WHEN IT WORKS: Learning Community Health Nursing Concepts from Clinical Experience

Article excerpt


Clinical faculty often struggle to design competency demonstrations that promote quality learning experiences. A nursing program in Oregon combined mental health and community health nursing practica and required well-planned, integrated competency demonstrations. This requirement became the impetus for students to promote the health of clients and learn clinical concepts that are difficult to experience in a typical term. Faculty coached students to make a significant contribution that would last beyond their clinical practica. A case study in competency demonstration design is described, and implications for curriculum development are presented.

Key Words Clinical Education - Clinical Concepts - Health Promotion - Community as Client - Community Partnering

FACULTY ALWAYS HOPE THAT CLINICAL EXPERIENCES WILL PROVIDE STUDENTS WITH THE OPPORTUNITY TO GRASP THE CONCEPTS OF THEIR SPECIALTY AREAS AND SEE POSITIVE OUTCOMES FROM THEIR WORK. If a practice-based learning project can cross over into service learning - a curricular activity that provides the opportunity to engage with and give hack to the community or agency that offered the experience (1) - so much the better. * Two concepts of community health nursing - community as client, where "the nursing focus is on the collective...good of the population" (2, p. 345), and community partnering, "collective action for a common endeavor or goal" (3, p. 451) - are introduced to students in community health theory. However, during a nine-week term in a clinical setting, students rarely have sufficient time to experience these concepts. Further, although students often come into contact with individuals from at-risk populations throughout their education, they may not have the opportunity to assess or intervene on their behalf as an aggregate.

THIS ARTICLE reports on what happened when competency demonstrations were combined to integrate the concepts of community as client, community partnering, and populations-at-risk and students had the opportunity to make significant contributions to clients and to the community.

Community/Mental Health Practicum CURRICULUM The community health nursing courses in an upper-division nursing program at a major medical research campus are senior-level courses that represent an often challenging paradigm shift for students who previously engaged primarily with individual clients. With the first group of accelerated baccalaureate students admitted to the program, community health nursing was combined with mental health nursing to become an eight-credit clinical course, "Community Mental Health Nursing." The accelerated baccalaureate program was designed for students who came to nursing with baccalaureate degrees in other majors, having demonstrated student success in higher education. The curriculum spanned six terms.

This clinical course was offered as part of the final term, when students were enrolled concurrently in both the community and mental health nursing theory courses. Competency demonstrations for the combined clinical included a mental health assessment, a process recording, a comprehensive community assessment, a health promotion teaching project benefiting an at-risk population, and case management for one to three clients. Students were initially overwhelmed by these projects until they recognized that they could integrate one with the other, enhancing and intensifying their learning while increasing their potential to make relevant contributions to the community that they served.

SETTING The primary and secondary authors were the clinical faculty and the other co-authors were three of 10 students assigned to an inner-city outreach center in Portland, Oregon. According to the brochure, the center's primary mission is to build community while fostering the "sacredness and dignity of all individuals." Another of its stated purposes is to serve as a "site for service education about the issues of poverty, social justice, mental illness, and community building."

Located in a geographic area where such issues are prevalent, the agency knew of and occasionally worked with other outreach agencies. However, as is often the case, the busyness of the work as well as the competition for funding tended to separate agencies rather than help them partner constructively to address shared client issues.

This setting exposed students to the efficacy of a social volunteer agency that does not use a medical model yet has a direct impact on the health of individuals. Students met clients at a community hospitality center in the mornings and then visited individual clients in single room occupancy (SRO) hotels in the afternoons, providing some health care case management for these needy individuals. The students spent two and a half days per week during a nine-week summer term engaged in these activities, while also conducting a comprehensive assessment of a geographic section of the community.

THE PROBLEM Statewide funding for the Oregon Health Plan (OHP), an innovative model utilizing Medicaid dollars to ration health care to the uninsured in the state of Oregon (4), was drastically cut in the early spring, leaving many of the mentally ill SRO and homeless residents without access to their prescribed medications. By early summer, although most of the funding had been restored, students learned through their community assessment that many individuals were unaware of this fact. In addition, there was usually a delay of several months for clients to reestablish with the health plan; if their coverage had lapsed, the wait was at least six months. Many clients functioned minimally without their prescribed medications.

Defining Their Focus To help clients achieve an optimal level of health, the students used their mental health assessment and case management skills in whatever ways they could, for example, linking clients with existing area resources to get assistance. However, hours and sometimes days were required to help individuals reestablish with the OHP. A further problem was the need to fill the gap between the application stage and receiving funding for medications. Sometimes the outreach agency staff covered the cost of prescriptions from their limited funds, or, more commonly, they would pay the health plan premiums for those clients most in need.

Through the process of completing their assessments, the three student co-authors became aware of uninsured mentally ill individuals who were unable to obtain their medications. Although agency representatives were aware of pharmaceutical assistance programs that could help such clients with their short-term needs, they considered the application process too complex and cumbersome to pursue. The demands on their time and financial resources as well as unfamiliarity with the computerized process seemed to be the major barriers.

As the three students engaged with clients and agencies, the focus for their health promotion teaching project became clear. They needed to unravel the application process for pharmaceutical assistance and put it in a user-friendly format on behalf of clients who did not qualify for OHP or were waiting for reinstatement of their benefits. The students determined that several agencies would want to participate in these assistance programs, and, to be most effective, they could offer a presentation to key people from these agencies. Although these students could have centered their efforts on any teaching need that might affect the health of the larger community, they blended the outcomes of their mental health and community assessments to define a specific focus that addressed the needs of many mentally ill residents in the community.

Taking Action Through various sources - agencies outside the area that were successfully using the pharmaceutical assistance process, representatives from pharmaceutical companies, and primary care providers within the community - the students learned that the procedure was less complicated than the agencies had perceived. However, certain contingencies created challenges. For example, each participating pharmaceutical company required dissimilar qualifying patient information, and referrals were required from primary care providers, which many clients did not have.

The students created a PowerPoint presentation and invited key representatives from community agencies to meet with them at a mutually agreed upon time. The clinical practice site offered its conference room for the meeting, and the students provided refreshments.

Representatives from three large agencies in the area attended the presentation. Throughout the meeting, the students encouraged the representatives to ask questions and share their concerns. They knowledgeably and patiently answered each question.

At the conclusion of the presentation, the students offered one-on-one computer assistance, helping representatives retrieve the PowerPoint presentation and access forms and procedures from the pharmaceutical companies. Each participant received a copy of the PowerPoint presentation on compact disk, along with a handbook containing applications and an outline of the application process for future reference and training others.

Several positive outcomes resulted from this teaching experience. The agency representatives, the students, and ultimately the clients all benefited. Some outcomes were anticipated, but others were quite unexpected. The key agency representatives spoke of their confidence in what they had learned and how they felt empowered to move forward and seek the assistance of pharmaceutical companies on behalf of their clients. Each took advantage of the students' offer to sit at the computer and access the material. This served to reinforce what they had learned and demystify the process. An unexpected outcome was that representatives of different agencies began to confer about working together to solve this problem and garner the support of area primary care physicians for this and other issues affecting their clients.

How Students Benefited Immediately following the presentation, the three students spoke about their satisfaction at having accurately assessed an authentic need within the community and finding a meaningful intervention that could have a positive impact on impoverished, mentally ill clients. As time has passed, the students, now professional nurses, have reflected on their learning. The following paragraphs were written from their point of view.

COMMUNITY AS CLIENT In early interactions with clients outside a hospital setting, the students continued to view encounters as discrete nurse-patient events. However, through this project, they discovered and gained a deep appreciation for a well-done community assessment, followed by carefully tailored nursing interventions that encompassed the community as client. Having grown to care deeply for both individual community members and the community-at-large, they were gratified to know that their work had the potential to make a positive difference in the lives of specific individuals as well as the community as a whole. Their work also clarified how crucial issues, policy concerns, and budgetary gaps in the area health care system affect the uninsured and reinforced the notion that individual actions can have a positive impact on greater societal issues.

COMMUNITY PARTNERING Fostering change on a community level while working on an assignment that others often see as limited was exciting. This experience brought students a sense of accomplishment and purpose by taking client teaching to another level, i.e., sharing information, tools, and resources with community organizations rather than individuals, thereby increasing the potential for greater influence within the community. Working with multiple agencies not only allowed information to be disseminated but encouraged collaboration and communication among agencies. It was an excellent exercise for the students in the importance of researching and evaluating existing resources as well as bringing a fresh perspective to agencies that work with the same clients/population but not necessarily collaboratively.

POPULATIONS AT RISK One student who now practices in an intensive care unit, caring for many patients who are critically ill as the result of years of poor health and lifestyle choices, stated: "I think back on this project and the impact of personal choices and the economic policies that determine individuals' options for health care, influencing each ICU patient, and how some outcomes might have been prevented or at least moderated."

SERVICE LEARNING The students applied their skills and energy to serve a real need - to fill a gap that affects the entire community: "The response was amazing. The agencies were thrilled and excited at what we showed them. In retrospect, what we had done did not seem difficult to us. We felt good because we had come to care about the clients and the agencies and wanted to leave something useful with them."

Faculty Perceptions Both faculty members noted that the students recognized their role in providing a valuable service to agencies within the community. In addition, faculty found through their enthusiastic journaling that students recognized how community partnering takes place, its value in resource enhancement for atrisk populations, and the impact on positive client outcomes that benefit the entire community.

The faculty also noted that the students' grasp of the comprehensive nature of community and mental health nursing was augmented by their careful and accurate assessment of clients' needs. Through coaching and encouraging students to think beyond the scope of the assignment, the instructors saw students make a tangible and significant contribution to the community, which is unusual in a nine-week term. In addition, the instructors perceived that when these now-nurses have the opportunity in their careers to improve their clients' care by partnering with the community, they will more readily and with confidence undertake the task. This expectation of success would not have happened without this type of practice-based learning in this particular setting.

Implications for Curriculum Design Beyond the community health concepts that the students learned and put into practice, some significant curricular planning implications emerged from this experience. These implications can be viewed in the context of a changing student population, competition for community-based sites for clinical practica, and a changing health care system.

STUDENT POPULATION With an upsurge in admissions to nursing programs throughout the United States, the nursing student population is becoming increasingly diverse. Students tend to be older, and many bring to their nursing education considerable life experience as well as professional experiences and skills; they also tend to bring very high expectations for themselves and their nursing programs (5,6). Competency demonstrations that force interaction with clinical concepts, such as community as client and community partnering, allow these "new" students to use their past experiences and forge innovative and relevant nursing roles (7,8). The three former student authors of this article, for example, brought considerable technological and collaborative group skills to this project with positive results.

At the same time, this diversity of student experience can be somewhat threatening to faculty, who tend to see themselves as knowledge-givers. Faculty may need help in shifting their focus to the facilitation of more learner-centered curricula (9,10).

CLINICAL PRACTICA With increasing competition among nursing programs for clinical sites as well as a shift within the health care system to more community-based nursing, nursing education needs to be creative in developing clinical experiences and venues. In this example, the site was already committed to educating health care students about the issues of poverty, social justice, mental illness, and community building. In other community-based sites, however, clinical faculty may need to take an active role in identifying learning goals that will help students expand their focus beyond the acute care role (11).

Parenthetically, though the curriculum for these accelerated baccalaureate students required it, faculty found that, given the current health care system and the treatment of the mentally ill, the integration of mental health nursing and community health nursing was not only workable but also pragmatic. It behooves nursing programs to strongly consider the realities of the health care system in designing curricula to prepare today's nursing workforce (12).

THE CHANGING HEALTH CARE SYSTEM Currently, efforts are made to limit health care costs by discharging acutely ill patients from the hospital as quickly as possible. This means that more and more nursing takes place in community-based settings (13,14). Students must learn to assess clients and conduct interventions in a variety of settings. As the baby boomer generation ages and technology lengthens lifespans - increasing the number of individuals who live with chronic illness - this trend is likely to continue.

The need for acute care nurses will never disappear. However, by providing quality community-based practica experiences earlier and integrating community concepts throughout the curriculum (15), students can learn collaborative problem-solving and community partnering skills that will benefit the recipients of the health care system and the communities in which they live (11,12,16,17).

Conclusion Nurse faculty always hope that students learn difficult clinical concepts firsthand. A primary key to quality clinical learning in this example included well-planned competency demonstrations that blended both community and mental health assessments. With faculty coaching that facilitated their efforts, students experienced these clinical concepts while contributing a valuable service to an at-risk client population. They helped preserve already scarce resources and offered solid contributions to community agencies.

Among the ultimate beneficiaries of this clinical project were the clients within the community and, of course, the students. The students concluded that the experience empowered them as nurses to actively promote partnerships on behalf of their future clients.


Faculty found that given the current health care system and the treatment of the mentally ill, the integration of mental health nursing and community health nursing was not only workable but also pragmatic. It behooves nursing programs to strongly consider the realities of the health care system in designing curricula to prepare today's nursing workforce.



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[Author Affiliation]

About the Authors Kathie Lasater, EdD, RN, is an assistant professor at the Oregon Health & Science University School of Nursing, Portland, where Linda Luce, MS, RN, is an instructor. Miriam Volpin, BS, RN, and Allison Terwilliger, MPH, RN, have been Hartford Scholars and are doctoral students, Oregon Health & Science University School of Nursing. Jackson Wild, BS, RN, is a staff nurse, Oregon Health & Science University Hospital. Contact Dr. Lasater at lasaterk@ohsu.edu for more information.


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