Using Tobacco Settlement Monies to Promote Competency among Nurses Practicing Public Health in Rural Communities
Carol Beth Isaac, MA, RN; Ellen M. Reichenbach, MSN, RN; Bevely J. Hays, PhD, RN
The State of Nebraska, where this project took place, has a population of approximately 1,713,000, with 2/3 of the population found in urban areas. Until 2001, only 22 of 93counties had functioning health departments, which led tolimitedpublic health services, especially in rural areas. In 2000, the State of Nebraska received $25,000,000/year in tobacco settlement monies, with 5.7million of this money designated for the building of public health infrastructure. As a result, 16 regional health departments were developed, and a “cash fund” implemented to support grants aimed at providing public health support and services. At that time, public health nursing services wereprovided by a combination of health departments and community action agencies across the state. Many ruralPHNs came to the public health arena with either an associate degree or diploma. There was also the reality of working mothers and wives in rural communities, who felt stretched to the limit and did not plan on getting a BSN or MSN.
It was within this context that the PHN Section of our statewide public health association received grant funding via the tobacco settlement monies. The first year of the project reached 45 nurses with varying educational backgrounds across the state, using live distance delivery methods to four sites. Each nurse attended three half-day satellite training sessions over a three month period. A five page, 62 item competency instrument developed by the PHN Section of the Minnesota Department of Health was used as a pretest (before session 1) and post-test (after session3). A 4th session was attended by the majority of PHNs with the purpose of strengthening areas identified from the competency instrument.
Most projects encounter barriers during their delivery, and our project was no exception. I would like to discuss a number of approaches we used when offering distance delivery to PHNs practicing in rural areas.
Approach #1 – Keep the material presented “personal & interesting.” This approach will help keep your audience engaged, even when the material is information intensive. The Nurse Educator who presented our session material was able to “connect” with the audience via her non-judgmental, interactive style. We supplemented our purchased curriculum with a rural focus, and anticipated “needed information” with the development of so many new health departments in NE. A participant satisfaction survey wascompleted following each session, and we moved quickly to make adjustments to the next session if at all possible.
Approach # 2 – Deal effectively with technical delivery. Having technical ability does not necessarily mean smooth delivery. Keeping participants actively engaged during distance delivery is very challenging, even if the technical delivery is perfect. Our experience was that the delay time associated with satellite delivery was not conducive to an interactive approach, and participants found it distracting. We also experienced technical difficulty during out last satellite session, when the most difficult material was being delivered by the Program Educator. This resulted in participant frustration and loss of interaction for 1/3 of the session. A key to keeping our participant groups intact and involved was the use of a site facilitator. We recruited a volunteer PHN site facilitator to manage the site and monitor any technical issues. Managing the site included administering and collecting all testing materials; making sure participants completed necessary paperwork for continuing education credit; distributing session handouts, and notifying the grant coordinator of any problems. The one site which did not have a facilitator lost the majority of their participants by Session 3, emphasizing the importance of a site facilitator for program success.
Approach # 3 –Choose your sites carefully. Location, travel time, a date that works for mostparticipants and honoring agency schedules are all keys to successful site selection. Participants had expressed a desire to limit their travel time to 4 hours round trip fora half-day training. This preference influenced our site selection choices, and we worked onfindingsatellite delivery sites with good environmental conditions.
Approach # 4 – Respect the “business” of the work place. A consistent theme we heard from PHNs was “there is not enough time to accomplish my work.” Many nurses cover multiple counties when providing client services. To attend the sessions, they needed to be convinced that the “information they were going to receive was worth the time & travel effort.” Agency heads were actively recruited to ensure they would allow staff participation in the project. Networking with front-line staff also allowed us to learn agency schedules and priorities. In addition, we worked at obtaining a commitment from participants by having them sign a statement saying they would attend all 3 sessions.
Our assessment for content was completed using the Minnesota Competency Instrument or C.I. The C.I. contained 13 public health related categories with 62 items that had an individual/family, community, and systems foci.Of the 45 PHNs who completed a tool at Session1, 25 completed a tool at Session 3, giving us 25 pairs for analysis. An analysis of means was completed on the 25 paired C.I.s, and showed an increasein all but 1 of the 62 items.The analysis was also done using clusters of questions we called categories, and showed an increase in the average mean in all 13 categories. For report purposes, an improvement was seen as an increase in the average mean, or a mean which stayed the same. An item-wise analysis was completed on the 25 paired C.I.s using a paired t-test. A positive statistically significant difference was noted in 37 of the 62 items, with 11 items showing significance at the .05 level; 22 items at the .01 level; and 4 items at the .001 level. Individual/family focused items showed significance for 9 out of 20 items; community focused items for 11 out 20 items and systems focused items for 17 our of 22 items. A category analysis using a paired t-test indicated that all 13 categories showed a positive statistically significant difference. Key Findings were as follows: (1) the participants’ self-rated competency for population-based public health nursing practice increased significantly; (2) the greatest increases in competency occurred within categories that emphasized community description; data analysis; and the problem solving process; (3) significant improvement was also seen in participants’ understanding of systems interventions followed by community interventions and individual/family interventions; (4) the least improvement occurred within categories that emphasized engagement of partners and health determinants.
Lastly, I would like to leave you with 3 implications for population-focused continuing education for PHNs:
1. Our project gave PHNs the “tools” to participate in the public health network in Nebraska. Their understanding of intervention strategies; core essentials; and competency levels increased significantly during this training period. Their increased confidence and comfort level in dialoging about public health issues wasnoticeable to co-workers and superiors alike.
2. The training provided a beginning foundationfor PHNs to work off of. Prior to the trainings, PHNs had a sense of “what they needed to do” to accomplish their work, but they were unable to “name it and claim it” from an intervention perspective. The question of “why we do what we do” finally got answered, once they incorporated training concepts into their practice.
3. The project gave PHNs the “okay” to include “community” as a valid part of their practice. Up until this time, their basic education and work had stressed an individual/family approach. The development of new health departments in rural Nebraska was forcing many PHNs into a community/systems role they were ill prepared for.
I would like to end by saying that we don’t claim to have all of the answers, but this was our personal experience in rural Nebraska, and it was effective. It was also a good use of the tobacco settlement monies.Thank-you.
1