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Received: 3 June 2020    Revised: 10 August 2020    Accepted: 12 August 2020

DOI: 10.1111/phn.12796

S P E C I A L F E AT U R E S – E D U C AT I O N

Service learning in public health nursing education: How

COVID-19 accelerated community-academic partnership

Ashley Gresh MA, MSN, RN, CNM, PhD1  | Sarah LaFave MPH, RN, PhD1 |
Veena Thamilselvan Undergraduate Student2 | Anne Batchelder MPH, MSN1 |
Jenna Mermer MSN, RN1 | Keilah Jacques MSW3 | Amy Greensfelder MSW4 |
Melissa Buckley PhD, MSW5 | Zeke Cohen MA6 | Ann Coy MAT6 | Nicole Warren PhD,
MPH, RN, CNM1

1
Johns Hopkins University School of
Nursing, Baltimore, MD, USA Abstract
2
Johns Hopkins University Krieger School of Days after COVID-19 physical distancing precautions were implemented, a coalition
Arts and Sciences, Baltimore, MD, USA
of community leaders in Baltimore City founded the Baltimore Neighbors Network
3
Johns Hopkins University Bloomberg
School of Public Health, Baltimore, MD, USA
(BNN), a volunteer network established to provide proactive phone-based support
4
Pro Bono Counseling Project, Baltimore, to older adults in Baltimore City. BNN was a community-driven approach aimed
MD, USA at reducing social isolation and improving health equity both during the pandemic
5
Coppin State University and Healing City
and long-term. This paper describes how the Johns Hopkins School of Nursing's
Baltimore, Baltimore, MD, USA
6
Healing City Baltimore and Baltimore City (JHUSON) public health nursing clinical faculty and students partnered with BNN
Council, Baltimore, MD, USA to support a community-driven crisis response effort while creatively meeting stu-
Correspondence dent learning objectives. While engaging in the work of BNN remotely, nursing stu-
Ashley Gresh, 525 North Wolfe Street, dents were able to meet competencies across all eight domains of the Quad Council
Baltimore, MD, 21205, 603-831-3942, USA.
Email: ashley.gresh@jhu.edu Coalition of Public Health Nursing Organizations. Schools of Nursing throughout the
country can use this partnership as a model of a service-learning strategy for public
health nursing education during a crisis.

KEYWORDS
aging, community, community-academic partnership, isolation, older adults, public health
nursing, service-learning, social support

1 |  BAC KG RO U N D 1.1 | COVID-19 and public health nursing education

During COVID-19, communities have had to respond quickly and cre-
atively to mitigate the negative impacts of isolation associated with
physical distancing precautions, particularly among older adults. At
the same time, nursing education programs are challenged to con-
tinue with traditional, face-to-face partnerships which are possible
unsafe for student participation. In this paper, we describe the part-
nership between the Johns Hopkins School of Nursing (JHUSON)
and the Baltimore Neighbors Network (BNN) as an example of an
innovative service-learning-based public health nursing educational
strategy in response to the COVID-19 pandemic.
As JHUSON transitioned to online learning, faculty worked to iden-
tify activities that would support meeting course objectives in the
absence of direct client contact. JHUSON’s prelicensure public
health nursing course used service-learning, a structured learning
experience that embraces authentic community partnership with
explicit learning objectives, social justice preparation, and critical
reflection (Mitchell et al., 2015; Owen, 2016; Seifer, 1998). Service-
learning pedagogy specifically addresses social determinants of
health and social justice in an effort to contextualize health dispari-
ties and build health equity (Sabo et al., 2015). For the purposes of

Public Health Nurs. 2020;00:1–10. wileyonlinelibrary.com/journal/phn© 2020 Wiley Periodicals LLC.     1 |

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2       GRESH et al.
this paper, we define social justice as the “equitable distribution of
benefits and burdens in a society” (Redman & Clark, 2002; p. 466).
The clinical competencies for this course were structured around
Tier 1 of the Quad Council Coalition (QCC) of Public Health Nursing
Organizations’ Community/Public Health Nursing Competencies
(Quad Council Coalition Competency Review Task Force, 2018).
Competencies progress across three tiers of mastery (Tier 1 for en-
try-level practice, Tier 2 for supervisory management, and Tier 3 for
senior leadership/management) and across eight domains: assess-
ment and analytics; policy development/program planning; commu-
nication; cultural competency; community dimensions of practice;
public health science; financial planning; evaluation and manage-
ment; and leadership and systems thinking. The QCC intentionally
designed the competencies to support community and public health
nurses in cultivating skills oriented toward working collaboratively
with community members to promote health equity and create deep
structural changes to these ends.
The JHUSON public health nursing course content includes
exploration of antioppressive frameworks to help ensure that the
clinical groups’ service-learning efforts were community-driven and
challenge historical power imbalances between community and ac-
ademic institutions. Antioppressive work “addresses social divisions
and structural inequalities… It aims to change the structure and pro-
cedures of service delivery” (Strier & Binyamin, 2014, p. 2096). The
JHUSON public health nursing course faculty and students part-
nered with community agencies including public schools, indepen-
dent senior residences, and social services agencies that supported
persons affected by HIV, homelessness, and substance use disor-
ders. Each week, students learned in the classroom and spent a full
day at their community site supporting and learning from the part-
ners’ staff and clients. According to service-learning scholars, the
application of service-learning pedagogy in the community includes
authentic partnerships that are responsive to articulations and modi-
fications of community concerns (Andrews & Leonard, 2018; Asghar
& Rowe, 2017; Latta et. al., 2018; Mitchell, 2008). As the COVID-19
crisis began, community partners closed their doors to nonessential
workers and JHUSON clinical learning went entirely online. While
online clinical simulations provided valuable learning experiences,
the community's needs were increasing as a result of the pandemic
and students were eager to respond.
1.2 | COVID-19 and older adult isolation
For many older individuals living in the community, mobility limita-
tions, visual impairments, and other intrinsic factors prevent them
from engaging in employment, volunteer work or social activities
outside the home. These challenges are compounded by extrinsic
factors including high-cost and inaccessible public transportation
and limited in-home services. These challenges result directly in the
social exclusion of older people. More than one third of adults in the
United States reported feeling lonely and more likely to experience
loneliness if they had a limited social network or were isolated due
to physical limitations (Anderson & Thayer, 2018). Isolation is not
only a risk factor for loneliness but also contribute to older persons
having limited access to information, practical assistance, food, and
other material resources, perpetuating inequalities and making isola-
tion an important social determinant of health (Cattell, 2001; Popay
et al., 2008). Isolation and loneliness are associated with a number
of health issues, including impaired immune response, poor cardiac
health, diminished sleep quality, and early mortality (Holt-Lunstad,
Smith, Baker, Harris, & Stephenson, 2015).
The COVID-19 pandemic increases threats to the independence
and well-being of older community members, who already are facing
challenges such as isolation and food insecurity (Shahid et al., 2020).
COVID-19 physical distancing precautions have prevented many older
adults from continuing activities that are inherent antidotes to loneli-
ness, such as attending senior centers, congregating with family and
friends, and engaging with their faith-based communities. Many com-
munity agencies are providing support for older adults during the pan-
demic, but these services can be difficult to identify for an older person
who is not leaving the home (Banskota, Mealy, & Goldberg, 2020). In
addition, while many services address essentials like access to food and
medication, resources to support older adults’ social and mental health
needs are less accessible (Panchal et al., 2020).
1.3 | Age and racial disparities in COVID-19
morbidity and mortality
Nationwide, 80% of COVID-related deaths have been in people
aged 65 or older with death rates higher among Black adults than
White adults revealing stark racial disparities in COVID-19 disease
outcomes (Centers for Disease Control & Prevention [CDC], 2020a;
CDC, 2020e). Older adults are at disproportionately higher risk of
complications if they contract COVID-19, as well as for isolation
and disconnection from community resources as a result of physi-
cal distancing precautions. This is especially true for older Black
adults who make up approximately 62% of Baltimore City residents
(U.S. Census Bureau, 2019). Because of decades of structural rac-
ism and disinvestment in urban neighborhoods, older Black adults
in Baltimore City experience high rates of poverty and chronic
diseases, including mental health disorders (Hale, Smith, Bowie,
LaVeist, & Thorpe, 2019; LaVeist, Pollack, Thorpe, Fesahazion, &
Gaskin, 2011; Pappoe, 2016). These comorbidities and the dis-
criminatory factors that put people at increased risk for them also
place older Black adults at higher risk for COVID-19 complications
(CDC, 2020b). In addition, of the adults in Baltimore, 42% have ex-
perienced three or more adverse childhood events and this trauma
can have lifelong consequences such as increased risk for cancer,
diabetes, heart disease, and suicide (Behavioral Health Systems
Baltimore, n.d.; CDC, 2020c). These traumatic experiences from
childhood remain largely unresolved in the current older adult
population and older adults with earlier life trauma have a have a
higher likelihood of risky behaviors and revictimization, especially
if their social support network is limited (Maschi, Baer, Morrissey,
GRESH et al.
& Moreno, 2013). The physical and mental health risks associated
with a history of trauma compounded by the impact of the COVID-
19 pandemic has the potential to negatively impact older adults’
health (Behavioral Health Systems Baltimore, n.d.).
1.4 | The Baltimore Neighbors Network
In February of 2020, the Elijah Cummings Healing City Act was
signed into law, requiring city agencies to undergo trauma-informed
training and establishing Healing City Baltimore, a trauma-informed
task force to evaluate trauma-responsiveness (Mayor's Office of
Children & Family Success, 2020). Days after physical distancing
precautions were introduced in Baltimore, a coalition of community
leaders founded the Baltimore Neighbors Network (BNN). BNN was
a community of trained volunteers who offered hope, comfort, and
social solidarity through phone-based connections. BNN’s founders
said that a primary reason for launching the program during the pan-
demic was because “Baltimore's greatest asset is our people. We are
the medicine” (Healing City Baltimore, 2020). BNN’s network of vol-
unteers make calls to older adults across Baltimore City to provide
companionship, conversation, and, when needed, assistance with
resource navigation. Because BNN’s coalition of partners included
a professional pro bono mental health counseling agency and other
supportive services, BNN volunteers could escalate mental health
concerns to licensed clinicians, creating a wrap-around system of so-
cial and mental health support for participants. BNN volunteers in-
vited neighbors who received calls to join the network of volunteers
and many volunteer callers were older adults themselves. While at
the time of writing, BNN did not specifically track volunteer demo-
graphics, this is planned for the coming months.
1.5 | The community academic-partnership
BNN aimed to reach all 85,000 older adults in Baltimore City during
the pandemic, and to offer ongoing weekly support to those who
would like repeat phone calls. To meet this demand, BNN issued a
broad call for volunteers. Recognizing an opportunity to support the
community while also providing a meaningful service-learning expe-
rience for students, local universities began partnering with BNN.
Student volunteers from University Department of Social Work,
University of Social Work, and JHUSON public health nursing stu-
dents participated in BNN. In this paper, we describe the partnership
between JHUSON and BNN as an example of an innovative, remote,
service-learning-based public health nursing educational strategy in
response to the COVID-19 pandemic.
2 | D E S I G N
We used the four core components of service-learning to guide
the formation and implementation of our community-academic
|
      3
partnership, that is, it should: (1) be experiential; (2) provide students
with structured opportunities to learn while addressing community
needs; (3) intentionally include opportunities for reflection; and (4)
have reciprocity at its foundation: both the students and the commu-
nity served should benefit (Bailey, Carpenter, & Harrington, 2002,
p.434).
2.1 | Experiential learning
After physical distancing precautions were put in place, one pub-
lic health nursing clinical instructor and her students transitioned
from in-person visits to phone calls to continue the support of
older adults at their senior housing building site. Through the calls,
students helped dozens of older adults navigate food and medi-
cal resources during the first week of the city's shutdown. Course
instructors then explored possibilities for expanding on this work
to meet virtually student learning objectives, while also sup-
porting the community. Around the same time, the City Council
invited health equity experts from the university, including from
JHUSON, to present potential strategies for addressing older adult
isolation and health disparities during the pandemic. Recognizing
our complementary goals, the City Council President facilitated a
connection between JHUSON and BNN and we joined forces. A
key logistical challenge was to quickly execute a memorandum of
understanding (MOU) between JHUSON and BNN so that nurs-
ing students could count BNN service as clinical hours. Because
JHUSON and BNN coalition leaders saw value in developing the
partnership to meet urgent needs, the process of executing an
MOU between the university and the community partner, which
typically takes months, was finalized within days.
2.2 | Structured opportunities to learn while
addressing community needs: implementation
After the MOU was executed, BNN coalition leaders offered an
online volunteer training (detailed below) for 135 students and 15
clinical instructors. All students were Master of Science Entry into
Nursing Program students. Demographics for this cohort were
not available at the time of this writing, however, the most re-
cently graduated cohort included 238 students, 85 (35%) of whom
identified as Hispanic, or Non-Hispanic Black, African American,
Asian, Native Hawaiian, or Pacific Islander or more than two races.
Following the BNN training, students made mock calls to older
adult volunteers. Over the remainder of the semester, students
spent a portion of their clinical days making calls to BNN neigh-
bors. During the first day of calls, a Zoom-based virtual meeting
room remained open for drop-in questions, staffed by a technical
support volunteer from BNN, faculty with public health nursing
expertise, and doctoral nursing students with expertise in older
adult services and resource navigation. Students periodically came
into the meeting room with questions and concerns. As students
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4       GRESH et al.
became more familiar with BNN processes and procedures, the
virtual meeting room was no longer necessary; instead, students
and their clinical instructors were able to access BNN organizing
team members as needed.
2.2.1 | Training
Following a background check, all BNN volunteers participate
in a 4.5-hr training which included an overview of the BNN call
script and data entry form, use of the calling system, and guid-
ance on using harm reduction and inclusive listening skills. Training
was conducted by BNN coalition members from the Pro Bono
Counseling Project and the Baltimore Community Mediation
Center. Because the nursing students in the public health nursing
course had developed competencies related to inclusive listening
in their mental health course work and clinical rotations, and due
to the urgency to onboard volunteers, the students participated
in an abbreviated version of the training that complemented con-
tent in their prelicensure program. JHUSON faculty and doctoral
students provided additional resource navigation training to stu-
dents to further connect the BNN volunteer experience to student
learning objectives.
2.2.2 | Technology
All BNN volunteer phone calls, including those made by nursing
students, were made through Telzio, a cloud-based telephone sys-
tem that allowed for unlimited calls to be placed on multiple devices
through a single phone number. Telzio allowed for three-way calls
and call transfers in the event of a crisis (e.g., to 9–1–1 or a crisis
hotline) or to make a warm hand-off to a community resource such
as a food bank or health care provider. BNN obtained older adult
phone numbers from TargetSMART ListBuilder, a database of pub-
licly available contact information. Volunteers submitted an AirTable
form entry after each phone call so that organizers could track calls
placed and referrals made (e.g., to food, pharmacy, mental health re-
sources). Entries did not include identifiable information about vol-
unteers or older adults.
2.2.3 | Call script and resource guide
A committee of BNN members, including mental health clinicians,
developed a standardized call script to help volunteers navigate con-
versations. The script guided volunteers to identify mental health
concerns and to refer to a licensed mental health provider if needed.
Volunteers were encouraged to adapt the wording of the script to
ensure that their calls with neighbors are conversational and en-
gaging. Volunteers used a BNN-developed resource guide to help
older adults navigate up-to-date resources relevant to the COVID-19
pandemic.
2.2.4 | Program data
BNN tracked the number of volunteers who applied and been
trained. A BNN technology lead volunteer reviewed data entry
forms daily to track the number of calls made, number of conver-
sations, number and type of resources referred, and duration of
calls. This de-identified aggregated information was updated bi-
weekly on the BNN website. In addition, the BNN technology lead
volunteer used the data to determine which neighbors would like
a call back to ensure connection to resources and which neigh-
bors would like ongoing weekly calls to build a relationship with
a volunteer.
2.3 | Critical reflection
Critical reflection is defined here as “the process of learning to ques-
tion social arrangements and structures that marginalize groups
of people” (Diemer, Rapa, Voight, & McWhirter, 2016, p. 216).
Participants learned how to examine ways of thinking and feel-
ing that perpetuate existing structures and misconceptions of the
world and others (Mitchell et al., 2015; Owen, 2016). To ensure that
critical reflection was a component of the student experience with
BNN, after each session of calls, JHUSON students and their clini-
cal instructors met virtually using a reflective model developed by
Rolfe, Freshwater, and Jasper (2001), the What? So What? Now What?
These reflection questions encouraged students to summarize what
they had just done (What?), consider its meaning to their own learn-
ing and to the community members who participated (So What?),
as well as its meaning for them and that community or organization
moving forward (Now What?).
2.4 | Reciprocity
Reciprocity builds the foundation of this community-academic part-
nership. The BNN organizing committee reported that it has been
beneficial for them because it has enabled BNN to dramatically in-
crease program capacity, rapid-test new logistical strategies with a
large number of willing volunteers, and infuse a meaningful intergen-
erational component into the program. For example, after review-
ing the data entries and feedback from students, BNN identified
necessary revisions to the script training to ensure that volunteers
internalized that establishing rapport and social connection was the
priority versus identifying and addressing practical resource needs
alone. BNN reports that one challenge with student volunteers is the
need to train a very large number of people at one time. Typically,
BNN caps each training session at about 30 participants but adapted
to train hundreds of students at a time. Overall, BNN reports that
the community-academic partnership has been beneficial for them
and they are enthusiastic to continue to include students in the pro-
gram to take part in all aspects of the intervention from implementa-
tion to evaluation.
GRESH et al.       5 |
3 | M E A S U R E S 4.1 | Student learning

The community-academic team agreed on evaluative measures that
would be meaningful to both JHUSON and BNN. To monitor and
evaluate the implementation of the community-academic partner-
ship, the following process measures are being collected:
● Number of students trained
● Number of conversations with older adults
● Number of clinical hours completed by students
● Number of referrals to mental health services
● Number of referrals to community services such as food delivery
● Portion of the call list that is “cleaned” for use by BNN (i.e., discon-
nected numbers removed from call list so that future volunteers
can invest time in calling warm numbers)
A community-academic partnership logic model was created (see
Figure 1) as a visual tool to depict the formation of the partnership
and its intended impact on older adults in Baltimore City as well as
its impact on the career development of the nursing students.
4 | O U TCO M E S
The BNN-JHUSON partnership was rapidly established to respond
to the needs of older adults in Baltimore City while providing a ser-
vice-learning opportunity for nursing students during the COVID-19
crisis.
The JHUSON public health nursing course competencies are aligned
with the Quad Council's competencies for public health nursing
(Quad Council Coalition Competency Review Task Force, 2018).
Below, we review the competencies, organized by the Quad Council
domain, demonstrated by students during the clinical hours they
completed through BNN. In Table 1, we provide specific examples of
student experiences that exemplify a particular competency linked
to each of the Quad Council's eight domains.
4.1.1 | Domain 1: Assessment and Analytic Skills
When making phone calls through BNN, students assessed if older
adults’ basic needs were met and if they were in need of mental
health support. During critical reflection, instructors intentionally
focused on discussions of health disparities and social justice, and
students identified disparities in access to resources and social sup-
port across the city's population. Students were able to identify
assets and gaps in infrastructure as health systems and community-
based organizations quickly worked to develop and adapt services
during the pandemic. Student reflections ranged from practical
considerations about how to improve the call script and keep the
resource list current, to substantive critical reflection about older
adults’ value to society and the relationship between systems-level
injustices and individual access to resources. As students continued
to learn online from their homes, many expressed that contributing

Community-Academic Partnership Logic Model

Inputs Outputs Outcomes - Impact

Activities: Outputs: Short-Term: Intermediate: Long-Term:

BNN coalition
Situation leaders
Clinical education Training Students trained to Build a Sustain BNN Reduce
•Intro – BNN provide
transitions from in-person Student volunteers community- post-COVID-19 loneliness and
coalition leaders & psychosocial academic social isolation
to online in response to JHUSON faculty support for older
COVID-19. JHUSON clinical partnership Develop a high among older
faculty and doctoral •Script training – adults, address between quality nursing adults in
students BNN coalition SDOH, and engage JHUSON and workforce to Baltimore City
Urgency of addressing the leaders in resource BNN address
American epidemic of Telzio (calling •Technical training - navigation determinants of Improve quality
social isolation that has system) BNN coalition Increase social health and health of life for older
leaders Older adults
been highlighted and support for older inequities adults in
Zoom (virtual •Resource guide contacted during adults Baltimore City
heightened by the training - JHUSON COVID-19
COVID-19 crisis. meeting room)
doctoral students pandemic Connect older
Call script adults with
Priorities Practice calls Older adults resources
Create a Resource guide referred to
Neighbor calls - resources including Train students to
community-academic
Airtable (data entry Zoom room open mental health respond to
partnership to proactively for on-call support support
respond to community and tracking) SDOH through
service-learning
health needs. Critical reflection Mental health
Memorandum of
Understanding consultations
between BNN and Data collection and provided as needed
JHUSON analysis
Program reports Evaluation

F I G U R E 1   Community-academic partnership logic model

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6       GRESH et al.

TA B L E 1   Community/Public Health Nursing [C/PHN] Competencies (Quad Council Coalition Competency Review Task Force, 2018)

Domain Title Competency Met Example

1 Assessment and “Use information technology effectively to collect,
Analytic Skills analyze, store, and retrieve data related to public
health nursing services for individuals, families,
and groups.”
2 Policy Development/ “Describe the implications and potential
Program Planning impacts of public health programs and policies
Skills on individuals, families, and groups within a
population.”
3 Communication Skills “Apply critical thinking and cultural awareness to
all communication modes (i.e., verbal, nonverbal,
written & electronic) with
individuals, the community, and stakeholders.”
4 Cultural Competency “Use determinants of health effectively when
Skills working with diverse individuals, families, and
groups.”
5 Community “Assist individuals, families, and groups to identify
Dimensions of and access necessary community resources
Practice Skills or services through the referral and follow-up
process.”
6 Public Health “Use evidence-based practice in population-level
Sciences Skills programs to contribute to meeting core public
health functions and the 10 essential public
health services.”
7 Financial Planning, “Interpret the impact of budget constraints on
Evaluation, and the delivery of public health nursing services to
Management Skills individuals, families, and groups.”
8 Leadership and “Influence health as a shared value through
Systems Thinking community engagement at the organizational
Skills and systems level.”
Students assessed the needs of their neighbors and
identified relevant resources and referrals. If no
resources in the BNN resource guide addressed a
particular need, students identified and provided
information to BNN on community resources or
offered information on service gaps for BNN to use
to inform future community planning.
Students incorporated their emerging knowledge
on antioppressive frameworks to describe how
COVID−19 exacerbates public health challenges in
this community and the individuals engaged in the
program.
If a student identified a neighbor issue that was
beyond their scope, they employed critical thinking
skills in communicating to escalate the issue to a
professional member of the interdisciplinary team.
For example, one student identified in partnership
with a neighbor that he was in acute respiratory
distress. With support from her clinical instructor,
she facilitated a warm hand-off to paramedics, while
staying on the line with the neighbor to ensure his
needs were met.
In connecting older adults throughout Baltimore with
resources, students utilized determinants of health to
effectively meet the needs of diverse individuals.
Students helped older adults connect with community
resources and services, based on BNN resources
guild, while also referring callers to instructors and
BNN leaders when needed.
Students participated in a community-driven approach
to identify and address a population-level challenge
during an acute health crisis.
In gaining a better understanding of the needs of
the older adults and navigating resources, students
learned about the limitations of available resources
due to budget constraints.
In reflection with instructors and peers, students
recognized how addressing population-level
health challenges like COVID−19, complicated by
existing structural inequities, requires community
engagement and leadership as demonstrated by this
BNN partnership.

to the pandemic response in Baltimore through their BNN calls pro- co-founded BNN met with students to provide a policy perspective,
vided them with a sense of purpose. reinforcing the importance of supporting community-based initia-
tives in public health policy and practice.

4.1.2 | Domain 2: Policy Development/Program

Planning Skills 4.1.3 | Domain 3: Communication Skills

The students supported the BNN team to develop and implement a
program from the ground up. As students made calls, they provided
input into program development and evaluation by offering feedback
to BNN on what to include in the future iterations of their call script,
data entry form, and resource guide. The City Councilperson who
This experience allowed students to engage in innovative communi-
cation methods as part of an interdisciplinary team. They employed
inclusive listening skills and delivered public health information,
when asked for, to members of the community. They also practiced
use of effective communication skills if they identified a neighbor
GRESH et al.
issue that was beyond their scope; in those cases, students esca-
lated problems via a warm hand-off to a clinical instructor, a pro
bono counselor through BNN, emergency services, or another pro-
fessional who could best support the neighbor.
4.1.4 | Domain 4: Cultural Competency Skills
Making calls through BNN allowed students the opportunity to re-
spond to a diverse community's needs and preferences during a cri-
sis. When making phone calls, students employed a client-directed
approach to care, inviting older adults to guide the conversation and
determine if and how they would like support. BNN also gave stu-
dents a first-hand understanding of the impact of determinants of
health during a crisis. Because their service-learning experience took
place during the first stage of the COVID-19 pandemic, students
saw how chronic stressors and systemic differences in access to re-
sources could accentuate disparities during an acute health crisis,
and how community-driven approaches could mitigate disparities.
According to Kumagai and Lypson (2009), this reorientation toward
critical consciousness, or recognizing the societal context surround-
ing health care as a first step in addressing solutions to systemic
challenges, is necessary to center equity in teaching the social de-
terminants of health.
4.1.5 | Domain 5: Community Dimensions of
Practice Skills
By partaking in the inception of the community-academic partner-
ship, students were able to observe and participate first-hand in
stakeholder engagement and development of community partner-
ships. BNN was founded by community members and relies entirely
on community time and resources to function; students were able to
contribute to this community-driven approach to care.
4.1.6 | Domain 6: Public Health Sciences Skills
This partnership exemplified one of the 10 Essential Public Health
Services which is to “mobilize community partnerships and action
to identify and solve health problems” (CDC, 2020d). Students were
able to be a part of mobilizing community partnerships to increase
social support in a time of acute crisis and to provide important real-
time information to government and community agencies on the re-
source needs of older adults.
4.1.7 | Domain 7: Financial Planning, Evaluation, and
Management Skills
Students witnessed the role of sound management skills in address-
ing community needs during a crisis, including through cross-sector
|
      7
management. In addition, an undergraduate student and two doc-
toral nursing students partnered with BNN coalition leaders and a
JHUSON faculty member to develop and submit a successful grant
application to improve sustainability of the program. These three
students were also involved in the community-academic team's
work to develop a more rigorous evaluation plan for BNN.
4.1.8 | Domain 8: Leadership and Systems
Thinking Skills
Clinical instructors invited students during reflection to consider
the implications of this initiative for health systems, population-level
health disparities and social justice. Throughout the debrief ses-
sions, students discussed linkages between hospital and community
healthcare and the importance of bridging the gap between the two
in order to improve quality of life for older adults.
4.2 | BNN services
Nursing students from the public health nursing course placed a
total of 2,950 calls over a 2-week period and engaged in conversa-
tions with 546 older adults. Each student contributed between 4
and 12 hr making calls to older adults through BNN. Nursing stu-
dents made an average of 22 calls each with calls averaging around
2.2 min per connected call. Calls ranged from short conversations
lasting roughly 30 s up to 12 min. Calls ranged from short touch-
points with older adults who did not identify any unmet needs, to
longer conversational and resource navigation calls. Through these
conversations, students made 21 referrals to mental health services,
25 referrals to food services, and 60 referrals to other community
resources. If an older adult agreed to follow-up phone calls, BNN
volunteers continued to call them on a weekly basis and assess if
they are able to access any resources that might have been referred
to them. During follow-up calls, volunteers were able to see in the
notes whether or not a resource was referred to the older adult.
However, there was no formal process put in place to follow-up with
each older adult to assess if referred resources were successfully
accessed. The students also identified 617 numbers no longer in ser-
vice that were removed from the call queue for future volunteers.
Generally, older adults have expressed appreciation for the calls
and are thankful for the check-in even if they declined to maintain a
weekly connection with a volunteer. Additionally, some older adults
enrolled as volunteer callers, demonstrating the potential for BNN to
build community connection.
5 | D I S CU S S I O N
The partnership between JHUSON and BNN was an example of an
innovative service-learning-based public nursing educational strat-
egy in response to the COVID-19 pandemic. While nursing educators
 |
8       GRESH et al.
using service-learning strive for authentic partnerships, these are
difficult to achieve. In this instance, there was actual power shar-
ing and shared decision making as we implemented a partnership
grounded in antioppressive frameworks. Important factors that led
to the success of this community-academic partnership are recep-
tiveness of BNN to the partnership, existing faculty and community
relationships, flexibility of clinical faculty, student readiness, course
commitment to serve Baltimoreans as directed by Baltimoreans,
the ability of contracts staff to quickly execute an MOU, and BNN’s
strong technical platform.
Community partnerships were needed to fulfill practicum re-
quirements that meet accreditation standards for student learning.
The relationship between students and their practicum sites has a
significant impact on not only their current learning but also poten-
tially their professional trajectories. But the literature is relatively
scant regarding how these partnerships benefit the community part-
ner (Karasik, 2020). This partnership between JHUSON and BNN
provided insight into how this relationship aligns with the reciprocity
model, as BNN sees students as valued members of the program and
hopes that the partnership will continue well after students com-
plete their educational requirements. Consistent with research on
student engagement and educationally purposeful learning activi-
ties (Taylor, Yochim, & Raykov, 2019), BNN endeavors to engage stu-
dents in all aspects of the intervention model and to provide support
and supervision whereby they will see themselves as vital members
of the team.
BNN is building a sustainable infrastructure that will continue to
positively impact older adults and students beyond the COVID-19
pandemic. Long term, this means that in addition to providing social
support, the project has the potential to address the many negative
outcomes associated with loneliness including depression, cognitive
decline, and immune system compromise (National Academies of
Sciences, Engineering, & Medicine, 2020). Because BNN volunteers
assist older adults with resource navigation when requested, this
project has the potential to facilitate access to food, health care, and
social services.
This sustainable, community-academic partnership can be mod-
eled by other community organizations and universities throughout
the country and with other populations at high risk for health ineq-
uities. Our work provides an exemplar of how to continue clinical
education during a crisis when in-person activities are not possible.
Many nursing students who participated noted that they were grate-
ful to be a part of this public health nursing course during the pan-
demic because it offered them a chance to participate in community
responses to COVID-19 as prelicensure students. After the public
health nursing course, 25 students asked to continue volunteering
with BNN on their own time, a testament to the impact of work
with BNN on student participants. JHUSON and BNN are continu-
ing their partnership: the summer rotation of prelicensure students
in psychiatric nursing will participate in BNN training and service in
addition to their previously planned clinical activities, and in the Fall
semester, a group of public health nursing students will be placed
with BNN for their clinical rotation. JHUSON is also partnering with
local universities to facilitate an interdisciplinary cohort of student
volunteers this summer.
There are limitations to this partnership. The program is running
without a comprehensive evaluation plan in place. This is due, in
part, to the fact that the services were launched so quickly amidst a
public health crisis. The community-academic team applied for and
recently received a small COVID-19 specific grant, more than 90%
of which will support BNN to train and support volunteers and to
develop a robust evaluation plan for the program, and the remainder
of which will support JHUSON faculty and student time to support
these activities. This planning includes developing mechanisms for
tracking if referred resources are successfully accessed by older
adults. In addition, BNN is now implementing exit surveys with all
volunteers; upcoming cohorts of students will receive a survey to
evaluate their experience at the end of each semester. Moving for-
ward, BNN and JHUSON will more formally evaluate student expe-
riences in this service-learning opportunity.
In addition, the rapid set-up and overall fatigue among students
and faculty participating in all-online learning during a stressful pe-
riod may have affected the quality of reflection. As students con-
tinue to engage with BNN, the need for critical reflection will be
reinforced. There were also some challenges related to students’
participation. Some students may have felt nervous or felt unpre-
pared to place cold calls, but we did not formally capture data on
their expectations for or concerns about the experience due to time
constraints. With more preparation time, it may have been helpful
to provide students with additional training to help them feel pre-
pared to respond to older adults’ resource and mental health needs
by phone. In addition, an important strength of BNN is that callers
are able to reach older adults who are potentially most disconnected
from services and supports, because calls are placed to all city resi-
dents as opposed to an existing organization's client list. The trade-
off to that strength is that callers often reach disconnected numbers
or people who are not interested in conversation or in need of sup-
port. In the future, it will be helpful to provide additional context
to students to help them understand the value of the “cold-call”
approach.
Finally, the experience is not generalizable because BNN was
a unique coalition of community leaders and such an organization
does not exist in all communities; however, other Schools of Nursing
can partner with local agencies on aging, public health departments
or other community organizations to do phone outreach to clients
during a crisis. In addition, the technological requirements and
set-up can be replicated; in fact, the BNN technical team has made
a concerted effort to create templates and documentation to help
other organizations jumpstart this work.
6 | CO N C LU S I O N
The BNN-JHUSON partnership provides an example of a ser-
vice-learning, online public health nursing educational strategy
in response to the COVID-19 pandemic. Critical service-learning
GRESH et al.
pedagogy and antioppressive frameworks provided the guidance for
shared-decision making and power-sharing necessary for progress
toward a socially just, equitable distribution of benefits and burdens.
In a time when teaching, learning and service are rapidly being trans-
formed by the COVID-19 pandemic, this collaboration was a much-
needed reminder that we have a duty to align academic efforts with
the community's priorities.
ORCID
Ashley Gresh  https://orcid.org/0000-0002-7181-8219
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How to cite this article: Gresh A, LaFave S, Thamilselvan V,
et al. Service learning in public health nursing education:
How COVID-19 accelerated community-academic
partnership. Public Health Nurs. 2020;00:1–10. https://doi.
org/10.1111/phn.12796
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