Abstract
Community immersion is an effective way of bringing concepts to life while nursing students are engaged with community members in the real world. Opportunities to apply, observe, and clarify abstract health promotion ideas, including social determinants of health, abound when seen in everyday interactions with individuals outside of an acute care setting. This article details the experiences of a community immersion class as it responded to the COVID-19 pandemic and had to transition mid-semester from an in-person course to a virtual format. Lessons learned from this unique experience provide a case for how to minimize disruptions to a health promotion class, maintain existing commitments with different community organizations, and adapt meaningful engagement to community needs during the pandemic.
Community immersion classes are central to teaching nursing students about social determinants of health. By providing opportunities for student nurses to see how community-level factors influence health outcomes before individuals are admitted in acute care settings, tenets of health promotion and illness prevention are reinforced (Brown et al., 2007; DiPadova-Stocks, 2005). When students are immersed with community-based health organizations, they are afforded a chance to reconcile concepts for which they may only have had theoretical awareness, practice cultural humility, and lay the groundwork for them to become health care leaders (Cleary & Hunt, 2010; Schaffer & Hargate, 2015; Thomas & Smith, 2017). In the spring of 2020, our community immersion class on addressing social determinants of health was on track to achieve these goals. Mid-semester it was necessary to suspend on site engagement due to the COVID-19 (coronavirus disease 2019) outbreak. With 18 undergraduate students placed across six community sites throughout Philadelphia, a challenge emerged about how to reconfigure a class originally designed around understanding social determinants of health through community immersion.
Addressing the Social Determinants of Health: Community Engagement Immersion (NURS 354) is a case study that uses a flipped classroom format in which students process class materials at community sites with preceptors while in-class time is focused on a deeper and interactive exploration of the course content with course faculty (Schroeder et al., 2019). While the majority of course time was dedicated to community engagement, there was a combination of in-person and online features that were incorporated into the class. Students were required to contribute to a weekly online discussion, attend three mandatory in-person classes (at the beginning, middle, and end of the semester), and take part in one supplementary class of their choice about a focused topic (e.g., racism and health, opioid abuse epidemic, sexual and gender minority health) taught by course faculty or invited experts. At the start of the semester, students were also required to collaborate with a community site staff member to develop and conduct a health-related project based on the goals and priorities of the community. This health-related project constituted 40% of students’ final grade.
Similar to other institutions of higher education, the unprecedented nature of the coronavirus (COVID-19) outbreak required classroom instruction to be provided online and for all community-based activities to be suspended. Our case study required 22 hours of onsite immersion and there was an immediate decision to redesign the course in early March 2020. It was necessary to discontinue students’ weekly attendance at their sites because the community partners had to halt their in-person operations. However, we made the decision to pivot to virtual engagement for reasons unique to our course content. First, as faculty with commitment to community engagement, we needed to ensure that our long-standing relationships with community partners were maintained. Abandoning these partners at the onset of a public health emergency would have been antithetical to the core values promulgated by the course. Second, the central tenet of this course was the emphasis on working with marginalized communities (e.g., families who were unstably housed, grade school students from underresourced communities). Providing support to high-risk communities was even more essential at a time of a global health crisis. Finally, because COVID-19 became an inescapable part of life, we could not ignore the rare opportunity for students to examine, in real-time, how a variety of communities would be differentially affected based on their existing constellation of health determinants.
Transitioning a Community-Immersion Class Online
Having only a week to respond to our university’s decision to suspend all community-based initiatives, NURS 354 faculty responded to the disruption in the semester by reassessing grading requirements, encouraging students to revise the required final project, and incorporate all the important lessons from the pandemic into our class.
Grading Flexibility
Suspension of student involvement in community outreach programs resulted in the inability of the course-required in-person community engagement (2 hours/week) to be completed. This required flexibility in grading criteria. Instead of discontinuing the course, we suspended the weekly, hourly requirement. The university allowed undergraduate students to take any course pass/fail, thus reducing stress and pressure over grades during a time of uncertainty. The change in grading structure was intended to prioritize learning over meeting set criteria and deadlines.
Reassessment of Final Projects
Almost immediately students began to reassess their goals for the class once in-person community outreach activities were suspended, indicating their continued commitment to community partnerships. Course faculty who had in-depth knowledge of each community partner site worked with the students to reimagine new goals that, while scaled down, would still be beneficial for community members. Faculty and students deliberated remotely with community partners on emergent needs and incorporated these in the revised projects. For example, two students who worked with a homeless shelter for unstably housed families responded to calls for an emergency donation drive and signed-up to be the lead contacts coordinating donations coming from the university. Additionally, one other student suggested several ways she could support her site remotely in a discussion board post. This included reaching out to site partners to disseminate science-based COVID-19 information and translating health education material in Spanish. The student added, “We are trustworthy sources for our communities and may, in some cases, have more weight in our recommendations than the government for some populations.” Students practiced humility and openness in asking the priorities of the community partners rather than bringing their own ideas of what the community “should learn,” giving our partners an opportunity to determine education content they deemed essential. The revisions to each project were mutually determined between site partners, the students, and course faculty.
Incorporating Teachable Moments
As the class transitioned completely online, faculty incorporated unfolding community health considerations and teachable moments into the class. To illustrate, the discussion boards provided a forum to discuss current events in Philadelphia and in students’ hometowns and states. Sharing perspectives from their home communities challenged students to apply the class learning objectives into familiar environments. In the first discussion about the social determinants of health and COVID-19, a student living in New York reflected, Queens is hit the hardest right now. Elmhurst, the hospital you’ve read about in the news . . . is right in the heart of the most diverse neighborhood of the most diverse county in the United States . . . it’s public, they take everyone who comes in, their patients speak over 150 languages, they try to hire a staff that looks like its patient population, and many of their patients are homeless, poor, and/or undocumented.
The discussions flourished with thoughtful contributions and a wide variety of viewpoints as students returned to their homes scattered throughout the country.
With the course faculty revising the planned online discussion board questions with prompts addressing social determinants of health in the context of COVID-19, students were able to recognize emerging gaps in care during this crisis. One student reflected, “Telehealth, as we discussed in lecture, is only as good as the technology available to the patient. Infrastructure will determine who is able to get care in this time.” Another student stated, I had learned that flexibility is always imperative when working as a healthcare employee in the community, but I didn’t realize just how flexible both community organizations and their partners have to be until the start of the COVID-19 pandemic.
Students noted that shared flexibility between themselves and the community organizations with whom they worked with was a key factor that affected the strength of the relationship during challenging times such as pandemics.
Best Practices
The unprecedented nature of COVID-19 in the spring of 2020 necessitated our faculty team to respond in ways that we hoped would model how community-based nurses respond in emergent yet thoughtful ways. While the university’s decision to offer pass/fail options undoubtedly alleviated the stress students would have been under had the traditional grading format been retained, other significant factors enabled course faculty to meet the challenges of the disrupted semester. These factors include the strong existing relationships we had with community partners prior to the pandemic, a class emphasis on humility and nimbleness, and a commitment to transparent communication.
Strong Community Partnerships
Now in its fourth year, NURS 354 has maintained an inventory of community partner sites with whom we have collaborated since the course’s inception. Premised on the belief that social determinants of health are best understood by students when they are engaged with community members at community sites, course faculty cultivated long-standing partnerships with local community organizations and their leadership to ensure that students were welcomed into a variety of communities. With the emergence of COVID-19, we were also able to rely on this strong partnership to check-in with community sites regularly about their needs as the pandemic unfolded in real time. On several occasions, we not only were able to be a sounding board for our community partners but also could freely verbalize our mutual feelings of uncertainty and vulnerability about current events. Furthermore, the course faculty’s repeated reassurance to partners of our ongoing availability ensured our continued ability to work with them and the communities they served as the local health crisis started to unfold.
An Emphasis on Humility and Nimbleness
With course faculty collectively experienced in health promotion for underserved populations, the default tone we set from the beginning of the semester involved a deference to residents in the community being experts on their own health and reality, and our gratitude for being invited into the community as guests. Our syllabus articulated the need for respectful partnerships and culturally appropriate language, while our lectures and readings provided opportunities to identify and correct problematic behavior that can occur when students are not adequately prepared to engage with communities. For example, course faculty noted the habit of some students to document their community engagement by posting pictures on social media such as Facebook or Instagram as a way to earn approval or “likes.” Similarly, course faculty emphasized the need for nimbleness when working with sites that might likely have limited staff or are fully managed by volunteers. With faculty underscoring the need for students to take their cue from residents in the community and learning to be flexible when unforeseen situations arise (e.g., last-minute cancellation of projects or changing of plans), we somehow prepared them for the ultimate disruption caused by COVID-19 in mid-March. Without needing to be prompted, students were quick to recall our class ethos and saw first-hand the centrality of humility and nimbleness.
Transparent Communication
As students watched coronavirus-related news unfold in late February and early March, course faculty were transparent in sharing information that was received from community sites and directives from university leadership. We were open about the indefinite nature of continuing with community engagement activities and relayed official guidance as it was received from school, city, and state officials. Informed by our work in disaster management and response, we were clear about information we shared with the students, including being honest about issues with which we were uncertain.
To ensure that students were able to transition with the mid-semester class changes and inquire about their unexpected transitions back to their homes, course faculty also held a special online session 2 weeks after in-person classes were suspended in our university. Structured as an online check-in, the first portion was focused on answering questions students had about our site partners (e.g., how site partners were faring, what types of assistance they needed) and the nature of the class going forward (e.g., potential resumption of classes, changes to the syllabus). Furthermore, messages from site partners were relayed during this time to the respective students in case there were ways students could assist from afar. For example, when faculty received an appeal for emergency fundraising from the shelter for unstably housed families, it was immediately shared with students who were then able to marshal online donations from their home states.
The second portion of the special online session focused on discussions around how social determinants of health were affecting students’ lives and relating to how these same issues may be manifesting for the most vulnerable members in their home communities. Issues such as difficulty maintaining social distance in multigenerational homes and essential workers’ inability to work from home were brought up by the students. In turn, course faculty related students’ observations and concerns back to class concepts tackled earlier in the semester such as discriminatory home loan practices (i.e., redlining policies) and systemic (i.e., overrepresentation of racial/ethnic minority individuals in frontline, low-paying industries).
Discussion
From this experience, we learned that community immersion courses could translate successfully into an online or virtual forum. An invaluable lesson learned from this class experience was that a commitment to community partners must not be abandoned in times of crisis. Transitioning a class online allowed students to acknowledge and address social determinants of health, thereby appreciating its full magnitude and consequent effects. The initial suspension by university leadership of all in-person community outreach activities was necessary to maintain the health and safety of students and site partners. However, despite disruptions in the semester, key factors and changes in our course structure allowed for continuous engagement and encouraged students to redesign their deliverables thoughtfully and creatively, innovating designs to allow resources to be accessed remotely (Wanner & Palmer, 2015). Problem-solving through obstacles when working with community members has been shown to expand student and faculty creativity and innovation (Qutishat et al., 2019). According to one student’s anonymous evaluation of the class, Despite the COVID-19 pandemic affecting community hours, I was actually able to complete the required 22 hours [online] and still maintain activities with our site virtually. I enjoyed the discussion boards because I was exposed to topics I've never heard of in other classes (e.g. geomedicine) and found a lot of value in reflecting based on the community and population we worked with.
The opportunity to revise students’ project deliverables and expectations, such as extending deadlines and changing to pass/fail grades, allowed students to reflect and adjust their projects to an online format. Flexible timelines allowed for students to exercise nimbleness in their deliverables, accounting for the limitations of virtual community engagement (Glogowska et al., 2011; White & Fantone, 2010). It was important for students to have a more flexible timeline in order to share ideas with and receive remote feedback from community members and faculty advisors (Soper & Ukot, 2016). Given the asynchronous nature of the online class, students were also able to discuss their evolving deliverables with their classmates on discussion board posts, giving them an opportunity to work through and refine ideas.
A goal of the curriculum, as outlined in the original syllabus, was for students to obtain self-awareness of personal biases while dispelling myths and stereotypes regarding underserved populations. As students returned home for the semester, they demonstrated these critical thinking skills and reflected on their own biases. One student indicated, Even now, as we are socially distancing because of COVID, I find myself asking more questions and considering different perspectives related to the pandemic. I have thought a lot about our families at my clinical site, but I have also thought a lot about many other vulnerable populations like individuals without homes, individuals using substances, and so many more.
Undergraduates, who are typically confined to the “campus bubble,” gained valuable perspective from engagement with the broader community, both in-person and virtually. Additionally, getting out of the classroom setting teaches undergraduate students how to communicate clearly about health topics with community members (Qutishat et al., 2019).
Responding to the events posed by the COVID-19 pandemic enhanced the student educational experience as they recognized and adjusted to their community sites’ needs during a crisis. Encouraging project continuation remotely reinforced the students’ commitment to community sites and underscored the value of maintaining community partnerships despite obstacles. Remote community engagement juxtaposed with health care’s transition to remote care (e.g., telehealth, drive-through testing sites) modeled the essential task of adapting to a population’s needs in real time. Furthermore, in their final discussion board, one student reflected, Keep asking questions. I think that’s the biggest takeaway from 354 . . . Sometimes we don’t even have to know exactly what we are looking for, but we can begin by asking ‘What am I missing?’ ‘What am I failing to look for?
This post reminded other students to notice which populations were missing in the news or lacking care throughout the COVID-19 public health crisis. These questions are critical for student nurses to ask as they embark on a career that will involve public health education and health promotion.
From the perspective of faculty who had to initiate the changes to the class mid-semester, the best practices we outlined above proved crucial in minimizing the disruptions to the class while retaining commitment to partners and our students’ education. Capitalizing on the trust established with site partners allowed for uninterrupted access to key leaders. Establishing expectations for students to be humble and nimble at the beginning of the semester fostered a productive group norm when circumstances demanded for them to be flexible. We also recommend communicating early and verbalizing clear support to community partners and students when faced by emergent situations. Acknowledging unknowns was not detrimental to managing the class and exemplified honest engagement and inhibited false expectations.
Conclusion
Through unexpected circumstances brought forth by the COVID-19 pandemic, we found success moving an in-person community health education course to a virtual learning experience. When transitioning an immersion experience online, the class may benefit from being flexible with grading standards, allowing for a reassessment of projects, and capitalizing on once-in-a-lifetime teachable moments. Factors that enabled the course to transition into a remote format included our existing strong partnerships with community members, a class ethos centered on humility and nimbleness, and a full commitment to transparent communication. Based on thought-provoking student responses through discussion board posts and the quality of revised final deliverables, the students not only remained dedicated to their community partnerships, but also exceeded expectations in meeting learning objectives. While we emphasize the value and richness of in-person, onsite community engagement to provide an in-depth perspective of the lived experiences of marginalized communities, we found that online community immersion was feasible and was able to meet student objectives given extraordinary circumstances.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
