4
Nursing Education and Professional Development

The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—what the reverse—which are of importance—which are of none—which are the evidence of neglect—and of what kind of neglect.

—Florence Nightingale, 1860, p. 105

Linking the skills of professional nursing described in this quote with the mastery of scientific knowledge of environmental health concepts from interdisciplinary studies is essential to the reform of the educational process for the health professions. Environmental effects on the health and welfare of individuals, families, and communities are increasingly complex and multifaceted. These effects require integrated knowledge of prevention and amelioration of environmental health consequences in all health professions education.

Of the 17 competencies of health professionals listed in Healthy America: Practitioners for 2005, An Agenda for Action for U.S. Health Professions Schools (Shugars et al., 1991a), 6 directly address the demand for the development of environmental health skills among providers: (1) understand the role of the physical environment on health; (2) respond to increased public, governmental, and third-party participation in health care; (3) care for the community's health; (4) expand access to care and improve the public's health; (5) emphasize prevention; and (6) promote healthy lifestyles. These competencies illustrate the different skills, values, and attitudes necessary to ensure improved health status outcomes in the twenty-first century. The incorporation of environmental health concepts and practice activities into professional education is critical for influencing health and disease outcomes worldwide.



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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 4 Nursing Education and Professional Development The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—what the reverse—which are of importance—which are of none—which are the evidence of neglect—and of what kind of neglect. —Florence Nightingale, 1860, p. 105 Linking the skills of professional nursing described in this quote with the mastery of scientific knowledge of environmental health concepts from interdisciplinary studies is essential to the reform of the educational process for the health professions. Environmental effects on the health and welfare of individuals, families, and communities are increasingly complex and multifaceted. These effects require integrated knowledge of prevention and amelioration of environmental health consequences in all health professions education. Of the 17 competencies of health professionals listed in Healthy America: Practitioners for 2005, An Agenda for Action for U.S. Health Professions Schools (Shugars et al., 1991a), 6 directly address the demand for the development of environmental health skills among providers: (1) understand the role of the physical environment on health; (2) respond to increased public, governmental, and third-party participation in health care; (3) care for the community's health; (4) expand access to care and improve the public's health; (5) emphasize prevention; and (6) promote healthy lifestyles. These competencies illustrate the different skills, values, and attitudes necessary to ensure improved health status outcomes in the twenty-first century. The incorporation of environmental health concepts and practice activities into professional education is critical for influencing health and disease outcomes worldwide.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health FACTORS AFFECTING NURSING CURRICULA Nursing education has developed its own reforms in tandem with higher education and with other health professions education. These reforms echo the need for nursing education to reexamine the values of environmental health in policy, nursing research, education, practice, and service (AACN, 1991; ANA, 1991; NLN, 1992). Tradition Although professional nursing education has traditionally included the concepts of health promotion, disease prevention, health protection, risk reduction, and population-based practice in its baccalaureate nursing degree programs, the scope and depth of such concepts and content are not consistent among programs. Commonly used nursing texts also vary in their inclusion of environmental health information. Nurses, along with physicians and pharmacists, report that the education they received regarding disease prevention was fair or poor in contrast to the excellent or good ratings of training they received regarding disease treatment or intervention (Shugars et al., 1991b). Trends In Nursing's Agenda for Health Care Reform (ANA, 1991), three premises underlie the framework for change relative to nursing education and environmental health: (1) that primary health care plays a basic and prominent role in service delivery, (2) that a better balance exists between the prevailing orientation to illness and cure and a new commitment to wellness and care, and (3) that nursing's long-term policy agenda must consider relationships among many factors, of which environmental factors are noted. This policy document asserts that nurses who are prepared from a primary health care framework with an emphasis on prevention and environmental factors will be the providers of choice in improving the health status of the U.S. population. Addressing nursing's need to accept the challenge of what she termed environmental compatibility, then-president of the American Academy of Nursing, Nola Pender, pointed out that by the year 2010, 70 percent of nurses will be practicing outside of acute-care facilities. To prepare for this shift, Pender indicates the need for curricula in schools of nursing to change. She underscores that attention in nursing education (actually, education in all health professions) should focus on high-risk environments and laments that "nursing curricula often fail to address environmental issues in-depth throughout the curriculum" (Pender, 1992, p. 201).

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Nursing faculty, Pender stresses, "should determine how the concept of high risk environments may be given more attention in the curricula and which critical environmental assessment and intervention strategies are appropriate for inclusion" (Pender, 1992, p. 201). Likewise, the American Association of Colleges of Nursing (AACN, 1991) endorses the necessity of curriculum revision to support nursing in the future. Nursing Education's Agenda for the 21st Century is not unlike the tenets called forth from the Pew Commission: broad content areas that are relevant to the development of healthy lifestyles and future health care solutions must be assembled. These content areas include health promotion and maintenance related to specific environmentally induced diseases (cancers, accidents and injuries, and trauma), as well as a particular emphasis on environmental and occupational health. The traditional approach to basic nursing education represented by all three avenues—associate degree, diploma, and baccalaureate nursing programs—has been to emphasize curriculum for micro-level, individual situations rather than the macro-level of intervention. Recognizing that this individual focus will not suffice for the needs of the twenty-first century, the National League for Nursing (NLN) emphasized that "preparing all graduates of nursing education for community-based care, therefore becomes the responsibility of all programs and all faculty—perhaps in varying degrees, but a commonly shared responsibility" (NLN, 1992, p. 12). The Association of Community Health Nursing Educators (ACHNE) published two documents describing the essentials of baccalaureate- and master's-level education for entry into community health nursing practice (ACHNE, 1992) and advanced practice nursing (ACHNE, 1991). Both documents build on reports from the American Nurses Association (ANA 1980, 1986), the World Health Organization (WHO, 1978), the American Association of Colleges of Nursing (AACN, 1986), the American Public Health Association (APHA, 1980), the U.S. Department of Health and Human Services (DHHS, 1988), and Jones et al. (1987). The community health content in the baccalaureate degree program specifies the inclusion of introductory environmental health and environmental hazards as essential to support the nurse generalist practice in the community (ACHNE, 1992). The content of the master's program to prepare advanced practice nurses in community and public health nursing specifies environmental health as a separate item linked more closely to the public health sciences than community and public health nursing (ACHNE, 1991). Thus, environmental health is considered essential to the education and practice of advanced practice nurses in community health and public health. It should be emphasized, however, that the development of competencies in environmental sciences for generalist and advanced

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health practice nurses who work in traditional settings such as hospitals and long-term-care facilities is also fundamental to their practice in these settings. Accreditation and Regulation The regulation of nursing education and practice is accomplished through a number of credentialing mechanisms. Each mechanism standardizes outcomes (competencies of graduates and practicing nurses) for the assurance of safe delivery of nursing care. Higher education programs in nursing are accredited by regional accrediting bodies as part of the larger institutional accreditation process. Additionally, schools of nursing seek accreditation from the NLN at the associate degree, diploma, baccalaureate, and master's levels. Within each state, approval for education programs is usually conferred by the state's regulatory board of nursing education content. However, no accrediting body in nursing currently considers environmental health content to be required for the receipt of accreditation. Official documents of professional nursing organizations endorse the presence of environmental health content in basic and graduate programs. However, accreditation mandates for schools of public health require education in environmental health sciences for graduates of public health programs. Currently, the roles of accrediting bodies and standards in mandating content ensure the visibility of environmental health in schools of public health. Such mechanisms of ensuring an environmental health content bear exploration for the accreditation process in schools of nursing. NURSING EDUCATION PATHWAYS Agreement on the common educational base required for entry into nursing has not yet been achieved (Fagin and Lynaugh, 1992; Oermann, 1994). Oermann argues that the explosion of knowledge, changing health care systems, and community-oriented care demand that nurses be prepared at the baccalaureate level. According to the U.S. Public Health Service (1992), 62 percent of the nurse workforce is prepared at the associate degree and diploma levels, whereas 30 percent of the nursing workforce is prepared at the baccalaureate level. Eight percent is prepared at the master's or doctoral level. When nurses, licensed by the profession, present themselves for employment unprepared for community-based, population-focused practice, the employer has three options: Do not hire, and let positions stay vacant, decreasing capacity for service;

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Hire and supplement education on the job with formal courses, workshops, and mentoring, with a concurrent investment in more intensive supervision to ensure safe practice; and Hire and decrease job expectations, limiting services to what the nurse is capable of providing, omitting environmental health. Some or all three of these options have occurred. The aggregate impact is a more limited overall capacity to deliver nursing services that address environmental concerns. Basic Nursing Education In 1994 NLN reported that the number of individuals graduating from the 1,484 registered nursing programs was 80,839-the highest level since 1985. Of these graduates, 65.4 percent (52,896) were from associate degree programs, 26.5 percent (21,415) were from baccalaureate degree programs, and 8 percent (6,528) were from diploma programs (NLN, (1994). However, the projected number of graduates from all three programs by 2000 is expected to shift only because the number of diploma graduates will be reduced to one-third of today's number of diploma graduates. Currently, two-thirds of the registered nurse workforce are graduates of associate degree programs with no curricular experience in public health or environmental health and no clinical experience in these fields (Havens and Stevens, 1990). The major obstacles to including environmental health are lack of curricular time and lack of faculty preparation. It is essential that these barriers be overcome to prepare adequately associate degree nurses to meet the health care demands of individuals, families, and the community. Professional nursing organizations (e.g., AACN, NLN, ANA, NCSBN [National Council of State Boards of Nursing]) play a major role in influencing the scope of nursing education. Although particular content themes and practical experiences are universal in nursing education (e.g., nursing process, growth, and development) and the graduates of the three types of nursing programs are eligible to take the same licensure exam (National Council Licensure Examination for Registered Nurses [NCLEX]), differences exist among the nursing programs regarding educational preparedness. These differences take the form of inconsistent learning experiences and limited development of competencies in areas of nursing practice essential for the environmental health component of nursing. These competencies include population-focused care, continuity of care, environmental health, health protection, health promotion, disease prevention, and community-based clinical experiences. Nurses are challenged to engage in activities that promote the Healthy

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health People 2000(DHHS, 1990) goals for increasing the time period during which people lead healthy lives, reducing health disparities and achieving access to disease prevention through health promotion, health protection (e.g., improved environmental health), preventive services, and surveillance and data systems. However, continued segmentation or exclusion of nursing competencies in environmental health within general nursing education will not promote nursing's full impact on the goals of Healthy People 2000. To be full participants in achieving the health objectives for the nation outlined in the Healthy People 2000 document, nurses must focus on population-based practice, risk reduction, and preventive services. This focus will require changes in nursing educational preparation, content of nursing practice, and practice settings. Graduate Nursing Education Specialization in nursing occurs at the master's level. In the 1994–1995 school year, there was a 10.7 percent increase in the number of master's degree students enrolled in nursing schools compared with the 1993–1994 school year (AACN, 1994). In 1993, master's programs in nursing numbered 252, with 136 of these offering nurse practitioner programs (NLN, 1994, p. 3). Master's programs prepare leaders for advanced practice nursing as clinical nurse specialists (CNS), nurse practitioners (NP), certified nurse-midwives (CNM), certified registered nurse anesthetists (CRNA), administrators, teachers, and consultants. Courses in nursing and other science disciplines provide advanced theoretical knowledge, assessment skills, role and leadership development, advanced clinical practice in a selected specialization, and the opportunity to critique and apply nursing theory and research as a scientific base for nursing practice. Increasingly, graduate nursing curricula include core courses such as health assessment, pharmacotherapeutics, health promotion, sociocultural and community health, health economics and policy, theory and ethics, as well as research. Specialty, leadership, and elective courses complete the requirements for the degree. To date, no standardized curriculum exists for the advanced practice of nursing. However, through regional workshops, the AACN is attempting to define academic instruction, practice, skills, and other essential standard elements of master's-level nursing education. In an AACN interim summary, a core curricular content for all nursing students in master's programs is recommended in the areas of research, economics, ethics and legal issues, health policy, professional role development, nursing theory, and cultural diversity. The areas of consensus on core curricular content for advanced practice nursing programs include advanced

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health health and physical assessment, pathophysiology, and advanced pharmacology. These areas represent the recommendations from participants in three of five AACN workshops. Increased emphasis has been placed on preparing nurses with advanced practice skills. Numbering nearly 100,000, these individuals have become a significant force in health care delivery (DeAngelis, 1994). The number of advanced practice nurses who graduate annually is predicted to increase by 50 percent by the year 2000, reaching 10,000 annually. Moreover, state laws and federal reimbursement legislation are expanding the authority of advanced practice nurses to practice independently, particularly in underserved rural and inner-city locations (Mundinger, 1994). The preparation of advanced practice nurses is a particularly fertile arena for addressing the environmental correlates of injury, disease, disability, and the management of acute and chronic illnesses. Advanced practice nurses are also in a strategic role to contribute to and influence the health of the U.S. population. While nurse practitioners primarily provide primary care and clinical nurse specialists are located in hospitals and provide care for more acutely ill persons, the distinctions are blurring. Education at the graduate level must provide the knowledge, skills, and competencies to prepare the APN to effectively incorporate environmental health assessment, risk management, referrals, and risk communication in to practice. Later in this chapter, Table 4.2 lists some graduate-level core courses, the relevant environmental health competencies, and suggested content for each. In addition, as in the basic education table, selected references are included. Environmental Health Content in Nursing Education National sample surveys of baccalaureate and master's nursing programs describing the content of environmental health in curricula were published in the early- to mid-1990s. Rogers (1991) surveyed 423 NLN-accredited schools of nursing with baccalaureate degree programs. Of the 423 schools, 222 (53 percent) responded, and 215 (97 percent) of the respondents indicated that they had some curricular content specific to occupational and environmental health. Information was solicited on eight major content areas within curricula. Four of the eight content areas contained environmental health content specific to the work environment. Respondents were asked to identify the courses in which this content was taught. Of the respondents, 70 percent–74.4 percent (mean) taught the content in community health nursing courses. Fewer than 15 percent reported teaching it in other courses, such as family nursing or epidemiology courses, or the content was integrated in various courses. Environmental

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health health content in medical-surgical nursing courses was identified by 0.8 percent–6.8 percent (mean) of the respondents and in occupational health nursing courses by 0.6 percent–1.4 percent (mean) of the respondents. The unavailability of a description of the presence and location of the environmental health content by those who did not respond to the survey raises a concern. If the lack of a response (47 percent) reflects an absence of environmental health content, then the environmental health content currently offered in nursing curricula nationwide may be seriously overestimated. Neufer (1994) points to the incongruity that community health nurses have not been leaders in the field of environmental health, despite their early reliance on Florence Nightingale's emphasis on environment. One indicator of nursing education's emphasis (or lack of it) on environmental health is the content included in current textbooks. In her review of current texts in community health, Neufer identified no text as having all of the factors necessary to address the concepts of environmental health in nursing. She concluded that ''although health professionals are becoming more aware of the public health hazards of pollution, community health nurses have not applied their skills in assessing and diagnosing related community health problems." Furthermore, because no text includes all of Neufer's factors, the conclusion follows that these environmental health content areas are not being taught in basic community health courses. Neufer emphasizes that, "the profession must grasp the challenges necessary to promote environmental health" (Neufer, 1994, p. 161). The importance of environmental health in graduate nursing programs was described in a national sample of 967 leaders in community health nursing service and education, with 588 (61 percent) responding (Selby et al., 1990). Environmental health sciences was a clearly designated target content area for master's-level community health nursing education in the official documents of ANA (1980, 1986), and the Council on Education for Public Health (CEPH, 1986). Environmental health was rank ordered 18 – 26 of the 43 content areas considered to be core parts of the master's-level community health nursing curriculum by both service and education respondents. A 1994 University of Minnesota study based on a review of 23 catalogs of schools of nursing with graduate programs in public health or community health nursing found that 17 percent (N = 4) required a course in environmental health (Ostwalt and Josten, 1994). In contrast, schools of public health that are accredited by CEPH must provide courses in five content areas, of which environmental health sciences is a requisite area (CEPH, 1986, p. 14). In a recent survey of 187 U.S. nurse practitioner programs, valid responses (90 questionnaires; 48 percent) revealed that

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health more than two-thirds of nurse practitioner program directors believed that greater emphasis should be placed on environmental health. Barriers to change included overcrowded curricula and inadequate faculty preparation. Two factors identified as most likely to facilitate the inclusion of environmental health were, first, the availability of nurse faculty with expertise and, second, access to information resources related to environmental health. Recommendations included (1) the incorporation of environmental health in case history or problem-based instructional designs, (2) inclusion of environmental health risks in patient- or community-assessment learning activities, and (3) use of educational resources such as the Agency for Toxic Substances and Disease Registry Newsletter and other training programs (Bellack et al., 1995). The National Institute for Occupational Safety and Health (NIOSH) provides funding for academic preparation and continuing education in the areas of occupational medicine and nursing, occupational safety, and industrial hygiene. NIOSH has established 14 Educational Resources Center (ERC) programs throughout the country in university settings since 1977 for the education and training of health professionals about occupational health in an interdisciplinary environment. Among the subjects of these programs are risk management and safety, environmental health practice, chemical process hazards, hazardous substance management, and environment and work physiology. The ERCs target occupational health and safety, a subset of the domain of environmental health education (DHHS, 1991). The Institute of Medicine (IOM) Committee on Enhancing Environmental Health in Nursing Practice conducted 12 focus groups across the country that included leaders of national nursing organizations; practicing nurses prepared from associate, diploma, baccalaureate, master's, and doctoral nursing programs; nurse practitioners; community, public health, and occupational health nurses; nurse educators; and nurse researchers (see Appendix E). Many of the participants illuminated the dilemma of crowded curricula and acknowledged that curricular reform in nursing education was a necessary part of reexamining the competencies required for nurses to deliver health care. Inclusion of environmental health concepts in all basic nursing curricula was recommended as a strategy for reform, as was a shift to context-of-care and community-based practice skills as foundations for nursing interventions. Participants supported the inclusion of general environmental health content and assessment skills in basic nursing courses, with an integration of environmental science as applied to basic and health sciences in pharmacology, physiology, and pathophysiology courses. Some participants voiced concern that environmental assessment was not sufficient and indicated that risk assessment, risk communication, and referrals are necessary skills for all basic

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health nursing graduates. A minority of focus group participants believed that environmental health content should be taught at the graduate level in preparation of specialists for the field. It is unclear however, whether these participants thought that environmental health content should be included at the graduate level only, or that graduate level education should be developed in addition to basic nursing education in environmental health. MODEL PROGRAM DEVELOPMENT The philosophical approach of the committee was not to develop a new curriculum, or dictate those elements necessary for basic nursing education. Rather the committee wanted to assist faculty in nursing programs to think about and incorporate environmental health content into existing programs. This section deals with four curricular concerns: (1) to identify the general competencies relevant to environmental health in nursing, (2) to suggest where those competencies may be addressed and integrated into the curriculum, (3) to provide examples of content areas conducive to the inclusion of environmental health in order to link educational activities with the competencies to be achieved, and (4) to suggest resources that will facilitate the teaching of environmental health issues. General Competencies As noted earlier in this chapter, the majority of nurses in the United States are being prepared for registered nurse licensure in associate degree (AD) and hospital diploma programs, with fewer graduating from baccalaureate degree programs. However, it is also known that many nurses with ADs and diplomas are employed in community or public health nursing positions, although community health concepts are not usually included in AD or diploma programs and are not tested in NCLEX. This pattern for testing and employment is not expected to change in the near future. Based on these facts, the differentiation of environmental health competencies for AD, diploma, and baccalaureate levels may seem an almost futile exercise for nursing education and practice. That is, in nursing education, environmental health content is not required for AD and diploma programs and is included minimally, if at all, in the community health component of baccalaureate programs. None of this content is part of the exam for nursing licensure. Nevertheless, nurses without basic community health nursing preparation are providing many of the community health nursing services in the nation. Given this somewhat paradoxical situation, in which there is a gap

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health between nursing education and practice, it is important to include environmental health content in as many undergraduate courses as possible. However, rather than detailing the exact environmental health content to be included in each nursing course at every level of nursing education, fairly specific guidelines are provided regarding major environmental health concepts and where these concepts might logically fit in existing nursing curricula. The advantage of this approach is that it allows nursing faculty to integrate environmental health content in an individualized manner based upon faculty expertise, available resources, and the curricular framework specific to each school of nursing. Toward this end, in Table 4.1, the first five courses are ordinarily found in AD and diploma programs, and all the courses are normally part of baccalaureate programs. Environmental health competencies and content examples for each major curricular area are included in Table 4.1 to illustrate the environmental health content that might be appropriate for different levels of basic nursing education. In addition, staff development and continuing education activities are important avenues for increasing the environmental health knowledge and skills of nurses, whatever their training. The environmental health nursing competency levels of the various types of preparation programs are not easily differentiated. In addition, such a differentiation may not serve a useful purpose at this time because preservice testing does not provide for making this distinction. Further, the level of environmental health competency an individual has attained does not determine employment opportunities or the lack of them for most nurses. The main purpose of including environmental health content in existing curricula at any level is to enhance nursing practice in all settings by increasing the awareness and integration of environmental health nursing skills and knowledge in the nursing service provided. The competencies listed in the box "General Competencies for Nurses" (see Box 3.4 in Chapter 3) are designed for all nurses. However, depending on the level of the educational program, not all competency applies. Curriculum Integration Points Prerequisites Students who enter a baccalaureate nursing program must complete a prenursing curriculum at the same college or university or at another educational institution such as a community college. All types of nursing preparation programs have some prerequisites that must be fulfilled before

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health partnership with a practicing nurse who is incorporating environmental health in his or her practice; involvement with students in practical projects about environmental concerns; a sabbatical (perhaps short-term) spent with environmental science faculty or at a practice site focused on the environment (U.S. or state Environmental Protection Agency); and fellowship awards within the school for faculty who design and implement a plan for increasing expertise in environmental health. ROLE OF FEDERAL, STATE, AND LOCAL HEALTH AGENCIES Various federal, state, and local agencies play a role in monitoring, supporting, and in some instances, funding the education of nurses. Foundations (e.g., the Pew Commission and the Robert Wood Johnson and Kellogg foundations) are also visible partners in educating health professionals. Federal Agencies Health Resources and Services Administration On the federal level, the single most influential body affecting nursing education and practice is the Bureau of Health Profession's Division of Nursing in the Health Resources and Services Administration (HRSA) of the U.S. Public Health Service, DHHS. The Division of Nursing of HRSA has a duly constituted National Advisory Council for Nurse Education and Practice (NACNEP) composed of nurses in service and education, members of the public, and nursing students that advise the secretary of DHHS in supporting a broad range of projects such as nursing education programs for disadvantaged individuals, advanced practice training grants, primary care preparation, and innovative educational approaches. The Division of Nursing of HRSA also undertakes analytical studies, such as workforce needs and educational-level composition, and the ethnic backgrounds, geographic distributions, and other factors related to nurses and nursing in the United States. On the basis of such data and projection studies, a major role for NACNEP is in influencing policy formulations and decisions regarding nursing education.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health National Institutes of Health The National Institute of Nursing Research as part of the National Institutes of Health (NIH) funds research on the nursing profession and nursing service delivery systems as well as nursing care outcomes. One result of nursing practice and preparation studies is skill mix, which is the use of various levels of nursing knowledge and clinical competence. Other federal agencies, such as the National Institute of Mental Health, National Institute on Aging, the Maternal and Child Health Bureau, the Agency for Health Care Policy and Research, also fund projects involving nurses. These projects can influence nursing education by recommending or making changes in recommended health care practices and nursing care systems. Many outcomes studies provide evidence for the basis of health policies that affect health care systems, priority setting, and reimbursement to providers, including nurses. However, conclusions based on the results of these studies are oriented more toward the future of nursing than to the basic preparation of nurses. One such conclusion is the need for an increase or decrease in the nursing workforce that is prepared for certain areas such as primary care. Federal and state environmental policies and agencies help to shape the practice of nursing, but they also have an informal or indirect effect on education programs. For example, if agencies or institutions are hiring only nurses with nurse practitioner certification, educational programs must increase their capacity to teach these students who are requesting this preparation. Otherwise, their enrollments may substantially decrease. Federal and state agencies remain a critically important resource for all of nursing. For example, environmental epidemiology, especially the study of hazardous waste sites in the United States, determines the nature and limitation of available data on environmental contaminants related to hazardous wastes sites. In addition, federal (e.g., the U.S. Environmental Protection Agency, National Institute of Environmental Health Sciences, and the U.S. Department of Energy) and state agencies are continuously involved in the process of defining which chemicals in the environment are of concern for human health or the levels at which action should be taken to protect human health (NRC, 1991). Such information, although it does not directly influence nursing curricula, can be a source for data and material (e.g., the TRI [Toxic Chemical Release Inventory] database with its user-friendly software) that would be valuable for the enhancement of nursing education, including continuing education programs for nurses in the field. Federal agencies provide specific "packages" for the education of

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health health professionals. For example, Clues to Unraveling the Association Between Illness and Environmental Exposure (Narkunas et al., 1994) is a 7.2 contact-hour program for nurses and environmental health professionals available from the Agency for Toxic Substances and Disease Registry (ATSDR), which is part of DHHS. Other agencies with educational programs include the National Center for Environmental Health and NIOSH (ERCs). The Occupational Safety and Health Administration is another federal agency that is a source of important information. A more complete listing of relevant federal agencies is contained in Appendix D. State and Local Agencies To ensure safe practice, each state board of nursing (or its equivalent) administers a licensing examination. Because each state board of nursing establishes its own scope of practice, it also has the responsibility to monitor the licensed nurse's practice within those parameters, or legal action can be taken. Other state agencies (e.g., health, occupational, and environmental agencies) have no direct jurisdiction over nursing education and practice. Local and state health departments employ nurses to provide services in such areas as public health, maternal-child health, school health, and other targeted areas or to specific populations, and they also serve as clinical practice sites for basic and graduate nursing students. However, funding and revenue sources tend to determine the scope of practice within the boundaries of each state's nursing practice act. For example, if funding for school-based clinics is provided and nurse practitioners are required for primary care, only those nurses who are certified by their state board and/or by the American Nurses Association as nurse practitioners can be employed.1 Although local and state environmental agencies can employ nurses, they have less direct or formal contact with nursing education programs. Yet, members of such agencies often serve on advisory committees to nursing education institutions and provide valuable real-world input for curricular improvement and the currency of curricular content. They also serve as resources for technical information and arrange material and sites for student field experience. Most states have separate health, education, social services, occupational safety and health, environment, consumer affairs, insurance, and other departments that tend to have minimal interagency contact or coordination of services. Therefore, in teaching nurses to practice with a 1    Some states have different (less) requirements for nurse practitioner registration than for ANA certification in specific areas, hence the "and/or." Then, however, they can only work within that specific state. ANA certification is recognized nationally.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health comprehensive approach to health that includes physical, mental, social, and environmental health, nursing educators must enable nurses to perform a conceptual integration. That is, they must develop the ability to apply the theoretical knowledge and clinical skills they learn to nursing practice in the way that services are made available to the public. The goal of including environmental health content in all nursing education is to incorporate the concepts into each step of the nursing process. METHODS FOR EVALUATING EFFECTIVENESS OF CURRICULUM The evaluation of a nursing education program is an integral part of its development. Sometimes, however, revisions of the curriculum are given considerable attention, whereas evaluation of the modifications is added as an afterthought. Methods of assessing curricular effectiveness depend on the objectives, content, teaching process, and learner. For example, students in an initial nursing preparation program will need to be evaluated on their knowledge and competencies for safe nursing practice. State licensing boards are given this responsibility, and NCLEX is the common testing mechanism. The rationale for including environmental health concepts in basic nursing curricula and in the examination for licensure as a registered nurse has been presented in this chapter. Because the environment is an increasingly important influence on public health, nurses already in practice should have access to the means for updating their knowledge and skills and applying them in their work settings. Continuing education and distance learning can provide the opportunities to stay current. Problem-based presentations, case studies, vignettes, and pre- and post-tests are means of presenting material as well as of determining the effectiveness of teaching-learning methods and material. Although preservice licensing tests are administered to assess baseline knowledge, advanced practice certification examinations and second licensure requirements are used to evaluate and/or ensure the acquisition of the additional knowledge and competencies needed for specialized nursing practice. The significance of environmental health in the nursing of individuals, families, and communities makes it imperative that relevant concepts be included and assessed for their currency in all areas of nursing education and practice. It follows that evaluation of the effectiveness of this inclusion by formal means, such as testing, and by informal methods, such as self-assessment of application in practice, is equally important. A flexible approach to evaluating curricular change is needed when various forms of teaching-learning are used. The commonly used formative

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health (process) and summative (outcome or impact) evaluation methods are useful approaches. Before making any changes, however, an evaluation of the feasibility of curricular revision is a necessary step. What environmental concepts can be included? Where in the nursing program can these concepts be incorporated (e.g., didactic and/or clinical components)? When within the course progression should the content be integrated? (See Table 4.2.) Furthermore, an assessment of the existing curriculum is needed to determine what, if any, environmental health content is already included and where other essential environmental health content might best fit. Faculty who are interested in teaching (or encouraging the teaching of) environmental health must be identified. These faculty can do much to stimulate the interest of students and fellow faculty in a subject by their enthusiasm, example, and commitment. Another essential step associated with the formative evaluation of curricular modification for the inclusion of environmental content is a form of needs assessment to determine the resources required to implement this activity. Which faculty have the capability and willingness to change the curriculum? How can faculty update or upgrade their own level of knowledge? Are there guest lecturers who would be willing to share their expertise? What resources, both teaching and financial, could be devoted to this activity? What support is needed and available to access teaching tools such as environmental health packets or brochures, audiovisual aids, and computer programs? A formative (process) evaluation of the curriculum would include the following: review and documentation of the feasibility of incorporating environmental health, what content is incorporated, how it is taught, how frequently, and who is involved. The summative or outcome evaluation is accomplished by measuring student performance on the "General Environmental Health Competencies for Nursing" outlined in Box 3.4 (see Chapter 3). Integrating evaluation activity into existing courses is realistic and amenable to implementation. Systematic planning for the incorporation of evaluation methods in courses within the revised curriculum would result in a relatively comprehensive assessment of program effectiveness with a minimum of added work for the faculty. Retention of knowledge and actual use of competencies in practice are more difficult to evaluate. Many nursing programs conduct follow-up surveys of their graduates regarding their employment, field of practice, adequacy of the curriculum, and recommendations for curricular changes. Questions regarding the environmental health content in their particular program and its use in their current practice could be added in order to collect additional evaluation data. To reiterate, a basic nursing curriculum with enhanced environmental health content in diploma and associate degree programs will be most

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health appropriately evaluated by identifying the specific content additions and then testing for the comprehension, retention, and application of that information. For example, if environmentally caused diseases are included in an existing medical-surgical course in an associate degree or diploma program, the concepts of assessment, referral, and risk communication should be examination items or clinical performance components of a student's evaluation. For a community health nursing course in a baccalaureate program, the impact of adding content on environmental health policy advocacy should be assessed by evaluating a student's understanding and application of policy and its influence in the didactic portion or in clinical work in a public health agency or community health organization. At the graduate level, evaluations of environmental health content in specialty areas need to be conducted within the master's courses associated with the specialty, such as specific environmental health risks for the elderly in gerontological nursing. As a further illustration, a master's level research course should include epidemiologic environmental health studies, and an evaluation of relevant concepts and critique methods could be done via examination items or an essay. At this time, licensure tests and specialty certification examinations use a role validation method of test content development. That is, the content of nursing practice in the field largely determines what is tested in the examinations. If nurses do not include environmental health in their practice, it is unrealistic to expect that such content would be covered in the examinations. Therefore, evaluations of curriculum with enhanced environmental health content would currently focus only on the major course(s) in which the additional content has been integrated. The specific method of course and student evaluation used is the prerogative of the faculty responsible for the course as a whole. Other effects of expanding environmental health content in nursing programs may include changes in faculty awareness and attitudes, increased administrative support for environmental health content, and its inclusion in a variety of educational (e.g., continuing education and distance learning) and health services (e.g., individual or group faculty practices) offered by the school of nursing. The ultimate objective, and perhaps the most difficult one to measure accurately, is the incorporation of environmental health content into nursing education and practice and the continuous evaluation of how effective it is accomplished in maintaining and promoting the health of individuals, families, and communities. Nonetheless, improvement in the health of all persons by the avoidance or reduction of environmentally induced illness or injury is a worthwhile goal for revising the curricula of nursing education programs.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health RECOMMENDATIONS To better prepare nurses for the environmental aspects of nursing practice, environmental health curriculum at all levels of nursing education should be enhanced. The committee recognizes that integrating environmental health content into an already crowded curriculum will require creativity on the part of faculty, as well as commitment on the part of educational administrators. Instead of viewing this content as completely new and separate, nursing educators may find ways to emphasize the environmental dimensions of existing courses. Such an integrated approach carries with it, however, the necessity for every faculty member to be knowledgeable about the influences of the environment on health and to actively include environmental content and examples in their teaching. This task is inherently difficult to achieve with a total faculty; a facilitating step would be to have at least one faculty member with particular expertise in environmental health who could champion the curricular adaptations and serve as an internal consultant to other faculty. The committee also recognizes that most nurses will continue to be educated at differing levels, that opportunities vary for including environmental health content. Moreover, nurses already in practice will not benefit directly from curricular changes in basic nursing education. Meeting the environmental health content needs of nurses in associate degree and diploma programs, and nurses already in practice requires the development of continuing education opportunities and other kinds of professional support for practitioners. In other words, a range of different strategies will be needed to meet the environmental health training needs of registered nurses (RNs) because of their widely varying employment circumstances. Levels of Education Recommendation 4.1: Environmental health concepts should be incorporated into all levels of nursing education. Rationale: Nurses in all settings encounter environmental influences on the health of individuals, families, and communities; therefore, environmental health concepts are essential to the preparation of nurses. Strategies for Achieving Recommendation 4.1: Identify the basic competencies to be included in the development of curricula, as well as the role of advanced practice nurses.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Integrate environmental health content into existing prerequisite and basic nursing courses. Develop programs (e.g., faculty fellowships) to increase faculty knowledge and skills in environmental health. Develop model curricula that incorporate environmental health content. Identify and apply educational technology appropriate to the environmental health content and the student population. Licensure and Certification Examinations Recommendation 4.2: Environmental health content should be included in nursing licensure and certification examinations. Rationale: Currently, basic nursing licensure and most certification examinations do not explicitly include environmental health content or questions. Strategies for Achieving Recommendation 4.2: Develop environmental health test items for nursing licensure and certification examinations. Relay evidence of environmental health content in job expectations and educational programs to state licensing boards and the National Council of State Boards of Nursing (NCSBN). Advocate the inclusion of environmental health in standards for accrediting nursing education (National League for Nursing (NLN) and practice American Nurses Association (ANA). Nurses with expertise in environmental health should participate in advisory committees or boards for certification examinations. Environmental Health Disciplines Recommendation 4.3: Expertise in various environmental health disciplines should be included in the education of nurses. Rationale: An interdisciplinary approach is needed to provide health care services required for health conditions caused by environmental factors.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Strategies for Achieving Recommendation 4.3: Include professionals from other disciplines associated with environmental health in teaching programs for nurses. Use multidisciplinary and interdisciplinary approaches for field experiences and clinical practice. Identify federal, state, and local environmental health resources. Lifelong Learning Recommendation 4.4: Environmental health content should be an integral part of lifelong learning and continuing education for nurses. Rationale: With rapid changes occurring in environmental influences on health, keeping current is an important responsibility of all nurses. Strategies for Achieving Recommendation 4.4: Existing educational materials (e.g., ATSDR Case Studies, CLUES program, and related IOM reports) should be disseminated more broadly. Nurses should participate in educational programs of professional organizations that include environmental health content. Professional journals should publish more articles on environmental health. Incorporate environmental health content in computer-based professional education programs. Educational Resources and Opportunities Recommendation 4.5: Professional associations, public agencies, and private organizations should provide more resources and educational opportunities to enhance environmental health in nursing practice. Rationale: Nurses will need a basic knowledge of environmental health concepts, resources, and intervention strategies to identify and successfully act upon environmental health problems. However opportunities for nurses to learn about environmentally related illnesses are severely limited because of such factors as a lack of support for continuing education, a lack of nursing faculty who are qualified to teach such content, a lack of support for faculty and program development, and a lack of institutional support for their attendance at such programs.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Strategies for Achieving Recommendation 4.5: Encourage professional associations to provide continuing education concerning environmental health, particularly associations that represent specialists in community and public health, pediatrics, occupational health, reproductive health, and primary care. Provide funding from public and private agencies to provide educational opportunities for nurses at all levels to enhance their knowledge of environmental concepts. Promote institutional support for continuing education in environmental health for (a) nurses to attend such programs, and (b) schools of nursing to develop programs on the topic of environmental health.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Florence Nightingale as she appeared at the time of the Crimean War: Engraving by G.E. Perine & Co. from a crayon drawing (no date). Property of Duke University Medical Center Library. History of Medicine Collections, Durham, NC.