- Email: [email protected]
An interdisciplinary community-based educational model
An Interdisciplinary Community-Based Educational Model MICHELLEA. BEAUCHESNE,DNSc, RN, PNP,* AND PATRICIAMAGUIREMESERVEY,PHD, RNt
The purpose of this article is to describe an innovative partnership among academia, community, and service to better meet the health care needs of underserved populations. The Center for Community Health Education, Research, and Service--a coalition of Boston education institutions, health services providers, and community agencies--was formed with a grant from the W. K. Kellogg Foundation. The initial goal was to establish academic community health centers comparable to the large teaching hospitals that combine service, education, and research as the cornerstone of their mission. With faculty based in the neighborhood health centers, students have learning opportunities to assess, plan care, and treat individuals and families using a community-based primary care model. The nature of the partnership, including the structure and process of implementation, is described. The developmental socialization of advanced practice nursing students in a community basedsetting is discussed. Educational and service outcomes are identified. (Index words: Advanced nursing practice; Community-based model; Education; Interdisciplinary education)J Prof Nurs 15:38-43, 1999. Copyright © 1999 by W.B. Saunders Company
INCE 1991, The Center for Community Health Education, Research, and Service (CCHERS), through a grant from W. K. Kellogg Foundation's Community Partnerships Initiative, has developed and implemented a highly successful, nationally recognized model of community-based primary care education for medical and undergraduate nursing students. CCHERS is a public-private partnership that includes the Northeastern University College of Nursing NUCON), Boston University (BU) School of Medi-
S
*AssociateProfessorand Coordinator of PrimaryCare Speciallzation, Collegeof Nursing,NortheasternUniversity,Boston,MA. ?Assistant to the President, Northeastern University, Boston, MA. Supported in part by a grant from the W. K. KelloggFoundation. Addresscorrespondenceand reprint requeststo Dr Beauchesne: Northeastern University,Collegeof Nursing, 401 RobinsonHall, Boston, MA 02115. Copyright© 1999 by W.B. SaundersCompany 8755-7223/99/1501-0010510.00/0 38
cine, Boston Medical Center (BMC), and Boston's Commission on Public Health; a network of community health centers; and communities. By educating students within medically underserved and economically disadvantaged communities, and by using servicelearning and interdisciplinary approaches, this partnership has radically transformed health professions education at Northeastern University and Boston University. The CCHERS initiative provides a ready-made link to the underserved communities where at-risk populations reside. It has helped socialize baccalaureate students into a broader view of nursing and has provided them with excellent role models in the advanced practice role who provide primary care to these populations. These health centers also participate in the nursing undergraduate cooperative education at Northeastern University. CCHERS has been successful in establishing academic community health centers comparable to the large teaching hospitals that have combined service, education, and research as the cornerstones of their mission. With faculty based in the neighborhood health centers, students have learning opportunities to assess, plan care, and treat individuals and their families using a community-based primary care model. Most recently, the graduate nursing faculty collaborated with CCHERS to develop a joint proposal, a Graduate Medicine/Graduate Nursing Education (GMNE) Initiative, which also has been funded by the W. K. Kellogg Foundation, to support a combined graduate nursing and medical education initiative that focuses on interdisciplinary, community-based primary care education. The purpose of this article is to describe the impact of this partnership on graduate nursing and medical education.
Background
This graduate initiative constitutes a logical extension of the pioneering work in postbaccalaureate and
JournalofProfessionalNursing, Vol 15, No 1 (January-February), 1999: pp 38-43
39
INTERDISCIPLINARY EDUCATION
undergraduate education of the CCHERS partnership. Northeastern University and Boston University have worked collaboratively with their community partners to revise nursing and medical curricula and to institutionalize, through extensive curricular changes, the core competencies of community-based primary care. Both the N U C O N and the BU School of Medicine require community experience and an orientation toward health promotion, disease prevention, and health care provision for underserved populations in their curricula. Three interrelated goals have guided CCHERS' mission. The first has been the need to nurture a community-based, primary care educational approach that would provide the emphasis to primary care that hospital-based education has afforded to specialty education in medicine and nursing. The second is to foster and build substantive community participation in the consortium's governance and policy making to assure that CCHERS' educational programs and health practices appropriately address the populations they are meant to serve. The third goal involves creating a progressive educational track that supports and stimulates urban youths interested in health careers who might reasonably be expected to practice in their own communities.
Three interrelated goals have guided CCHERS" mission.
CCHERS has accomplished the groundwork to achieve these goals. The first mission is being addressed by the incorporation of two universities, a large city hospital and a health department, and an extensive network of community health centers and agencies into a collaborative team that oversees a primary care educational program. Both the N U C O N and BU's School of Medicine emphasize within their curricula a community-based, primary care focus. A network of academic community health centers, called the Academic Community Health Center, has been created and linked closely to the universities and to numerous community organizations (schools, elder services, youth programs, and daycare centers). The Academic Community Health Center now serves as a unifying hub for students' primary care clinical education, which is taught by an expanding nucleus of community faculty. It is at the health centers and through their service placements that students experi-
ence a community-based health approach with professionals from a variety of disciplines. The second mission, that of assuring that community constituents are true partners playing an integral role in the consortium's decision making, has been emphasized from the inception. At the heart of the consortium is the Board of Directors, established in the same model as a community-based health center board of directors. CCHERS by-laws expressly indicate that the consortium's Board of Directors, representing all of the coalitions partner institutions and communities, has the final voice in policy decisions. The board delineates the mission of the collaborative efforts and oversees all community-related policy decisions. O f its 24 directors, eight are community representatives, eight come from health centers, and eight come from universities and hospitals. The CCHERS board also serves as the overarching governance structure for the GMNE initiative. The resulting partnership links the universities, the health centers, and the communities, enabling the community to identify health service needs and to match those service opportunities with the appropriate educational levels and needs of the medical and nursing students, residents, and advanced practice nurse students. The CCHERS' partnership also has built the foundations for its third mission: a connecting educational pathway into the health professions. Although Boston is renowned for its health and educational institutions, every year fewer than 1 per cent of its public school graduates enter programs leading to a health career. To begin to remedy the chronic underrepresentation of people of color in health professions, CCHERS fosters an educational continuum that provides inner-city students with opportunities to develop academic and personal skills and makes available social and family supports to facilitate their pursuit of health careers. The educational pathway begins in the middle school years, progresses through affiliated high school programs--Health Careers Academy and East Boston's Hope Alliance--and continues into college and university health professions programs. The W. K. Kellogg GMNE initiative represents the final piece in that seamless pathway that CCHERS has envisioned.
THE W. K. KELLOGG GMNE INITIATIVE
Nationally respected graduate nursing and residency programs that include strong community-based
40
BEAUCHESNE AND MESERVEY
primary care specializations already existed at both universities and BMC. BMC offers pediatric and internal medicine residencies in primary care in conjunction with BU School of Medicine. Since its inception in 1989, the Primary Care Specialization within the Graduate School of Nursing at Northeastern University has aimed to prepare pediatric, adult/ older adult, and family nurse practitioners to provide primary care to underserved populations. In 1994, a Home Health Nurse Practitioner Program was launched within the Community Health Specialization to provide yet another avenue for primary care education. Both universities and the hospital strongly support emphasizing the base of the community practice in their respective programs. It is the goal of the W. K. Kellogg GMNE Initiative to enable these already-established programs to fulfill the following objectives: (1) extend community-based primary care experiences; (2) develop an innovative, creative, interdisciplinary educational model; and (3) extend faculties' interests in urban primary care. At the same time, this initiative will strengthen the network of academic community health centers, which are already becoming the loci where diverse resources concentrate to provide rich educational opportunities for communitybased education.
NURSE PRACTITIONER EDUCATION
The Draft Year 2000 Objective (U.S. Department of Health and Human Services, 1991) clearly speaks to the need to increase access for all citizens to health services. A major purpose of this project is to educate nurse practitioners who are better prepared to provide primary care to underserved populations. It has become evident that educators need to prepare nurse practitioners who can not only provide primary care to individuals and families but who can impact public policy and empower communities to accomplish this goal (Fenton, Rounds, & Anderson, 1991; Forker, 1996). Primary care can be narrowly defined as the care the client receives within the health care system at the first point of contact to resolve a presenting problem (American Nurses Association, 1985). The World Health Organization (1978) advocates for a broader definition of primary health care that recognizes the family and community as the basis for providing health care in various settings. According to this definition, primary health care promotes maximum community and individual self-reliance and participation in the planning, organization, operation,
and control of primary care. We can only successfully increase access to primary health care through decreasing barriers to health care services, increasing utilization of services, and improving the health of the community as a whole (Whelan, 1995). Although the NUCON's Primary Care Specialization has successfully prepared nurse practitioners to meet the health needs ofunderserved populations, it is clear that we need to develop a more comprehensive, community-based primary care curriculum to meet the health care needs of the future (Knollmueller, 1994). Experts on health policy and health education debate the differences between community-oriented versus community-based care (Siegal, 1996). The basic elements of community-oriented primary care (COPC) include primary care, epidemiology, defined populations, defined health problems, and community involvement. COPC uses the scientific principles of epidemiology, biostatistics, and public health to understand community health issues and integrates concepts of primary care with assessment, analysis, planned interventions, and evaluation of community programs to improve the health status of the community as a whole (Siegel). Community-based care refers to care, which may or may not be medical, that takes place in community settings. The goal of any community-based educational program is to highlight the special concerns of an identified population through a community-oriented primary care approach by teaching students in that very community base. A community can be described by natural borders, such as geography, or by population, risk of illness/adverse outcomes, or special needs (Goldhagen, 1996). People live in communities. Primary care is learned best in the community.
COMMUNITY-BASED EXPERIENCES
It is the intent of this initiative to build on the foundations laid by CCHERS and articulated in the philosophy of the Northeastern University Model (Table 1). Although graduates receive many clinically precepted experiences in these health centers already, they will be more fully integrated into the partnership through participating in interdisciplinary-based community care. The development of longitudinal community-based experiences enables graduate nursing students to develop more depth in their experiences within the community and expand their learning activities in both clinical practice and in research (Zungolo, 1995).
INTERDISCIPLINARYEDUCATION TABLE 1. The Northeastern University Model Nursing students learn about the multiple aspects of a neighborhood and build relationships with residents and providers by returning to the same area for clinical placements across the curriculum. Neighborhood residents and health care providers collaborate with the college of nursing and share in the educational process of its students. The collaborative process provides an opportunity for community residents and the academic participants to learn more about the realities of each other's worlds. Client-centered health care, developed in this collaborative process, empowers both the nursing students and the residents of the neighborhood to become involved in interventions. Students learn to view health/illness as part of the total lived experience of their clients.
41
the evolving health care environment (Finocchio, Dower, McMahon, Gragnola, and the Task Force on Health Care Workforce Regulation, 1995). In their health center base, the graduate nursing student will be paired with medical residents in appropriate teams, eg, pediatric nurse practitioner students with pediatric residents. This team, in turn, will be matched with a clinical precepting team or a nurse practitioner and attending physician who have worked coUaboratively and who have shared responsibility for a panel of patients. In their community agency experiences, the nurse practitioner student and resident will become a further part of an ongoing interdisciplinary team.
Data from Zungolo (1995).
Community-based experiences should be viewed not as an adjunct to but as an integral part of nursing education. The goals of community-based education include students gaining an understanding of the following (Kohr & Barnett, 1996): 1. the role and contribution of health care providers within the community and health care system; 2. the community context and determinants that affect the delivery of primary health care; and 3. the role of advocacy and need for collaboration. The focus of community-based learning experiences are varied and diverse in nature and include multiple settings (Table 2). The interdisciplinary team should be the central learning unit of any community experience. In the current project, both graduate nursing students and medical residents participate as members of a collaborative team in underserved communities. Because integrated team care is thought to be the most effective and efficient way to promote comprehensive quality care of complex health issues nationally, it will continue to grow in importance in TABLE 2. Community-Based Leaning Experiences Health supervision, health promotion, disease prevention Cultural sensitivity in health care Disease-based programs High-risk populations Home-based programs Institutional approaches to special needs Data from Siegel (1996).
• . . integrated team care is thought to be the most effective and efficient way to promote comprehensive quafity c a r e • . .
To assure that community practice is at the base of this model, four significant curricular trends will be implemented. 1. Clinical practice within a community health center will expose the learners to a diversified patient mix with a variety of health concerns. They also will be exposed to the complex array of familial, cultural, and socioeconomic factors that affect health. 2. An interdisciplinary community experience caring for a high-risk population will be developed to enable the student/resident health care team to practice communitybased primary care as part of an existing interdisciplinary team. The opportunity to work with the sophisticated role models of these teams will provide a strong base for the student/resident's future practice. 3. A new 2-year interdisciplinary seminar will be instituted emphasizing an epidemiological approach to community-based primary care. Monthly seminars and self-directed reading programs will be designed to supplement the continuing clinical experience and bring all participants together across sites. Faculty preceptors from the Academic Community Health Center, in collaboration with university faculty, will coordinate the seminars,
42
BEAUCHESNEAND MESERVEY
which will be presented to the GMNE cohort rotating from center to center. Content will emphasize public health and epidemiological aspects of care; the cultural, social, and health contexts pertinent to urban community practice; and the increasingly important policy and business aspects of care. . Nurse practitioner students and residents will undertake a steadily increasing communitybased clinical project in association with either the student/resident's continuity clinic or interdisciplinary experience. In addition to complementing existing services, nursing students will conduct a project or participate as an integral part of an ongoing project that has significance for this community-based practice and that benefits the existing team's work. Appropriate topics may include examining needs assessment data, conducting new needs assessments, and evaluating utilization patterns or efficacy of services. Through this interdisciplinary, community-based approach, graduate nursing students and residents are expected to gain a working knowledge of and an appreciation for the complexity of caring for urban, underserved communities in the neighborhood setting. Key outcomes suggested by the program include, graduates accomplishing the following: 1. choose careers in primary care in underserved settings, particularly inner-city, low-income communities; 2. demonstrate knowledge of community needs and resources; 3. demonstrate competence in providing comprehensive primary care services; 4. work effectively within interdisciplinary teams; 5. understand the contributions and methods of public health, epidemiological, and applied research approaches in the community setting; and 6. be prepared to deliver community-based primary care.
attaining specific educational outcomes will be rated. Focus group evaluations will be completed by project staff twice a year to review strategies of program, barriers to implementation, and progress to date. Written evaluations of each component of the program will be developed and completed annually by both university and community faculty and residents and graduate nursing students.
Summary As we enter the 21st century, the challenge to improve the health of our nation is gaining impetus and recognition. The Draft Year 2000 Objectives (US Department of Health and Human Services, 1991) stress the priority areas of health promotion, health protection, preventive services, and systemwide improvements. Nurse practitioners have been documented to be cost-effective providers of quality care (Pew Health Professions Commissions, 1994). We need to prepare nurse practitioners who can provide primary care for individuals and families and can also assess, plan, intervene, and evaluate the needs of communities (Kulig & Wilde, 1996). Communitybased primary care nurse practitioner programs must be developed that include foundations in providing primary care to families in specific populations through the assessment and management of health concerns, including health promotion and prevention. In addition, community health concepts, such as community assessment analysis, must be integrated into practice settings. To effect change on a larger scale, nurse practitioners must contribute or conduct primary care research in the community as well. There exists a need for more effective links between community and academic institutions for the provision of practical and pertinent learning experiences on the graduate level. The authors hope that through the efforts of the innovative partnership described in this model that the following outcomes can be achieved: (1) nurse practice students will be socialized into a broader view of primary care; (2) a commitment to the provision of primary health care for underserved populations will be fostered; and (3) the quality and quantity of community-based service offerings will be improved.
EVALUATION
Evaluation of educational outcomes will be accomplished through a variety of sources. Community faculty/preceptor evaluations will be completed on an annual basis in which students' progress toward
Acknowledgment The authors thank the CCHERS and the Task Force on Graduate Education for their support and assistance in the development of this project.
43
INTERDISCIPLINARY EDUCATION
References
American Nurses Association. (1985). Scope of practice for the primary health care nurse practitioner. Kansas City, MO: Author. Fenton, M. V., Rounds, L. R., &Anderson, E. T. (1991). Combining the role of the nurse practitioner and the community health nurse. Journal of the American Academy of Nurse Practitioners, 3, 99-105. Finocchio, L. J., Dower, C. M., McMahon, T., Gragnola, C. M., and the Task Force on Health Care Workforce Regulation. (1995). Reforming health care work force regulation: Policy considerationsfor the 21st century. San Francisco: Pew Health Professions Commission. Forker, J. (1996). Perspectives on assessment: Assessing competency for community-focused nursing practice. Nurse Educator, 21, 6-7. Goldhagen, J. (1996). Community resources. In T. DeWitt & K. Roberts (Eds.), Pediatric education in community settings:A manual (pp. 37-41). Arlington, VA: National Center for Education in Maternal and Child Health. Knollmueller, R. (1994). Thinking about tomorrow for nursing: Changes and challenges. Journal of Continuing Education in Nursing, 25, 196-201. Kohr, A., & Barnett, S. (1996). The role of community faculty in educating medical students and residents. In T. Dewitt & K. Roberts (Eds.), Pediatric education in commu-
nity settings:A manual (pp. 42-51). Arlington, VA: National Center for Education in Maternal and Child Health. Kulig, J. A., & Wilde, I. (1996). Collaboration between communities and universities: Completion of a community needs assessment. Public Health Nursing, 13, 112-119. Pew Health Professions Commission. (1994). Nurse practitioners: Doubling the graduates by the year 2000. San Francisco: Author. Siegel, B. (1996). Populations. In T. Dewitt & K. Roberts (Eds.), Pediatric education in community settings: A manual (pp. 33-38). Arlington, VA: National Center for Education in Maternal and Child Health. US Department of Health and Human Services. (1991). Healthy People 2000: National health promotion and disease prevention objectives. Washington, D.C.: Author. Whelan, E. (1995). The health corner: A communitybased nursing model to maximize access to primary care. Public Health Reports, 110, 184-188. World Health Organization. (1978). Alma-Am 1978: Primary health care report of the International Conference on Primary Health Care. Geneva, Switzerland: Author. Zungolo, E. (1995). Preface. In E S. Matteson (Ed.), Teaching nursing in the neighborhoods: The Northeastern University Model. New York: Springer.
The purpose of this article is to describe an innovative partnership among academia, community, and service to better meet the health care needs of underserved populations. The Center for Community Health Education, Research, and Service--a coalition of Boston education institutions, health services providers, and community agencies--was formed with a grant from the W. K. Kellogg Foundation. The initial goal was to establish academic community health centers comparable to the large teaching hospitals that combine service, education, and research as the cornerstone of their mission. With faculty based in the neighborhood health centers, students have learning opportunities to assess, plan care, and treat individuals and families using a community-based primary care model. The nature of the partnership, including the structure and process of implementation, is described. The developmental socialization of advanced practice nursing students in a community basedsetting is discussed. Educational and service outcomes are identified. (Index words: Advanced nursing practice; Community-based model; Education; Interdisciplinary education)J Prof Nurs 15:38-43, 1999. Copyright © 1999 by W.B. Saunders Company
INCE 1991, The Center for Community Health Education, Research, and Service (CCHERS), through a grant from W. K. Kellogg Foundation's Community Partnerships Initiative, has developed and implemented a highly successful, nationally recognized model of community-based primary care education for medical and undergraduate nursing students. CCHERS is a public-private partnership that includes the Northeastern University College of Nursing NUCON), Boston University (BU) School of Medi-
S
*AssociateProfessorand Coordinator of PrimaryCare Speciallzation, Collegeof Nursing,NortheasternUniversity,Boston,MA. ?Assistant to the President, Northeastern University, Boston, MA. Supported in part by a grant from the W. K. KelloggFoundation. Addresscorrespondenceand reprint requeststo Dr Beauchesne: Northeastern University,Collegeof Nursing, 401 RobinsonHall, Boston, MA 02115. Copyright© 1999 by W.B. SaundersCompany 8755-7223/99/1501-0010510.00/0 38
cine, Boston Medical Center (BMC), and Boston's Commission on Public Health; a network of community health centers; and communities. By educating students within medically underserved and economically disadvantaged communities, and by using servicelearning and interdisciplinary approaches, this partnership has radically transformed health professions education at Northeastern University and Boston University. The CCHERS initiative provides a ready-made link to the underserved communities where at-risk populations reside. It has helped socialize baccalaureate students into a broader view of nursing and has provided them with excellent role models in the advanced practice role who provide primary care to these populations. These health centers also participate in the nursing undergraduate cooperative education at Northeastern University. CCHERS has been successful in establishing academic community health centers comparable to the large teaching hospitals that have combined service, education, and research as the cornerstones of their mission. With faculty based in the neighborhood health centers, students have learning opportunities to assess, plan care, and treat individuals and their families using a community-based primary care model. Most recently, the graduate nursing faculty collaborated with CCHERS to develop a joint proposal, a Graduate Medicine/Graduate Nursing Education (GMNE) Initiative, which also has been funded by the W. K. Kellogg Foundation, to support a combined graduate nursing and medical education initiative that focuses on interdisciplinary, community-based primary care education. The purpose of this article is to describe the impact of this partnership on graduate nursing and medical education.
Background
This graduate initiative constitutes a logical extension of the pioneering work in postbaccalaureate and
JournalofProfessionalNursing, Vol 15, No 1 (January-February), 1999: pp 38-43
39
INTERDISCIPLINARY EDUCATION
undergraduate education of the CCHERS partnership. Northeastern University and Boston University have worked collaboratively with their community partners to revise nursing and medical curricula and to institutionalize, through extensive curricular changes, the core competencies of community-based primary care. Both the N U C O N and the BU School of Medicine require community experience and an orientation toward health promotion, disease prevention, and health care provision for underserved populations in their curricula. Three interrelated goals have guided CCHERS' mission. The first has been the need to nurture a community-based, primary care educational approach that would provide the emphasis to primary care that hospital-based education has afforded to specialty education in medicine and nursing. The second is to foster and build substantive community participation in the consortium's governance and policy making to assure that CCHERS' educational programs and health practices appropriately address the populations they are meant to serve. The third goal involves creating a progressive educational track that supports and stimulates urban youths interested in health careers who might reasonably be expected to practice in their own communities.
Three interrelated goals have guided CCHERS" mission.
CCHERS has accomplished the groundwork to achieve these goals. The first mission is being addressed by the incorporation of two universities, a large city hospital and a health department, and an extensive network of community health centers and agencies into a collaborative team that oversees a primary care educational program. Both the N U C O N and BU's School of Medicine emphasize within their curricula a community-based, primary care focus. A network of academic community health centers, called the Academic Community Health Center, has been created and linked closely to the universities and to numerous community organizations (schools, elder services, youth programs, and daycare centers). The Academic Community Health Center now serves as a unifying hub for students' primary care clinical education, which is taught by an expanding nucleus of community faculty. It is at the health centers and through their service placements that students experi-
ence a community-based health approach with professionals from a variety of disciplines. The second mission, that of assuring that community constituents are true partners playing an integral role in the consortium's decision making, has been emphasized from the inception. At the heart of the consortium is the Board of Directors, established in the same model as a community-based health center board of directors. CCHERS by-laws expressly indicate that the consortium's Board of Directors, representing all of the coalitions partner institutions and communities, has the final voice in policy decisions. The board delineates the mission of the collaborative efforts and oversees all community-related policy decisions. O f its 24 directors, eight are community representatives, eight come from health centers, and eight come from universities and hospitals. The CCHERS board also serves as the overarching governance structure for the GMNE initiative. The resulting partnership links the universities, the health centers, and the communities, enabling the community to identify health service needs and to match those service opportunities with the appropriate educational levels and needs of the medical and nursing students, residents, and advanced practice nurse students. The CCHERS' partnership also has built the foundations for its third mission: a connecting educational pathway into the health professions. Although Boston is renowned for its health and educational institutions, every year fewer than 1 per cent of its public school graduates enter programs leading to a health career. To begin to remedy the chronic underrepresentation of people of color in health professions, CCHERS fosters an educational continuum that provides inner-city students with opportunities to develop academic and personal skills and makes available social and family supports to facilitate their pursuit of health careers. The educational pathway begins in the middle school years, progresses through affiliated high school programs--Health Careers Academy and East Boston's Hope Alliance--and continues into college and university health professions programs. The W. K. Kellogg GMNE initiative represents the final piece in that seamless pathway that CCHERS has envisioned.
THE W. K. KELLOGG GMNE INITIATIVE
Nationally respected graduate nursing and residency programs that include strong community-based
40
BEAUCHESNE AND MESERVEY
primary care specializations already existed at both universities and BMC. BMC offers pediatric and internal medicine residencies in primary care in conjunction with BU School of Medicine. Since its inception in 1989, the Primary Care Specialization within the Graduate School of Nursing at Northeastern University has aimed to prepare pediatric, adult/ older adult, and family nurse practitioners to provide primary care to underserved populations. In 1994, a Home Health Nurse Practitioner Program was launched within the Community Health Specialization to provide yet another avenue for primary care education. Both universities and the hospital strongly support emphasizing the base of the community practice in their respective programs. It is the goal of the W. K. Kellogg GMNE Initiative to enable these already-established programs to fulfill the following objectives: (1) extend community-based primary care experiences; (2) develop an innovative, creative, interdisciplinary educational model; and (3) extend faculties' interests in urban primary care. At the same time, this initiative will strengthen the network of academic community health centers, which are already becoming the loci where diverse resources concentrate to provide rich educational opportunities for communitybased education.
NURSE PRACTITIONER EDUCATION
The Draft Year 2000 Objective (U.S. Department of Health and Human Services, 1991) clearly speaks to the need to increase access for all citizens to health services. A major purpose of this project is to educate nurse practitioners who are better prepared to provide primary care to underserved populations. It has become evident that educators need to prepare nurse practitioners who can not only provide primary care to individuals and families but who can impact public policy and empower communities to accomplish this goal (Fenton, Rounds, & Anderson, 1991; Forker, 1996). Primary care can be narrowly defined as the care the client receives within the health care system at the first point of contact to resolve a presenting problem (American Nurses Association, 1985). The World Health Organization (1978) advocates for a broader definition of primary health care that recognizes the family and community as the basis for providing health care in various settings. According to this definition, primary health care promotes maximum community and individual self-reliance and participation in the planning, organization, operation,
and control of primary care. We can only successfully increase access to primary health care through decreasing barriers to health care services, increasing utilization of services, and improving the health of the community as a whole (Whelan, 1995). Although the NUCON's Primary Care Specialization has successfully prepared nurse practitioners to meet the health needs ofunderserved populations, it is clear that we need to develop a more comprehensive, community-based primary care curriculum to meet the health care needs of the future (Knollmueller, 1994). Experts on health policy and health education debate the differences between community-oriented versus community-based care (Siegal, 1996). The basic elements of community-oriented primary care (COPC) include primary care, epidemiology, defined populations, defined health problems, and community involvement. COPC uses the scientific principles of epidemiology, biostatistics, and public health to understand community health issues and integrates concepts of primary care with assessment, analysis, planned interventions, and evaluation of community programs to improve the health status of the community as a whole (Siegel). Community-based care refers to care, which may or may not be medical, that takes place in community settings. The goal of any community-based educational program is to highlight the special concerns of an identified population through a community-oriented primary care approach by teaching students in that very community base. A community can be described by natural borders, such as geography, or by population, risk of illness/adverse outcomes, or special needs (Goldhagen, 1996). People live in communities. Primary care is learned best in the community.
COMMUNITY-BASED EXPERIENCES
It is the intent of this initiative to build on the foundations laid by CCHERS and articulated in the philosophy of the Northeastern University Model (Table 1). Although graduates receive many clinically precepted experiences in these health centers already, they will be more fully integrated into the partnership through participating in interdisciplinary-based community care. The development of longitudinal community-based experiences enables graduate nursing students to develop more depth in their experiences within the community and expand their learning activities in both clinical practice and in research (Zungolo, 1995).
INTERDISCIPLINARYEDUCATION TABLE 1. The Northeastern University Model Nursing students learn about the multiple aspects of a neighborhood and build relationships with residents and providers by returning to the same area for clinical placements across the curriculum. Neighborhood residents and health care providers collaborate with the college of nursing and share in the educational process of its students. The collaborative process provides an opportunity for community residents and the academic participants to learn more about the realities of each other's worlds. Client-centered health care, developed in this collaborative process, empowers both the nursing students and the residents of the neighborhood to become involved in interventions. Students learn to view health/illness as part of the total lived experience of their clients.
41
the evolving health care environment (Finocchio, Dower, McMahon, Gragnola, and the Task Force on Health Care Workforce Regulation, 1995). In their health center base, the graduate nursing student will be paired with medical residents in appropriate teams, eg, pediatric nurse practitioner students with pediatric residents. This team, in turn, will be matched with a clinical precepting team or a nurse practitioner and attending physician who have worked coUaboratively and who have shared responsibility for a panel of patients. In their community agency experiences, the nurse practitioner student and resident will become a further part of an ongoing interdisciplinary team.
Data from Zungolo (1995).
Community-based experiences should be viewed not as an adjunct to but as an integral part of nursing education. The goals of community-based education include students gaining an understanding of the following (Kohr & Barnett, 1996): 1. the role and contribution of health care providers within the community and health care system; 2. the community context and determinants that affect the delivery of primary health care; and 3. the role of advocacy and need for collaboration. The focus of community-based learning experiences are varied and diverse in nature and include multiple settings (Table 2). The interdisciplinary team should be the central learning unit of any community experience. In the current project, both graduate nursing students and medical residents participate as members of a collaborative team in underserved communities. Because integrated team care is thought to be the most effective and efficient way to promote comprehensive quality care of complex health issues nationally, it will continue to grow in importance in TABLE 2. Community-Based Leaning Experiences Health supervision, health promotion, disease prevention Cultural sensitivity in health care Disease-based programs High-risk populations Home-based programs Institutional approaches to special needs Data from Siegel (1996).
• . . integrated team care is thought to be the most effective and efficient way to promote comprehensive quafity c a r e • . .
To assure that community practice is at the base of this model, four significant curricular trends will be implemented. 1. Clinical practice within a community health center will expose the learners to a diversified patient mix with a variety of health concerns. They also will be exposed to the complex array of familial, cultural, and socioeconomic factors that affect health. 2. An interdisciplinary community experience caring for a high-risk population will be developed to enable the student/resident health care team to practice communitybased primary care as part of an existing interdisciplinary team. The opportunity to work with the sophisticated role models of these teams will provide a strong base for the student/resident's future practice. 3. A new 2-year interdisciplinary seminar will be instituted emphasizing an epidemiological approach to community-based primary care. Monthly seminars and self-directed reading programs will be designed to supplement the continuing clinical experience and bring all participants together across sites. Faculty preceptors from the Academic Community Health Center, in collaboration with university faculty, will coordinate the seminars,
42
BEAUCHESNEAND MESERVEY
which will be presented to the GMNE cohort rotating from center to center. Content will emphasize public health and epidemiological aspects of care; the cultural, social, and health contexts pertinent to urban community practice; and the increasingly important policy and business aspects of care. . Nurse practitioner students and residents will undertake a steadily increasing communitybased clinical project in association with either the student/resident's continuity clinic or interdisciplinary experience. In addition to complementing existing services, nursing students will conduct a project or participate as an integral part of an ongoing project that has significance for this community-based practice and that benefits the existing team's work. Appropriate topics may include examining needs assessment data, conducting new needs assessments, and evaluating utilization patterns or efficacy of services. Through this interdisciplinary, community-based approach, graduate nursing students and residents are expected to gain a working knowledge of and an appreciation for the complexity of caring for urban, underserved communities in the neighborhood setting. Key outcomes suggested by the program include, graduates accomplishing the following: 1. choose careers in primary care in underserved settings, particularly inner-city, low-income communities; 2. demonstrate knowledge of community needs and resources; 3. demonstrate competence in providing comprehensive primary care services; 4. work effectively within interdisciplinary teams; 5. understand the contributions and methods of public health, epidemiological, and applied research approaches in the community setting; and 6. be prepared to deliver community-based primary care.
attaining specific educational outcomes will be rated. Focus group evaluations will be completed by project staff twice a year to review strategies of program, barriers to implementation, and progress to date. Written evaluations of each component of the program will be developed and completed annually by both university and community faculty and residents and graduate nursing students.
Summary As we enter the 21st century, the challenge to improve the health of our nation is gaining impetus and recognition. The Draft Year 2000 Objectives (US Department of Health and Human Services, 1991) stress the priority areas of health promotion, health protection, preventive services, and systemwide improvements. Nurse practitioners have been documented to be cost-effective providers of quality care (Pew Health Professions Commissions, 1994). We need to prepare nurse practitioners who can provide primary care for individuals and families and can also assess, plan, intervene, and evaluate the needs of communities (Kulig & Wilde, 1996). Communitybased primary care nurse practitioner programs must be developed that include foundations in providing primary care to families in specific populations through the assessment and management of health concerns, including health promotion and prevention. In addition, community health concepts, such as community assessment analysis, must be integrated into practice settings. To effect change on a larger scale, nurse practitioners must contribute or conduct primary care research in the community as well. There exists a need for more effective links between community and academic institutions for the provision of practical and pertinent learning experiences on the graduate level. The authors hope that through the efforts of the innovative partnership described in this model that the following outcomes can be achieved: (1) nurse practice students will be socialized into a broader view of primary care; (2) a commitment to the provision of primary health care for underserved populations will be fostered; and (3) the quality and quantity of community-based service offerings will be improved.
EVALUATION
Evaluation of educational outcomes will be accomplished through a variety of sources. Community faculty/preceptor evaluations will be completed on an annual basis in which students' progress toward
Acknowledgment The authors thank the CCHERS and the Task Force on Graduate Education for their support and assistance in the development of this project.
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INTERDISCIPLINARY EDUCATION
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