Developing an Academic and American Indian Tribal Partnership in Education: A Model of Community Health Nursing Clinical Education

Abstract

American Indian tribes shoulder a heavy burden in health inequities and recognize the value of partnerships with academic institutions. This paper describes a unique education model developed through a partnership between a School of Nursing and 2 Pacific Northwest tribes to provide clinical education for students. Over 3 years, students and faculty worked with 2 tribal communities to design research and implement education programs.

American Indian tribes shoulder a heavy burden in health inequities and are beginning to recognize the need to partner with academic institutions to address their health concerns (1, 2). Nursing educators seek models for preparing nursing students in transcultural nursing practice (3–7). Through a 3-year National Institute of Nursing Research (NINR) grant, we were provided funding to build tribal capacity in research and to expand our clinical teaching partnerships with 2 Pacific Northwest Coastal tribes and our School of Nursing. In this paper, we present our unique clinical teaching model of value to nurse educators involved in clinical service learning.

Background

American Indian and Alaska Natives (AI/AN) shoulder a heavy burden of health inequities. It has been recognized that greater emphasis on translational, evidence-based research with clear measurable outcomes is needed (1, 2, 8, 9). Despite this recognized need, challenges in translational research with American Indian populations can be daunting due to a history of mistrust of research and researchers, the need for an extended investment of time to develop collaborative relationships, travel costs, and a lack of nursing and health sciences researchers and tribal community members who are prepared to engage in these unique collaborative partnerships (10). In particular, rural American Indian tribal communities typically have limited experience in collaborating with academic researchers to implement evidence-based research, and existing research structures within academic institutions are not designed to support teaching and research with American Indian communities (10). Thus there is a need for appropriate teaching models and the development of collaborative infrastructures to support academic tribal partnerships to address tribal health concerns.

Cultural competence is widely recognized as an essential component of education in nursing, yet nursing faculty often struggle to develop effective teaching approaches (4–7, 11). Immersion in transcultural settings has been recognized as an important aspect of this education process (12, 13). A Blue Ribbon Panel on the Future of Nursing Education noted the importance of education that supports students’ understanding of the nursing role in relation to patient, family, and systems/structures of care (14). The panel further recommended revisions in the usual “rotation” models and suggested that opportunities for immersion experiences and long-term collaborative relationships should be designed. Delineating the skills that can be obtained in a clinical setting was also a priority, as well as providing greater clarity in the articulation of the goals of clinical education.

Since the work of the Blue Ribbon Panel, and the Think Tank on Transforming Nursing education, a number of authors (15, 16) have suggested that a new paradigm in nursing education is needed along with innovative approaches involving greater collaboration among students, faculty, and clinical agencies. An example of work to address issues in clinical nursing education is the efforts of the Oregon Consortium for Nursing Education (17). They noted as well as others (18) that often clinical education is based on the availability of sites rather than the relationship of the experiences to the course objectives and have undertaken efforts to consider more creative and innovative approaches to clinical nursing education.

Along with the challenges of providing meaningful clinical education for nursing students, community health nurses working in transcultural settings have long noted that the skills in developing cultural competence are only vaguely understood (19, 20) and that there is a need to develop teaching approaches that integrate cultural issues into clinical activities. Community health nursing faculty have recognized the importance of offering immersion experiences that expose students to other cultures and awaken them to the understanding of the complexities of working in a culture other than their own. MacAvoy and Lippman (6) and St. Clair and McKeney (13) suggested that longer immersion within a cultural setting, rather than the more typical short clinical experiences, would provide nursing students with a clearer understanding of cultural complexities such as ethno-relativism. Furthermore, Hunt and Swiggum (5) investigated the impact of an intermittent service learning clinical rotation of students with homeless families and found that developing cultural competence cannot occur in a classroom setting, but requires time and progressive experience under faculty supervision.

In considering models of clinical experience, nursing academicians have distinguished traditional clinical education from service education (21, 22). Service learning places emphasis on balancing the service needs of the community with academic education goals and focuses on reciprocal learning in which faculty, community partners, and students are all learners (18). Such an approach is congruent with the current movements in community health nursing practice and research with the emphasis on community engagement and community based participatory research (CBPR) (10, 23–27). Campinha-Bacote (11) suggested that Leininger’s transcultural theory (28) along with cultural awareness, knowledge and skills provide the basis for service based clinical education in community health nursing. Multicultural education and service learning are powerful partners (7). Flannery and Ward (4) also suggested that service learning contributes to the preparation of practitioners committed to contributing to their communities. In our 3-year, service learning project, we drew on community engagement models, primarily, CBPR (27, 29, 30), to build tribal capacity in research and to implement a unique teaching model designed to enhance student understanding and skills in building community partnerships.

The tribes in this project were relatively small (1,000 members each). The health epidemiology profile of each tribe was similar to the national and regional data. Increasing physical activity and improving nutrition was a priority in 1 tribe, which sought to address diabetes through upstream efforts in prevention; increasing rates of breast cancer was addressed by the other tribe through women’s health screening education and providing programs for breast cancer survivors.

Educational Model Design and Structure

The teaching model we used in this project was a clinical service model, in which both undergraduate and graduate students were immersed in the tribal communities under University faculty supervision, to develop practice skills in partnership building, core public health competencies, program planning, and transcultural nursing practice. We created an overarching administrative structure for the project that involved the project Principal Investigators, tribal Community Research Associates, a faculty evaluator, and a faculty consultant in CBPR and transcultural education. This core team provided guidance for the entire project; we also created a Project Advisory Committee that was comprised of tribal, faculty, student, and community agency partners. For the education model, we created a core team of instructors, which included both University nursing faculty, Community Research Associates hired from the tribes, and tribal clinical preceptors.

Based on principles of CBPR (27, 29, 30), we involved the tribe in all phases of the work including the design of the grant application, implementation, evaluation, and dissemination. Our clinical educational objectives were linked to the established objectives within the school of nursing for undergraduate and graduate programs in community health and tailored for this particular site rotation. Both graduate and undergraduate course objectives included demonstration of the following: a) an understanding of the community health nursing role in a transcultural setting; b) skills in program planning; c) an ability to translate research evidence into practice; d) an ability to work effectively in teams; e) skills in communication and community engagement; and f) an understanding of Pacific Northwest American Indian cultural values, beliefs, patterns of communication and health concerns. Content focused on theoretical models for community health practice, particularly program planning, community engagement, and issues in transcultural nursing. Major Pacific Northwest American Indian health concerns, cultural values, and patterns of communication were emphasized.

Outcome evaluations of the entire project were based on World Health Organization principles for health promotion evaluation (31). In evaluating the education model, we examined the overall administrative structure, education approaches, and student progress. Faculty participated in quarterly conference calls in which the design and structure of the education model were discussed and conferred weekly while working together in the tribes. Faculty and students engaged in both formative (in progress) and outcome evaluation. Community Research Associates and tribal preceptors partnered in providing feedback in the evaluation process. Student progress was based on course objectives. Faculty held evaluation sessions with students at the end of the quarter in which work was related to the course objectives. Sustainability was ensured by linking the model to structures and systems in both the tribes and the School of Nursing. Tribal Community Research Associates were given faculty appointments.

Clinical Education Model, Requirements, and Activities

Both undergraduate and graduate students participated in service learning clinical experience. During the 3 years of the project, 60 undergraduate, 13 graduate students (11 Doctor of Nursing Practice [DNP] and 2 Masters of Nursing [MN]), and 3 faculty members were physically present in the tribal communities. The rotation for undergraduate students was for 1 quarter, 4 credit hours (1 credit was equal to 3 hours in clinical practice) for a total of 12 hours each week for 10 weeks. DNP students completed 17 credit hours provided over 5 quarters; MN students completed 9 clinical credit hours provided over 3 quarters. DNP students also completed a capstone project, and the MN students did a project or thesis. These projects required continued investment of time in the tribal communities.

Undergraduate students took a core community health didactic theory course and a clinical course in conjunction with the clinical rotation. The graduate students were required to complete a 3-hour theory course in conjunction with the clinical rotation. The clinical rotation also required 3 hours each week of didactic instruction.

Students gained an understanding of culturally appropriate approaches as they developed the knowledge, skills, and behaviors outlined in the standard clinical course objectives, while providing services to the tribes. Tribal Community Research Associates provided insights into content needed to address issue such as the tribal history of mistrust in partnerships, tribal sovereignty, and health concerns. They participated in developing a video recording on this content, which was made available for students and faculty in the School of Nursing. In building partnership skills, teamwork was emphasized, and students worked in teams comprised of undergraduate and graduate students, faculty, and tribal community members.

A typical clinical rotation day began with a ferry ride of about 45 minutes to the tribal communities. During that time, team planning for the day and preparation of handmade “gift” items for tribal elders and others, who contributed to the program, was undertaken. The core objectives and course content were tailored to address the clinical activities for that day, and undergraduate students prepared and provided presentations on topics in American Indian health. The framework of program planning was emphasized in the clinical education. Sessions were held on assessment, establishing goals and objectives, community engagement, program design, materials development, and evaluation. The rest of the day students worked with the tribes, including participating in planning teams; analyzing data; conducting needs assessments; and designing, implementing, and evaluating health promotion programs. Students also participated in the daily events of the tribe such as elder dinners, exercise classes, and other activities as they occurred. They learned that building partnerships takes time, careful observation, and involvement in tribal activities. On the ferry ride home, students discussed their activities and experiences of the day with each other and with faculty. Reflective thinking was addressed with a journaling assignment.

While much of the leadership and direction for education was provided by academic faculty, community mentors were also actively involved in the “hands-on” education experiences. A Project Advisory Committee, comprised of tribal community members, tribal community research associates, university faculty and students, and representatives of community agencies in the region met biannually to provide a forum for all involved to share resources and consider the potential for additional collaborations to meet the needs of the tribes. Student work was featured at these meetings.

During the course of their program of study, DNP students spent a total of 3 years working in the tribal communities. In the first year, students engaged in assessment, understanding cultural issues, and building trusting relationships through participation in small health planning and implementation teams with the undergraduate students and faculty. Some were involved in projects in which they participated in research proposal development with the tribes. In the second year, they began the work of creating or linking to a planning team in the tribe to address an identified community health concern for their capstone project; in the third year they implemented the capstone project, which required review by the tribal council and planning team. Thus students were deeply immersed in conducting a project that required community partnership. They learned how to work with the tribe to develop the Memorandum of Understanding (MOU) to document the working relationship for the capstone project.

The following examples provide further understanding of work that was undertaken by students. In 1 tribe, students participated in the development of a breast cancer survivorship education event and small grant to support further community awareness on breast health. Some students supported planning activities with the nutritionist and community health nurses to increase physical activity and reintroduce traditional foods and nutrition. With the DNP capstone studies, students conducted interviews and offered recommendations for the evaluation of a large tribal community program planning CBPR team; they also worked with a tribal planning team to develop policies for tribal consideration related to nutrition and the purchase of foods and provided recommendations for recruitment and retention of participants in a physical activity program. Master’s students conducted literature reviews and participated in cancer prevention programs and the design of a diabetes education program. They participated in transcribing, coding and analyzing interview data, and in planning for tribally conducted focus groups.

Results

Establishing rapport, building supportive partnerships, and developing sustainable infrastructures to support long term relationships are all critical to address health needs in American Indian tribal communities. We employed an individual in each tribe to serve as the Community Research Associate and gave them faculty appointments to provide them access to University resources such as the library, to enhance their curriculum vitae for grant submission, and to solidify our working relationships and their mentorship of our students. They in turn provided teaching mentorship for students and engaged students in program planning and research to meet tribal health concerns at the individual, family, community, systems and policy levels.

With our new model of teaching, we have been able to offer opportunities for students to work collaboratively in teams to learn how to develop, implement, and evaluate programs, and write small research proposals. They also engaged in practice inquiry in which they have translated evidence to practice. Faculty and students partnered with the tribes in the submission of 2 R01 applications and supported the tribes in the submission of a number of grant applications, which were awarded; students were then able to participate in the implementation. Thus, it was possible to integrate teaching, research, and practice.

Challenges and Lessons Learned

We encountered some challenges and learned some important lessons in this effort. A major challenge with the service/practice model was juggling schedules of faculty, students, and the community. All participants had complex schedules and commitments, and many important community events did not occur on the day scheduled for the clinical rotation each week. Focusing on flexibility, allowing credit time shifts, and faculty follow-up between clinical days resulted in creative adjustments that enabled us to juggle the community needs with the availability of students and faculty. Coordination also was a challenge. Through the creation of the core team framework, we held monthly conference calls to coordinate the work across University faculty and Community Research Associates. In addition, the Principal Investigators invested time in communications with individual faculty and community preceptors to address coordination issues. To assure that all (faculty and students) maintained a sense of the whole scope of the work in both tribes, we held a summary discussion at the end of each quarter.

In summary, the National League for Nursing has called for the development of creative clinical teaching models that provide students with a greater understanding of nursing care in the context of family, systems, structures and community (14), and American Indian/Alaska Natives recognize a need for long term academic partnerships to address their health needs (1, 2). Our School of Nursing received funding to blend these 2 needs by providing a service learning clinical experience for both undergraduate and graduate nursing students, in the context of building American Indian tribal capacity to engage in translational research. This model provided students and tribal representatives an opportunity to work collaboratively in program planning and research proposal development; in so doing, the students have been able to learn and demonstrate skills needed in community health nursing practice in a tribal community. In this teaching model, we have addressed many of the identified issues in clinical nursing education. We also have established structures and partnerships to ensure long term relationships with the tribal communities such as sustainability through the provision of faculty appointments for the tribal Community Research Associates. We found that the following key elements were critical in this partnership building education effort: a) ensuring a long term relationship through structural change, b) engaging tribal members in provision of the education, and c) employing a community engagement/CBPR research philosophy and practice models in the research and teaching efforts.

While our teaching model presented challenges, we were able to achieve our goals. Flexibility, attention to communications, and collaborative structures contributed to success. Our University/tribal partnership teaching model contributes to greater understanding of culturally appropriate, partnership building in community health nursing clinical education. This unique teaching model that combines teaching, research, and practice in partnership building is of value to nurse educators and others seeking creative ways to build community partnerships.