Addressing Challenges in Undergraduate Community Health Nursing Clinical

Community health nursing care is a comprehensive look at an individual, family, and community; however, that can be challenging for undergraduate nursing students to figure out. Unlike acute health care, which focuses on individual patients with urgent or severe short-term illnesses, community health nursing care focuses on promoting and protecting the populations' health through healthy lifestyles within a complex community context. The outbreak of new infectious diseases (such as COVID-19 [coronavirus disease 2019]) and the rising health care costs and complications associated with non-communicable diseases emphasize the importance of community health nursing care (Kuo et al., 2021).

The undergraduate nursing students enrolled in a community health nursing clinical course were assigned to assess vulnerable populations within a community impacted by social determinants of health (SDOH), identify opportunities and challenges, and develop appropriate evidence-based community interventions. Because these community-based interventions do not often produce immediate results, the students struggle associating community-based experiences with learning and the clinical course learning objectives. Innovative teaching-learning approaches are crucial to enable nursing students to make these connections. This article describes an innovative approach using Kolb's experiential learning theory to guide and enhance student learning in the undergraduate community health nursing clinical course (Kolb, 1984). Unlike behavioral and cognitive learning theories, experiential learning theory takes a holistic and integrative approach to learning. Behavioral learning theories tends to deny the role of subjective experience in the learning process. Cognitive learning theories emphasize acquisition, manipulation, and recall of concepts as the process of learning. The use of students' reflections in this article was approved by the James Madison University institutional review board (Protocol ID-23-4174).

The Course

During community health nursing clinical course, students systematically assess individuals, families, and the community to analyze the impact of societal and cultural changes on health across the lifespan. Upon completion of the assessment, the students must work collaboratively with the community agencies and leaders to incorporate evidence-based theoretical concepts to develop and implement population-focused community health promotion and disease prevention interventions. Table 1 showcases course objectives.

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Students enrolled in the community health nursing clinical course are in their last semester and ready to graduate. Although 80% of the enrolled students desire to work in the intensive care unit or emergency department after graduation and the remaining 20% plan to work in Labor and Delivery and Pediatric/Neonatal intensive care unit, students must remember that people's illnesses do not begin in the hospital but within their communities where live. Nursing students read The Future of Nursing 2020–2030 chapter two of the SDOH for this clinical (National Academies of Sciences, Engineering, and Medicine et al., 2021).

During the seven-week community health clinical course students attend the Gus Bus mobile classroom afterschool program and the local food bank for their clinical experience. In partnership, these community agencies' mobile units drive to two neighborhoods for two hours at each stop. The community where the clinical experience occurs prides itself in its multi-cultural and diverse residents. The local high school has students from 100 different countries, with 59 different languages spoken (Harrisonburg City Public Schools, n.d.). The neighborhoods where the students attend community clinical, consist mainly of families who are refugees or immigrants with distinctive cultural beliefs and English is not their first language. Majority of the families primarily speak Spanish, followed by Arabic and Turkish. The families might also have financial and transportation barriers to access resources. These neighborhoods are also considered to be dangerous and unsafe with high rates of violence and social disorders.

The Gus Bus program offers academic skills, such as reading, writing, and math in low-stake environment for the children in K- Grade 5 using fun, engaging and interactive activities. Contained within the Gus Bus is the mobile classroom which promotes social-emotional growth and improves educational achievement for the children. The local food bank provides shelf-stable foods and fresh produce to the families. Additionally, the local food bank will sometimes provide recipes for the produce they will be distributing that day. At the stops, the nursing students conduct family and community assessments. The students must identify areas of need and work collaboratively with the Gus Bus staff and family members to develop and implement evidence-based, population-focused community-based interventions.

The Opportunity for Innovation/Change

Within seven weeks, nursing students must identify aspects of the SDOH impacting the health promotion and disease prevention for racially, and culturally diverse families, then develop and implement a population specific community-based intervention. However, students do not see the value of this community-based experience and struggled with associating the experience with learning and the clinical course learning objectives. To remedy this, a theoretically guided reflective process was used to help students begin to understand, learn, and develop skills to apply in real-world situations.

In 2021, the American Association of Colleges of Nursing (AACN) mandated nursing schools to focus on competency-based nursing education (CBE) with observable and measurable student learning outcomes (AACN, 2021). The emphasis is on mastery of essential skills, knowledge, and behaviors for safe and effective nursing care. The AACN competency 10.2 for entry-level is that a nursing student will engage in guided and spontaneous reflection of their practice (AACN, 2021). The transformative strategy was aligned with this AACN competency. Additionally, the National Council of State Boards of Nursing (NCSBN) is developing the Next Generation National Council Licensure Examination (NGN), designed to assess nursing students' ability to apply their skills and knowledge to real-world situations (NCSBN, 2023). The connection between these two agencies is that they both emphasize assessing students' competence during the clinical experience. The students in the community clinical course engaged in weekly theoretically guided reflection practice that helped them understand the connections between their experiences and SDOH concepts, and the value of community-based nursing education; ultimately meeting the course objectives.

Kolb's Experiential Learning Theory

Kolb's experiential learning theory assumes that experience forms and re-forms ideas (Kolb, 1984). The purpose of education is to stimulate the spirit of inquiry and skill in getting knowledge, not memorization of concepts. Experiences are understood through apprehension (participation in actual experience) and comprehension (abstract conceptualization outside the actual experience) (Kolb, 1984). Learning occurs when experiences are transformed to understand situations. Kolb's experiential learning theory involves four circular stages with the students (1) encountering a new concrete experience, (2) engaging in reflection to review the situation and their feelings about the experience, (3) using logic to conceptualize abstracts so they can understand the relationship between their community-based experience, learning, and the course objectives, and (4) engaging in active experimentation with new observations to confirm the concepts and the connections during their subsequent encounter.

Ludwig et al. (2017) successfully improved student learning using Kolb's learning cycle in a multidisciplinary innovation didactic course. Similarly, Lisko and O'Dell (2010) effectively developed and evaluated critical thinking skills in undergraduate nursing students during simulation using Kolb's theory. A theoretically guided self-reflection process after clinical experience, allows deep reflective practices related to more significant student learning, resulting in better learning outcomes (Harvey et al., 2016^; Kolb, 1984).

Outcomes/Impact

During the first three weeks of clinical students assessed the families and the community. The students conducted a community windshield assessment (James Madison University, Department of Nursing, 2022a), community data-mapping wheel using Anderson MacFarlane Wheel (James Madison University, Department of Nursing, 2022b), and key informant interviews. Based on the findings, at week four, students started developing a culturally appropriate community- evidence-based intervention. During the last week of the clinical course, the students and the Gus Bus arranged a family engagement night. Students implemented a culturally appropriate healthy eating education for adults and an interactive MyPlate healthy eating education station for the children. The education programs were both in English and in Spanish. During the adult education session, there was a Spanish interpreter to help with translation. Other common interventions included were dental hygiene, hand washing, a pamphlet with available community resources, and education on cyber bullying and how to minimize children screen time.

The guided reflection helped students translate experience into concepts and associate community-based clinical experience with their learning and clinical course learning objectives. After each clinical experience, these questions were posted on the canvas assignment module to guide student reflections: During clinical experience, what did you do, see, hear, and feel? What community challenges, differences, or uniqueness did you identify? What assumptions did you have before going to clinical site related to SDOH, health disparities and health equity, and are they the same? How do you think these are related to your learning and the course? What do you want to do with this knowledge? The impression from reading the student reflections is that students associate the community-based experience with their learning and have met clinical course learning objectives.

Nursing students had the impression that they sat around and learned nothing during community health clinical. They also reported they had the perception that the neighborhoods were dangerous and unsafe. Through the guided reflection, the students reported changed opinions about the experience and the value of community health clinical experience. “This shows that community health is so important because not everyone has the same opportunities within the same community.” “Overall, this experience was a positive one, and better awareness of our community health needs” Students reported the experience gave them a unique perspective of community-based learning.

Innovative strategies to help students through their learning process can be transformative and enhance student learning. “After Gus Bus and what I had taken away from being within different areas of the community, I want to help the community. I want to make changes to communities. I want to help those that lack resources and access to privileged opportunities.” Students reported feeling welcome regardless of different behaviors and attitudes the children had toward each other, such as encouraging and supportive versus disrespectful. The disrespectful behaviors did not derail the nursing students from going back to the neighborhoods for clinical experience.

Using Kolb's experiential learning theory allowed the students to associate their experience with their course learning objectives and enhanced their learning. Students used appropriate methodologies to assess and examine SDOH impacting the health care needs of culturally diverse and underserved community. “I could understand how different households, incomes, and lifestyles raise children. I heard many different verbal words and noticed much different behavior during the activities with children.” “With this knowledge, I want to change how I interact and approach the children.” Students learned community health challenges that may not be solved within a short time, however, needing immediate attention. For example, some days, by the time the food truck reaches the second stop, some produce or foods will be finished. “As I was in the different neighborhoods, I noticed many people came to get food. I assumed many people lacked the money to buy enough food since many were waiting for the weekly food truck. I already knew that [name of city] had much poverty in it, but it made me upset seeing people wait for the food truck that did not come.”

Also, some of the older children were left to the responsibility of taking care of their younger siblings because their parents had to work until late at night. Students reported the need to advocate for culturally appropriate afterschool or food stamps programs that can be accessible to these communities. “In my practice, I want to make sure I am not a nurse that is insensitive and ignorant.” The student learned that health equity is important in providing culturally appropriate nursing care. “As a future nurse, I want to ensure I am looking at my community and thinking about these things to provide the best patient outcomes.” The deep level of reflection offered students a lens that connected community-based clinical nursing experience with their learning and course learning outcomes.

Conclusion

This article centers on using Kolb's experiential learning theory to enhance undergraduate nursing student learning in a community health nursing clinical experience within complex contexts. During community health nursing care clinical experience, students were able to examine the SDOH impacting a culturally diverse vulnerable population, develop and implement a culturally appropriate adult healthy eating education and an interactive MyPlate education for the children attending Gus Bus.

The innovative, theoretically guided reflective process has proven transformative and enhanced student learning during the community health nursing clinical experience and associate the experience with the clinical course learning objectives. Through this innovative process, students can visualize themselves applying what they learned during their education into actual life practice and be advocates in shaping tomorrow's health care systems. Students can advocate for policies that examine the SDOH and implement culturally appropriate community-based programs.

Although Kolb's experiential learning theory has been transformative in enhancing student learning in community health nursing care clinical education, its potential usefulness was not examined in acute care clinical settings. Therefore, exploring the advantages of this theory in these settings might be necessary to appreciate its transformative effect on student learning outcomes. Additionally, Kolb's experiential learning theory was used with two groups of 10 students within a cohort of 90 students, thus, a small sample size. The next step would be to use the theory and analyze student reelections for the whole cohort. Faculty who want to use Kolb's experiential learning in their teaching are encouraged to review Kolb's classic work (Kolb, 1984). It is increasingly imperative for faculty to expand and update their instructional methods to enhance student learning as the landscape of teaching and practice environments evolve.