In nursing education, progress needs to be transformative across curricula to meet student learning needs. Designing flexible, meaningful clinical experiences that prepare students to meet patient needs holistically is in keeping with calls for nursing education reform (National League for Nursing, 2003). This article describes the integration of innovative experiential learning activities to provide a well-rounded population health nursing course experience.
BACKGROUND
The evolution of nursing to meet societal needs requires educators to respond with adaptive teaching methods to engage and inform the future workforce. Online distance learning is a practical strategy to meet present-day learner needs (Kozlowski-Gibson, 2018; Richter & Schuessler, 2019), provide flexibility and accessibility, and address varied learning styles (Post et al., 2017). Properly designed online courses deliver content for foundational knowledge and skills for entry to practice.
Experiences that expand student understanding and perspective on the complexity of patients and health care system challenges are essential to nursing education (Yancey, 2019). In online courses without a clinical component, educators struggle to provide authenticity for content, while students grapple with translating abstract concepts to patient situations. Experiential learning with authentic, immersive experiences promotes a shift in student perspective, yielding a broader approach to patient care and more successful learning (Eyler, 2009). However, in most undergraduate nursing programs, clinicals are primarily in acute care facilities, distanced from the social determinants of health (SDOH), and students may be ill-equipped to understand complex patient situations and how care extends into the community.
In our online population health nursing course, faculty identified a need to improve student understanding of health equity, health disparities, and SDOH. The innovative design includes the scaffolding of virtual interactive assignments and a simulation experience. Activities are designed to enhance student familiarity with authentic patient situations with a population perspective in a complex health care system. Interactive assignments promote engagement and increase students' understanding, confidence, and competence (Gray-Miceli, 2019). Simulation incorporates the influence of SDOH on health care and helps shift students' perspectives on patient-centered care. The goal of the redesign was to promote the transformation of nursing with the next generation workforce and engage the spirit of inquiry for improvement.
SCAFFOLDING POPULATION HEALTH CONTENT
Teaching and evaluation methods employed in the course include interactive community challenge (CC) case studies, weekly quizzes, and a group project grounded by didactic content. Service-learning and a capstone simulation are also employed. Assignments target population health concepts, collaborative and independent efforts, and relevance across nursing roles. Leveling application and interlinking content scaffolds the student experience for the most interactive and perspective-altering elements of the course.
Brief weekly recorded lectures grounded in population health and health promotion theories provide the foundation for the course. Weekly quizzes and CCs concentrate on the application of didactic content, use of clinical judgment, and the integration of resources focusing on health and social, psychological, and socioeconomic challenges. CCs require students to independently identify patient needs, research community resources, utilize population health concepts, and reflect on how these scenarios will impact their professional nursing care.
The CCs focus around two client scenarios and challenge students to navigate resources and interventions to address SDOH. The first features an older male individual with multiple comorbidities and a recent below-the-knee amputation with challenges around access, financial stress, disability, and age. The second scenario, which features a family with an overweight child, prompts students to identify developmentally appropriate teaching about nutrition and physical activity. Students must navigate qualification requirements for government assistance and resources to advance the caregiver's education and ameliorate SDOH. Safety interventions and activities realistic to living in government-assisted housing are discussed. Students reflect on how the scenarios and CCs have influenced their approach to nursing care.
For a group project, students must identify a community, collect and analyze community assessment data, and design interventions for a population at heightened risk for a public health concern (e.g., adolescents at high risk for obesity). Interventions incorporate resources, short- and long-term strategies, and evaluation methods to improve the health of the selected population. Project participation illustrates the value of collaboration, a mainstay of population health, in creating an evidence-based health management plan while enhancing application of course content.
SERVICE-LEARNING AND CAPSTONE EXPERIENCES
Thirty service-learning hours, both direct and indirect, are required to meet course requirements. Course faculty maintain cooperative agreements with more than 25 agencies to ensure a mutually beneficial relationship with clear expectations for the agencies and students; agencies include food banks, senior services, and organizations managing patients with SDOH considerations. Students choose from affiliated agencies and arrange experiences independently. They work directly with agency leaders and learn leadership and organizational skills through activities such as client interactions and implementation of events central to the agency's mission. Intentional service-learning and reflection engage students as health advocates in the larger social context.
The summative experiential learning activity is purposefully incorporated to apply and expand knowledge gained across the course. The capstone activity was originally designed for student teams to complete in person over two hours, followed by a live debriefing session; because of COVID-19, student teams now complete the main activity in their home communities, review a recorded debriefing, and interact on small-group discussion boards.
The teams navigate the community, seeking resources to meet daily and unexpected needs while considering the effects of specific SDOH challenges in a patient scenario. For example, an elderly head of household (HOH) who is legally blind requires a cane and has osteoarthritis and atrial fibrillation. The HOH and another household member, a college student unable to assist consistently with daily needs, live on a poverty-level income. The activity incorporates planned and unanticipated living expenses, health difficulties, and transportation concerns. As students evaluate accessibility of resources, they must consider local affordable transportation options. Role-playing the HOH and accomplishing a list of necessary health maintenance tasks, students assess the distance, time, and physical effort of navigating from the home address to the health clinic and other locations within the community.
Students complete a debriefing facilitated by faculty trained in "debriefing with good judgment" (Rudolph et al., 2006). Faculty with clinical expertise in community health and rural populations participate in the debriefing to provide a complete, collaborative perspective. Students come to learn that communities vary widely by transportation accessibility, sidewalks, and proximity of resources, such as stores and clinics. Discussion of accessibility differences, even within the same city, amplifies policy's influence on health and well-being, enriching and humanizing patient situations. Students also explore how food deserts and minimal shopping options in rural and urban settings influence the cost of health care equipment, medications, and essential food items. For example, groups compare the cost and accessibility of fresh fruit in their assigned communities. Through simulation and debriefing, they also reflect on how the second household member, a college student, affects household resources and address specific needs such as school expenses and stable Internet access.
FUTURE DIRECTIONS
Analysis is under way of a pre/post survey on perceptions of how SDOH affect health behaviors and health risks. Enriching nursing students' knowledge beyond foundational competencies toward understanding broader influencers of health may build empathy toward others' experiences and influence future practice. Experiential learning can influence student development into a patient-centered nurse who rises among peers to influence health care culture and enhance health equity in the broader system, one nurse at a time. Nurse educators can build readiness for practice with a purposeful pedagogy of scaffolding experiences to enrich students' underlying philosophy of nursing care and shift perspectives about those for whom they care.
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