International Journal of NursingEducation Scholarship

Volume 5, Issue 1 2008 Article 22

Preparing the Community Health NursingWorkforce: Internal and External Enablers and

Challenges Influencing UndergraduateNursing Programs in Canada

Ruta K. Valaitis∗ Christina J. Rajsic† Benita Cohen‡

Lynnette Leeseberg Stamler∗∗ Donna Meagher-Stewart†† Susan A. Froude‡‡

∗McMaster University, valaitis@mcmaster.ca†University of Toronto, c.rajsic@utoronto.ca‡University of Manitoba, benita cohen@umanitoba.ca

∗∗University of Saskatchewan, lynnette.stamler@usask.ca††Dalhousie University, donna.meagher-stewart@dal.ca‡‡Western Regional School of Nursing, sfroude@swgc.mun.ca

Copyright c©2008 The Berkeley Electronic Press. All rights reserved.

Preparing the Community Health NursingWorkforce: Internal and External Enablers and

Challenges Influencing UndergraduateNursing Programs in Canada∗

Ruta K. Valaitis, Christina J. Rajsic, Benita Cohen, Lynnette Leeseberg Stamler,Donna Meagher-Stewart, and Susan A. Froude

Abstract

The Canadian Schools of Nursing (CASN) task force on public health was mandated to fa-cilitate Schools of Nursing to provide students with the foundation required to meet the CanadianCommunity Health Nursing Standards of Practice. This paper reports on an environmental scanthat explored barriers and enablers influencing the integration of community health nursing con-tent in baccalaureate education in Canada. Data was collected over three phases including: 1)a pan-Canadian survey of nursing schools, 2) completion of open-ended workbook questions byeducators, policy makers, administrators, and community health nursing managers attending apan-Canadian symposium on community health nursing, and 3) recorded notes from the sym-posium. The response rate for the survey was 72.5% (n = 61 schools) and approximately 125stakeholders participated in symposium activities. Internal and external enablers and challengesas well as recommendations for practice and education are presented.

KEYWORDS: nursing education, community health nursing, standards, baccalaureate

∗We would like to acknowledge the contributions of all members of the Canadian Association ofSchools of Nursing’s (CASN) Subcommittee on Public Health in the design of the methods anddata collection in this work. Members include: Margaret Antolovich, Pat Gibson, Pat Griffin,Omaima Mansi, Heather Pattulo, Pat Seaman, Jo Ann Tober, and all authors on this paper. Wewould also like to sincerely thank and acknowledge the Public Health Agency of Canada, JaneUnderwood and Joan Reiter for their support that enabled this work to be completed and DinaIdriss for her expert assistance with recruitment, data gathering and cleaning.

Canadian Schools of Nursing that deliver all or part of nursing

baccalaureate education are invited to become members of the Canadian

Association of Schools of Nursing (CASN), the Canadian nursing education

accreditation body. In response to a growing awareness and interest in community

health issues across the country, CASN created a taskforce in 2004 to examine

community health nursing undergraduate education. The mandate of the task

force was to assist CASN members in ensuring that all baccalaureate graduates of

Canadian schools of nursing obtain a foundation towards meeting the expected

entry-level competencies based on the Canadian Community Health Nursing

Standards of Practice (CCHNSoP), which were released in 2003 (Community

Health Nurses Association of Canada). In the CCHNSoP, outlined are

expectations for a community nurse after two years of practice. Membership in

the taskforce included educators from CASN member schools and representatives

from practice.

A mandate of the Public Health Agency of Canada is to build human

resource capacity in public health, including nursing. In collaboration with the

Public Health Agency of Canada and CASN, the taskforce conducted an

environmental scan. The purpose was to identify strengths and gaps within current

undergraduate nursing curricula (structures/content), and identify enablers and

challenges in delivering community health nursing education (processes) in

CASN member undergraduate nursing schools. A guiding framework was the

CCHNSoP. Process issues (enablers and challenges) were largely explored

through qualitative data collection strategies and are reported in this article.

LITERATURE REVIEW

The majority of literature on integration of community health concepts in

undergraduate nursing education comes from the United States (U.S.), where a

curriculum revolution initiated at the federal level led to major changes in

professional nursing. The Pew Health Professions Commission (O’Neil, 1993)

recommended that U.S. nursing programs reorient curricula to provide greater

emphasis on health promotion and population-based care. The rationale for the

shift from acute, hospital-based care to community-based care was part of a broad

policy change, which would see a care location shift resulting in cost savings

related to lowered hospitalizations. The community nursing role was considered

to be integral for ongoing health education and disease monitoring in the

community. The role was also viewed in the context of working with populations

in partnership with communities rather than individuals, and required

“fundamental realignments of nursing education program[s], not merely add-on

courses or educational experiences to the existing curricula” (O’Neil, p. 89). The

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Pew Commission encouraged university-community partnerships, leading to an

increase in ‘service-learning’ opportunities for health professional students to fill

the health care gap in under-serviced populations. While models of ‘service

learning’ vary, Redman and Clark (2002) suggest that the essential component is

a partnership between the campus and a community, with community agencies

defining their needs for service and educators providing structured learning

experiences for students to meet those needs. They also noted that students’

critical reflections on the social forces that led to the community need and the

student-as-citizen’s civic responsibility in addressing that need, are characteristics

of service-learning models.

The National League for Nursing’s (1993) position statement pointed to

the importance of moving the focus of a large part of content and clinical nursing

education from acute care to community-based settings. These developments

spawned widespread curriculum revision across the U.S. to the end of the decade.

Since the mid-1990s, most American literature on the integration of community

health content into undergraduate curricula, describes experiences of various

nursing programs as they shifted from a traditional medical model to a

community-based care model (Conger, Baldwin, Agegglen, & Callister, 1999;

Edwards & Alley, 2002; Reece, Mawn, & Scollin, 2003; Speck, 2003; Staats,

2003; Thomas & Carroll, 2006).

In Europe, the World Health Organization (2000) called for the inclusion

of health promotion in all nursing curricula. Results from a literature review

conducted by Whitehead (2006), showed that health promotion has been

inadequately incorporated into nursing education programs. Students have had

little opportunity to apply health promotion theory in their practice. And when

they have, the focus has been primarily on health education in disease and life-

style oriented contexts as opposed to a broader ‘determinants of health’ approach

to health promotion. A stronger curriculum focused on health promotion and

education has been placed on pre- and post-registration nursing programs in the

U.K. (Holt & Warne, 2007). This is believed to be related to U.K. policies that

have emphasized health promotion and prevention within nursing activities, in all

nursing settings beyond primary care, school health and health visiting. Holt and

Warne found a perceived lack of health promotion and education practice

opportunities in student clinical placements which has resulted in devaluing of

this role. Results from a literature review and key informant interviews in the

U.K. conducted by Latter, Speller, Westwood, and Latchem (2003) indicated that

exposure to public health practice placements for pre-registration students “is

limited at present, due to the demands on placement availability created by large

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student cohorts, the requirement for longer placement experiences and the

comparative lack of development of public health nursing roles to date" (p.215).

In Canada, there have been no policy statements leading to radical reform

of community health nursing education. Furthermore, the literature on integration

of community health content into Canadian undergraduate curricula is sparse.

However, there is evidence of nursing’s widespread adoption in Canada of the

concept of Primary Health Care (PHC), which emphasizes community

participation and empowerment, health promotion and disease prevention, inter-

disciplinary and inter-sectoral partnerships for health and social development, and

appropriate use of technology (Smith, 2004). The application of the principles of

PHC has had a major influence on Canadian undergraduate nursing education. A

2005 survey of Canadian nursing programs conducted by the CASN Task Force

on Public Health Education (CASN, 2007) found that most undergraduate

programs in Canada report covering the topic of PHC in some way. A review of

approaches to community health clinical education in Canadian baccalaureate

nursing programs (Cohen & Gregory, 2007), indicated that about 20 percent of

programs used PHC as a conceptual framework for community health clinical

education; however, the understanding and/or application of PHC principles to

community health nursing practice was a common expectation in clinical course

objectives. They found that, unlike the U.S., where the emphasis in baccalaureate

education has been on a shift toward community-based nursing (i.e., providing

nursing care to clients in community settings), Canadian programs stress

community health nursing, emphasizing health promotion and disease prevention.

However, there was significant variation in community health clinical courses

(content, process, outcomes) across the country, which suggests a need for

national dialogue/consensus regarding standard curriculum content for

community health nursing education in Canada.

PURPOSE AND OBJECTIVES

The purpose of this environmental scan was to explore internal and

external enablers and challenges influencing the integration of community health

content in baccalaureate nursing education in Canada. The objectives of the paper

are to: 1. describe enablers and challenges with respect to intra-organizational

factors in community health settings (external) that influence the teaching

learning process; 2. explore enablers and challenges with respect to intra-

organizational factors in academe (internal) that influence the teaching-learning

process; 3. investigate the enablers and challenges with respect to partnerships

between community health settings and academe that influence the teaching-

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learning process, and; 4. identify recommendations to guide further enhancement

of community health content in baccalaureate curricula in Canada.

METHODS

To obtain a comprehensive understanding of the enablers and challenges,

three phases of data collection were conducted involving different sources and

methods, each phase building on the next. In Phase 1, an online survey was

conducted with CASN member schools; in Phase 2, key stakeholders answered

broad open-ended questions in a workbook prior to attending a Pan-Canadian

symposium on community health nursing education; in Phase 3, recorded notes

were collected from all symposium discussions to include in the analysis (Table

1). Although the authors did not obtain ethics clearance for this environmental

scan, permission was obtained from participants for all quotes used in this

manuscript.

Table 1

Summary of Data Collection

Phase Strategy Participant response

1 – Pan-Canadian

Survey

Survey sent to all 91

CASN member Schools

of Nursing

66 member schools

responded

(72.5% response rate)

2 – Pre-symposium

Workbooks

Workbook questions pre-

circulated by email to all

registered participants

65 workbooks completed

by nurse educators and

nurse leaders

3 – Symposium Invitations emailed to

CASN member schools

and key nursing leaders

125 community health

nursing educators and

leaders attended

In Phase 1, the CASN taskforce developed a web-based survey to examine

the current status of Canadian undergraduate public health nursing education.

Questions pertained to internal and external enabling and challenging influences

that impacted community health nursing curriculum content and delivery as well

as participant’s interest in participating in a pan-Canadian follow up symposium.

The survey was pilot-tested with 5 member schools, suggested areas for

improvements were identified, and edits were made accordingly. Based on pilot-

test results, respondents needed to consult with colleagues to complete the survey.

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Therefore, participants were provided with a printer-friendly survey to enable

easier survey completion. The survey was distributed in web-based and paper

formats to 91 CASN member schools in May 2005. Deans or Program Directors

were sent a letter of invitation to participate, survey instructions, a glossary of

terms, a survey formatted for printing, and a link to the online version. They were

asked to forward the survey to faculty most knowledgeable about the curriculum.

Respondents were asked to enter their responses online, by mail or fax, and phone

reminders were made to increase response rates.

A full day, pan-Canadian symposium on public heath nursing education

was held in May, 2006 to gain further understanding of enablers and challenges

for integrating community health nursing in the curricula. In Phase 2, participants

were asked to complete workbook questions prior to attending the symposium.

The objectives were to present, validate and expand on Phase 1 findings and assist

in the development of key community health nursing education recommendations

for CASN. Symposium participants included representatives from more than 60

of the 91 CASN member schools, with some schools supporting more than one

participant. Other attendees included staff from the Public Health Agency of

Canada, the Canadian Nurses Association, provincial nursing associations, and

nursing policy officers from various provinces. More than 20 public health

nursing directors and managers, who were attending a concurrent meeting, joined

the symposium for parts of the day. Thus, the symposium was represented by

approximately 125 key stakeholders including educators, policy makers and

decision-makers in community health nursing. Workbook questions explored

student placements in community, enablers and barriers in supporting students’

move to meeting the CCHNSoP, and the nature of internal and external

relationships required for successful partnerships between academia and

community agencies.

In Phase 3, results from Phase 1 and 2 were shared at the symposium,

followed by small and large group discussions to help interpret results and begin

formulating recommendations. Notes recorded from the day were collected. In

addition, approximately 100 public health nurse managers met in British

Columbia to discuss the workbook questions and submitted a joint response to the

taskforce for inclusion.

ANALYSIS

NVivo2 qualitative analysis software was used to code the open-ended

questions in the Phase 1 survey. The lead author coded responses and reviewed

coding with a sub-group of the taskforce in a face-to-face meeting. Consensus

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was reached on all coding, thereby strengthening research rigor. Minor codes

were grouped into larger themes by the sub-group. All data collected from Phase

1 and 2 were reviewed in a face-to-face meeting prior to the symposium. The

major findings were shared with symposium participants in order to validate

results, expand upon interpretations, and serve as a member check. This was

followed by the second author who conducted more detailed analysis of data from

Phase 2 and 3, building and expanding on the themes from Phase I using

HyperRESEARCH software; and the coding structure, which was reviewed by the

first author. Codes mapped onto the initial Phase I coding structure went well. All

French language responses (online, handwritten and verbal responses) were

translated and coded. The final analysis was reviewed in depth by taskforce

members as a peer-review.

RESULTS

Sixty-six surveys were received from the 91 CASN member schools of

nursing (72.5% response rate), which offer generic, collaborative integrated

‘DEC-BAC’ programs (College Diploma to Degree programs in the Province of

Quebec), and/or post-RN programs with degree designations of BScN or BN. Of

these, 86.4% of programs were offered in English, 9.1% in French and 4.5% were

bilingual. The highest response rates were from Atlantic and Prairie Provinces and

the Territories. Although the lowest percentage response rates were from British

Columbia, Quebec, and Ontario, these provinces had a greater number of

responses than others, since they have more schools.

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0 10 20 30 40 50 60 70

Number of faculty teaching CHN

Faculty preparation for CHN

Understanding community as partner

Faculty commitment to CHN

Curriculum renewal

Culture of collaborative program

Accelerated Program

Funding

Space

Time

Percentage

Enabling Neutral Challenging Not Applicable

Figure 1 Internal influences on community health nursing curriculum (n=61).

Respondents rated a list of internal and external influences with respect to

their impact on community health content in their program (1 to 5 scale, and not

applicable) (Figures 1 and 2). Enablers referred to influences enabling the

delivery of community health nursing content in program(s). Internal enabling

influences (scored 1 or 2) were curriculum revision/renewal (65.6%);

understanding of the concept of community as partner versus community as

context (63.9%); faculty preparation for teaching community health nursing

(63.9%); number of faculty teaching community health nursing content (63.9%);

and faculty commitment to community health nursing (62.3%). Issues rated as the

greatest internal challenges (scored 4 or 5) were space (60.7%) and funding

(39.3%). External challenges were preceptors (59.3%); negotiating placements

with others (e.g., LPNs, NPs, MDs, Midwifery, geography, social science, and

kinesiology) (58.3%); health care restructuring (57.4%); the nature of the practice

environment (45.9%); and the current political climate (42.6%). A smaller

percentage of respondents identified external enabling influences as, the nature of

the practice environment (36.1%); the licensing body approval process (36.1%);

preceptors (33.9%); accreditation (32.8%); and current political climate (26.2%).

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0 10 20 30 40 50 60 70

Nature of practice environment

Licensing Body Approval Process

Preceptors (N=59)

Accreditation

Current Political Climate

Health Care Restructuring

Negotiating Placements (N=60)

Percentage

Enabling Neutral Challenging Not Applicable

Figure 2 External influences on community health nursing curriculum.

(n = 61 except where noted)

Phase 1, 2 and 3 results provide a deeper understanding of enablers and

challenges influencing community health nursing curriculum content and delivery

(Table 2). Internal enablers and challenges refer to factors situated in the

academic context while external enablers and challenges refer to broader

community factors.

External Enablers

The major theme that emerged as an external enabler was strong

community-academic partnerships. Many respondents reported having supportive

partnerships which helped strengthen community health nursing educational

experiences for students. To illustrate,

We could not have had such a strong emphasis on community health

without our relationship with public health unit. The support has been

outstanding and they are not one of the teaching health units. They deserve

credit for this success…

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Table 2

Summary of Major Themes Influencing Community Health Content in Schools of

Nursing in Canada

Enablers Challenges

External:

• Strong community-

academic partnerships

• Placement: increased demand /

reduced supply, limited exposure to

varieties of community nursing

placements and activities within

placements (resulting in fewer

nursing role models), as well as

limited clinical space for students

• Preceptor: lack of valuing of the

preceptor role, lack of skilled

preceptors, lack of protected time and

compensation for preceptors, and

burnout.

• Community health devalued versus

acute care sector

Internal:

• Supportive curriculum

structure and process

• Faculty champions

• Problems with curriculum structure

and process: dominance and valuing

of illness / acute care in academe and

difficulties integrating community

health nursing components

throughout the curriculum.

• Lack of qualified faculty to teach

community health: shortage of faculty

prepared to teach community health,

with an understanding community

health concepts.

• Weak community health leadership in

academe: negatively impacting

integration of community health

curriculum content, and budget

implications for community health

nursing educational resources.

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Respondents described formal and informal community-academic partnerships.

One supportive formal partnership model was the teaching health unit.

The Ontario PHRED (Public Health Research Education and Development

Program) model has strengthened public health nursing education,

research and practice through increased opportunities provided to our

students by the partnerships and experience that faculty have brought from

their PHRED joint appointments.

Another example was provincial legislation that supported collaboration

between education and the health sector to facilitate student learning. In this

structure, faculty maintained ongoing consultations with inter-professional

clinical coordinators and nurse leaders. They created a new nurse educator faculty

position to assist preceptors (the position is dependent upon agency accepting a

significant cohort of students). Marketing strategies were designed to help

agencies value student contributions, particularly through community health

promotion projects. Faculty visited clinical sites to collaborate with preceptors

and monitor student learning. Nurse preceptors were offered 3 year positions as

clinical instructors where they were offered privileges within the university,

thereby encouraging sustained involvement.

Internal Enablers

Two major themes denoted internal enablers that influenced community

health content in nursing schools - curriculum structure and process, and faculty

champions. Curriculum structures and processes referred to establishing a

curriculum rooted in the CCHNSoP, sequencing the curriculum to support

community health nursing throughout the program, and teaching foundational

concepts and supporting a PHC-based curriculum. One school reported having a

course including a learning plan and evaluation template rooted in the CCHNSoP.

Many schools sequenced community health nursing throughout the program

rather than as a stand-alone course, and health promotion was emphasized in the

first year. Some schools reported that their programs were strengthened by the

inclusion of foundational concepts, such as health promotion, caring, PHC,

determinants of health, and critical social theory. Others developed their curricula

based on PHC, which positively impacted community content in the program. As

described by one respondent,

…due to new program development, faculty have embraced the primary

health care approach to professional nursing practice and delivery of

health care. We aim to work at embedding the principles of PHC and

community health into the integrated program.

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Having faculty champions in community health nursing was found to be

an important enabler in Canadian nursing schools. Many, but not all, respondents

reported that their faculty had good preparation, passion and commitment for

community health, which resulted in students having excellent supervision in

community. Respondents often commented on the quality and quantity of faculty

preparation in community health as an enabler:

…[ an enabler is] the number of faculty members in our department with

advanced practice and education in the area of community health nursing.

Additionally, faculty members who do not have this background are very

receptive to learning more about community health concepts and

incorporating these into their classes.

External Challenges

Three external challenges emerged including: placement challenges,

preceptor challenges, and devaluing of community health (versus acute care).

Placement challenges. These were related to: a) increased demand /

reduced supply of placements, b) limited exposure to varieties of community

nursing placements and few activities within placements (resulting in fewer

nursing role models), and c) limited clinical office space for students. Increased

demand / reduced supply of student placements was related to two factors –

increased competition for placements and health care restructuring. Increased

competition for placements was described as being the result of higher student

numbers related to the growth of college programs, as well as a general lack of

community resources. Many comments addressed challenges related to a lack of

available traditional community placements. Restructuring of health care

environments also had an impact on the supply of community placements. One

respondent wrote that:

The government of this province is restructuring public health into the

hospital corporation with no protected budget. The future role of public

health is of major concern. Because of this restructuring, there is no

opportunity at this time, for our students to have placement with public

health.

The second placement challenge was related to limited exposure to

varieties of community nursing placements and activities within them. Placement

activities were often restricted (such as, lack of permission to administer

immunizations, limited access to vulnerable populations, and observation-only

placements). For example, agency staff working with vulnerable populations can

overprotect their population. Limited role modeling by nurses was also reported

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as a challenge; students had minimal contact with community health nurses and

thus limited exposure to their roles and activities. The use of non-traditional

placements and non-nursing teachers has, therefore, created complex challenges

for educators:

Community settings can usually accommodate small groups of students,

usually one at a time. With increases in enrolment, this presents a

challenge to find meaningful community health placements where

community health nurses are there to model their role.

A third placement challenge was limitation in clinical space for students,

which potentially made students feel unwelcome in their placements. The above

challenges represented a general apathy in community agencies towards students,

which transferred to clinical preceptors.

Preceptor challenges. These were related to four factors including: a)

lack of valuing of the preceptor role, b) lack of skilled preceptors, c) lack of

protected time and compensation for preceptors, and d) preceptor burnout. Lack

of valuing of the preceptor role by agencies was reported repeatedly. This was

linked to the lack of skilled preceptors and protected time for preceptorship. The

following comment describes preceptor challenges exacerbated by the focus on

illness care:

The focus in nursing remains on illness care and therefore community is

devalued at times. We are in CONSTANT competition for placements

and we have to beg for preceptors and sites. We believe that in order for

facilities that employ nurses to receive accreditation, they have to take a

certain percentage of students annually (some sort of a ratio system) or

they do not get accredited. Further, that those that precept, have this

valued and affirmed and that a part of their work is taken away so they

have the time to do this. It is such a stretch for them and we find it is rare

that agencies value preceptorship as much as universities invite them to.

A challenge for preceptors was the need to increase their knowledge and skills,

including PHC principles and the CCHNSoP:

…additional challenges include [the] community health nursing

professional population that does not necessarily have the educational

preparation to engage in co-teaching community health nursing concepts:

local community health nurses are largely unaware of Primary Health Care

principles; Population Health Promotion; may not value participating in

student teaching.

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This was strongly supported in workbook responses. Many nurses reported

lacking knowledge of the CCHNSoP, which further amplified their lack of buy-in.

One nurse noted that the standards were not always the bottom line in home

health nursing; rather the emphasis was on getting the job done efficiently. A lack

of protected time and compensation for preceptors was another challenge reported

by many participants, resulting in a further devaluation of the role. It was often

viewed as a voluntary activity, adding additional workload to an already

overburdened staff. One participant explained that, “community health nurses

traditionally view [preceptorship] as an additional workload task and either expect

financial compensation for engaging in clinical student teaching (no resources

available) or view participation as strictly on a ‘volunteer’ basis.” Since clinical

placements are at premium, it is not surprising that many respondents noted

preceptor burnout as a challenge. This was largely related to increased public

health nursing workload, where staff and agency burnout was considered a real

and present danger.

Devaluing of community health. Another major theme viewed as an

external challenge was community health nursing being undervalued.

Government preoccupation with the acute care sector and care of individuals

rather than communities has reduced opportunities for community health

education. Many respondents supported this, noting that funding and power

remains with hospitals, with a focus on individual care and an illness versus

wellness approach, thereby further devaluing community:

The current government is fixated on acute care needs and wanting to

churn out new grads as fast as possible. There is little attention to the need

for more funding to the education or practice settings to increase

community health education opportunities.

One respondent commented that this problem was associated with government

preferences to fund colleges over baccalaureate programs: “…increased funding

goes to nursing education programs at less than the baccalaureate level, which

impedes the preparation of nurses to practice in the community.”

Internal Challenges

Internal challenges were grouped into three major themes including:

problems with curriculum structure and process, lack of qualified faculty for

community health nursing, and weak community health leadership in academe.

Problems with curriculum structure and process. The challenges with

curriculum structure and process were explained by two factors – dominance and

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valuing of illness/acute care in academe, and difficulties integrating community

health nursing components throughout the curriculum. Coinciding with the

external challenge of community health devalued, numerous respondents felt that

dominance of acute care also exists in academic settings. Some respondents

voiced this as a constant threat to community health: “what challenges us is the

power of the dominant voice that insists that nursing students must have more

thorough and senior preparation (theory and especially clinical practice) in acute

care/institutional nursing, rather than community practice.” “Community health

content never seems to be given as much recognition as content such as med-surg

which seems to receive more monetary / staff resources for ensuring

comprehensive clinical education etc..” Faculty felt that students also devalued

community health nursing. A number of respondents commented on students’

preferences for hospital placements: “the majority of jobs for new graduates are

hospital based. As the students plan their final practice placements, they often

choose acute care.”

Lack of qualified faculty for community health nursing. The second

challenge was related to problems with integration of community health into the

curriculum. This theme took into account philosophies and approaches to teaching

community health. For example, one respondent felt it was challenging to assist

placement staff to understand the philosophy of the curriculum and course

expectations of students. Another explained that philosophical conflicts exist

when delivery programs are based on a behavioural orientation rather than

determinants of health, and social environmental approaches which are more

consistent with CCHNSoP. A manager noted that there were unrealistic course

goals in education that must be made more compatible with public health agency

goals and objectives. A few comments were also made indicating the importance

of teaching community health nursing as a process integrated into the curriculum,

rather than as a series of topics.

In contrast to the internal enabler,-faculty champions, the second theme

that was a challenge for many schools was lack of qualified faculty to teach

community health. Shortages of faculty prepared to teach community health

nursing were explained by faculty retirements and moves, few graduate-degree

prepared community health nursing faculty, and few faculty members with

practical community health experience. The shortage was exacerbated by faculty

members’ lack of knowledge of current community health issues and concepts. As

noted by one participant, “adding to this challenge [are] instructors who have

never worked in the community or having very little practice experience in the

community, have poor understanding of key community concepts and then being

thrust into this clinical practice setting.” A participant also commented that

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community college collaborative program faculty members do not have expertise

in community health nursing.

Weak community health leadership in academe. Weak community

health nursing leadership in educational nursing organizations impacted

negatively on integration of community health curriculum content and educational

resources. Several respondents lamented that few nursing program leaders have

community health backgrounds. Some participants noted that it was essential for

top administration to buy-in to community health nursing and the CCHNSoP. One

participant shared some of these challenges:

Community health nursing faculty are not represented within the Program

Director positions. Program decision makers are unaware of the impact of

the province’s community health nursing population profile on our

community health nursing program, therefore are unaware of the unique

challenges faculty experience recruiting community partners (nurse

preceptors at community sites), collaborating with these partners, and

developing the necessary supports for student learning (student health

promotion projects; focus on family, aggregates; health promotion rather

than medical care; need for bilingual teaching materials).

A lack of valuing of community health by academic administrators led to budget

allocation problems that impacted negatively on community health nursing

education including: high faculty-student ratios, administrative complexity from

offering multiple programs (Post RN/BN, accelerated, collaborative), and space

problems. The variety of program options offered by many schools was reported

to overburden clinical resources. In addition, participants also reported higher

student/faculty ratios in community (1:12) compared to hospitals settings (1:8).

Community health nursing faculty resources were further stretched by requiring

faculty to monitor students in up to 10 to12 rural and urban communities, which

imposed additional travel time. The result: reduced faculty time spent with each

student in community.

Strategies to Overcome Challenges

Respondents identified a number of strategies to overcome these

challenges. To promote preceptor availability within programs, respondents

suggested: a) permitting nurses to have a choice to be preceptors rather than

being forced by management; b) increasing incentives through access to library

resources and other recognition strategies; and c) providing nurses with lighter

workloads to accommodate students. Despite the problems associated with non-

traditional placements, a number of respondents identified unique non-traditional

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placements as a solution for placement shortages. School administrators were

urged to construct learning opportunities that develop competencies outside of

formal practice settings through non-traditional placements, such as correctional

facilities, seniors and drop-in centres. For example, one respondent described a

provincially-funded rural incentive program, which enabled students to complete

practicum experiences in remote and rural settings. Solutions to overcome

practice environment challenges focused on improving communication between

academic and practice settings. For example, preceptors and managers were

encouraged to discuss the amount of guidance and supervision to expect from

faculty, and community program managers could meet with faculty as a group to

discuss student placement opportunities.

DISCUSSION AND RECOMMENDATIONS

It is generally accepted that teaching community health nursing requires a

strong practice component. Nursing is an applied science that requires theory and

practice to adequately prepare individuals to meet expected entry-level

competencies for community health nursing. Supported by the findings, there are

decreasing supplies of clinical placements to support community nursing

education (Latter et al., 2003; UKCC, 1999). Although there are a number of

valid and significant reasons for this, three major themes were identified that

contributed most significantly to the success or ‘failure’ of integrating community

health content into undergraduate nursing programs. Overall, placement

challenges, preceptor challenges and devaluing of community health nursing as

compared to acute care, were the major overarching themes. These factors are

well supported in the literature. Research has also shown that there are

insufficient community health clinical sites to accommodate students (Sweeney &

de Peyster, 2005). In the U.S., funding for illness prevention and health promotion

activities was cut dramatically, and there have been serious shortages of public

health nurses. At the same time, schools have been encouraged to increase

community-based curriculum content (Quad Council of Public Health Nursing

Organizations, 2007). In addition, students have preconceived ideas that ‘real’

nursing involves taking care of sick patients in the hospital (Ervin, Bickes, &

Myers Schim, 2006; Speck, 2003). There is pressure for students to master acute

care content to pass licensing examinations and manage “high-tech” care in

community-based settings (Ervin et al.). Other challenges include the mismatch of

didactic content delivered in courses, such as the care of adults in acute care and

the community as the care setting (Ervin et al.). The present environmental scan

results corroborated the findings of Edwards and Alley (2002), who found

resistance from faculty members regarding the balance of community-based

versus acute care curriculum content. The results also supported Ervin et al., as

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well as Speck’s (2003) work, who found that there are few faculty members with

community health clinical experience, which leads to work overload for

experienced faculty.

To address these challenges, respondents identified value in a curriculum

that supports community health nursing content. It has been suggested by others

(Irvine, 2007; Nehls & Vandermause, 2004; Thomas & Carroll, 2006) that a

supportive academic environment which ensures faculty knowledge of

community health content and principles is essential to ensure community nursing

practice is addressed adequately in undergraduate education. When nursing

schools have a strong community health curriculum, improved relationships

between clinical agencies and academe can and should be built. These

relationships are essential to ensure enough community placements and

opportunities exist for students. Nehls and Vandermause, discussed the need to

have community-focused nursing education to support students, faculty and

agencies. Although having strong community relationships were found to be an

enabler in the present study, others have identified that it has been a challenge to

establish long-term relationships with community agencies and groups (Edwards

& Alley, 2002).

The findings of this investigation highlight examples of successful

relationships between academe and clinical agencies, which are shown to provide

mutual benefits to all partners involved. Although community-academic

partnerships can be formal or informal, the teaching health unit model (Black,

Edwards, McKnight, Valaitis, & Van Dover, 1989) and the Community Academic

Practice Alliance (Ganley et al. 2004), which represent formal partnerships, have

been found to support community health nursing education. The models described

in the current findings required local government support. With such dedicated

resources, programs can provide appropriate community faculty and funding for

placements to integrate all program components required for beginning entry level

community health nursing standards. Although having strong community

relationships were found to be an enabler in this study, others have identified that

it has been challenging to establish long-term relationships with community

agencies and groups (Edwards & Alley, 2002). Latter et al., (2003), and Thomas

and Carroll (2006) support the notion that legislative policy helped the transition

from acute care focused health education to community health education. As

governments and administration provide more financial and personnel resources,

the opportunity to shift curriculum and create stronger partnerships increases.

This foundation is the basis of the key recommendations taken forward to CASN.

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As problems contributing to limitations with preceptors and practice

environments become more complicated, so do the strategies required to

overcome them. The present scan identified a variety of strategies to manage

preceptor stressors: providing nurses a choice whether or not to be preceptors,

increasing incentives and recognition for the role, and reducing workload to

accommodate students. Providing nurses a choice of whether or not to be

preceptors has been supported in the literature. If qualified and valued staff

members are asked repeatedly to be preceptors and do not receive rewards or

support, burnout can occur (Dibert & Goldenberg, 1995; Usher, Nolan, Reser,

Owens, & Tollefson, 1999). With respect to workload, research supports the need

for preceptors to have release time from normal duties to orient students, review

and revise goals and objectives throughout the experience, as well as conduct

evaluations (Ohrling & Hallberg, 2001; Usher et al.). This scan also addressed

solutions to placement stressors, namely the use of non-traditional placements.

Also urged in the literature is that innovative community placements such as

parish, corrections, aboriginal, rural and international placement settings, can be

transformative for gaining witness to poverty, inequities and marginalization, as

well as increasing critical engagement and commitment to social change (Reimer-

Kirkham, VanHofwegen & Hoe Harwood, 2005). In addition, innovative

partnerships with housing authorities for the elderly and disabled have been found

to be valuable for student placements (Ellenbecker, O’Brien, & Byrne, 2002).

Educators in the U.K. have delineated criteria for non-traditional nursing

community experiences, including placements which can provide: a) variety of

health and social care resources over 14 weeks: and b) qualified and enthusiastic

nurse mentors who have the knowledge to facilitate a broad community

experience, and can offer weekly contact for a minimum of 2 shifts weekly.

CONCLUSION

This environmental scan illustrates the need for stronger partnerships

between academe and community clinical agencies. Allocation of resources for

education in community nursing is as important as that for acute care, if we wish

to have a nursing workforce prepared to meet future health care demands.

Recommendations encouraging this balance have been forwarded to the CASN

Board of Directors and the Public Health Agency of Canada. This scan has

highlighted the need to send a strong message to governments, educators and

administrators to ensure that there are adequate and appropriate resources, in

funding, and human and technical resources, to guarantee deserved recognition

for undergraduate community nursing preparation in Canadian nursing schools.

Through the efforts of CASN and the Public Health Agency of Canada, it is

hoped that faculty will champion and be supported in their efforts to prepare new

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graduates for community health nursing positions, and thereby meet the health

care needs of the 21st century.

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