It Takes a Village: Addressing Health Inequities Via Nurse Practitioner Education

Introduction: This presentation describes how nurse practitioner (NP) education can be used to ameliorate the effects of health inequities in an urban area. In the United States (U.S.) minorities who reside in urban areas experience noticeable health inequities when compared with their white counterparts.  Primary care providers offer valuable preventive care and screening services that are needed to prevent and manage chronic conditions. Early screening, detection and access to primary care services can make a significant difference in the quality and longevity of an individual’s life. Nurse practitioners can ease the burden of the primary care shortage however they must be provided with meaningful learning experiences that will encourage them to remain in primary care.  Providers are often reluctant to precept NP students due to concerns of decreased productivity.  In areas where there are several nurse practitioner programs, students often compete for limited clinical practicum sites and preceptors.  All of these factors negatively affect the NP student’s experience making it challenging for NP faculty to find appropriate clinical learning experiences for NP students.

Service learning (SL) in its traditional sense is a way of incorporating community service into an educational experience.  SL as an educational technique is often used with children in primary and secondary schools.  In nursing we typically see SL in the undergraduate curriculum.   When combined with the principles of community based participatory research (CBPR) the technique becomes much more sophisticated and can be used to address areas of health inequities within a community. Using the combined approach of SL and CBPR has allowed faculty at Rutgers University College of Nursing to increase the number of high quality primary care agencies and practicum preceptors available to students, especially in pediatrics. 

Intervention: In Newark NJ there are approximately 22,000 infants and preschoolers who reside in the community. Most of the children attend preschool however many do not receive preventive health screenings. Utilizing the principles of CBPR the program director met with service agencies and schools to identify needs for their preschool population.  A memorandum of understanding was developed with specific outcome goals for the term of involvement. In the spring of 2013 we piloted a learning experience within an existing course for NP students to provide hands on primary care and screening for young children in a community setting.

Students were randomly assigned to the community group. For half of the semester, seven weeks, students worked in the community settings providing wellness care and for seven weeks they worked in traditional primary care offices providing preventive but mostly acute care. The program director met with the leadership of the various community agencies to coordinate logistics.  Prior to visiting the sites students received training in the skills lab for vision, developmental and obesity screening and referral procedures for the preschool age child.  Pre and post course assessments were done with the students to determine their level of skills knowledge and their comfort level working in urban areas with minority populations. Student provided care, collected data, made necessary referrals and prepared detailed reports for the service agencies.

Results: Prior to the learning experience 100% of the NP students stated they had only partial  knowledge of child growth and development and health screening and only 83% had partial knowledge of nutrition.  After the experience 100% of the students indicated that they had full knowledge and understanding of the subject matter. Prior to the experience 30% of the students indicated that they were uncomfortable caring for children and 85% indicated that they were uncomfortable working with minorities in urban settings.  After the experience 85% of the students indicated that they were extremely comfortable caring for children and 15% indicated that they were comfortable.  Post experience 50% of the students indicated that they were extremely comfortable working with minorities in urban settings and 50% indicated that they were comfortable.  Student comments were overwhelming positive.  Many commented that the experience helped them with the didactic course and all recommended that the experience be incorporated as a permanent part of the course.

NP students provided services for 368 children between the ages of 6 mo and ten years of age.  59 referrals were made for obesity, six referrals were made for failure to thrive/underweight, six referrals were made for vision deficits, twelve referrals were made for speech delays, three referrals were made for gross motor deficits and two referrals were made for detailed developmental/autism assessment. The community agencies were appreciative of the services provided. Parents of the children who received referrals for health or developmental services expressed appreciation.  One preschool used the data that was presented to make changes to their preschool program.

 Next Steps: Based on the findings and feedback the community primary care rotation is now a permanent part of the pediatric practicum course.  After  a successful implementation one year ago community health agencies, health care foundations and social service agencies are now reaching out to the College of Nursing to aid and partner in initiatives that benefit large segments of the urban population and help the agencies meet their charge to the community. As a result, training and screening will be expanded to include oral health assessment and fluoride varnish application and lead and hemoglobin testing and referral.