A dramatic change in health care since the release of the Institute of Medicine (2011)Future of Nursing report has been the shift in the delivery of health care to the community setting. This is particularly true in pediatrics, where at least 70 percent of all clinical care now takes place in primary care settings (Mohr et al., 2005). This trend is expected to continue as population-focused health becomes the norm (Erwin & Brownson, 2017).
The traditional model of clinical education in acute care settings offered few opportunities for students to practice in the community. One remedy is for schools of nursing to support learning activities that focus on the social determinants of health (SDOH), those conditions in which people are born, grow, live, work, and age (Centers for Disease Control and Prevention, 2018), through the formation of community-academic partnerships (CAPs; National Academies of Sciences, Engineering, and Medicine, 2016).
This article describes the development of an innovative undergraduate pediatric clinical rotation that focused on the needs of adolescents of Mexican heritage. The experience was designed as a CAP between a school of nursing and a Mexican American community-based organization (CBO). It focused on an underserved subgroup of second-generation immigrants; it was carried out in a summer day camp, a nontraditional setting; and it utilized a variety of educational activities to address health issues identified by the adolescents.
BACKGROUND
The city of New Brunswick, New Jersey, sits at one end of a transnational migration stream that begins in southern Mexico. Following an unprecedented influx of immigrants in the 2000s, it is estimated that more than 40 percent of the full-time residents of New Brunswick are immigrant families from the poorest indigenous Mexican states (Data USA, 2018). Many of these families now have teenage children born in the United States.
In Mexican immigrant families, adolescents are often expected to use their knowledge of English and US cultural/institutional practices to communicate and carry out tasks for their families (Van Hook & Glick, 2020). Many parents in this community work multiple jobs, and their teenage children are unsupervised for long periods during the summer. During informal conversations, we learned that parents were concerned that long periods of idleness left their teens unprepared for the return to school in the fall and increased the likelihood they would become involved with drugs or gangs. To remedy this situation, the CBO obtained funding to provide a structured summer day camp experience for teenagers, focused on building skills for adulthood. The CBO executive director invited nursing students to conduct educational sessions on health-related topics of interest to the teenagers.
DESIGN
To reinforce the concepts and competencies in the pediatric undergraduate nursing course, students were invited to participate in a six-week community-based day camp for adolescents of Mexican heritage, ages 11 to 17. Students met with the adolescents in a group setting one to two times weekly over a six-week period (70 hours total). By the completion of the clinical experience, students were expected to: 1) identify health promotion and risk reduction needs and disease prevention strategies; 2) analyze biological, sociocultural, spiritual, economic, political, ethical, legal, and environmental factors that impact the health of culturally diverse adolescents; 3) identify health concerns and issues for the adolescent population, and 4) implement a teaching plan to improve selected health outcomes.
Needs Assessment
Nursing students began by conducting a needs assessment to determine the learning needs and preferences of the teenagers and their parents. Areas identified by the two groups included cyberbullying/bullying; dangers of vaping/smoking and drugs; healthy diet choices and physical activity, hydration, and sleep hygiene; and social media, self-esteem building, and mental health/stress management. The topics were approved by the CBO executive director. The choice to include input from community members is consistent with National League for Nursing recommendations (Christensen & Simmons, 2019), which support community input to inform the relevance of the nursing curricula. The nursing students conferred with pediatric clinical faculty members to review topics and teaching plans and their congruence with course objectives and health outcomes.
Implementation
For two successive summer semesters, a clinical group of six to seven nursing students met with 18 teenagers in the day camp. The students were charged with designing a creative, interactive educational session that was developmentally appropriate. Teaching sessions were preceded by an ice breaker activity. In the 45-minute teaching sessions, students utilized active learning strategies, such as return demonstrations, think-pair-share, group discussions, role-playing, and games. These techniques helped to foster "problem posing" or bidirectional learning. In this model, both the nursing students and the adolescents were engaged in a process of mutual learning through dialogue. The teenagers spoke candidly during group discussions, particularly with regard to sources of stress in their lives. Two topics emerged as major stressors: concerns about the teens' Mexican-born parents being deported and issues related to domestic violence/sexual assault. Information about community resources for assistance and referral were shared with students and clinical faculty, as well as with the teen participants.
We also recruited a Latina sexual abuse nurse examiner, who met with faculty and students to suggest community resources for referral. The sexual abuse nurse examiner also met with the adolescents to answer questions and provide emotional support.
In addition to the teaching sessions, students made plans to eat meals with the teens, sit in on Mexican art and culture classes, and participate in informal conversations. The inclusion of the nursing students in these activities was designed to promote a connection to the Mexican immigrant population and to familiarize the nursing students with SDOH in the community.
EVALUATION
The most common methods used to evaluate the effectiveness of the students' teaching plans were teach-back and return demonstration. Adolescents demonstrated their newly acquired psychomotor skills following teaching sessions on healthy cooking, mindfulness meditation, and aerobic exercise. They also engaged in goal setting around longer term health outcomes requiring behavior change. When a new group of nursing students met with the adolescents in the second summer, several students from the previous year returned and reported they had adopted these healthy behaviors into their daily routines.
Upon completion of the clinical experience, the nursing students engaged in a reflective journaling activity. Students were asked to: 1) identify SDOH for the community and local resources available for health promotion and 2) identify the impact of the experience on their nursing practice. The students identified SDOH specific to the community, including the political climate, citizenship status, and language. The students reported that, through their social interactions with the teens, they developed greater awareness of health equity issues from the perspective of the Mexican immigrant community. The students acknowledged that, prior to this clinical experience, they had little knowledge of the health concerns of Mexican immigrants in their community. The teenagers were positive about the experience as well; since attending the camp, several expressed an interest in participating in an ongoing research study with faculty to learn more about health issues in their community.
CONCLUSION
Our experience with the design and implementation of the innovative community pediatric clinical taught us that CAPs can be an innovative teaching strategy to promote student learning and contribute to the overall health of the community. Through the CAP, undergraduate nursing students were able to identify specific SDOHs that impact community health. In turn, the students utilized a variety of interactive educational activities to address health issues of concern to a historically underserved group. The summer day camp setting provided a unique opportunity for nursing students to meet the adolescents "on their turf." Schools of nursing should consider partnering with CBOs to develop community-based clinical experiences to enhance student learning about population health and SDOH.
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