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CHERYL W. THOMPSON, RN, DNP
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ANDJULIA A. BUCHER, RN, P
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The purpose of this article is to describe how community health competencies for baccalaureate nursing education have been met by locating clinical experiences in nurse-managed wellness centers. Such centers are an ideal setting for students to integrate theoretical concepts into clinical practice while building on previous learning. Students are able to develop skills in community health nursing practice at individual, family, and population level. In addition, the practice setting provides other advantages. Clients who represent a vulnerable population group receive valuable health services. Students gain learning opportunities that are broader than community health competencies, and faculty are provided clinical practice, research, and scholarship opportunities. The challenges to year-round sustainability of nurse-managed centers are burdensome; however, the benefits outweigh the difficulty of those challenges. (Index words: Community health nursing; Nurse-managed centers; Nurse managed wellness centers; Nursing education; Community/Public health nursing competencies; Clinical education) J Prof Nurs 29:155–162, 2013. © 2013 Elsevier Inc. All rights reserved.C
LINICAL EDUCATION IN nursing ideallyin-tegrates theoretical concepts in clinical practice settings. The Institute of Medicine (IOM, 2010) has emphasized the importance of enhancing nursing clinical education in community settings as a priority. However, obtaining adequate numbers of sites for this clinical education poses challenges for nurse educators (Wade & Hayes, 2010). The purpose of this article is to describe how public/community health nursing competencies for bac-calaureate nursing education have been met by locating clinical experiences in nurse-managed wellness centers (NMWCs). What began as an effort to create a clinical setting where these competencies could be met emerged as an opportunity that provided other advantages for clients, students, and faculty. These advantages outweigh the burdens brought on by maintaining NMWCs throughout semester breaks.
Community/Public Health Nursing in
Baccalaureate Education
In the United States, generalist nursing practice in community health is considered an integration of nursing and public health concepts. This practice is referred to as community/public health nursing (C/PHN), and a bache-lor's degree in nursing is the minimum practice require-ment (Association of Community Health Nurse Educators [ACHNE], 2010). Practice settings traditionally have been in public health or nonprofit visiting nurse associations. By the 1970s, when changes to Medicare reimbursement for home health services changed nursing practice in visiting nurse associations, C/PHN evolved to embrace a practice focus rather than a setting focus. The core competencies of C/PHN practice are based on a community or population focus and, as such, synthesize nursing and public health practice. The practice emphasizes health promotion and disease prevention for individuals, families, and commu-nities in settings that include public health, home health, schools, and industry. An underpinning of C/PHN practice is eliminating health disparities. Practice often focuses on vulnerable population groups (ACHNE, 2010). As with all areas of health care, evidence-based practice underlies C/PHN practice.
⁎Associate Professor, York College of Pennsylvania, York, PA. Address correspondence to Dr. Thompson: 1247 Water Street, Wrightsville, PA 17368. E-mail: cthompso@ycp.edu
8755-7223/12/$ - see front matter
Journal of Professional Nursing, Vol 29, No. 3 (May/June), 2013: pp 155–162 155
The guidelines for competencies in C/PHN education and practice are outlined by four official organizations: (a) theAACN (2008)Essentials of Baccalaureate Educa-tion for Professional Nursing Practice, (b) the American Nurses Association (2007) Public Health Nursing Scope and Standards of Practice, (c) theQuad Council of Public Health Nursing Organizations (2004), Quad Council Public Health Nursing Competencies, and (d) the ACHNE (2010) Essentials of Baccalaureate Nursing Education for Entry-Level Community/Public Health Nurs-ing. The ACHNE Essentials incorporate concepts and competencies related to community and population practice from each of the first three documents. As such, these provide the framework for development and evaluation of baccalaureate C/PHN course theory and clinical, and also, the template for describing student behavioral outcomes met in baccalaureate community health nursing clinical.
Community/Public Health Nursing Clinical
Traditionally, clinical education sites for C/PHN are located in clinics, school health units, public health departments, home health agencies, and other commu-nity-based agencies (ACHNE, 2010). Such sites offer opportunities for students to provide one-on-one care in addition to providing community or population-focused care. However, nurse educators struggle with challenges to obtaining clinical sites where students can integrate theoretical concepts related to C/PHN practice (Broussard, 2011; Carter, Kaiser, O'Hare, & Callister, 2006; Wade & Hayes, 2010). These challenges include the following:
1) Securing sites that accommodate groups of 8 to 10 students.
2) Accommodating increasing numbers of students.
3) Negotiating competition among schools for clinical placement.
4) Supervising students at multiple sites.
5) Obtaining clinical site preceptors who role model C/PHN practice competencies.
6) Obtaining practice settings with population-focused model.
Many of these challenges have been overcome in one school of nursing where student clinical is conducted in NMWCs.
Nurse-Managed Wellness Centers
NMWCs are a subset of nurse-managed centers (NMCs), where nurses provide and manage health services within a nursing framework rather than a traditional medical model of care (Hansen-Turton, Miller, & Greiner, 2009). What distinguishes NMCs from NMWCs is that NMCs provide primary care services that include diagnosis, treatment, and management of disease and illness by nurse practitioners and nurse midwives, whereas NMWCs primarily focus on health promotion, disease prevention, and wellness (National Nursing Centers Consortium, 2011). In NMWCs, nursing services include
health assessment, health education, goal setting, health coaching, and community resource referral and are provided at the individual, family, and population level (Hansen-Turton et al., 2009). Housed in schools, freestanding community centers, public housing, and workplaces (Bonney, Goetze-Bradley, & Rose, 2009; Campbell & Aday, 2001;Resick, Leonardo, Kruman, & Carlson, 2010; Turner & Stanhope, 2008), NMWCs typically serve vulnerable population groups.
The NMWCs described here are discrete sites located within public housing complexes. In each of these sites, one community health nursing faculty practices as the C/PHN clinician for the site, supervising wellness services provided by students to individuals, families, and populations within a defined public housing complex. The housing authority partners are willing to expand NMWCs into any low-income complexes they manage, so there are opportunities to develop more sites as student enrollment increases. Because the school of nursing operates the NMWC, there is no competition for the clinical site from other schools of nursing. Rather than rely on other nurse preceptors who may not be able to role model or articulate C/PHN practice, the commu-nity health faculty role model practice. Therefore, many of the challenges to providing community clinical sites that integrate C/PHN concepts are overcome by utilizing NMWCs for community health clinical (Table 1).
Meeting Community/Public Health Competencies
in NMWCs
Various descriptions of NMWCs in general can be found in the literature (Barkauskas et al., 2006; Bonney et al., 2009; King, 2008; Pohl, Barkauskas, Benkert, & Breer, 2007; Resick et al., 2010; Sherrod & Morrison, 2008), but these descriptions do not link the NMWC services to meeting C/PHN competencies within a baccalaureate curriculum. Clinical experiences that are similar to the NMWC services described here can be found. A population-focused wellness program for individuals with developmental disabilities through partnership with an agency that serves children and adults with disabilities is described byAiley and O'Rourke (2008). Individual wellness care provided by senior nursing students through partnership with the college's well-ness center is reported byAponte and Egues (2010). A senior-level practicum experience within a combined community/mental health nursing course where students coordinated community resources for population that have mental illness, are homeless, and are residing in single room occupancy (SRO) hotels is also reported (Lasater, Luce, Volpin, Terwilliger, & Wild, 2007).
Nurse-Managed Wellness Centers for Students at York College of Pennsylvania (YCP) a private, liberal arts college in south central Pennsylvania, community health nursing is a discrete six-credit course with 3-classroom hours and three credits of clinical hours. The theoretical and clinical learning objectives (Table 2) encompass ACHNE (2010) core values that include community/ population as client, prevention, partnership, healthy
environment, and diversity and ACHNE core knowl-edge basic competencies that include communication, epidemiology and biostatistics, community/population assessment, community/population planning, policy development, assurance, health promotion and illness reduction, disease management, information and health technology, environmental health, global health, ethics and social justice, coordinator and manager, and emergency preparedness, response, and recovery (ACHNE, 2010). The didactic course is 3 hours per week; the clinical is one 9-hour day per week over a 15-week semester. Each clinical faculty has as a minimum of a master's degree in nursing with C/PHN practice experience.
The first NMWC was opened in a public housing complex with a diverse, low-income population in 2001 in collaboration with the Housing Authority of York. The
project was funded by a 2000 U.S. Department of Housing and Urban Development Resident Services and Delivery Model (RSDM) Grant. The decision to provide wellness rather than primary care services was made for two reasons: at that time, YCP did not offer a nurse practitioner tract in the graduate program, and the community health needs assessment reflected that the housing complex residents had access to primary care. An apartment in the complex was taken off-line to provide space for the center, and year-round staffing was funded for thefirst 3 years by the RSDM grant. The YCP Department of Nursing funded clinical resources, supplies, and staffing for 1 day by a faculty member who practiced a dual role as faculty for eight community health nursing students and as C/PHN clinician for the center.
When it became apparent that the NMWC provided an opportunity for students to meet the community health nursing course clinical objectives, the NMWC model was expanded to other similarly populated public housing complexes, neighborhoods, and an SRO building so that an NMWC clinical would be available for every student enrolled in the course. As of the fall of 2010, clinical experiences are provided in eight NMWCs for 64 senior-level nursing students each semester.
In each NMWC, nursing care focuses on health promotion and disease prevention to individuals, families, and communities. Individual and family level care in-cludes health and physical assessments, fall risk, safety and other specific risk assessments, lifestyle and health behavior assessments, and cultural assessment. Individual care integrates previous content from foundational nursing courses that include human growth and develop-ment, pathophysiology, pharmacology, health assessdevelop-ment, nursing for individuals with chronic health conditions, nursing care for pediatrics, and nursing care for the childbearing woman. In the NMWC, clinical one-on-one care builds on previous learning while incorporating C/ PHN practice concepts related to health promotion and wellness within the context of chronic disease.
Health teaching is an important aspect of client care and includes information about proper use of medica-tions, disease self-management, health promotion, and disease prevention strategies. Students are able to see the Table 1. Overcoming Organizational Challenges to Community Health Nursing Clinical Placement
Existing challenges in academic programs Advantages of NMWC clinical placement
Securing sites that accommodate groups of 8 to 10 students
Group of eight students can be accommodated in one site Accommodating increasing number of students NMWC services or centers can be started in or expanded to new
neighborhoods and settings as course enrollment increases Negotiating competition among schools for
clinical placement
NMWC provide clinical placement for all students eliminating need for competing for community sites
Supervising students in multiple sites Faculty supervises in one NMWC site rather than traveling to multiple sites Obtaining clinical site preceptors who role
model C/PHN practice
Faculty serve as NMWC clinical site preceptor Obtaining practice settings with
population-focused practice model
Defined community/population allows students to apply community
health nursing process and implement health promotion/disease prevention intervention within defined NMWC aggregate
Table 2. Community Health Nursing Course Objectives
At the end of the semester student will be able to do the following:
1) Analyze the relationships among the environment, health care policy, health care system, genetics, and behavior in relationship to individual and population health.
2) Identify epidemiological concepts related to infectious diseases and their application through the nursing process and therapeutic interventions with diverse individuals, families, and populations across the lifespan.
3) Discuss selected chronic and acute health problems that include infectious diseases and health conditions that are prevalent in diverse populations across the lifespan.
4) Identify actual and potential health problems and health promotion/ disease prevention interventions directed toward individuals, families, and populations.
5) Apply the community nursing process with individual patients and with an aggregate in an NMWC.
6) Examine evidence-based practice interventions directed toward health promotion and disease prevention interventions. 7) Identify strategies for improving cultural competence in providing
nursing care to individuals, families, and populations.
8) Conduct risk assessment on individual and aggregate patients. 9) Collaborate with other health professionals, staff, student peers, and faculty to meet the needs of individual and aggregate patients.
157 CLINICAL COMPETENCIES
ACHNE core knowledge ACHNE basic competencies NMWC clinical activities
Community Utilizes appropriate media to disseminate health information Use print and electronic media, social gatekeepers, and community networks as sources to enhance client education
Communicates with linguistic and cultural sensitivity Create written materials to communicate NMWC activities such as blood pressure screening Communicates appropriately with clients of differing levels of health literacy
Utilize multiple resources (print, electronic, and media) for health education Provide individualized health education within continuous client relationship Epidemiology and biostatistics Identifies health related data, including aggregate level data, relevant to client situations Complete comprehensive community assessment that compares demographic
and epidemiologic data of NMWC aggregate, city, state, and national level data Evaluates the quality of data sources
Retrieve data from multiple sources Interprets basic health-related data
Interpret data to prioritize problems and plan interventions Uses health-related data to plan interventions
Community/Population assessment Uses community assessment data in the development of priorities, expected outcomes, and interventions
Use data from comprehensive community assessment to prioritize, plan, implement, and evaluate a community level intervention within the NMWC Identifies individuals, groups, communities, and/or populations with health needs
Community/Population planning Collaborates with appropriate participants in a community project Communicate with housing authority partners in prioritizing, planning, and implementing a community level intervention
Participates with community members and leaders in planning,
implementing, and evaluating health interventions Communicate client information to refer client needs to providers and other community agencies
Considers resources and budget in the planning and delivery of programs, policies, and services
Identify community resource accessibility when making referrals with clients Plans for process and outcome evaluation related to program,
policies, and services Identify and communicate resource gaps to community partners and planners Health promotion and risk reduction Assesses impact of culture on health-related practices and beliefs Incorporate cultural health assessment into nursing process with individuals,
families, and community client. Assesses health risks of individuals, families, communities, and populations
Complete a comprehensive community client assessment Initiates community partnerships for goal setting and planning,
implementing, and evaluating interventions Perform a holistic assessment of the individual client that includes spiritual, social, cultural, psychological, risk, and health assessment
Educates individuals, families, communities, and populations about health issues
Identify and incorporate health protective measures that improve client health Implements multilevel approaches for health promotion and risk reduction
Empowers clients to improve health
Illness and disease management Assesses health status of clients Use assessment findings to diagnose, plan, deliver, and evaluate evidence-based nursing interventions
Integrates knowledge of appropriate developmental theories into planning of interventions
Document individual, family, and community interventions. Implements appropriate nursing interventions
Documents care according to professional standards
Information and health care technology Uses computer for assessment and documentation of practice activities Use electronic reference resources to plan individual patient care
Uses the Internet to access assessment data and intervention resources Use Internet data sources to gather information for comprehensive community assessment Uses technology in community health interventions Utilize electronic resources to enhance community level intervention
Environmental health Conducts community, workplace, and home environmental assessment Conduct a windshield survey as part of the comprehensive community assessment
Includes environmental risk questions in health histories of individuals and families Incorporate environmental assessment as part of holistic assessment for individual, family, and aggregate Educates individuals, families, communities, and populations about environmental health and safety issues
Human diversity Discusses the interdependence of people, their cultures, and their spaces Discuss impact of poverty on health
Recognizes the impact of discrimination on health Discuss issues related to social justice for low-income individuals, families, and aggregate Ethics and social justice Uses ethic problem-solving strategies to address dilemmas related to
care of individuals, families, communities, and populations
Facilitate advocacy for filling service gaps that are identified in the community Assists clients in developing skills for self-advocacy
Fosters environments in which healthy lifestyle may be practiced Adheres to professional standards of community/public health practice Education committee of theACHNE (2010).
THOMPSO
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importance of thorough assessment and models of behavior change. Another common intervention is community resource referral to facilitate appropriate use of primary care and other health care and social service resources.
Individual visits take place in the NMWC space (off-line apartment or room) or in the client's home. Students are assigned individual clients, and the faculty supervises client care. When the family is the unit of care, home visits are conducted. Prior to home visits, students review the plan of care with the faculty. Aggregate interventions, such as blood pressure screening, exercise class, diabetes support group, and health fairs, are conducted in common areas in the buildings or in the neighborhoods. The greatest burden for maintaining NMWCs is eliminating service interruptions that occur when the college is not in session. As the NMWCs have expanded, the community health course coordinator has managed sustainability of NMWCs. This responsi-bility includes securing grant funding to support staffing by the faculty and paid student interns when the college is not in session.
Case Studies. The following case studies illustrate the care provided and clinical activities that meet ACHNE C/PHN competencies (Table 3).
Individual Level. JB is a 68-year-old African American male with chronic obstructive pulmonary disease, diabetes, and heart disease. He lives alone and has no family or social support. JB is obese and ambulates with a walker. He leaves his apartment for medical appoint-ments and relies on public transportation. Prior to the initiation of NMWC services, JB had periodic hospital-izations for pneumonia. When the NMWC services were established, the housing complex manager referred him for services. Upon initial assessment, it was clear that JB needed additional community resources, and the faculty assisted the student in making a referral to the Office of Aging for meals on homemaker services. Each week, the student conducts a home visit for assessment, which includes physical assessment, home safety evaluation, medication reconciliation, and socialization. The med-ication reconciliation has been instrumental in prevent-ing medication errors because JB's medication regimen was complex, and he frequently would “forget” or misplace his medications or check his blood sugar. After each home visit, the student reports visitfindings to the faculty. As needed, the faculty confirms physical assessment findings, and significant changes are reported to JB's primary care provider who has modified JB's medication regimen based on assessmentfindings. The student also incorporates health protective strate-gies for JB's care that includes identifying motivational strategies to promote behavior change related to managing his diabetes and losing weight. After 3 months of NMWC student care, JB improved his medication adherence and lost 5 lb. The students encouraged JB to participate in the exercise classes and diabetes support
group conducted by the NMWC students in his building. Through this, he has begun to socialize with several other residents in his building.
Family Level. A program offered through the NMWC is Asthma Safe Kids (ASKs) that provides home visits for assessment of asthma triggers in the home, teaching to the caregiver, and home products such as mattress covers and cleaning supplies (Bucher & Thompson, 2012). Students created and distributed flyers for the ASK program throughout the targeted NMWC neigh-borhood. Following receipt of theflyer, JR requested an ASK home visit. JR is a 40-year-old male who lives in a two-bedroom apartment with his 35-year-old girlfriend and her three children. Her 8-year-old son has been diagnosed with asthma and has had three asthma-related hospitalizations in the past year. However, he did not have follow-up care after these hospitalizations. The other children, a 4-year-old daughter and a 6-year-old son, do not have asthma and have not been receiving any health care. All three children share a bedroom. JR is disabled because of a back injury and has chronic pain. The student provided home visits with the ASK program focus and offered teaching on asthma self-care and reduction of triggers specific to the home assessment. JR and his girlfriend were motivated to make suggested changes and were willing to continue to receive visits for health assessment and teaching. The student taught JR about nonpharmacological interven-tions for pain relief and assisted him in developing a graduated exercise program to increase his strength and endurance. Information about health care resources for the children was provided, and the student facilitated referral to care for all three children.
Population Level. Each NMWC is located within a public housing apartment building, neighborhood housing complex, or SRO building; therefore, the population is discrete and easily identifiable. Population-focused in-terventions are regularly provided through the NMWCs, and these interventions also provide case-finding oppor-tunities. For example, routine blood pressure screening, an evidence-based intervention that improves outcomes for individuals with primary or secondary hypertension, is conducted at each NMWC. Students are guided by faculty to use blood pressure screening as a case-finding strategy for identifying individuals or families who would benefit from NMWC services and to develop communi-cation skills to explain NMWC services. In addition, appropriate assessment and referral is inherent in any screening intervention. Other population-focused in-terventions that are regularly conducted are exercise classes and diabetes support group. In addition, each NMWC student clinical group is assigned to work collaboratively to complete a community assessment of the housing complex population. Following the analysis of the assessment, the students identify a problem list and prioritize the problems. This is followed by literature reviews to identify evidence-based interventions for a selected problem, and each student group then works 159 CLINICAL COMPETENCIES
collaboratively to synthesize, plan, implement, and evaluate an evidence-based intervention.
The following case study illustrates a population-focused intervention:
The complex consists of three buildings, each with 90 apartments. Ninety-two percent of the residents are older than 60 years; the remaining 15% are disabled either with physical or with mental health disability. Forty two percent are African American, 31% are non-Hispanic Caucasian, 21% are Hispanic, and the remaining 3% describe other racial or ethnic background. The majority (90%) of the residents claim a household income of less than $10,000/year, and approximately 20% of the residents are either wheelchair bound or use assistive devices. The complex is located in an urban area, with access to public transportation. Community assessment data collection methods included windshield survey, informant interviews, and participant observation. The priority health problem was identified as depression. Students identified pet therapy inter-ventions that had been shown to decrease depres-sion and facilitated the incorporation of pet therapy into weekly blood pressure screenings. Participation in blood pressure screenings increased by 20%, and residents were noted to remain in the lobby for longer periods before, during, and after blood pressure screening.
Other Advantages of NMWCs as Clinical Sites
Advantages for Clients. Although development of the NMWCs had an education focus, the services provided are a benefit to the clients, who represent a vulnerable population group. Anecdotally, the housing authority partners have consistently expressed satisfaction with the NMWC services and reported that services promote independent living and decrease housing management casework service costs. The case studies are anecdotal depictions of improved health outcomes and appropriate utilization of health care resources that occur when NMWC services are provided. Quantitative data have been collected through a retrospective chart review and findings document improvement in the YCP NMWC patients' knowledge, behavior, and status related to health problems (Thompson, Monsen, Wanamaker, Augustyniak, & Thompson, 2012). These findings are consistent with patient outcomes reported in a similar NMWC at Duquesne University in Pittsburgh, PA (Resick et al., 2011).Advantages for Students. Both currently and historical-ly, YCP nursing students and the general student body at York College have lacked diversity. For the majority of students, cultural diversity has not been a part of their life experience. In the NMWCs, many nursing students have their first life experience working with diverse popula-tions and with individuals in poverty. For these students, the NMWC clinical experience helps them develop a
better understanding of cultural factors that influence health decision making. In end-of-semester reflections, students report that the experiences changed the lens by which they view clients and families. Students who had not previously been“downtown” or in the low-income neighborhoods gain insight into the many obstacles vulnerability creates for adopting healthy behaviors. Students discover that they had taken for granted things such as access to healthy food, safe neighborhoods, and places to walk and exercise. The following are examples of student reflections:
This clinical was unlike any I have ever done. I've always had a sheltered life, and this clinical opened my eyes to the battles with society that the low-income residents deal with every day. I think this kind of experience is going to make me a better, more compassionate nurse.This clinical experience was definitely an ‘eye-opener’ to the cultures and lifestyles of a population that is so close geographi-cally, but so far away psychosocially. The experi-ences that the group of people went through in their life and have shared with us are not even comparable to what I have experienced before with myself or with other clients.
These student reflections provide anecdotal evidence that NMWC client encounters modify their previously held beliefs. To date, only this anecdotal data have been collected. Plans are in place to conduct a study to measure cultural competence before and after the NMWC clinical experience.
Another advantage for students is the opportunity to establish a continuous therapeutic relationship with clients. For the most part, weekly clinical experiences in nursing are with different patients for each clinical day. Because continuity of care is foundational for practice within the NMWCs, students see the same assigned clients each week for the full semester. For many students, this is their first clinical experience where they are able to form a therapeutic student (nurse)–patient relationship that develops over time. The value of this type of continuous relationship for students has been described in other settings (Kruger, Roush, Olinzock, & Bloom, 2010; Thompson & Feeney, 2004).
The student intern positions for NMWC staffing when the college is not in session are available for students who complete the community health course and provide opportunity for students to continue working with the same clients throughout semester breaks. Fewer than eight students are needed for off-semester staffing because the focus, when the college is not in session, shifts from education to practice, fewer aggregate interventions are conducted, case-finding activities are decreased, and as appropriate, client visits are less frequent. The students who work as interns are hired prior to the end of each semester, and faculty in each NMWC facilitate continuity of
care by assuring student interns are familiar with assigned clients.
Advantages for Faculty. The NMWCs provide a setting for faculty practice and research and scholarship opportunity. Unique to this setting in baccalaureate clinical education is the opportunity for faculty to practice as clinician, preceptor, and faculty.
Unlike traditional clinical settings where students are assigned to one nurse preceptor, in the NMWC the faculty is the nurse preceptor. The faculty are direct care providers, who delegate care to students. The opportu-nity for direct care and ongoing relationship with clients is unique for faculty in an academic setting. Faculty are able to role model nursing practice, and students benefit by watching faculty in this direct practice role.
NMWC practice also offers opportunity for faculty research and scholarship. Faculty have sponsored five student posters reporting community health nursing process related to NMWC population-focused interven-tions presented at the YCP Student Scholar's Day. Program proposals written by faculty for diabetes support group intervention, technology, ASK, and tobacco cessation program have been funded. Pre-sentations have been made about NMWCs as an innovative partnership at a state-level housing agency conference, innovative funding strategies for sustain-ability at the National NMCs Consortium Conference, and on meaningful use of outcomes data at the International Omaha System Conference (Martin, 2005). Studies include the retrospective chart review documenting patient outcomes (Thompson et al., 2012) and the ASK project. To date, faculty have served as preceptor to four master's students who have completed capstone projects in the NMWCs.
Challenges to Maintaining NMWCs
The positive outcomes provided by the NMWCs for student learning, for clients, and for faculty have been clear. The most burdensome aspect of offering this clinical experience is maintaining NMWC operations when the college is not in session (King & Resick, 2009). Service interruptions that adversely impact quality of care and ability to maintain trusting relationships with the clients require year-round operation of the NMWCs. At YCP, course sequencing is such that the community health nursing course is offered only in the fall and spring semesters, which assures staffing in each NMWC with a community health faculty and clinical group of eight students 30 weeks a year. During the semester breaks, the NMWCs have been staffed with faculty and paid student interns. These staffing levels have depended upon funding from grants and donations with additional support from the college. Obtaining this funding and management of year-round operations is an administra-tive responsibility that is in addition to maintaining best practice standards and assuring consistency among the NMWCs. These administrative responsibilities contrib-ute substantially to the workload of the community
health course coordinator. However, the value of the clinical experience and the benefits to the clients, students, and faculty has provided incentive for commit-ment to this workload.
Summary
The NMWCs provide a clinical practice setting for baccalaureate nursing students in community health nursing. The clinical practice concepts learned through providing care to low-income individuals, families, and populations meets ACHNE competencies for C/PHN. Not only does this address theIOM (2010)call for increased emphasis on community clinical experiences but it also provides a setting where theoretical concepts are effec-tively transitioned into the clinical practice. Clients who represent a vulnerable population receive services not available anywhere in the traditional health care system that improve knowledge, behavior, and status related to health problems. The NMWCs also provide other benefits for students and a faculty practice setting within an academic setting, with opportunities for research and scholarship. Challenges to sustainability impact faculty time resources; however, the benefits for students, clients, and faculty outweigh the burden of those challenges.
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