Week # 6

SPECIAL FEATURES: CLINICAL CONCEPTS

Academic-Practice Partnership in Public Health Nursing: Working with Families in a Village-Based Collaboration Rebecca A. Davis, DNP, RN and Dianne Travers Gustafson, PhD, RN Creighton University College of Nursing, Omaha, Nebraska

Correspondence to:

Rebecca A. Davis, Creighton University College of Nursing, 2500 California Plaza, Omaha, NE 69178. E-mail: [email protected]

ABSTRACT Objectives: The purpose of this program development and evaluation project was to promote healthy families and communities by creating academic-practice partnerships, educat- ing BSN students and building family-nursing student partnerships that were supported by a “village” of interconnected resources. Design and Sample: A mixed-methods design was used for the project. Data were collected from a convenience sample of vulnerable families, BSN students engaged in PHN practica, and partner members. Measures: Nine tools were developed to capture data over two semesters including a GIS mapping strategy. Results: One hundred and seventy-five home visits were completed with 20 families, 14 of whom needed interpreter assistance. Families reported satisfaction with the quality of home visits, education, and assistance toward health goals. Fifty-three students provided 202 educational interventions, 39 community resource connections, and 46 care transitions. Students reported linking theory with practice and valued the PHN practicum experience. Academic-practice partners identified opportunities for program development and sustain- ability. GIS mapping illustrated complex family linkages to community resources. Conclusions: Results suggest that young, vulnerable families benefit from public health nursing (PHN) home visits, but sustaining home visit programs is challenging. Academic-practice partnerships can guide students and families partnered in a reciprocal relationship with village resources.

Key words: maternal-child health, neighborhoods, partnerships, undergraduate nursing educa- tion, vulnerable populations.

Family and community influence how children grow and learn. To help children and families reach their full potential, communities must provide healthy environments and services that support their development. Data on income alone do not provide a complete picture of child and family vul- nerability, multiple factors challenge family well- being. Extensive evidence shows that public health nurse (PHN)-family partnerships effectively pro- mote the growth and development of children and families and achieve healthy outcomes with long- lasting effects (Howard & Brooks-Gunn, 2009; Kitzman et al., 2010; Olds et al., 2004).

Public health nurse practice involves preventive care and advocacy for vulnerable populations found

in diverse settings (Kulbok, Thatcher, Park, & Mesza- ros, 2012). However, families with limited protective factors are underserved, and thus voiceless, if they do not meet specific risk criteria for publicly funded PHN home visitation programs. Yet outcomes-based programs accountable for improving family and community health are exactly what policymakers have called for. Evidence shows that every dollar invested in the Nurse-Family Partnership model saves $5.70 in later health care interventions (Nurse- Family Partnership [NFP], 2013). While providing PHN home visitation programs is an ongoing fiscal and political public health challenge, the numbers of young, vulnerable families grow rapidly. The 2011 national Child Well-Being Index reports that American

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children’s quality of life has stalled despite increases in general economic growth (Foundation for Child Development, 2011).

PHNs are strong advocates for maternal-child and family health, but their numbers are dwin- dling as state and local budgets are cut and their positions eliminated (Association of State and Territorial Health Officials, 2008; Robert Wood Johnson Foundation, 2011). At the same time, schools and colleges of nursing have increased nursing student enrollment to meet the demand for a well-educated nurse workforce (Institute of Medicine [IOM], 2011). Public health nursing edu- cation at the baccalaureate level (BSN) is essen- tial, as professional nursing practice includes the individual, family, community, and population as clients (American Association of Colleges of Nurs- ing [AACN], 2012; Callen et al., 2010; Savage & Kub, 2009). Colleges and schools of nursing col- laborate with PHNs in local and state public health departments for student learning sites and experiences; however, the “downsizing” of staff and home visitation programs diminishes these opportunities.

Strong partnerships are necessary to build upon PHN services such as home visitation for vul- nerable families. An academic-practice partnership leverages PHN services, benefits BSN students through meaningful public health nursing practica and supports families through health promotion and community connections. Together, colleges of nursing and PHNs are powerful advocates for pro- moting healthy families, and academic-PHN prac- tice partnerships both advance the health of communities and educate nurses for practice excel- lence (AACN, 2012).

Advanced practice PHN requires competency in leadership and systems thinking skills (Quad Council Competencies, 2011). A community or “vil- lage” level intervention is complex with multiple and multifaceted contributing factors. Because of the complexity, there is not a singular problem to define. Rather, a collection of possible determi- nants, challenges, and outcomes exist. A Doctor of Nursing Practice (DNP) program development and evaluation project was designed to: (1) develop an academic-practice partnership among public health faculty in three colleges and schools of nursing and the PHNs practicing in a local public health depart- ment, (2) educate baccalaureate nursing students

for public health practice, (3) build nurse and nurs- ing student-family partnerships, and (4) promote the health and development of children and fami- lies in the “village” served by the public health dis- trict. An additional purpose of the project was to collectively evaluate the outcomes for each of the four program constructs.

Background Research suggests home visiting families, regardless of their level of need, can only be effective when the necessary community infrastructure is in place (Pew Charitable Trusts, 2013). Dodge and Good- man (2012) describe an innovative and successful home visit program using a model that builds sup- port of community agencies, providers, and volun- teer groups to assure family connections with community services. Assessment of the built envi- ronment, access to community services, and resources available to support basic human needs are typical in public health nursing. While a home visit allows the PHN access to assess family needs, a referral to community services and an evaluation of the resultant outcome is necessary to complete the nursing intervention. Without supportive com- munity/neighborhood infrastructure, this process is limited at best. Using Geographic Information Sys- tem (GIS) technology, these factors can be mapped and further analyzed for PHN practice. A frame- work developed by DeGuzman and Kulbok (2012) identifies factors affecting the walkability of the neighborhood built environment including regional inequalities, social and economic conditions, along with the influences of public health nursing and nursing policy advocacy. These become pathways that impact individual level health outcomes (De- Guzman & Kulbok, 2012).

The neighborhood or “village” where a family calls home is a familiar place. A Nigerian Igbo and Yoruba proverb states “it takes a whole village to raise a child” (Healey, 1998). In her 1996 book, Hil- lary Rodham Clinton adopted this proverb to illus- trate a vision for America’s children focused on the importance individuals and groups, along with their families, have on children’s well-being. In this pro- ject, a “village” is a smaller subset of a population in the broader community and includes families living in a geographic area and interconnected by shared space, relationships, and services they utilize.

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Each year, it is estimated that 500,000 chil- dren are born to vulnerable, first-time mothers living in poverty (NFP, 2011). A 2012 National Center for Children in Poverty report states the number of infants and toddlers (0–3 years of age) living in low-income families is on the rise, increasing from 44% in 2005 to 48% in 2010 (Addy & Wight, 2012). Many families are at risk due to living in high-risk neighborhoods, having low incomes, or adolescent parenting (America’s children in brief: Key national indicators of well-being’s, 2012; Mel- med, 2009; Nievar, Van Egeren, & Pollard, 2010). Poverty contributes to disparity in achieving family health goals, increases vulnerability, and limits access to resources that reduce health risks. Pro- gram development and investments to improve children’s health and developmental outcomes are national goals and evidence-based home visitation programs are a critical element in a comprehensive early childhood health system (Health Resources and Services Administration [HRSA], 2013; Healthy People 2020, 2011). In addition, the U.S. Depart- ment of Health and Human Services [USDHHS] action plan to reduce racial and ethnic health dis- parities (USDHHS, 2011), identifies home visiting programs as one way to meet the diverse needs of underserved minority families.

Ultimately, families are best equipped to iden- tify needed support systems and care that provides direction, information, and education for health. Public health nurses identify and promote family assets that positively affect health and well-being. Communities also seek strategies to improve the health of their citizens. To strengthen child and adolescent health, Benson, Leffert, Scales, and Blyth (2012) identify three core principles leading to comprehensive community change: collabora- tion, comprehensiveness, and civic engagement. Promoting health, then, is collaborative, develop- mental, and visualized as a broader community imperative.

PHNs provide unique leadership and contribu- tions to families, communities, and the health care system. The Affordable Care Act (ACA) authorizes the creation of a Maternal, Infant, and Early Child- hood Home Visiting Program, responding to diverse health and development needs of children and families and providing an “unprecedented opportunity” for collaboration and partnerships with families (HRSA, 2013, para 3). PHNs, with a

history of home visitation expertise, are positioned to lead the ACA initiative (Keller, Garrett, & Dre- hobl, 2011a). The Nurse-Family Partnership, a home visitation program, consistently demonstrates positive outcomes with at-risk children and families (Azzi-Lessing, 2011; Keller et al., 2011a; McNaugh- ton, 2004). PHNs bring professional expertise and experience to the relationship, helping families build confidence and gain trust in their abilities to confront emotional, social, and physical challenges (NFP, 2011). Despite the evidence, a gap in mater- nal-child home visitation services for vulnerable young families exists due to a diminishing invest- ment in public health services and professionals, including PHNs. In their commissioned paper on Public Health Nursing for The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), Keller et al. (2011a) reported that budget cuts in local and state health departments led to a decrease in the number of PHN positions. Ultimately, at-risk populations are left without the supportive services needed to build healthy families.

A growing shortage of faculty prepared to teach public health nursing at the baccalaureate and graduate levels and fewer practice sites for mean- ingful PHN experiences contribute to the dilemma (Collier et al., 2010; Keller et al., 2011a; Wade & Hayes, 2010). Developing the public health nursing workforce is a crucial research priority yielding sci- entific evidence for population-based nursing prac- tice (Association of Community Health Nurse Educators, 2010). A reduced public health nursing workforce, fewer research prepared faculty and lim- ited research grant funds affect the volume of PHN research and dissemination, thus, reducing study to assure and advance evidence-based practice.

In the educational process, BSN students “prac- tice” alongside PHNs in community settings, including home visiting, while guided by public health faculty. The public health student experience provides opportunities to integrate and apply com- plex concepts such as health promotion and disease prevention, health disparities, chronic disease case management, and the structure of health systems.

Preparing the future PHN workforce relies on collaboration between practice and academia (Kel- ler, Schaffer, Schoon, Brueshoff, & Jost, 2011b). A well-constructed and equitable partnership between academia and practice is foundational to student engagement in public health, both validating PHN

Davis and Travers Gustafson: Village-Based Collaboration 329

staff practice and developing the future PHN work- force (Keller et al., 2011b; University of Michigan Center of Excellence in Public Health Workforce Studies, 2013). Academic-practice partnerships, leading to positive family health outcomes, are potential vehicles for external funding, building community capacity, and complementing the exist- ing PHN workforce.

Methods

A village-based PHN collaboration (Figure 1) con- ceptually links academic/practice partnerships, BSN students engaged in public health curricula, and young, vulnerable families seeking public health nurse home visits. The synergy generated is greater than the sum of their individual capabilities, opti- mizing the potential for improved family health. In the “village,” positive health outcomes provide the collective synergy to drive this continuous process, leading to community-level change that reflects interactive and collaborative multilevel systems.

Design and sample A mixed-methods design, incorporating both quan- titative and qualitative approaches, was used in the development and evaluation of the village-level PHN partnership program. Creswell (2014) describes mixed methods as a combination of approaches to provide a more complete under- standing of the research problem. The design also supports elements of program evaluation, a key component in the program development process (Rhyne, Bogue, Kukulka, & Fulmer, 1998).

In every instance, care was taken to capture, appreciate, and articulate the “voice” or perspec- tive of each of the participant groups in the pro- gram. Both qualitative and quantitative data collection relate to families receiving home visits, academic/practice partnerships, and BSN students in community/public health practica working together in the broader context of the “village.” The setting for the program was a small Midwest- ern city with a population of approximately 265,000 people. A convenience sample of 20 fami- lies agreed to participate in home visits with BSN students. Families were informed of the program while seeking services at the local public health department. If they requested home visits, PHN faculty initiated communication via phone to

explain the program and services the family might expect.

The study was approved by the University Institutional Review Board. Participation in home visitation was voluntary and could be terminated at any time by the family. A consent form outlining client rights and confidentiality was reviewed and signatures obtained at the time of the first home visit. All participants were provided with informa- tion about the project methods and aims, and all data collection was anonymous.

Measures A program planning and evaluation process model developed by D. E. Grimes provided a public health framework theoretically consistent with the purpose of the project (Grimes & Weller, 2012). Four central elements of program development and evaluation are to: analyze the problem, specify the goal and outcomes, plan the program, then implement and evaluate. These actions are continuous, so that the program is always in an active state of development and evaluation. Ultimately, the process leads to a higher level of health for the population (Grimes & Weller, 2012).

VILLAGE

Families

BSN Students

Health Outcomes (Synergy)

Academic/Practice Partnerships

Community Services

Built Environment

Basic Needs Resources

Figure 1. Village-based PHN Collaboration Note: Model illustrating the “village,” where young families, students, and academic-practice partners interact with resources to achieve the overall outcome of a healthy family

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Similarly, the goals and health outcomes of the “village” drive community-level change that reflects interactive, collaborative, and multiple level sys- tems. The measureable objectives for the program align with the framework and relate to the program goals, reflect the outcomes, provide measures of person, place, and time, and specify the intended outcomes. Objectives meeting those criteria were identified for each of the four constructs of the pro- ject: families, academic/practice partnerships, BSN students, and the village. Data analysis was accom- plished using simple descriptive statistics to sum- marize quantitative findings, while qualitative data were reviewed through constant comparison to identify key ideas, major themes, and persistent patterns of responses. Data relating to each emerg- ing theme were reviewed for similarities and varia- tions in meaning. Data collection tools for each of the four constructs were adapted from existing sources or developed specifically for this project. Process data on home visits, documentation of fam- ily goals, follow-up plans, and overall satisfaction with home visits were collected for participating families. Data for the academic-practice partnership included a summary of partnership development and focus group reports. Tools for self-assessment of entry-level PHN competencies and evaluating learning outcomes captured BSN student data. Finally, a GIS map illustrated “village-level” data relevant to the built environment (Table 1).

A first step for the program development and evaluation project was to advance an existing infor- mal collaboration between the local public health agency and area schools of nursing to a formal aca- demic-practice partnership. The objectives for the partnership were twofold: to design a process for

family referrals, communication, and documenta- tion prior to initiating student experiences, and to appraise documentation, summarize process out- comes, and identify areas for development as the program progressed. Field notes from formative meetings were used to highlight partnership pur- pose, goals, and work plan. Agency PHNs and Community/Public Health nursing faculty partici- pated in two focus groups, one at the conclusion of each semester to identify and evaluate goals and outcomes of the partnership. Emerging themes were identified and provided a descriptive summary articulating the academic-partnership “voice”.

To provide a foundation for family data collec- tion, partners agreed to a consistent documentation process to capture home visit process data, commu- nicate nursing interventions, and to report family goals and transition/follow-up plans. This record provided a mechanism for multiple students to plan and implement interventions for one family over the course of the academic year. Families agreeing to participate were offered weekly home visits with a nursing student during the fall and spring semesters of the 2012–2013 academic year. Pro- gram objectives for the construct of “family” were to collect process outcome data on home visits, describe family health goals, assure transition plans existed for continuity of care, and to obtain mea- sures of family satisfaction with home visits. Home visit process data including the number of home visit encounters, screening interventions, and com- munity referrals were documented by students fol- lowing each home visit. Students engaged family members in mutual goal setting activity and docu- mented these goals in the family record. Students provided a written transition/follow-up plan for

TABLE 1. Project Tools

Construct Tool Data type

Families 1. Home visit data (number of visits, screening interventions, community referrals)

Quantitative

2. Family health goals Qualitative 3. Follow-up plans Quantitative 4. Family satisfaction with home visits Quantitative and qualitative

Academic-Practice Partnerships

5. Project development summary Qualitative 6. Partner focus groups Qualitative

BSN Students 7. Self-assessment of entry-level PHN competencies Qualitative 8. Evaluation of learning outcomes Quantitative

Village 9. GIS map (illustrates geographic distance between home and supportive village/community agencies)

Quantitative

Davis and Travers Gustafson: Village-Based Collaboration 331

subsequent student. Faculty completed a chart audit at the end of each semester to capture process data and to assure the family goals and follow-up plans were present at the completion of student practica experiences. In addition, families were asked to complete a 13-question written survey to assess satisfaction with student home visits. The survey provided quantitative and qualitative data evaluating their home visit experience. Qualified medical interpretation services were provided by the local health department for each home visit encounter.

Objectives for the BSN student construct related to the practicum experience. Emerging themes from self-reflection data and quantitative data from survey results were used to articulate stu- dent perceptions of learning. Students provided reflections and self-assessments of their home visit practice based on novice PHN competencies (Schaf- fer et al., 2011). Students also completed a short survey on the applicability of the PHN practicum experience to their future practice, adapted from a form described by Zandee, Bossenbroek, Friesen, Blech, and Engbers (2010). Responses were mea- sured using a scale of 1 “disagree” to 5 “agree.”

The relationship between where family partici- pants live and the geographic location of their sup- port systems are illustrated with GIS mapping technology. These “village” support systems are identified as health-related community resources, agencies, and infrastructure. Neighborhood map- ping using GIS technology was chosen to analyze spatial data related to the village. This strategy has been used successfully to study health-related out- comes (Aronson, Wallis, O’Campo, & Schafer, 2007). Comparison of the geographic distance between where families reside and the services they need, along with an overlay of the built environ- ment is a measure of health impact. The GIS map provided expanded community assessment data allowing academic-practice partners to use a broader, systematic lens to compare and contrast availability of health-related resources for vulnera- ble young families.

Results

Data were collected and analyzed during academic year 2012–2013. Academic-practice partnership field notes from project initiation meetings and two

focus groups (one in each semester), revealed three key factors driving the project: vulnerable families with no access to home visitation, systems/policy changes affecting capacity to provide home visita- tion, and the significant need for quality student experiences. These indicators suggested a need for an innovative program with a collaborative focus. The opportunity to study these complex issues and create a new course of action is in concert with the Doctor of Nursing Practice program development and evaluation project. The program purpose, to support healthy families in healthy villages, was reflected in a central theme, “every vulnerable young family needs a public health nurse.” Project strengths, identified by partners, included collabo- rative focus, equity in sharing referrals, and an inclusive approach. Opportunities for improvement included partnership processes, role clarification, documentation, communications (including inter- pretation and plain language materials), transition planning, and evaluation.

Twenty young families had 175 home visits, with a mean of nine visits each, from 53 students over two semesters. Fourteen immigrant or refugee families required interpreters for home visits. Forty-three nursing students documented interven- tions connecting families to medical/dental provid- ers and community agencies (39) or using of screening tools for in-depth assessment and referral (4). Students documented 202 educational inter- ventions focused on nutrition (92), home and com- munity safety (51), child development (48), and environmental health concerns (11). Students facili- tated family identification of health goals. Three main goal themes emerged as follows: the impor- tance of a healthy family, healthy feeding/eating habits, and child and family safety. Family care transition plans documenting outcomes at the end of home visit partnerships were completed 87% of the time.

Seven family satisfaction surveys were returned (35% response rate) and the quality of home visits was rated as excellent (71.4%) or good (28.6%). Families reported that students were professional, respectful, and supportive while helping them to better understand their children’s developmental and health needs and set parenting goals. Respon- dents requested language appropriate materials on child development and family health. In addition, parents sought help with referrals for employment,

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food access, safe housing, and English language classes.

Themes and illustrative quotes from BSN stu- dent self-assessment and reflection data aligned with novice PHN competencies were identified (Table 2). Fifty-four students completed the anony- mous 4-question survey at the conclusion of their home visit experience. The means of responses are as follows: whether the experience met their learn- ing needs (3.87), whether they would recommend it to other students (3.98), and whether the learning they experienced would help them practice effec- tively in the community (4.13) and in acute care settings (3.80).

GIS mapping visually captured complex “vil- lage” data. Most families (70%) resided in a central area of the city where there was limited green space, multifamily dwellings, and dense population. While centrally located, families travelled an aver- age of 3.6 miles to access primary care provider offices. A small number of grocery suppliers (usu- ally ethnic-specific) existed, along with food distri- bution/pantry sites and community gardens. Bus routes, area schools, English classes sites, cultural and community centers, and the local Health and Human Service office were mapped, illustrating spatial distances to important community resources.

Discussion

Collaborative relationship development and learn- ing among all partners in the village drives family health outcomes and thus, community health. Vul- nerable families, in partnership with BSN students, actively work to promote their own health. The theme “every vulnerable young family needs a pub- lic health nurse” identified in the academic-practice partnership gains momentum as students expand the capacity of home visitation programs.

Qualified, professional interpreters are vital to relationship and partnership development with families and an essential resource to ensure the family “voice” is heard. Interpreters are recognized interdisciplinary team members in daily PHN prac- tice, but this introduces complex new learning for many BSN students and is an area for further development. Experiential learning through home visitation leads to understanding of the broader public health agenda in achieving health equity and

supports national action plans to reduce racial and ethnic disparities (USDHHS, 2011). Themes identi- fied through student self-assessment of PHN entry- level competencies and family data reporting stu- dent home visitors were “always culturally sensi- tive” affirms this.

Understanding and interacting within complex community systems can be challenging even for the expert PHN. GIS technology expands traditional survey methods used by PHNs in community assessment, and an important learning tool for community/public health nursing students. By melding visual representations of spatial geography with assessment of the built environment, the PHN identifies village assets and barriers that better illustrate complex factors affecting family health. Collaborative efforts with community agencies and services become more purposeful, and intended outcomes from community referrals are measured and evaluated. Together with nurse-family relation- ship insights, this tool gives direction for meaning- ful PHN interventions and advocacy efforts that tell the story and context of family and village daily life.

Data confirm that students provide assessment- based interventions and referrals and that seamless transition from student to student or student to health department is essential. Communication between the family, student, faculty, and PHN each time a student-family partnership concludes will improve clarity of information and continuity of care. For example, students and families can pur- posefully review and update family health goals and collaboratively plan for ongoing home visits prior to care transition. Dialogue regarding changes in assessment findings, completed interventions, and future plans coach students to apply case manage- ment and collaboration skills. Accurate and orga- nized documentation is also supported, ensuring that concerns or outstanding referrals are clearly communicated back to the PHN/health depart- ment.

Learning opportunities are inherent for each academic-practice partner and collectively for the program. Challenges exist in both navigating breaks in home visits due to the academic calendar and nurse-family relationships given multiple student visitors. Family satisfaction survey responses com- plement student self-assessment of competencies, indicating that relationships, partnerships, and

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TABLE 2. BSN Student Self-Assessment of PHN Competencies

Entry-level PHN competency Themes Illustrators

1. Apply the public health nursing process to communities, systems, individuals, and families

• We practiced assessment, intervention, education/teaching, referral, and evaluation during home visits and with community organizations

• We developed partnerships and relationships with individuals, families, organizations, and communities to promote holistic health

• “Need to look at the whole picture and the resources around them in the community”

• “We talked and evaluated the progress he was making and improvised the interventions as needed”

2. Utilize basic epidemiologic principles (the incidence, distribution, and control of disease in a population) in public health nursing practice

• We educated individuals, families, and groups about immunizations to prevent disease

• We administered flu vaccinations for families PHNs are active in disease investigations.

• We monitor and track trends, evaluate epidemiologic data, and intervene to prevent disease spread

Learned to “collaborate with other health care providers to control the disease from spreading to an ever-greater amount of the population.”

3. Utilize collaboration to achieve public health goals

We collaborated with clients/family members, instructors, peers, health care providers, agencies, interpreters, public, and community nurses to set and work toward health goals

“Collaborated with PHNs and others to ensure continuity of care.”

4. Work within the responsibility and authority of the governmental public health system

We practiced within the scope of a supervised student practice and followed established rules and processes in public health professional nursing roles

“Maintained professionalism with clients—represented the community agency.”

5. Practice public health nursing within the auspices of the Nurse Practice Act

We practiced professionally and provided quality care through assessment, education, and advocacy

“I just listened to my patients and their concerns and made sure they had the proper resources available to them so they could properly care for themselves and their family.”

6. Effectively communicate with communities, systems, individuals, families, and colleagues

We communicated with individuals and families by listening, asking questions, and building relationships. We effectively utilized resources of supportive professionals to determine interventions in our student nurse and family partnership

• “I answered them with clear answers, and questions I did not know or understand, I went back to the health department and researched the answer to relay to the client at the next visit”

• “Without communication, you wouldn’t get much accomplished”

7. Establish and maintain caring relationships with communities, systems, individuals, and families

We built caring relationships through supportive actions, working to develop trust, and providing clear communication

“Let my client know they could ask me any questions they had.”

(continued)

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positive health outcomes are shaped within the vil- lage. How the village can provide continuity and support for these important reciprocal student nurse-family relationships is another area for devel- opment.

Student competency self-assessment is a viable method for evaluating clinical and teaching-learn- ing outcomes. Strategies to practice competencies rely on integrative teaching-learning activities

(Carter, Kaiser, O’Hare, & Callister, 2006). Student self-assessments that indicate understanding of entry-level PHN competencies signal engagement in learning and application of theory to practice. In addition, students value their public health practi- cum experience and think it will help them practice more effectively in acute care settings.

For this program, expanding faculty workload to include a care coordination role is a vital yet

TABLE 2. (Continued)

Entry-level PHN competency Themes Illustrators

8. Show evidence of commitment to social justice, the greater good, and the public health principles

We recognized how education and advocacy by the public health nurse assist families to achieve their health goals, and this also contributes to the greater good

• “The client I saw would most likely have not been able to afford a home health nurse . . . the clients were not charged for the service I gave . . . it means that the community as a whole benefits”

• “It didn’t matter what background they came from, how much or how little help they needed, it was important to me to do anything to benefit the outcome of our visits”

9. Demonstrate nonjudgmental and unconditional acceptance of people different from self

We honor beliefs of persons unlike ourselves through respect and professionalism

“Differences didn’t affect our relationship, if anything we learned from it.”

10. Incorporate mental, physical, emotional, social, spiritual, and environmental aspects of health into assessment, planning, implementation, and evaluation

We used a holistic approach to assess all aspects of health and determine how the nursing process can be applied

“You assess your patient . . . then you plan how you can better that area . . . then implement these things . . . evaluate if your interventions worked and why or why not.”

11. Demonstrate leadership in public health nursing with communities, systems, individuals, and families

We were able to develop leadership skills by working independently in the public health nurse role

• “I did not stop trying” • “I took initiative” • “At first I was unsure, but by

the second visit I was willing to take it on and do my best”

• “Being the client’s advocate is being a leader, and I felt we did that by helping and teaching at every visit”

• “Respectful of culture and life choices Supported, not judged, educated, not forced to change.”

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challenging adjustment, as formal oversight of student-family cases is supported by the broad structure of the home visit program and not assigned to specific PHN caseloads. Both PHNs and students value each other as professional resources; however, the collaborative partnership must define clear processes to ensure that families are informed, students are prepared and services are documented. Shared professional responsibility for nursing care is a key factor in program quality.

No participant “voice” is louder than another and every contribution is important to academic- practice partnerships intent on improving family and community health. Recruiting family partici- pants, interpreters, and community representatives to join the academic-practice partnership can lead to greater village awareness and expand the reach of the program. Active and engaged partners poten- tiate collective synergy, helping to identify opportu- nities for families to achieve positive health outcomes. This connects the theme “every young vulnerable family needs a public health nurse” to the program purpose, promoting healthy families in a healthy community/village.

Student learning in practica may be enhanced by linking entry-level practice competency to stu- dent self-assessment. Faculty reviewing PHN entry- level competencies with students and PHN precep- tors prior to initiating home visits clarifies learning expectations and practicum outcomes. Simulated home visits prior to actual practice may help increase student confidence, reduce time-consum- ing faculty care coordination, and prepare students for communication and relationship development early in family visits.

The village partnership relies on PHNs and fac- ulty with shared purpose and commitment to an ongoing development process. Partners create a “learning platform” for students to experience the PHN role, meet learning outcomes, and engage PHNs in coaching/mentoring students. PHN com- petencies in analytic and assessment skills, policy development/program planning, communication, cultural competency, community dimensions of practice, public health science, financial manage- ment, and leadership and systems thinking (Quad Council of Public Health Nursing Organizations, 2011) guide entry-level/students, PHNs, and PHN faculty. When formal academic-practice partner- ships share the same standards, programs can be

readily replicated and deliver measurable results to strengthen evidence-based practice.

Mapping the built environment through GIS and analyzing potential connections with health determinants provides rich assessment data. PHNs can use this tool for community participatory research. A framework for educating policymakers with a complete family and village health story becomes plausible, combining (1) a visual represen- tation of where a population lives in relation to needed community resources, (2) an assessment of the built environment, and (3) the context of daily lived experience that becomes known during rela- tionship building. Advanced PHNs can use this framework to promote health impact assessment, a process to evaluate health effects of projects or policies before they are built or implemented (Centers for Disease Control and Prevention [CDC], 2012). These assessments contribute to “health in all policies” (National Association of County and City Health Officials, 2013), an approach to increase decision-makers’ awareness of the health implications of policy development and implementation.

Sustaining the “village” project as an integrated partnership model will be challenging and require resource development. However, it is a PHN “value-added” contribution to population health and has the potential to provide a return on invest- ment over time. Identifying PHN interventions that link intervention and optimal population outcome is critical to a public health research agenda (Issel, Bekemeier, & Kneipp, 2012). Program plans that incorporate evidence-based strategies (such as the NFP), supported by ongoing PHN research, can have a direct impact on high-level health care sys- tems change.

The 2012 Public Health Nurse Workforce sur- vey results recommend efforts to “promote and enhance mutually beneficial academic-practice partnerships” (University of Michigan Center of Excellence in Public Health Workforce Studies, 2013, p. 10). Collaborative programs in public health are complex and challenging, yet there is promise for innovative strategies that are con- structed by partnerships between PHN faculty and nurses. In a “village-based” collaboration, the academic-practice partnership is dedicated to working together for healthy families in healthy communities.

336 Public Health Nursing Volume 32 Number 4 July/August 2015

Acknowledgments

The authors acknowledge the Lincoln-Lancaster County Health Department public health nurses, Community Health Nursing fac- ulty from the University Of Nebraska Medical Center College Of Nursing – Lincoln campus and the Union College Nursing Program, students and faculty from Bryan College of Health Sciences, and Creighton University College of Nursing.

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