A tripartite learning partnership in health promotion.
The shift in health care towards primary health services and health
promotion requires nursing education to ensure students learn to
practice in partnership with communities. In primary health care
settings opportunities for students to learn the participatory
communication skills required for collaborative practice have been found
to be constrained by a range of factors. An innovative approach
increasingly being reported is for nurse educators and students to work
with groups in the community, for example with teenage mothers. In
mental health this approach is common, with consumers willingly working
with nurse educators and students to complement the experience students
gain working alongside health care professionals. This paper describes a
partnership between a New Zealand nursing programme and a community
trust whereby nursing students together with youth enrolled at a local
high school promoted health. The nursing students reported that the
experience encouraged them to view their practice from the perspective
of the young people with whom they were working, and to see their
efforts in the school setting as part of the wider community's
health. It is argued that this strategy successfully contributed to the
students' acquisition of the collaborative skills required to
develop nursing partnerships within communities.
Key Words: Health promotion, clinical learning, partnership, primary health care, nursing students.
Health promotion (Methods)
Nursing education (Usage)
|Publication:||Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2011 Nursing Praxis in New Zealand ISSN: 0112-7438|
|Issue:||Date: July, 2011 Source Volume: 27 Source Issue: 2|
|Topic:||Event Code: 360 Services information|
|Product:||Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
In recent years the number of nurses working in community based practice that has a population health perspective is increasing, while the number of nurses working in hospitals is decreasing (Benner, Sutphen, Leonard, & Day, 2010; McMurray & Clendon, 2010; Nursing Council of New Zealand [NCNZ], 2010a). Nursing education is striving to ensure that this shift towards more emphasis on primary health care services is reflected in clinical learning (Carryer, 2008; Chapple & Aston, 2004; Association of Community Health Nurse Educators [ACHNE], 2010; NCNZ, 2010b).
Undergraduate nursing students in New Zealand (NZ) have been required for many years, following Dr Helen Carpenter's benchmark report on nursing education in 1971, to have clinical experience in a variety of clinical settings to ensure their learning reflects the contemporary healthcare context (Carpenter, 1971). Despite this requirement the need for a greater focus on primary health care has recently been identified in a review of educational standards for entry to practice (NCNZ, 2010b). Challenges for nursing education in this area are reported internationally (ACHNE, 2010; Holt & Warne, 2007; Kenyon & Peckover, 2008; Swearingen, 2009). Nurses and educators working in community based health report that they have struggled to incorporate nursing students' clinical experience into practice (Kenyon & Peckover). Students also report issues to do with integrating health promotion theory with practice (Holt & Warne). A recent report by ACHNE's Education Committee suggests that it is time to focus on practice where there is a community level population focus and where support is available to develop competencies identified as essential in community health nursing practice (ACHNE; Swearingen). These essential competencies include partnership skills which are highly valued in the NZ context where the principles of Te Tiriti o Waitangi underpin health care policy (Ministry of Health [MOH], 2001).
One educational approach which addresses the concerns outlined is well established in mental health nursing both in NZ and internationally, and is popular in other areas of nursing internationally including primary health care. This requires nurse academics to have a direct relationship with consumers of health services (Bennett & Baikie, 2003; Hayward & Weber, 2003; Repper & Breeze, 2007; Schneebeli, O'Brien, Lampshire, & Hamer, 2010; Whittaker & Taylor, 2004). Repper and Breeze in their literature review of educators who involve users in the preparation of health professionals, found that when educators work with consumers students were supported to develop the skills that consumers prioritise. This finding is especially useful in primary health care and health promotion where notions of partnership and empowerment underlie policy goals in population based community health. Repper and Breeze caution that there is a need to track relationships between consumers, health professional educators and students. Therefore, this paper describes a service-based learning partnership in New Zealand where a nurse educator worked with a community trust to enable undergraduate nursing students to develop their health promotion skills with local high school students.
New Zealand Context
Nursing in NZ has been identified as being "crucial to the implementation" (MOH, 2001, p. 23) of the Primary Health Care Strategy which is designed to address the health needs of the NZ population. A range of approaches has been implemented in recent years to upskill student nurses and graduates working in this sector (Finlayson, Sheridan, & Cumming, 2009; Haggarty, McEldowney, Wilson, & Holloway, 2009; MOH, 2003a, 2005, 2008). Given the blurring of boundaries between community-based care which can include nursing activities in secondary care, disease prevention and community health promotion (ACHNE, 2010; McMurray & Clendon, 2010) defining the particular skills needed for primary health care nursing practice has been acknowledged as complex. In NZ the largest group of nurses working in the primary health care area is practice nurses whose role includes both health maintenance and health promotion (Hefford et al., 2010). This paper uses the terms primary health care and community based health care interchangeably. Both incorporate the notion of health promotion.
There are clear changes in the employment settings of the nursing workforce in NZ reflecting the move in direction of health care service delivery both in NZ and internationally. In North America 68.1% of nurses in 1984 worked in hospitals, by 2006 this number had dropped to 56.2% (Benner et al., 2010). The pattern is the same in NZ and, although actual figures are hard to obtain, Cook (2009) claims 50% of nurses are working in primary health care. The Nursing Council of New Zealand, however, report that 20-22% are working in this area, with another 4-7% working in community health, Maori and Pacific services and 48% of nurses working in acute hospital settings (NCNZ, 2010a).
District Health Boards (DHBs) employ 62% of nurses with most working in hospital areas with high acuity (District Health Board NZ Future Workforce, 2009). Most graduates practice within the DHB's (Haggarty et al., 2009). These statistics are likely to explain why acute care dominates undergraduate nursing education (NCNZ, 2010b). However it is also likely that there may be wider constraints on access for nursing students to primary health care nursing settings (NCNZ, 2010b). In the programme in which the students who took part in the project to be described in this paper were enrolled, the majority (88%) of undergraduate clinical experience hours were accessed in environments other than community health.
An important issue arising from the dominance of acute care for undergraduate clinical learning is that hospital-based nurses have been found to focus on health education rather than health promotion in its broadest sense (Carlson & Warne, 2007; Dympna, 2007; Piper, 2008). Piper, in a qualitative study of 32 registered nurses working in an acute care hospital in the UK, found that "for the most part the narrow meaning given to health promotion ... was related to limited forms of intervention and not activities associated with the Ottawa Charter" (p. 195). One participant referred to population targets in relation to health promotion as "government propaganda" (p. 193).
In contrast to the limited understanding of health promotion by some nurses working in hospitals, recent research with primary healthcare nurses working in school communities reveals nursing practice that incorporates the wider social determinants of health and also partnership perspectives (Barnes, Courtney, Pratt, & Walsh, 2004; Cleaver & Rich, 2005; Kool et al., 2008; Murphy & Polivka, 2007; Northrup, Cottrell, & Wittberg, 2008; Speroni, Earley, & Atherton, 2007; Summers et al., 2003). Collaborative relationships have been identified between nurses and groups in the community with these being described as: embracing patterns of partnership (Kool et al.); partnering across sectors (Northrup et al); extending practice to include afterschool programmes (Speroni et al.); advocating for 'latchkey' programme parental preferences (Murphy & Povlika); negotiating to overcome gatekeeper barriers to promote youth sexual health (Cleaver & Rich); working alongside students, teachers and parents (Barnes et al.); and finally, gathering survey data to shape practice (Summers et al.). These practices meet the call for nurses to "... no longer adopt the role of 'expert' but work 'for' and 'with' rather than 'on' the people for whom the change is intended" (Carlson & Warne, 2007, p. 511; MOH, 2001).
Gaining access to practice where nurses use these participatory skills which enable partnerships to be established with consumers in the community has been reported as difficult for nurse educators in the UK. Holt and Warne (2007) found in a study of 100 second year pre-registration nursing programmes that they experienced a "dichotomy" (p. 373) and a need for "greater congruence" (p. 379) between health promotion theory and practice. Kenyon and Peckover (2008) studying the issue from the perspective of the registered nurses and academics, found that placing students in community and primary health care settings was best described as a juggling act for both clinicians and educators. In their UK qualitative study with 28 staff in a Primary Care Trust (PCT) the difficulties encountered during clinical placements of nursing students included managing a 'different' kind of relationship between clients and nurse. Organising opportunities for students to engage with clients was found to be hampered by the changing context in which care is delivered in community settings, such as in home visiting and other outreach services. As was pointed out by Kenyon and Peckover this environment contrasts with institutional settings where the close working relationships found in these environments, such as hospitals, limited students independent and self directed learning.
Working directly with communities offers another way for nursing education to develop and complement nursing students' clinical experiences (Hjalmhult, 2009; Lasater, Luce, Volpin, Terwilliger, & Wild, 2007; Repper & Breeze, 2007; Whittaker & Taylor, 2004). This could address the problems which have been reported between primary and community health care practitioners and nurse educators (Carlson & Warne, 2007; Dympna, 2007; Holt & Warne, 2007; Kenyon & Peckover, 2008; NCNZ, 2010a; Piper, 2008; Whitehead, 2007). What this means is that the nurse educators (the academics) work alongside the students as they develop partnerships with consumers, thus offering the opportunity to gain access to consumers where they live and work in the community thereby extending clinical experience beyond the recognised healthcare services. For example, Bentley and Ellison (2005) found that undergraduate students working cooperatively with teen mothers as part of the Early Head Start initiative in Alabama, developed their understanding of the teens health care concerns and cultural difference, as well as developing a sense of responsibility towards community groups. Partnerships between nursing education and communities indicate that they develop the students' collaborative skills which area pre-requisite for effective promotion of primary health care in the community (Hayward & Weber, 2003; Whittaker & Taylor, 2004).
The Project: Promoting Health in a New Zealand Community Setting
A tripartite partnership between a Community Trust, the University nursing programme and a local high school in a NZ community enabled undergraduate nursing students to work with youth to promote health in the school classroom over a four year period from 2005-2008. The goals of the partners in this project were complementary. The nursing programme was promoting and delivering the Bachelor of Nursing (BN) programme. The Community Trust, which is funded jointly by a community and the Ministry of Social Development, was assisting local youth to transition into the workforce or tertiary education and the school was developing the health component of their curriculum. The Trust invited educators from the nursing programme, as a regional education provider, to support its goals and to work through them with the school. The nursing programme recognised this invitation as an opportunity to develop undergraduate nursing students' skills and to concurrently promote youth health.
The curriculum topic chosen by the school was nutrition, exercise and health reflecting the Health Promoting Schools Organisation 'Healthy Eating Healthy Action' (HEHA) (MOH, 2003b) campaign. This was described as a strategic approach towards improving nutrition, increasing physical activity and achieving healthy weight where people live, work and play. The second year baccalaureate nursing students who participated in the project were enrolled in a course, the learning outcomes of which emphasised health promoting practice in primary healthcare settings. The project consisted of a group of eight students working with the school teachers and youth to develop an interactive classroom session held in both semesters of each year over the four years of the partnership with the school.
The nursing students worked directly with senior school students (16) to plan and deliver an hour long workshop session to junior students (>200) during a day designated for delivery of components of the 'health' curriculum. Planning consisted of these senior school students and the nursing students meeting at the school three times early in each semester and negotiating topics and activities for the session. The nursing students then went away and prepared the resources, and in this stage of the project visited members of the local community to gain support. This led to one supermarket supplying food samples for demonstration purposes during the sessions and health centres providing pamphlets and some equipment for visual aids during the session. The nursing students worked alongside the senior school students as they prepared to facilitate the small group workshop activities with the junior school students (the ratio was two nursing students to four senior school students). On the 'health' day all the junior students rotated through the hour long sessions being delivered by the senior students, and during the day each small group of nurses mentored the senior students during the delivery of the sessions.
The nursing students were supervised by academic staff throughout the planning and delivery of the project. Pass/fail criteria were used to evaluate all the learning outcomes being met during the project. The assessments included a written evaluation of each group's performance of the overall task, including planning and delivery of the final health sessions to junior students; a peer assessment by each member of another group member's contribution to the group process'. As well there was an individually written reflection by each group member on their own learning during the execution of the project. The Trust staff" carried out a written narrative evaluation which served as a further reflective exercise for the nursing students.
Evaluation of the Project
Through participating in this project the nursing students reported in their written evaluations that they had enjoyed promoting health with youth and engaging in health education on a topic in which the school students had enthusiastically participated. The Trust analysis of their written evaluations showed that the school students' understanding of nutritional requirements had improved and that the high school reported the project had successfully contributed to the schools' expansion of the health component of the curriculum.
During their planning discussions with the school students the nursing students working on this project reported their realisation of the depth of the school students' prior knowledge about nutrition, exercise and health. They then worked out that their role was to build on this knowledge and explore any issues the school students identified in managing the relationship between food, activity and keeping well. This realisation also applied to exploring the best teaching strategies to be used in the classroom to share their nursing knowledge and ensure it was relevant and appropriate to youth. A major factor which emerged from the nursing students' reflections was an awareness of the level of respect the junior students demonstrated for the senior students by their engagement with the latter during the delivery of the sessions. The younger students responded positively and teachers also reported that they were pleasantly surprised by the degree of interest shown by these students. By discerning this esteem, the nursing students recognised the ability of the mentoring process to empower the school students. This aspect of the project demonstrates the development of negotiation skills and shared decision making, skills which underlie the ability to build the partnerships necessary for the implementation of primary health care policy (Carlson & Warne, 2007; Whittaker & Taylor, 2004).
The nursing students also reported making links between this project work and their clinical placements with primary health care nurses, where some had taken part in home visiting and screening clinics in the same community in which the school was located. The nursing students talked about understanding the school students within their wider communities.
During the conduct of this project the health needs of the community were aligned with the learning needs of nursing students. Working in a partnership relationship required the nursing students to focus on the needs of the students and the school, and to understand the goals of the Community Trust as well. This requirement meant that they were given the chance to develop their collaborative skills, an acknowledged pre-requisite for promoting community health (ACHNE, 2010; Carlson & Warne, 2007; Hayward & Weber, 2003; Holt & Warne, 2007; MOH, 2001; Swearingen, 2009; Whitehead, 2007; Whittaker & Taylor, 2004). This also meant that the nursing students could see the project through what Holt and Warne describe as a "wider lens" (p. 375) rather than the single dimension of health services. Viewing individuals in this way has been described by Hjalmhult (2009) as an essential part of the "new paradigm" (p. 3139) of public health nursing practice where the community itself is recognised as the client. This project therefore made it possible for these nursing students to see their efforts within the school environment as an example of what Lasater et al. (2007) describe as communityfocused practice.
Because the project located the nursing students within the school itself, they were able to see the students in an environment where the impact of social determinants on health could be recognised. They could also practise their health promoting communication skills in the real world of the community without creating any of the unease between nursing education and nursing practice which has been reported in the UK (Holt & Warne, 2007; Kenyon & Peckover, 2008).
The tripartite relationship underlying the project described in this report provided a structured opportunity in a NZ school setting for nursing students to collaborate across the health, education and social development sectors. Working directly with the youth in this school enabled the nursing students to develop the communication and collaboration skills necessary for working in partnership, skills which, particularly in the NZ context, are necessary to promote self-determination. These transferable skills were encouraged in the students in a context where there was no strain on nursing resources. However, more research on the relationship between nursing education and community partnerships is necessary to ensure that on graduation New Zealand undergraduate nurses are well prepared to meet the challenges facing nursing as health care shifts into the community--where communities themselves will be identifying their health needs.
The author would like to acknowledge Sandi Savage, School Partnership Facilitator, Partners Porirua and Brad Williamson, Year 10 Dean, Head of Health, Aotea College, Porirua.
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Susan Scott, RN, RM, MA, Senior Lecturer, School of Health and Social Sciences, Massey University, Wellington Campus
Scott, S. (2011). A Tripartite learning partnership in health promotion. Nursing Praxis in New Zealand, 27(2), 16-23.
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