By Janine White
In every health history, there’s a life story— and a nurse listening. At bedsides. In emergency rooms. During regular checkups. They hear about the apartment evictions, food insecurity, job loss, lack of transportation. All of them impact a patient’s health.
But with that listening comes great potential to improve community health and effect lasting change. Through the Primary Care NP Civic Engagement Project (course N656, Professional Role Issues for Nurse Practitioners), course director June Treston aims to make sure Penn Nursing graduates have the tools they need to make a difference.
“We need to make sure that our students know how to take care of patients. But it’s equally important that they understand their role as primary care providers goes beyond the clinical setting,” says Treston DNP CRNP GNu’92 GRN’21, Director of the Family Nurse Practitioner Program.
During the Civic Engagement Project, nurses pursuing their master’s in family medicine, adult gerontology, pediatrics, or psychiatric mental health prototype and test solutions that reduce health disparities for underserved populations.
They work in groups, choosing an issue that impacts populations in and around Philadelphia. They brainstorm with guidance from Treston or seek ideas at the SNF Paideia Program, which fosters civic leadership at Penn, or from the School’s well-established partnerships with community organizations.
Most recently, in Fall 2021, they tackled diabetes education for people who are incarcerated, internet access for low-income families, job training for survivors of human trafficking, menstrual equity for young people facing homelessness, scam detection education for the elderly, and more.
“Our students are so incredible,” Treston says. “They are passionate about providing great care and improving the health of their patients and communities, and they really are the source of so many great ideas.”
Penn Nursing students have a long history of volunteering, but N656 goes bigger, to the level of what Treston calls a “service learning project.” Students must research the history and current context of the issue they choose, and they learn to apply design thinking principles (see sidebar, The 5 Steps to Design Thinking) to develop a proposed solution. They have to create an action plan in col- laboration with a liaison who provides the perspective of the community in focus.
“Communities have their own set of strengths,” Treston says. “They’ve already identified problems and solutions. To have respect for what’s going on is an important step of the process.”
Start With Listening
“Empathy” is the first of five steps in the design- ing thinking that the Civic Engagement Project students employ—and Jolie Jemmott GNu’22 saw firsthand how listening can send an effort to devel- op a solution in a new direction.
Jemmott, an RN and Amy Gutmann Leadership Scholar, and her fellow psychiatric mental health nurse practitioner students, picked homelessness as their issue. They headed out to talk with un- housed people in Philadelphia with snack bags, masks, and water bottles. The group also created informational handouts, with the idea to connect people to available emergency housing resources— but the pamphlets weren’t well received. As they met and talked to people living on the streets and in cars, abandoned buildings, and train and bus stations, they learned that many intentionally avoid- ed shelters. Some people disliked the restrictive environment, with rules about coming and going impeding their autonomy.
“Some have experienced sexual assault in shel- ters, or people stealing their belongings,” Jemmott says. “We had to really just interact with them to understand where they were coming from. And we figured out that a lot of them don’t like going into shelters and a lot of them are being affected by violence.”
Jemmott and team learned the individuals they spoke with prioritized staying warm over getting information on the nearest shelter. They expressed a need for blankets and coats, along with a desire for tools they needed to fix and maintain the rolling carts that held their belongings. “As long as they were able to be stable where they were at that moment and able to move their stuff around efficiently, that’s what they were worried about,” Jemmott says.
With this realization, the group determined there is a great need to address the numerous en- vironmental hazards that unhoused people face. They brainstormed ways to advocate for making shelters safer places. While they didn’t have as much time to develop a solution due to the pivot, Treston says the group’s N656 experience still had the intended effect.
“I feel like that was one of the most successful groups because they really got a better understanding of not only the process of design thinking, but the needs of those individuals that they didn’t have when they first came into the project,” says Treston. “They absolutely had a light bulb go off when they really spent time with homeless people.”
She knows from personal experience how crucial empathy is to developing successful solutions for community challenges.
Treston has been working with domestic vio- lence victims since she was an RN. Early on, she signed up to volunteer at a shelter for women, with a plan to promote the importance of breast self-exams and breast cancer screenings. Then she got there and started talking to them. She discovered preventive care was the last thing on their minds.
“They’re there with their kids. They lost their house. Their abuser is trying to kill them. They don’t really care if they have breast cancer,” Treston recalls of that eye-opening time. “So I found it was much better to do wellness sessions and focus on self-esteem.” She pivoted and created a space for self-care hair and makeup sessions and time to talk about what was going on in their lives.
“You might have the very best intentions of what you want to do with a community based on current medical problems or health needs,” Treston notes. “But when you get out into the community, you realize that’s not what they need.”
The Five Steps of Design Thinking
According to June Treston, faculty leader of the Primary Care NP Civic Engagement Project, design thinking is essential to helping students in the course N656 address community health issues effectively. Every fall, she incorporates modules from the school’s Design Thinking course to guide them.
Essentially, design thinking takes practitioners through five steps to create innovative solutions: empathy, define, ideate, prototype, and test.
Along the way, community members impacted by the issues are centered. Empathy prompts students to gain a deeper understanding not only about how a problem affects a group, but also to learn about the group’s ideas for solutions.
“Ideate doesn’t happen in a silo,” Treston says. “That’s with community leaders and the community.”
She emphasizes that the last step is to test the prototype— not implement a solution. The expectation is that early ideas will need to be improved upon. “That’s one of the things that we wanted the students to really understand,” says Treston.
“The hallmark of innovation is failure because without failure you can’t have success. You have to try different things and be prepared to fail in order to come up with a solution that’s going to work.”
Pat Osborne RN GNu’22 participated in the Civic Engagement Project in Fall 2021, and he offers an encouraging spin on the testing phase. “It’s only failure if you actually give up,” he says.
Jolie Jemmott GNu’22, an RN and an Amy Gutmann Leadership Scholar, agrees. “Obviously no one wants to fail, but failure here is a lesson learned. And what are you going to take from that lesson to better your prototype in the next steps?”
According to Treston, the steps of design thinking are very similar to the profession’s quality improvement approach. Osborne likens it to medical algorithms. “It definitely makes it easier to take a group of people and explore problems and solutions in a way that makes sense and really moves things forward,” he says.
When Amy Gutmann Leadership Scholar Bellinda Accimé RN GNu’22, first heard about design thinking in the Civic Engagement Project, she recalled a conference she attended a few years ago. (Along with Jemmott and Accimé, two other Amy Gutmann Leadership Scholars, Juliana Ivanof and Key Duy Nguyen, took N656 in Fall 2021. The endowed program aims to help develop “nurse leaders who deliver exceptional evidence-based care, design research, inform policy, spark innovation, and advocate for social justice, worldwide.”) An NGO worker gave a talk about a costly project to bring toilet infrastructure to a Ghanaian village. He recounted that the project was a failure—because the residents were satisfied with their existing sanitation system.
“They didn’t empathize. They never connected with the people of that village to find out what their human experience was, and what they really needed,” Accimé recalls of his story. “And I think that this project provided me personally an opportunity to empathize in a different way. I think all of us in the project would say we really had to consider a perspective that we never had before.”
Accimé thinks health care can benefit from more upfront empathy in addressing community health challenges. “We can definitely jump to the ideate process first, without stopping to consider what is the experience of the person who’s going to be using this,” she says. “I think sometimes we work backwards, as opposed to what is the population in front of us and what do they need?”
Treston believes that graduates with N656 under their belts will have a powerful tool they can use forever, in health care and as a human being: “Design thinking is just a great way in any kind of setting to really approach problems and to successfully come up with solutions and test them.”
From Classroom to Community
With its semester-long academic structure, the Civic Engagement Project is among many learning opportunities at Penn Nursing that shepherd students from textbooks to hands-on experience.
Bellinda Accimé RN GNu’22, says her group appreciated the chance to apply what they were studying at Penn to make a true impact. “To use the education that you are receiving in real time, to help create something with an organization that maybe lasts beyond your time with that organization, that was a different type of opportunity,” says Accimé, also an Amy Gutmann Leadership Scholar.
Accimé’s group worked with the Survivors Alliance for Growth and Employment (SAGE), which provides job train- ing to survivors of human trafficking. Many have gaps in work history that make putting a resume together difficult. Some have a criminal record that prevents them from passing back- ground checks. They are also dealing with the trauma of being trafficked.
SAGE asked the students to create an objective rubric that survivors and their mentors could use to discuss career skills progress. The organization already had 13 “work behaviors” to review during these weekly sessions, in order to measure whether participants were successfully meeting expectations and to identify where they needed improvement. Both survivor and mentor grade each behavior, and there’s a tendency for the former to be overly self-critical.
“We needed something that would address the breakdown of confidence, the demoralization, that people who have been trafficked are often subject to. We wanted participants to have an accurate sense of where they were, not to discount them- selves, and give themselves the credit where the credit was due,” Accimé explains.
In considering the perspective of the survivor, Accimé and the group identified the need for clear and concise, measurable definitions for the behaviors that left no room for ambiguity.
“The priority was the participants’ well-being. We wanted to provide as much clarity as we could because I’m sure that there is a lot of uncertainty in what to expect when you re-enter the workplace, for whatever reason,” she says.
Ingredients of Innovation
Ideally, Civic Engagement Project students choose an issue they are already passionate about, Treston says, because “I think that’s where we come up with the most innovative solutions.”
In that regard, Pat Osborne GNu’22 had a head start. The RN is working at Penn Medicine Lancaster General Health while studying to be a family nurse practitioner. For a hospital community health needs assessment, he had already interviewed a representative from a local refugee resettlement agency. And as a global health minor, he had done an independent study on COVID vaccine distribution among the refugee population in that central Pennsylvania region. In the Civic Engagement Project, he says, “I saw the opportunity to again work with that com- munity. And not only find something that would be of benefit to them, but also something that might help enhance my own understanding of the chal- lenges that they encounter.”
Osborne knew from the assessment that mental health was among the many unmet needs for those who had resettled from Nepal, Syria, Democratic Republic of Congo, and beyond. He was aware the resettlement agency had an interest in a peer sup- port model, but they didn’t know what that would look like exactly. He pitched the Lancaster community issue to his N656 group, and they agreed. They eventually developed a prototype that aimed to bring together refugees to connect through their shared experience of leaving their countries and navigating a brand-new one.
They created a discussion guide that participants could use to lead their own discussions. It starts with easy, get-to-know-you questions such as “What do you miss from home?” and “What’s your new favorite food that you discovered here?”
“We weren’t trying to delve into the most serious issues that they’ve experienced as much as trying to form bonds between the participants, get them to see that as a group, they have strengths, that they have this resiliency that they can access,” Osborne says.
By the end of the semester, the group piloted a peer support meeting that was scheduled for one hour—and lasted two because the participants were having such a good time.
From the second the semester starts, the clock is ticking on the Civic Engagement Project’s potential for impact. Treston and the nurse practitioner students feel the urgency to shape solutions that can carry on without them.
Osborne says his team discussed sustainability early on. They collaborated with other students, from Penn and Millersville University, who were refugees themselves and who resettled in the US years ago and had an interest in mental health. Several of them, he says, are still working on the idea and hope to move it past the pilot stage. He has also reached out to some faculty about continuing the peer-to-peer mental health project with students from other classes.
“I thought this was such a good experience, I wondered if other students would like to be involved,” he says. “And maybe they can get an appreciation for the refugee community and all that they go through by working with them as well.”
“We really need nurses to step up. You’re seeing issues in the community. You’re working with community members. You need to take that next step and look at things from a legislative level, if you’re going to truly make long-term changes.”
The effort also helped Osborne see all that nurses can accomplish outside the clinical setting
“We were able to do this pilot with just some volunteer time and $20; $10 for the rental of the room and $10 for coffee and snacks,” he says. “There are problems that we might want to address within our own community that might be out of the scope of the organization we work for, or might not be as easily achievable within the organizational constraints. Nurses might find that if they go and try to do something outside of the organization, they have more flexibility.”
According to Treston, beyond interventions, the key to long-lasting change is nurses advocating for policies that lead to community-wide health improvements. She herself has served on the New Jersey Advisory Council on Domestic Violence. For her doctoral research she considered the potential to change federal housing policy for better health out- comes for Medicaid recipients experiencing homelessness.
To that end, the students write an op-ed as part of the course, to hone the skill of voicing a position publicly. The topic can be connected to their project, or focus anywhere they want to see change. Osborne wrote about COVID vaccines. Jemmott penned an op-ed on disparities in health care in regard to COVID 19. Accimé called for incorporating critical race theory in medical and nursing education. Treston is proud that several students had their pieces published in major news outlets.
“We really need nurses to step up. You’re seeing issues in the community. You’re working with community members. You need to take that next step and look at things from a legislative level, if you’re going to truly make long-term changes,” Treston says.
She also hopes the lasting impact goes both ways, and that students walk away with a better understanding of what they can accomplish. “When our students graduate from Penn, I want them to have the skills to do this in the community, in their clinical setting, and not be scared to fail because failure is part of the innovation process,” she says.
Accimé, for one, is ready. As she transitions from full-time student back to professional nursing, now as an NP, she is thinking about her career through the lens of her civic engagement experience.
“What does my practice look like with design thinking at hand?” she says. “COVID has changed so many different needs for people. We have people who maybe lost employment during the pandemic. They lost family members. They lost the ability to bury their family member in a way that aligned with their culture. What do they need from health care now?”