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Imogene: A Simulation Innovation to Teach Community Health Nursing
Clinical Simulation in Nursing (2013) 9, e513-e519
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Featured Article
Imogene: A Simulation Innovation to Teach Community Health Nursing Aliyah Mawji, RN, PhDa,*, Candace Lind, RN, PhDb a b
Assistant Professor, School of Nursing, Mount Royal University, Calgary, AB T3E 6K6, Canada Assistant Professor, Faculty of Nursing, University of Calgary, Calgary, AB T2N 1N4, Canada KEYWORDS community health theory; simulation innovation; social justice; social determinants of health; health promotion
Abstract: Although simulation is well established as a method to teach skills and concepts related to the acute care setting, we propose that educators begin to expand their thinking of the use of simulation to engage students in learning community health course content. This article demonstrates how medium-fidelity and low-fidelity simulation can be used in theory courses to introduce broad community health nursing concepts to junior and senior students, including social justice, harm reduction, activism, and social determinants of health. We share this simulation innovation and invite others to explore incorporating this innovation into their own classroom settings. Cite this article: Mawji, A., & Lind, C. (2013, November). Imogene: A simulation innovation to teach community health nursing. Clinical Simulation in Nursing, 9(11), e513-e519. http://dx.doi.org/10.1016/j.ecns.2013.03.004. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Introduction Community health nursing is recognized as a specialty area of nursing practice in many parts of the world (Clark, 2008). Villeneuve and MacDonald (2006) predict that by 2020, approximately 66% of all nurses in Canada will practice in a variety of community-based settings. Community health nurses work with individuals, families, communities, and populations to build capacity and promote an environment that supports health (Diem & Moyer, 2005). One of the principal values of community health is social justice (Donley, 2010; Drevdahl, 2013). The beliefs underlying social justice hinge on fairness in the way people are treated, how decisions are made, and how resources are No extramural funding was received for this work. No commercial financial support was received for this work. * Corresponding author: [email protected] (A. Mawji).
distributed (Drevdahl, 2013). The focus of social justice is on the relationships among people, the respect all people are entitled to, and on how society promotes (or impedes) individuals’ or groups’ health (Jecker, 2008). In this way, social justice exemplifies the primary purpose of community health, which is to improve the health and well-being of individuals, families, communities, and populations (Gostin & Powers, 2006). The importance of social justice is also emphasized in recent documents published by the Canadian Nurses Association (2006, 2010) and the Canadian Public Health Association (2010). Over the past few decades, there has been an increase in concerns raised about widening inequities in the health status of people in North America and worldwide (Wallerstein, Yen, & Syme, 2011). With this context in mind, it is important to take a more overt approach to incorporating the concept of social justice in theory content in undergraduate community health nursing classes. We
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experienced challenges engaging our senior undergraduate students in learning community health nursing principles and practices, with classroom comments received such as ‘‘I don’t understand why I need to learn community health when all I want to do is work in acute care.’’ Some students denigrated the importance of this knowledge for their Key Points own future practice, regard Simulation has a strong less of their desired practice history of use in teachsettings. Overall, many stuing acute care skills. dents did not value or under Simulation can be used stand community health and in theory classes to its impact on individuals’ teach broad concepts. health. This was of grave This article provides an concern to our instructors. example of how simulaHow could we draw paraltion was used to teach lels to their areas of interest? concepts such as social How could we show the imjustice in a community portance of the principles health theory class. and practices we were teaching in a way that had a meaningful impact on our students? This article will demonstrate how we fostered a simulation learning environment (INASCL, 2011) in a theory course, and how social justice and other key community health concepts are now taught through the use of simulation in community health theory classes.
Literature Review Simulation technology has been incorporated into nursing programs for years. Several advantages for using simulation in nursing education have been identified. For example, simulation techniques offer a safe environment for learners as a way to improve nursing competence (Garrett, MacPhee, & Jackson, 2011). Simulation also allows students to become more comfortable in receiving feedback about their clinical performance and provides consistent and comparable experiences for all students (KimGodwin, Livsey, Ezzell, & Highsmith, 2013). In addition, students learn a mix of technical and nontechnical skills including communication, teamwork, and delegation (Medley & Horne, 2005). Within the Canadian context, students and instructors have reported positive learning experiences with simulation, particularly in understanding complex patient care scenarios, multidisciplinary team scenarios, team-based learning, and reflective debriefing (Garrett et al., 2011). Furthermore, simulation technology has been applauded for its role in developing clinical reasoning skills to enhance nurses’ abilities to build upon previous knowledge and past experiences to effectively manage new or unfamiliar situations (Lapkin, LevettJones, Bellchambers, & Fernandez, 2010). A variety of simulation equipment is available for nurse educators to access, offering opportunities to use an
expansive assortment of teaching methods and techniques. Simulation ‘‘fidelity’’ is defined as the believability or the degree to which a simulated experience approximates reality (INASCL, 2011). As fidelity increases, realism increases. The level of fidelity is determined by the environment, resources used, and participant-related factors. ‘‘Fidelity can involve a variety of dimensions, including (a) physical factors such as environment, equipment, and related tools; (b) psychological factors such as emotions, beliefs, and self-awareness of participants; (c) social factors such as participant and instructor motivation and goals; (d) culture of the group; and (e) degree of openness and trust, as well as participants’ modes of thinking’’ (INASCL, 2011, p. S5). Nursing programs tend to use more lowfidelity simulation than medium- or high-fidelity simulation (Garrett et al., 2011). We describe below the details of how we used both low- and medium-fidelity exercises in our community health theory class setting. Although many nursing programs have made large investments in simulation technology with great potential for nursing education, this potential has been underestimated and underused (Medley & Horne, 2005). Simulation technology is best known for preparing students to practice nursing with patients in an acute care setting. Very little attention has been focused on using simulation to prepare nurses to work in the community; however, this is beginning to change, particularly in the area of home care in the United States and in the United Kingdom. In the United States, Kim-Godwin et al. (2013) used a home visit simulation experience as part of community health clinical rotations. Phillips, Grant, Milligan, and Moss (2012) described how a home environment simulation experience was developed to teach cultural competence to undergraduate nursing students within the context of home care in the United States. Unsworth, Tuffnell, and Platt (2011) used simulation to teach students about specific disease presentations in the context of home care decision making in the United Kingdom. Lastly, Campbell, Themessl-Huber, Mole, and Scarlett (2007) described simulating a home visit in a client’s home environment in the United Kingdom, with an intent to challenge students’ beliefs and values related to clients and members of other professions. Although Patterson and Hutlon (2012) engaged U.S. students in a poverty simulation role-play experience within their community health clinical practicum, to our knowledge, we are the first to explore using manikin simulation to teach broader concepts of community health, such as social justice, within the context of a theory course.
Key Concepts in Community Health An earlier opportunity to revise our undergraduate community health theory course led to a search for key concepts we felt were important to teach our students so they could have a strong foundation upon which they could
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build their future nursing practices. The population health promotion model (Flynn, 1999), which arose from the landmark Ottawa Charter health promotion actions (World Health Organization, Health and Welfare Canada & Canadian Public Health Association, 1986) provided the foundation for our work. Primary health care, advocacy, and activism in nursing, community development, harm reduction, social determinants of health, upstream approaches to health, levels of prevention, and the importance of understanding and addressing the root causes of health issues in populations formed the basis of our new curriculum. Key additional concepts emerging in the Canadian nursing literature included social justice and equity (CNA, 2006). Social justice focuses on the health of the general population and defines the determinants of health as being societal in nature (CNA, 2010). Social justice is defined as one of the most important goals of social progress, with nurses having an obligation to take responsible action to eliminate forms of systematic inequity and oppression inherent in diverse social groups, such as racism, sexism, heterosexism, and classism. Social justice is described as the degree of equal opportunity made available by the political, social, and economic structures and values of a society; in other words ‘‘Social justice means the fair distribution of society’s benefits, responsibilities and their consequences. It focuses on the relative position of one social group in relationship to others in society as well as on the root causes of disparities and what can be done to eliminate them’’ (CNA, 2006, p. 7). Underlying this statement is the belief that people are entitled equally to key ends such as health protection and minimum standards of income. The social determinants of health include income and social status, social environments, work and working conditions, education, social support networks, genetic endowment, personal coping skills, health services, healthy child development, culture, physical environments, and gender (Flynn, 1999). There have been many renditions of these determinants; however, present in all of them is the need for these social determinants of health to show the interplay between the multifaceted factors that influence the health of individuals and communities, demonstrating that what determines one’s health extends far beyond simply lifestyle choices. Social determinants of health are now considered the primary influences of health across the lifespan (Raphael, 2012). For example, poverty is a huge underlying root cause of many of the issues that people experience in relation to their social determinants of health. Indeed, Raphael (2006) suggested these determinants of health are a much stronger predictor of health status than behavioral factors, even obesity and tobacco use (Lind, Loewen, & Mawji, 2012). Adoption of health-threatening behaviors are strongly shaped by the social and economic environments in which people live. High levels of stress and little
control produce behaviors aimed at ameliorating tensions, such as high fat diets, poor nutrition, and tobacco use. In efforts to bring these key concepts to life in our classroom, we developed a simulation activity as one of our teaching tools.
Imogene: A Simulation Manikin Imogene Henderson was brought into class on either the first or second day of the term to engage students’ interest in class content and to set the stage for the key community health concepts the course would be covering. Imogene is a manikin dressed as a homeless, battered sex trade worker. Moulage techniques are used on the manikin to simulate dirt and injuries, including fresh lacerations on her arms, bruises, a black eye, and bleeding from her nose and ear (Figure 1). In addition she has bruising on both upper arms in the shape of hand prints and track marks on her antecubital fossa. Imogene is dressed in her ‘‘working clothes,’’ complete with jewelry and makeup. A case study of her life story is presented in Appendix A.
Process Using Imogene has proven to be a flexible simulation exercise. Developed initially as a case study for a senior-
Figure 1
Imogene Henderson, the manikin.
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level community health theory course, she was then adapted for a junior-level community health theory course. The adaptation occurred because the nursing curriculum was revised and community health became a junior-level course. Faculty members felt that Imogene was an invaluable simulation exercise to carry forward into the new curriculum. For the junior-level course, it was a low-fidelity exercise, and for the senior course, it was a medium-fidelity exercise, targeted at building upon previous acute care learning. The two iterations are described below. Medium Fidelity For the medium-fidelity exercise, Imogene was introduced as a 1-hour exercise in the first day of the community health theory class. Imogene was brought to the front of the theory classroom on a stretcher. Two instructors facilitated the activity. One instructor asked for a group of four student volunteers to come to the front of the room and, in front of their classmates, use their acute-care skills to complete a head-to-toe assessment of the extent of Imogene’s injuries. They were then asked to consider which health issues she might be at risk for. They were told they could ask Imogene questions. The rest of the students were encouraged to provide input and suggestions to the four student volunteers. While one instructor managed this process, the other instructor was hidden behind a screen with a microphone, providing the voice of Imogene through the manikin to answer students’ assessment questions. Students checked the manikin’s blood pressure, assessed injuries, and asked her questions. The scenario was that Imogene had come into the emergency department dirty, with bruises, a black eye, lacerations, track marks, a congested cough with crackles and gray sputum, and a blood pressure of 145/90. Imogene asked questions such as ‘‘Can I go for a smoke?’’ and made statements like ‘‘My boyfriend got mad and hit me, it’s no big deal, I’ve had worse injuries.’’ Imogene’s history was shared with the class following a discussion of their initial impressions gained from the head-to-toe assessments (including her vital signs). A warning that the story had content that might be upsetting to some students was given before the story was read, and afterward counseling resources were shared with the class in case anyone was upset and needed support. We felt it was very important to share Imogene’s life history with the class after they had already completed their assessments and had started to form impressions about who she was. One class instructor read Imogene’s story of her childhood to the class. We found the story was very powerful; the room was silent when Imogene’s sequence of life events during her childhood was shared with the students. We then handed out a series of questions for students to answer in small groups. The small group questions posed included: 1. What risks did you pick out from Imogene’s story? 2. How is she likely treated by society, in general?
3. Is it okay that Imogene’s life has turned out this way? 4. What is it that we as nurses can do about this? Students were then asked to share their answers with the class, using one spokesperson per group. Students identified risks such as tobacco and drug use, possible sexually transmitted infection, elevated blood pressure, low selfesteem, lack of social support, lack of education, and a high-risk working environment. The larger class conversation evolved into a discussion of the roles nurses play in scenarios such as Imogene’s. Heated discussions arose when students shared how attitudes, beliefs, and assumptions affect nursing behaviors, regardless of the setting. Discussions at times also led into the area of harm reduction and nursing roles in tertiary forms of prevention. This exercise set the stage for addressing the bigger picture of the health of individuals, communities, and population groups. Imogene assisted students to identify how the concepts of social justice, community development, and harm reduction can be used in concert with the determinants of health in the population health promotion model (Flynn, 1999) to promote health at the individual, family, community, system, and population levels. This medium-fidelity exercise introduced community health nursing where the focus is on a much broader picture of people’s lives and their health than students were familiar with. The course focus was on identifying and addressing root causes of health issues nurses see in practice, rather than solely focusing on individual outcomes related to lifestyle or other issues. Low Fidelity Once the undergraduate curriculum had been revised, we decided to preserve the teaching success we had experienced with Imogene when used with senior students. Imogene had to be adapted to a learner context where the students had not yet had any acute care experience. We were therefore unable to ask them to complete a head-totoe assessment; instead we asked the students to look at her injuries and speculate what might have happened to her. The low-fidelity adaptation of Imogene achieved similar objectives for us as course instructors; however, some key differences were necessary to adjust for the junior-level course. This version of the simulation included less significant levels of equipment and related tools than the medium-fidelity version. On the second day of our junior-level class, our manikin in full moulage was brought to the classroom in a wheelchair, laid out on a table at the front of the room, and covered with a sheet until we were ready to start the exercise. The only introduction students were given was that this was Imogene Henderson who was laying on a stretcher in our simulated emergency department. In the low-fidelity simulation, we focused on appearance rather than head-to-toe assessment and vital signs skills for our community health learning context. Additionally, Imogene
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did not have a voice and students could not ask her questions. In this exercise, small groups of approximately eight students at a time were asked to come to the front of the classroom to view Imogene for 2-3 minutes, jot notes on the injuries they saw, then spend a few minutes sharing their initial observations and impressions of Imogene with each other and postulate on what might have happened to her. They were given no history and no other information at this point. Students were to simply record their observations. Students were asked to consider the following questions: (a) ‘‘What did you see?’’ (b) ‘‘What state is she in?’’ and (c) ‘‘What might have happened?’’ Once all of the student groups had viewed Imogene up close and conferred with their group members, the instructor asked a spokesperson from each group to share his or her group’s findings in a large class discussion, until all of the observations and initial impressions had been shared. Students discussed their thoughts about the health problems Imogene might have and their initial impressions as they looked at her laid out on the table. Most of the student groups suggested Imogene appeared to be a prostitute (related to her clothing and appearance), and that it looked like she had been beaten up based on the nature of the bruising and cuts they saw on her face and upper body. Assumptions and value judgments were evident in the student comments and ranged from more neutral suggestions for interventions based on harm-reduction principles (they correctly identified the needle-track marks) to outright blaming her for her apparent assault because of her profession. One student commented that she deserved this based on her choice to be a prostitute. Following the whole class discussion, the instructor then read Imogene’s one-page history of her childhood (Appendix A) to the class. The warning described previously was given and counseling resources were made available. The students were given a worksheet outlining Imogene’s story and the first three of the four original questions to answer as a group. They were asked to identify the health risks they picked out from Imogene’s assessment and her story, to discuss how she is likely treated by society, and to provide a rationale for their response to whether or not it is okay that her life has turned out this way. A large class discussion ensued following this exercise with a focus that evolved to include the potential effects of stigmatization on people’s health, social determinants of health, and larger societal implications. The effects of health care professionals’ beliefs and attitudes and how they impact interactions with different populations were also regularly raised in these discussions. For the junior course, Imogene was also used as a case study that became the focus of an end-of-semester group presentation (the semester was 13 weeks long), representing critical thinking, clinical reasoning, and clinical judgment at a novice nurse level (INASCL, 2011). She had evolved to become a capstone evaluative learning tool for students where they were tasked to develop a series
of recommended interventions to address Imogene’s health issues and improve her social determinants of health. For this assignment three additional scenarios were developed, representing key points in Imogene’s life where nursing interventions may have prevented future health issues (Appendix B). Briefly, one scenario was when Imogene was in grade 6 and had complained to her teacher about recurring stomach aches. The second scenario was when Imogene was 14 years old and discovered that she was pregnant; the third scenario was Imogene as an adult at the current point in time where she expressed her desire to get off the streets and to help some of her friends get off the streets as well. Students were assigned in groups to one of the three life-point scenarios and were asked to intervene with a series of strategies that would promote her health and help prevent a future deterioration of her health. Students used the aforementioned key course concepts to identify and address key issues, framing their interventions within the population health promotion model to address social determinants of health and multiple action strategies and levels for action (i.e., at the individual, family, community, structural or system, or societal level). On presentation day, Imogene (the manikin) attended the students’ presentations, at the corresponding age. Two scenarios required us to use child manikins, the other to bring the adult Imogene in her working attire, but with only remnants of her injuries (i.e., faded yellow bruising to indicate healing had occurred).
Implications for Teaching and Research The cultures of the two groups of students involved in this simulation experience varied significantly, as did their modes of thinking (INASCL, 2011). The novice learners (junior students) were socialized to think through a community lens much sooner than the learners who had worked with one another for 2 years prior to participating in the medium-fidelity version. The junior students may have had a higher degree of trust and openness to this in-class activity than the learners who had been exposed to acute care settings prior to participating in the medium-fidelity exercise. We felt both versions of the simulation exercise were effective in addressing the dimension of psychological factors (emotions, values, beliefs, and self-awareness) of students (INASCL, 2011). There are a variety of ways that students can be encouraged to explore concepts and relationships between concepts in a theory classroom environment. We chose to incorporate a simulation learning environment (INASCL, 2011) into our theory course as a way for the students to understand the application of theory to community health practice. This proved to be a valuable exercise wherein students’ values, beliefs, and attitudes about marginalized groups of people were explored and challenged. Students were also challenged to think about how concepts related
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to community health could be valued, respected, and implemented, regardless of the practice setting they choose to work in after graduation. Although simulation is well established as a method to teach skills and concepts related to the acute care setting, we propose that educators begin to expand their thinking of the use of simulation to engage students in learning community health course content. In addition, we feel simulation can be an effective teaching tool to bring abstract course concepts to life. Research studies should be undertaken to evaluate the effectiveness of such simulation exercises within the context of theory classes.
Conclusion This article has demonstrated how simulation can be used in theory courses to introduce broad community health nursing concepts to junior and senior students, including social justice, harm reduction, activism, and social determinants of health. This is an example of a teaching innovation that also caught the eye of the public. Through our success in using this simulation exercise, we received extensive local and national media coverage including a video interview with the Canadian Broadcasting Corporation News, a television interview with the host of a morning show, and various print exposures. In conclusion, as we continue to revise and refine this particular simulation, we offer Imogene as a teaching innovation for others to explore. Implementing this teaching innovation was exciting and invigorating for our instructors. It was equally exciting for our students who were more actively engaged in the learning process and demonstrated much enthusiasm for learning community health content. We feel we have only skimmed the surface of potential applications of Imogene and invite others to explore incorporating her into their own classroom settings.
References Campbell, M., Themessl-Huber, M., Mole, L., & Scarlett, V. (2007). Using simulation to prepare students for interprofessional work in the community. Journal of Nursing Education, 46(7), 340. Canadian Nurses Association (CNA). (2006). Social justice . a means to an end, an end in itself. Ottawa, ON: Author. Canadian Nurses Association (CNA). (2010). Social justice . a means to an end, an end in itself (2nd ed.). Ottawa, ON: Author. Canadian Public Health Association. (2010). Public healthe community health nursing practice in Canada: Roles and activities (4th ed.). Retrieved April 18, 2013, from http://www.cpha.ca/uploads/pubs/ 3-1bk04214.pdf Clark, M. J. (2008). Community health nursing: Advocacy for population health (5th ed.). Upper Saddle River, NJ: Pearson Education.
Diem, E., & Moyer, A. (2005). Community health nursing projects: Making a difference. Philadelphia: Lippincott Williams & Wilkins. Donley, R. (2010). Nursing, social justice and the marketplace. Health Progress, 91, 34-37. Drevdhal, D. J. (2013). Injustice, suffering, difference: How can community health nursing address the suffering of others? Journal of Community Health Nursing, 30(1), 49-58. Flynn, L. (1999). Population health promotion model. Revised from original model developed by N. Hamilton and T. Bhatti, Health Promotion Development Division, Health Canada, 1996. Winnipeg, MB: Health Canada, Manitoba/Saskatchewan Region. Garrett, B. M., MacPhee, M., & Jackson, C. (2011). Implementing highfidelity simulation in Canada: Reflections on 3 years of practice. Nurse Education Today, 31, 671-676. Gostin, L. O., & Powers, M. (2006). What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs, 25, 1053-1060. International Nursing Association for Clinical Simulation and Learning (INASCL). Board of Directors. (2011). Standard I: Terminology. Clinical Simulation in Nursing, 7(4S), S3-S7. http://dx.doi.org/10.1016/j.ecns.20 11.05.005. Jecker, N. S. (2008). Response to open peer commentaries on ‘‘a broader view of justice.’’ American Journal of Bioethics, 8, W1-W2. Kim-Godwin, Y. S., Livsey, K. R., Ezzell, D., & Highsmith, C. (2013). Home visit simulation using a standardized patient. Clinical Simulation in Nursing, 9(2), e55-e61. http://dx.doi.org/10.1016/j.ecns.2011.09.003. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6(6), e207-e222. http://dx.doi.org/10.10 16/j.ecns.2010.05.005. Lind, C., Loewen, S., & Mawji, A. (2012). Health promotion. In D. D’Amico, C. Barbarito, N. Harder, & C. Twomey (Eds.), Health & physical assessment in nursing (Canadian ed.). (pp. 22-36) Toronto, ON: Pearson Canada. Medley, C. F., & Horne, C. (2005). Using simulation technology for undergraduate nursing education. Journal of Nursing Education, 44(1), 31-34. Patterson, N., & Hutlon, L. J. (2012). Enhancing nursing students’ understanding of poverty through simulation. Public Health Nursing, 29(2), 143-151. Phillips, J., Grant, J. S., Milligan, G. W., & Moss, J. (2012). Using a multicultural family simulation in public health nursing education. Clinical Simulation in Nursing, 8(5), e187-e189. http://dx.doi.org/10.10 16/j.ecns.2011.08.007. Raphael, D. (2006). Social determinants of health: Present status, unanswered questions, and future directions. International Journal of Health Services, 36(4), 651-677. Raphael, D. (2012). Educating the Canadian public about the social determinants of health: The time for local public health action is now! Global Health Promotion, 19(3), 54-59. Unsworth, J., Tuffnell, C., & Platt, A. (2011). Safe care at home: Use of simulation training to improve standards. British Journal of Community Nursing, 16(7), 334-339. Villeneuve, M., & MacDonald, J. (2006). Toward 2020: Visions for nursing. Ottawa, ON: Canadian Nurses Association. Wallerstein, N. B., Yen, I. H., & Syme, S. L. (2011). Integration of social epidemiology and community-engaged interventions to improve health equity. American Journal of Public Health, 101(5), 822-830. World Health Organization, Health and Welfare Canada, & Canadian Public Health Association. (1986). Ottawa charter for health promotion. Geneva, Switzerland: Author.
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Appendix A
Appendix B
Imogene Henderson’s Story
Three Scenarios Representing Key Points in Imogene’s Life
Imogene is a 34-year-old Caucasian female. She was born in 1979 Calgary, Alberta; into a lower socioeconomic status family. Her father, John, completed grade 11 and earned $2.90 per hour as a janitor in the local high school in Ogden. Her mother, Sally, completed grade 6 before she had to quit school and help out on the family farm. Luckily her grandmother taught her how to sew as there was no money to spend on ready-made clothing in those days. Sally was a seamstress who worked from home so she could care for her five children. She earned approximately $0.50 per hour sewing and mending clothes 2 days a week. An hour of her work would buy one loaf of bread for her family. Life was difficult for the Hendersons. Many evenings John would frequent the local bar and it wasn’t unusual for him to come home drunk and angry. Often Sally would take the brunt of his anger and she hid her bruises when she needed to go do her errands. She would often need to venture out on foot on cold winter days to the bus stop that was three blocks away. Imogene is the oldest of five children and needed to stay home to babysit and look after her siblings when her mom was ‘‘unwell.’’ The family’s favorite uncle, Tom, was a frequent visitor and often brought presents. Imogene recognized early on that she was Uncle Tom’s favorite as he would give her an extra present if he could touch her. This relationship with Uncle Tom escalated into a sexual relationship. At the age of 14 Imogene told her parents that she was pregnant. Her parents were angry and ashamed and arranged for Imogene to have a ‘‘backyard’’ abortion. As a result, Imogene developed an infection that was accompanied by pain. Her cousin Steve was able to find some morphine pills from his friends. Imogene often found herself asking Steve to find more. Sally and John would often find Imogene sleeping when she should have been at school. Imogene would disappear for days at a time, leaving her siblings alone, and when she did come home, it was a volatile place. One day after the umpteenth visit from the truant officer, John, in a drunken rage, threw Imogene into the wall, breaking her left arm, then picked her up and physically threw her out into the street yelling for her never to come back home, saying ‘‘you’re no child of mine!’’ As a result Imogene never returned to school and started surviving on the street.
Scenario A The clock of time has been turned back and you have an opportunity to intervene in Imogene’s life before some of the future events will happened. You are a community health nurse who works in Imogene’s elementary school, where she is attending grade 6. Her teacher is worried about Genie’s recurring stomach aches and asks you to see her. The teacher shares with you that she thinks things are troubled at home. Although a referral to a family physician to assess for a biomedical issue may be appropriate, you also know that stomach aches can be a symptom of emotional upset in children. Using the population health promotion model, consider individual and other levels at which health promoting change could occur. Scenario B The clock of time has been turned back and you have an opportunity to intervene in Imogene’s life in a time of trouble in her adolescence. You are a community health nurse working at a sexual health clinic and 14-year-old Genie has come to see you because she worries she may be pregnant. Once the physical assessment and tests have been completed, you see an opportunity to develop rapport with Genie and address some of the larger issues that are occurring in her life. Using the population health promotion model, consider individual and other levels at which health promoting change could occur. Scenario C You are a community health nurse who is working with Imogene now at age 34, after she expressed a desire to get off the streets. Imogene shares that she has been a sex trade worker for the past several years, and she regularly gets beaten by her ‘‘boyfriend’’ who is her pimp. In addition, Genie smokes, drinks, and also uses illegal drugs from time to time. She also wants to help her street friends who she worries about, especially because of the levels of violence she sometimes sees on the streets. Using the population health promotion model, consider multiple levels for action and strategies for change that could directly or indirectly promote the health of Genie and this community of people.
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Featured Article
Imogene: A Simulation Innovation to Teach Community Health Nursing Aliyah Mawji, RN, PhDa,*, Candace Lind, RN, PhDb a b
Assistant Professor, School of Nursing, Mount Royal University, Calgary, AB T3E 6K6, Canada Assistant Professor, Faculty of Nursing, University of Calgary, Calgary, AB T2N 1N4, Canada KEYWORDS community health theory; simulation innovation; social justice; social determinants of health; health promotion
Abstract: Although simulation is well established as a method to teach skills and concepts related to the acute care setting, we propose that educators begin to expand their thinking of the use of simulation to engage students in learning community health course content. This article demonstrates how medium-fidelity and low-fidelity simulation can be used in theory courses to introduce broad community health nursing concepts to junior and senior students, including social justice, harm reduction, activism, and social determinants of health. We share this simulation innovation and invite others to explore incorporating this innovation into their own classroom settings. Cite this article: Mawji, A., & Lind, C. (2013, November). Imogene: A simulation innovation to teach community health nursing. Clinical Simulation in Nursing, 9(11), e513-e519. http://dx.doi.org/10.1016/j.ecns.2013.03.004. Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Introduction Community health nursing is recognized as a specialty area of nursing practice in many parts of the world (Clark, 2008). Villeneuve and MacDonald (2006) predict that by 2020, approximately 66% of all nurses in Canada will practice in a variety of community-based settings. Community health nurses work with individuals, families, communities, and populations to build capacity and promote an environment that supports health (Diem & Moyer, 2005). One of the principal values of community health is social justice (Donley, 2010; Drevdahl, 2013). The beliefs underlying social justice hinge on fairness in the way people are treated, how decisions are made, and how resources are No extramural funding was received for this work. No commercial financial support was received for this work. * Corresponding author: [email protected] (A. Mawji).
distributed (Drevdahl, 2013). The focus of social justice is on the relationships among people, the respect all people are entitled to, and on how society promotes (or impedes) individuals’ or groups’ health (Jecker, 2008). In this way, social justice exemplifies the primary purpose of community health, which is to improve the health and well-being of individuals, families, communities, and populations (Gostin & Powers, 2006). The importance of social justice is also emphasized in recent documents published by the Canadian Nurses Association (2006, 2010) and the Canadian Public Health Association (2010). Over the past few decades, there has been an increase in concerns raised about widening inequities in the health status of people in North America and worldwide (Wallerstein, Yen, & Syme, 2011). With this context in mind, it is important to take a more overt approach to incorporating the concept of social justice in theory content in undergraduate community health nursing classes. We
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experienced challenges engaging our senior undergraduate students in learning community health nursing principles and practices, with classroom comments received such as ‘‘I don’t understand why I need to learn community health when all I want to do is work in acute care.’’ Some students denigrated the importance of this knowledge for their Key Points own future practice, regard Simulation has a strong less of their desired practice history of use in teachsettings. Overall, many stuing acute care skills. dents did not value or under Simulation can be used stand community health and in theory classes to its impact on individuals’ teach broad concepts. health. This was of grave This article provides an concern to our instructors. example of how simulaHow could we draw paraltion was used to teach lels to their areas of interest? concepts such as social How could we show the imjustice in a community portance of the principles health theory class. and practices we were teaching in a way that had a meaningful impact on our students? This article will demonstrate how we fostered a simulation learning environment (INASCL, 2011) in a theory course, and how social justice and other key community health concepts are now taught through the use of simulation in community health theory classes.
Literature Review Simulation technology has been incorporated into nursing programs for years. Several advantages for using simulation in nursing education have been identified. For example, simulation techniques offer a safe environment for learners as a way to improve nursing competence (Garrett, MacPhee, & Jackson, 2011). Simulation also allows students to become more comfortable in receiving feedback about their clinical performance and provides consistent and comparable experiences for all students (KimGodwin, Livsey, Ezzell, & Highsmith, 2013). In addition, students learn a mix of technical and nontechnical skills including communication, teamwork, and delegation (Medley & Horne, 2005). Within the Canadian context, students and instructors have reported positive learning experiences with simulation, particularly in understanding complex patient care scenarios, multidisciplinary team scenarios, team-based learning, and reflective debriefing (Garrett et al., 2011). Furthermore, simulation technology has been applauded for its role in developing clinical reasoning skills to enhance nurses’ abilities to build upon previous knowledge and past experiences to effectively manage new or unfamiliar situations (Lapkin, LevettJones, Bellchambers, & Fernandez, 2010). A variety of simulation equipment is available for nurse educators to access, offering opportunities to use an
expansive assortment of teaching methods and techniques. Simulation ‘‘fidelity’’ is defined as the believability or the degree to which a simulated experience approximates reality (INASCL, 2011). As fidelity increases, realism increases. The level of fidelity is determined by the environment, resources used, and participant-related factors. ‘‘Fidelity can involve a variety of dimensions, including (a) physical factors such as environment, equipment, and related tools; (b) psychological factors such as emotions, beliefs, and self-awareness of participants; (c) social factors such as participant and instructor motivation and goals; (d) culture of the group; and (e) degree of openness and trust, as well as participants’ modes of thinking’’ (INASCL, 2011, p. S5). Nursing programs tend to use more lowfidelity simulation than medium- or high-fidelity simulation (Garrett et al., 2011). We describe below the details of how we used both low- and medium-fidelity exercises in our community health theory class setting. Although many nursing programs have made large investments in simulation technology with great potential for nursing education, this potential has been underestimated and underused (Medley & Horne, 2005). Simulation technology is best known for preparing students to practice nursing with patients in an acute care setting. Very little attention has been focused on using simulation to prepare nurses to work in the community; however, this is beginning to change, particularly in the area of home care in the United States and in the United Kingdom. In the United States, Kim-Godwin et al. (2013) used a home visit simulation experience as part of community health clinical rotations. Phillips, Grant, Milligan, and Moss (2012) described how a home environment simulation experience was developed to teach cultural competence to undergraduate nursing students within the context of home care in the United States. Unsworth, Tuffnell, and Platt (2011) used simulation to teach students about specific disease presentations in the context of home care decision making in the United Kingdom. Lastly, Campbell, Themessl-Huber, Mole, and Scarlett (2007) described simulating a home visit in a client’s home environment in the United Kingdom, with an intent to challenge students’ beliefs and values related to clients and members of other professions. Although Patterson and Hutlon (2012) engaged U.S. students in a poverty simulation role-play experience within their community health clinical practicum, to our knowledge, we are the first to explore using manikin simulation to teach broader concepts of community health, such as social justice, within the context of a theory course.
Key Concepts in Community Health An earlier opportunity to revise our undergraduate community health theory course led to a search for key concepts we felt were important to teach our students so they could have a strong foundation upon which they could
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build their future nursing practices. The population health promotion model (Flynn, 1999), which arose from the landmark Ottawa Charter health promotion actions (World Health Organization, Health and Welfare Canada & Canadian Public Health Association, 1986) provided the foundation for our work. Primary health care, advocacy, and activism in nursing, community development, harm reduction, social determinants of health, upstream approaches to health, levels of prevention, and the importance of understanding and addressing the root causes of health issues in populations formed the basis of our new curriculum. Key additional concepts emerging in the Canadian nursing literature included social justice and equity (CNA, 2006). Social justice focuses on the health of the general population and defines the determinants of health as being societal in nature (CNA, 2010). Social justice is defined as one of the most important goals of social progress, with nurses having an obligation to take responsible action to eliminate forms of systematic inequity and oppression inherent in diverse social groups, such as racism, sexism, heterosexism, and classism. Social justice is described as the degree of equal opportunity made available by the political, social, and economic structures and values of a society; in other words ‘‘Social justice means the fair distribution of society’s benefits, responsibilities and their consequences. It focuses on the relative position of one social group in relationship to others in society as well as on the root causes of disparities and what can be done to eliminate them’’ (CNA, 2006, p. 7). Underlying this statement is the belief that people are entitled equally to key ends such as health protection and minimum standards of income. The social determinants of health include income and social status, social environments, work and working conditions, education, social support networks, genetic endowment, personal coping skills, health services, healthy child development, culture, physical environments, and gender (Flynn, 1999). There have been many renditions of these determinants; however, present in all of them is the need for these social determinants of health to show the interplay between the multifaceted factors that influence the health of individuals and communities, demonstrating that what determines one’s health extends far beyond simply lifestyle choices. Social determinants of health are now considered the primary influences of health across the lifespan (Raphael, 2012). For example, poverty is a huge underlying root cause of many of the issues that people experience in relation to their social determinants of health. Indeed, Raphael (2006) suggested these determinants of health are a much stronger predictor of health status than behavioral factors, even obesity and tobacco use (Lind, Loewen, & Mawji, 2012). Adoption of health-threatening behaviors are strongly shaped by the social and economic environments in which people live. High levels of stress and little
control produce behaviors aimed at ameliorating tensions, such as high fat diets, poor nutrition, and tobacco use. In efforts to bring these key concepts to life in our classroom, we developed a simulation activity as one of our teaching tools.
Imogene: A Simulation Manikin Imogene Henderson was brought into class on either the first or second day of the term to engage students’ interest in class content and to set the stage for the key community health concepts the course would be covering. Imogene is a manikin dressed as a homeless, battered sex trade worker. Moulage techniques are used on the manikin to simulate dirt and injuries, including fresh lacerations on her arms, bruises, a black eye, and bleeding from her nose and ear (Figure 1). In addition she has bruising on both upper arms in the shape of hand prints and track marks on her antecubital fossa. Imogene is dressed in her ‘‘working clothes,’’ complete with jewelry and makeup. A case study of her life story is presented in Appendix A.
Process Using Imogene has proven to be a flexible simulation exercise. Developed initially as a case study for a senior-
Figure 1
Imogene Henderson, the manikin.
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level community health theory course, she was then adapted for a junior-level community health theory course. The adaptation occurred because the nursing curriculum was revised and community health became a junior-level course. Faculty members felt that Imogene was an invaluable simulation exercise to carry forward into the new curriculum. For the junior-level course, it was a low-fidelity exercise, and for the senior course, it was a medium-fidelity exercise, targeted at building upon previous acute care learning. The two iterations are described below. Medium Fidelity For the medium-fidelity exercise, Imogene was introduced as a 1-hour exercise in the first day of the community health theory class. Imogene was brought to the front of the theory classroom on a stretcher. Two instructors facilitated the activity. One instructor asked for a group of four student volunteers to come to the front of the room and, in front of their classmates, use their acute-care skills to complete a head-to-toe assessment of the extent of Imogene’s injuries. They were then asked to consider which health issues she might be at risk for. They were told they could ask Imogene questions. The rest of the students were encouraged to provide input and suggestions to the four student volunteers. While one instructor managed this process, the other instructor was hidden behind a screen with a microphone, providing the voice of Imogene through the manikin to answer students’ assessment questions. Students checked the manikin’s blood pressure, assessed injuries, and asked her questions. The scenario was that Imogene had come into the emergency department dirty, with bruises, a black eye, lacerations, track marks, a congested cough with crackles and gray sputum, and a blood pressure of 145/90. Imogene asked questions such as ‘‘Can I go for a smoke?’’ and made statements like ‘‘My boyfriend got mad and hit me, it’s no big deal, I’ve had worse injuries.’’ Imogene’s history was shared with the class following a discussion of their initial impressions gained from the head-to-toe assessments (including her vital signs). A warning that the story had content that might be upsetting to some students was given before the story was read, and afterward counseling resources were shared with the class in case anyone was upset and needed support. We felt it was very important to share Imogene’s life history with the class after they had already completed their assessments and had started to form impressions about who she was. One class instructor read Imogene’s story of her childhood to the class. We found the story was very powerful; the room was silent when Imogene’s sequence of life events during her childhood was shared with the students. We then handed out a series of questions for students to answer in small groups. The small group questions posed included: 1. What risks did you pick out from Imogene’s story? 2. How is she likely treated by society, in general?
3. Is it okay that Imogene’s life has turned out this way? 4. What is it that we as nurses can do about this? Students were then asked to share their answers with the class, using one spokesperson per group. Students identified risks such as tobacco and drug use, possible sexually transmitted infection, elevated blood pressure, low selfesteem, lack of social support, lack of education, and a high-risk working environment. The larger class conversation evolved into a discussion of the roles nurses play in scenarios such as Imogene’s. Heated discussions arose when students shared how attitudes, beliefs, and assumptions affect nursing behaviors, regardless of the setting. Discussions at times also led into the area of harm reduction and nursing roles in tertiary forms of prevention. This exercise set the stage for addressing the bigger picture of the health of individuals, communities, and population groups. Imogene assisted students to identify how the concepts of social justice, community development, and harm reduction can be used in concert with the determinants of health in the population health promotion model (Flynn, 1999) to promote health at the individual, family, community, system, and population levels. This medium-fidelity exercise introduced community health nursing where the focus is on a much broader picture of people’s lives and their health than students were familiar with. The course focus was on identifying and addressing root causes of health issues nurses see in practice, rather than solely focusing on individual outcomes related to lifestyle or other issues. Low Fidelity Once the undergraduate curriculum had been revised, we decided to preserve the teaching success we had experienced with Imogene when used with senior students. Imogene had to be adapted to a learner context where the students had not yet had any acute care experience. We were therefore unable to ask them to complete a head-totoe assessment; instead we asked the students to look at her injuries and speculate what might have happened to her. The low-fidelity adaptation of Imogene achieved similar objectives for us as course instructors; however, some key differences were necessary to adjust for the junior-level course. This version of the simulation included less significant levels of equipment and related tools than the medium-fidelity version. On the second day of our junior-level class, our manikin in full moulage was brought to the classroom in a wheelchair, laid out on a table at the front of the room, and covered with a sheet until we were ready to start the exercise. The only introduction students were given was that this was Imogene Henderson who was laying on a stretcher in our simulated emergency department. In the low-fidelity simulation, we focused on appearance rather than head-to-toe assessment and vital signs skills for our community health learning context. Additionally, Imogene
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did not have a voice and students could not ask her questions. In this exercise, small groups of approximately eight students at a time were asked to come to the front of the classroom to view Imogene for 2-3 minutes, jot notes on the injuries they saw, then spend a few minutes sharing their initial observations and impressions of Imogene with each other and postulate on what might have happened to her. They were given no history and no other information at this point. Students were to simply record their observations. Students were asked to consider the following questions: (a) ‘‘What did you see?’’ (b) ‘‘What state is she in?’’ and (c) ‘‘What might have happened?’’ Once all of the student groups had viewed Imogene up close and conferred with their group members, the instructor asked a spokesperson from each group to share his or her group’s findings in a large class discussion, until all of the observations and initial impressions had been shared. Students discussed their thoughts about the health problems Imogene might have and their initial impressions as they looked at her laid out on the table. Most of the student groups suggested Imogene appeared to be a prostitute (related to her clothing and appearance), and that it looked like she had been beaten up based on the nature of the bruising and cuts they saw on her face and upper body. Assumptions and value judgments were evident in the student comments and ranged from more neutral suggestions for interventions based on harm-reduction principles (they correctly identified the needle-track marks) to outright blaming her for her apparent assault because of her profession. One student commented that she deserved this based on her choice to be a prostitute. Following the whole class discussion, the instructor then read Imogene’s one-page history of her childhood (Appendix A) to the class. The warning described previously was given and counseling resources were made available. The students were given a worksheet outlining Imogene’s story and the first three of the four original questions to answer as a group. They were asked to identify the health risks they picked out from Imogene’s assessment and her story, to discuss how she is likely treated by society, and to provide a rationale for their response to whether or not it is okay that her life has turned out this way. A large class discussion ensued following this exercise with a focus that evolved to include the potential effects of stigmatization on people’s health, social determinants of health, and larger societal implications. The effects of health care professionals’ beliefs and attitudes and how they impact interactions with different populations were also regularly raised in these discussions. For the junior course, Imogene was also used as a case study that became the focus of an end-of-semester group presentation (the semester was 13 weeks long), representing critical thinking, clinical reasoning, and clinical judgment at a novice nurse level (INASCL, 2011). She had evolved to become a capstone evaluative learning tool for students where they were tasked to develop a series
of recommended interventions to address Imogene’s health issues and improve her social determinants of health. For this assignment three additional scenarios were developed, representing key points in Imogene’s life where nursing interventions may have prevented future health issues (Appendix B). Briefly, one scenario was when Imogene was in grade 6 and had complained to her teacher about recurring stomach aches. The second scenario was when Imogene was 14 years old and discovered that she was pregnant; the third scenario was Imogene as an adult at the current point in time where she expressed her desire to get off the streets and to help some of her friends get off the streets as well. Students were assigned in groups to one of the three life-point scenarios and were asked to intervene with a series of strategies that would promote her health and help prevent a future deterioration of her health. Students used the aforementioned key course concepts to identify and address key issues, framing their interventions within the population health promotion model to address social determinants of health and multiple action strategies and levels for action (i.e., at the individual, family, community, structural or system, or societal level). On presentation day, Imogene (the manikin) attended the students’ presentations, at the corresponding age. Two scenarios required us to use child manikins, the other to bring the adult Imogene in her working attire, but with only remnants of her injuries (i.e., faded yellow bruising to indicate healing had occurred).
Implications for Teaching and Research The cultures of the two groups of students involved in this simulation experience varied significantly, as did their modes of thinking (INASCL, 2011). The novice learners (junior students) were socialized to think through a community lens much sooner than the learners who had worked with one another for 2 years prior to participating in the medium-fidelity version. The junior students may have had a higher degree of trust and openness to this in-class activity than the learners who had been exposed to acute care settings prior to participating in the medium-fidelity exercise. We felt both versions of the simulation exercise were effective in addressing the dimension of psychological factors (emotions, values, beliefs, and self-awareness) of students (INASCL, 2011). There are a variety of ways that students can be encouraged to explore concepts and relationships between concepts in a theory classroom environment. We chose to incorporate a simulation learning environment (INASCL, 2011) into our theory course as a way for the students to understand the application of theory to community health practice. This proved to be a valuable exercise wherein students’ values, beliefs, and attitudes about marginalized groups of people were explored and challenged. Students were also challenged to think about how concepts related
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to community health could be valued, respected, and implemented, regardless of the practice setting they choose to work in after graduation. Although simulation is well established as a method to teach skills and concepts related to the acute care setting, we propose that educators begin to expand their thinking of the use of simulation to engage students in learning community health course content. In addition, we feel simulation can be an effective teaching tool to bring abstract course concepts to life. Research studies should be undertaken to evaluate the effectiveness of such simulation exercises within the context of theory classes.
Conclusion This article has demonstrated how simulation can be used in theory courses to introduce broad community health nursing concepts to junior and senior students, including social justice, harm reduction, activism, and social determinants of health. This is an example of a teaching innovation that also caught the eye of the public. Through our success in using this simulation exercise, we received extensive local and national media coverage including a video interview with the Canadian Broadcasting Corporation News, a television interview with the host of a morning show, and various print exposures. In conclusion, as we continue to revise and refine this particular simulation, we offer Imogene as a teaching innovation for others to explore. Implementing this teaching innovation was exciting and invigorating for our instructors. It was equally exciting for our students who were more actively engaged in the learning process and demonstrated much enthusiasm for learning community health content. We feel we have only skimmed the surface of potential applications of Imogene and invite others to explore incorporating her into their own classroom settings.
References Campbell, M., Themessl-Huber, M., Mole, L., & Scarlett, V. (2007). Using simulation to prepare students for interprofessional work in the community. Journal of Nursing Education, 46(7), 340. Canadian Nurses Association (CNA). (2006). Social justice . a means to an end, an end in itself. Ottawa, ON: Author. Canadian Nurses Association (CNA). (2010). Social justice . a means to an end, an end in itself (2nd ed.). Ottawa, ON: Author. Canadian Public Health Association. (2010). Public healthe community health nursing practice in Canada: Roles and activities (4th ed.). Retrieved April 18, 2013, from http://www.cpha.ca/uploads/pubs/ 3-1bk04214.pdf Clark, M. J. (2008). Community health nursing: Advocacy for population health (5th ed.). Upper Saddle River, NJ: Pearson Education.
Diem, E., & Moyer, A. (2005). Community health nursing projects: Making a difference. Philadelphia: Lippincott Williams & Wilkins. Donley, R. (2010). Nursing, social justice and the marketplace. Health Progress, 91, 34-37. Drevdhal, D. J. (2013). Injustice, suffering, difference: How can community health nursing address the suffering of others? Journal of Community Health Nursing, 30(1), 49-58. Flynn, L. (1999). Population health promotion model. Revised from original model developed by N. Hamilton and T. Bhatti, Health Promotion Development Division, Health Canada, 1996. Winnipeg, MB: Health Canada, Manitoba/Saskatchewan Region. Garrett, B. M., MacPhee, M., & Jackson, C. (2011). Implementing highfidelity simulation in Canada: Reflections on 3 years of practice. Nurse Education Today, 31, 671-676. Gostin, L. O., & Powers, M. (2006). What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs, 25, 1053-1060. International Nursing Association for Clinical Simulation and Learning (INASCL). Board of Directors. (2011). Standard I: Terminology. Clinical Simulation in Nursing, 7(4S), S3-S7. http://dx.doi.org/10.1016/j.ecns.20 11.05.005. Jecker, N. S. (2008). Response to open peer commentaries on ‘‘a broader view of justice.’’ American Journal of Bioethics, 8, W1-W2. Kim-Godwin, Y. S., Livsey, K. R., Ezzell, D., & Highsmith, C. (2013). Home visit simulation using a standardized patient. Clinical Simulation in Nursing, 9(2), e55-e61. http://dx.doi.org/10.1016/j.ecns.2011.09.003. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6(6), e207-e222. http://dx.doi.org/10.10 16/j.ecns.2010.05.005. Lind, C., Loewen, S., & Mawji, A. (2012). Health promotion. In D. D’Amico, C. Barbarito, N. Harder, & C. Twomey (Eds.), Health & physical assessment in nursing (Canadian ed.). (pp. 22-36) Toronto, ON: Pearson Canada. Medley, C. F., & Horne, C. (2005). Using simulation technology for undergraduate nursing education. Journal of Nursing Education, 44(1), 31-34. Patterson, N., & Hutlon, L. J. (2012). Enhancing nursing students’ understanding of poverty through simulation. Public Health Nursing, 29(2), 143-151. Phillips, J., Grant, J. S., Milligan, G. W., & Moss, J. (2012). Using a multicultural family simulation in public health nursing education. Clinical Simulation in Nursing, 8(5), e187-e189. http://dx.doi.org/10.10 16/j.ecns.2011.08.007. Raphael, D. (2006). Social determinants of health: Present status, unanswered questions, and future directions. International Journal of Health Services, 36(4), 651-677. Raphael, D. (2012). Educating the Canadian public about the social determinants of health: The time for local public health action is now! Global Health Promotion, 19(3), 54-59. Unsworth, J., Tuffnell, C., & Platt, A. (2011). Safe care at home: Use of simulation training to improve standards. British Journal of Community Nursing, 16(7), 334-339. Villeneuve, M., & MacDonald, J. (2006). Toward 2020: Visions for nursing. Ottawa, ON: Canadian Nurses Association. Wallerstein, N. B., Yen, I. H., & Syme, S. L. (2011). Integration of social epidemiology and community-engaged interventions to improve health equity. American Journal of Public Health, 101(5), 822-830. World Health Organization, Health and Welfare Canada, & Canadian Public Health Association. (1986). Ottawa charter for health promotion. Geneva, Switzerland: Author.
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Appendix A
Appendix B
Imogene Henderson’s Story
Three Scenarios Representing Key Points in Imogene’s Life
Imogene is a 34-year-old Caucasian female. She was born in 1979 Calgary, Alberta; into a lower socioeconomic status family. Her father, John, completed grade 11 and earned $2.90 per hour as a janitor in the local high school in Ogden. Her mother, Sally, completed grade 6 before she had to quit school and help out on the family farm. Luckily her grandmother taught her how to sew as there was no money to spend on ready-made clothing in those days. Sally was a seamstress who worked from home so she could care for her five children. She earned approximately $0.50 per hour sewing and mending clothes 2 days a week. An hour of her work would buy one loaf of bread for her family. Life was difficult for the Hendersons. Many evenings John would frequent the local bar and it wasn’t unusual for him to come home drunk and angry. Often Sally would take the brunt of his anger and she hid her bruises when she needed to go do her errands. She would often need to venture out on foot on cold winter days to the bus stop that was three blocks away. Imogene is the oldest of five children and needed to stay home to babysit and look after her siblings when her mom was ‘‘unwell.’’ The family’s favorite uncle, Tom, was a frequent visitor and often brought presents. Imogene recognized early on that she was Uncle Tom’s favorite as he would give her an extra present if he could touch her. This relationship with Uncle Tom escalated into a sexual relationship. At the age of 14 Imogene told her parents that she was pregnant. Her parents were angry and ashamed and arranged for Imogene to have a ‘‘backyard’’ abortion. As a result, Imogene developed an infection that was accompanied by pain. Her cousin Steve was able to find some morphine pills from his friends. Imogene often found herself asking Steve to find more. Sally and John would often find Imogene sleeping when she should have been at school. Imogene would disappear for days at a time, leaving her siblings alone, and when she did come home, it was a volatile place. One day after the umpteenth visit from the truant officer, John, in a drunken rage, threw Imogene into the wall, breaking her left arm, then picked her up and physically threw her out into the street yelling for her never to come back home, saying ‘‘you’re no child of mine!’’ As a result Imogene never returned to school and started surviving on the street.
Scenario A The clock of time has been turned back and you have an opportunity to intervene in Imogene’s life before some of the future events will happened. You are a community health nurse who works in Imogene’s elementary school, where she is attending grade 6. Her teacher is worried about Genie’s recurring stomach aches and asks you to see her. The teacher shares with you that she thinks things are troubled at home. Although a referral to a family physician to assess for a biomedical issue may be appropriate, you also know that stomach aches can be a symptom of emotional upset in children. Using the population health promotion model, consider individual and other levels at which health promoting change could occur. Scenario B The clock of time has been turned back and you have an opportunity to intervene in Imogene’s life in a time of trouble in her adolescence. You are a community health nurse working at a sexual health clinic and 14-year-old Genie has come to see you because she worries she may be pregnant. Once the physical assessment and tests have been completed, you see an opportunity to develop rapport with Genie and address some of the larger issues that are occurring in her life. Using the population health promotion model, consider individual and other levels at which health promoting change could occur. Scenario C You are a community health nurse who is working with Imogene now at age 34, after she expressed a desire to get off the streets. Imogene shares that she has been a sex trade worker for the past several years, and she regularly gets beaten by her ‘‘boyfriend’’ who is her pimp. In addition, Genie smokes, drinks, and also uses illegal drugs from time to time. She also wants to help her street friends who she worries about, especially because of the levels of violence she sometimes sees on the streets. Using the population health promotion model, consider multiple levels for action and strategies for change that could directly or indirectly promote the health of Genie and this community of people.
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