According to the Centers for Disease Control and Prevention (2013), the elderly population (>65 years old) is expected to double in the next 25 years. Just over one third (33 percent) of older adults covered by Medicare have incomes below the federal poverty level, with approximately 45 percent having incomes below 200 percent of the federal poverty level (Cubanski, Casillas, & Daminco, 2015). Among older adults, two out of three have at least one chronic condition. The cost of caring for these individuals accounts for roughly 66 percent of the US health care budget (Centers for Disease Control and Prevention, 2013). Registered nurses are needed to help older adults remain safe and healthy in their homes.
Research has shown that nursing students often have negative perceptions of working with older adults (Baumbusch, Dahlke, & Phinney, 2012), and many students indicate little or no desire to work in long-term care settings. However, meaningful clinical exposure to older adults can have an impact on student attitudes toward working with this population (Kydd, Wild, & Nelson, 2013). The need to prepare students to work effectively with aging populations, coupled with ongoing challenges for clinical placements, requires innovative strategies to support meaningful student learning. Examples of high-impact practices include first-year experiences, learning communities, capstone projects and internships, and collaborative projects (Kuh, 2008).
The innovative teaching strategy described in this article involves the use of two high-impact learning strategies: undergraduate student engagement in research and community-based service-learning. Undergraduate research has been found to have a positive impact on cognitive-related outcomes, undergraduate student learning outcome attainment, persistence to graduation, and intent to enroll in graduate school (Kilgo, Ezell Sheets, & Pascarella, 2015). Service-learning has been found to support awareness of and openness to diversity and enhance community and civic engagement (Kuh, 2008). It has the potential to have a positive impact on outcome attainment for older residents and undergraduate students.
DEVELOPMENT OF A HOME VISIT PROGRAM
Faculty teaching in an undergraduate accelerated baccalaureate program recognized the potential to develop a home visit program using a service-learning model to help meet an unmet community need and expand site options for community practicum experiences. The goals of the home visit program were to create powerful learning experiences for students working with older adults and help students recognize the impact of social determinants of health and the challenges of living in poverty. Contractual arrangements were developed with the local Council on Aging (which hires service coordinators at the sites) and the affordable housing provider. Clients for the program were identified by service coordinators as willing to have regular visits by nursing students.
A consent form for participation in the program by residents was developed and reviewed by the university legal counsel; the form indicated that visits were intended to be learning experiences and not intended to replace provision of health services. The consent form also established a contract of confidentiality for information shared between residents and students/faculty unless a safety issue was identified. All participants signed the form.
PROGRAM ACTIVITIES
As part of a summer-long community/mental health practicum, groups of six to eight students conducted weekly home visits to residents in a variety of low-income senior housing communities. Before engaging in the home visit program, students completed training on deescalation techniques and took part in a home visit safety training program. During the program, students worked with clients to enhance therapeutic communication skills and master technical skills such as blood pressure checks. They also reviewed medications, provided education on how to eat healthy on a budget, and developed their assessment skills related to home safety evaluation. They also learned about and shared information on community resources.
Students worked with clients in pairs until they felt comfortable providing independent home visits. A faculty member was onsite at all times for students to call, if needed, to accompany them to a resident's apartment or help them resolve an issue. After each client encounter, students debriefed individually (or in pairs) with the faculty member and wrote a narrative note summarizing their visit. Faculty provided feedback on how to improve narrative documentation skills.
At the end of the clinical day, the group met in a private location and debriefed the students' experiences. The debriefing served as an important activity for faculty to help "put the pieces together" for students and relate their experiences to classroom content.
ADDING A RESEARCH COMPONENT
In 2016, the home visit program expanded to three additional sites. One of the new housing provider partners was exploring the possibility of embedding a full-time community nurse in a newly developed low-income community. The faculty member and the community partner identified types of data needed to justify the position. That resulted in the development of a research project to examine the kinds of nursing activities that took place during the visits and to gather data on client-directed goal attainment. This development allowed us to include both engagement in undergraduate research as well as service-learning in this clinical practicum. The research study was approved by the university human subject review board, and all students were on-boarded as research assistants for the study.
One of the interventions in the study was the use of action planning and coping planning techniques to help residents to develop health goals. Action planning and coping planning are volitional planning interventions designed to help clients identify potential barriers that might prevent them from achieving their goal or desired state, as well as cues to action to assist in engaging in a desired behavior change (Hagger & Luszczynska, 2014). By conducting this study intervention, students were able to practice an evidence-based method for client-directed goal setting. On subsequent visits, goal setting worksheets were reviewed to monitor goal progress. (See Supplemental Digital Content, available at http://links.lww.com/NEP/A119, for an example of the goal-setting worksheet.)
PROGRAM IMPACT
This project resulted in benefits for the residents, housing providers, and service coordinators, as well as for students. Students provided 346 home visits to more than 130 low-income senior residents, representing about 20 percent of the population in six different low-income housing communities. Fifty-five percent of residents reported meeting their goals; 92.31 percent reporting making progress toward goals being met. The service coordinators often commented on how the visits added value to the residents' lives and how they were helpful for them. The housing provider saw this program as an added benefit for residents that helped the agency meet its goals to integrate health and housing services.
As part of the course evaluation, students were asked to identify the most important lesson they learned as a result of engaging in home visit experiences. Students identified four thematic areas of learning: 1) communication skills, 2) the need to know about community resources, 3) new insights on the needs of aging populations, and 4) enhanced understanding of the challenges this population experiences. These findings support that the program accomplished its goals and supported student learning outcomes for the course.
IMPLICATIONS FOR NURSING EDUCATION
Nurse educators can develop innovative clinical practicum experiences by embedding high-impact learning practices such as service-learning experiences and exposure to research. Partnerships with low-income housing providers can be used to develop powerful learning opportunities for students in community settings. Such experiences can better prepare nurses to meet the needs of aging populations and result in positive impacts for residents living in these communities.
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