Public Health Nursing Vol. 32 No. 4, pp. 327–338 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12135
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, educating 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 sustainability. 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 education, 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 vulnerability, multiple factors challenge family wellbeing. Extensive evidence shows that public health nurse (PHN)-family partnerships effectively promote the growth and development of children and families and achieve healthy outcomes with longlasting 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, & Meszaros, 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 (NurseFamily 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
327
328
Public Health Nursing
Volume 32
Number 4
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 dwindling 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 education at the baccalaureate level (BSN) is essential, as professional nursing practice includes the individual, family, community, and population as clients (American Association of Colleges of Nursing [AACN], 2012; Callen et al., 2010; Savage & Kub, 2009). Colleges and schools of nursing collaborate 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 vulnerable 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 promoting healthy families, and academic-PHN practice partnerships both advance the health of communities and educate nurses for practice excellence (AACN, 2012). Advanced practice PHN requires competency in leadership and systems thinking skills (Quad Council Competencies, 2011). A community or “village” 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 determinants, 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 department, (2) educate baccalaureate nursing students
July/August 2015
for public health practice, (3) build nurse and nursing student-family partnerships, and (4) promote the health and development of children and families in the “village” served by the public health district. 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 Goodman (2012) describe an innovative and successful home visit program using a model that builds support of community agencies, providers, and volunteer groups to assure family connections with community services. Assessment of the built environment, 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 community/neighborhood infrastructure, this process is limited at best. Using Geographic Information System (GIS) technology, these factors can be mapped and further analyzed for PHN practice. A framework 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 (DeGuzman & 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, Hillary Rodham Clinton adopted this proverb to illustrate 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 project, 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.
Davis and Travers Gustafson: Village-Based Collaboration Each year, it is estimated that 500,000 children 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; Melmed, 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. Program 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. Department of Health and Human Services [USDHHS] action plan to reduce racial and ethnic health disparities (USDHHS, 2011), identifies home visiting programs as one way to meet the diverse needs of underserved minority families. Ultimately, families are best equipped to identify 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: collaboration, comprehensiveness, and civic engagement. Promoting health, then, is collaborative, developmental, and visualized as a broader community imperative. PHNs provide unique leadership and contributions to families, communities, and the health care system. The Affordable Care Act (ACA) authorizes the creation of a Maternal, Infant, and Early Childhood 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
329
history of home visitation expertise, are positioned to lead the ACA initiative (Keller, Garrett, & Drehobl, 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; McNaughton, 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 maternal-child home visitation services for vulnerable young families exists due to a diminishing investment 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 meaningful 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 scientific evidence for population-based nursing practice (Association of Community Health Nurse Educators, 2010). A reduced public health nursing workforce, fewer research prepared faculty and limited 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 “practice” 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 complex 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 (Keller, 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
330
Public Health Nursing
Volume 32
Number 4
staff practice and developing the future PHN workforce (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 existing PHN workforce.
July/August 2015
VILLAGE
Families
Built Environment
Health Outcomes (Synergy)
Methods A village-based PHN collaboration (Figure 1) conceptually 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, optimizing 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 quantitative 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 understanding 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 perspective of each of the participant groups in the program. 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 Midwestern city with a population of approximately 265,000 people. A convenience sample of 20 families 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
Basic Needs Resources
Academic/Practice Partnerships
BSN Students
Community Services
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
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 information 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).
Davis and Travers Gustafson: Village-Based Collaboration Similarly, the goals and health outcomes of the “village” drive community-level change that reflects interactive, collaborative, and multiple level systems. 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 project: families, academic/practice partnerships, BSN students, and the village. Data analysis was accomplished using simple descriptive statistics to summarize 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 emerging theme were reviewed for similarities and variations 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 family 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 informal collaboration between the local public health agency and area schools of nursing to a formal academic-practice partnership. The objectives for the partnership were twofold: to design a process for
331
family referrals, communication, and documentation prior to initiating student experiences, and to appraise documentation, summarize process outcomes, and identify areas for development as the program progressed. Field notes from formative meetings were used to highlight partnership purpose, goals, and work plan. Agency PHNs and Community/Public Health nursing faculty participated 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 collection, partners agreed to a consistent documentation process to capture home visit process data, communicate 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. Program 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 measures of family satisfaction with home visits. Home visit process data including the number of home visit encounters, screening interventions, and community referrals were documented by students following each home visit. Students engaged family members in mutual goal setting activity and documented these goals in the family record. Students provided a written transition/follow-up plan for
TABLE 1. Project Tools Construct
Tool
Families
1. Home visit data (number of visits, screening interventions, community referrals) 2. Family health goals 3. Follow-up plans 4. Family satisfaction with home visits 5. Project development summary 6. Partner focus groups 7. Self-assessment of entry-level PHN competencies 8. Evaluation of learning outcomes 9. GIS map (illustrates geographic distance between home and supportive village/community agencies)
Academic-Practice Partnerships BSN Students Village
Data type Quantitative Qualitative Quantitative Quantitative and qualitative Qualitative Qualitative Qualitative Quantitative Quantitative
332
Public Health Nursing
Volume 32
Number 4
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 student perceptions of learning. Students provided reflections and self-assessments of their home visit practice based on novice PHN competencies (Schaffer 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 measured using a scale of 1 “disagree” to 5 “agree.” The relationship between where family participants live and the geographic location of their support systems are illustrated with GIS mapping technology. These “village” support systems are identified as health-related community resources, agencies, and infrastructure. Neighborhood mapping using GIS technology was chosen to analyze spatial data related to the village. This strategy has been used successfully to study health-related outcomes (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 environment 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 vulnerable young families.
Results Data were collected and analyzed during academic year 2012–2013. Academic-practice partnership field notes from project initiation meetings and two
July/August 2015
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 visitation, 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 collaborative focus, equity in sharing referrals, and an inclusive approach. Opportunities for improvement included partnership processes, role clarification, documentation, communications (including interpretation 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 interventions connecting families to medical/dental providers and community agencies (39) or using of screening tools for in-depth assessment and referral (4). Students documented 202 educational interventions focused on nutrition (92), home and community safety (51), child development (48), and environmental health concerns (11). Students facilitated family identification of health goals. Three main goal themes emerged as follows: the importance 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. Respondents requested language appropriate materials on child development and family health. In addition, parents sought help with referrals for employment,
Davis and Travers Gustafson: Village-Based Collaboration food access, safe housing, and English language classes. Themes and illustrative quotes from BSN student self-assessment and reflection data aligned with novice PHN competencies were identified (Table 2). Fifty-four students completed the anonymous 4-question survey at the conclusion of their home visit experience. The means of responses are as follows: whether the experience met their learning needs (3.87), whether they would recommend it to other students (3.98), and whether the learning they experienced would help them practice effectively in the community (4.13) and in acute care settings (3.80). GIS mapping visually captured complex “village” 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 average of 3.6 miles to access primary care provider offices. A small number of grocery suppliers (usually ethnic-specific) existed, along with food distribution/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 learning among all partners in the village drives family health outcomes and thus, community health. Vulnerable families, in partnership with BSN students, actively work to promote their own health. The theme “every vulnerable young family needs a public 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 practice, 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
333
supports national action plans to reduce racial and ethnic disparities (USDHHS, 2011). Themes identified through student self-assessment of PHN entrylevel competencies and family data reporting student home visitors were “always culturally sensitive” 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 relationship insights, this tool gives direction for meaningful PHN interventions and advocacy efforts that tell the story and context of family and village daily life. Data confirm that students provide assessmentbased 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 purposefully 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 management and collaboration skills. Accurate and organized documentation is also supported, ensuring that concerns or outstanding referrals are clearly communicated back to the PHN/health department. 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 complement student self-assessment of competencies, indicating that relationships, partnerships, and
334
Public Health Nursing
Volume 32
Number 4
July/August 2015
TABLE 2. BSN Student Self-Assessment of PHN Competencies Entry-level PHN competency 1. Apply the public health nursing process to communities, systems, individuals, and families
Themes
• 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 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 We collaborated with clients/family members, instructors, peers, health care providers, agencies, interpreters, public, and community nurses to set and work toward health goals We practiced within the scope of a supervised student practice and followed established rules and processes in public health professional nursing roles We practiced professionally and provided quality care through assessment, education, and advocacy
•
2. Utilize basic epidemiologic principles (the incidence, distribution, and control of disease in a population) in public health nursing practice
3. Utilize collaboration to achieve public health goals
4. Work within the responsibility and authority of the governmental public health system 5. Practice public health nursing within the auspices of the Nurse Practice Act
6. Effectively communicate with communities, systems, individuals, families, and colleagues
7. Establish and maintain caring relationships with communities, systems, individuals, and families
• •
Illustrators
• “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”
Learned to “collaborate with other health care providers to control the disease from spreading to an ever-greater amount of the population.”
•
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
We built caring relationships through supportive actions, working to develop trust, and providing clear communication
“Collaborated with PHNs and others to ensure continuity of care.”
“Maintained professionalism with clients—represented the community agency.”
“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.” “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”
•
•
“Let my client know they could ask me any questions they had.”
(continued)
Davis and Travers Gustafson: Village-Based Collaboration
335
TABLE 2. (Continued) Entry-level PHN competency 8. Show evidence of commitment to social justice, the greater good, and the public health principles
Themes
Illustrators
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
•
9. Demonstrate nonjudgmental and unconditional acceptance of people different from self 10. Incorporate mental, physical, emotional, social, spiritual, and environmental aspects of health into assessment, planning, implementation, and evaluation 11. Demonstrate leadership in public health nursing with communities, systems, individuals, and families
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”
We honor beliefs of persons unlike ourselves through respect and professionalism
“Differences didn’t affect our relationship, if anything we learned from it.”
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.”
We were able to develop leadership skills by working independently in the public health nurse role
not stop trying” • “I“I did initiative” • “Attook • first I was unsure, but by
• •
positive health outcomes are shaped within the village. How the village can provide continuity and support for these important reciprocal student nurse-family relationships is another area for development. Student competency self-assessment is a viable method for evaluating clinical and teaching-learning outcomes. Strategies to practice competencies rely on integrative teaching-learning activities
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.”
(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 practicum 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
336
Public Health Nursing
Volume 32
Number 4
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 academicpractice partnerships intent on improving family and community health. Recruiting family participants, 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 potentiate collective synergy, helping to identify opportunities 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 student self-assessment. Faculty reviewing PHN entrylevel competencies with students and PHN preceptors 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-consuming faculty care coordination, and prepare students for communication and relationship development early in family visits. The village partnership relies on PHNs and faculty 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 competencies in analytic and assessment skills, policy development/program planning, communication, cultural competency, community dimensions of practice, public health science, financial management, 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 partnerships share the same standards, programs can be
July/August 2015
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 representation 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 relationship 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 investment 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 systems change. The 2012 Public Health Nurse Workforce survey 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 constructed 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.
Davis and Travers Gustafson: Village-Based Collaboration
Acknowledgments The authors acknowledge the Lincoln-Lancaster County Health Department public health nurses, Community Health Nursing faculty 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.
References Addy, S., & Wight, V. R. (2012). Basic facts about low-income children, 2010: Children under age 18. Retrieved from http:// www.nccp.org/publications/pdf/text_1049.pdf American Association of Colleges of Nursing [AACN] (2012). AACN & CDC Partner to advance the public health nursing workforce. Retrieved from http://www.aacn.nche.edu/news/articles/2012/cdc-public-health America’s children in brief: Key national indicators of well-being. (2012). Retrieved from http://www.childstats.gov/pdf/ ac2012/ac_12.pdf Aronson, R. E., Wallis, A. B., O’Campo, P. J., & Schafer, P. (2007). Neighborhood mapping and evaluation: A methodology for participatory community health initiatives. Maternal & Child Health Journal, 11(4), 373–383. Association of Community Health Nursing Educators [ACHNE] Research Committee (2010). Research priorities for Public Health Nursing. Public Health Nursing, 27(1), 94–100. Association of State and Territorial Health Officials. (2008). 2007 State Public Health Workforce Shortage Report. Retrieved from http://www.astho.org/Display/AssetDisplay.aspx? id=500 Azzi-Lessing, L. (2011). Home visitation programs: Critical issues and future directions. Early Childhood Research Quarterly, 26(4), 387–398. Benson, P. L., Leffert, N., Scales, P. C., & Blyth, D. A. (2012). Beyond the “Village” rhetoric: Creating healthy communities for children and adolescents. Applied Developmental Science, 16(1), 3–23. Callen, B., Block, D., Joyce, B., Lutz, J., Brown-Schott, N., & Smith, C. M. (2010). Essentials of baccalaureate nursing education for entry-level community/public health. Public Health Nursing, 27(4), 371–382. Carter, K. F., Kaiser, K. L., O’Hare, P., & Callister, L. C. (2006). Use of PHN competencies and ACHNE essentials to develop teaching-learning strategies for generalist C/PHN curricula. Public Health Nursing, 23(2), 146–160. Centers for Disease Control and Prevention [CDC]. (2012). Health impact assessment. Retrieved from http://www.cdc.gov/ healthyplaces/hia.htm Collier, J., Davidson, G., Allen, C. B., Dieckmann, J., Hoke, M. M., & Sawaya, M. A. (2010). Academic faculty qualifications for community/public health nursing: An association of community health nursing educator’s position paper. Public Health Nursing, 27(1), 89–93. Creswell, J. W. (2014). Research design: Qualitative, quantitative and mixed methods approaches. [ISBN-10 1452226105] Thousand Oaks, CA: Sage Publications. DeGuzman, P. B., & Kulbok, P. A. (2012). Changing health outcomes of vulnerable populations through nursing’s influence on neighborhood built environment: A framework for nursing research. Journal of Nursing Scholarship, 44(4), 341–348. Dodge, K., & Goodman, B. (2012). Durham connects impact evaluation executive summary Pew Center on the States. Retrieved from www.pewstates.org/. . ./PCS. . ./Durham_Connects_executive_summary.pdf Foundation for Child Development (2011). Child and youth wellbeing index. Retrieved from http://fcd-us.org/sites/default/ files/FINAL%20CWI%20Report.pdf
337
Grimes, D. E., & Weller, N. F. (2012). Evaluating populations and population health. In J. V. Hickey & C. A. Brosnan (Eds.), Evaluation of health care quality in advanced practice nursing [ISBN-10: 0826107664] (1st ed., pp. 159–176). New York: Springer Publishing Company. Healey, J. G. (1998). African Proverb of the Month November, 1998. Retrieved from http://www.afriprov.org/index.php/ african-proverb-of-the-month/23-1998proverbs/137-November-1998-proverb.html Health Resources and Services Administration [HRSA] - U.S. Department of Health and Human Services (2013). Maternal, infant, and early childhood home visiting program. Retrieved from http://mchb.hrsa.gov/programs/homevisiting/ Healthy People 2020. (2011). Early and middle childhood. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=10 Howard, K. S., & Brooks-Gunn, J. (2009). The role of home-visiting programs in preventing child abuse and neglect. Future of Children, 19(2), 119–146. Institute of Medicine [IOM] (2011). The future of nursing: Leading change, advancing health. Retrieved from http://thefutureofnursing.org/IOM-Report Issel, L. M., Bekemeier, B., & Kneipp, S. (2012). A public health nursing research agenda. Public Health Nursing, 29(4), 330–342. Keller, L. O., Garrett, T., & Drehobl, P. (2011a). Public health nursing: Transforming health across populations. The future of nursing: Leading change, advancing health. (Institute of Medicine). Washington, DC: The National Academies Press. Keller, L. O., Schaffer, M. A., Schoon, P. M., Brueshoff, B., & Jost, R. (2011b). Finding common ground in public health nursing education and practice. Public Health Nursing, 28(3), 261–270. Kitzman, H. J., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., et al. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a random trial among children at age 12 years. Archives of Pediatric Adolescent Medicine, 164(5), 412–418. Kulbok, P. A., Thatcher, E., Park, E., & Meszaros, P. S. (2012). Evolving public health nursing roles: Focus on community participatory health promotion and prevention. Online Journal of Issues in Nursing, 17(2), 1. McNaughton, D. B. (2004). Nurse home visits to maternal-child clients: A review of intervention research. Public Health Nursing, 21(3), 207–219. Melmed, M. E. (2009). Hearing on early childhood home visitation. Submitted to the subcommittee on income security and family support of the house committee on ways and means. Retrieved from http://main.zerotothree.org/site/DocServer/ Home_Visiting_06-09-09.pdf?docID=9001 National Association of County and City Health Officials. (2013). Health in all policies. Retrieved from http://www.naccho. org/topics/environmental/HiAP/ Nievar, M. A., Van Egeren, L. A., & Pollard, S. (2010). A metaanalysis of home visiting programs: Moderators of improvements in maternal behavior. Infant Mental Health Journal, 31(5), 499–520. Nurse-Family Partnership [NFP]. (2011). Evidence-based Public Policy. Retrieved from http://www.nursefamilypartnership. org/public-policy Nurse-Family Partnership [NFP]. (2013). Benefits and costs – A rigorously tested program with measureable results. Retrieved from http://www.nursefamilypartnership.org/assets/PDF/ Fact-sheets/NFP_Benefits-Cost Olds, D. L., Robinson, J. A., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., et al. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics. Retrieved from http://eorder. sheridan.com/3_0/app/orders/1546/article.php
338
Public Health Nursing
Volume 32
Number 4
Pew Charitable Trusts. (2013). Expanding home visiting research: New measures of success. Retrieved from www.pewstates. org/uploadedFiles/PCS. . ./HOME_Summit_Brief.pdf Quad Council Competencies. (2011). Quad Council Competencies for public health nurses – summer 2011. Retrieved from http://www.resourcenter.net/images/ACHNE/Files/QuadCouncilCompetenciesForPublicHealthNurses_Summer2011. pdf Rhyne, R., Bogue, R., Kukulka, G., & Fulmer, H. (1998). Community oriented primary care: Health care for the 21st century. Washington, DC: American Public Health Association. Robert Wood Johnson Foundation. (2011). Recession takes bite out of nation’s public health nursing infrastructure. Retrieved from http://www.rwjf.org/pr/product.jsp?id=73642 Savage, C., & Kub, J. (2009). Public Health and nursing: A natural partnership. International Journal of Environmental Research and Public Health, 6, 2843–2848. Schaffer, M. A., Cross, S., Keller, L. O., Nelson, P., Schoon, P. M., & Henton, P. (2011). The henry street consortium population-
July/August 2015
based competencies for educating public health nursing students. Public Health Nursing, 28(1), 78–90. University of Michigan Center of Excellence in Public Health Workforce Studies. (2013). Enumeration and characterization of the public health nurse workforce: Findings of the 2012 public health nurse workforce surveys. Ann Arbor, MI: University of Michigan. Retrieved from http://www.rwjf.org/ content/dam/farm/reports/reports/2013/rwjf406659 U.S. Department of Health and Human Services [USDHHS]. (2011). HHS action plan to reduce racial and ethnic disparities: A nation free of disparities in health and health care. Retrieved from http://minorityhealth.hhs.gov/npa/files/ Plans/HHS/HHS_Plan_complete.pdf Wade, G. H., & Hayes, E. (2010). Challenges and opportunities associated with preceptored community health clinical experiences. Public Health Nursing, 27(5), 459–467. Zandee, G., Bossenbroek, D., Friesen, M., Blech, K., & Engbers, R. (2010). Effectiveness of community health Worker/Nursing student teams as a strategy for public health nursing education. Public Health Nursing, 27(3), 277–284.
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, educating 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 sustainability. 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 education, 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 vulnerability, multiple factors challenge family wellbeing. Extensive evidence shows that public health nurse (PHN)-family partnerships effectively promote the growth and development of children and families and achieve healthy outcomes with longlasting 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, & Meszaros, 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 (NurseFamily 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
327
328
Public Health Nursing
Volume 32
Number 4
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 dwindling 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 education at the baccalaureate level (BSN) is essential, as professional nursing practice includes the individual, family, community, and population as clients (American Association of Colleges of Nursing [AACN], 2012; Callen et al., 2010; Savage & Kub, 2009). Colleges and schools of nursing collaborate 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 vulnerable 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 promoting healthy families, and academic-PHN practice partnerships both advance the health of communities and educate nurses for practice excellence (AACN, 2012). Advanced practice PHN requires competency in leadership and systems thinking skills (Quad Council Competencies, 2011). A community or “village” 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 determinants, 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 department, (2) educate baccalaureate nursing students
July/August 2015
for public health practice, (3) build nurse and nursing student-family partnerships, and (4) promote the health and development of children and families in the “village” served by the public health district. 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 Goodman (2012) describe an innovative and successful home visit program using a model that builds support of community agencies, providers, and volunteer groups to assure family connections with community services. Assessment of the built environment, 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 community/neighborhood infrastructure, this process is limited at best. Using Geographic Information System (GIS) technology, these factors can be mapped and further analyzed for PHN practice. A framework 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 (DeGuzman & 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, Hillary Rodham Clinton adopted this proverb to illustrate 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 project, 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.
Davis and Travers Gustafson: Village-Based Collaboration Each year, it is estimated that 500,000 children 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; Melmed, 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. Program 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. Department of Health and Human Services [USDHHS] action plan to reduce racial and ethnic health disparities (USDHHS, 2011), identifies home visiting programs as one way to meet the diverse needs of underserved minority families. Ultimately, families are best equipped to identify 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: collaboration, comprehensiveness, and civic engagement. Promoting health, then, is collaborative, developmental, and visualized as a broader community imperative. PHNs provide unique leadership and contributions to families, communities, and the health care system. The Affordable Care Act (ACA) authorizes the creation of a Maternal, Infant, and Early Childhood 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
329
history of home visitation expertise, are positioned to lead the ACA initiative (Keller, Garrett, & Drehobl, 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; McNaughton, 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 maternal-child home visitation services for vulnerable young families exists due to a diminishing investment 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 meaningful 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 scientific evidence for population-based nursing practice (Association of Community Health Nurse Educators, 2010). A reduced public health nursing workforce, fewer research prepared faculty and limited 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 “practice” 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 complex 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 (Keller, 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
330
Public Health Nursing
Volume 32
Number 4
staff practice and developing the future PHN workforce (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 existing PHN workforce.
July/August 2015
VILLAGE
Families
Built Environment
Health Outcomes (Synergy)
Methods A village-based PHN collaboration (Figure 1) conceptually 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, optimizing 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 quantitative 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 understanding 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 perspective of each of the participant groups in the program. 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 Midwestern city with a population of approximately 265,000 people. A convenience sample of 20 families 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
Basic Needs Resources
Academic/Practice Partnerships
BSN Students
Community Services
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
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 information 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).
Davis and Travers Gustafson: Village-Based Collaboration Similarly, the goals and health outcomes of the “village” drive community-level change that reflects interactive, collaborative, and multiple level systems. 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 project: families, academic/practice partnerships, BSN students, and the village. Data analysis was accomplished using simple descriptive statistics to summarize 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 emerging theme were reviewed for similarities and variations 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 family 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 informal collaboration between the local public health agency and area schools of nursing to a formal academic-practice partnership. The objectives for the partnership were twofold: to design a process for
331
family referrals, communication, and documentation prior to initiating student experiences, and to appraise documentation, summarize process outcomes, and identify areas for development as the program progressed. Field notes from formative meetings were used to highlight partnership purpose, goals, and work plan. Agency PHNs and Community/Public Health nursing faculty participated 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 collection, partners agreed to a consistent documentation process to capture home visit process data, communicate 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. Program 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 measures of family satisfaction with home visits. Home visit process data including the number of home visit encounters, screening interventions, and community referrals were documented by students following each home visit. Students engaged family members in mutual goal setting activity and documented these goals in the family record. Students provided a written transition/follow-up plan for
TABLE 1. Project Tools Construct
Tool
Families
1. Home visit data (number of visits, screening interventions, community referrals) 2. Family health goals 3. Follow-up plans 4. Family satisfaction with home visits 5. Project development summary 6. Partner focus groups 7. Self-assessment of entry-level PHN competencies 8. Evaluation of learning outcomes 9. GIS map (illustrates geographic distance between home and supportive village/community agencies)
Academic-Practice Partnerships BSN Students Village
Data type Quantitative Qualitative Quantitative Quantitative and qualitative Qualitative Qualitative Qualitative Quantitative Quantitative
332
Public Health Nursing
Volume 32
Number 4
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 student perceptions of learning. Students provided reflections and self-assessments of their home visit practice based on novice PHN competencies (Schaffer 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 measured using a scale of 1 “disagree” to 5 “agree.” The relationship between where family participants live and the geographic location of their support systems are illustrated with GIS mapping technology. These “village” support systems are identified as health-related community resources, agencies, and infrastructure. Neighborhood mapping using GIS technology was chosen to analyze spatial data related to the village. This strategy has been used successfully to study health-related outcomes (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 environment 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 vulnerable young families.
Results Data were collected and analyzed during academic year 2012–2013. Academic-practice partnership field notes from project initiation meetings and two
July/August 2015
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 visitation, 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 collaborative focus, equity in sharing referrals, and an inclusive approach. Opportunities for improvement included partnership processes, role clarification, documentation, communications (including interpretation 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 interventions connecting families to medical/dental providers and community agencies (39) or using of screening tools for in-depth assessment and referral (4). Students documented 202 educational interventions focused on nutrition (92), home and community safety (51), child development (48), and environmental health concerns (11). Students facilitated family identification of health goals. Three main goal themes emerged as follows: the importance 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. Respondents requested language appropriate materials on child development and family health. In addition, parents sought help with referrals for employment,
Davis and Travers Gustafson: Village-Based Collaboration food access, safe housing, and English language classes. Themes and illustrative quotes from BSN student self-assessment and reflection data aligned with novice PHN competencies were identified (Table 2). Fifty-four students completed the anonymous 4-question survey at the conclusion of their home visit experience. The means of responses are as follows: whether the experience met their learning needs (3.87), whether they would recommend it to other students (3.98), and whether the learning they experienced would help them practice effectively in the community (4.13) and in acute care settings (3.80). GIS mapping visually captured complex “village” 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 average of 3.6 miles to access primary care provider offices. A small number of grocery suppliers (usually ethnic-specific) existed, along with food distribution/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 learning among all partners in the village drives family health outcomes and thus, community health. Vulnerable families, in partnership with BSN students, actively work to promote their own health. The theme “every vulnerable young family needs a public 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 practice, 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
333
supports national action plans to reduce racial and ethnic disparities (USDHHS, 2011). Themes identified through student self-assessment of PHN entrylevel competencies and family data reporting student home visitors were “always culturally sensitive” 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 relationship insights, this tool gives direction for meaningful PHN interventions and advocacy efforts that tell the story and context of family and village daily life. Data confirm that students provide assessmentbased 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 purposefully 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 management and collaboration skills. Accurate and organized documentation is also supported, ensuring that concerns or outstanding referrals are clearly communicated back to the PHN/health department. 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 complement student self-assessment of competencies, indicating that relationships, partnerships, and
334
Public Health Nursing
Volume 32
Number 4
July/August 2015
TABLE 2. BSN Student Self-Assessment of PHN Competencies Entry-level PHN competency 1. Apply the public health nursing process to communities, systems, individuals, and families
Themes
• 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 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 We collaborated with clients/family members, instructors, peers, health care providers, agencies, interpreters, public, and community nurses to set and work toward health goals We practiced within the scope of a supervised student practice and followed established rules and processes in public health professional nursing roles We practiced professionally and provided quality care through assessment, education, and advocacy
•
2. Utilize basic epidemiologic principles (the incidence, distribution, and control of disease in a population) in public health nursing practice
3. Utilize collaboration to achieve public health goals
4. Work within the responsibility and authority of the governmental public health system 5. Practice public health nursing within the auspices of the Nurse Practice Act
6. Effectively communicate with communities, systems, individuals, families, and colleagues
7. Establish and maintain caring relationships with communities, systems, individuals, and families
• •
Illustrators
• “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”
Learned to “collaborate with other health care providers to control the disease from spreading to an ever-greater amount of the population.”
•
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
We built caring relationships through supportive actions, working to develop trust, and providing clear communication
“Collaborated with PHNs and others to ensure continuity of care.”
“Maintained professionalism with clients—represented the community agency.”
“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.” “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”
•
•
“Let my client know they could ask me any questions they had.”
(continued)
Davis and Travers Gustafson: Village-Based Collaboration
335
TABLE 2. (Continued) Entry-level PHN competency 8. Show evidence of commitment to social justice, the greater good, and the public health principles
Themes
Illustrators
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
•
9. Demonstrate nonjudgmental and unconditional acceptance of people different from self 10. Incorporate mental, physical, emotional, social, spiritual, and environmental aspects of health into assessment, planning, implementation, and evaluation 11. Demonstrate leadership in public health nursing with communities, systems, individuals, and families
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”
We honor beliefs of persons unlike ourselves through respect and professionalism
“Differences didn’t affect our relationship, if anything we learned from it.”
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.”
We were able to develop leadership skills by working independently in the public health nurse role
not stop trying” • “I“I did initiative” • “Attook • first I was unsure, but by
• •
positive health outcomes are shaped within the village. How the village can provide continuity and support for these important reciprocal student nurse-family relationships is another area for development. Student competency self-assessment is a viable method for evaluating clinical and teaching-learning outcomes. Strategies to practice competencies rely on integrative teaching-learning activities
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.”
(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 practicum 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
336
Public Health Nursing
Volume 32
Number 4
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 academicpractice partnerships intent on improving family and community health. Recruiting family participants, 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 potentiate collective synergy, helping to identify opportunities 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 student self-assessment. Faculty reviewing PHN entrylevel competencies with students and PHN preceptors 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-consuming faculty care coordination, and prepare students for communication and relationship development early in family visits. The village partnership relies on PHNs and faculty 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 competencies in analytic and assessment skills, policy development/program planning, communication, cultural competency, community dimensions of practice, public health science, financial management, 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 partnerships share the same standards, programs can be
July/August 2015
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 representation 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 relationship 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 investment 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 systems change. The 2012 Public Health Nurse Workforce survey 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 constructed 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.
Davis and Travers Gustafson: Village-Based Collaboration
Acknowledgments The authors acknowledge the Lincoln-Lancaster County Health Department public health nurses, Community Health Nursing faculty 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.
References Addy, S., & Wight, V. R. (2012). Basic facts about low-income children, 2010: Children under age 18. Retrieved from http:// www.nccp.org/publications/pdf/text_1049.pdf American Association of Colleges of Nursing [AACN] (2012). AACN & CDC Partner to advance the public health nursing workforce. Retrieved from http://www.aacn.nche.edu/news/articles/2012/cdc-public-health America’s children in brief: Key national indicators of well-being. (2012). Retrieved from http://www.childstats.gov/pdf/ ac2012/ac_12.pdf Aronson, R. E., Wallis, A. B., O’Campo, P. J., & Schafer, P. (2007). Neighborhood mapping and evaluation: A methodology for participatory community health initiatives. Maternal & Child Health Journal, 11(4), 373–383. Association of Community Health Nursing Educators [ACHNE] Research Committee (2010). Research priorities for Public Health Nursing. Public Health Nursing, 27(1), 94–100. Association of State and Territorial Health Officials. (2008). 2007 State Public Health Workforce Shortage Report. Retrieved from http://www.astho.org/Display/AssetDisplay.aspx? id=500 Azzi-Lessing, L. (2011). Home visitation programs: Critical issues and future directions. Early Childhood Research Quarterly, 26(4), 387–398. Benson, P. L., Leffert, N., Scales, P. C., & Blyth, D. A. (2012). Beyond the “Village” rhetoric: Creating healthy communities for children and adolescents. Applied Developmental Science, 16(1), 3–23. Callen, B., Block, D., Joyce, B., Lutz, J., Brown-Schott, N., & Smith, C. M. (2010). Essentials of baccalaureate nursing education for entry-level community/public health. Public Health Nursing, 27(4), 371–382. Carter, K. F., Kaiser, K. L., O’Hare, P., & Callister, L. C. (2006). Use of PHN competencies and ACHNE essentials to develop teaching-learning strategies for generalist C/PHN curricula. Public Health Nursing, 23(2), 146–160. Centers for Disease Control and Prevention [CDC]. (2012). Health impact assessment. Retrieved from http://www.cdc.gov/ healthyplaces/hia.htm Collier, J., Davidson, G., Allen, C. B., Dieckmann, J., Hoke, M. M., & Sawaya, M. A. (2010). Academic faculty qualifications for community/public health nursing: An association of community health nursing educator’s position paper. Public Health Nursing, 27(1), 89–93. Creswell, J. W. (2014). Research design: Qualitative, quantitative and mixed methods approaches. [ISBN-10 1452226105] Thousand Oaks, CA: Sage Publications. DeGuzman, P. B., & Kulbok, P. A. (2012). Changing health outcomes of vulnerable populations through nursing’s influence on neighborhood built environment: A framework for nursing research. Journal of Nursing Scholarship, 44(4), 341–348. Dodge, K., & Goodman, B. (2012). Durham connects impact evaluation executive summary Pew Center on the States. Retrieved from www.pewstates.org/. . ./PCS. . ./Durham_Connects_executive_summary.pdf Foundation for Child Development (2011). Child and youth wellbeing index. Retrieved from http://fcd-us.org/sites/default/ files/FINAL%20CWI%20Report.pdf
337
Grimes, D. E., & Weller, N. F. (2012). Evaluating populations and population health. In J. V. Hickey & C. A. Brosnan (Eds.), Evaluation of health care quality in advanced practice nursing [ISBN-10: 0826107664] (1st ed., pp. 159–176). New York: Springer Publishing Company. Healey, J. G. (1998). African Proverb of the Month November, 1998. Retrieved from http://www.afriprov.org/index.php/ african-proverb-of-the-month/23-1998proverbs/137-November-1998-proverb.html Health Resources and Services Administration [HRSA] - U.S. Department of Health and Human Services (2013). Maternal, infant, and early childhood home visiting program. Retrieved from http://mchb.hrsa.gov/programs/homevisiting/ Healthy People 2020. (2011). Early and middle childhood. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=10 Howard, K. S., & Brooks-Gunn, J. (2009). The role of home-visiting programs in preventing child abuse and neglect. Future of Children, 19(2), 119–146. Institute of Medicine [IOM] (2011). The future of nursing: Leading change, advancing health. Retrieved from http://thefutureofnursing.org/IOM-Report Issel, L. M., Bekemeier, B., & Kneipp, S. (2012). A public health nursing research agenda. Public Health Nursing, 29(4), 330–342. Keller, L. O., Garrett, T., & Drehobl, P. (2011a). Public health nursing: Transforming health across populations. The future of nursing: Leading change, advancing health. (Institute of Medicine). Washington, DC: The National Academies Press. Keller, L. O., Schaffer, M. A., Schoon, P. M., Brueshoff, B., & Jost, R. (2011b). Finding common ground in public health nursing education and practice. Public Health Nursing, 28(3), 261–270. Kitzman, H. J., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., et al. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a random trial among children at age 12 years. Archives of Pediatric Adolescent Medicine, 164(5), 412–418. Kulbok, P. A., Thatcher, E., Park, E., & Meszaros, P. S. (2012). Evolving public health nursing roles: Focus on community participatory health promotion and prevention. Online Journal of Issues in Nursing, 17(2), 1. McNaughton, D. B. (2004). Nurse home visits to maternal-child clients: A review of intervention research. Public Health Nursing, 21(3), 207–219. Melmed, M. E. (2009). Hearing on early childhood home visitation. Submitted to the subcommittee on income security and family support of the house committee on ways and means. Retrieved from http://main.zerotothree.org/site/DocServer/ Home_Visiting_06-09-09.pdf?docID=9001 National Association of County and City Health Officials. (2013). Health in all policies. Retrieved from http://www.naccho. org/topics/environmental/HiAP/ Nievar, M. A., Van Egeren, L. A., & Pollard, S. (2010). A metaanalysis of home visiting programs: Moderators of improvements in maternal behavior. Infant Mental Health Journal, 31(5), 499–520. Nurse-Family Partnership [NFP]. (2011). Evidence-based Public Policy. Retrieved from http://www.nursefamilypartnership. org/public-policy Nurse-Family Partnership [NFP]. (2013). Benefits and costs – A rigorously tested program with measureable results. Retrieved from http://www.nursefamilypartnership.org/assets/PDF/ Fact-sheets/NFP_Benefits-Cost Olds, D. L., Robinson, J. A., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., et al. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics. Retrieved from http://eorder. sheridan.com/3_0/app/orders/1546/article.php
338
Public Health Nursing
Volume 32
Number 4
Pew Charitable Trusts. (2013). Expanding home visiting research: New measures of success. Retrieved from www.pewstates. org/uploadedFiles/PCS. . ./HOME_Summit_Brief.pdf Quad Council Competencies. (2011). Quad Council Competencies for public health nurses – summer 2011. Retrieved from http://www.resourcenter.net/images/ACHNE/Files/QuadCouncilCompetenciesForPublicHealthNurses_Summer2011. pdf Rhyne, R., Bogue, R., Kukulka, G., & Fulmer, H. (1998). Community oriented primary care: Health care for the 21st century. Washington, DC: American Public Health Association. Robert Wood Johnson Foundation. (2011). Recession takes bite out of nation’s public health nursing infrastructure. Retrieved from http://www.rwjf.org/pr/product.jsp?id=73642 Savage, C., & Kub, J. (2009). Public Health and nursing: A natural partnership. International Journal of Environmental Research and Public Health, 6, 2843–2848. Schaffer, M. A., Cross, S., Keller, L. O., Nelson, P., Schoon, P. M., & Henton, P. (2011). The henry street consortium population-
July/August 2015
based competencies for educating public health nursing students. Public Health Nursing, 28(1), 78–90. University of Michigan Center of Excellence in Public Health Workforce Studies. (2013). Enumeration and characterization of the public health nurse workforce: Findings of the 2012 public health nurse workforce surveys. Ann Arbor, MI: University of Michigan. Retrieved from http://www.rwjf.org/ content/dam/farm/reports/reports/2013/rwjf406659 U.S. Department of Health and Human Services [USDHHS]. (2011). HHS action plan to reduce racial and ethnic disparities: A nation free of disparities in health and health care. Retrieved from http://minorityhealth.hhs.gov/npa/files/ Plans/HHS/HHS_Plan_complete.pdf Wade, G. H., & Hayes, E. (2010). Challenges and opportunities associated with preceptored community health clinical experiences. Public Health Nursing, 27(5), 459–467. Zandee, G., Bossenbroek, D., Friesen, M., Blech, K., & Engbers, R. (2010). Effectiveness of community health Worker/Nursing student teams as a strategy for public health nursing education. Public Health Nursing, 27(3), 277–284.
