Public health nursing promotes and protects the health of individuals, families, and communities where they live, work, and play (Swider, Levin, & Kulbok, 2015). Historically, nursing education programs have collaborated with community/public health agencies in facilitating achievement of these goals. These experiences allowed students to acquire knowledge and competencies related to public health nursing identified by the Association of Community Health Nursing Educators (ACHNE, 2010).
In recent years, decreased funding for public health services and a scarcity of community/public health sites have made it challenging to identify community-based learning opportunities for students. These challenges create opportunities for the development of innovative clinical partnerships in nontraditional settings, including community organizations that do not deliver health care.
Nursing education and practice are emphasizing competency-based practice in all areas of nursing (Levin, Swider, Breakwell, Cowell, & Reising, 2013). Yet there is little research that examines the process of acquiring competence in nontraditional community/public health clinical settings. This article presents the findings of a pilot study that examined student perceptions of the acquisition of generalist core knowledge and basic community/public health competencies through a partnership with a not-for-profit community organization and an insurance broker. The Centers for Disease Control and Prevention (CDC, 2016) Workplace Health Model informed this partnership and the research. This model emphasizes an ecological approach, focusing on reduction of health risks and multilevel interventions.
BACKGROUND
The program was initiated when representatives from a nonprofit organization and an insurance broker approached the university to explore student involvement in health promotion activities. The nonprofit organization provides training and employment for individuals with disabilities and/or life challenges. Employees are engaged in retail sales of donated goods or provide cleaning services to government sites. The insurance broker provides guidance about improving employee health outcomes. Nurse faculty recognized that a partnership could facilitate student acquisition of core knowledge and competencies in community/public health nursing, raise awareness of the social determinants of health, and increase community assessment skills.
Goals for the clinical experience included assisting employees in navigating the health care system and providing high quality, evidence-based health education. Using the Workplace Health Model (CDC, 2016), which describes four steps in building a workplace health promotion program, the students assessed, developed, implemented, and evaluated a workplace health promotion program aimed at the identification and reduction of health risks. Student-designed interventions at 13 retail and 2 custodial sites promoted the use of preventative health services, finding a medical home, and health education to manage chronic disease. Employees were informed about the program and invited to consult with students individually during breaks and health promotion classes.
METHOD
Approval was received from the university institutional review board to administer a survey to a convenience sample of senior-level prelicensure BSN students enrolled in a 15-week clinical component of a community/public health nursing course; 52 students assigned to the site over a six-semester period were invited to participate. Students were informed that participation was voluntary and would not affect their grades. The investigators used 32 competencies identified in the ACHNE (2010)Essentials of Baccalaureate Nursing Education for Entry Level Community/Public Health Nursing Practice as items in the electronic survey; competencies were peer-reviewed and developed by expert nurses.
Using a 5-point Likert scale (1 = not at all influential, 5 = extremely influential), participants were instructed to rate how influential this clinical experience was in facilitating knowledge and skill acquisition. Each core knowledge area was associated with several related basic competencies. Two open-ended questions focused on perceptions of the impact of clinical interventions on workplace health and implications for their future professional practice. Descriptive statistics were used to determine means and rank the 10 essential core knowledge areas and associated competencies. Responses to the open-ended questions were examined for common themes.
RESULTS
The final sample consisted of 25 students, a 48 percent response rate. Only completed surveys were included in the sample. Following are the percentages of students reporting the nontraditional environment as influential to extremely influential for the core knowledge areas: human diversity (96 percent), health promotion/risk reduction (91), communication (89), coordinator/manager (87), epidemiology (83), information/health care technology (80), ethics/social justice (79), community/population assessment (79), illness/disease management (76), and environmental health (71).
Means were calculated for the associated basic competencies. The highest means were clustered under the core knowledge area of human diversity, including respect for persons with differing values (4.38) and recognizing the impact of discrimination on health (4.08). Educating individuals, families, and communities about health issues (4.00) and client empowerment (3.84) were associated with health promotion and risk reduction. Communicating with clients with different levels of health literacy (3.80), assessing health needs and assets of communities/populations (3.70), and assessing the health risks of individuals, families, and communities (3.56) were perceived as influential. The lowest mean scores were using the CDC Workplace Model as a basis for assessment (2.44) and recognizing that environmental justice ensures protection from environmental hazards (2.92).
Responses to the open-ended questions centered on client empowerment and building healthy work environments. Describing the impact of the program, a student observed, "The employees seemed to be more motivated to take control of their health." Students reported gaining a better understanding of the need for public health services for the underserved and an improved ability to think of nursing practice beyond the hospital setting.
DISCUSSION
This study's findings support the work of others who described the development, implementation, and evaluation of nontraditional sites (Simpson, 2012; Van Doren & Vander Werf, 2012). Randolph, Evans, and Bacon (2016) described the development of a student-managed clinic and use of a clinical evaluation tool based on the Quality and Safety Education for Nurses as well as ACHNE competencies. The current investigation differed in its use of an online quantitative survey to examine students' perceptions of knowledge acquisition of ACHNE competencies in baccalaureate students.
The rankings provide context for the participants' perceptions of the clinical placement. The highest ranked core knowledge areas were human diversity, health promotion/risk reduction, and communication, which likely relate to the student-initiated interventions on the assessment of individual health risks, health education activities, employee empowerment, and assistance with health care system navigation. The organization's diverse workforce allowed for reflection on the impact of health disparities and health equity. The lowest ranked area was environmental health with related competencies focused on environmental justice and protection from environmental hazards. This rating likely reflected students' perceptions of their limited influence on environmental change in retail and custodial settings. The core area of community/population assessment also ranked lower; the related competency reflected use of the CDC Workplace Health Model as a basis for assessment. Changes in faculty may have contributed to less emphasis of the model.
This study was limited by sample size and the experience of one nursing program's collaboration with a nontraditional clinical partner and an insurance broker. Although the investigator-designed survey used selected ACHNE (2010) competencies as survey items, it addressed only 10 of the 15 core knowledge areas and lacked established reliability and validity. The results, however, suggest the participants perceived the clinical experience as influential in developing core knowledge and basic competencies.
This pilot study adds to the existing body of knowledge by presenting student perceptions of acquisition of public health nursing essential knowledge and skills in a nontraditional community setting. Recommendations for future investigations include establishing reliability and validity of the survey instrument and comparing the acquisition of all 15 of the core knowledge areas and associated basic community/public health competencies in traditional and nontraditional clinical settings. In today's health care arena, there is increasing attention around the social determinants of health and building healthy communities. This nursing education initiative, which explored perceptions of student experiences beyond traditional health care sectors, supports the Robert Wood Johnson Foundation's (2017) assertion that collaboration and engagement across sectors is essential to promote health, wellness, and health equity.
REFERENCES