- Email: [email protected]
Innovations in Community-Based Nursing Education: Transitioning Faculty
Innovations in Community-Based Nursing Education: Transitioning Faculty KIMBERLY FERREN CARTER, PHD, RN,* MAGGIE FOURNIER, MS, RN,y SUSAN GROVER, PHD, RN,z ERMALYNN M. KIEHL, PHD, ARNP,§ AND KATHLEEN M. SIMS, PSYD, RNO
The health-care climate is changing rapidly and in ways that challenge the abilities of professionals who provide health care. Nursing educators are preparing professional nurses who can think critically, use sound clinical judgment, and participate as full partners in shaping health-care delivery and policy. Therefore, many schools of nursing, including five schools of nursing whose experiences are synthesized in this article, are revising their curricula to a community-based nursing perspective. Strategies to assist faculty in the transition to a community-based nursing curriculum include using change theory, creating a supportive environment, reducing tension and isolation, and evaluating. Potential challenges during transition include addressing grief and loss, overcoming the tedium of curricular development, moving the revision along while allowing opportunities for faculty input and consensus building, exploring alternative pedagogies, managing faculty workload and qualification issues, and preparing for transition. Outcomes include a more complete understanding of the community client as a partner in the delivery of health care, increased visibility and role modeling to potential future candidates for health careers, cultural transformations within a university, and promotion of the overall health of a community. (Index Words: Community-based nursing
*Professor and Associate Director, School of Nursing, Radford University, Radford, VA. yAssociate Professor, College of Nursing and Health Professions, University of Southern Maine, Portland, ME. zChair, Department of Family Community Nursing and Professor, College of Nursing, East Tennessee State University, Johnson City, TN. §Associate Professor, School of Nursing, College of Health & Public Affairs, University of Central Florida, Orlando, FL. OAssociate Professor, School of Nursing, Linfield College, Portland, OR. Address correspondence and reprint requests to Dr. Carter: Radford University School of Nursing, Box 6964, Radford, VA 24142. E-mail: [email protected] 8755-7223/$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2005.04.004
education; Curriculum; Faculty transition) J Prof Nurs 21:167 – 174, 2005. A 2005 Elsevier Inc. All rights reserved.
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N THE LAST decade, the nursing literature and other professional documents have increasingly indicated that the focus of nursing education was changing to respond to the instability of the United States health-care system (American Association of Colleges of Nursing [AACN], 1996, 1998; National League for Nursing [NLN], 1993). Concurrently, the United States has been facing a growing crisis with respect to a lack of affordable health-care insurance and increasing costs of prescription drugs, particularly for the older population. Communities are struggling with large numbers of people across the life span who are receiving minimal or no health care because they cannot afford or access services. Kerfoot (1997) notes that the rapidity of change now occurring in the health-care industry challenges nursing education to develop programs to support newer models of care delivery. Consistent themes have been emerging, including nurses’ essential needs to be educated in providing and coordinating care for individuals, families, aggregates, and communities and to be prepared in making independent nursing decisions in both structured and unstructured settings (NLN, 2003). Therefore, the challenge for nursing educators is to prepare professional nurses who can think critically, use sound clinical judgment, and participate as full partners in shaping health-care delivery and policy. Nurses now must be able to practice across multiple settings, several of which are not traditional venues for practice (AACN, 1997). Numerous professional groups including the AACN (1996,1997), the American Organization of Nurse Executives (1996), and the Pew Health Professions Commission (1993)
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endorse baccalaureate preparation for nurses as critical to address the expanding knowledge base and complexity of the health-care system. The AACN (1998) notes that the preparation of entry-level professional nurses requires a greater orientation to community-based primary care and an emphasis on health promotion, maintenance, and cost–effective coordinated care. The AACN (1997, p. 1) also predicts that: With constant changes predicted in health care for the foreseeable future, it is imperative that nursing education programs themselves act as agents of change. It is the responsibility of nursing education, in collaboration with practice settings, to shape practice, not merely respond to changes in the practice environment.
The purpose of this article is to review the community-based model of nursing education and address issues relevant to transitioning to a community-based nursing curriculum. Community-based Nursing Education Model
Community-based nursing education (CBNE) is a pedagogy that enables students to learn to provide nursing care for people no matter where they encounter them. This expanded approach to nursing education offers the opportunity to use different teaching strategies and settings in addition to hospitals, where traditional nursing education programs based most of their clinical experiences on (Matteson, 2000). Community-based nursing education provides nurses with a new model for clinical learning and provides the necessary opportunities for undergraduate nurses to: c c c c
Provide care along a continuum from wellness to illness; Work with interdisciplinary teams; Work within and across diverse health-care delivery environments and communities; and Provide care for diverse populations, including diverse ages, sex, ethnicity, healthy–ill populations, and acute–chronic health states (AACN, 1999, p. ii).
Although most core competencies, core knowledge areas, and professional roles outlined in The Essentials Of Baccalaureate Education For Professional Nursing Practice (AACN, 1998) can be taught using the community-based model in community clinical sites,
this does not preclude the necessity for hospital clinical experience. It just redirects the focus of clinical education to caring for people within their own environment rather than only for those in a hospital setting. Furthermore, the key for the success of this model is an ongoing partnership between nursing education and the community (NLN, 1996). Unique to the CBNE model is the opportunity for nursing students to learn and develop partnership skills with stakeholders in their communities. This experience heightens communication and leadership skills and allows for creativity in solving community health problems to emerge. Community-based nursing education has received more attention since the AACN, supported by the Helene Fuld Health Trust, held workshops in 1998. Faculty teams at these workshops developed projects for implementing concepts of CBNE in nursing curricula. Some faculty were already involved in changes leading to a CBNE curriculum. Ideas and experiences were shared in an effort to assist other schools. However, a clear and consistent theme pervaded: faculty were grappling with how to transition to this new paradigm in nursing education. The following section shares experiences of transition, challenges, and outcomes of moving to a CBNE curriculum.
Faculty Development Strategies
Faculty traditionally teach what they know, and as the CBNE movement began, most faculty knew a health-care system that either no longer existed or was quickly dying. Few had been introduced by either education or research to a consumer-driven, community-based primary health-care system. Even fewer were knowledgeable of what their role would entail as educators for such a system. Before curriculum reform must come faculty reform (NLN, 1992), yet the CBNE movement had a momentum that would not wait until faculty knowledge and understanding of the needs for and impact of such a change materialized. More recently, a guidebook was published to assist schools of nursing to implement CBNE in their undergraduate programs. The document is helpful specifically in educating new faculty to the CBNE model (Stanley, Kiehl, Matteson, McMahon, & Schmid, 2002). Faculty development is about change and growth. Individual faculty may have a passion about a particular area of nursing knowledge and practice.
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This expertise has been acquired through years of experience and teaching and usually has been acquired in small shifts of change. When confronted with a major change in the nursing curriculum, the security of faculty in their expertise can teeter on the edge of competency. Therefore, appropriate support throughout the developmental process of change is vital to assist faculty in securing a new balance. The initial step in faculty development is that of any change: creating dissatisfaction with the status quo or, in this case, the current curriculum (Edelman & Mandle, 1998). Key faculty members, curriculum committees, and deans (or directors) are vital at this time. Literature including research regarding CBNE can be collected, distributed, and discussed for relevance to a particular curriculum. Reports and articles from health-related organizations about shifts or trends in health-care delivery and the requisite skills of nurses can be circulated. In addition, preparation for an accreditation review may provide an impetus to examine different ways of educating people for nursing. Statistics showing nurse employment settings can also demonstrate needed shifts for education. Such information can be summarized and shared in committees, faculty meetings, development lunches, and workshops. Consultants may also be brought for workshops on various topics related to a particular approach or strategy. Challenges and opportunities can be explored in informal settings before a decision to make a change is made. Once approximately 30% of faculty indicate readiness to move ahead of the dissatisfaction stage, plans for an actual change can be made (Edelman & Mandle, 1998). Faculty workshops can be held with groups developing visions of a community-based curriculum. This is a time for creativity and innovation in the curriculum, often challenging the bsacred cowsQ serving as obstacles to curricular growth. Groups can include faculty, students, and nurses in clinical practice. Key people who were actively involved in the earlier stage should be involved in each group to provide support, encouragement, and information regarding the possible change. Faculty do not want to lose their special teaching expertise. They must be able to see how their content can be shifted to fit the new curriculum context. People look for the familiar in new situations. Finding the familiar supports a sense of security and competence and enables one to more easily make a transition. Deans have a key role in sustaining the vision of a new curriculum. Creating a supportive environment for faculty to make change is elemental to that role.
When faculty realize that their knowledge and expertise can be included in a community-based nursing curriculum, resistance to change will lessen. This can be a time for very practical support of faculty. Financial stipends for faculty time in community fellowships can foster development of nursing practice in different settings. Mentoring partnerships with community-based nurses can assist faculty in understanding and applying community-based concepts in practice settings before teaching students. Faculty with community nursing expertise can come alongside other faculty to share expertise, resources, and teaching strategies. Faculty can be sent to CBNE conferences to acquire information and become resources for others. Workload adjustments may be implemented to support faculty in the work-intensive requirements of curriculum revision. A curriculum plan is best developed and implemented by an entire nursing faculty. A vested interest of time, energy, ideas, and interest will sustain the momentum for change. As a plan is implemented, faculty meetings can be used to share challenges and solve problems. Such meetings can reduce any sense of isolation in course development and implementation. Stress of change can also be managed through sensitive and timely sharing of frustrations or disappointments. Humor can also be used to diffuse the tension inherent in change. As the former curriculum is phased out, time for grieving losses should be taken. Celebrations of past successes and rituals of transitions can be developed for this passage to a new curriculum. Finally, as a curriculum becomes securely in place, evaluation must take place. This process should be ongoing with the use of criteria established by faculty and each school’s accrediting bodies. Evaluation data can be collected from the start of the curriculum, but care should be taken not to make changes too quickly. Practice with the course materials and teaching strategies may be the best approach before making any change in the new curriculum. Faculty continue to need support and development as they deal with student concerns and community-based content (Edelman & Mandle, 1998).
Challenges Along the Way
The transition to a community-based curriculum gives rise to multiple challenges for nursing faculty, staff, and students. Sensitive leadership throughout the transition process allows for the identification of
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challenges and initiation of steps to overcome them. By engaging faculty, staff, and students throughout the revision change process, the resulting curriculum is owned, stimulating, and effective. This section focuses on strategies for dealing with challenges faced by faculty, but these strategies can be modified to include staff and students. Once faculty have progressed from the process of dissatisfaction to that of readiness to change, as described earlier, issues of grief and loss may linger. Letting go of bthe way we have always done itQ can be painful and frightening for some faculty and staff. Some may express these uncomfortable feelings in a manner reflecting resistance to change. Doll (1993, p. 11) argues that this fear is related to a perceived loss of control that bkeeps us confined to the realm of mediocrity.Q The council process (Zimmerman & Coyle, 1996) is one strategy that promotes the resolution of residual grief, loss, and fear. It focuses on speaking and listening from the heart, being of lean expression, and being spontaneous. This allows faculty and staff to acknowledge feelings of grief, loss, and fear openly and allows for expression in a nonthreatening environment. Resolution of these residual issues promotes commitment to a new curriculum and a shared sense of teamwork. Much can be learned from those who resist change, and it is useful to hear the essence of their objections to identify and overcome potential problems. However, the time to move on with the change arises and complete unanimity may be impossible. At such times, the leaders in implementing the change are key in moving the transition forward, coaching and encouraging the resisters along the way. The meticulous, detailed work required for a curriculum transition requires a great deal of faculty time and energy. Some nursing faculty do not have formal education related to curriculum development, so the learning curve may be steep for a person or persons leading the faculty revision. Using a model such as that of VanOrt and Putt (1985), Sequential Steps in Curriculum Process, to lead faculty through a revision process can be useful in allowing faculty to see the steps required for curriculum revision and track progress through the process. If possible, partial (50–75%) release time for persons leading a revision effort allows for focused energy and realistic workload. If release time is not possible, it is important to acknowledge that the revision process may take longer. However, it is crucial that all faculty be actively and regularly involved in the revision process to allow for the
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emergence of a curriculum that is owned and esteemed. An important role for curriculum revision coordinators is to monitor the status of faculty agreement on key issues and pace the progress of the revision. Coordinators must have skills in achieving a balance between allowing enough discussion to resolve issues and conforming to reason to progress the process when a consensus is elusive. The written work (course proposals, syllabi, etc.) of curriculum revision is monotonous and dry. Use of teams to develop and write such items as course proposals and syllabi can stimulate creative synergy. Allowing for curriculum work time within the work month, where meetings are focused on the curriculum, is another effective strategy. For example, if faculty meetings are generally scheduled on Tuesday mornings, then months with a fifth Tuesday are designated for curriculum work. Faculty can actually be energized and excited by these meetings if they are conducted in ways that allow for a relaxed, social environment. Curriculum meetings can have an added result of positive team building for faculty and staff. For example, planning potluck meals or, if foundational or departmental funds allow, providing a nutritious meal as part of the meeting allows for social interactions and informal discussions from which creative curricular thinking can occur. Door prizes and raffles of donated items (such as gift certificates from local restaurants or an item from the school’s bookstore) can entice faculty and staff to arrive at meetings on time or recognize collective work. A local masseuse or masseur may be willing to provide mini-neck massages while faculty are in curriculum meetings. Creativity in coordinating curriculum meetings can spawn creative curricular outcomes, faculty team building, and positive forward progress. Traditional curricula have been based on inhospital and non-hospital (community) dichotomies. Some community-based curricula texts perpetuate these dichotomies, whereas others reflect differing perspectives on community-based care. Faculty must collectively resolve what a community-based curriculum means to them (Mueller & Henshaw, 1997). This should be documented into a definition for CBNE, or a similar term, because this unifying definition will be revisited frequently to focus the revision. As faculty who have traditionally taught the hospital component of former curricula shift into non-hospital settings, faculty will need to build new and different clinical skills in the community. Issues that were traditionally in the community
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health course such as home care safety and hygiene will need to be readjusted into other courses as necessary so as not to be lost as students begin using these techniques in courses other than the community course. Applying interactive teaching strategies in classroom and clinical conference settings can allow exploration of community clinical skills in a nonthreatening environment, and faculty members with community expertise can serve as resources for the integration of these strategies. Every faculty has members with expertise in community health; however, issues of territoriality and turf can be barriers in discussions and must be examined by faculty. It can be effective to bring guests from the local community or national-level speakers to discuss these issues. Curriculum revision is also an excellent time to explore other pedagogical strategies such as narrative pedagogy (Diekelmann, 2001). The addition of clinical settings beyond hospitals such as free clinics, home health, neighborhoods, Head Start, and schools introduces challenges such as clinical supervision staffing, workload, faculty accessibility to students, and faculty comfort in a wide array of settings (Mueller & Henshaw, 1997; Noble, Redmond, Williams, & Langley, 1996). This comfort zone is achieved through faculty engagement with community agencies, which requires additional time and resources. Unless the faculty establish strong relationships with neighborhoods and agencies, alienation between each community and institution will occur, thereby decreasing the educational value of the experience. Faculty must explore feasibility issues when adding clinical settings to a curriculum. Once challenges along the way toward curriculum revision have been addressed and implementation is approaching, planning for a transition between new and old curricula is important. How will students not in the regular path of progression in the old curriculum (i.e., out of sequence) be handled? How will communication of the new curriculum to prospective students not yet in the curriculum be achieved? How will the curricular changes be communicated to internal and external communities of interest such as faculty for premajor courses and clinical agency administration and preceptors/staff? Involving school of nursing staff, recruitment faculty, current students, and advising staff in these and similar discussions will promote a smoother transition to a communitybased nursing curriculum.
Outcomes
Community-based nursing education expands traditional nursing education boundaries and has created significant positive outcomes for faculty, students, communities, and institutions. One of the major outcomes is that faculty become immersed in their community and understand the community client as a partner in the delivery of health care. No longer is the academic faculty the source of all knowledge. The focus on this partnership emphasizes that the community and faculty are teachers and learners simultaneously. This give-and-take process is foundational to the idea of community empowerment where groups and individuals take charge over their lives. Faculty learn to view the notion of empowering a client at the macro level. They learn to be flexible and adaptive as they devise ways to put community needs before academic timetables. For example, a curriculum can be adapted to schedule a community event on a weekend instead of during a scheduled class time. Another benefit to the faculty is that the community becomes their practice site; they become a part of the community. Because faculty are visible and consistently involved, the community becomes more responsive to a mutual dialogue about needs and innovative solutions. The dialogue embraces individuals from a variety of nonacademic backgrounds who can contribute greatly. At this collaborative level, community members, students, and faculty are involved in planning curricula that will both educate students and improve the overall health of the community. Faculty subsequently facilitate the implementation of these innovative solutions through health fairs, programs, and other interventions with students. Thus, the traditional concept of the academy as the bivory towerQ is dispelled both in theory and in practice. Reece, Mawn, and Scollin (2003) found that faculty transition into a community-based curriculum was both positive and negative. On a nine-scale questionnaire that assessed the transition experience, faculty indicated that the most positive response was in the category of satisfaction. Satisfaction was related to encouraging students’ critical thinking, working with students and nurses in clinical sites, and role modeling. The two lowest subscales were planning and environment, implying that more time was needed to plan such a program that impacts both student activities and reallocation of faculty time and resources. Bednash and Stanley (2002) describe the importance of using a variety of settings for clinical
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experiences so that students learn to care for people across the life span in both structured and unstructured settings. The unstructured community setting captures some of the most critical competencies that students acquire. They learn how to assess the needs of and provide care to diverse populations in a particular community. In addition, the visibility of nursing students in these communities provides role models for the youth to attend a university and enter a health profession. To learn how to care for people in communities requires that faculty and students become involved in the delivery of health care on a consistent basis. Students develop a better sense of the community because they have experiences over time. Small interactions in pieces enable students to conceptualize the complex interactions between groups, communities, and the environment. The outcomes for the community are numerous, with particular impact on client care. As a result of assessment, planning, and programmatic interventions, students and faculty directly provide service to a large number of individuals. In one school, more than 40,000 individuals were served in 1 year. Community clients in a large housing project were the recipients of home visits, school projects, and health promotion groups. The outcomes resulted in improved health awareness for this population. In another community, the overall cardiovascular mortality rates improved as a result of community-based care where faculty and students were involved in schools, industries, agencies, organizations, and many community fairs (Edwards & Smith, 1997). As a result, communities are more apt to approach the university to discuss potential community health problems. A final important outcome of CBNE is the change that occurs in other university curricula. At one university, there was a significant increase in service learning courses for other colleges as well as an increased interest in interdisciplinary education (Edwards & Smith, 1998). A cultural transformation occurred when the educational infrastructure moved to a plethora of interprofessional collaborations across academic disciplines. Nursing set this example for partnering in community agencies and across disciplines.
Lessons Learned by Five Nursing Schools
One of the conceptual goals of Radford University School of Nursing faculty during curriculum
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transition planning was that community reflects a continuum of care for clients, rather than the hospital and non-hospital definitions that traditionally depict community. Faculty are pleased with the communitybased education (CBE) curriculum’s comprehensive approach, which allows for a broad application of the community-as-location perspective. This has subsequently allowed the community health course to focus on aggregates and populations more comprehensively. Student feedback reflects satisfaction with this approach, allowing them to participate more completely and seamlessly in the health experiences of individuals, families, aggregates, and communities. After 8 years of the CBE curriculum, the University of Central Florida engages basic and accelerated prelicensure students, RNs to BSNs/MSNs, and graduate students in 14 community nursing centers (CNCs) in underserved communities. The number of students assigned to each CNC ranges from 45 to 145 over the course of 1 year, serving from 2,600 to more than 14,000 clients per CNC annually. A recent faculty evaluation resulted in 82% of the CNC faculty rating their CNC experience as excellent, including the CNC facilities, availability of learning opportunities for students, quality of community partnerships, safety within the community, and impact that students have on the health of the community residents. The University of Central Florida faculty have learned that rich experiences in the CNC communities require much work and creativity by faculty but that the outcome is well worth the effort. Community-based education graduates have an awareness and sensitivity of the lived experience and the human condition on a very different level compared with those who graduated under a different model. The biggest threat that we have faced is the misperception of acute care organizations that a CBE nursing program yields less prepared graduate nurses. In reality, there is no difference in acute care clinical hours in the CBE curriculum and in total clinical hours due to increased community hours. The current nursing shortage is affecting all areas of nursing practice not just in acute care settings, and our challenge is to remain steadfast in the commitment to educate generalist undergraduate nurses who are knowledgeable and skillful in meeting the health-care needs of people throughout the life span and across the health–illness continuum in a variety of settings. The Linfield College was pleased to have a successful accreditation visit after implementing their CBE curriculum, receiving full accreditation and commendations on the vision of the curriculum and
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on the courage that the faculty demonstrated in doing something new and daring. One challenge addressed by the Linfield College faculty is orienting part-time faculty to the concepts of the community-based curriculum. By instituting a new faculty orientation that includes an overview of the curriculum and community-based concepts, these orientation needs have been resolved. In addition, an annual retreat for part-time faculty to address particular issues and challenges that they may have with implementing the curriculum in clinical settings has been quite effective. These activities have increased the consistency of the message given to students. As the faculty of the East Tennessee State University College of Nursing transitioned to a CBE curriculum, the college’s mission similarly changed to that of bfacilitating the health of the community.Q To fulfill this mission, the faculty implemented the bhome baseQ concept, integrating community through the entire curriculum, to prepare graduates in identifying, participating, and practicing in partnerships with communities. On the first day of the nursing curriculum, students choose a geographical community with which to work throughout their nursing student experience. In an initial course, students participate in a community assessment using key informant interviews, doing windshield surveys, and studying data-based research on community demographics. During the next three semesters, students rotate out of clinical courses to participate in their home base with assignments that relate to the particular clinical course content. For example, in women’s health and pediatrics, students will go into schools and teach about previously identified health needs such as nutrition and pregnancy prevention. In the chronic clinical course, students make home visits to elderly individuals in their particular community. During the last semester, students take the final community course where they plan and implement a large community project. Immersion in the community enables the students to continuously assess needs and establish collaborative partnerships. Students develop a better sense of the community because they have the experience over time instead of just a snapshot of the community during one course. Small interactions in pieces enable the students to
conceptualize the complex interaction between groups, communities, and the environment. The experience of collaborating with communities has taught the students independence and flexibility. The University of Southern Maine College of Nursing and Health Professions was surprised to find that when faculty gave up the need to carefully control the experience and trusted students bto step up to the plate,Q students exceeded the faculty’s performance expectations. Students are confident and clear about the community partnership experience and significantly develop their leadership skills when they are involved in the minutiae of planning. For example, students in the Casco Bay Islands and Fishing Community Partnership do not only conduct screening and flu clinics on the islands and at other sites but are also fully immersed in planning and evaluation. They mutually plan with community leaders and other key resources, inventory and order supplies, seek small grants, and sell sweatshirts to support and underwrite the partnership and its activities. For them to do this responsibly, faculty need to relinquish control, albeit with a watchful eye. Experienced faculty at this institution see CBE as the best way for University of Southern Maine nursing students to learn not only about the needs of particular underserved cohorts in the community but also how to best meet those needs.
Conclusion
In conclusion, the CBNE curriculum will continue to grow and evolve as more communities and schools of nursing partner for the greater good of citizens and students alike. Transitioning to a community-based curriculum requires many changes for faculty. Challenges in the process of change can be met with specific strategies designed to educate and support faculty as additional expertise and competence are acquired. Students can learn the skills needed to function in the evolving health-care system and make a difference in the health of the people served. As future professional nurses, they will provide the leadership, innovation, and appreciation of the ideal that nurses have a responsibility to serve their communities.
References American Association of Colleges of Nursing. (1996). The baccalaureate degree in nursing as minimal preparation for professional practice. Washington, DC: Author.
American Association of Colleges of Nursing. (1997). A vision of baccalaureate and graduate nursing education: The next decade. Washington, DC: Author.
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American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Association of Colleges of Nursing’s Position Paper. (1999). Essential clinical resources for nursing academic mission. Washington, DC: Author. American Organization of Nurse Executives. (1996). The business of nursing. Chicago, IL: American Hospital Publications. Bednash, G., & Stanley, J. (2002). Nursing meets patient needs with community-based education. Health Searchlight, 2, 3. Diekelmann, N. (2001). Narrative pedagogy: Heideggerian hermeneutical analyses of lived experiences of students, teachers, and clinicians. Advances in Nursing Science, 23, 53 –71. Doll, W. (1993). Challenging curriculum icons: A postmodern, post-structural preamble. Atlanta, GA: Southern Council on Collegiate Education for Nursing in affiliation with the Southern Regional Education Board. Edelman, E. L., & Mandle, C. L. (1998). Health promotion throughout the lifespan. St. Louis, MO: Mosby. Edwards, J., & Smith, P. (1998). Impact of interdisciplinary education in underserved areas: Health professions collaboration in Tennessee. Journal of Professional Nursing, 14, 144– 149. Edwards, J. B., & Smith, P. L. (1997). Impact of interdisciplinary education in underserved areas: Health professions collaboration in rural Tennessee. Proceedings of the American Association of Colleges of Nursing’s Master’s Education Conference, December 4 –6, 1996 (pp. 21 –27). San Antonio, TX: American Association of Colleges of Nursing. Kerfoot, K. M. (1997). Role redesign: What has it accomplished? Online journal of issues in nursing available http://www.nursingworld.org/ojin/tpc5/tpc5_3.htm. Matteson, P. S. (2000). What is community-based education? American Association of Colleges of Nursing and Helene Fuld Health Trust monographs from the Proceedings of the AACN & Helene Fuld Health Trust
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1999 Faculty-Development Workshops on Communitybased education. Implementing community-based education in the undergraduate nursing curriculum (pp. 5 – 11). Washington, DC: American Association of Colleges of Nursing. Mueller, A., & Henshaw, J. (1997). Transforming the total curriculum to educate the millennium nurse. In M. Tagliareni, B. Marckx (Eds.). Teaching in the community: Preparing nurses for the 21st century (pp. 147 –162). New York: National League for Nursing Press. National League for Nursing. (1992). An agenda for nursing education reform. National League for Nursing. New York, NY: Author. National League for Nursing. (1993). Competencies for new graduates. New York, NY: Author. National League for Nursing. (1996). Nursing data source 1996. Trends in contemporary nursing education (Vol. I). New York, NY: NLN Press (Publication No. 19-6932). National League for Nursing (2003). Innovation in nursing education: A call to reform. New York, NY: Author. Noble, M., Redmond, G., Williams, J., & Langley, C. (1996). A community-focused curriculum. Nursing and Health Care: Perspectives on Community, 17, 66– 71. Pew Health Professions Commission. (1993). Health professions education for the future: Schools in service to the nation: Report of the Pew Health Professions Commission. San Francisco, CA: UCSF Center for the Health Professions. Reece, S., Mawn, B., & Scollin, P. (2003). Evaluation of faculty transition into a community-based curriculum. Journal of Nursing Education, 42, 43 –47. Stanley, J., Kiehl, E., Matteson, P., McMahon, C., & Schmid, E. (2002). Moving forward with community-based nursing education. Washington, DC: American Association of Colleges of Nursing. VanOrt, S. R., & Putt, A. M. (1985). Teaching in collegiate schools of nursing. Boston: Little Brown Co. Zimmerman, J., & Coyle, V. (1996). The way of council. Las Vegas, NV: Bramble Books.
The health-care climate is changing rapidly and in ways that challenge the abilities of professionals who provide health care. Nursing educators are preparing professional nurses who can think critically, use sound clinical judgment, and participate as full partners in shaping health-care delivery and policy. Therefore, many schools of nursing, including five schools of nursing whose experiences are synthesized in this article, are revising their curricula to a community-based nursing perspective. Strategies to assist faculty in the transition to a community-based nursing curriculum include using change theory, creating a supportive environment, reducing tension and isolation, and evaluating. Potential challenges during transition include addressing grief and loss, overcoming the tedium of curricular development, moving the revision along while allowing opportunities for faculty input and consensus building, exploring alternative pedagogies, managing faculty workload and qualification issues, and preparing for transition. Outcomes include a more complete understanding of the community client as a partner in the delivery of health care, increased visibility and role modeling to potential future candidates for health careers, cultural transformations within a university, and promotion of the overall health of a community. (Index Words: Community-based nursing
*Professor and Associate Director, School of Nursing, Radford University, Radford, VA. yAssociate Professor, College of Nursing and Health Professions, University of Southern Maine, Portland, ME. zChair, Department of Family Community Nursing and Professor, College of Nursing, East Tennessee State University, Johnson City, TN. §Associate Professor, School of Nursing, College of Health & Public Affairs, University of Central Florida, Orlando, FL. OAssociate Professor, School of Nursing, Linfield College, Portland, OR. Address correspondence and reprint requests to Dr. Carter: Radford University School of Nursing, Box 6964, Radford, VA 24142. E-mail: [email protected] 8755-7223/$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2005.04.004
education; Curriculum; Faculty transition) J Prof Nurs 21:167 – 174, 2005. A 2005 Elsevier Inc. All rights reserved.
I
N THE LAST decade, the nursing literature and other professional documents have increasingly indicated that the focus of nursing education was changing to respond to the instability of the United States health-care system (American Association of Colleges of Nursing [AACN], 1996, 1998; National League for Nursing [NLN], 1993). Concurrently, the United States has been facing a growing crisis with respect to a lack of affordable health-care insurance and increasing costs of prescription drugs, particularly for the older population. Communities are struggling with large numbers of people across the life span who are receiving minimal or no health care because they cannot afford or access services. Kerfoot (1997) notes that the rapidity of change now occurring in the health-care industry challenges nursing education to develop programs to support newer models of care delivery. Consistent themes have been emerging, including nurses’ essential needs to be educated in providing and coordinating care for individuals, families, aggregates, and communities and to be prepared in making independent nursing decisions in both structured and unstructured settings (NLN, 2003). Therefore, the challenge for nursing educators is to prepare professional nurses who can think critically, use sound clinical judgment, and participate as full partners in shaping health-care delivery and policy. Nurses now must be able to practice across multiple settings, several of which are not traditional venues for practice (AACN, 1997). Numerous professional groups including the AACN (1996,1997), the American Organization of Nurse Executives (1996), and the Pew Health Professions Commission (1993)
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endorse baccalaureate preparation for nurses as critical to address the expanding knowledge base and complexity of the health-care system. The AACN (1998) notes that the preparation of entry-level professional nurses requires a greater orientation to community-based primary care and an emphasis on health promotion, maintenance, and cost–effective coordinated care. The AACN (1997, p. 1) also predicts that: With constant changes predicted in health care for the foreseeable future, it is imperative that nursing education programs themselves act as agents of change. It is the responsibility of nursing education, in collaboration with practice settings, to shape practice, not merely respond to changes in the practice environment.
The purpose of this article is to review the community-based model of nursing education and address issues relevant to transitioning to a community-based nursing curriculum. Community-based Nursing Education Model
Community-based nursing education (CBNE) is a pedagogy that enables students to learn to provide nursing care for people no matter where they encounter them. This expanded approach to nursing education offers the opportunity to use different teaching strategies and settings in addition to hospitals, where traditional nursing education programs based most of their clinical experiences on (Matteson, 2000). Community-based nursing education provides nurses with a new model for clinical learning and provides the necessary opportunities for undergraduate nurses to: c c c c
Provide care along a continuum from wellness to illness; Work with interdisciplinary teams; Work within and across diverse health-care delivery environments and communities; and Provide care for diverse populations, including diverse ages, sex, ethnicity, healthy–ill populations, and acute–chronic health states (AACN, 1999, p. ii).
Although most core competencies, core knowledge areas, and professional roles outlined in The Essentials Of Baccalaureate Education For Professional Nursing Practice (AACN, 1998) can be taught using the community-based model in community clinical sites,
this does not preclude the necessity for hospital clinical experience. It just redirects the focus of clinical education to caring for people within their own environment rather than only for those in a hospital setting. Furthermore, the key for the success of this model is an ongoing partnership between nursing education and the community (NLN, 1996). Unique to the CBNE model is the opportunity for nursing students to learn and develop partnership skills with stakeholders in their communities. This experience heightens communication and leadership skills and allows for creativity in solving community health problems to emerge. Community-based nursing education has received more attention since the AACN, supported by the Helene Fuld Health Trust, held workshops in 1998. Faculty teams at these workshops developed projects for implementing concepts of CBNE in nursing curricula. Some faculty were already involved in changes leading to a CBNE curriculum. Ideas and experiences were shared in an effort to assist other schools. However, a clear and consistent theme pervaded: faculty were grappling with how to transition to this new paradigm in nursing education. The following section shares experiences of transition, challenges, and outcomes of moving to a CBNE curriculum.
Faculty Development Strategies
Faculty traditionally teach what they know, and as the CBNE movement began, most faculty knew a health-care system that either no longer existed or was quickly dying. Few had been introduced by either education or research to a consumer-driven, community-based primary health-care system. Even fewer were knowledgeable of what their role would entail as educators for such a system. Before curriculum reform must come faculty reform (NLN, 1992), yet the CBNE movement had a momentum that would not wait until faculty knowledge and understanding of the needs for and impact of such a change materialized. More recently, a guidebook was published to assist schools of nursing to implement CBNE in their undergraduate programs. The document is helpful specifically in educating new faculty to the CBNE model (Stanley, Kiehl, Matteson, McMahon, & Schmid, 2002). Faculty development is about change and growth. Individual faculty may have a passion about a particular area of nursing knowledge and practice.
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This expertise has been acquired through years of experience and teaching and usually has been acquired in small shifts of change. When confronted with a major change in the nursing curriculum, the security of faculty in their expertise can teeter on the edge of competency. Therefore, appropriate support throughout the developmental process of change is vital to assist faculty in securing a new balance. The initial step in faculty development is that of any change: creating dissatisfaction with the status quo or, in this case, the current curriculum (Edelman & Mandle, 1998). Key faculty members, curriculum committees, and deans (or directors) are vital at this time. Literature including research regarding CBNE can be collected, distributed, and discussed for relevance to a particular curriculum. Reports and articles from health-related organizations about shifts or trends in health-care delivery and the requisite skills of nurses can be circulated. In addition, preparation for an accreditation review may provide an impetus to examine different ways of educating people for nursing. Statistics showing nurse employment settings can also demonstrate needed shifts for education. Such information can be summarized and shared in committees, faculty meetings, development lunches, and workshops. Consultants may also be brought for workshops on various topics related to a particular approach or strategy. Challenges and opportunities can be explored in informal settings before a decision to make a change is made. Once approximately 30% of faculty indicate readiness to move ahead of the dissatisfaction stage, plans for an actual change can be made (Edelman & Mandle, 1998). Faculty workshops can be held with groups developing visions of a community-based curriculum. This is a time for creativity and innovation in the curriculum, often challenging the bsacred cowsQ serving as obstacles to curricular growth. Groups can include faculty, students, and nurses in clinical practice. Key people who were actively involved in the earlier stage should be involved in each group to provide support, encouragement, and information regarding the possible change. Faculty do not want to lose their special teaching expertise. They must be able to see how their content can be shifted to fit the new curriculum context. People look for the familiar in new situations. Finding the familiar supports a sense of security and competence and enables one to more easily make a transition. Deans have a key role in sustaining the vision of a new curriculum. Creating a supportive environment for faculty to make change is elemental to that role.
When faculty realize that their knowledge and expertise can be included in a community-based nursing curriculum, resistance to change will lessen. This can be a time for very practical support of faculty. Financial stipends for faculty time in community fellowships can foster development of nursing practice in different settings. Mentoring partnerships with community-based nurses can assist faculty in understanding and applying community-based concepts in practice settings before teaching students. Faculty with community nursing expertise can come alongside other faculty to share expertise, resources, and teaching strategies. Faculty can be sent to CBNE conferences to acquire information and become resources for others. Workload adjustments may be implemented to support faculty in the work-intensive requirements of curriculum revision. A curriculum plan is best developed and implemented by an entire nursing faculty. A vested interest of time, energy, ideas, and interest will sustain the momentum for change. As a plan is implemented, faculty meetings can be used to share challenges and solve problems. Such meetings can reduce any sense of isolation in course development and implementation. Stress of change can also be managed through sensitive and timely sharing of frustrations or disappointments. Humor can also be used to diffuse the tension inherent in change. As the former curriculum is phased out, time for grieving losses should be taken. Celebrations of past successes and rituals of transitions can be developed for this passage to a new curriculum. Finally, as a curriculum becomes securely in place, evaluation must take place. This process should be ongoing with the use of criteria established by faculty and each school’s accrediting bodies. Evaluation data can be collected from the start of the curriculum, but care should be taken not to make changes too quickly. Practice with the course materials and teaching strategies may be the best approach before making any change in the new curriculum. Faculty continue to need support and development as they deal with student concerns and community-based content (Edelman & Mandle, 1998).
Challenges Along the Way
The transition to a community-based curriculum gives rise to multiple challenges for nursing faculty, staff, and students. Sensitive leadership throughout the transition process allows for the identification of
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challenges and initiation of steps to overcome them. By engaging faculty, staff, and students throughout the revision change process, the resulting curriculum is owned, stimulating, and effective. This section focuses on strategies for dealing with challenges faced by faculty, but these strategies can be modified to include staff and students. Once faculty have progressed from the process of dissatisfaction to that of readiness to change, as described earlier, issues of grief and loss may linger. Letting go of bthe way we have always done itQ can be painful and frightening for some faculty and staff. Some may express these uncomfortable feelings in a manner reflecting resistance to change. Doll (1993, p. 11) argues that this fear is related to a perceived loss of control that bkeeps us confined to the realm of mediocrity.Q The council process (Zimmerman & Coyle, 1996) is one strategy that promotes the resolution of residual grief, loss, and fear. It focuses on speaking and listening from the heart, being of lean expression, and being spontaneous. This allows faculty and staff to acknowledge feelings of grief, loss, and fear openly and allows for expression in a nonthreatening environment. Resolution of these residual issues promotes commitment to a new curriculum and a shared sense of teamwork. Much can be learned from those who resist change, and it is useful to hear the essence of their objections to identify and overcome potential problems. However, the time to move on with the change arises and complete unanimity may be impossible. At such times, the leaders in implementing the change are key in moving the transition forward, coaching and encouraging the resisters along the way. The meticulous, detailed work required for a curriculum transition requires a great deal of faculty time and energy. Some nursing faculty do not have formal education related to curriculum development, so the learning curve may be steep for a person or persons leading the faculty revision. Using a model such as that of VanOrt and Putt (1985), Sequential Steps in Curriculum Process, to lead faculty through a revision process can be useful in allowing faculty to see the steps required for curriculum revision and track progress through the process. If possible, partial (50–75%) release time for persons leading a revision effort allows for focused energy and realistic workload. If release time is not possible, it is important to acknowledge that the revision process may take longer. However, it is crucial that all faculty be actively and regularly involved in the revision process to allow for the
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emergence of a curriculum that is owned and esteemed. An important role for curriculum revision coordinators is to monitor the status of faculty agreement on key issues and pace the progress of the revision. Coordinators must have skills in achieving a balance between allowing enough discussion to resolve issues and conforming to reason to progress the process when a consensus is elusive. The written work (course proposals, syllabi, etc.) of curriculum revision is monotonous and dry. Use of teams to develop and write such items as course proposals and syllabi can stimulate creative synergy. Allowing for curriculum work time within the work month, where meetings are focused on the curriculum, is another effective strategy. For example, if faculty meetings are generally scheduled on Tuesday mornings, then months with a fifth Tuesday are designated for curriculum work. Faculty can actually be energized and excited by these meetings if they are conducted in ways that allow for a relaxed, social environment. Curriculum meetings can have an added result of positive team building for faculty and staff. For example, planning potluck meals or, if foundational or departmental funds allow, providing a nutritious meal as part of the meeting allows for social interactions and informal discussions from which creative curricular thinking can occur. Door prizes and raffles of donated items (such as gift certificates from local restaurants or an item from the school’s bookstore) can entice faculty and staff to arrive at meetings on time or recognize collective work. A local masseuse or masseur may be willing to provide mini-neck massages while faculty are in curriculum meetings. Creativity in coordinating curriculum meetings can spawn creative curricular outcomes, faculty team building, and positive forward progress. Traditional curricula have been based on inhospital and non-hospital (community) dichotomies. Some community-based curricula texts perpetuate these dichotomies, whereas others reflect differing perspectives on community-based care. Faculty must collectively resolve what a community-based curriculum means to them (Mueller & Henshaw, 1997). This should be documented into a definition for CBNE, or a similar term, because this unifying definition will be revisited frequently to focus the revision. As faculty who have traditionally taught the hospital component of former curricula shift into non-hospital settings, faculty will need to build new and different clinical skills in the community. Issues that were traditionally in the community
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health course such as home care safety and hygiene will need to be readjusted into other courses as necessary so as not to be lost as students begin using these techniques in courses other than the community course. Applying interactive teaching strategies in classroom and clinical conference settings can allow exploration of community clinical skills in a nonthreatening environment, and faculty members with community expertise can serve as resources for the integration of these strategies. Every faculty has members with expertise in community health; however, issues of territoriality and turf can be barriers in discussions and must be examined by faculty. It can be effective to bring guests from the local community or national-level speakers to discuss these issues. Curriculum revision is also an excellent time to explore other pedagogical strategies such as narrative pedagogy (Diekelmann, 2001). The addition of clinical settings beyond hospitals such as free clinics, home health, neighborhoods, Head Start, and schools introduces challenges such as clinical supervision staffing, workload, faculty accessibility to students, and faculty comfort in a wide array of settings (Mueller & Henshaw, 1997; Noble, Redmond, Williams, & Langley, 1996). This comfort zone is achieved through faculty engagement with community agencies, which requires additional time and resources. Unless the faculty establish strong relationships with neighborhoods and agencies, alienation between each community and institution will occur, thereby decreasing the educational value of the experience. Faculty must explore feasibility issues when adding clinical settings to a curriculum. Once challenges along the way toward curriculum revision have been addressed and implementation is approaching, planning for a transition between new and old curricula is important. How will students not in the regular path of progression in the old curriculum (i.e., out of sequence) be handled? How will communication of the new curriculum to prospective students not yet in the curriculum be achieved? How will the curricular changes be communicated to internal and external communities of interest such as faculty for premajor courses and clinical agency administration and preceptors/staff? Involving school of nursing staff, recruitment faculty, current students, and advising staff in these and similar discussions will promote a smoother transition to a communitybased nursing curriculum.
Outcomes
Community-based nursing education expands traditional nursing education boundaries and has created significant positive outcomes for faculty, students, communities, and institutions. One of the major outcomes is that faculty become immersed in their community and understand the community client as a partner in the delivery of health care. No longer is the academic faculty the source of all knowledge. The focus on this partnership emphasizes that the community and faculty are teachers and learners simultaneously. This give-and-take process is foundational to the idea of community empowerment where groups and individuals take charge over their lives. Faculty learn to view the notion of empowering a client at the macro level. They learn to be flexible and adaptive as they devise ways to put community needs before academic timetables. For example, a curriculum can be adapted to schedule a community event on a weekend instead of during a scheduled class time. Another benefit to the faculty is that the community becomes their practice site; they become a part of the community. Because faculty are visible and consistently involved, the community becomes more responsive to a mutual dialogue about needs and innovative solutions. The dialogue embraces individuals from a variety of nonacademic backgrounds who can contribute greatly. At this collaborative level, community members, students, and faculty are involved in planning curricula that will both educate students and improve the overall health of the community. Faculty subsequently facilitate the implementation of these innovative solutions through health fairs, programs, and other interventions with students. Thus, the traditional concept of the academy as the bivory towerQ is dispelled both in theory and in practice. Reece, Mawn, and Scollin (2003) found that faculty transition into a community-based curriculum was both positive and negative. On a nine-scale questionnaire that assessed the transition experience, faculty indicated that the most positive response was in the category of satisfaction. Satisfaction was related to encouraging students’ critical thinking, working with students and nurses in clinical sites, and role modeling. The two lowest subscales were planning and environment, implying that more time was needed to plan such a program that impacts both student activities and reallocation of faculty time and resources. Bednash and Stanley (2002) describe the importance of using a variety of settings for clinical
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experiences so that students learn to care for people across the life span in both structured and unstructured settings. The unstructured community setting captures some of the most critical competencies that students acquire. They learn how to assess the needs of and provide care to diverse populations in a particular community. In addition, the visibility of nursing students in these communities provides role models for the youth to attend a university and enter a health profession. To learn how to care for people in communities requires that faculty and students become involved in the delivery of health care on a consistent basis. Students develop a better sense of the community because they have experiences over time. Small interactions in pieces enable students to conceptualize the complex interactions between groups, communities, and the environment. The outcomes for the community are numerous, with particular impact on client care. As a result of assessment, planning, and programmatic interventions, students and faculty directly provide service to a large number of individuals. In one school, more than 40,000 individuals were served in 1 year. Community clients in a large housing project were the recipients of home visits, school projects, and health promotion groups. The outcomes resulted in improved health awareness for this population. In another community, the overall cardiovascular mortality rates improved as a result of community-based care where faculty and students were involved in schools, industries, agencies, organizations, and many community fairs (Edwards & Smith, 1997). As a result, communities are more apt to approach the university to discuss potential community health problems. A final important outcome of CBNE is the change that occurs in other university curricula. At one university, there was a significant increase in service learning courses for other colleges as well as an increased interest in interdisciplinary education (Edwards & Smith, 1998). A cultural transformation occurred when the educational infrastructure moved to a plethora of interprofessional collaborations across academic disciplines. Nursing set this example for partnering in community agencies and across disciplines.
Lessons Learned by Five Nursing Schools
One of the conceptual goals of Radford University School of Nursing faculty during curriculum
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transition planning was that community reflects a continuum of care for clients, rather than the hospital and non-hospital definitions that traditionally depict community. Faculty are pleased with the communitybased education (CBE) curriculum’s comprehensive approach, which allows for a broad application of the community-as-location perspective. This has subsequently allowed the community health course to focus on aggregates and populations more comprehensively. Student feedback reflects satisfaction with this approach, allowing them to participate more completely and seamlessly in the health experiences of individuals, families, aggregates, and communities. After 8 years of the CBE curriculum, the University of Central Florida engages basic and accelerated prelicensure students, RNs to BSNs/MSNs, and graduate students in 14 community nursing centers (CNCs) in underserved communities. The number of students assigned to each CNC ranges from 45 to 145 over the course of 1 year, serving from 2,600 to more than 14,000 clients per CNC annually. A recent faculty evaluation resulted in 82% of the CNC faculty rating their CNC experience as excellent, including the CNC facilities, availability of learning opportunities for students, quality of community partnerships, safety within the community, and impact that students have on the health of the community residents. The University of Central Florida faculty have learned that rich experiences in the CNC communities require much work and creativity by faculty but that the outcome is well worth the effort. Community-based education graduates have an awareness and sensitivity of the lived experience and the human condition on a very different level compared with those who graduated under a different model. The biggest threat that we have faced is the misperception of acute care organizations that a CBE nursing program yields less prepared graduate nurses. In reality, there is no difference in acute care clinical hours in the CBE curriculum and in total clinical hours due to increased community hours. The current nursing shortage is affecting all areas of nursing practice not just in acute care settings, and our challenge is to remain steadfast in the commitment to educate generalist undergraduate nurses who are knowledgeable and skillful in meeting the health-care needs of people throughout the life span and across the health–illness continuum in a variety of settings. The Linfield College was pleased to have a successful accreditation visit after implementing their CBE curriculum, receiving full accreditation and commendations on the vision of the curriculum and
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on the courage that the faculty demonstrated in doing something new and daring. One challenge addressed by the Linfield College faculty is orienting part-time faculty to the concepts of the community-based curriculum. By instituting a new faculty orientation that includes an overview of the curriculum and community-based concepts, these orientation needs have been resolved. In addition, an annual retreat for part-time faculty to address particular issues and challenges that they may have with implementing the curriculum in clinical settings has been quite effective. These activities have increased the consistency of the message given to students. As the faculty of the East Tennessee State University College of Nursing transitioned to a CBE curriculum, the college’s mission similarly changed to that of bfacilitating the health of the community.Q To fulfill this mission, the faculty implemented the bhome baseQ concept, integrating community through the entire curriculum, to prepare graduates in identifying, participating, and practicing in partnerships with communities. On the first day of the nursing curriculum, students choose a geographical community with which to work throughout their nursing student experience. In an initial course, students participate in a community assessment using key informant interviews, doing windshield surveys, and studying data-based research on community demographics. During the next three semesters, students rotate out of clinical courses to participate in their home base with assignments that relate to the particular clinical course content. For example, in women’s health and pediatrics, students will go into schools and teach about previously identified health needs such as nutrition and pregnancy prevention. In the chronic clinical course, students make home visits to elderly individuals in their particular community. During the last semester, students take the final community course where they plan and implement a large community project. Immersion in the community enables the students to continuously assess needs and establish collaborative partnerships. Students develop a better sense of the community because they have the experience over time instead of just a snapshot of the community during one course. Small interactions in pieces enable the students to
conceptualize the complex interaction between groups, communities, and the environment. The experience of collaborating with communities has taught the students independence and flexibility. The University of Southern Maine College of Nursing and Health Professions was surprised to find that when faculty gave up the need to carefully control the experience and trusted students bto step up to the plate,Q students exceeded the faculty’s performance expectations. Students are confident and clear about the community partnership experience and significantly develop their leadership skills when they are involved in the minutiae of planning. For example, students in the Casco Bay Islands and Fishing Community Partnership do not only conduct screening and flu clinics on the islands and at other sites but are also fully immersed in planning and evaluation. They mutually plan with community leaders and other key resources, inventory and order supplies, seek small grants, and sell sweatshirts to support and underwrite the partnership and its activities. For them to do this responsibly, faculty need to relinquish control, albeit with a watchful eye. Experienced faculty at this institution see CBE as the best way for University of Southern Maine nursing students to learn not only about the needs of particular underserved cohorts in the community but also how to best meet those needs.
Conclusion
In conclusion, the CBNE curriculum will continue to grow and evolve as more communities and schools of nursing partner for the greater good of citizens and students alike. Transitioning to a community-based curriculum requires many changes for faculty. Challenges in the process of change can be met with specific strategies designed to educate and support faculty as additional expertise and competence are acquired. Students can learn the skills needed to function in the evolving health-care system and make a difference in the health of the people served. As future professional nurses, they will provide the leadership, innovation, and appreciation of the ideal that nurses have a responsibility to serve their communities.
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