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“Nursing Students Assaulted”: Considering Student Safety in Community-Focused Experiences
“NURSING STUDENTS ASSAULTED”: CONSIDERING STUDENT SAFETY IN COMMUNITY-FOCUSED EXPERIENCES RHONDA E. MANEVAL, D.ED., RN*
AND
JANE KURZ, PHD, RN†
Community nursing experiences for undergraduate students have progressed beyond communitybased home visits to a wide array of community-focused experiences in neighborhood-based centers, clinics, shelters, and schools. Our Bachelor of Science in Nursing program chose to use sites situated within neighborhoods close to campus in order to promote student and faculty engagement in the local community. These neighborhood sites provide opportunities for students to deliver nursing services to underserved and vulnerable populations experiencing poverty and health disparities. Some of these neighborhoods are designated as high crime areas that may potentially increase the risk of harm to students and faculty. There is a need to acknowledge the risk to personal safety and to proactively create policies and guidelines to reduce potential harm to students engaged in communityfocused experiences. When a group of baccalaureate nursing students was assaulted while walking to a neighborhood clinic, the faculty was challenged as how to respond given the lack of policies and guidelines. Through our experience, we share strategies to promote personal safety for students and recommend transparency by administrators regarding potential safety risks to students engaged in community-focused fieldwork activities. (Index words: Nursing students; Community health nursing; Safety; Clinical education) J Prof Nurs 32:246–251, 2016. © 2016 Elsevier Inc. All rights reserved.
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HERE IS A growing trend within undergraduate nursing education to develop curricula that strike a balance between disease-oriented and health promotionoriented approaches to nursing education. Historically, the majority of clinical education experiences have occurred in hospitals and other acute and subacute care facilities. In curricula in which health promotion is now a major component, community health experiences are being given increased time and focus. There are a number of factors responsible for this shift (Lynch, 2014) and include recommendations from the Institute of Medicine's Future of Nursing Report (Institute of Medicine Report, 2010), the
*Director, Undergraduate Nursing Programs, Associate Professor, Nursing, Michigan State University, College of Nursing, East Lansing, MI 48824. †Chair, Undergraduate Nursing Programs, LaSalle University, School of Nursing and Health Sciences, Philadelphia, PA 19141. Address correspondence to Rhonda E. Maneval: Director, Undergraduate Nursing Programs, Associate Professor, Nursing, Michigan State University, College of Nursing, East Lansing, MI 48824, 3840 Lone Pine, Apt 7, Holt. E-mail: [email protected] (R.E. Maneval), [email protected] (J. Kurz) 8755-7223 246 http://dx.doi.org/10.1016/j.profnurs.2015.11.001
Carnegie Foundation for the Advancement of Teaching Report: Educating Nurses: A Call for Radical Transformation (Benner, Sutphen, Leonard, & Day, 2010), the Patient Protection and Affordable Care Act (H.R. 3590–111th Congress, 2009; The Patient Protection and Care Act, 2010), and the American Association of Colleges of Nursing (2008). These entities all recommend an expansion of nursing education and services to local communities with an increased focus on health promotion and disease prevention interventions. As a result of the Patient Protection and Affordable Care Act, in 2015, 11.4 million new people enrolled in health insurance coverage (US Department of Health and Human Services, 2015), increasing access to primary health care services. This resulted in an increased need for primary health care providers and for baccalaureate-educated nurses skilled in health promotion and therapeutic lifestyle management. In addition, these new initiatives are contributing to expanded roles for public health nurses such as community health advocates, community educators, public health policymakers, and researchers (Kulbok, Thatcher, Park, & Meszaros, 2012). Nurses are also working in expanded sites such as neighborhood centers, housing developments, parishes, school health programs, worksites, and homeless shelters (Kulbok et al., 2012).
Journal of Professional Nursing, Vol 32, No. 3 (May/June), 2016: pp 246–251 © 2016 Elsevier Inc. All rights reserved.
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In the past, community experiences for undergraduate nursing students were community based, relying on home health care agencies or local public health departments. In this model, the student is assigned to a home health nurse to provide direct nursing care to clients in their homes or to a public health nurse who is providing direct care services to vulnerable or at-risk people. In a community-based model, the focus is on the individual level of nursing care and nursing services with a disease-oriented focus, and although nurses in this model are practicing in the community, they are not practicing public health (Cohen & Gregory, 2009). Programs embracing a health promotion orientation are more often using a community health-focused model rather than community-based model. Cohen and Gregory (2009) defines community health as focusing on health promotion and disease prevention that targets populations rather than individuals. The Association of Community Health Nursing Educators (ACHNE) also differentiates between two levels of community nursing, which they term community-based nursing and community-focused nursing (ACHNE, 2009). ACHNE defines community-based nursing as focusing on the individual with the goal of influencing individual health outcomes, while community-focused nursing targets at-risk populations with the goal of attaining health outcomes and reducing risk. Clinical practice experiences in community-focused health encompass a wide variety of sites that may or may not have a professional nursing presence (Pijl-Zieber & Kalischuk, 2011). Examples include homeless shelters, refugee service centers, senior centers, minute clinics, faith-based organizations, community wellness centers, and primary care offices (Thompson & Bucher, 2013). Personal safety of students has always been a concern during community experiences (Lang, Edwards, & Fleiszer, 2008). In the past, students would travel to client homes or within the community with an experienced nurse or faculty member. The experienced nurse navigated the environment and provided a degree of safety and security for the student. With the increased use of community-focused health experiences has come an increased concern regarding student safety. In our BSN program, which is located in a large urban community, students utilize public transportation and travel about the city to a variety of community sites. Students typically are not going into client homes but, rather, traveling to sites located in neighborhoods with high needs for health care services but which also have high crime rates, frequent episodes of gang-related violence, high levels of street drug usage, abandoned and neglected buildings, and deteriorating infrastructure. Strategies to limit risk and enhance safety are needed given the desire to expose students to a variety of community-focused experiences in high-need areas. To date, there is a limited amount of research available on the topic of personal safety during community-focused experiences and nursing students. There is some related literature that explores the topic of personal safety, but it is primarily focused on community-based models of care and home care workers.
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Literature Review Home care safety risks associated with geographic location include high-crime neighborhoods, gang presence, illegal drug activity, street loitering by youths and men, poor neighborhood lighting, presence of abandoned and deteriorated buildings, and poorly maintained streets (Fazzone, Barloon, McConnell, & Chitty, 2000; Fitzwater & Gates, 2000; Gellner, Landers, O'Rourke, & Schlegel, 1994; Hayes, Carter, Carroll, & Morin, 1996; Kendra, Weiker, Simon, Grant, & Shullick, 1996; McPhaul, Lipscomb, & Johnson, 2010; Sylvester & Reisener, 2002). Fazzone et al. (2000) performed a qualitative study with 50 direct home care staff and 11 administrators in the midwest. Participants were asked to describe unsafe conditions within the patient's home or neighborhood. Participants reported going into areas where gunfights and drive-by shootings were common and “where police would not go.” Other unsafe conditions near patients' homes included men or adolescents loitering on the street, gang activity, police raids, broken glass or debris, “run-down” homes, poor lighting, rats, and hostile dogs. Organizational and administrative issues impacting safety included the lack of policies and procedures and/or the lack of enforcement of those policies, lack of familiarity with the community and neighborhood, delay of security assistance, absence of a “check-in” system when staff traveled in high-risk areas, lack of administrative support, and failure or delay of staff to report incidents. Participants also reported that although they receive some training on personal safety, it was inadequate to meet their needs. Recommendations include ongoing education and training and comprehensive personal safety policies and procedure that address the actual threats to safety found in the environment. Sylvester and Reisener (2002) conducted a mixedmethods descriptive study to explore perceived risks and actual exposures to danger in the home care environment. Of the 43 participants, 16% felt unsafe when making home visits, 30% felt that agency measures were not in place to ensure their safety, and 20% felt that the agency did not respond to safety concerns by staff (Beaver, 2014). Strategies undertaken to address these issues included a comprehensive list of safety recommendations for staff to utilize when traveling. The list includes suggestions such as getting directions, carrying a cell phone, not carrying a purse, being aware of surroundings, walking confidently, using eye contact, avoiding isolated areas, and leaving unsafe situations immediately and contacting a manager. Home care patients were also required to sign an agreement to remove safety risk from the environment such as weapons, animals, and illegal drugs. Patients were also required to agree to not expose the staff member to verbal or physical abuse. As a result of these measures, staff reported feeling less unsafe and more supported by the agency. A few studies focus on nursing students' feelings regarding the risk to their personal safety when engaged in community clinical experiences (Carroll, Morin, Hayes, & Carter, 1999; Leh, 2011; Morin, Hayes, Carroll, & Chamberlain, 2002). In a descriptive qualitative study, Leh (2011) asked nursing students about their feelings
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concerning community health clinical experiences. One of the major themes of particular relevance to safety in community clinical experiences was the contemplation of risk to personal and client safety while in the community. Students shared a sense of vulnerability with most “acutely uncomfortable with the prospect of entering homes and neighborhoods, fearing the risk of becoming innocent victims of violence” (p. 624). This study highlights the need for educators to be aware of student concerns and be proactive in addressing them prior to student experiences in the community. Leh (2011) calls for faculty to prepare students better for these experiences and instructors to acknowledge students' fears related to potential safety risks. Skillen, Olson, and Gilbert (2003) discuss four educational strategies for promoting safety of nursing students during community-based rotations. The first strategy is a student checklist that includes five sections—personal preparation, agency preparation, vehicle preparation, environmental surveillance, and response to situations. Students are instructed to review the checklist prior to their home nursing experience and discuss any item on the list for which they are unsure or uncomfortable with their faculty member. Preparation includes such items as planning the route in advance, carrying a cell phone, keeping one arm free, telephoning clients in advance to arrange meeting time, and describing best practices for home visit safety (Kendra & George, 2001). Environmental surveillance examples include observing for unsecured animals, observing for persons consuming alcohol or street drugs, and scanning the environment for potential dangers. Conducting small group learning activities focusing on safety and risk in home care, requiring students to complete Web-based module on personal safety in community health, and use of scenario-based learning activities were all identified as additional strategies used with students to promote student safety in community health. The need to acknowledge potential risk and proactively create policies and guidelines to reduce the potential harm to students and faculty is a critical part of community-focused program planning and development. Unfortunately, in our case, these policies and guidelines did not emerge until after the occurrence of a serious safety issue involving our students in route to their community-focused experience. It was at that time that we realized that we had provided no direct training regarding risk assessment and risk reduction strategies, other than faculty-developed suggested travel routes for students and the general safety and security guidelines provided by the university. We also lacked formal policies and procedures for students to follow in the event of an actual or perceived threat or in cases where real harm had come to the student. What follows is a description of the event.
Safety Incident One late November morning four female nursing students rode the subway to their assigned clinical site. The trip involved a 10-minute subway train ride and a six-block walk through a high-crime neighborhood known for drug activity and gang violence. The students
boarded the subway at a stop on campus. During the train ride, they had their cell phones out, checking messages and texting, and were engaged in conversation among themselves. When they exited the subway station at approximately 7:30 a.m., the streets were sparsely populated. They did not notice that a young male, who had been on the train with them, followed them until they were at an underpass at which time he grabbed a student by her hair and threw her against the brick wall. He stated that he had a gun in his pocket and that they all had to give him their money and cell phones. One student sprinted away to obtain help. The other three students gave him the items. The young male quickly pocketed everything and ran in the opposite direction. The student who had run away went to the community health center and alerted the staff and her instructor, who called the police. The police arrived, and students provided a description of the perpetrator, and other officers fanned out in the area to search for the suspect. In spite of their efforts, the suspect was never found. Later that afternoon, the neighborhood block captains also went door-to-door in the community with a sketch to determine if anyone could identify the suspect. Although the neighborhood residents could not identify him, it was reported that many expressed outrage that nursing students had been victimized in their community. University police were contacted and escorted the student who sustained a potential head injury to the emergency department for examination. Once she was medically cleared, she joined her student colleagues at the police substation where they all provided their formal statements to describe the events. The faculty member alerted the program administrator who immediately contacted the department chair, dean's office, and university counseling and request that they see the students immediately. She then met the students and faculty member at the police station, retrieved the students, and took them to the counseling center. She also called each parent to let them know what happened and to inform them of the university's next steps. This assault occurred a few days prior to the start of the 4-day Thanksgiving holiday. These students opted to leave campus and return to their homes early. They did return the following week; all but one agreed to return to the site; that student was reassigned to a site adjacent to campus. All completed the last 2 weeks of clinical without incident.
Discussion No student had ever reported being assaulted in the last 40 years of this program's existence. This caused the faculty to reflect on the decision to use community-focused clinical sites located in the neighborhoods surrounding campus. It had been a conscious decision to use local sites rather than have students travel longer distances to sites with less crime in more affluent areas of the city. This decision was grounded in the university and college mission of public service, social activism, and community engagement. In retrospect, we realized that we had not
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fully appreciated how this decision might impact students, faculty, and the program. There is a dearth of information about criminal assaults involving U.S. nursing students attending colleges. University students, in general, who were victims of violent crime often experienced the events as a result of their own drug or alcohol use or a consequence of their own behaviors (Saewyc et al., 2009) Nationally, 80% of the campus crime is caused by students and typically does not involve a weapon (Glasgow, Dreher, & Oxholm, 2012). Universities in the past 10 years have worked diligently to develop many strategies to ensure campus safety. Many have an entire department of public safety or a division of student affairs or the office of student life that focus on providing educational sessions that help increase student awareness of dangers and self-protective behaviors. Other common strategies are key card access to buildings (especially dorms), obvious video cameras, blue light telephones, police patrols, and police escorts across campus. The U.S. Department of Education requires all schools to publish their crime data for the last 3 years to alert students and families of potential dangers. The intent is that students will adopt the appropriate safeguards to protect themselves. Although these interventions are laudable, they do not help the nursing student who leaves the campus to attend clinical at a community or primary care site. The faculty ascribe to a number of professional ideologies which guided the development and implementation of the community-focused curriculum. These included caring, advocacy, activism, ethics, access to health care, and the right to health care. The faculty within this urban university was committed to working with underserved and vulnerable populations in which health disparities and poverty were endemic. Delivering nursing services to those in most need of services was integral to the program, the curriculum, and the development of professional nurses. Fieldwork experience in local communities sensitizes and teaches students about the determinants of health such as quality of schools, environmental safety, affordable nutritious food, and public safety, all of which can impact the health of people who live in those communities (Callen et al., 2013). These also help to develop culturally sensitive and culturally competent professional nurses. However, the reality is that our program is located in a major city that has been cited as one of the top 25 most dangerous cities in the United States primarily because of illegal gun trade and drug activity (Business Insider, 2015). Local crime statistics for the neighborhoods in which our particular community sites occupy warranted a review of how our program was ensuring student and faculty safety. More formal safety education programs and risk reduction strategies were required if these clinical experiences were to continue. The immediate administrative response was through e-mail. The dean sent a message to all nursing students notifying them of the assault with an invitation to share any concerns or unsafe experiences with the associate chair and/or their faculty. Faculty discussed the situation with their student groups to determine if a problem existed at any one site. No pattern was noted, but faculty
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reported that these discussions revealed anxiety and concern on the part of students. Three faculty members also revisited all community sites using public transportation to ensure that the safest route was being suggested. Recommended routes for travel had been posted for students prior to the incident. However, the students involved reported making a conscious decision not to follow the recommended route because they felt the bus took too long, was crowded, and made too many stops. When it was pointed out that the bus had a stop directly across the street from their community site, they responded that they had not fully considered the safety issue but, rather, were focused on travel time and comfort. It was clear to faculty, given the traditional age of our students and their naivety regarding personal safety that there was a need for improved personal safety measures and proactive steps to educate students. The conversations with students and the student victims helped to guide the development of recommendations and interventions to address the issue. These strategies include travel safety guidelines for public transportation and personal vehicle, travel incident reporting guidelines, and mandatory safety workshops. Refer to Tables 1A and 1B: Recommendation to enhance personal safety when traveling to and from clinical/fieldwork sites and Table 2: Guidelines for reporting travel incidents. Using the available suggestions in the literature, guidelines were created and placed in the student handbook, published on the Web site, reviewed with students during new student orientation and, again, reviewed during their first community postconference. Annually, the department of nursing hosts a mandatory 2-hour workshop on student safety. This workshop includes the chief of university police
Table 1A. Recommendation to Enhance Personal Safety When Traveling to and From Clinical Experiences: Using Public Transportation Travel using public transportation Follow the recommended route when traveling by bus or subway. Know the directions to the clinical site prior to leaving home. Travel in groups, never alone. Have your clinical faculty member's telephone number in your cell phone in case you become lost. Never carry a purse. Keep your money and keys in a small wallet that fits in your pocket. Always walk with one arm free. Walk with confidence. Use eye contact when looking at others. Do not openly display technology when traveling, e.g., laptops, I-Pads, MP3 player, or I-phones. Do not talk on your cell phone or text while walking. Do not have earbuds in use. Be aware of your surroundings; do not engage in excessive conversation. Avoid isolated areas. Trust your instincts. If you feel unsafe, leave the area. Call your instructor when it is safe to do so. Communicate any safety concerns to your clinical instructor or any faculty member immediately.
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Table 1B. Recommendation to Enhance Personal Safety When Traveling to and From Clinical Experiences: Using Personal Vehicle Travel using personal vehicle Obtain directions to site prior to the first clinical day. Test drive your vehicle to the clinical site and calculate estimated travel time. Check with your clinical instructor about the availability for parking prior to deciding to drive. If street parking is the only option, park in view of the clinic site. Residents often save a parking spot by placing lawn chairs in front of their homes. Do not remove. Keep your doors locked at all times while in vehicle. Do not text or talk on your cell phone while driving, parking, and exiting your vehicle. Lock your car upon exiting. Lock valuables in your trunk prior to traveling to the clinical site. Never have valuables visible in your car. Do not carry a purse; keep money and valuables in a pocket. Do not exit the car if you feel unsafe. Find a different parking spot or call your instructor. When returning to your car, have keys in hand when leaving the clinical site. Do not drive down dead-end streets that makes turning around difficult. Do not drive down alleys with debris or glass that may cause flat tires. Do not drive down narrow streets that could restrict movement if you need to exit the vehicle.
who reviews risk reduction behavior and what to do if victimized. This presentation is made more meaningful by the sharing of real examples based upon the chief's 20-plus years of experience. The program also reviews specifics regarding travel to clinical sites, the role of students and faculty in creating a culture of safety, and specific reporting mechanism within the department of nursing for actual or perceived threats to safety. The reporting of threats to safety was particularly important to improving communication
Table 2. Guidelines for Reporting Travel Incidents Guidelines for reporting travel incidents Definition: A travel incident is defined as an event that occurs when traveling to or from a clinical site that has the potential of injury, loss of personal property, and/or causes fear or concern. Procedure: 1. If you are a victim of crime, immediately contact the police by calling 911 on your cell phone and follow their directions. If possible, notify your clinical instructor who will contact the department for further instructions. 2. If during your travel you experience an event that has the potential for injury or makes you uncomfortable or threatened, do the following: A. Upon arrival at the clinical site or at home after clinical, call your faculty member. He/She will notify the administrator who will contact you to discuss in greater detail. B. Submit report of incident to the department of nursing e-mail account ([email protected]) documenting an unsafe travel situation or event that you witnessed. In the e-mail, include the names of involved persons, accurate description, time of event, and exact location.
between faculty and students in regard to safety. The culture of personal safety created by the new guidelines and recommendations helped students to see that faculty not only acknowledged the problem but also wanted to be proactive in helping students feel safe. Students report their concerns in a number of ways; some use the electronic reporting system, whereas others speak directly to their clinical faculty, who then reported concerns to the associate chair. All of these data are shared with the office of student safety and security that then makes recommendations. For example, one student group was concerned that a cluster of men gathering at a corner near where they walked to their clinical site posed a possible threat. These men would call out to the students and make lewd and suggestive remarks. The response by university police was to notify the city policy substation in the area, which would then have a patrol car at the site when students were traveling to and from clinical.
Conclusion Anecdotal reports by faculty suggests that students are more consistently using recommended travel routes and appear to be more attentive and aware of how to reduce risk and use personal safety strategies. There have been no additional incidents involving students to date. Our experience highlights the need for the creation of policies and guidelines to promote personal safety for students in the community. Simultaneously, there needs to be transparency within the program in which administrators and faculty acknowledge the safety risks that might exist with community-focused fieldwork activities to parents and students. Acknowledging the issue provides opportunities to share strategies that have been employed to address the issue. We have found that this approach opens the lines of communication and reduces parent and student anxiety. Parents and students are reassured because faculty and administration are fully aware of the risks and are viewed as taking proactive steps to reduce those risks. Although our recommendations focus on communityfocused experiences in high-crime neighborhoods, they may also be useful in decreasing risk for students traveling to clinical experiences in other settings. As our experience demonstrates that there is a need for more information on how program administrators and faculty can best provide for student safety, there is also a need for evidence-based strategies to address the issue of student personal safety. Research should focus on identifying effective strategies to decrease student anxiety and reduce incidents of harm to students. It is essential that nursing faculty promote a culture of safety, educate students to environmental threats, and assist students in developing strategies to decrease risk. In conclusion, this nursing faculty did address the clinical incident while effectively collaborating with a team of university administrators, counselors, and police. The example presented here can be used by others to proactively plan to address safety issues with undergraduate nursing students.
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References American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/education/ essentials.htm. Association of Community Health Nursing Educators (ACHNE) (2009). Essentials of baccalaureate nursing education for entry level community/public health nursing. (Available from Association of Community Health Nursing Educators, 10200 West 4th Avenue, Suite 304, Wheat Ridge, CO 80033). Retrieved from http://www. achne.org/files/essentialsofbaccalaureate_fall_2009.pdf. Beaver, D. (2014). Visiting nurse service and home healthcare visitation safety. Journal of Healthcare Protection Management, 30, 107–116. Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. Carnegie Foundation for the Advancement of Teaching. San Francisco: Jossey-Bass. Business Insider (2015). The 25 most dangerous cities in America. Accessed on March 22, 2015 at http://www. businessinsider.com/most-dangerous-cities-in-america-2013-6. Callen, B., Smith, C. M., Joyce, B., Lutz, J., Brown-Schott, N. & Block, D. (2013). Teaching/Learning strategies for the essentials of baccalaureate nursing education for entry-level community/public health nursing. Public Health Nursing, 30, 537–547. Carroll, M., Morin, K., Hayes, E. & Carter, S. (1999). Assessing students' perceived threats to safety in the community: Instrument refinement. Nurse Educator, 24, 31–35. Cohen, B. E. & Gregory, D. (2009). Community health clinical education in Canada: Part 1 – State of the art. International Journal of Nursing Educational Scholarship, 6, 1–17. Fazzone, P., Barloon, L., McConnell, S. & Chitty, J. (2000). Personal safety, violence, and home health. Public Health Nursing, 17, 43–52. Fitzwater, E. & Gates, D. (2000). Violence and home care: A focus group study. Home Healthcare Nurse, 18, 596–605. Gellner, P., Landers, S., O'Rourke, D. & Schlegel, M. (1994). Community health nursing in the 1990s – risky business? Holistic Nursing Practice, 8, 15–21. Glasgow, M., Dreher, H. & Oxholm, C. (2012). Legal issues confronting today's nursing faculty: A case study approach. Philadelphia, PA: F.A. Davis, Co. H.R. 3590–111th Congress (2009). Patient Protection and Affordable Care Act. GovTrack.us (database of federal legislation). (Retrieved November 21, 2010, from http://www.govtrack.us/ congress/bill.xpd?bill=h111-3590I). Hayes, E., Carter, S., Carroll, M. & Morin, K. (1996). Managing fear associated with nursing in urban environments: First steps. Public Health Nursing, 13, 90–96.
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Institute of Medicine Report (2010). Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine: The future of nursing: Leading change, advancing health. Washington, D.C: National Academy Press. Kendra, M. & George, V. (2001). Defining risk in home visiting. Public Health Nursing, 18, 128–137. Kendra, M., Weiker, A., Simon, S., Grant, A. & Shullick, D. (1996). Safety concerns affecting delivery of home health care. Public Health Nursing, 13, 83–89. Kulbok, P. A., Thatcher, E., Park, E. & Meszaros, P. S. (2012). Evolving public health nursing roles: Focus on community participatory health promotion and prevention. Online Journal of Issues in Nursing, 17, 1. Lang, A., Edwards, N. & Fleiszer, A. (2008). Safety in home care: A broadened perspective of patient safety. International Journal For Quality In Health Care, 20, 130–135. Leh, S. K. (2011). Nursing students' preconceptions of the community health clinical experience: Implications for nursing education. Journal of Nursing Education, 50, 620–627. Lynch, A. C. (2014). I am responsible for safety, so now what? Journal of Healthcare Protection Management, 30, 17–27. McPhaul, K., Lipscomb, J. & Johnson, J. (2010). Assessing risk for violence on home health visits. Home Healthcare Nurse, 28, 278–289. Morin, K., Hayes, E., Carroll, M. & Chamberlain, B. (2002). Selected factors associated with students' perceptions of threat in the community. Public Health Nursing, 19, 451–459. Pijl-Zieber, E. M. & Kalischuk, R. G. (2011). Community health nursing practice education: Preparing the next generation. International Journal of Nursing Education Scholarship, 8, 1–13. Saewyc, W., Brown, D., Plane, M., Mundt, M., Zakletskaia, M. & Fleming, M. (2009). Gender differences in violence exposure among university students attending campus health clinics in the United States and Canada. Journal of Adolescent Health, 45, 587–594. Skillen, D., Olson, J. & Gilbert, J. (2003). Promoting personal safety in community health: Four educational strategies. Nurse Educator, 28, 89–94. Sylvester, B. & Reisener, L. (2002). Scared to go to work: A home care performance improvement initiative. Journal of Nursing Care Quality, 17, 71–82. The Patient Protection and Affordable Care Act, Pub. L. No. 111-148, (March 23, 2010). Thompson, C. W. & Bucher, J. A. (2013). Meeting baccalaureate public/community health nursing education competencies in nurse-managed wellness centers. Journal of Professional Nursing, 29, 155–162. US Department of Health and Human Services (2015). By the numbers: Open enrollment for health insurance. Retrieved March 11, 2015 from http://www.hhs.gov/healthcare/facts/ factsheets/2015/02/open-enrollment-by-the-numbers.html.
AND
JANE KURZ, PHD, RN†
Community nursing experiences for undergraduate students have progressed beyond communitybased home visits to a wide array of community-focused experiences in neighborhood-based centers, clinics, shelters, and schools. Our Bachelor of Science in Nursing program chose to use sites situated within neighborhoods close to campus in order to promote student and faculty engagement in the local community. These neighborhood sites provide opportunities for students to deliver nursing services to underserved and vulnerable populations experiencing poverty and health disparities. Some of these neighborhoods are designated as high crime areas that may potentially increase the risk of harm to students and faculty. There is a need to acknowledge the risk to personal safety and to proactively create policies and guidelines to reduce potential harm to students engaged in communityfocused experiences. When a group of baccalaureate nursing students was assaulted while walking to a neighborhood clinic, the faculty was challenged as how to respond given the lack of policies and guidelines. Through our experience, we share strategies to promote personal safety for students and recommend transparency by administrators regarding potential safety risks to students engaged in community-focused fieldwork activities. (Index words: Nursing students; Community health nursing; Safety; Clinical education) J Prof Nurs 32:246–251, 2016. © 2016 Elsevier Inc. All rights reserved.
T
HERE IS A growing trend within undergraduate nursing education to develop curricula that strike a balance between disease-oriented and health promotionoriented approaches to nursing education. Historically, the majority of clinical education experiences have occurred in hospitals and other acute and subacute care facilities. In curricula in which health promotion is now a major component, community health experiences are being given increased time and focus. There are a number of factors responsible for this shift (Lynch, 2014) and include recommendations from the Institute of Medicine's Future of Nursing Report (Institute of Medicine Report, 2010), the
*Director, Undergraduate Nursing Programs, Associate Professor, Nursing, Michigan State University, College of Nursing, East Lansing, MI 48824. †Chair, Undergraduate Nursing Programs, LaSalle University, School of Nursing and Health Sciences, Philadelphia, PA 19141. Address correspondence to Rhonda E. Maneval: Director, Undergraduate Nursing Programs, Associate Professor, Nursing, Michigan State University, College of Nursing, East Lansing, MI 48824, 3840 Lone Pine, Apt 7, Holt. E-mail: [email protected] (R.E. Maneval), [email protected] (J. Kurz) 8755-7223 246 http://dx.doi.org/10.1016/j.profnurs.2015.11.001
Carnegie Foundation for the Advancement of Teaching Report: Educating Nurses: A Call for Radical Transformation (Benner, Sutphen, Leonard, & Day, 2010), the Patient Protection and Affordable Care Act (H.R. 3590–111th Congress, 2009; The Patient Protection and Care Act, 2010), and the American Association of Colleges of Nursing (2008). These entities all recommend an expansion of nursing education and services to local communities with an increased focus on health promotion and disease prevention interventions. As a result of the Patient Protection and Affordable Care Act, in 2015, 11.4 million new people enrolled in health insurance coverage (US Department of Health and Human Services, 2015), increasing access to primary health care services. This resulted in an increased need for primary health care providers and for baccalaureate-educated nurses skilled in health promotion and therapeutic lifestyle management. In addition, these new initiatives are contributing to expanded roles for public health nurses such as community health advocates, community educators, public health policymakers, and researchers (Kulbok, Thatcher, Park, & Meszaros, 2012). Nurses are also working in expanded sites such as neighborhood centers, housing developments, parishes, school health programs, worksites, and homeless shelters (Kulbok et al., 2012).
Journal of Professional Nursing, Vol 32, No. 3 (May/June), 2016: pp 246–251 © 2016 Elsevier Inc. All rights reserved.
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In the past, community experiences for undergraduate nursing students were community based, relying on home health care agencies or local public health departments. In this model, the student is assigned to a home health nurse to provide direct nursing care to clients in their homes or to a public health nurse who is providing direct care services to vulnerable or at-risk people. In a community-based model, the focus is on the individual level of nursing care and nursing services with a disease-oriented focus, and although nurses in this model are practicing in the community, they are not practicing public health (Cohen & Gregory, 2009). Programs embracing a health promotion orientation are more often using a community health-focused model rather than community-based model. Cohen and Gregory (2009) defines community health as focusing on health promotion and disease prevention that targets populations rather than individuals. The Association of Community Health Nursing Educators (ACHNE) also differentiates between two levels of community nursing, which they term community-based nursing and community-focused nursing (ACHNE, 2009). ACHNE defines community-based nursing as focusing on the individual with the goal of influencing individual health outcomes, while community-focused nursing targets at-risk populations with the goal of attaining health outcomes and reducing risk. Clinical practice experiences in community-focused health encompass a wide variety of sites that may or may not have a professional nursing presence (Pijl-Zieber & Kalischuk, 2011). Examples include homeless shelters, refugee service centers, senior centers, minute clinics, faith-based organizations, community wellness centers, and primary care offices (Thompson & Bucher, 2013). Personal safety of students has always been a concern during community experiences (Lang, Edwards, & Fleiszer, 2008). In the past, students would travel to client homes or within the community with an experienced nurse or faculty member. The experienced nurse navigated the environment and provided a degree of safety and security for the student. With the increased use of community-focused health experiences has come an increased concern regarding student safety. In our BSN program, which is located in a large urban community, students utilize public transportation and travel about the city to a variety of community sites. Students typically are not going into client homes but, rather, traveling to sites located in neighborhoods with high needs for health care services but which also have high crime rates, frequent episodes of gang-related violence, high levels of street drug usage, abandoned and neglected buildings, and deteriorating infrastructure. Strategies to limit risk and enhance safety are needed given the desire to expose students to a variety of community-focused experiences in high-need areas. To date, there is a limited amount of research available on the topic of personal safety during community-focused experiences and nursing students. There is some related literature that explores the topic of personal safety, but it is primarily focused on community-based models of care and home care workers.
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Literature Review Home care safety risks associated with geographic location include high-crime neighborhoods, gang presence, illegal drug activity, street loitering by youths and men, poor neighborhood lighting, presence of abandoned and deteriorated buildings, and poorly maintained streets (Fazzone, Barloon, McConnell, & Chitty, 2000; Fitzwater & Gates, 2000; Gellner, Landers, O'Rourke, & Schlegel, 1994; Hayes, Carter, Carroll, & Morin, 1996; Kendra, Weiker, Simon, Grant, & Shullick, 1996; McPhaul, Lipscomb, & Johnson, 2010; Sylvester & Reisener, 2002). Fazzone et al. (2000) performed a qualitative study with 50 direct home care staff and 11 administrators in the midwest. Participants were asked to describe unsafe conditions within the patient's home or neighborhood. Participants reported going into areas where gunfights and drive-by shootings were common and “where police would not go.” Other unsafe conditions near patients' homes included men or adolescents loitering on the street, gang activity, police raids, broken glass or debris, “run-down” homes, poor lighting, rats, and hostile dogs. Organizational and administrative issues impacting safety included the lack of policies and procedures and/or the lack of enforcement of those policies, lack of familiarity with the community and neighborhood, delay of security assistance, absence of a “check-in” system when staff traveled in high-risk areas, lack of administrative support, and failure or delay of staff to report incidents. Participants also reported that although they receive some training on personal safety, it was inadequate to meet their needs. Recommendations include ongoing education and training and comprehensive personal safety policies and procedure that address the actual threats to safety found in the environment. Sylvester and Reisener (2002) conducted a mixedmethods descriptive study to explore perceived risks and actual exposures to danger in the home care environment. Of the 43 participants, 16% felt unsafe when making home visits, 30% felt that agency measures were not in place to ensure their safety, and 20% felt that the agency did not respond to safety concerns by staff (Beaver, 2014). Strategies undertaken to address these issues included a comprehensive list of safety recommendations for staff to utilize when traveling. The list includes suggestions such as getting directions, carrying a cell phone, not carrying a purse, being aware of surroundings, walking confidently, using eye contact, avoiding isolated areas, and leaving unsafe situations immediately and contacting a manager. Home care patients were also required to sign an agreement to remove safety risk from the environment such as weapons, animals, and illegal drugs. Patients were also required to agree to not expose the staff member to verbal or physical abuse. As a result of these measures, staff reported feeling less unsafe and more supported by the agency. A few studies focus on nursing students' feelings regarding the risk to their personal safety when engaged in community clinical experiences (Carroll, Morin, Hayes, & Carter, 1999; Leh, 2011; Morin, Hayes, Carroll, & Chamberlain, 2002). In a descriptive qualitative study, Leh (2011) asked nursing students about their feelings
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concerning community health clinical experiences. One of the major themes of particular relevance to safety in community clinical experiences was the contemplation of risk to personal and client safety while in the community. Students shared a sense of vulnerability with most “acutely uncomfortable with the prospect of entering homes and neighborhoods, fearing the risk of becoming innocent victims of violence” (p. 624). This study highlights the need for educators to be aware of student concerns and be proactive in addressing them prior to student experiences in the community. Leh (2011) calls for faculty to prepare students better for these experiences and instructors to acknowledge students' fears related to potential safety risks. Skillen, Olson, and Gilbert (2003) discuss four educational strategies for promoting safety of nursing students during community-based rotations. The first strategy is a student checklist that includes five sections—personal preparation, agency preparation, vehicle preparation, environmental surveillance, and response to situations. Students are instructed to review the checklist prior to their home nursing experience and discuss any item on the list for which they are unsure or uncomfortable with their faculty member. Preparation includes such items as planning the route in advance, carrying a cell phone, keeping one arm free, telephoning clients in advance to arrange meeting time, and describing best practices for home visit safety (Kendra & George, 2001). Environmental surveillance examples include observing for unsecured animals, observing for persons consuming alcohol or street drugs, and scanning the environment for potential dangers. Conducting small group learning activities focusing on safety and risk in home care, requiring students to complete Web-based module on personal safety in community health, and use of scenario-based learning activities were all identified as additional strategies used with students to promote student safety in community health. The need to acknowledge potential risk and proactively create policies and guidelines to reduce the potential harm to students and faculty is a critical part of community-focused program planning and development. Unfortunately, in our case, these policies and guidelines did not emerge until after the occurrence of a serious safety issue involving our students in route to their community-focused experience. It was at that time that we realized that we had provided no direct training regarding risk assessment and risk reduction strategies, other than faculty-developed suggested travel routes for students and the general safety and security guidelines provided by the university. We also lacked formal policies and procedures for students to follow in the event of an actual or perceived threat or in cases where real harm had come to the student. What follows is a description of the event.
Safety Incident One late November morning four female nursing students rode the subway to their assigned clinical site. The trip involved a 10-minute subway train ride and a six-block walk through a high-crime neighborhood known for drug activity and gang violence. The students
boarded the subway at a stop on campus. During the train ride, they had their cell phones out, checking messages and texting, and were engaged in conversation among themselves. When they exited the subway station at approximately 7:30 a.m., the streets were sparsely populated. They did not notice that a young male, who had been on the train with them, followed them until they were at an underpass at which time he grabbed a student by her hair and threw her against the brick wall. He stated that he had a gun in his pocket and that they all had to give him their money and cell phones. One student sprinted away to obtain help. The other three students gave him the items. The young male quickly pocketed everything and ran in the opposite direction. The student who had run away went to the community health center and alerted the staff and her instructor, who called the police. The police arrived, and students provided a description of the perpetrator, and other officers fanned out in the area to search for the suspect. In spite of their efforts, the suspect was never found. Later that afternoon, the neighborhood block captains also went door-to-door in the community with a sketch to determine if anyone could identify the suspect. Although the neighborhood residents could not identify him, it was reported that many expressed outrage that nursing students had been victimized in their community. University police were contacted and escorted the student who sustained a potential head injury to the emergency department for examination. Once she was medically cleared, she joined her student colleagues at the police substation where they all provided their formal statements to describe the events. The faculty member alerted the program administrator who immediately contacted the department chair, dean's office, and university counseling and request that they see the students immediately. She then met the students and faculty member at the police station, retrieved the students, and took them to the counseling center. She also called each parent to let them know what happened and to inform them of the university's next steps. This assault occurred a few days prior to the start of the 4-day Thanksgiving holiday. These students opted to leave campus and return to their homes early. They did return the following week; all but one agreed to return to the site; that student was reassigned to a site adjacent to campus. All completed the last 2 weeks of clinical without incident.
Discussion No student had ever reported being assaulted in the last 40 years of this program's existence. This caused the faculty to reflect on the decision to use community-focused clinical sites located in the neighborhoods surrounding campus. It had been a conscious decision to use local sites rather than have students travel longer distances to sites with less crime in more affluent areas of the city. This decision was grounded in the university and college mission of public service, social activism, and community engagement. In retrospect, we realized that we had not
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fully appreciated how this decision might impact students, faculty, and the program. There is a dearth of information about criminal assaults involving U.S. nursing students attending colleges. University students, in general, who were victims of violent crime often experienced the events as a result of their own drug or alcohol use or a consequence of their own behaviors (Saewyc et al., 2009) Nationally, 80% of the campus crime is caused by students and typically does not involve a weapon (Glasgow, Dreher, & Oxholm, 2012). Universities in the past 10 years have worked diligently to develop many strategies to ensure campus safety. Many have an entire department of public safety or a division of student affairs or the office of student life that focus on providing educational sessions that help increase student awareness of dangers and self-protective behaviors. Other common strategies are key card access to buildings (especially dorms), obvious video cameras, blue light telephones, police patrols, and police escorts across campus. The U.S. Department of Education requires all schools to publish their crime data for the last 3 years to alert students and families of potential dangers. The intent is that students will adopt the appropriate safeguards to protect themselves. Although these interventions are laudable, they do not help the nursing student who leaves the campus to attend clinical at a community or primary care site. The faculty ascribe to a number of professional ideologies which guided the development and implementation of the community-focused curriculum. These included caring, advocacy, activism, ethics, access to health care, and the right to health care. The faculty within this urban university was committed to working with underserved and vulnerable populations in which health disparities and poverty were endemic. Delivering nursing services to those in most need of services was integral to the program, the curriculum, and the development of professional nurses. Fieldwork experience in local communities sensitizes and teaches students about the determinants of health such as quality of schools, environmental safety, affordable nutritious food, and public safety, all of which can impact the health of people who live in those communities (Callen et al., 2013). These also help to develop culturally sensitive and culturally competent professional nurses. However, the reality is that our program is located in a major city that has been cited as one of the top 25 most dangerous cities in the United States primarily because of illegal gun trade and drug activity (Business Insider, 2015). Local crime statistics for the neighborhoods in which our particular community sites occupy warranted a review of how our program was ensuring student and faculty safety. More formal safety education programs and risk reduction strategies were required if these clinical experiences were to continue. The immediate administrative response was through e-mail. The dean sent a message to all nursing students notifying them of the assault with an invitation to share any concerns or unsafe experiences with the associate chair and/or their faculty. Faculty discussed the situation with their student groups to determine if a problem existed at any one site. No pattern was noted, but faculty
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reported that these discussions revealed anxiety and concern on the part of students. Three faculty members also revisited all community sites using public transportation to ensure that the safest route was being suggested. Recommended routes for travel had been posted for students prior to the incident. However, the students involved reported making a conscious decision not to follow the recommended route because they felt the bus took too long, was crowded, and made too many stops. When it was pointed out that the bus had a stop directly across the street from their community site, they responded that they had not fully considered the safety issue but, rather, were focused on travel time and comfort. It was clear to faculty, given the traditional age of our students and their naivety regarding personal safety that there was a need for improved personal safety measures and proactive steps to educate students. The conversations with students and the student victims helped to guide the development of recommendations and interventions to address the issue. These strategies include travel safety guidelines for public transportation and personal vehicle, travel incident reporting guidelines, and mandatory safety workshops. Refer to Tables 1A and 1B: Recommendation to enhance personal safety when traveling to and from clinical/fieldwork sites and Table 2: Guidelines for reporting travel incidents. Using the available suggestions in the literature, guidelines were created and placed in the student handbook, published on the Web site, reviewed with students during new student orientation and, again, reviewed during their first community postconference. Annually, the department of nursing hosts a mandatory 2-hour workshop on student safety. This workshop includes the chief of university police
Table 1A. Recommendation to Enhance Personal Safety When Traveling to and From Clinical Experiences: Using Public Transportation Travel using public transportation Follow the recommended route when traveling by bus or subway. Know the directions to the clinical site prior to leaving home. Travel in groups, never alone. Have your clinical faculty member's telephone number in your cell phone in case you become lost. Never carry a purse. Keep your money and keys in a small wallet that fits in your pocket. Always walk with one arm free. Walk with confidence. Use eye contact when looking at others. Do not openly display technology when traveling, e.g., laptops, I-Pads, MP3 player, or I-phones. Do not talk on your cell phone or text while walking. Do not have earbuds in use. Be aware of your surroundings; do not engage in excessive conversation. Avoid isolated areas. Trust your instincts. If you feel unsafe, leave the area. Call your instructor when it is safe to do so. Communicate any safety concerns to your clinical instructor or any faculty member immediately.
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Table 1B. Recommendation to Enhance Personal Safety When Traveling to and From Clinical Experiences: Using Personal Vehicle Travel using personal vehicle Obtain directions to site prior to the first clinical day. Test drive your vehicle to the clinical site and calculate estimated travel time. Check with your clinical instructor about the availability for parking prior to deciding to drive. If street parking is the only option, park in view of the clinic site. Residents often save a parking spot by placing lawn chairs in front of their homes. Do not remove. Keep your doors locked at all times while in vehicle. Do not text or talk on your cell phone while driving, parking, and exiting your vehicle. Lock your car upon exiting. Lock valuables in your trunk prior to traveling to the clinical site. Never have valuables visible in your car. Do not carry a purse; keep money and valuables in a pocket. Do not exit the car if you feel unsafe. Find a different parking spot or call your instructor. When returning to your car, have keys in hand when leaving the clinical site. Do not drive down dead-end streets that makes turning around difficult. Do not drive down alleys with debris or glass that may cause flat tires. Do not drive down narrow streets that could restrict movement if you need to exit the vehicle.
who reviews risk reduction behavior and what to do if victimized. This presentation is made more meaningful by the sharing of real examples based upon the chief's 20-plus years of experience. The program also reviews specifics regarding travel to clinical sites, the role of students and faculty in creating a culture of safety, and specific reporting mechanism within the department of nursing for actual or perceived threats to safety. The reporting of threats to safety was particularly important to improving communication
Table 2. Guidelines for Reporting Travel Incidents Guidelines for reporting travel incidents Definition: A travel incident is defined as an event that occurs when traveling to or from a clinical site that has the potential of injury, loss of personal property, and/or causes fear or concern. Procedure: 1. If you are a victim of crime, immediately contact the police by calling 911 on your cell phone and follow their directions. If possible, notify your clinical instructor who will contact the department for further instructions. 2. If during your travel you experience an event that has the potential for injury or makes you uncomfortable or threatened, do the following: A. Upon arrival at the clinical site or at home after clinical, call your faculty member. He/She will notify the administrator who will contact you to discuss in greater detail. B. Submit report of incident to the department of nursing e-mail account ([email protected]) documenting an unsafe travel situation or event that you witnessed. In the e-mail, include the names of involved persons, accurate description, time of event, and exact location.
between faculty and students in regard to safety. The culture of personal safety created by the new guidelines and recommendations helped students to see that faculty not only acknowledged the problem but also wanted to be proactive in helping students feel safe. Students report their concerns in a number of ways; some use the electronic reporting system, whereas others speak directly to their clinical faculty, who then reported concerns to the associate chair. All of these data are shared with the office of student safety and security that then makes recommendations. For example, one student group was concerned that a cluster of men gathering at a corner near where they walked to their clinical site posed a possible threat. These men would call out to the students and make lewd and suggestive remarks. The response by university police was to notify the city policy substation in the area, which would then have a patrol car at the site when students were traveling to and from clinical.
Conclusion Anecdotal reports by faculty suggests that students are more consistently using recommended travel routes and appear to be more attentive and aware of how to reduce risk and use personal safety strategies. There have been no additional incidents involving students to date. Our experience highlights the need for the creation of policies and guidelines to promote personal safety for students in the community. Simultaneously, there needs to be transparency within the program in which administrators and faculty acknowledge the safety risks that might exist with community-focused fieldwork activities to parents and students. Acknowledging the issue provides opportunities to share strategies that have been employed to address the issue. We have found that this approach opens the lines of communication and reduces parent and student anxiety. Parents and students are reassured because faculty and administration are fully aware of the risks and are viewed as taking proactive steps to reduce those risks. Although our recommendations focus on communityfocused experiences in high-crime neighborhoods, they may also be useful in decreasing risk for students traveling to clinical experiences in other settings. As our experience demonstrates that there is a need for more information on how program administrators and faculty can best provide for student safety, there is also a need for evidence-based strategies to address the issue of student personal safety. Research should focus on identifying effective strategies to decrease student anxiety and reduce incidents of harm to students. It is essential that nursing faculty promote a culture of safety, educate students to environmental threats, and assist students in developing strategies to decrease risk. In conclusion, this nursing faculty did address the clinical incident while effectively collaborating with a team of university administrators, counselors, and police. The example presented here can be used by others to proactively plan to address safety issues with undergraduate nursing students.
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