nurturing way to what the person might need to let them go on to something better. If that's a better death, a better management disease process, a better understanding of how to treat their children, a better understanding of how to relate to others, a better medication....You're trying to get them to something better. "
Reclaiming, or seeing for the first time, a vision of nursing as responding, bearing witness, and guiding affirmed this student's philosophy of nursing. Perhaps for the novice student, the essence of community-driven nursing is more easily grasped in communitybased settings. In the community, students are encouraged to develop reciprocal relationships with patients that are underscored by a holistic and consumer-oriented view of health care.
Conclusions It has been a challenge for nurse educators to reach consensus on what constitutes community-based nursing. In day-today practice, community-based nursing may or may not demonstrate a strong ideological commitment to working with, not simply in, the community. The results of this study suggest that the philosophical underpinnings of community-based nursing can be restored and expanded through a community-driven nursing curriculum.
This common mission focuses attention on how teachers, students, and patients collaboratively learn with one another regardless of setting. By recasting the roles and responsibilities of teachers, students, and community preceptors, visions emerge that are grounded in mutual goals and ways of thinking about nursing that are contextual and reflexive. By continually seeking new understandings of teacher-learner partnerships and nursing as a way of thinking, nursing curricula and instruction can be transformed regardless of clinical setting. Ultimately, the future of community-based nursing and nursing in general - may be better served.
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About the Authors Nadine Nehls, PhD, RN, is an associate professor and associate dean for academic programs, University of Wisconsin-Madison School of Nursing. Roxanne Vandermause, MS, RN, is a project assistant, University of Wisconsin-Madison School of Nursing. This research was supported by the Helene Fuld Health Trust-HSBC Bank USA. For more information, contact Dr. Nehls at firstname.lastname@example.org.…
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Publication information: Article title: COMMUNITY-DRIVEN NURSING: TRANSFORMING Nursing Curricula and Instruction. Contributors: Nehls, Nadine - Author, Vandermause, Roxanne - Author. Journal title: Nursing Education Perspectives. Volume: 25. Issue: 2 Publication date: March/April 2004. Page number: 81+. © 2009 National League for Nursing, Inc. Provided by ProQuest LLC. All Rights Reserved.