The Effect of Community Nurse Practice for Medical Students Who Rotate in Emergency Medicine

Abstract

Background: Emergency medicine in Japan traditionally emphasizes critically ill patients, but recent trends show an increase in minor illness cases influenced by social factors. This study assessed integrating community nurse (CN) training into an emergency medicine elective to evaluate its effect on students’ self-achievement and communication skills. Methods: Medical students rotating in the emergency department participated. Those choosing the CN training spent one week in the community, while others remained hospital-based. Surveys evaluated self-achievement of Shimane University emergency medicine objectives and communication skills per the Model Core Curriculum. Analyses used t-tests. Results: Of 35 students, 21 (60%) completed surveys. Satisfaction levels did not differ significantly between CN and non-CN groups (4.0 ± 0.70 vs. 4.5 ± 0.63, p = 0.15). Regression analysis indicated satisfaction correlated only with online practice availability. No significant differences emerged for goals or communication items (all p > 0.05), although CN participants tended to rate higher on patient proximity, communication, and social engagement. Discussion: CN training maintained overall satisfaction and slightly enhanced communication and social aspects, aligning with shifts toward psychosocial care in emergency medicine. Conclusions: Integrating CN practice did not significantly impact emergency medicine knowledge or skill satisfaction but showed a trend toward improved communication and social purpose satisfaction. Larger-scale studies are needed for validation.

1. Introduction

In Japan, emergency medicine was developed to treat critically ill patients. Emergency physicians have tried to save cardiac arrest patients, severe trauma patients, and so on. In recent years, however, patients visiting the emergency room are not necessarily those with serious illnesses, but rather an increasing number of patients with physical symptoms that result from social difficulties in life [1]. Social difficulties include loneliness, poverty, alcoholism, and domestic violence. Therefore, we believe that future emergency medical care will require visiting and listening to local residents to determine how they live and their problems. This trend is observed internationally, where emergency physicians are increasingly required to address social issues influencing health, and thus these approaches need to be included in emergency medicine training [2].

The emergency department elective training for sixth-year students at Shimane University used to be a four-week emergency department outpatient training program, but from 2021, those who wished to spend one of those four weeks at a community nursing company could do so. The community nurse is a new role that began in Unnan City, Shimane, Japan. They are a group of people who do not work in a hospital but live in the community and connect with other people to empower the town. Examples of their activity include “Osekkai conferences,” which are town meetings to solve the town residents’ problems [3,4,5].

The first year of the community nurses’ rotation was completed. Few universities offer community nurse-like training during the emergency center training period, and it is not clear how this training would benefit students or whether it would reduce the educational effectiveness of the training as an emergency practice.

The aim of this study was to determine whether participation in a community nurse rotation during the emergency department elective influences medical students’ self-assessed achievement of rotation goals, including communication competencies, compared to those who did not participate in the community nurse rotation. We also sought to clarify how students perceive their attainment of specific educational objectives defined by the emergency department rotation curriculum, as measured by a self-assessment instrument designed for this purpose. The rotation objectives for the emergency department elective were based on the General Instructional Objectives (GIOs) and Specific Behavioral Objectives (SBOs) set by the Department of Emergency and Critical Care Medicine at Shimane University Hospital. The questionnaire items used in this study directly reflect these objectives, as well as the core competencies for communication and professionalism defined in the Japanese Model Core Curriculum for Medical Education, which serves as the national educational standard for all Japanese medical schools.

2. Materials and Methods

2.1. Participants

The study participants were students who had selected emergency department training as part of their elective training (n = 35). Of the participants in the emergency department training, those who wished to participate in community nurse training spent one week out of the four weeks in the community nurse training (n = 7), while those who did not participate spent four weeks in the emergency department of the university hospital (n = 28).

2.2. Instruments and Measurements

The survey instrument included 20 items on educational objectives and communication (

Table 1. Questions asked.

Q1: Acquired practical clinical skills for emergency patients and outpatient general clinical department patients.

Q2: Acquired the ability to present clinical content.

Q3: Acquired the ability to practice inpatient treatment under the guidance of a physician.

Q4: Acquired the ability to provide patient-centered care.

Q5: Can explain the importance of vital signs in initial diagnosis.

Q6: Can evaluate emergency severity and plan diagnostic treatment.

Q7: Can diagnose without missing significant conditions.

Q8: Can develop a basic clinical strategy for common diseases.

Q9: Can explain appropriate treatment plans to each patient.

Q10: Can learn the appropriate way to interact with patients and their families.

Q11: Can explain the methods and skills of communication (both linguistic and non-linguistic) and summarize the impact of communication on attitude or behavior.

Q12: Can build good relationships through communication.

Q13: Can listen to and empathize with patients and their families.

Q14: Can fully consider the mental and physical pain of patients and their families.

Q15: Can explain in language that is easy for patients to understand.

Q16: Can understand the patient’s psychological and social background and the challenges of living an independent life and can extract and organize the problems they face.

Q17: Can explain that medical acts are based on a contractual trust relationship between the patient and the physician.

Q18: Can explain how to deal with the patient’s requests (examination, transfer, referral).

Q19: Can consider the privacy of patients.

Q20: Understands the obligation of confidentiality and the importance of providing information to patients and can handle it appropriately.

Questions 1 to 4 are the GIOs and questions 5 to 10 are the SBOs of the Department of Emergency Medicine, Shimane University. Questions 11 to 20 are the items listed in the Communication section of the Japanese Model Core Curriculum for Medical Schools.

), as well as questions about age, sex, and overall satisfaction with the emergency department rotation. The 20 questionnaires were developed by the researchers based on the GIO and SBO established by the Department of Emergency and Critical Care Medicine at Shimane University, and communication-related items from the Model Core Curriculum for Medical Schools (set by the Ministry of Education, Culture, Sports, Science and Technology). Participants responded to each item, including overall satisfaction, using a 5-point Likert scale (1 = least learned, 5 = most learned). Internal consistency reliability (Cronbach’s alpha) was not calculated in this study.

2.3. Procedure

All eligible sixth-year students who completed the emergency department rotation were invited to participate in a web-based survey, which was administered after final grading to avoid any impact on academic evaluation. The survey was conducted from 15 December 2022 to 5 January 2023, and participation was voluntary and anonymous.

For the Community Nurse Practicum, applicants spent one week of the four-week elective in community-based activities coordinated by Community Nurses, Inc. During this practicum, students engaged in home visits and participated in local problem-solving through casual conversations with residents, aiming to develop their skills in psychosocial communication and problem identification.

Clinical training at Shimane University Medical School is a six-year program, with clinical clerkships beginning in the fifth year. In their final year, students complete four-week elective rotations, including emergency medicine, where they participate in patient care and clinical decision-making under supervision.

The primary outcomes included the comparison of mean self-rated scores between community nurse participants and non-participants for each survey item, as well as the proportion of students achieving a score of 4 or 5 on each item.

The medical school system in Japan is a six-year system and clinical training begins in the fifth year at the Shimane University School of Medicine. Students rotate through all departments over a period of approximately one year, and in the final year, they rotate through selected departments over a period of four weeks as part of their medical practice participation training. In emergency medical centers, students mainly treat patients who visit the emergency room and discuss their assessment, examination, and treatment plans with the doctors in charge.

2.4. Data Analysis

All statistical analyses were performed using R version [4.3.1] (The R Foundation for Statistical Computing, Vienna, Austria). Descriptive statistics, including mean and standard deviation (SD), were calculated for participant characteristics and survey item scores. The mean self-assessment scores were compared between the community nurse rotation group and the non-participation group using independent samples t-tests. Statistical significance was set at p < 0.05 (two-sided). In addition to t-tests, multiple regression analysis was conducted to examine the association between potential predictors (age, sex, community nurse company participation, and online participation) and overall satisfaction with the emergency department rotation. Multiple regression analysis was performed because overall satisfaction may be influenced by the presence of online practicum due to COVID-19, and by sociodemographic factors such as age and sex, especially in the context of community nurse practicum involving home visits and other activities. All analyses included only complete responses; missing data were handled by listwise deletion. The sample size was not set a priori as required, but all participants in the emergency department training were surveyed. This study was approved by the Medical Research Ethics Committee of Shimane University Faculty of Medicine. The informed consent was obtained from all the participants.

3. Results

During the study period, 21 of 35 emergency department rotators responded to the survey (60% response rate). The average age of respondents was 26.4 years, 8 were male, 12 were female, and 1 did not respond. Five community nurse practicums participated and sixteen did not participate. Three students participated in an online practicum week during the emergency department practicum period because of the COVID-19 pandemic.

The mean overall satisfaction with emergency department training was not significantly different between CNC participants and non-participants (4.0 ± 0.70 vs. 4.5 ± 0.63, p = 0.15). Multiple regression analysis of the factors affecting overall satisfaction with emergency department rotation was only significant in the presence of online practice for at least one week. CNC participation did not increase or decrease overall satisfaction with the emergency medicine rotation (

Table 2. Multiple regression analysis of factors affecting overall satisfaction with emergency department rotation.

	β	Lower	Upper	p Value
Age	−0.014	−0.09	0.06	0.68
Sex	0.016	−0.46	0.49	0.94
Online	−1.19	−2.01	−0.38	0.01
CNC	−0.07	−0.76	0.60	0.81

Online: Part of the practice was conducted online because of the COVID-19 pandemic. CNC: Community nurse company participation.

).

A comparison of the GIOs and SBOs of the practices set by the Department of Emergency Medicine at Shimane University and the communication items of the Japanese Model Core Curriculum for Medical Schools is shown in

Table 3. Average achievement rate of each questionnaire 1 through 5 (1 = least to 5 = maximum).

	CNC−	CNC+	p Value
Q1	4.44 ± 0.63	4.20 ± 1.30	0.58
Q2	4.19 ± 0.54	3.60 ± 1.14	0.12
Q3	3.62 ± 1.02	3.80 ± 1.10	0.75
Q4	4.06 ± 0.57	4.40 ± 0.55	0.26
Q5	4.19 ± 0.75	4.20 ± 1.30	0.98
Q6	3.94 ± 0.68	3.60 ± 1.67	0.51
Q7	3.75 ± 0.68	3.20 ± 1.48	0.25
Q8	3.81 ± 0.83	3.60 ± 1.14	0.65
Q9	3.25 ± 0.86	3.20 ± 0.84	0.91
Q10	4.19 ± 0.54	4.00 ± 1.22	0.63
Q11	4.06 ± 0.68	4.25 ± 0.50	0.61
Q12	4.19 ± 0.66	4.20 ± 0.45	0.97
Q13	4.50 ± 0.73	4.50 ± 0.58	1.00
Q14	4.25 ± 0.45	4.20 ± 0.45	0.83
Q15	3.81 ± 0.54	4.20 ± 0.45	0.17
Q16	3.69 ± 0.60	4.00 ± 0.00	0.27
Q17	3.88 ± 0.72	3.40 ± 1.52	0.34
Q18	3.00 ± 1.15	3.60 ± 1.14	0.32
Q19	4.37 ± 0.72	4.00 ± 1.22	0.40
Q20	4.56 ± 0.51	4.20 ± 0.84	0.25

CNC−: community nurse non-participants, CNC+: community nurse participants.

. No statistically significant differences were found between CNC participants and non-participants for any of the items (Table 3). Similarly, no significant differences were found when students who had one week of online practice were excluded from the comparison (total N = 18, CNC− = 15, CNC+ = 3). Although not statistically significant, the percentages of CNC participants who scored 4 or 5 on the satisfaction scale were high for Q3, 4, 11, 12, 13, 15, 16, and 18.

4. Discussion

We introduced community nurse practices into the rotation of the emergency medicine department. In this study, we primarily aimed to compare the self-attainment of emergency department rotation goals—measured by GIO, SBO, and communication items—between CNC participants and non-participants. The results showed that there were no statistically significant differences in self-attainment scores between the two groups. However, the proportion of CNC participants who rated 4 or 5 on certain items, such as staying close to patients, communication, and social engagement, tended to be higher, suggesting a possible positive trend. These findings indicate that participation in the community nurse rotation did not significantly improve or impair students’ self-attainment of rotation goals, but may provide some benefit in specific domains such as psychosocial communication and social understanding. Overall satisfaction with the emergency medicine rotation also did not differ significantly between groups.

Traditionally, emergency medicine has focused on treating critically ill patients. However, in recent years, many patients with minor illnesses have visited emergency centers. There is a growing number of educational programs that incorporate public health and social determinants of health into emergency medicine residency curricula [6,7]. The usefulness of training with Simulated Patients has been proposed as a method for training undergraduates in healthcare-related communication skills [8,9]. While such methods are useful for communication skills in the examination room, we believe that education to understand the psychosocial aspects of patients is insufficient [10,11]. In addition to communication skills in the exam room, communication skills are essential to clarify the social aspects of the patient, such as where the patient lives and what kind of anxiety is essential to understanding the patients’ real problems. Citizen involvement improves medical trainees [12,13]. In the Japanese Model Core Curriculum for Medical Schools revised in 2022, there is a new chapter called “Generalism,” which is focused on seeing the patient as a local neighbor. This community nurse practice emphasizes opportunities to interact with diverse people in their daily lives as residents of the community, such as the “Osekkai conference” [14,15], and we believe that this will contribute to the improvement of communication skills in terms of this Generalism education. This tendency is not limited to Japan, as previous studies from other countries have also highlighted the importance of understanding patients’ social context and the value of community-based approaches in emergency medicine training [2,16].

The observed positive trend in the CNC group, though not statistically significant, invites a descriptive and theoretical interpretation. This trend may be explained by the involvement in real live community. Unlike traditional classroom or even in-hospital settings, the community nursing practice immersed students in patients’ authentic living environments. This direct exposure to the “psychosocial aspects of patients” provides a learning context that is difficult to replicate. Students in the CNC likely moved from being passive observers to legitimate peripheral participants in the community’s health ecosystem. This experience, such as participating in an “Osekkai conference,” fosters an understanding of patients not just as clinical cases, but as individuals embedded in a social web. This finding is consistent with previous research on attitudes toward homeless patients. Although emergency department rotations provide medical students with opportunities to encounter homeless individuals, these experiences alone do not necessarily lead to improved attitudes toward homeless people [17]. Therefore, our results suggest that emergency medicine rotations should place emphasis on experiential learning in community settings, enabling students to engage more deeply with the social realities of patients’ lives.

This study had several limitations. First, the number of participants in this study was too small to detect statistically significant differences. Additionally, due to the limited sample size, we were unable to perform multivariable analyses to control for potential confounding variables. This may have introduced residual confounding. We intend to continue this investigation with a larger sample in future studies to enable more robust statistical analyses. Second, because CNC rotation was voluntary, it is possible that students who requested CNC rotation had good communication skills before the rotation. However, since the question asked was whether they thought they had acquired the relevant skills through the emergency department rotation, we do not believe that this effect was significant. Third, this study is based on a self-achievement/self-assessment test, and thus potential biases such as the Dunning–Kruger effect and social desirability bias may have affected the results. We would like to conduct a further study using more objective assessment methods (such as pre- and post-tests or external evaluations) in addition to self-assessment surveys to reduce the impact of these biases. Fourth, this study is a non-randomized design, and the response rate was low, and these lead to a severe bias. This study is a research study as well as a form of education itself. Because it is also a university education, it must first and foremost reflect the will of the students, and the collection of questionnaires must also reflect the free will of the students so as not to affect their grade evaluation, so the accuracy of the research must inevitably be reduced.

5. Conclusions

We introduced community nursing practices into the rotation of the emergency medicine department. The satisfaction rates with emergency medicine knowledge and skills did not differ. The satisfaction rate of communication and social purposes was not significantly different but tended to be higher in CNC rotation participants. Further studies involving more participants are required to confirm this hypothesis.