META-ANALYSES

Contents lists available at ScienceDirect

Journal of Professional Nursing

journal homepage: www.elsevier.com/locate/jpnu

Community engaged service in pathophysiology and pharmacology Sara B. Adams Indiana University Northwest, 3400 Broadway Avenue, Dunes Medical Professional Building, 3118 Gary, IN, USA

A R T I C L E I N F O

Keywords: Service learning Evidence-informed teaching Pathophysiology Pharmacology

A B S T R A C T

When community engaged service learning (CESL) is integrated as a component of nursing education, student learning outcomes are improved. Utilizing this pedagogical strategy in undergraduate pathophysiology and pharmacology courses comes with a unique set of challenges and barriers. However, integrating this high im- pact, evidence-informed approach offers an opportunity for students to advance knowledge of course concepts while meeting the needs of underserved community groups. Forty-two sophomore level nursing students en- rolled in pathophysiology and pharmacology completed semester long projects in the community. Student re- flective responses were collected, analyzed for content, and revealed themes of perceived community connec- tion, empathy, and empowerment to become community engaged leaders.

Introduction

Introductory pathophysiology and pharmacology (patho/pharm) courses in nursing contain an overwhelming amount of subject matter (Thomas & Schuessler, 2016). Conventional teaching strategies, such as lecture, are effective for content delivery. However, lack of opportunity for direct clinical application of material presents a barrier to effec- tively teaching patho/pharm concepts (Foster, Collins, Dong, Nteff, & Pinkney, 2017). Community engaged service learning (CESL) is one evidence-informed approach that, when used intentionally, can serve as a mechanism to solidify patho/pharm content and to create an oppor- tunity for cultivating empathy and empowerment among students while meeting community-identified goals.

Service learning is defined as “a structured learning experience that combines community service with explicit learning objectives, pre- paration, and reflection” (Seifer, 1998, p. 274). Available evidence on CESL in nursing education overwhelmingly supports improvements in nursing student confidence, clinical skill acquisition, and communica- tion (Sandberg, 2018; Saylor et al., 2018). Additionally, students who are exposed to CESL are more likely to be civically engaged, socially accountable, and have improved knowledge of health disparities upon graduation (Bryant-Moore et al., 2018). Efforts have been made to in- crease the use of CESL across nursing curricula (Thomas & Smith, 2017). However, given the need for students and faculty to spend ex- tended time in the community environment, very little has been written about how this teaching technique might be integrated successfully into nursing courses without an allotted clinical component.

The purpose

Indiana University Northwest is situated in an underserved area with consistently poor health outcomes and multiple known health disparities, particularly related to chronic disease. Therefore, engage- ment with the community is considered one of the pillars of educating nursing students at this location. The purpose of this pilot project was to address community-identified needs and provide students with a “practical application” component to introductory, patho/pharm through a service experience. Since one additional obstacle identified by faculty intending to integrate CESL into nursing courses is financial support (Sandberg, 2018), a small grant was applied for and received from Indiana Campus Compact to support this work.

The projects

Community-based projects were integrated into a 4-credit hour hybrid pathophysiology and pharmacology course that did not have a clinical component. Students were divided into eight groups of about six or seven students per group. Students spent the first 6 weeks of the semester planning for project delivery. In the planning process, students were connected with a community leader and began the process of goal creation. Students were given a timeline and assignments that would be completed on a bi-weekly basis. For example, in week one to two, students were asked to assign project roles to all members of the group and contact the community leader to schedule an introductory meeting. Following the initial meeting with community members (weeks 3–4), students were asked to create an assessment of the community. This would include background information on the population impacted by

https://doi.org/10.1016/j.profnurs.2020.08.016 Received 11 April 2020; Received in revised form 20 August 2020; Accepted 26 August 2020

E-mail address: sabadams@iun.edu.

Journal of Professional Nursing 36 (2020) 625–627

Available online 27 August 2020 8755-7223/ © 2020 Elsevier Inc. All rights reserved.

T

the problem or issue that was identified. For example, one student group reported on the incidence of hypertension in black males in the immediate area, in the county, in the state, and in the nation. This was done with the intent of establishing epidemiologic patterns of inequity. The next assignment was for students to report their co-created goals, objectives, and plan for implementation of the health-related projects. Finally, students were asked to create an evaluation strategy to ensure that the implementation had an impact. A poster presentation was de- signed by each student group detailing their projects and was submitted for presentation at the campus student research and creative activity event. Students reported their progress on a biweekly basis to the course instructor. The projects were worth 10% of the student total grade and although time commitment varied per group. Students re- ported spending about 20 h (range18–24 h) throughout the course of the semester including project implementation and presentations.

Student projects focused primarily on chronic disease, medications used to treat these conditions, and health promotion activities. One community connection was made with the local housing authority which resulted in an opioid crisis awareness project. Students explored local area statistics on opioid use, then created, and delivered an in- formational discussion session with residents. As a result, students not only were able to gain an in-depth understanding of how opioids work in the body, but also were afforded an opportunity to teach local area residents about opioids, the current crisis, how to recognize signs and symptoms of overdose, and where to locate community resources re- lated to opioid use.

Another student group worked with the Indiana Black Barbershop Health Initiative which is a community program that uses volunteers to deliver health information and screenings to minority males at local area barber shops. Students explored local area data on chronic disease and developed information packets related to the most common chronic diseases that impact this population. Students participated in the health initiative by providing health information on chronic diseases in addi- tion to blood pressure and blood glucose screenings. Delivering health information on hypertension, type 2 diabetes, and chronic obstructive pulmonary disease required the students to gain an in-depth knowledge about the disease processes and create a comprehensive education plan. Additionally, students fielded questions about medications that parti- cipants were taking for their chronic diseases. This offered students the opportunity to connect the medications with the disease process in a practical way, while providing service.

One student group created and delivered a workshop for local area older adults on how to create a modified personal health record. Students educated participants on how to keep medical information in a form that can be updated routinely. Students delivered teaching on chronic diseases, and helped participants create connections between their own diagnoses and the multiple medications they were prescribed. Additionally, students educated older adult attendees on the use of technology and helped each participant create their own health docu- ment.

Additionally, one group partnered with a local faith-based organi- zation to deliver information on diet and nutrition including vitamins and minerals. The students used the organization's community garden to plan the upcoming garden season incorporating education about health, nutrition, and how to identify locally grown produce as a source of essential nutrients. This information was also linked to primary and tertiary prevention of chronic disease through dietary changes.

Other student groups delivered health information related to chronic diseases, exercise, and stress reduction, and offered screenings at a local area walking path where community members regularly meet for exercise. The students organized stations where the walkers could gather information and be screened. Additionally, students took to strolling the path to ask walkers questions and engage with them about their health and experiences.

Methods and results

Forty-two sophomore level students engaged with community members. Data were collected from students' written reflections on their community engagement experiences and were analyzed for con- tent using a modified content analysis strategy (Miles, Huberman, & Saldana, 2016). First and second cycle descriptive and narrative coding were implemented (Miles et al., 2016). Participation in the CESL group project and individual reflections were required components of the course. However, allowing reflective responses to be used as data was entirely voluntary and no additional credit was given or received for participation. This project and the subsequent data collection were approved by the Indiana University institutional review board as ex- empt.

Reflective responses as results

Reflection is an essential component of the service experience for students (Schmidt & Brown, 2016). Reflective response questions were formulated following Kolb's experiential learning cycle (Kolb, 2015). “What?,” “So what?,” and “Now what?,” were implemented as broad question categories intended to encourage students to first, reflect ob- jectively on the experience, then analyze the meaning and impact of the experience, and finally, to evaluate “what happens next” because of the experience.

What: creating connections and building empathy

Questions such as, “Describe the experience” and “Describe your role in the experience” led students to recognize that creating genuine connections with community members is an important component of health communication. One student noted that, “even though we had materials to give to them, listening and sharing was more important to understanding their experience.” Another student reflected that, “spending time with the people was the best part. Making connections and reaching out to community members.” One student noted that “it seemed crazy to go into a church and plant seeds with people, but that is how you make connections and begin to create health change.”

Empathy cultivation in the health professional begins with gaining an in-depth understanding of the patient/person experience (Hojat, 2016). Students in this group recognized that effective communication was one method of connecting with community members which is the foundation to empathy. Empathy in nurses has been directly linked to improved patient outcomes (DelCanale et al., 2012; Lavoie, 2015; Yang, Hargreaves, & Bostrom, 2014). Community engaged service appears to be one way to begin to nurture professional empathy in nursing stu- dents.

So what?: enhancing community knowledge and meeting community needs

“Describe the impact on the community members,” was the primary question that guided this reflective section. This question led to student responses that included thoughts about providing resources to improve health and inspiring community action. “More than one person said they were diagnosed with hypertension and given medication but never knew how the medication worked. We provided the information and made sure it was understood,” said one student. Another student re- flected that, “one person in our group said he might potentially really need the information about opioid overdose because he knows people who have been in situations where they didn't know what to do.” Another student suggested that “sharing health knowledge has a trickle- down effect…if a community member knows something, they can pass it on.”

Since project goals and objectives were co-created with community members, students tailored the projects to meet this demand. From these reflective statements, it is apparent that community members felt

S.B. Adams Journal of Professional Nursing 36 (2020) 625–627

626

that the information was important and would be useful. Engaging the community to determine health priorities is one way to ensure that the projects were valued by community members. Students spent con- centrated periods of time with patho/pharm knowledge in order to be able to effectively teach the content and engage in meaningful discus- sion with community members.

Now what?: empowering students to be community engaged leaders

This section was guided by the primary question, “How did this experience impact your perceptions and how will it impact your future practice?” Students felt empowered to support health in the community as a result of the experience. “I want to support a healthy community through education and advocacy, especially when I am a nurse,” said one student. Another student reflected that “Nurses are forward thin- kers and can see problems and work in important ways to help fix community problems. I feel empowered to be a part of that now.” “I think nurses can be a positive force for health in communities.”

Empowerment is necessary for nursing students to develop a sense of self-efficacy in caring for patients (Bradbury-Jones, Sambrook, & Irvine, 2011). Creating opportunities for student empowerment through community engagement early in the curriculum sets the foundation for growth in this area. Student responses revealed themes of self- em- powerment and a sense of advocacy. However, students also felt that through their actions, they could empower community members.

Barriers and lessons learned

Engaging with the community through the creation of a service project was viewed as an opportunity to support student learning and course objectives related to chronic disease, medications, and health promotion. In addition to the known existing barriers to using CESL as a pedagogical strategy, one challenge specific to integrating CESL into patho/pharm meant that students had to be prepared to lead, teach, and discuss topics that were new to them. This took additional time and preparation for the students and faculty. Some barriers that might be encountered by faculty wishing to integrate this project is establishing community relationships. Since this University is well-established in the community, finding opportunities and contacting community leaders was fairly easy. It is recommended that faculty begin contacting com- munity leaders and agencies well before the start of projects to ensure that they are open to student engagement. Since this community was accepting of students, projects were well received, and community leaders provided an abundance of positive feedback. The projects were also accepted for presentation at an annual university event designed to promote student research and creative activity.

Conclusion

Students who engaged in this CESL experience took away more than

knowledge of patho/pharm concepts. Students made connections with communities which reinforced the importance of relationship building and empathy and resulted in students feeling empowered to harness their own knowledge to support underserved groups. Additionally, providing students with the opportunity to become actively involved in community work early in the nursing curriculum lays the foundation for future community engagement. Designing service experiences in an introductory patho/pharm course took some creativity and innovation since there were no required clinical hours included in the course. However, the vast learning value that was added to the course was well worth the additional effort. This pilot work paved the way for con- tinued community engaged activities associated with this course over the subsequent semesters.

References

Bradbury-Jones, C., Sambrook, S., & Irvine, F. (2011). Empowerment and being valued: A phenomenological study of nursing students’ experiences of clinical practice. Nurse Educaiton Today, 31, 368–372. https://doi.org/10.1016/j.nedt.2010.07.008.

Bryant-Moore, K., Bachelder, A., Rainey, L., Hayman, R., Bessette, A., & Williams, C. (2018). Use of service learning to increase master’s level nursing students’ under- standing of social determinants of health and health disparities. Journal of Transcultural Nursing, 29, 473–479. https://doi.org/10.1177/1043659617753043.

DelCanale, S., Louis, D. Z., Maio, V., Wang, X., Rossi, G., Hojat, M., & Gonnella, J. (2012). The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy. Academic Medicine, 87, 1243–1249. https://doi.org/10.1097/ACM.0b013e3182628fbf.

Foster, V., Collins, E., Dong, H., Nteff, G., & Pinkney, L. (2017). Teaching clinical phar- macology to undergraduate nursing student: Barriers and strategies. Open Journal of Nursing, 7, 918–929. https://doi.org/10.4236/ojn.2017.78068.

Hojat, M. (2016). Empathy in health professions education and patient care (2nd ed.). Springer.

Kolb, D. A. (2015). Experiential learning: Experience as the source of learning and develop- ment (2nd ed.). Upper Saddle River, NJ: Pearson.

Lavoie, K. H. (2015). Five e’s to support mothers with postpartum depression for breastfeeding success. International Journal of Childbirth Education, 30(2), 55–61.

Miles, M. B., Huberman, A. M., & Saldana, J. (2016). Qualitative data analysis: A methods sourcebook (3rd ed.). Sage.

Sandberg, M. T. (2018). Nursing faculty perceptions of service learning: An integrative review. Journal of Nursing Education, 57, 584–589. https://doi.org/10.3928/ 01484834-20180921-03.

Saylor, J., Hertsenberg, L., McQuillan, M., O’Connell, A., Shoe, K., & Calamaro, C. J. (2018). Effects of service learning experience on confidence nd clinical skills in baccalaureate nursing students. Nurse Education Today, 61, 43–48.

Schmidt, N. A., & Brown, J. M. (2016). Service learning in undergraduate nursing edu- cation: Strategies to reflect meaningful reflection. Journal of Professional Nursing, 32, 101–106. https://doi.org/10.1016/j.profnurs.2015.06.006.

Seifer, S. D. (1998). Service-learning: Community-campus partnerships for health pro- fessions education. Academic Medicine, 73, 273–277.

Thomas, M. H., & Smith, R. S. (2017). Building community engagement: Incorporation of service learning in a nursing curriculum. Nurse Education Today, 52, 63–65.

Thomas, V., & Schuessler, J. B. (2016). Using innovative teaching strategies to improve outcomes in a pharmacology course. Nursing Education Perspectives, 37, 174–176. https://doi.org/10.5480/14-1402.

Yang, C. P., Hargreaves, W. A., & Bostrom, A. (2014). Association of empathy of nursing staff with reduction of seclusion and restraint in psychiatric inpatient care. Psychiatric Services, 65, 251–254.

S.B. Adams Journal of Professional Nursing 36 (2020) 625–627

627