TOWARDS AN EVIDENCE-BASED APPROACH TO CURRICULUM REVISION CLINICAL EDUCATION MODELS FOR COMMUNITY HEALTH NURSING PRACTICE

ACKNOWLEDGEMENTS Co-Investigator: Dr. David Gregory, Professor, School of Health Sciences, University of Lethbridge Research Assistant: Margaret Rauliuk Study supported by a grant from the Faculty of Nursing Endowment Fund

BACKGROUND UM-Faculty of Nursing (FON) curriculum revision Gap in 4th year: senior community health nursing theory course only Proposal to develop community health clinical Need for evidence-based decision re: structure/approach to developing new course

COMMUNITY HEALTH COMPETENCIES & PRACTICE STANDARDS All reflect a broad socio-environmental perspective, guided by principles of PHC Particular emphasis on: Partnership/collaboration Determinants of health Social justice, advocacy, influencing policy change all viewed as part of CHN role

OBJECTIVES OF STUDY To establish ‘state of the art’ of community health clinical education models (CH-CEMs) To identify what CH-CEMs currently being applied in Canadian nursing programs To make recommendations to UM-FON regarding new CH clinical course

METHODOLOGY Literature review Qualitative content analysis of current Canadian community health clinical course syllabi Focus groups with community health clinical course leaders

LITERATURE REVIEW Very few Canadian examples of CH-CEMs Concepts related to PHC appear to have been widely integrated into Canadian undergrad curricula– at least, in theory Evidence of use of non-traditional community practicum sites In summary, lack of clear picture of current CH-CEMs being used in Canadian programs

CONTENT ANALYSIS OF CLINICAL COURSE SYLLABI Invitation sent to baccalaureate nursing programs offering senior-level community health course(s) with a distinct clinical component In the case of collaborative university-college programs, only university partners were included Documentation received for 29 courses from 24 of 31 (77%) of English programs (no response from Francophone programs)

LIMITATIONS May have missed innovative approaches from non-participating programs Volume of information received ranged from minimal to extensive, resulting in data gaps that could not always be filled Missed some programs that had withdrawn from collaborative programs

LIMITATIONS (cont’d) Administrative dimensions of clinical courses not apparent in course syllabi (focus groups provided some enlightenment, but not comprehensive) Findings arise solely from clinical course documentation; gaps that we identify may be covered in associated theory courses

CLINICAL COURSE SYLLABI: CONTENT CATEGORIES Course conceptual framework Course objectives Clinical hours (number and format) Types of clinical/practicum sites Methods of evaluation

COURSE CONCEPTUAL FRAMEWORK Single overarching [n=12] Combination [n=6] Constellation of concepts [10] Broad Focused One course classified as ‘other’

COURSE CONCEPTUAL FRAMEWORK (cont’d) In summary, most conceptual frameworks in course syllabi were congruent with those identified in literature, entry-level competencies, standards as central to contemporary CHN practice However, PHC wasn’t reflected as strongly as we anticipated

COURSE OBJECTIVES Constant comparative analysis resulted in objectives being sorted into three major thematic categories and sub-categories Largest category: professional role Predominance of objectives related to collaboration and partnerships (but focus on understanding rather than doing)

COURSE OBJECTIVES (cont’d) Other characteristics of professional role not reflected strongly in objectives: Ethics Advocacy, social/political action Cultural competence Use of technology

COURSE OBJECTIVES (cont’d) Second largest category: nursing process Objectives related to assessment dominant (two-thirds) Only 5 objectives (out of 60 in this category) related to assessment of the DOH in the community

COURSE OBJECTIVES (cont’d) Other areas with limited focus Objectives focused on assessing capacity Objectives focused on developing assessment skills Objectives focused on collaborative priority setting or planning

CLINICAL/PRACTICUM SETTING Traditional Public Health only [3] Broad Community Health [7] Mixed: health/non-health (primarily non-health) [13]

SUPERVISION All types used clinical instructors or faculty advisors, in addition to course coordinator Traditional PH sites used nurse preceptors Broad community health and mixed models did not necessarily use nurse mentors

CLINICAL HOURS/FORMAT Total hours ranged from 14 (one term) to 390 (two terms) Majority were in the 100-200 hour range Courses offered over two terms in six programs Most common format: 2 days/wk (one term) Only three programs offered clinical hours in blocks

EVALUTION Eight broad methods identified Learning plan/contract Clinical/professional practice evaluation Community health assessment/planning/ promotion project Seminar/Tutorial Individual written (reflective journals, clinical practice portfolios, analytical papers) Group written (CHA/CHP) Presentations Teaching

OBSERVATIONS RE: CHA/CHP ASSIGNMENTS Two-thirds of programs required students to engage in a CHA and/or CHP project Approximately one-third involved assessment only (all in one term) Another third involved all phases Remaining third assigned students to work on an existing project, or to develop their own project based on needs identified by aggregate

OBSERVATIONS RE: CHA/CHP ASSIGNMENTS (cont’d) None of the assignments involved broad geographic CHA Focus was on aggregates or populations within the community context

FOCUS GROUP INTERVIEWS (FGIs) Two separate but related findings from content analysis influenced development of this phase of study Majority of programs using non-health settings (mixed model) Few course objectives or assignments related to preparing students for role in addressing SDOH and promoting SJ/equity

FOCUS GROUPS (cont’d) Clinical course leaders from programs using the mixed model of clinical sites invited to participate 12 course leaders representing 11 out of 13 eligible programs participated in three separate 75-minute FGIs

FOCUS GROUP QUESTIONS “How can we ensure that students develop knowledge and skills related to the CHN’s role in addressing social determinants of health and promoting social justice/equity?” “What are the supervision challenges associated with developing this particular knowledge and skills set?”

ENABLING FACTORS Exposure to these concepts in theory course essential, but not sufficient Curriculum that promotes SJ/equity approach and focus on SDOH throughout program is ideal Students’ values/attitudes regarding these concepts need to be formulated early

ENABLING FACTORS (cont’d) Non-traditional settings that address needs of vulnerable populations ideal But…traditional Public Health sites may offer opportunities as well Nature of supervision a key factor

ENABLING FACTORS (cont’d) Cadre of clinical instructors with solid understanding of these concepts critical (‘weavers’) Selection/hiring/orientation of clinical instructors essential Non-RN agency mentors require orientation as well

ENABLING FACTORS (cont’d) Student-to-clinical instructor ratio should be viewed just as it would be in an acute care setting (i.e., 6-8 students per instructor is the ideal) Space within learning environment to help students appreciate how principles of SJ/ equity, SDOH are actualized across host of agencies, populations

CHALLENGES/TENSIONS Type of site may depend on other factors rather than philosophical choice (e.g., hours available, student numbers, availability) Challenge of finding clinical instructors (or agency mentors) with solid grounding in these concepts

CHALLENGES/TENSIONS (cont’d) Non-traditional sites may not offer opportunity to demonstrate a number of CHN roles (e.g., traditional PH) Students don’t always see value of non-traditional sites or non-RN mentors

FOCUS GROUP QUESTION #3 “Given the shift in community health clinical education to student placement in non-traditional settings, how can baccalaureate programs ensure that students have the opportunity to develop traditional entry-level Public Health core competencies?”

TRADITIONAL PUBLIC HEALTH CORE COMPETENCIES Supporting theory courses can cover a lot of this material Need to identify what is reasonable expectation for PH core competencies at novice level

IMPORTANT MESSAGES Need to spend a lot of time building partnerships with community agencies (especially non-traditional) Community health clinical placement coordinator required – beginning a minimum of one year prior to clinical course Emphasis on assessment should not supercede other elements of the community health nursing process Don’t be locked into a particular CH-CEM (create model that is supportive of specific context)

CONCLUSION Findings raise a number of questions/ issues about what we, as a collective of educators, are doing related to CH clinical education Requires healthy dialogue WHAT DO YOU THINK?

SOME QUESTIONS RAISED “Should we be concerned that there is such an extreme range of hours allotted for community health practicum experiences across the country?” “If the shift to use of non-traditional sites for clinical practice is the ‘wave of the present,’ what supports and/or infrastructure need to be in place?” “Is relying on the theoretical component of the curriculum to cover traditional Public Health content (e.g., CDC) putting the nursing profession/public at risk?”