Hendrickx_603_Formatted Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 142 Pediatric Clinical for Nursing Students in Rural Areas: The Camp Nursing Experience Lori Hendrickx, EdD, RN, CCRN, CNL 1 Heidi Pelzel, MSN, RN 2 Linda Burdette, PhD, RN 3 Nancy Hartung, MSN, RN, CDE 4 1 Professor, College of Nursing, South Dakota State University, Lori.Hendrickx@sdstate.edu 2 Instructor, College of Nursing, South Dakota State University, Heidi.Pelzel@sdstate.edu 3 Assistant Dean and Associate Professor, College of Nursing, South Dakota State University, Linda.Burdette@sdstate.edu 4 Educator, Sanford Aberdeen Diabetes Center, South Dakota, Nancy.Hartung@sanfordhealth.org Abstract Problem: Clinical placement for nursing students in pediatrics can be challenging in rural settings. Hospitals in rural areas typically do not have the numbers of pediatric patients necessary to provide individual inpatient pediatric experiences for a group of nursing students nor can community settings accommodate a full group of students at once. Children’s hospitals or hospitals with pediatric inpatient units are often a significant distance from nursing programs located in rural areas and there is competition among nursing programs for placement in these facilities. A study by the Institute of Pediatric Nursing (IPN) in cooperation with the American Association of Colleges of Nursing (AACN) concluded that nursing schools had challenges finding pediatric clinical sites and that pediatric content was lacking in depth and breadth (McCarthy & Wyatt, 2014). Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 143 Alternative Clinical Placement: For one nursing program located in a rural area, nursing students were placed at summer camps for children with various health care needs, including diabetes, developmental delays and special needs. Placing nursing students in a pediatric clinical experience at summer camps provided a supervised environment where they interacted with children with a variety of health care needs and provided care that included recognizing signs of diabetic emergencies, working with insulin pumps, administering medications and feedings via gastric tubes, providing basic first aid, health promotion and health teaching, and engaging in therapeutic communication. Outcomes: Evaluation of the summer camp experience was positive from students, faculty and camp personnel and student learning outcomes for the pediatric clinical course were met. Summer camps can provide excellent learning experiences for nursing students and serve as viable alternatives for pediatric clinical sites when inpatient pediatric facilities are not available. Keywords: Pediatrics, Clinical Experience, Children, Nursing Education, Summer Camps Pediatric Clinical for Nursing Students in Rural Areas: The Camp Nursing Experience Finding clinical placements for pediatric experiences can be challenging for nursing education programs located in rural settings (Hensel, Malinowski, & Watts, 2015). Rural hospitals typically do not have the numbers of pediatric patients necessary to provide individual pediatric experiences for an entire clinical group nor can rural community settings accommodate a full clinical group at one time. Additionally, children’s hospitals or hospitals with designated pediatric inpatient units are often a significant distance. While many nursing programs do travel to urban children’s hospitals or hospitals with pediatric units for clinical, there is often competition among nursing schools for clinical placement in these facilities. The competition for clinical placement at children’s hospitals and the distance many programs must travel are barriers for rural nursing Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 144 programs, resulting in lack of exposure to caring for children. This lack of exposure may potentially deter nursing students from pursuing pediatric nursing upon graduation (Institute of Pediatric Nursing [IPN], n.d. Across the United States, nursing programs have turned away qualified applicants due in part to a lack of clinical sites (American Association of Colleges of Nursing [AACN], 2017). Specifically related to pediatric clinical, the IPN in cooperation with the AACN concluded that nursing schools were challenged in finding pediatric clinical sites and pediatric content was lacking in depth and breadth (McCarthy & Wyatt, 2014). These issues have the potential to affect the pediatric nursing workforce at a time when children’s health care is more complex due to challenging chronic health conditions and evolving behavioral health issues. Challenges in finding appropriate inpatient pediatric clinical experiences have resulted in the use of alternative sites for the care of children. Many nursing programs use home health, ambulatory care settings, schools, clinics and community settings serving children with health care needs. While all of these provide excellent learning opportunities, the settings often restrict the number of students they can accommodate at one time. The IPN has published a list of alternative sites for inpatient pediatric clinical and includes, among others, summer camps for children and adolescents (IPN, n.d.). Many camps are designed to offer a camp experience for children with various health care needs, allowing nursing students to provide care in a supervised setting. The possibility of taking nursing students to camps for pediatric clinical placement was initially piloted with one clinical group at a College of Nursing located in a rural Midwestern state. This nursing program is located 175 miles from the nearest children’s hospital, making clinical placement difficult. The pilot group was successful and led to Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 145 the expansion of all clinical groups being placed at summer camps for their pediatric clinical rotations. Review of Literature Several barriers to providing adequate pediatric clinical experiences have been identified in the literature. Challenges include competition for quality acute care clinical sites, inadequate numbers of clinical instructors, fewer direct hands-on pediatric learning opportunities, and limited opportunities for medication administration (Evans, 2017; McCarthy & Wyatt, 2014). These challenges are more problematic in rural areas where the added issue of distance from pediatric acute care settings is a factor. The movement of pediatric clinical experiences out of the acute care setting has been supported by the IPN (n.d.) and summer camps are prevalent in rural areas. Completing pediatric clinical experiences at summer camps for children with health care needs offers a solution to the difficulty finding appropriate acute care pediatric clinical sites. History of Camping Historically, for children with specialized health care needs, camping was not always considered a viable option. However, organized camping experiences for children with special needs have been documented since 1899, with the establishment of a permanent site in Wisconsin in 1901 (Gilmore, 2016). Eels (1986) published a manuscript describing the history of organized camping and detailed the development of camps for children with health care issues. While the number of camps for children with special needs grew from 200 to 3,200 by 1947, the types of camps also grew. Over time, many camps were established that serve children with multiple diagnoses such as diabetes, cancer, HIV/AIDS, muscular dystrophy, mental health issues and a range of physical and intellectual challenges (Gilmore, 2016). Many camps for children with special needs use a Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 146 partnership model. These camps partner with a hospital or other agency to develop camps that are accessible for specific campers. Clinical Placement at Camp Historically, placing nursing students at camps for children with special health care needs has been reported as a viable option for pediatric clinical (Totten & Fonnesbeck, 2002). Nursing students at UCLA served as counselors at a camp for children with cancer and muscular dystrophy where they participated in camp activities and in the infirmary working with the camp nurse. The students had the opportunity to perform specialized skills such as catheterization, injections, and work with central ports. Students reported positive learning experiences and camp staff rated the nursing students’ performance as excellent (Nash, 1987). Praeger (1997) described successful implementation of camps as clinical sites and identified methods for identifying appropriate camps, selecting and confirming a camp, and preparing students for the camp experience. Students were given the option of participating in the camp experience, which included caring for children with diabetes, seizure disorders, myelomeningocele, cerebral palsy and traumatic brain injury. In a descriptive study, Vogt, Chavez, and Schaffner (2011) used reflective journaling to describe nursing students’ experience at a camp for children with diabetes. Participants (N=26) reported positive reactions, a sense of responsibility toward their assigned cabins, and an increased knowledge of diabetes (Vogt et al., 2011). While many camps are weeklong, one nursing program used a weekend, overnight camp for children with special needs for pediatric clinical. Through focus groups, a post-conference, and an online forum, students indicated they were able to do a variety of psychomotor skills and learned several key lessons including: 1) that the camp supported patient-centered care, 2) students felt Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 147 supported and relaxed and 3) that scheduling was a barrier. Despite the scheduling issues, the authors indicated a desire to continue the camp experience for students as a pediatric clinical option (Hensel et al., 2015). Evans (2017) used a qualitative narrative design to explore how placing fourth year nursing students in a camp setting met course outcomes. Results showed the camp setting provided the opportunity to demonstrate principals of patient safety, critical inquiry, preventative/promotional health, reflective practice and advocacy. Alternative Clinical Experience The pediatric clinical rotation for nursing students varies among nursing programs. According to McCarthy and Wyatt (2014), pediatric clinical sites should transition from a focus on primary care or hospital settings to more community, home, and school-based experiences. In order to accommodate the shifting trends of pediatric nursing, one rural Midwestern baccalaureate nursing program adapted the pediatric clinical rotation to be a summer camp-based experience. Student learning outcomes within the syllabus included goals of providing therapeutic communication; performing developmentally appropriate assessment, interventions, and evaluation; and applying critical thinking/clinical reasoning/clinical judgement skills. Student performance standards for evaluation included timeliness, safety and efficiency of care, professional communication, and active engagement with clinical participants. During the clinical rotation, students’ theoretical knowledge was linked to clinical practice through pediatric case conferences, medication review sessions, and daily pre-briefing and debriefing discussions. Procedure for Camp Preparation Preparation for the camp clinical experience was key to nursing student success. At the beginning of the semester, the course syllabus was reviewed and students were informed of clinical Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 148 expectations. Students were offered the option to travel to a camp location or stay near the university campus for a day camp clinical rotation. Students were given the choice because the travel and overnight immersion requirements were difficult for some students. Grant funding was obtained to cover the cost of the cabin rentals where applicable. Orientation to the camp experience itself was standardized, but supplementary orientation varied by camp. Basic camp orientation included performance evaluation procedure, professional communication review, and additional professional nursing student role expectations. Supplemental orientation to each specific camp clinical was provided. This supplemental orientation included travel arrangements, camp housing, meal accommodations, appropriate camp nurse attire, anticipated types of cares that would be performed and an overview of the individual camp. Camp #1 Camp #1 was envisioned through a partnership between a Center for the Arts and a theater company. This camp is held on a barrier-free modern replica of an 1880s town. The camp provides visual and performing arts opportunities which are modified for individual campers. Campers have a summer camp experience while exploring their love of theater and performing arts. Campers try out for performance roles and practice for an official performance at the conclusion of camp. While campers practice their performance extensively, the location is completely handicap accessible and affords campers of all abilities and disabilities to participate in many activities, including horseback riding, pontoon rides, fishing, archery, water activities, swimming, and campfire time. Camp counselors are responsible for the safety and health care of campers. Many of the campers have chronic disease processes requiring specialized healthcare personnel, a need that Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 149 nursing students can fill through clinical placement. Nursing students and instructors are present at camp from “check-in” to “check-out”, providing students an opportunity to meet parents/guardians, learn camper names, medication regimens and health care requirements. Nursing students perform care for campers with diagnoses such as autism, Downs’s syndrome, cerebral palsy, anxiety disorder, depression, celiac disease, epilepsy, fetal alcohol syndrome, and attention deficit hyperactivity disorder, among others. The daily routine starts with morning medication administration for at least 30 of the 40 campers. Some campers require gastric tube administration of medications. This routine occurs again at 1100 and at 2000 for bedtime medications. If campers receive medications at additional times throughout the day nursing students have a reminder system to ensure these medications are administered at the camper’s usual time. Parental consent allows the student nurse to administer many over-the-counter (OTC) medications to campers. These OTC medications are administered only after a focused assessment is conducted. Safely administering medications to many children over a short period of time can be a challenge for nursing students who are more familiar with the acute care routine; one that includes a bar code scanner and wrist bands. Student nurses quickly learn to adapt and develop additional safety checks to accommodate the camp environment. Medication administration is not the only task the students complete. Nursing students are “on- call” during the theater practice times for camper safety and healthcare needs. During additional camp activities, the student nurses accompany campers to the lake, riding arena, archery range, “old west main-street”, and hiking trails. The role of the student nurse includes treatment of cuts and scrapes, sprains or strains, and other injuries. If a camper suffers a severe injury, nursing students collaborate with camp staff to follow appropriate protocols or procedures, including notifying a camper’s parent of the current concern. The camp nurse day is often 14 hours long by Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 150 the time bedtime cares are completed and the campers are in bed. Because the camp accommodates campers of all abilities, challenging situations with campers can be encountered during the clinical rotation. Campers with cerebral palsy may be non-verbal and wheelchair bound, require tube feedings, medication administration through a gastric tube, and frequent personal hygiene cares. In partnership with camp counselors, nursing students worked out alternative communication methods and options for getting the campers out of the wheelchair to participate in activities. Camp #2 Camp #2 is a week-long residential summer camp for children with type 1 diabetes. In 2018, one-hundred-twenty campers attended the camp, along with forty-two staff members. Camp staff are volunteers, including pediatricians, pediatric endocrinologists, physician assistants, nurse practitioners, certified diabetes educators, nurses, dietitians, and social workers, as well as non- licensed personnel. Many of the staff have type 1 diabetes themselves and are former campers. This week-long camp began a collaborative partnership with a Midwestern, rural College of Nursing in 2014, offering a unique pediatric clinical experience for accelerated BSN nursing students. A typical clinical group is 8-9 nursing students. Nursing student responsibilities are identical to those of unlicensed camp staff. Each carries a fanny pack equipped with a glucometer, test strips, disposable lancets, cotton balls, alcohol preps, hypoglycemia treatment guidelines, documentation slips, and glucose tablets. During staff orientation, the nursing students and faculty member receive instruction and demonstrate competency of skills via the teach back method. Each student is assigned to a camper cabin, spending on average 10-12 hours on site daily. While at camp, most campers test blood glucose on average ten times per day, so students become experts with glucose testing by the end of the week. Other responsibilities include observing and/or Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 151 assisting campers with carbohydrate counting, insulin injections/insulin pump bolusing and insulin pump site changes, as directed by camp medical and nursing staff. Because this is a pediatric rotation, students are encouraged to interact with campers and develop appropriate relationships in order to gain comfort and experience working with children. Campers share a unique perspective about living with type 1 diabetes. The same is true for the many staff who also live with type 1 diabetes. Nursing students are encouraged to participate in camp activities during the week, giving them additional opportunities to interact with campers and staff. Camp activities include swimming, paddle boats, canoes, paddle boards, fishing, basketball, sand volleyball, and crafts. The pediatric clinical rotation provides a unique educational opportunity for complete immersion into the world of type 1 diabetes. Students report positive clinical experiences. The camp not only benefits greatly from having the additional staff on site, but a number of students have returned to volunteer as camp nurses after passing the NCLEX. Evaluation At the conclusion of the week-long clinical experience, students have a debriefing session with their clinical group and instructor. Students discuss the experience as a pediatric clinical option, giving feedback addressing ways to maximize the experience for future clinical groups. Additionally, students complete an evaluation that addresses the following: positive and negative attributes of the experience, suggestions for improvement and how faculty can better prepare the students for the camp experience. Comments have been overwhelmingly positive. Students shared that they learned a great deal about diabetes or other specific childhood disorders, improved their techniques in communicating with children, got excellent experience in pediatric medication administration and learned more about mental health issues facing children. One student Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 152 commented: “Not only did I learn about diabetes, meds, and insulin pumps but I learned about the psychological toll of having diabetes as a kid.” The students often commented about the opportunity for hands-on learning at camp, particularly related to medication administration, diabetes management and psychosocial interaction. Another student commented: I had a great experience at camp for my pediatric clinical opportunity. I feel as though we had a great variety of patients and situations. We had some awesome acute care opportunities as well as great interactions with kids of various ability levels. Oh, and I got great experience with giving a whole bunch of meds in not a whole bunch of time. Students’ suggestions for improvement resulted in increased instruction on the management of insulin pumps and carbohydrate counting. The pre-camp orientation sessions were revised to reflect students’ comments requesting additional preparation for caring for children with special needs. Nursing students were able to meet learning outcomes for the pediatric clinical course. They demonstrated integrity and therapeutic communication with children, peers, and staff; promoted health through teaching and managing illness; demonstrated applicable nursing roles; performed developmentally appropriate population-based assessment, intervention, and evaluation, including health teaching, screening, and referral; and applied critical thinking, clinical reasoning, and clinical judgment to patient care. Resources Numerous resources are available to programs interested in establishing pediatric clinical experiences at camps for children with health care needs. While many are specific to a particular illness, others are for children with a variety of health care needs. The American Camp Association (ACA) has a “Find a Camp” function that helps identify what type of camp the searcher is Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 153 interested in. Additionally, the ACA web site allows one to identify camps for children with special needs or for specific populations. The ACA site has information on over 3700 camps (ACA, n.d.). More specific to nursing is the Association of Camp Nurses, which offers a wealth of information about camp nursing, including education and resources, research, and information about specific states’ programs. It has published the Scope and Standards of Camp Nursing and Practice Guidelines for camp nurses (Association of Camp Nursing, 2017). See Table 1 for resources for camps for children with special health care needs. Table 1 Camp Nursing Resources Name Website American Camp Association https://www.acacamps.org/ Association of Camp Nurses https://www.campnurse.org/ American Diabetes Association http://www.diabetes.org Camp Mak-A-Dream https://www.campdream.org/ Camp Quality USA https://www.campqualityusa.org/ Camp One Step https://camponestep.org/ Kidscamps https://www.kidscamps.com/ Muscular Dystrophy Association https://www.mda.org/summer-camp Ped-Onc Resource Center http://www.ped-onc.org/ SOAR https://soarnc.org/ Conclusion In rural areas, nursing programs face significant difficulty providing acute care, in-patient pediatric clinical experiences due to distance from children’s hospitals or hospitals with pediatric units, competition for available clinical sites and the changing demographic related to where children with specialized health care needs receive care. While this nursing program is based in a rural setting, camp nursing experiences are valuable for nursing students from all backgrounds. The camp experience has provided a viable alternative to the acute care setting as resources continue to be scarce. Camps should be considered when planning pediatric clinical experiences Online Journal of Rural Nursing and Health Care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 154 for nursing students as a feasible alternative where students can provide care for children in a fun- filled learning environment and still meet the curricular requirements of a pediatric clinical course. Acknowledgement Grant Funding Provided by a Dawley Seed Grant Award References American Association of Colleges of Nursing (2017). 2016-2017 Enrollment and \graduations in baccalaureate and graduate programs in nursing. Washington, D.C.: Author. Publication No. 16-17-01 American Camp Association. (n.d.). Find a camp. 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