Yasmeen Jan Mohammad  ( Aga Khan University School of Nursing and Midwifery (AKU-SONAM), Karachi, Pakistan )
Samina Vertejee  ( Aga Khan University School of Nursing and Midwifery (AKU-SONAM), Karachi, Pakistan. )
Saleema Gulzar  ( Aga Khan University School of Nursing and Midwifery (AKU-SONAM), Karachi, Pakistan )
Shireen Shehzad  ( Aga Khan University School of Nursing and Midwifery (AKU-SONAM), Karachi, Pakistan )
Saima Sachwani  ( Aga Khan University School of Nursing and Midwifery (AKU-SONAM), Karachi, Pakistan )

Objective: To explore the perceptions and experiences of students and faculty about the modified community clinical model.
Methods: The descriptive qualitative study was conducted at a nationally-accredited Baccalaureate School of Nursing and Midwifery in Pakistan in November 2016, and comprised final year students enrolled in Advanced Concepts in Community Health Nursing course, and experienced community health nursing faculty members. Individual interviews were conducted with students while faculty members were requested to write out their reflections. On the basis of this data, codes and categories were identified which led to two broader themes; window of opportunities, and challenges in practice.
Results: Of the 17 subjects, 12 (70.6%) were students and 5(29.4%) were faculty members. All subjects were females. The window of opportunities theme had three categories: perceived comfort and safety; stakeholder's involvement and support; and open door for personal recognition and self-image. The challenges in practice theme had two categories: time consuming, and home visits. Faculty reflections highlighted the need for sustaining student-related activities within the communities.
Conclusion: The findings are suggestive of a wide range of application of the modified clinical model at undergraduate nursing education level.
Keywords: Community health nursing, Undergraduate nursing students, Pakistan, Experiences, Faculty perceptions. (JPMA 69: 1253; 2019)

Introduction

The recent shifts in healthcare paradigm from acute to community-centred care, along with the modification of educational and community-based healthcare, have vividly surfaced as the one of the viable solutions to meet sustainable developmental goals (SDGs).¹ Hence, the developing countries around the world, such as Pakistan, must look upon innovative approaches to educational programmes and trainings for community health nurses (CHNs) who are well-equipped to respond comprehensively to the health care demands. ² Being resource-constraint and jeopardised under the burden of diseases, Pakistan is ranked the sixth most populous country. ³ To address the national need, Pakistan Nursing Council (PNC) in 1985 initiated the Community Health Nursing (CHN) course as a sub-set of national nursing curriculum for undergraduate nurses. ⁵  Currently, CHN comprises almost 21% of the nursing curriculum. It aims at building the national capacity, and to prepare future primary healthcare workforce to address the emerging needs of the community. ⁵  Using context-based innovative approaches in teaching, the CHN course is recognised as an important aspect of preparing undergraduate baccalaureate nurses. This approach facilitates in-depth knowledge, attitudes and skills necessary for practicing CHN in community settings. ⁶  Globally, CHNs work in a variety of settings and provides all levels of care, including primary, secondary and tertiary. ⁷  Similarly, in the context of different countries, students nurses have been trained in various settings to practise community care. ⁸ Undergraduate nursing curriculum focusses on handson training while delivering the theory; likewise the CHN course also ensures theory and practice together which helps students to strengthen their knowledge, skills and competencies relevant to the promotion of community health. Students on clinical rotations work hand in hand with community stakeholders by considering key elements, such as culturally sensitive care, community empowerment, and sustainability. In the current clinical model, several logistic arrangements are involved, including, among others, students' transportation, faculty supervision, favourable community site for student safety and minimum travel time. Several concerns have been raised by students and faculty about the current clinical teaching model, including student's comfort in a strange community, high saturation level in communities, lack of follow-up on students' projects, increased travelling time to the communities, and students' safety and security. In addition, the increased number of students enrolled in nursing programmes is also supportive of concerns raised by students and faculty. The current clinical model is in practice for a long time, but there is no empirical evidence available locally to validate its effectiveness. Internationally, several other models have been tested to address similar issues. The current study was planned to gather in-depth insight on students and faculty experiences and perceptions of the modified community- based clinical model.

Subjects and Methods

The descriptive qualitative study was conducted at a nationally-accredited Baccalaureate School of Nursing and Midwifery in Pakistan in November 2016, and comprised final year students enrolled in Advanced Concepts in Community Health Nursing course, and experienced community health nursing faculty members. The institution selected offers PNC-prescribed CHN course to undergraduate nursing students. Under the new clinical model, students are grouped together based on the proximity of their dwelling and are sent for clinical teaching exposure along with a clinical faculty member to the selected areas. Using purposive sampling, students aged 21-23 years who consented to take part in the study were enrolled. Faculty members who had taught CHN courses in the preceding five years were invited to write reflections of their clinical experiences of teaching CHN in the undergraduate nursing programme. This sampling facilitated obtaining the cases deemed information-rich for the study.^9,10 After ethical approval was obtained from the institutional ethics committee, data was collected using individual interviews and reflections. Qualitative data analysis is the process of organising and structuring the data to extract meaning for necessaryfuture recommendations.9 Creswell's six steps of content analysis have been found to be both logical and credible¹¹  and in line with it, all interviews, field notes and reflections were organised for analysis after interviews were converted into transcripts. In the second step, transcripts were read multiple times to develop in depth understanding to extract more meaning in the context of the study. In the third step, codes were derived, and they were studied for similarities and differences. In the fourth step, the codes were grouped into categories. Next, the categories were clustered to generate themes. And, finally, the themes were compared with literature. ¹¹

Results

Of the 17 subjects, 12(70.6%) were students and 5(29.4%) were faculty members. All subjects were females. Many participants felt that undertaking CHN clinical practice in their own territory was very different than exposure to other communities during their initial years. To capture the essence of differences, the finding was grouped into 2 major themes: window of opportunities, and challenges in practice.
Under the first theme, 3 categories were identified thefirst of which was 'Perceived comfort and safety'. In the traditional model, students often expressed feelings of insecurity, and an unsettling sense that led to demotivation for community practice experience. However, with the use of current, modified model, while working in either their own area or a nearby area of their dwelling, they verbalised the feelings of comfort and safety.

As a participant verbalised: "I have also worked in community in Year II of undergraduate nursing programme, but this time it was a more interactive time with community and stakeholders." (R9)
Another participant attended her clinical placement commented: "Experience of CHN clinical was goodthroughout. I was comfortable in interaction with community people. As we were working with our own

people in close community, I felt safe." ( R1 )

A participant, who associated her current community experience with her past practice, shared: "My experience in community was very nice. We were comfortable in interaction with community. Community was safe and secure to work with."
(R6)Another participant, highlighting the benefits of personal recognition and self-image, verbalised: "It was a good learning opportunity for the ones who are passionate to work for the community. It does not only teach us how to integrate our theoretical knowledge with practice but also motivated to work along with building relations with the stakeholders and community leaders. Our experience was pretty good as the community we

worked in was the one we belonged to." (R13).
The second category under the theme was 'Stakeholders' involvement and support'. To function smoothly in community, most students are often dependent on stakeholders' involvement and support. Participants being from the same community reiterated high level of stakeholder support under the new clinical model. A par ticipant shared her experience regarding community stakeholders' involvement and support, saying: "Initially, I felt hesitation in interaction, but soon I received encouragement from all stakeholders. As we were working, I felt the need of community, and we received much cooperation from high officials of the community." (R4)

Another participant, expressing value of stakeholders' involvement and support, shared: "We were comfortable in interaction with the community. All members of community and stakeholders were very supportive and cooperative." (R6)
Integral to stakeholders' support, another participant verbalised: "All stakeholders, cooperated with us and also guided us with their ideas, especially health board members." (R8)

The third categor y was 'Open door for personal recognition and self-image'. Working within their own community gave the participants a sense of personalrecognition amongst their own people. In addition, they were also able to engage with various stakeholders much easily, especially those holding leading positions in the community.

One participant reported: "It was a good experience as it helped us to enhance different skills, like communication, creative and critical thinking etc. Because of this project, I got a chance to be familiar with different people living in my community. Apart from that, I was also able to interact with well-known NGOs."



(R10)

Another participant stated: "Before this community visit,

my family, friends and a few people knew that I was a

student nurse. After this visit, I was exposed to a larger

population." (R2)

Similarly, acknowledging the identity, the participant shared: "Once I was on voluntary duty and one of thewomen approached me and shared her health status after doctor consultation, and she shared few difficulties in terms of prescription compliance. I provided health education to her on diet, exercise and importance ofcompliance to medication. She also asked me to inform

her of future health education sessions."
(R2) Interestingly, personal recognition and self-image was also identified as an important mechanism for sustaining acceptance of CHN role in the future. The following citations support this idea:
"Since we had a chance to run a project, therefore it proved to be very useful for the ones who want to be a community nurse in future."
(R5) "This current experience provided me guidance for my career. I started considering CHN as well as public health sector as my future career choices."
(R10) "In my opinion, we can continue with the CHN clinical with this community as the people are helpful, compassionate and respectful. But this is a developed or groomed society to some extent."
(R8) The second theme related to challenges in practice and the first category under that theme was 'Time Consuming'. For some midwives, it was the most important challenge. The students' activities often required time, but at times they felt demotivated as the time given for clinical rotation was not enough to complete the task, and forced them to complete the expected clinical objectives within the limited time. One participant stated: "Though I felt safe and respected throughout, it was time-consuming as it required a lot of effort to prepare or execute the project effectively."

(R8) Similarly, another participant, for whom time was major constraint, expressed her feelings thus: "The toughest thing about the community working is to collaborate with stakeholders and different types of difficulties were faced in time management while meeting with the stakeholders."
(R9) The second category under the theme was 'Perceived unwelcome.' A welcoming attitude on the part of the community was one of the motivating factors for students. However, for some participants, their services were not regarded as beneficial, and consequently they were not welcomed. A participant said: "In terms of interaction with community, it was a bit difficult since not everybody in the community welcomed us in their homes even though we tried out best to build rapport."
(R11) The participants also reported that the community's welcome developed an understanding between the CHN and the beneficiaries in order to initiate and sustain the activities. Referring to the unwelcoming remarks, one participant said: "In terms of my experience during the CHN clinical, it was an interesting and very learning experience. But at times, interaction with community was a bit difficult since many in the community even before listening to us closed the door saying they were and that we should come later.
(R10). Participants also acknowledged past colleagues' reputation as one of the reasons for not being welcomed. One participant commented: "Whenever we interviewed any family member during the need assessment, most people said, 'students come every year and they do not do anything good for us … they just collect data every year … what do they do with this, we never know."
(R8) The reflections offered by the faculty were in support of change from the traditional to the modified CHN clinical teaching model. One of the key reasons supporting the change was that in times of political unrest and city disturbances, or incidents like kidnapping, robbery, and rapes, the faculty felt highly unsafe and insecure to take the students to the communities which were at some distance. Therefore, they strongly recommended that the community clinical exposure should be within or in close proximity of students' (especially for girls') residential area. Having community-based clinical rotations within the proximity will serve several benefits. First, students' clinical projects could continue regardless of any situation, which could result in continuity of care and rapport-building between the community and the students. Secondly, it minimises the travelling time and increases students' comfort level as they work within or in close proximity of their residential area. In addition, it enhances productive time that the students are able to spend with the community people and stakeholders to implement the projects. Finally, as the duration of clinical rotation is short, it is essential that strategies should be in place for the community to take ownership of their healthcare needs and project sustainability. This modified community teaching model allows students to implement projects not only during their rotations, but even after their rotation is over and it can even be extended after the students complete the course. In the past, due to travelling distance, short clinical rotation and missed clinical days due to city disturbances, students and faculty had expressed dis-satisfaction with the community clinical rotation. In particular, the issues were raised regarding project sustainability as students were not able to follow up with the communities and it was a challenge to prepare the community to take ownership within a short time period.

Discussion

The study explored students' perception and faculty reflections regarding CHN clinical teaching models practised during the undergraduate nursing programme. When examining the responses of the students, undertaking the community clinical experience in theirown localities (defined as residential area of each student) was identified by the majority of participants as an enjoyable experience. In addition, the participants compared the two models of clinical teaching, traditional (consisting of faculty assigning the students randomly) and the current (student getting assigned within the geographical area of their dwelling). According to them, the community clinical experience in their own setting was considered a valuable experience as many participants felt this model opened a window for opportunity to sustain or continue the project work later. This finding is consistent with an earlier study that evaluated the experiences of nursing students in a seven-week course designed to develop community nursing and cultural competence among junior and senior nursing students. ¹²  Moreover, the findings revealed that the participants expressed satisfaction with current modified CHN clinical teaching model. Their contentment was related to their comfort, safety and achieving stakeholders' cooperation that they received for executing their project work. These findings are in line with the findings with another study. ¹³  Besides, the participants added they were excited and motivated while working in their own settings as it allowed them to set a stage for themselves to increase their visibility as nurses within the local community. This aspect of experience had opened a door for their future prospects to adapt a CHN career. This resonates with earlier findings. ¹⁴  The findings substantiate the importance of using local communities for community teaching experience. This suggests that the current undergraduate nursing curricula may require revision in terms of selecting clinical teaching placements that may meet students' expectations and needs. The current study also revealed that at times community expressed lack of receptivity towards CHNs or was resistant to utilise local health facilities. The National Household Health Survey (NHHS) of around 70,000 households and 200,000 residents in China in 2003 found that 85% people who became ill had sought healthcare at a large, distant hospital, even though their n earest centre or station was within 1. 5km. ¹⁵ A few participants in the current study also highlighted challenges related to the current clinical teaching models. These included time constraints, and unwelcoming attitudes. These findings are in line with a qualitative study. ¹³   The current study focussed on one cohort of students who underwent the new clinical model. However, the researchers were not able to contact the graduates to ask for their opinions on the traditional model of community clinical exposure, which would have been a rich dataset to compare. Therefore, findings cannot be generalised to other nursing institutions and settings. A multi-centre study would have been much better. Despite the limitations, the findings suggest that more extensive research should be conducted to study the viability of the modified clinical model and to identify measures to replicate the model at the national level.

Conclusion

Subjects viewed modified community clinical placement as a window of opportunity. Many of the participants expressed positive experience with their practice placement. Majority of participants frequently mentioned that they felt comfortable, safe and supported since this experience enabled them to increase their visibility in the community. This kind of experience also offered them a chance to build rapport with various community leaders.

Disclaimer: None.

Conflict of interest: None.
Source of Funding: None.

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