Promoting Colorectal Cancer Awareness in Undergraduate Community Health Nursing Education: A...

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Promoting Colorectal CancerAwareness in UndergraduateCommunity Health Nursing Education: ACommunity–Academic CollaborationTsu-Yin Wu a , Patrick J. Wozny b & D. M. Raymond III aa School of Nursing , Eastern Michigan University , Ypsilanti ,Michiganb Ann Arbor Veterans Health Care System , Ann Arbor , MichiganPublished online: 12 Nov 2013.

To cite this article: Tsu-Yin Wu , Patrick J. Wozny & D. M. Raymond III (2013) PromotingColorectal Cancer Awareness in Undergraduate Community Health Nursing Education: ACommunity–Academic Collaboration, Journal of Community Health Nursing, 30:4, 175-184, DOI:10.1080/07370016.2013.838471

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Promoting Colorectal Cancer Awareness inUndergraduate Community Health Nursing Education:

A Community–Academic Collaboration

Tsu-Yin WuSchool of Nursing, Eastern Michigan University, Ypsilanti, Michigan

Patrick J. WoznyAnn Arbor Veterans Health Care System, Ann Arbor, Michigan

D. M. Raymond IIISchool of Nursing, Eastern Michigan University, Ypsilanti, Michigan

An innovative collaborative partnership between bachelor of science nursing (BSN) students andlocal public schools was developed in response to a call for increasing awareness of colorectal cancer(CRC) screening in Michigan’s underserved populations; through this partnership, community healthnursing students provide health education for middle- and high-school aged students who becamecolon health ambassadors and delivered important messages about the importance of colorectal cancerscreenings for their significant others age 50 and older. At the completion, the program reachedapproximately 1,800 school-age students and their family members. The program provides nursingstudents with unique service-learning experience while improving their theoretical knowledge andclinical skills in health disparities and community health nursing. The purpose of this article is todescribe the development and implementation of this community-academic collaboration and discussthe evaluation of educational outcomes as community health nursing experience.

Colorectal cancer (CRC) is the third most common cancer in both men and women in the UnitedStates (American Cancer Society [ACS], 2012). There is strong evidence to suggest that CRCscreening beginning at age 50 reduces the incidence and mortality of the disease (Department ofHealth and Human Services/Centers for Disease Control, 2009). CRC rates have been decreasingover the past 20 years, with a greater decline in the past 10 years. This is attributed partly to anincrease in screening, which can lead to the detection and removal of colorectal polyps beforethey become cancerous (ACS, 2008). Polyps can be present in the colon for years before theybecome cancerous, therefore screening and early detection are essential (ACS, 2008). Regular

This work was supported by a competitive state funding through the Michigan Public Health Institute.Address correspondence to Tsu-Yin Wu, Professor & PhD Program Director, School of Nursing, Eastern Michigan

University, 311 Everett L. Marshall Building, Ypsilanti, MI 48197. E-mail: tywu@umich.edu

176 WU ET AL.

screening for CRC can reduce deaths by as much as 60% (Department of Health and HumanServices/Centers for Disease Control, 2009).

Despite the increasing rates of CRC screening, findings of the National Health Survey from theCenters for Disease Control (2009) indicate the rates are still below recommended levels. About42 million people who are at average risk for developing CRC had not been screened according tothe national guidelines (Department of Health and Human Services/Centers for Disease Control,2009).

In Michigan, colorectal cancer is the third leading cause of cancer-related deaths; an esti-mated total number of 5,020 men and women were diagnosed with invasive colorectal cancerand 1,720 men and women died from the disease in 2009 (Michigan Department of CommunityHealth, 2009). Approximately 49% of adults 50 years and older in Michigan screened with afecal occult blood test (FOBT) for screening and 66% have had a colonoscopy exam. Individualswith lower socioeconomic status and without health insurance were less likely to ever have had acolonoscopy (Peterson, Dwyer, Mulvaney, Dietrich, & Rothman, 2007). In addition, the screeningrates were lower among African Americans (AAs), 57% compared to 61% of all age appropri-ate respondents (Michigan Department of Community Health, 2012). Reduced screening ratesare likely to be associated with lower frequency of AAs being diagnosed with cancer at an earlystage and lower 5-year survival rates than Caucasians (American Cancer Society, 2008). AAswere diagnosed more at the distant stage (25%) compared to Caucasians (16%). The five-yearsurvival rate of colorectal cancer receiving treatment at the early stage is 90%, compared to an11% survival rate for diagnosis at the distant stage (Michigan Department of Community Health,2010). The disparity showed in current national and local Michigan data demonstrate the criticalneed, and also an opportunity, to improve quality of life and health outcomes in this underservedpopulation.

Several barriers have been noted for poor CRC screening rates in underserved populations.Reported barriers include fear of a painful examination, fatalistic views of cancer screening, lowliteracy rates, lack of trust in their doctors, and lack of awareness regarding CRC (Powe, 2002).Providing education on CRC is an effective way to promote awareness of CRC and the needfor screening. Several strategic methods shown to be effective in providing education to under-served populations include face-to-face interviews, explaining the importance of screening in theform of story, and providing community-based educational interventions (Ueland, Hornung, &Greenwald, 2006).

Community-based interventions can take place in various locations, including schools, seniorcommunity centers, parks, and outside of grocery stores. These interventions promote awarenessof CRC and increase the intention to be screened among participants (Greenwald, 2006; Zittlemanet al., 2009). Providing a culturally based program has also been shown to lead to greater par-ticipation in the screening process (Powe, Ntekop, & Barron, 2004). These findings support theeffectiveness for implementation of creative educational interventions partnered with communi-ties to deliver culturally sensitive education toward increasing knowledge about CRC. The projectreported herein used an innovative intervention to promote CRC awareness and screening in aMichigan school district where (a) high incident rates of CRC were reported, and (b) it wascomprised of an ethnically diverse population.

This article documents the processes of having nursing students engage in a community-basedCRC awareness campaign. The goal of this article is to report the development and imple-mentation of community–academic collaboration in community health nursing education and

COMMUNITY HEALTH NURSING EDUCATION 177

to evaluate the effectiveness of this service-learning project. Specifically, the article aims to(a) examine the nursing students’ perceptions in learning, acquisition of skills, and perceptionsof value with this community-based CRC screening project as a clinical experience; and (b)explore the nursing students’ creative ideas and practical methods of delivering education to thecommunity and using their own words to describe what they gained from this experience.

CONCEPTUAL SUPPORT AND IMPLEMENTATION

In this study, the LIVE conceptual framework developed by Bernick and Clark (2008) was appliedto guide the working process for nursing students in engaging and learning about communityhealth nursing. Integrating the metaparadigm of nursing that includes the concepts of health, nurs-ing, environment, and human being, the process incorporates knowledge learned in the classroomand hands-on experience practiced through a series of teaching/learning exchanges.

Based on Bloom’s taxonomy of learning (Forehand, 2005), which outlines a classification oflevels of intellectual behavior used in learning, the LIVE is an acronym for four phases used inthe framework— learning, inviting, valuing, and engaging. Each phase of the framework pro-vides strategies that the teacher and student can use in attainment of knowledge (Bernick &Clark, 2008). Four learning objectives (i.e., acquisition, application, analysis, and synthesisof knowledge) specified in the LIVE model were utilized throughout this project in design,implementation, and evaluation of the teaching–learning experience.

The first phase, learning, involves knowledge acquisition of the community and its members.Concepts such as community assessment, population health, and health promotion are introducedto students to apply them to practice. This study paired a group of volunteer professional oncologynurses with nursing students enrolled in the community health course. The oncology nurses pro-vided the nursing students a CRC-screening education program that included: (a) general projectinformation, (b) an introduction to CRC disease information, (c) statistical cancer rates amongminority and underserved populations, and (d) the role of a community education volunteer.

The second phase, inviting, incorporates the application of knowledge objective. In this study,the nursing students were challenged to apply their nursing knowledge and CRC training in thecommunity of interest. Assigned groups of nursing students went to selected middle- and high-school classrooms in the community and gave presentations addressing the importance CRCscreening and risks for colon cancer. These middle- and high-school students were trained tobecome colon health ambassadors to deliver important messages about the importance of CRCscreenings for their loved ones age 50 and older. The education sessions were developed bythe nursing students. Sessions were tailored to the various levels within the school classroomenvironment. Although allowing for variability in education level and engaging activities, a fewcommon threads were required of all sessions. All presentations were developed to present con-tent that focused on managing risk factors for CRC, including information on diet and exercise.Additionally, materials and support were given to the school-age students to write letters to fam-ily members and neighbors’, age 50 and over, encouraging them to obtain CRC screening. Theywere also given preprinted information on CRC to include with the letters.

Valuing is the third phase in the LIVE model, and involves analysis and synthesis of knowl-edge. Valuing aims to develop an understanding of ethics and values of self and communityengagement with participants. The students made connections between knowledge, theories,

178 WU ET AL.

and concepts to see the larger picture. The local school district administrators were very inter-ested in being part of this CRC education project; their interest and appreciation facilitatedperceptions of value for the nursing students. At the completion of the project activities, it is esti-mated that the nursing students delivered over 80 CRC-screening-awareness presentations in thecommunity and the program reached approximately 1,800 school-age students and their familymembers.

The final LIVE model phase is engaging. This phase encourages the synthesis and actual-ization of healing and caring within the community. Synthesis for the student nurses unfoldsthrough their examination of the practical experience supported by concepts learned in theirlecture/theory course work. As a conclusion to the CRC program a celebration was held a fewmonths following the classroom intervention. The celebration theme was titled “Healthy Colon,Healthy Family.” The event was held at a local community center; all of the nursing students andlocal middle- and high-school students and their family members were invited. CRC awarenessand screening information was also promoted as part of the program. Health professionals, com-munity leaders, CRC cancer survivors, and project participants were invited as featured speakersto share their experiences. This venue provided further context for the nursing students to developmeaning and value for the community health nurse role, investment in community, and altruism.The LIVE model provides conceptual framework for nurse educators to facilitate nursing stu-dents in becoming critical and reflective thinkers and encourages the learner to make connectionsbetween theoretical-based education and what they learn through practical experience (Bernick &Clark, 2008; Pierson, 1998).

PROJECT EVALUATION

Over the course of the project, student-learning outcomes were evaluated with both quantitativeand qualitative data. The study obtained ethical approval from the Institutional Review Boardat Eastern Michigan University. After the conclusion of the community-based CRC screeningawareness campaign, nursing students filled out the Colorectal Health Presentation Evaluation(CHPE) tool, which consisted of three sections with a total of 14 items. The first section con-sisted of demographic information including gender, previous degree/major, age, and what yearthe student started the nursing program. The second section consisted of questions related to stu-dents’ perceptions of value of the activity as measured by a 5-point Likert scale (ranging from 1 =did not agree totally to 5 = strongly agree); specifically, items regarding (a) knowledge gained incommunity health, (b) skills developed that will impact future practices serving minority popula-tions, (c) perceived value of this project as part of the community health clinical, and (d) intentionto consider a career in community health nursing.

Student evaluations also contained a narrative component that was administered through focusgroups. During the focus groups, four questions were used to allow students providing input inregards to what innovations they used, what worked, what did not work, and what additionalcomments/suggestions they had. This information was gathered after the students filled out theevaluation surveys. The focus group meetings were recorded and later transcribed. The answersfor each question were individually analyzed. The separated information was synthesized intothemes and linked back to the CHPE question items. Toward triangulation of the research data,the focus group results were used to inform and validate the questionnaire responses.

The following research questions were examined through this service-learning project: (a)Do nursing students gain knowledge about community health, develop skills in working withminority populations, and perceive that this experience has value in their clinical work? (b) Whatis the effect of gender, age, and academic major on the knowledge obtainment, skills development,and values among nursing students? (c) What correlations exist between knowledge, skills, andvalues in relation to thoughts on specialization?

The data analysis was conducted using SPSS Version 15.0 (SPSS 2007). Analysis includedgeneration of descriptive statistics, and running t-tests, and Pearson bivariate correlations. Thealpha significance level was set at .05. In addition, data was gathered from focus groups madeup of the nursing student participants, which provided supporting context and information for theevaluation tool results.

RESULTS

Sample Characteristics

The nursing students (N = 36) who participated in the CRC screening campaign were predom-inantly women (80%, n = 29). The samples mean age was 31 years (SD = 6.6). There were17 different previously earned degrees reported, those leading were education (17%, n = 5) fol-lowed by business (8%, n = 3). More than half of these students previously earned a bachelordegree in a nonscience field (56%, n = 20). Most of these students started the second-degreenursing program about 1 year before involvement with the CRC campaign (67%, n = 24).

Differences Among Gender, Age, and Academic Major

A series of independent-sample t-tests were conducted to compare the items of gaining knowl-edge, developing skills, finding value in the activity and thinking of specializing in communityhealth nursing between (a) science versus nonscience majors, (b) younger (under 25 years old)versus older groups, and (3) men versus women (Tables 1, 2, and 3 respectively). The results werenot statistically significant; however, interesting trends were noted. Those second-degree studentswith previous nonscience-majors reported higher scores in gaining knowledge and developingskills than science majors. Similar trends were found for the women and older students where

TABLE 1Comparisons of Four Learning Outcomes Between Younger Versus Older

Nursing Students

Age < 25 Age ≥ 25

Mean SD Mean SD t df (p)

Gain knowledge 2.67 .58 3.72 1.10 1.613 26 0.119Develop skills 2.67 .58 3.08 1.58 0.443 26 0.661Value in clinical 3.22 .39 3.32 1.32 0.126 26 0.901Specializing in CHN 1.00 .00 2.48 1.58 1.591 26 0.124

Note. CHN = community health nursing.

180 WU ET AL.

TABLE 2Comparisons of Four Learning Outcomes Between Male Versus Female

Nursing Students

Male Female

Mean SD Mean SD T df (p)

Gain knowledge 2.86 2.86 3.75 0.97 1.917 33 0.064Develop skills 2.00 1.29 3.00 1.52 1.602 33 0.119Value in clinical 2.71 1.22 3.30 1.29 1.077 33 0.289Specializing in CHN 1.14 0.69 2.43 1.60 2.064 33 0.047

TABLE 3Comparisons of Four Learning Outcomes Between Science-Major Versus

Nonscience-Major Nursing Students

Science Nonscience

Mean SD Mean SD t df (p)

Gain knowledge 3.71 .49 3.70 1.26 0.029 25 0.977Develop skills 3.14 .90 3.00 1.59 0.224 25 0.825Value in clinical 3.00 1.09 3.38 1.34 0.680 25 0.503Specializing in CHN 2.29 1.25 2.50 1.54 0.331 25 0.744

they reported higher values for all three items (i.e., knowledge, skills, and value) than the menand younger students respectively. The one noted statistically significant result was that womenwere more likely to consider specializing in community health nursing than men were.

Correlations Between Knowledge, Skills, Values and Specialization

A series of Pearson correlation tests were done to assess the relationship between the nursing stu-dents’ views on specialization in community health nursing with the variables knowledge gained,skills developed, and value. The results showed that thinking of specializing in community healthnursing correlated moderately with both gaining knowledge about community health (r = 0.42,p = 0.01) and developing skills working with minority populations (r = 0.42, p = 0.008).The relationship suggests that as perceptions of gaining knowledge and development of skillsincreased, so did the level of agreement given to considering specializing in community healthnursing. It was also noted that as agreement increased, that knowledge was gained by the students,they reported increased agreement that skills were developed (r = 0.65, p < .05). However, valueof clinical coursework was not related to a preference toward specializing in CHN (r = 0.25,p = ns).

Results From Focus Groups

The following qualitative themes and ideas were based on the four open-ended questions posedin the focus groups. The nursing students were asked: “Please tell us what worked well in thisclinical activity;” “Please tell us what did not work so well in this clinical activity;” “Pleasetell us about your innovations in this presentation;” and “Do you have any other suggestions orcomments?” Table 4 presents a summary of the nursing student comments, and the summarythemes the researcher assigned to the comments.

DISCUSSION

Community education programs are effective to promote awareness and the need for CRC screen-ing and prevention (Gellert, Braun, Morris, & Starkey, 2006; Greenwald, 2006; Zittleman et al.,2009). The original goal of the community-based CRC screening awareness program was touncover the unique needs of minority populations dealing with CRC screening and then imple-ment an innovative CRC screening and awareness campaign in an underserved community. Thisproject opened up avenues for further discovery, including the benefit of this experience as aservice-learning activity that includes collaboration with professionals in the community anddevelopment of creative strategies for teaching school-age students about an important healthpromotion topic.

This study demonstrated that implementing a community-based CRC screening campaignas a clinical experience for community health nursing students can be effective for increas-ing their knowledge about, and interest in, community health nursing. Consistent with previousstudies on student involvement with community-based health promotion projects (Arbuthnot,Hansen-Ketchum, Jewers, Moseley, & Wilson, 2007; Broom, 2001; Brosnan et al., 2005), thisstudy provided a means for nursing students to discover principles of epidemiology, educationaltheories, teamwork, critical-thinking, and effective teaching strategies to educate school-ageindividuals about the topic related to an important health issue. The students embraced thiseducational opportunity to apply theory learned in the classroom, which led to a deeper under-standing of health promotion techniques and developing collaborative working relationships withcommunity stakeholders.

Although the majority of the participants in our study claimed to have had a positive experi-ence, there was a small group of nursing students who claimed to have had a poor experience withthe project, stating that some of the instructors were “disorganized” or that they felt that the highschool students were “rude and disrespectful.” Even for this small group, the LIVE tool may aidin explanation of their dissatisfaction. During the process, the nursing students were introducedto the four phases of the LIVE model: learning, inviting, valuing, and engaging. Discussions wereused to facilitate the process of learning about the community, community assessment, and imple-mentation of a project intervention. Ultimately, the nursing students were required to engage thisprocess as part of their program coursework. During the process, engaging school-age studentsin the topic of CRC can present significant challenges, including limited classroom managementskills and the discussion of a sensitive health topic (for example, procedure of colonoscopy) witholder teen groups.

182 WU ET AL.

TABLE 4Summary of Nursing Students’ Feedback Based on Colorectal Cancer Campaign

Questions/Themes Examples/Quotes

What worked well?Small nursing student

groups.“With smaller groups we were able to come together and create fun and entertaining

presentations.”Supportive clinical

instructors.“Having a clinical instructor who works closely helps us feel better prepared for the

presentations.”Supportive classroom

teachers.“Having a closely involved nursing instructor with small groups of 2 or 3 nursing

students leads to best preparation.”“An involved classroom teacher creates a supportive environment.”“One teacher incorporated our presentation into her daily lesson plan which helped to

maintain order in the classroom.”Some teachers offered incentives such as bonus points and extra credit for participation

and writing letters. One classroom teacher provided support by reinforcing thepathophysiology of CRC, and provided additional pictures.

What did not work?Age of parents. Many of the parents were between 30 and 40 years old.Maturity of school students. “Many of the students seemed disinterested because they were too young to see the

magnitude of cancer.”Organizational problems. “When using the words rectum and rectal many students thought it was funny and

giggled.”Classroom teacher support. “We moved from room to room until a permanent spot for our presentation was found.”Nursing students perception

of self ability“The audio equipment did not work so we had to ad-lib part of our presentation.”

“We prepared our presentation for middle school students only to be reassigned to asenior level honors biology class.”

“The classroom teacher stepped aside and did not help control the classroom.”Some of the nursing students complained the project was “too demanding” and

“anxiety producing.”

Innovations?Presentation method Predominant method was PowerPoint presentations.

“We kept the presentations brief and used age appropriate language.”Creative use of visual aids “We incorporated the voice of Homer Simpson® to engage the attention of the

students.”“We incorporated educational videos found on YouTube®.”

Using games as aneducational tool

“We used an anatomical man to show the colon anatomy.”

One group created homemade props depicting a colon and polyps using balloons, balls,and string. One group displayed FOBT kits and posters showing healthy andunhealthy colons. A teaching strategy of dividing the class into groups based on CRCmorbidity and mortality percentages illustrated the significance of the problem. Twogroups used a Jeopardy® game with buzzers as fun strategy to review the material.

Suggestions?Overcoming age boundaries Ask the teachers to have students think of someone over age 50 and bring in a name

with correct spelling and address.If students cannot think of anyone over 50, ask students parents to provide a name.

Getting the letters sent “A sample letter would be helpful as a framework for the younger students.”“Ask the students to include 3 things they learned from the presentation in their letter.”Assist the students with addressing the letters and provide a postage stamp.

Improved organization Provide for communication between nursing groups and schools to discuss issues suchas room assignment, function of audio-visual equipment and presentation plans.

The service-learning model demonstrated in this project can be beneficial and replicated innursing education. Nursing faculty in community health and other clinical specialties could part-ner with other community organizations and agencies for health promotion clinical opportunities.This type of collaborative partnership can provide a rich clinical opportunity to foster nursingstudents’ expertise in health promotion and risk reduction.

Limitations and Future Direction

Because this study utilized a self-report questionnaire, it is subject to bias from students poten-tially giving socially desirable responses or incomplete forms (i.e., missing data). Generalizationsof the findings are limited by the relatively small sample size, and focus on a specific intervention.The participants were a homogeneous group being overwhelmingly female with similar educa-tional backgrounds. It would be difficult to generalize the findings to all nursing student groups.

Potential areas for further research beyond this study include: (a) determining whether projectslike this should be a regular component of the community nursing course, (b) determining if nurs-ing students involvement in community projects actually contributes to increase CRC screening,(c) examining what was learned in regards to methods of teaching school-age students about amajor public health issue, and (d) considering if the learned outcomes can lead to developmentof evidence-based practice for community health nursing.

Conclusion

The LIVE tool provides a useful framework for integrating community health experiences forBSN students and encourages in-depth learning, specifically for understanding the relationshipbetween theory and practice (Bernick & Clark, 2008). In this project, the evaluation data suggestthat the community–academic partnership can effectively provide a valuable learning experiencein each phase (learning, inviting, valuing, and engaging). Nursing students were able to achievethe goal of becoming critical and reflective thinkers who connect classroom knowledge withpractical experience and gain a much more comprehensive understanding between theory andexperience. The Affordable Care Act has prompted a shift in health care toward prevention andwellness; consequently, health promotion and disease prevention will need nurse educators toreexamine curricula and provide students opportunities to engage in this transformation in healthcare. This community–academic partnership provides a unique opportunity for undergraduatenursing students to work with professional nurse mentors, internalize the knowledge of CRC,and present it to community. In this project, nursing students experienced the role of being aprofessional by applying the knowledge learned and devising innovative strategies for teachinghealth promotion to school-age students while gaining knowledge and skills through the synthesisof theory and practice and obtaining value of self and community engagement.

REFERENCES

American Cancer Society. (2008). Racial gap widens as colorectal cancer death rates drop. Retrieved May 8, 2012 fromhttp://www.cancer.org/Cancer/news/News/racial-gap-widens-as-colorectal-cancer-death-rate-drops

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Arbuthnot, E., Hansen-Ketchum, P. A., Jewers, H., Moseley, J., & Wilson, C. (2007). Bringing theory to life: Engagingnursing students in a collaborative population-based screening project. International Journal of Nursing EducationScholarship, 4(1), 1–11. doi:10.2202/1548-923x.1358

Bernick, L., & Clark, S. (2008). LIVE: A tool to support student/teacher enactment of community health nursing praxis.International Journal of Nursing Education Scholarship, 5(1), 1–18. doi:10.2202/1548-923x.1485

Broom, B. L. (2001). Assessing the value of the follow-through family project for students and families. Journal ofNursing Education, 40, 79–85.

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