Borgos_664_Formatted Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 118 Navigating public health clinical placements for rural online RN-BSN students Jill C. Borgos, PhD, MS, RN 1 1Assistant Professor of Nursing, School of Education, Health, and Human Services, State University of New York at Plattsburgh, jcrom007@plattsburgh.edu Abstract Purpose: In rural settings scarce public health resources potentially limits the opportunities for nursing students living in these areas to participate in traditional one to one precepted experiences with public health agencies. To meet the revised Commission on Collegiate Nursing Education Standards related to direct clinical practice, creative strategies are needed for online degree seeking RN-BSN students who live in rural areas. This article explores an alternative learning experience by partnering students with a nonprofit healthcare institute to work on state health initiatives in the geographic region where the students reside. Process: In the absence of adequate opportunities for one to one precepted clinical experiences, students living in rural areas completing an online RN-BS program were partnered with a non- profit health organization. The students participate in an experiential learning experience to fulfill clinical hours in a public health setting as required by the Commission on Collegiate Nursing Education. In this case a cohort of students worked with a nonprofit healthcare institute on New York State’s T-21 campaign to further advance their knowledge on health initiatives driven by state health reform policy and actively participate in community-based education. Conclusion: With a growing focus on population-based care and caring for vulnerable populations, particularly in rural areas, seeking clinical activities through partnerships with non- profit healthcare institute to improve health outcomes at the community level offers an alternative Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 119 approach to engaging online degree seeking RN-BSN students in experiential clinical learning in communities with limited public health agency placements. Keywords: interprofessional learning, nursing accreditation, rural nursing students, service- learning pedagogy Navigating public health clinical placements for rural online RN-BSN students With a growing focus on population-based care, health disparities, health equity, and vulnerable populations in nursing education, registered nurses to Bachelor of Science in nursing (RN-BSN) students need educational experiences in these areas. However, the scarce resources in public health in some rural areas makes getting these experiences challenging for the online RN- BSN student population. While the traditional one to one precepted model may continue to work in some geographic areas, collaborations and partnerships with state level initiatives through nonprofit health institutes may serve as a meaningful alternative experience. Delivery models of higher education have been and continue to evolve to provide access and opportunity not previously envisioned. Securing traditional one to one precepted clinical placements for RN-BSN students in online degree programs can pose challenges, especially for cohorts of students who live in more rural or remote areas seeking placements in the same region at the same time. Finding multiple clinical placements for students in rural settings in the areas of community and public health poses a particular challenge as public health agencies are in some cases understaffed due to limited financial support, and as a result they may be unable to support student learning (Pettit, 2019; Himmelstein & Woolhandler, 2016). In New York State for example, county public health departments are in part funded through local tax dollars and their budgets are managed by a board of locally elected county supervisors (Pettit, 2019). During times of economic hardship, funding Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 120 and support for public health services are at risk of being reduced due to competing demands on local budgets (Pettit, 2019). In the absence of adequately funded and staffed public health agencies, traditional one to one clinical placement for cohorts of students in rural areas may not be an option. Alternative approaches to clinical experiences are needed to meet program outcomes, State Department of Education guidelines, and the Commission on Collegiate Nursing Education (CCNE) accreditation standards. Defining Rural in New York State Rural regions of the United States are often categorized as sparsely populated areas where resources are often limited due to the geographic isolation. The definition of rural is not universal, but it is estimated by the US Census Bureau that approximately 46 million Americans or 15% of the U.S. population live in rural areas (Centers for Disease Control and Prevention [CDC], 2017). Differing definitions of rural can be found across federal and state agency websites. In some cases, the definition of rural is overlapping or used in a similar vein across agencies. A few examples of government agencies using different or overlapping definitions of rural include the US Census Bureau, the US Department of Agriculture, the Office of Management and Budget (OMB), the Centers for Disease Control and Prevention, the Health Resources & Service Administration, and the Federal Office of Rural Health Policy (Rural Health Information Hub, 2019; CDC, 2017). Some of the common characteristics distinguishing rural regions from urban or nonmetropolitan areas is the size of a population within defined boundaries, land use or how densely settled an area is, and proximity to other more populated regions with economic interests tied to the labor market (US Department of Agriculture -Economic Research Service [USDA-ERS], 2020; Cromartie & Buchlotz, 2008). The USDA-ERS (2019) notes that the US Census bureau differentiates geographic areas “strictly on measures of population size and density” with rural being any area Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 121 with a population measuring 2,500 or fewer residents. In a slightly different statistically measured definition, the Health Resources & Service Administration (2020) notes that the OMB defines rural as any region that is not classified as either a “Metro or Micro” metropolitan area or not part of a “Metropolitan Statistical Area” which includes areas with populations under 10,000. This definition by OMB expands the estimated number of Americans living in rural areas to 17%. States such as New York, with a population in 2010 of 19.58 million and approximately 12% of its population living in rural areas, has further defined rural in order to meet economic needs specific to the distribution of its population within its borders (Schultz, 2019). In 2011 New York State concluded that an “one-size fits all” approach did not adequately reflect the economic growth needs of the state (Schultz, 2019). The size of New York and its immense diversity required differing needs across the state and these differences created the need to find an alternative way in which to measure the needs of its population from a resource perspective (Schultz, 2019). At that time, New York was divided into 10 Regional Economic Development Councils which were then further divided into 36 different economic regions with four separate groupings of the 36 economic regions (Schultz, 2019). The four economic groupings were identified using OMB Metropolitan Statistical Area (MSA) framework. The four economic groupings were divided into Downstate MSA, Upstate MSA, Upstate Micropolitan Statistical Area (SA), and Rural Counties unaffiliated with a formal MSA. For the purposes of this paper discussing RN-BSN students in New York State, rural is defined using the New York State designated definition of Rural Counties and Upstate Micropolitan SA collectively which specifies any rural county that is not part of a metropolitan region and does not have a city of 10,000 residents and counties with one city with at least 10,000 residents respectively and not part of a MSA. Seven Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 122 percent of New York State’s population lives in one of these two statistically defined areas (Schultz, 2019). Revised Accreditation Standards In June 2018 revised accreditation standards were released by CCNE with the expectation that by January 1, 2019 all programs seeking accreditation needed to be in compliance with the revised standards “regardless of the date of the last or next on-site evaluation” (Commission on Collegiate Nursing Education [CCNE], 2018, p.1). Revisions across parts of CCNE’s standards II and III elaborate on expectations of clinical experiences for post-licensure baccalaureate distance learning programs. Key Element II-B speaks to programs needing to be able to offer sufficient clinical sites and that these clinical sites are able to help students “to achieve the program’s mission, goals, and expected outcomes” (CCNE, 2018, p.2). In Standard III, Key Element III-G speaks to the importance of using “teaching-learning practices… to expose students to diverse life experiences, perspectives, backgrounds” (CCNE, 2018, p. 2). Key Element III-H goes on to highlight the need for students to have the opportunity to engage in clinical experiences with “planned clinical activities that…foster interprofessional collaborative practice” (CCNE, 2018, p.1). And further, Key Element III-H states that all programs, including distance education preparing students for direct clinical roles such as “post-licensure baccalaureate tracks”, must “provide direct care experience designed to advance the knowledge and expertise in a clinical practice” (CCNE, 2019, p.2). These revised Key Elements provide direction and a renewed perspective on ways to deliver direct clinical experiences for RN-BSN students in online programs living in remote or rural areas. In order to meet the current and revised CCNE Standards related to direct practice experiences and given the ongoing challenges in finding one to one clinical placements in public Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 123 health for RN-BSN students in rural settings, an alternative learning experience was designed. This experience was focused to help students meet the clinical hours required by the New York State Department of Education in the area of community and public health, meet the CCNE Standards for clinical practice experience, and achieve the program’s mission, goals, and expected outcomes. The goal was to engage the RN-BSN students in a meaningful direct public health experience by connecting the students with the needs of their community in an interprofessional and evidenced- based setting centered on addressing ongoing state public health policy initiatives. RN-BSN students, as adult learners, often bring a whole host of experiences to the classroom (Taylor, et al., 2000). Translating these experiences into meaningful contributions to improve the overall health of their communities as future nursing leaders was one part of the overall learning experience. Alternative Learning Experience The strategy used to provide a meaningful learning experience for rural online RN-BSN students was to connect a group of students to an ongoing New York State health initiative which also had significant implications to their local rural setting. This strategy was grounded pedagogically in a service-learning approach. Service-learning pedagogy links theory to practice through connecting students with an identified community need for the dual purpose of improving community health outcomes and providing a learning opportunity for students (Murray, 2013; Marcus et al., 2011). In this case, the students were asked to work as a group with a nonprofit healthcare institute on New York State’s T21 campaign designed to limit tobacco sales to adults 21 and over (New York State Governor’s Office, 2019; Institute of Medicine, 2015). Some independent nonprofit healthcare institutes focus their efforts and mission on “advancing population health outcomes by connecting healthcare organizations, businesses, payors, and county and state agencies to improve care, increase access, and lower costs” (Adirondack Health Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 124 Institute, 2020). These types of healthcare institutes offer potential opportunities for creative partnerships in working with students in rural settings on healthcare initiatives. By working with the health care nonprofit organization, the goal was to connect the students to an identified community need to address improving health outcomes and providing a learning environment for the students (Murray, 2013; Marcus et al., 2011). In this same vein, the goal was for students to meet program and course outcomes of using evidence-based practice to address health issues across the health system, exploring relationships between policy and nursing practice, using communication strategies to meet educational needs of a population, and assuming a leadership role in improving quality care at the community level. For this project, under the supervision of a faculty member, eight online RN-BSN students, who lived within a one-hour geographic radius of each other, met with the director of community initiatives and support administrators at the nonprofit health institute focusing on New York State health initiatives, to gain perspective on New York State’s T21 campaign. It was determined through these meetings that one of the ways to communicate with the population in the community most impacted by the T21 campaign was to connect with local high school students, high school administrators, and parents. This connection evolved into a plan for the students to create a visually representative presentation of tobacco sales in the local community tied with evidenced-based data on long term health outcomes related to tobacco use. To do this the students reached out to a local high school health educator to determine interest in partnering with the school to hold an evening presentation for the high school students, high school administrators, and parents. In preparation for the community presentation the students conducted a literature review of the research on the historical development of the tobacco industry, youth behavior related to smoking, long term health outcomes, and tobacco marketing. To illuminate the connection Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 125 between tobacco sales and marketing strategies aimed at youth within the local community the students conducted a comprehensive windshield assessment of tobacco and e-cigarette vendors in the community that included pictures and geographic mapping. The geographic mapping highlighted the proximity of tobacco sales within walking distance to neighborhoods and K-12 schools. The pictures visually highlighted the colorful displays of tobacco products at the height level aimed to attract youth. At the conclusion of their data collection, the students presented on both New York State’s T21 initiative and their findings from the windshield survey of their community to a group of high school health students, parents, high school faculty and administrators, and directors from the nonprofit health institute. The nursing students had the opportunity to field questions from all the audience members. In particular, the geographic mapping visual of tobacco sales and colorful tobacco product displays generated questions from audience members as it created the most relatable connection between the data and community. As students who were also RNs working in acute care settings in the surrounding community, they could speak with personal experience to the long-term health outcomes they see every day in the inpatient setting. This served as a touch point for the students in terms of relevance and confidence with the subject matter. Given the lack of public health resources in rural areas of New York State and the subsequent lack of learning opportunities at public health agencies, this service-learning activity provided an alternative clinical approach to the one to one precepted clinical experience by directly engaging a group of students in their community. Through this experience students gained an appreciation for working as a team with each other on a project, participating in interprofessional collaboration by working with professionals outside of nursing at a nonprofit health organization, engaging in the collection of evidence-based research with the intent to influence decision making, Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 126 and they demonstrated oral presentation skills to a community of interest. The project provided an opportunity for the students to positively affect the population health outcomes in the nearby community where they live and work as health care professionals. In debriefing sessions, the students reported a sense of professionalism, a connection with an important health issue impacting their community, an understanding of how to inform a population at risk, and pride in being able to contribute to a meaningful and impactful experience. The students’ overall reflection of the learning experience aligned with course outcomes and prior surveys on service learning experiences which include “confidence in educating clients”, “the ability to identify needs in a community”, “appreciation for the role of a community -based nurse”, and making the connection between “classroom learning and future clinical practice”(Murray, 2013 p.622; Bassi, 2011; Balakas and Sparks, 2010). Conclusion The goal of this experience was to provide online RN-BSN students direct engagement in the work of providing valuable education to members of a community and to engender a feeling of professionalism and confidence in the students. The learning experience helped students meet program and course learning outcomes related to interprofessional collaboration and partnership with stakeholders, participate in community assessment, demonstrate effective advocacy within a community, and it helped them to develop communication strategies. Meeting these course and program outcomes aligned with CCNE Key Element II-B. CCNE accreditation Key Elements III -G and III-H were also realized, as students were able to complete a direct patient (patient defined here as the community group) experience, a planned activity that involved interprofessional collaboration with professionals working on health care policy initiatives, an exposure to a diverse Online Journal of Rural Nursing and Health Care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 127 group, and through their research and presentation the students were able to advance their knowledge in clinical expertise in public health (CCNE, 2018). Just as the “one-size fits all” approach to defining rural does not adequately address the economic needs of New York State given the diversity and expanse of its geography, the same can be inferred about the application of learning activities in a clinical setting for online RN-BSN students. The alternative learning activity discussed in this article may pose limitations in different settings if replicated. Not every model, program, and course experience can be duplicated in the same way. Variations exist in student populations, geographic locations, institutional mission, student needs, and program requirements. In this case a collective group of students living in rural areas in the same state but in proximity to each other were able to work together despite being in an online program. Additionally, the online nursing program had an already established relationship with a K-12 school district and the community in which the students lived, inevitability contributing to the access to opportunities through these relationships. This may not be the case for other programs thinking about ways to connect online students in rural areas to service-learning activities. 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