Healthy Neighborhood Healthy Heart Initiative (Healthy Heart) is a collaborative service learning experience to address identified health concerns of neighborhood residents. Healthy Heart is a collaborative program of Cuyahoga Community College (CCC) Nursing Education Department, Saint Vincent Charity Hospital (SVCH) Community Outreach Department, and five low-income urban apartment complexes. The program utilizes service learning framework and coalition building. As a result, academic institutions, agencies, target populations, and the community as a whole are positively impacted and collaborate in the experience. The goals of the initiative are to:
- Empower individuals, families, and groups to make informed health care decisions based on screening results
- Sensitize students to the health concerns of a multicultural community
- Promote community-based practice aimed at addressing unmet, identified health concerns
- Create a sustainable community partnership.
Healthy Neighborhood Partnership is designed to fulfill the mission of CCC to be an active partner in the life of the community by providing disease prevention and health promotion screening and health teaching for a low-income, urban, and primarily gerontology population. Students, under the supervision of a CCC Nursing Department faculty member, perform one-on-one health assessments, health histories, medication review, and self-care assessments. Students also develop, implement and evaluate health education and exercise activities, as well as encourage health promotion goal identification. Students provide screenings for blood pressure, glucose monitoring, testing for cholesterol, and prostate specific antigen (PSA). Referrals are made as appropriate. Students develop, implement, and evaluate health education directed towards reduction of risk factors for stroke, heart disease, hypertension, and diabetes. Health promotion activities are focused on personal and goals identified and prioritized by participants attending the Healthy Heart visits.
Building the Bridge with the Community
In 1996, CCC formed Healthy Neighborhood Partnership, which initially focused on vision and hearing screenings, height and weight measurements, growth and development screenings, immunization record screening, and temperature, pulse, blood pressure, and respiration monitoring to children ages 2-6 at urban day care centers. Adults accompanying the children are offered blood pressure screenings and nutrition information. The program has focused on screening of children, and instruction and screening of parents. In 2000, the Department of Nursing of CCC with the Community Outreach department of SVCH piloted Healthy Neighborhood Healthy Heart as a collaborative pilot with several high rise and apartment complex residences of low income and primarily gerontology population, many with mental health concerns.
Needs assessments included results of surveys and focus groups with residents as well as analyses of key informant interviews of resident council representatives, health professionals, resident directors, and social workers. The needs assessments indicated a disease prevention and health promotion focus on the major conditions of heart disease, hypertension, arthritis, lung disease, stroke, and diabetes mellitus. Three consulting agencies included the Northeast Ohio Division of the American Heart Association (AHA), the Center for Healthy Communities Professions, Service Learning Service Midwest Consortium, and the National Community Campus Partnerships for Health.
A pilot project of eight students was initiated for two semesters under the direction of a CCC faculty member. Service learning objectives were determined by residents, residence directors, nursing students, nursing faculty, and Saint Vincent Community Outreach staff. The learning objectives, service objectives, and service learning objectives are summarized on the following table:
|Learning Objective||Service Objective||Service Learning Objective|
|1. Second semester nursing students require clinical experience in addressing disease prevention for chronic conditions in the community.||Residents require regular screenings and referrals for chronic conditions.||Second semester nursing students will provide residents with regular screenings and referrals for chronic conditions|
|2. Second semester nursing students require a clinical experience to sensitize them to a multicultural community.||Residents require consistent attention to multifaceted and unmet health and social needs.||Second semester students will identify and address the multifaceted health and social needs of residents.|
|3. Second semester nursing students require a clinical experience providing health promotion activities.||Residents require empowerment in, knowledge of, and resources for self-care.||Second semester nursing students will provide residents with health education, disease prevention, and health promotion materials and resources.|
Self-assessments and reflections from students indicated that the community experience was valuable as an adjunct to the community health theory course. Reflections from the students included:
- ‘I like this form of nursing. I think this is what I want to do.’
- ‘It’s one thing to read about these problems in the text; it really makes it come alive to work with people on their own turf.’
Following the pilot project, the Healthy Heart Initiative was then incorporated into the nursing curriculum and has continued to expand to screenings at other inner city sites, health fairs, and community centers. Five urban community resident sites include Cedar Extension, Lupica Towers, Garden Valley Neighborhood Center, Phyllis Wheatley, and Arbor Park. An average of twenty residents participates in each session.
As of February 2004, Healthy Heart has engaged over 500 associate degree nursing students in the service learning experience. Total resident participation as of May 2003 was 522. Over 80 percent of the resident participants attend the screenings and health promotion activities on a regular basis. The age distribution is: 26 residents between ages 18-29; 148 residents between ages 30-49; 157 residents between ages 50-64; and 107 residents over 65. Thirty-five medical referrals have been made to SVCH services, local physicians, and community health clinics. In thirty referrals, the resident followed through with the appointment. In five referrals, residents did not follow through with the appointment. Over 100 influenza vaccinations have been administered to residents. Students also provide health education and promotion activities which include the following topics: senior safety, cancer prevention, osteoporosis, diabetic diet, healthy foods, smoking cessation, reading food labels related to low sodium diets, cholesterol, and exercise (specifically chair exercises).
Bridging Classroom to Community Civic Commitment
The connection from classroom theory to civic commitment is bridged by introducing CCC Associate Degree Nursing students to the healthcare needs of the community surrounding the college campus located in the inner city. Theory to clinical practice, clinical practice to reflection, reflection to increased understanding and awareness of community healthcare needs, and initial commitment to community involvement are integral to CCC Community Service Learning project. Theory is taught in a Community Health Course, a one-credit course in our curriculum, available in the classroom or on the Web. Students learn basic concepts of Community Nursing, which includes the community environment, community healthcare needs, cultural and socioeconomic aspects. In addition to lectures, students work in small groups completing a required project based on community healthcare needs. A specific aspect of community healthcare needs, i.e. aging population, drug abuse, teen pregnancy, obesity and socioeconomic impacts on health care are topics presented to peers through a teaching project. Classroom presentations to peers complete the theory component. Teaching methods, which include PowerPoint presentations, poster displays, and design and use of printed materials are used by the students to facilitate their teaching projects. Lively group discussions enhance student engagement and contribute much to the learning process.
The clinical component is a two-day, ten-hour experience, provided during a twelve-week clinical rotation in the first semester medical-surgical course. Clinical practice begins with an orientation process, which is held at our collaborating hospital. This two-hour orientation presented by our multidisciplinary team introduces the student to the healthcare needs, cultural, socioeconomic, and environmental factors that make up the population served.
Students are addressed as team members providing health screenings to this specific community. Their role is valued as a vital part of the team. Most important in this orientation process is to refocus the students to an increasing self-awareness of their values, strengths, cultural preconceptions and awareness of the difference in approach from hospital to community. The community setting provides a slower pace and an opportunity with more time to establish rapport, and learn the ‘story’ of each individual client through use of communication skills, flexibility and adapting to a community environment through translating the task skills from the hospital to each different unique environment are requirements for a successful experience.
The Clinical instructors’ role is integral to successful student outcomes. Addressing each student as a team member, collaborating with each student, ‘coaching’ vs. ‘leading’ provide a supportive and safe environment conducive to learning. As students use communication skills to establish rapport with clients, the instructor establishes rapport with each student. Communication skills, positive affirmation, and providing timely feedback with cues to improving skills are key components of the instructors’ role. Role modeling behaviors that promote relationships with clients, supporting students in a positive way, and facilitating students to be creative are essential to the process.
Reflection begins at orientation with team members providing realistic scenarios and case studies that reflect clinical practice in the areas served. Students are encouraged to dialogue using their past experiences or knowledge of healthcare from clinical and/or lifestyle experiences. At the end of each clinical day we have a group reflection on the events, experiences, feelings, and any comments positive or negative are encouraged. The available social worker, nurse practitioner, health advocate, or personnel from the facility regularly attend and contribute to our group reflection.
A written clinical assignment that requires personal reflection and a self-evaluation are required. These assignments are discussed at the orientation, which provides students with the time to process and review the expected behaviors, prior to meeting with clients. Students establish rapport, and interact and review charts with their individual clients. Blood pressure, pulse, weight, glucose and cholesterol checks, and current health status and practices are completed and reviewed.
In this way, students gain knowledge of cultural, socioeconomic, and healthcare problems through interacting with their clients. Clients gain knowledge of diabetes, hypertension, cardiovascular risk factors, and health promotion from the students. Literature, pamphlets, flyers, and teaching projects based on health promotion are used to educate clients about wellness, or reduction of cardiovascular risk factors. Abnormal findings or concerns are referred to the instructor or social worker who follows-up and/or makes a referral. The student is encouraged and essentially becomes a client advocate. Increased awareness of community, healthcare obstacles, culture, and socioeconomic conditions are expressed by students in their personal reflections.
Some students plan to volunteer or work in the community post graduation. The following comments are just a sample reflecting the essence of student responses:
- ‘He was so excited to show me that he could get out of his wheelchair and exercise. Then I looked down at his feet. His shoes had a worn out sole and some laces [missing]. [I] couldn’t stop staring at those feet. I almost cried, yet he was so happy. I think about all the pairs of shoes I have, and he had one pair. There’s so many things I take for granted.’
- ‘Not every patient has money to take care of themselves properly. In most cases, it is not that the [patients don’t] want to eat healthy, or do not want to take their prescription medication, it is because they cannot afford to do these things.’
- ‘I learned not to pass judgment on people just because of the area in which they live. I was real apprehensive at first, but after meeting my first client and getting to know her, I realized these are just people too and they appreciated our help. They are good-hearted, caring individuals who are trying to make it like everyone else. I came out admiring their strength, I don’t know if I could make it in their shoes.’
- ‘Bring healthcare back to basics: a simple conversation between two people who have something to share with each other.’
- ‘I want to volunteer in a community outreach program when I graduate.’
- ‘Noncompliance of some is based on many obstacles they face, not laziness.’
- ‘I used the material I learned about diabetes and diet; hypertension among the African American population is a big issue’
- ‘This is the first time that I worked with the inner city population. I find that they are as health conscious as any of the populations, however, they lack the basic health knowledge in general; I met at least one person who has not visited a doctor’s office because of lack of insurance; I enjoy the feeling that there is no racial boundary between me and my clients.’
- ‘Just because a person is disadvantaged when it comes to healthcare does not mean they aren’t interested. I was able to teach someone about the meds they are taking’
- ‘It’s important to listen more to the clients instead of doing the questioning.’
Health screening in the inner city surrounding our Community College by Associate Degree Nursing students is the service learning bridge that connects theory to civic responsibility. Connecting theory to civic responsibility is a process facilitated through a collaborative effort with community agencies, a clinical instructor comfortable with assisting students to process experiences within a non-threatening environment, and a team that allows students to be creative and support each other as a team member. Reflection, as a group as well as personal reflection, is the vehicle that enables the process. Outcomes include increased self and community awareness, firsthand knowledge of community healthcare issues, importance of effective communication skills, identification of stereotyping and ethnocentrism, and experiencing the teaching-learning process mutually with their clients. Commitment to volunteer in the community as a registered nurse completes the bridging process from theory to civic responsibility.
About the Authors
Christine Beck, CRN, MSN/MA, CNS is an Assistant Professor of Nursing at Cuyahoga Community College teaching Community Health Nursing. She received the MSN/MA at Case Western Reserve University in Cleveland, Ohio. Ms. Beck has presented at both the eleventh and twelfth Campus Compact National Center for Community Colleges Annual National Conference and received the 2002 Frontiers in Nursing Award from the Ohio League for Nursing for innovative teaching in community health nursing. Contact Christine at email@example.com, or (216) 987-5235.
Joan Wiencek Knurek, RN, MSN,CNS is an Assistant Professor of Nursing at Cuyahoga Community College. She received the MSN from Medical College of Ohio in 1990. Ms. Wiencek Knurek’s current practice includes psychiatric nursing and as clinical instructor in community health, coordinating and supervising service learning experiences. Contact Joan at firstname.lastname@example.org, or (216) 987-5237.