Bautista, Jared Kenan C. BSN 4B www.medscape.

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Advanced Practice Nursing Education: Opening Doors to Community Collaboration

Marjorie D. Weiss, PhD, APNP; Karine Spiegel, PhD Posted: 05/03/2005; Topics in Advanced Practice Nursing eJournal. 2005;5(2) 2005 Medscape

Introduction
Our communities need nurse practitioners (NPs) to serve as leaders in health promotion. Too often, the perspective of local government and business leaders, the news media, and the public at-large is that NPs are "midlevel providers," busy staffing clinics and outpatient services in lieu of physicians. Rarely are NPs perceived as leaders in fostering the overall health of communities. News media personnel searching for "expert" opinions or insights on community health issues, therefore, are much more likely to turn to hospital administrators, prominent physicians, and managed care industry leaders than community NPs. Given that NPs represent a growing, cost-effective, highly efficient sector of healthcare professionals in the United States who also have both an expertise in health promotion and a unique focus on holism, preparing NPs for community roles seems natural as well as important. Nursing textbooks on community health, used by today's NP students, proclaim the value of the advanced practice nurse in promoting community health. In Wisconsin, students are exposed to politics, policy development, and political action through the Wisconsin Nursing Association (WNA), their course work, and their clinical experiences. Once the courses are completed, however, and NPs are certified and actively practicing, they quickly become inundated with the daily requirements of their new positions and often ignore the larger community focus. Nursing educators, nursing students, and nurses in traditional practice settings rarely have opportunities to interact with nurses involved in "nontraditional" practice settings such as schools and geriatric facilities like assisted living institutions. One way to start addressing the lack of visibility of NPs in the community is to develop strategies for enhancing community involvement during the educational process. In Wisconsin, public and private funders and policymakers are beginning to push the development of community/university partnerships, as well as the use of these partnerships in regional economic planning.[1] Community-campus partnerships are emerging as one way to encourage community involvement among the campus as a whole. The creation of community-campus relationships have been accelerated by incentives from organizations such as the Corporation for National and Community Service, the US Department of Housing and Urban Development Office of University partnerships, and various foundation program initiatives requiring collaborative approaches.[2] Grants provided collaboratively among Blue Cross-Blue Shield of Wisconsin, the University of Wisconsin, and the Medical College of Wisconsin serve as an example of this type of an initiative to link academic organizations to the community through community health research and practice. Many times, these partnerships are developed and fostered through medical schools and colleges of business and public administration, however, with little input and participation from nursing faculty. Institutional barriers related to tenure and promotion sometimes prevent faculty from electing to participate in community-based participatory research (CBPR).[3] Nursing faculty involvement in community service is not valued as highly as teaching and scholarship in decisions related to tenure and promotion. In addition, the amount of time required for clinical

supervision, maintenance of clinical competency, and teaching load often preclude involvement in community service.

Service-Learning
Service-learning is the link between educational organizations and the community. It engages students and faculty in community-identified concerns, connecting their academic coursework and research to roles in community service and citizenship. NP faculty and students learn to understand their role as a health professional and a citizen in a larger societal context.[4] Service-learning is becoming more prominent in both medical and nursing training programs. The integration of service-learning in NP graduate programs to enhance community visibility and promote potential community leadership roles can be accomplished in a number of ways, such as:

Involving NP and master's level nursing students in community assessment processes; Encouraging the development of team projects that provide a tangible community service product; Revising coursework to include active involvement in community health initiatives and local political health issues; Developing collaborative programs with other disciplines that promote the development of strategic planning, organizational behavior, leadership, marketing, cultural diversity, and communication courses; Promoting active involvement in community-based health outcomes measurement; and Fostering involvement and leadership in worksite/campus health promotion.

Involvement in Community Assessment/Resource Allocations

Involving students in CBPR can augment the community-campus partnership. More formal training in CBPR would be beneficial for both academically based researchers and community members.[5] Israel and colleagues identified key principles integral to the success of such research partnerships. [6] In order to promote CBPR, NPs need to integrate the following skills into practice:

Recognize community as a unit of identity; Discover the strengths and resources in a community; Facilitate collaboration; Address health issues from a variety of perspectives; and Commit to long-term involvement in community health promotion.

NP students can learn these principles through service-learning that is linked to community needs assessments. To accomplish this, nurse educators can contact organizations performing community needs assessment projects and offer to find students who might serve as representatives of the "college" community. Examples of organizations include the local United Way, Community Foundation, the Chamber of Commerce, or other "development" groups. Student participation in these community-based projects could be linked to research coursework. Students could also get involved by volunteering to serve on a local United Way allocations committee. Allocations discussions provide good insight into funding mechanisms for community

nonprofit organizations. As a byproduct of this activity, the student gains an appreciation of the scope of services available through the community's nonprofit agencies.

Tangible Community Service Through Meaningful Team Projects

Team projects are often developed as a component of expected coursework. By focusing the attention of the students on "real" vs "theoretical" team projects, the students develop planning, organizational, and communication skills that can be useful adjuncts for future practice. Previously at the University of Wisconsin, students in a clinical practice management course were required to develop a business plan for a "new venture" or new business product and present this to their peers. This year, the students will be taking on 3 community projects. They will work in teams to address "new business issues" for 2 community clinics for the underserved/uninsured and for an outreach program at a local emergency homeless shelter. Students in another course developed an educational outreach program for this emergency shelter, populated the "store front" windows of a local health department with health promotion messages, and developed a communications/marketing plan for the Hispanic community of one of the community clinics. To get students involved in these types of community collaborative activities, an instructor should:

Be well-versed in the needs of the community; Be aware of the activities and needs of the local nonprofit agencies; and Have good working relationships with directors and funders of local nonprofit agencies.

Active Involvement in Local Healthcare Politics

Most advanced practice nursing education programs provide course content in healthcare policy and politics. These courses provide a great opportunity for the advanced practice nursing student to develop an understanding and appreciation of the complexity of local healthcare politics by fostering active participation in political activities. Nurse educators need to link assignments to action. For example, students might be required to actively participate in antismoking activities, an environmental protection group, or a church-related coalition promoting treatment instead of prison for substance abuse arrests. Students can also be encouraged to get involved by writing letters to the local newspaper, legislators, and local politicians expressing their opinions on matters that affect the health of the community. Other issues that could spark political involvement include insufficient walking trails or biking paths, care for the uninsured in a community, stem-cell research, and prescription coverage for the elderly. Students need to be encouraged to first participate in community healthrelated activities and then link this participation to theory and research, analysis, and writing. The key to encouraging involvement in local politics is an instructor who firmly believes in the importance of local participation, models these activities, and can direct the students to community contacts to initiate involvement. Instructors who know their community and are aware of local politics can provide students with access to these learning experiences.

Collaborative Educational Efforts

To become effective community leaders in health promotion, NPs should get involved in educational programs that promote the development of skills required for success in this type of leadership role. Such skills include communication, leadership training, and "business" acumen. Advanced practice nurses and nursing leaders need to be savvy business people, well-schooled in strategic planning, marketing, finance, outcomes measurement, and organizational development. In addition, these nurses need to have a well-developed

appreciation for diversity, cultural implications of care, and the ability to communicate as effectively in the board room as in the exam room. Collaborative arrangements with other departments such as Business Administration, Public Policy Administration, and Epidemiology may enhance curriculum focused on community healthcare business skills. Diversity and cultural skill development could be enhanced by collaboration with a school for the Arts, Women's Studies, and multicultural groups within the educational organization and in the community. The key to collaborative education is systematically addressing the artificial "departmental" barriers that are inherent in educational organizations. Administration needs to provide the encouragement, time, and resources needed to promote collaborative approaches to advanced practice nursing and management education.

Involvement in Healthcare Outcomes Measurement and Management

In many communities, local healthcare providers are required to monitor and measure a variety of healthcare outcomes. Data collection for Health Plan Employer Data and Information Set (HEDIS) indicators, such as percent of diabetics receiving retinal exams, is common in most ambulatory care settings. Some physician groups have linked with local businesses to begin their own assessment of clinical outcomes and are publishing these for their community. The Wisconsin Collaborative for HealthCare Quality is involved in providing the community with comparisons of care among healthcare organizations.[7] These efforts will soon be expanded to individual physician outcomes. Ambulatory care settings provide many opportunities for involvement in practice-specific research and dissemination of findings for NP students and practicing NPs with a community focus.

Worksite/Campus Health Promotion

NPs, nurse educators, and nursing students should be leaders in worksite and campus health promotion efforts. Too often, we see human resource departments and physical education programs leading the way in worksite and student health promotion efforts. NPs and nurse managers should use their community health promotion skills at the worksite in planning efforts, serving on committees, and acting as a role model for peers and students. Effective worksite health promotion by NPs and nursing students requires:

Commitment from administration to make this a priority; A committed team of professionals representing all facets of the organization; Willingness to try new ways of promoting health; Modeling of good health practices; and Strategies for outcome measurement that quantify the effectiveness of health promotion efforts.

Advanced practice nurses and nursing managers should embrace health promotion efforts by their organization as an excellent opportunity to showcase the value that NPs and nursing managers bring to that organization. NP students should also be encouraged to get involved in campus health promotion efforts and to serve as student leaders in these efforts; for example, they can help organize "fun runs/walks," health promotion fairs, and health screening services.