Public Health Nursing Vol. 32 No. 2, pp. 169–176 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12131
SPECIAL FEATURES: EDUCATION
The Impact of the Care Equity Project with Community/Public Health Nursing Students Sylvia Kamau-Small, M.S.,1 Barbara Joyce, Ph.D., C.N.S., R.N.,2 Neysa Bermingham, B.A.,1 Jada Roberts, M.F.A., M.B.A., M.A.E.D./A.E.T.,1 and Curtis Robbins, M.A.1 1
Community and Local Government Relations, Kaiser Permanente Colorado, Denver, Colorado; and 2Beth-El School of Nursing, University of Colorado at Colorado Springs, Colorado Springs, Colorado Correspondence to: Sylvia Kamau-Small, Community Benefit, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237. E-mail: [email protected]
ABSTRACT Objective: The purpose of this article is to report on the evaluation process of a multi-disciplinary interactive teaching-learning workshop implemented in a college of nursing baccalaureate program. Design and Sample: A 6-hr workshop on cultural humility and care equity was implemented using educational theater to bring clinical situations involved in community/public health practice into the classroom. One hundred and forty-nine students participated in the workshop. Stages of Change (Prochaska and DiClemente [2005] Handbook of psychotherapy integration. New York: Oxford University Press) and the Learning Transfer Barriers Framework (Price, Miller, Rahm, Brace, & Larson [2010] Journal of Continuing Education in the Health Professions, 30, 237–245.) provided conceptual underpinnings for project evaluation. Measures: Nursing students completed a quiz, postworkshop online surveys at 2 and 8 weeks, and a clinical application report (CAR). Survey data provided information on barriers to the transfer of knowledge from theory class to the clinical setting. Qualitative methods were used to audit the CARs. Each CAR was independently reviewed to determine the Stage of Change reflected in the narrative. Results: Workshop evaluation outcomes provide evidence that cultural humility skill building has created behavior change in clinical practice for new health care community/public health nursing providers. Key words: barriers to change, care equity, community/public health nursing, cultural humility, interactive education, multi-disciplinary education, outcome evaluation, stages of change, theater health education.
Background A philosophic premise of public health practice is “health for all” and community/public health nursing competencies delineate a commitment to a social justice ethic of health care (American Public Health Association, 2014). Community/public health nurses assist clients to overcome barriers and connect with available resources. In order to be effective, nurses must continually engage in selfreflection to identify attitudes and behaviors that may influence care delivery, and promote advocacy and fairness in health care delivery. Preparing com-
munity/public health nursing students for attention to socioeconomic barriers that influence the nursepatient relationship through the use of educational theater in the cultural humility and care equity project provided the data for this project evaluation. The experiential learning model (Kolb, 1984) was used as a foundation to the development of the content related to cultural humility. Live theater and professional actors were used to inspire, motivate, generate curiosity, and address the concepts relevant to increase cultural humility. The project workshop contained content to encourage
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participants to recognize and consider the potential effect of snap judgment and first impressions (Gladwell, 2005) within clinical interactions and included modules that explored emotional skills of self-awareness, and willingness to learn (Meyer, 2006). The workshop incorporated live theater presentation, role playing, an interactive board game, and experiential activities that provided reflection on past socializing and influence on current practice and to address the idea of hospitality and its importance to building relationships. Group activities provided participants the opportunity to explore the effect of predisposed thinking, and how it shapes thoughts and beliefs. The long-term goal of the project workshop was to prepare nursing students to provide quality care to diverse community populations. In 2011, the United States experienced a 15.7% uninsured rate, 46 million people living in poverty, and 7.8% of people without jobs. These populations also experience disproportionately greater health disparities, or worse health outcomes, than those with greater financial means (The Annie E. Casey Foundation, 2013). Addressing the concept of patient advocacy to decrease health disparities and address health equity is an essential competency of community/public health nursing practice (Callen et al., 2009). Improved health professions education in cultural competency in baccalaureate nursing education has been identified as one of the critical and potentially most effective interventions to eliminate health care disparities (Calvillo et al., 2009). Several models of cultural competence (Campinha-Bacote, 2002; Leininger, 1985) provide theoretical underpinning to the essential content of community/public health practice. Cultural awareness and cultural humility (Campinha-Bacote, 2002; Tervalon & Murray-Garcia, 1998) involve the process of recognition of one’s biases, prejudices and assumptions about individuals who are different. Motivating the health care provider to want to engage in the process of becoming culturally aware, knowledgeable, and skillful is an important goal for undergraduate nursing programs and health service organizations.
Project objective The necessity for community/public health nursing educators to address diversity and social justice (Callen et al., 2009) provided faculty with the challenge
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of evaluating learning outcomes of instructional strategies. Evaluating change in nurses’ behavior facilitates understanding of program innovation and effectiveness, and provides data to strengthen community/public health nursing curriculum and health care delivery. The objectives of this project evaluation were to: evaluate identified barriers to change in health provider behavior, and to evaluate behavior change over the span of the semester. Prochaska and DiClemente (2005) describe a transtheoretical model of behavior change that assesses an individual’s readiness to act on a new healthier behavior. The stages of change are defined as precontemplation, contemplation, determination, action, maintenance, and relapse. The model provides strategies or processes of change to guide an individual through the behavior change process. The transtheoretical model has been most explicitly used with individual personal health behavior change. A unique aspect of the current project is the application of the stages of change framework to student behaviors as future health care providers. This project used the stages-of-change model to guide workshop development and implementation, and to examine behavior change that manifest cultural humility and the provision of equity in care. The stages of maintenance, relapse, and termination were not evident in the evaluation data; therefore, they will not be addressed in this manuscript. Table 1 defines each type of change and describes the objectives for creating change in individuals related to the content of cultural humility. Project goals and related evaluation strategies are depicted for each of the four stages of change in this project.
Methods The program In the spring semester of 2011, a pilot project was conducted with 32 nursing students. The project consisted of a 3-hr program, and students were asked to complete a 2- and 8-week post-project evaluation. The pilot also included a community debriefing of 12 stakeholders who participated in the workshop. The community stakeholder debriefing provided specific recommendations which included increasing the length of the workshop to 6 hr to allow for more role play experiences and increased time for student reflection.
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TABLE 1. Application of Stages of Readiness to Change to Project Stages of readiness to change Precontemplation
Contemplation
Determination
Action
Definition Not considering change
Ambivalent about change
Committed to change
Teaching objectives • Identify individual’s goals • Provide information • Bolster self-efficacy • Develop discrepancy between goal & behavior • Elicit self-motivational statements
• Strengthen commitment to change • Plan strategies for change
Involved in change • Identify and manage new barriers • Recognize relapse or impending relapse
Project objectives to achieve readiness stage Raise awareness and illuminate the social determinants that potentially affect health interactions Provide experiential learning activities using educational theater to increase cultural awareness, application of skill and cultural humility in health care delivery Uncover experiences to generate dialog and reflect on hospitality as a method to meet the needs of a diverse population Evaluate the impact of course content on participant knowledge and behavior
Project evaluation strategies • Quiz
• On-line Survey at 2 weeks post- workshop • Clinical Application Reports (CARs) • Clinical Application Reports (CARs)
• Clinical Application Reports (CARs) • Survey Questionnaire at 2 and 8 weeks postworkshop
The project consisted of four, 6-hr workshops conducted with senior level nursing students in fall 2011, spring, summer, and fall 2012. The project was substituted for the traditional essential didactic content on the relevance of culture and values for community/public health nursing practice (Callen et al., 2009; Maurer & Smith, 2012). Students participated in the project workshop which involved content, theater presentation, and simulation. Students were assigned readings prior to the workshop. The project was scheduled the first week of each semester. Although some key stakeholders participated in each workshop they did not participate in the evaluation project.
either the traditional or the accelerated baccalaureate nursing programs. The community/public health nursing course was 8-week, combined with hybrid-type instruction and traditional on-site lectures, online weekly quizzes, surveys, and clinical application reports (CARs). The course also involved course assignments related to specific course objectives and a 96-hr clinical practicum. Students were assigned clinical practicum, 2 days a week, approximately 15 hr per week in agencies working with the underinsured or uninsured. Each semester course enrollment ranged from 25 to 40 nursing students. The total sample for this project evaluation was 149 students.
Design and sample The target audience for this project consisted of undergraduate nursing students enrolled in a senior level community/public health nursing course in
Measures Traditional quizzes to evaluate knowledge, two online survey questionnaires to evaluate program effectiveness related to student intent-to-change
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behavior, and an audit of the CAR to evaluate behavior change provided instruments for data collection and data management. The Transfer Barrier Framework (Price, Miller, Rahm, Brace, & Larson, 2010) was used to identify and code barriers described by students in open-ended responses from the 2- and 8-week post- workshop surveys. The Stages of Change (Prochaska & DiClemente, 2005) was used as an audit tool to identify narrative statements that reflected the respective definition of the stage. Capturing the characteristics of cultural humility and provision of care equity was attempted by the use of mixed instrument evaluation that used qualitative methods such as CARs and traditional quantitative survey methods.
Quiz The 1-hr quiz included twelve multiple choice questions posted on-line at the end of the workshop. The quiz validated knowledge related to cultural competence, cultural assessment, health disparity, diversity, impact of poverty, social justice, and providing care to racially and ethnically diverse populations which was included in the total course grade. Postworkshop surveys Two required on-line surveys were used to evaluate nursing students’ learning from the project workshop. The project surveys were included in the learning assignments and pass/fail requirements of the clinical portion of the course. The first survey was due 2 weeks after the workshop. The second survey was due during the final week of the semester—8 weeks after the workshop. The questions used for the 2-week postsurvey were extrapolated from the Transfer Barriers Framework (Price et al., 2010):
• Do • • •
you feel the learning objectives for the program were met? What one to three things will you commit to putting into practice/work as a result of attending this workshop? What barriers do you perceive might impact your ability to make these desired changes? What was the most valuable part of this workshop?
The final survey was completed 8 weeks after the project workshop, after students had 7 weeks of
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clinical practicum to apply the content related to cultural humility and care equity. The survey questions were:
• From the learning at the project workshop, you •
indicated your intent to make a change(s) in your practice; what, if any, changes in your practice have you made? From your learning at the project workshop, have you identified any barriers in your practice or work that may have influenced your ability to make planned changes?
Clinical application report A course assignment included a weekly CAR. The CAR asked the students to apply knowledge from the didactic course lecture and teaching activities to their assigned practicum that week. The course included six CARs during the semester. A rubric was developed for the clinical instructor to use in grading the weekly CAR. The components of the grading rubric included quality, referencing literature, and higher level thinking with a fifty-point maximum grade. Each student earned a grade each week for application of content to their assigned clinical site or target population. The questions the students were asked to respond to on week-2 CARs were:
• Describe •
how you might use the information provided by the cultural humility and care equity workshop in working with your assigned populations Based on your experiences in the workshop, please identify your commitment to incorporate/ change into your practice
For the purposes of this evaluation project, only the CAR for week two was used for evaluation because the questions were specific to the workshop. All clinical instructors in the course submitted their students’ CARs for purposes of project outcome evaluation. Assigned grades, individual student, and instructor names were removed from the documents prior to project evaluation.
Analytic strategy A team-based approach to project evaluation with members from the health professional education institution and the health delivery organization was used to evaluate survey responses. Using the defini-
Kamau-Small et al.: Community/Public Health Nursing Practice tions of the Stages of Change (Prochaska & DiClemente, 2005) student narrative responses were assigned a stage of change. When categorizing qualitative narrative responses with the stages of change codes, the following categorization was used:
• Precontemplation: Narrative that provides broad
•
• •
or vague language about improving communication or continuing exposure to different community groups. Student identifies discrepancies between the expected or modeled behavior and their actual behavior. Contemplation: Narrative that provides language highlighting plans to change an existing practice to an improved practice, such as communication or open mindedness. Comments that refer to interaction with the patient that displays awareness and reflection, and/or self-motivational statements which allude to behavior change. Determination: Narrative that addresses detailed plans to incorporate or implement improvements in care for patients. Action: Narrative detailing active changes or improvements made in patient care during the clinical practicum (Prochaska & DiClemente, 2005).
Precontemplation and contemplation stages of change were identified by student comments that included sharing self-motivational statements, alluding to behavior change, identifying discrepancies between the expected or modeled behavior and their actual behavior. Precontemplation and contemplation stages were combined to document self-awareness. The descriptions and objectives in the stages of change for precontemplation and contemplation categories display change in thinking, thereby indicating increased awareness. The descriptions and objectives in the stages of change for precontemplation and contemplation categories display change in thinking but do not indicate change in action. Change in behavior during practicum was evaluated by students’ comments that indicate planning strategies for change or reporting taking actions to change. This reflects determination in readiness to change. Students that reported taking actions involving change during their practicum were categorized as behavior change.
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During survey evaluation, the narrative responses were also coded using the four BECT categories which included staff, organization, providers, time, and patient/members. Responses related to the category staff included references to barriers of staff knowledge, clinical skills and willingness of staff to engage. The category of organization referred to barriers reflected by comments related to policies, organizational structure and workload. The category provider was modified to include student provider and referenced comments regarding having the personal knowledge, training and experience to perform the tasks. The time category referred to having enough time to apply new concepts, new techniques or to practice new skills. The patient/member category included references to patients’ understanding and convictions about their own care, or patients’ complicated health conditions (Price et al., 2010). The evaluation team transferred qualitative responses to the respective category of the BECT instrument. The results were reported in the number of responses per category.
Clinical application report evaluation An audit tool was developed to facilitate review of each CAR. Each clinical report was reviewed and assigned a stage of change by a member of the evaluation team. Data analysis involved identifying key phrases or statements made by the student that corresponded with the project definitions of each stage of change. Phrases were highlighted or underlined. A team approach was then used for secondary review and to validate or confirm the initial stage of change assignment. Quotes were transferred onto the audit tool. The project team discussed any discrepancies to determine a consensus.
Results Quiz Raw scores were used to record quiz grades. Each student received a maximum score of twelve points on the diversity quiz which was included in total quiz grades for the course. Quiz grades accounted for 10% of the total course grade. As expected, due to the open book nature of the exam, grades on the Diversity Quiz were excellent, with 100% of the students receiving either eleven or twelve points on the quiz.
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Surveys Two weeks postworkshop, students identified specific aspects of the workshop that they found most valuable. Twenty-three percent rated the theater piece most valuable, followed by 22% who rated the interactive activities most valuable. Thirty-five percent of students identified valuable aspects of the workshop that did not fit within any of the other broad themes definable by the workshop content; these were labeled “other.” An example of a student’s response that was labeled “other” was: “Learning to be aware of personal biases affecting my care provided, the interactions, and challenges made by the presenters.” ~ Nursing student. The remaining 20% of students identified various other aspects of the workshop as most valuable. Behavior change results The 2-week post-survey indicated that 83% (N = 124) of the students indicated an increase in awareness (precontemplation and contemplation combined). Thirteen percent reported evidence of behavior change and 4% (N = 5) indicated a change in behavior. An example of a nursing student response that reflects change in awareness: is “I am more open minded and accepting of others’ opinions and suggestions.” At 8 weeks, post clinical practicum, 58% (N = 85) reported change in awareness and 28% (N = 42) reported change in behavior. Fourteen percent reported no change in behavior. An example of a survey response that reflected change in behavior: “I had previously formed a mental model that people in a community are unwilling to get involved and work together to fix a problem. Being aware of this mental model, my team put together a community health fair. I was shocked at how willing the community was to come together and help out. So, this program allowed me to be aware of my own mental models—but also be willing to change them.” ~ Nursing student. Change in behavior from the 2-week postworkshop to the 8-week postworkshop reflected an increase from 3% to 25% (N = 37). Barriers to change results Student responses that indicated a barrier to practice were coded using the BECT categories. At 2 weeks 76% (N = 113) reported barriers in the practice of the cultural and care equity content.
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Fifty-six percent (N = 83) of the students described student/provider barriers, 13% (N = 19) described organizational barriers and 7% (N = 11) described time barriers. No staff barriers were identified. Fifteen percent (N = 23) of students did not identify any barriers in practice of the cultural and care equity content. At 8 weeks, 59% (N = 81) reported student/ provider barriers. Twenty-nine percent (N = 39) described student/provider barriers which is reflected in this student statement “One of my barriers is the ability to relate to all my patients. Many patients are older, and it will be hard to understand their experiences.” Fourteen percent (N = 19) reported organizational barriers which is reflected in this student statement “the healthcare system itself causes many barriers.” Five percent (N = 7) reported barriers related to time as reflected in this specific student statement “not enough time available.” Seven percent (N = 10) reported patient/member barriers as reflected by this student statement: “. . .seeing patients that don’t care about their long term health.” Two percent (N = 3) reported staff barriers reflected in this statement: “ Some barriers I have come to face have been getting the full team on board and making sure everyone was following the plan as discussed.” Forty-one percent (N = 56) reported no barriers to changing behavior during the practicum. Therefore, after the workshop and practicum, there was a 26% (N = 33) change in students report of no barriers. This could be a reflection of the skills and tools from the workshop that they successfully incorporated into their practice, or a reflection of students’ over-confidence of their skill level.
Clinical application reports A total of 86 CARs were evaluated. In the CARs, precontemplation was described by 26% of students (n = 22) and identified by comments delineated in the definition of precontemplation. An example of a student quote that reflected precontemplation was: “Students working as community health nurses must approach each person as individuals.” Thirty-seven percent of students (n = 32) described statements that indicated contemplation and a beginning awareness of the need-to-change behavior. An example reflecting a student’s stage of contemplation to change their practice was: “Being
Kamau-Small et al.: Community/Public Health Nursing Practice able to work in these areas, allowed me to use communication skills, cultural competency skills and leadership and systems thinking.” Thirty-one percent of students’ (n = 27) comments reflected determination to make change in behavior: “The simple topics she brought up really had me reflecting on my own biases and personal opinions that I form about others in a ‘blink’ . . . I have become more aware of how this labeling is doing myself a disservice . . . I need to set a new goal for myself . . . be less judgmental, destroy my files, view patients as individuals.” Five students’ comments detailed action in changing behavior. An example of a student quote that reflected action was: “. . .the EMT I was working with didn’t seem interested in talking with this patient other than for his visit and his medication list. I noticed that spending a little time with this couple asking a few questions and listening to what they had to say made a difference to them. They were very thankful for the help I offered and even made a point to stop and thank me on the way out.”
Discussion Health care disparities and care inequity is a widely documented health care problem (Centers for Disease Control and Prevention-Division of Community Health, 2013; Cohen, Iton, Davis, & Rodriquez, 2009). Advocacy requires an application of the ethical principles, most specifically respect, fairness, and integrity. This cultural humility and care equity project represents the use of an overt activity and experience—educational theater—to change nursing student behavior with the long-term goal of modifying care of underserved and vulnerable populations. The evaluation project confirmed that barriers to change exist and are primarily (56%) provider/student related which lend to the importance of the provision of teaching-learning strategies to confront this health care problem. Evaluation results reflect the nursing students’ application of content, concepts, and tools provided in the project workshop into patient interactions during practicum. To our knowledge, this is the first project to use stages of change in evaluation of potential health provider (nursing student) behavior. Educational theater as a tool of emotional and cognitive reappraisal of values held by the nursing student in relation to provision of care was accepted. The
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results of this project evaluation indicated that the majority of student nurses (83%) reported increased awareness by week two. Contemplation was most frequently experienced (37%), demonstrating a beginning awareness of plans to change an existing practice with determination the second most frequently experienced type of change. Nursing students’ application of content, concepts, and tools provided in the workshop translated into positive patient interactions during practicum. Twenty-eight percent of respondents reported making change in behavior that was identified by a change or implementation of an action with a patient during practicum 8 weeks after attending the project workshops. Thirty-one percent of student narratives described actual improvements in care for patients, compared with 3% at week two. Student’s responses in the CARs results identified 26% precontemplation, which reflects the need for addressing continuity in changing behavior, and consideration for additional intervention to sustain behavior change. The process of change is a major dimension of the Transtheoretical Model that attempts to increase understanding of how shifts in behavior occur (Prochaska, DiClemente & Norcross, 1992). Part of the decision to change behavior and move from one stage to the next is based on the pros and cons of change. Use of the BECT to identify barriers to change was an initial attempt to identify negative factors (cons) influencing the ethical decisions that may influence practice of community/public health nursing practice. Transitions between stages of change need to be further evaluated with the use of the processes of change to quantify effective change. Particular methodological strengths of this work include the theoretical underpinnings and the quantitative and qualitative measures of evaluation. However, limitations of the project evaluation warrant consideration. First, the major limitation was the lack of a formal research design which limits the interpretation of results to the behavior of the cohort. While, one cannot say that there is an association between the project workshop and change in student behavior, participation in the workshop is suggestive of improvements in care for patients. Second, data were based on self-report. Future evaluations could be strengthened by comparing self-report results with the observations of external
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raters or clinical instructors. Including an interobserver reliability experience and relationship to grades on the CAR would add to the depth of evidence. The incorporation of preworkshop assessments to identify baselines, use of all of the weekly CAR report results to foster sustained change, and use of a 6-month postworkshop evaluation would add depth and validity to project evaluation. Assessment and consideration of how barriers influence change in clinical practice and the environment of health care delivery are important. This assessment lends itself to further evaluation to identify more opportunities for cultural humility skill building to elevate nursing practice further. The identified barriers to change results seemed to align more with internal student/provider barriers than external organizational or time-related factors, which provide rationale for continuing this education and intervention for impact on health care delivery. The arts, specifically theater as a change process, can have an impact on nursing students by providing opportunity to experience and express feelings, gain understanding, and support effective nursing interactions with increased empathy and compassion. Tracking and reporting outcomes of cultural humility and care equity education in the health care setting is a new area to explore. Nursing faculty and service providers should continue to work together to evaluate behavior change in order to target nursing practice outcomes that could potentially effect sustained change in behavior and health care delivery.
References American Public Health Association. (2014). About public health nursing: Member groups and affiliations section. Retrieved
March/April 2015 from http://www.apha.org/membergroups/sections/aphasections/phn/about/ Callen, B., Block, D., Joyce, B., Lutz, J., Schott, N. B., Smith, C. M., et al. (2009). Essentials of baccalaureate nursing education for entry level community/public health nursing. Retrieved from http://www.achne.org/files/EssentialsOfBaccalaureate_Fall_2009.pdf Calvillo, E., Clark, L., Ballantyne, J. E., Pacquiao, D., Purnell, L. D., & Villarruel, A. M. (2009). Cultural competency in baccalaureate nursing education. Transcultural Nursing Society, 20, 137–145. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Transcultural Nursing Society, 13, 181–184. Centers for Disease Control and Prevention-Division of Community Health. (2013). A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. Atlanta, GA: US Department of Health and Human Services. Cohen, L., Iton, A., Davis, R., & Rodriquez, S. (2009). A time of opportunity: Local solutions to reduce inequities in health and safety. San Francisco, CA: Prevention Institute. Gladwell, M. (2005). Blink: The power of thinking without thinking (1st ed.). New York: Little, Brown and Company. Kolb, D. A. (1984). Experimental learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall. Leininger, M. M. (1985). Transcultural care diversity and universality: A theory of nursing. Nursing and Health Care, 6, 208– 212. Maurer, F., & Smith, C. (2012). Community/public health nursing practice: Health for families and populations. (October) (5th ed.). St. Louis, MO: Elsevier. Meyer, D. (2006). Setting the table: The transforming power of hospitality in business. New York: Harper Collins. Price, D. W., Miller, E. K., Rahm, A. K., Brace, N. E., & Larson, R. S. (2010). Assessment of barriers to changing practice as CME outcomes. Journal of Continuing Education in the Health Professions, 30, 237–245. Prochaska, J. O., & DiClemente, C. C. (2005). The transtheoretical approach. In M. R. Goldfried (Ed.), Handbook of psychotherapy integration (2nd ed., pp. 147–171). New York: Oxford University Press. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. American Psychologist, 47, 1102–1114. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 118. The Annie E. Casey Foundation. (2013). Kids count. Retrieved from http://www.aecf.org/majorinitiatives/kidscount.aspx? rules=2
SPECIAL FEATURES: EDUCATION
The Impact of the Care Equity Project with Community/Public Health Nursing Students Sylvia Kamau-Small, M.S.,1 Barbara Joyce, Ph.D., C.N.S., R.N.,2 Neysa Bermingham, B.A.,1 Jada Roberts, M.F.A., M.B.A., M.A.E.D./A.E.T.,1 and Curtis Robbins, M.A.1 1
Community and Local Government Relations, Kaiser Permanente Colorado, Denver, Colorado; and 2Beth-El School of Nursing, University of Colorado at Colorado Springs, Colorado Springs, Colorado Correspondence to: Sylvia Kamau-Small, Community Benefit, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237. E-mail: [email protected]
ABSTRACT Objective: The purpose of this article is to report on the evaluation process of a multi-disciplinary interactive teaching-learning workshop implemented in a college of nursing baccalaureate program. Design and Sample: A 6-hr workshop on cultural humility and care equity was implemented using educational theater to bring clinical situations involved in community/public health practice into the classroom. One hundred and forty-nine students participated in the workshop. Stages of Change (Prochaska and DiClemente [2005] Handbook of psychotherapy integration. New York: Oxford University Press) and the Learning Transfer Barriers Framework (Price, Miller, Rahm, Brace, & Larson [2010] Journal of Continuing Education in the Health Professions, 30, 237–245.) provided conceptual underpinnings for project evaluation. Measures: Nursing students completed a quiz, postworkshop online surveys at 2 and 8 weeks, and a clinical application report (CAR). Survey data provided information on barriers to the transfer of knowledge from theory class to the clinical setting. Qualitative methods were used to audit the CARs. Each CAR was independently reviewed to determine the Stage of Change reflected in the narrative. Results: Workshop evaluation outcomes provide evidence that cultural humility skill building has created behavior change in clinical practice for new health care community/public health nursing providers. Key words: barriers to change, care equity, community/public health nursing, cultural humility, interactive education, multi-disciplinary education, outcome evaluation, stages of change, theater health education.
Background A philosophic premise of public health practice is “health for all” and community/public health nursing competencies delineate a commitment to a social justice ethic of health care (American Public Health Association, 2014). Community/public health nurses assist clients to overcome barriers and connect with available resources. In order to be effective, nurses must continually engage in selfreflection to identify attitudes and behaviors that may influence care delivery, and promote advocacy and fairness in health care delivery. Preparing com-
munity/public health nursing students for attention to socioeconomic barriers that influence the nursepatient relationship through the use of educational theater in the cultural humility and care equity project provided the data for this project evaluation. The experiential learning model (Kolb, 1984) was used as a foundation to the development of the content related to cultural humility. Live theater and professional actors were used to inspire, motivate, generate curiosity, and address the concepts relevant to increase cultural humility. The project workshop contained content to encourage
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participants to recognize and consider the potential effect of snap judgment and first impressions (Gladwell, 2005) within clinical interactions and included modules that explored emotional skills of self-awareness, and willingness to learn (Meyer, 2006). The workshop incorporated live theater presentation, role playing, an interactive board game, and experiential activities that provided reflection on past socializing and influence on current practice and to address the idea of hospitality and its importance to building relationships. Group activities provided participants the opportunity to explore the effect of predisposed thinking, and how it shapes thoughts and beliefs. The long-term goal of the project workshop was to prepare nursing students to provide quality care to diverse community populations. In 2011, the United States experienced a 15.7% uninsured rate, 46 million people living in poverty, and 7.8% of people without jobs. These populations also experience disproportionately greater health disparities, or worse health outcomes, than those with greater financial means (The Annie E. Casey Foundation, 2013). Addressing the concept of patient advocacy to decrease health disparities and address health equity is an essential competency of community/public health nursing practice (Callen et al., 2009). Improved health professions education in cultural competency in baccalaureate nursing education has been identified as one of the critical and potentially most effective interventions to eliminate health care disparities (Calvillo et al., 2009). Several models of cultural competence (Campinha-Bacote, 2002; Leininger, 1985) provide theoretical underpinning to the essential content of community/public health practice. Cultural awareness and cultural humility (Campinha-Bacote, 2002; Tervalon & Murray-Garcia, 1998) involve the process of recognition of one’s biases, prejudices and assumptions about individuals who are different. Motivating the health care provider to want to engage in the process of becoming culturally aware, knowledgeable, and skillful is an important goal for undergraduate nursing programs and health service organizations.
Project objective The necessity for community/public health nursing educators to address diversity and social justice (Callen et al., 2009) provided faculty with the challenge
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of evaluating learning outcomes of instructional strategies. Evaluating change in nurses’ behavior facilitates understanding of program innovation and effectiveness, and provides data to strengthen community/public health nursing curriculum and health care delivery. The objectives of this project evaluation were to: evaluate identified barriers to change in health provider behavior, and to evaluate behavior change over the span of the semester. Prochaska and DiClemente (2005) describe a transtheoretical model of behavior change that assesses an individual’s readiness to act on a new healthier behavior. The stages of change are defined as precontemplation, contemplation, determination, action, maintenance, and relapse. The model provides strategies or processes of change to guide an individual through the behavior change process. The transtheoretical model has been most explicitly used with individual personal health behavior change. A unique aspect of the current project is the application of the stages of change framework to student behaviors as future health care providers. This project used the stages-of-change model to guide workshop development and implementation, and to examine behavior change that manifest cultural humility and the provision of equity in care. The stages of maintenance, relapse, and termination were not evident in the evaluation data; therefore, they will not be addressed in this manuscript. Table 1 defines each type of change and describes the objectives for creating change in individuals related to the content of cultural humility. Project goals and related evaluation strategies are depicted for each of the four stages of change in this project.
Methods The program In the spring semester of 2011, a pilot project was conducted with 32 nursing students. The project consisted of a 3-hr program, and students were asked to complete a 2- and 8-week post-project evaluation. The pilot also included a community debriefing of 12 stakeholders who participated in the workshop. The community stakeholder debriefing provided specific recommendations which included increasing the length of the workshop to 6 hr to allow for more role play experiences and increased time for student reflection.
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TABLE 1. Application of Stages of Readiness to Change to Project Stages of readiness to change Precontemplation
Contemplation
Determination
Action
Definition Not considering change
Ambivalent about change
Committed to change
Teaching objectives • Identify individual’s goals • Provide information • Bolster self-efficacy • Develop discrepancy between goal & behavior • Elicit self-motivational statements
• Strengthen commitment to change • Plan strategies for change
Involved in change • Identify and manage new barriers • Recognize relapse or impending relapse
Project objectives to achieve readiness stage Raise awareness and illuminate the social determinants that potentially affect health interactions Provide experiential learning activities using educational theater to increase cultural awareness, application of skill and cultural humility in health care delivery Uncover experiences to generate dialog and reflect on hospitality as a method to meet the needs of a diverse population Evaluate the impact of course content on participant knowledge and behavior
Project evaluation strategies • Quiz
• On-line Survey at 2 weeks post- workshop • Clinical Application Reports (CARs) • Clinical Application Reports (CARs)
• Clinical Application Reports (CARs) • Survey Questionnaire at 2 and 8 weeks postworkshop
The project consisted of four, 6-hr workshops conducted with senior level nursing students in fall 2011, spring, summer, and fall 2012. The project was substituted for the traditional essential didactic content on the relevance of culture and values for community/public health nursing practice (Callen et al., 2009; Maurer & Smith, 2012). Students participated in the project workshop which involved content, theater presentation, and simulation. Students were assigned readings prior to the workshop. The project was scheduled the first week of each semester. Although some key stakeholders participated in each workshop they did not participate in the evaluation project.
either the traditional or the accelerated baccalaureate nursing programs. The community/public health nursing course was 8-week, combined with hybrid-type instruction and traditional on-site lectures, online weekly quizzes, surveys, and clinical application reports (CARs). The course also involved course assignments related to specific course objectives and a 96-hr clinical practicum. Students were assigned clinical practicum, 2 days a week, approximately 15 hr per week in agencies working with the underinsured or uninsured. Each semester course enrollment ranged from 25 to 40 nursing students. The total sample for this project evaluation was 149 students.
Design and sample The target audience for this project consisted of undergraduate nursing students enrolled in a senior level community/public health nursing course in
Measures Traditional quizzes to evaluate knowledge, two online survey questionnaires to evaluate program effectiveness related to student intent-to-change
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behavior, and an audit of the CAR to evaluate behavior change provided instruments for data collection and data management. The Transfer Barrier Framework (Price, Miller, Rahm, Brace, & Larson, 2010) was used to identify and code barriers described by students in open-ended responses from the 2- and 8-week post- workshop surveys. The Stages of Change (Prochaska & DiClemente, 2005) was used as an audit tool to identify narrative statements that reflected the respective definition of the stage. Capturing the characteristics of cultural humility and provision of care equity was attempted by the use of mixed instrument evaluation that used qualitative methods such as CARs and traditional quantitative survey methods.
Quiz The 1-hr quiz included twelve multiple choice questions posted on-line at the end of the workshop. The quiz validated knowledge related to cultural competence, cultural assessment, health disparity, diversity, impact of poverty, social justice, and providing care to racially and ethnically diverse populations which was included in the total course grade. Postworkshop surveys Two required on-line surveys were used to evaluate nursing students’ learning from the project workshop. The project surveys were included in the learning assignments and pass/fail requirements of the clinical portion of the course. The first survey was due 2 weeks after the workshop. The second survey was due during the final week of the semester—8 weeks after the workshop. The questions used for the 2-week postsurvey were extrapolated from the Transfer Barriers Framework (Price et al., 2010):
• Do • • •
you feel the learning objectives for the program were met? What one to three things will you commit to putting into practice/work as a result of attending this workshop? What barriers do you perceive might impact your ability to make these desired changes? What was the most valuable part of this workshop?
The final survey was completed 8 weeks after the project workshop, after students had 7 weeks of
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clinical practicum to apply the content related to cultural humility and care equity. The survey questions were:
• From the learning at the project workshop, you •
indicated your intent to make a change(s) in your practice; what, if any, changes in your practice have you made? From your learning at the project workshop, have you identified any barriers in your practice or work that may have influenced your ability to make planned changes?
Clinical application report A course assignment included a weekly CAR. The CAR asked the students to apply knowledge from the didactic course lecture and teaching activities to their assigned practicum that week. The course included six CARs during the semester. A rubric was developed for the clinical instructor to use in grading the weekly CAR. The components of the grading rubric included quality, referencing literature, and higher level thinking with a fifty-point maximum grade. Each student earned a grade each week for application of content to their assigned clinical site or target population. The questions the students were asked to respond to on week-2 CARs were:
• Describe •
how you might use the information provided by the cultural humility and care equity workshop in working with your assigned populations Based on your experiences in the workshop, please identify your commitment to incorporate/ change into your practice
For the purposes of this evaluation project, only the CAR for week two was used for evaluation because the questions were specific to the workshop. All clinical instructors in the course submitted their students’ CARs for purposes of project outcome evaluation. Assigned grades, individual student, and instructor names were removed from the documents prior to project evaluation.
Analytic strategy A team-based approach to project evaluation with members from the health professional education institution and the health delivery organization was used to evaluate survey responses. Using the defini-
Kamau-Small et al.: Community/Public Health Nursing Practice tions of the Stages of Change (Prochaska & DiClemente, 2005) student narrative responses were assigned a stage of change. When categorizing qualitative narrative responses with the stages of change codes, the following categorization was used:
• Precontemplation: Narrative that provides broad
•
• •
or vague language about improving communication or continuing exposure to different community groups. Student identifies discrepancies between the expected or modeled behavior and their actual behavior. Contemplation: Narrative that provides language highlighting plans to change an existing practice to an improved practice, such as communication or open mindedness. Comments that refer to interaction with the patient that displays awareness and reflection, and/or self-motivational statements which allude to behavior change. Determination: Narrative that addresses detailed plans to incorporate or implement improvements in care for patients. Action: Narrative detailing active changes or improvements made in patient care during the clinical practicum (Prochaska & DiClemente, 2005).
Precontemplation and contemplation stages of change were identified by student comments that included sharing self-motivational statements, alluding to behavior change, identifying discrepancies between the expected or modeled behavior and their actual behavior. Precontemplation and contemplation stages were combined to document self-awareness. The descriptions and objectives in the stages of change for precontemplation and contemplation categories display change in thinking, thereby indicating increased awareness. The descriptions and objectives in the stages of change for precontemplation and contemplation categories display change in thinking but do not indicate change in action. Change in behavior during practicum was evaluated by students’ comments that indicate planning strategies for change or reporting taking actions to change. This reflects determination in readiness to change. Students that reported taking actions involving change during their practicum were categorized as behavior change.
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During survey evaluation, the narrative responses were also coded using the four BECT categories which included staff, organization, providers, time, and patient/members. Responses related to the category staff included references to barriers of staff knowledge, clinical skills and willingness of staff to engage. The category of organization referred to barriers reflected by comments related to policies, organizational structure and workload. The category provider was modified to include student provider and referenced comments regarding having the personal knowledge, training and experience to perform the tasks. The time category referred to having enough time to apply new concepts, new techniques or to practice new skills. The patient/member category included references to patients’ understanding and convictions about their own care, or patients’ complicated health conditions (Price et al., 2010). The evaluation team transferred qualitative responses to the respective category of the BECT instrument. The results were reported in the number of responses per category.
Clinical application report evaluation An audit tool was developed to facilitate review of each CAR. Each clinical report was reviewed and assigned a stage of change by a member of the evaluation team. Data analysis involved identifying key phrases or statements made by the student that corresponded with the project definitions of each stage of change. Phrases were highlighted or underlined. A team approach was then used for secondary review and to validate or confirm the initial stage of change assignment. Quotes were transferred onto the audit tool. The project team discussed any discrepancies to determine a consensus.
Results Quiz Raw scores were used to record quiz grades. Each student received a maximum score of twelve points on the diversity quiz which was included in total quiz grades for the course. Quiz grades accounted for 10% of the total course grade. As expected, due to the open book nature of the exam, grades on the Diversity Quiz were excellent, with 100% of the students receiving either eleven or twelve points on the quiz.
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Surveys Two weeks postworkshop, students identified specific aspects of the workshop that they found most valuable. Twenty-three percent rated the theater piece most valuable, followed by 22% who rated the interactive activities most valuable. Thirty-five percent of students identified valuable aspects of the workshop that did not fit within any of the other broad themes definable by the workshop content; these were labeled “other.” An example of a student’s response that was labeled “other” was: “Learning to be aware of personal biases affecting my care provided, the interactions, and challenges made by the presenters.” ~ Nursing student. The remaining 20% of students identified various other aspects of the workshop as most valuable. Behavior change results The 2-week post-survey indicated that 83% (N = 124) of the students indicated an increase in awareness (precontemplation and contemplation combined). Thirteen percent reported evidence of behavior change and 4% (N = 5) indicated a change in behavior. An example of a nursing student response that reflects change in awareness: is “I am more open minded and accepting of others’ opinions and suggestions.” At 8 weeks, post clinical practicum, 58% (N = 85) reported change in awareness and 28% (N = 42) reported change in behavior. Fourteen percent reported no change in behavior. An example of a survey response that reflected change in behavior: “I had previously formed a mental model that people in a community are unwilling to get involved and work together to fix a problem. Being aware of this mental model, my team put together a community health fair. I was shocked at how willing the community was to come together and help out. So, this program allowed me to be aware of my own mental models—but also be willing to change them.” ~ Nursing student. Change in behavior from the 2-week postworkshop to the 8-week postworkshop reflected an increase from 3% to 25% (N = 37). Barriers to change results Student responses that indicated a barrier to practice were coded using the BECT categories. At 2 weeks 76% (N = 113) reported barriers in the practice of the cultural and care equity content.
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Fifty-six percent (N = 83) of the students described student/provider barriers, 13% (N = 19) described organizational barriers and 7% (N = 11) described time barriers. No staff barriers were identified. Fifteen percent (N = 23) of students did not identify any barriers in practice of the cultural and care equity content. At 8 weeks, 59% (N = 81) reported student/ provider barriers. Twenty-nine percent (N = 39) described student/provider barriers which is reflected in this student statement “One of my barriers is the ability to relate to all my patients. Many patients are older, and it will be hard to understand their experiences.” Fourteen percent (N = 19) reported organizational barriers which is reflected in this student statement “the healthcare system itself causes many barriers.” Five percent (N = 7) reported barriers related to time as reflected in this specific student statement “not enough time available.” Seven percent (N = 10) reported patient/member barriers as reflected by this student statement: “. . .seeing patients that don’t care about their long term health.” Two percent (N = 3) reported staff barriers reflected in this statement: “ Some barriers I have come to face have been getting the full team on board and making sure everyone was following the plan as discussed.” Forty-one percent (N = 56) reported no barriers to changing behavior during the practicum. Therefore, after the workshop and practicum, there was a 26% (N = 33) change in students report of no barriers. This could be a reflection of the skills and tools from the workshop that they successfully incorporated into their practice, or a reflection of students’ over-confidence of their skill level.
Clinical application reports A total of 86 CARs were evaluated. In the CARs, precontemplation was described by 26% of students (n = 22) and identified by comments delineated in the definition of precontemplation. An example of a student quote that reflected precontemplation was: “Students working as community health nurses must approach each person as individuals.” Thirty-seven percent of students (n = 32) described statements that indicated contemplation and a beginning awareness of the need-to-change behavior. An example reflecting a student’s stage of contemplation to change their practice was: “Being
Kamau-Small et al.: Community/Public Health Nursing Practice able to work in these areas, allowed me to use communication skills, cultural competency skills and leadership and systems thinking.” Thirty-one percent of students’ (n = 27) comments reflected determination to make change in behavior: “The simple topics she brought up really had me reflecting on my own biases and personal opinions that I form about others in a ‘blink’ . . . I have become more aware of how this labeling is doing myself a disservice . . . I need to set a new goal for myself . . . be less judgmental, destroy my files, view patients as individuals.” Five students’ comments detailed action in changing behavior. An example of a student quote that reflected action was: “. . .the EMT I was working with didn’t seem interested in talking with this patient other than for his visit and his medication list. I noticed that spending a little time with this couple asking a few questions and listening to what they had to say made a difference to them. They were very thankful for the help I offered and even made a point to stop and thank me on the way out.”
Discussion Health care disparities and care inequity is a widely documented health care problem (Centers for Disease Control and Prevention-Division of Community Health, 2013; Cohen, Iton, Davis, & Rodriquez, 2009). Advocacy requires an application of the ethical principles, most specifically respect, fairness, and integrity. This cultural humility and care equity project represents the use of an overt activity and experience—educational theater—to change nursing student behavior with the long-term goal of modifying care of underserved and vulnerable populations. The evaluation project confirmed that barriers to change exist and are primarily (56%) provider/student related which lend to the importance of the provision of teaching-learning strategies to confront this health care problem. Evaluation results reflect the nursing students’ application of content, concepts, and tools provided in the project workshop into patient interactions during practicum. To our knowledge, this is the first project to use stages of change in evaluation of potential health provider (nursing student) behavior. Educational theater as a tool of emotional and cognitive reappraisal of values held by the nursing student in relation to provision of care was accepted. The
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results of this project evaluation indicated that the majority of student nurses (83%) reported increased awareness by week two. Contemplation was most frequently experienced (37%), demonstrating a beginning awareness of plans to change an existing practice with determination the second most frequently experienced type of change. Nursing students’ application of content, concepts, and tools provided in the workshop translated into positive patient interactions during practicum. Twenty-eight percent of respondents reported making change in behavior that was identified by a change or implementation of an action with a patient during practicum 8 weeks after attending the project workshops. Thirty-one percent of student narratives described actual improvements in care for patients, compared with 3% at week two. Student’s responses in the CARs results identified 26% precontemplation, which reflects the need for addressing continuity in changing behavior, and consideration for additional intervention to sustain behavior change. The process of change is a major dimension of the Transtheoretical Model that attempts to increase understanding of how shifts in behavior occur (Prochaska, DiClemente & Norcross, 1992). Part of the decision to change behavior and move from one stage to the next is based on the pros and cons of change. Use of the BECT to identify barriers to change was an initial attempt to identify negative factors (cons) influencing the ethical decisions that may influence practice of community/public health nursing practice. Transitions between stages of change need to be further evaluated with the use of the processes of change to quantify effective change. Particular methodological strengths of this work include the theoretical underpinnings and the quantitative and qualitative measures of evaluation. However, limitations of the project evaluation warrant consideration. First, the major limitation was the lack of a formal research design which limits the interpretation of results to the behavior of the cohort. While, one cannot say that there is an association between the project workshop and change in student behavior, participation in the workshop is suggestive of improvements in care for patients. Second, data were based on self-report. Future evaluations could be strengthened by comparing self-report results with the observations of external
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raters or clinical instructors. Including an interobserver reliability experience and relationship to grades on the CAR would add to the depth of evidence. The incorporation of preworkshop assessments to identify baselines, use of all of the weekly CAR report results to foster sustained change, and use of a 6-month postworkshop evaluation would add depth and validity to project evaluation. Assessment and consideration of how barriers influence change in clinical practice and the environment of health care delivery are important. This assessment lends itself to further evaluation to identify more opportunities for cultural humility skill building to elevate nursing practice further. The identified barriers to change results seemed to align more with internal student/provider barriers than external organizational or time-related factors, which provide rationale for continuing this education and intervention for impact on health care delivery. The arts, specifically theater as a change process, can have an impact on nursing students by providing opportunity to experience and express feelings, gain understanding, and support effective nursing interactions with increased empathy and compassion. Tracking and reporting outcomes of cultural humility and care equity education in the health care setting is a new area to explore. Nursing faculty and service providers should continue to work together to evaluate behavior change in order to target nursing practice outcomes that could potentially effect sustained change in behavior and health care delivery.
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