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public health nursing
Setting a New Course for Advanced Practice Community/Public Health Nursing KATHERINE LAUX KAISER, PHD, RN,* KATHLEEN L. BARR, PHD, RN,* AND BEVELY J. HAYS, PHD, RN†
In recent years the changes in the organization and delivery of health care have created an environment that places great demands on nursing education at all levels. Determining a sound, responsive course of study in advanced practice community/public health nursing (C/PHN) is dependent on clear educational outcomes and competencies. Outcomes and competencies for C/PHN practice need to continue to be derived from the rich knowledge, experience, and research tradition with populations living in the community. However, in today’s health care environment, these outcomes and competencies also must be integrated within the context of a very different health care system perspective. This article describes the outcomes and competency indicators developed to guide a curriculum designed to integrate traditional C/PHN and a health systems perspective for students seeking advanced practice education in C/PHN at the College of Nursing, University of Nebraska Medical Center. (Index words: Advanced practice community/ public health nursing; outcomes/competancy)
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N RECENT YEARS there has been an emphasis on articulating clear outcomes and associated competencies for nursing educational programs as one way to evaluate effectiveness of curricula (Eichelberger & Hewlett, 1999; Lutrell, Lenburg, Scherbel, Jacob, & Koch, 1999). This article describes the outcomes and competency indicators developed to guide the curric-
*Associate Professor, University of Nebraska Medical Center College of Nursing, Omaha, NE. †Emeritus Associate Professor, University of Nebraska Medical Center College of Nursing, Omaha, NE. Supported in part by a Department of Health and Human Services Bureau of Health Professions Advanced Nurse Education Program grant (1-D23-NU-01260-01) and a University of Nebraska Medical Center Educational Technology small grant (MGA/22-071-081). Address correspondence and reprint requests to Dr. Kaiser: University of Nebraska Medical Center College of Nursing, Room 4061, 985330 Nebraska Medical Center, Omaha, NE 681985330. E-mail: [email protected] © 2003 Elsevier Inc. All rights reserved. 8755-7223/03/1904-0000$30.00/0 doi:10.1016/S8755-7223(03)00088-7
ulum for students seeking advanced nursing practice education in community/public health nursing (C/PHN) at the College of Nursing, University of Nebraska Medical Center. Specification of the expected student outcomes, by the faculty, was influenced strongly by the characteristics and health needs of Nebraska along with the evolution and current tensions within the health care environment and professional nursing. This expected outcomes and competencies development work occurred in conjunction with a curriculum revision that resulted in a Health Systems Nurse Specialist (HSNS) program, with C/PHN as 1 of 3 advanced nursing practice options. The University of Nebraska is a land-grant university whose College of Nursing has a long history of innovative delivery of nursing education via multiple campuses and distance educational methods to prepare basic and advanced practice nurses (Boyle, 1972, 1977; Leichsenring, 1972; Yeaworth, 1996; Yeaworth, Pullen, Zimmerman, & Hays, 2001; Yeaworth & Schmidt, 1999). In a recent example of this commitment to meet the educational needs of Nebraskans, several graduate nursing faculty developed a creative curriculum to prepare advanced practice nurses with skills tailored to practice at a health systems level. The curriculum encompasses the specialty options of C/PHN, nursing administration, and nursing informatics (Westmoreland & Hays, 2002). The interactions among faculty from within these 3 specialties fostered identification of shared expected outcomes that (1) facilitate student development needed for each specialty’s practice, but also (2) promote the strong shared knowledge base that is necessary when a health systems perspective is emphasized. The health system perspective that provided a foundation for the curriculum work considered the dramatic health care system changes that were emerging at the time. Primarily these included the information explosion, health care organization and financing paradigm shifts, and the demand for a better match of health system outcomes to
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expenditures that were occurring when this faculty group began their work in 1996-1997. The expected outcomes presented are a synthesis that evolved from this faculty’s curriculum-building effort. Before describing the expected outcomes and competency indicators for C/PHN graduates of this curriculum, a discussion of the national and regional influences that stimulated this new curriculum are presented.
Characteristics and Health Needs of Nebraska
Nebraska is a mostly rural state with 87 of 93 counties designated as either rural or frontier. Forty-one rural counties are federally designated medically underserved areas and 53 counties are health professional shortage areas. Rural Nebraska counties have a poverty level of 12 percent, compared with 8 percent in metropolitan counties. Nebraska faces several challenges in the ongoing effort to improve the health status of its residents. Many of the state’s rural areas are medically underserved with needs in both public health and medical systems capacity. The 2000 census revealed an overall growth rate of 8 percent in Nebraska, but 53 Nebraska counties (57 percent) experienced a decrease in size, generally owing to an outward migration of the younger population (U.S. Census Bureau, 2000). Such decreases in the population base make it even more difficult to provide important public health and medical services in these areas because it is more difficult to recruit and retain health care professionals and to sustain institutional health services such as hospitals (Nebraska Health and Human Services System, 1999). Many of Nebraska’s rural health care organizations, including 75 rural hospitals, are struggling to remain viable. These delivery systems are being stressed by (1) the farm crisis that has increased the number of uninsured, (2) a shifting and increasing ethnic diversity, (3) a large elderly population with chronic health problems, (4) substantial shifts in patterns of rural health care funding, (5) inadequate funding and infrastructure for public health initiatives, and (6) increasing demands to use data to design programs and deliver the health care needed for Nebraskans. Additionally, the state has underdeveloped systems of nonacute care such as case management, community health supports, personnel training and development, data management, and quality monitoring. The changing composition of Nebraska’s citizenry
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requires adjustments in priority health services to avoid an exacerbation of health disparities. In recent years, the ethnic minority populations have grown throughout Nebraska so that there are now minorities in every county in the state, with minorities in 2000 comprising 10.4 percent of the state’s population (U.S. Census Bureau, 2000). In addition, Nebraska has 4 major Native American nations located primarily in rural areas across the northern areas of the state. Migrant or seasonal farm workers, largely located in rural western and central Nebraska, total about 20,000 and contribute to the high unintentional injury rate. At the same time, the state continues to face the challenges of providing for the health needs of the elderly who comprise a high percentage of Nebraska residents, with 13.6 percent of Nebraskans now 65 years or older. Nebraska ranks ninth among all states in populations over 65 and second with populations over 85. The population in rural Nebraska is disproportionately elderly, averaging 18 percent of county totals compared with 10 percent in Nebraska’s metropolitan counties. Chronic health problems with this population constitute an important health need within the state and providing community-level services to assist the elderly to maintain independence is crucial but highly variable among communities. Two major issues in public health in the state have been lack of an established funding mechanism for public health and a long-standing lack of formal organizational infrastructure for public health (Nebraska Preventive Health Advisory Committee, December, 1998). In fact, throughout the 1990s Nebraska ranked 50th among all states in funding for public health. In an encouraging development, the 2001 Nebraska legislature allocated $9 million dollars of Nebraska’s tobacco settlement monies to develop public health infrastructure and better address minority health needs across the state. Now and in the foreseeable future, advanced practice community/public health nurses will be needed to help communities who are medically underserved participate in the development of public health services throughout Nebraska. The present ability of the state of Nebraska to respond to the health needs of its rural medically underserved citizenry is compromised owing to workforce shortages of advanced practice nurses who can provide leadership in building public health infrastructure, culturally competent health care, skilled use of data (data analysis, integrated data systems), community partnering, and population capacity building. In addition, skills in community assessment and programming are
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needed throughout the state to help identify priority needs, recommend possible solutions, and participate in program development to ameliorate such challenging health needs. In summary, there is a crucial need in Nebraska for advanced practice community/public health nurses with traditional public health skills who also have a solid knowledge base and skill set with a focus on the systems level. This is particularly important in our state, which has an emerging, nontraditional public health infrastructure. Using community and population health skills, these advanced practice nurses can partner with communities and geographically unique health systems across the state to determine priority health needs, develop interventions and programs, and monitor population health outcomes. Tensions Within America’s Health Care Environment and Professional Nursing HEALTH CARE
One aspect of the Health Care Reform movement of the 1990s was a discussion of the need to move the health system eventually toward managing population health rather than just managing care (Peterson & Kane, 1997). At the same time, the U.S. Federal government’s preventive health initiatives, Healthy People 2000 and Healthy People 2010 (U.S. Department of Health and Human Services, 1991; 2000) brought increasing attention to the importance of populationbased health management practice. Nursing’s Agenda for Health Care Reform emphasized increased access and better health care for broad segments of the population through primary health care, which could be delivered through a variety of health care alternatives that would reduce costs and allow clients to have more choice (American Nurses Association, 1991). Health policy statements have called for setting a new course for health care in many specific areas, including health promotion, disease prevention, screening, immunizations, and preparation of health care providers. In addition, Healthy People 2010 sets a specific goal to increase the proportion of schools of medicine, schools of nursing, and other health professional training schools whose basic curriculum includes preventive health training as part of the core curriculum. Current policy statements and health system recommendations signal that the health care system is being purposively steered away from its 20th century course that focused primarily on the provision of medical services driven by technologic advances toward health
promotion and primary care. These health system directional changes require important shifts in emphasis within professional nursing. The C/PHN specialty has a rich tradition of valuing and striving to integrate population-focused services with all social systems, especially the health system. However, because of workforce and categoric funding issues the specialty has not had adequate tools or opportunities to consistently make health system integration a practice emphasis. The Minnesota Department of Health’s Public Health Nursing Practice for the 21st Century model emerged from the public health nursing experience of over 200 public health nurses practicing in Minnesota in 1994 (Keller, Strohschein, LiaHoagberg, & Schaffer, 1998). The work of public health nurses included interventions focused at the systems level. Population-based systems-focused practice is described as changing “organizations, policies, laws, and power structures” (Keller et al. p. 209). This intervention level relates to the systems’ impact on health and can be a more effective way of impacting population health than an individual focus. The model that emerged from the Minnesota work, known as the intervention wheel, provides system-focused examples of public health nursing for all 17 identified interventions (Lia-Hoagberg, Schaffer, & Strohschein, 1999; Public Health Nursing Section, 2001). NURSING EDUCATION
The rapidly changing health care environment has created a call to shift the academic vision that has guided the education of health professionals (Shugars, O’Neil, Badger, 1991; American Association of Colleges of Nursing, 1999; Center for the Health Professions, 2000). The call for such shifts has generated dispute and debate regarding what constitutes the best match of professional personnel in regard to training and skill acquisition, and the future needs of the health care system and the populations it serves. Two national focus groups of key informants convened to examine the training needs of the C/PHN workforce and enumerated a lengthy list of social, economic, technological, epidemiologic, and governmental forces that affect C/PHN practice and the context of that practice (Gebbie & Hwang, 2000). Many of the points listed from the focus group work indicate that a great deal of the change in the health care environment is related to needed health systems change. The results of the national focus groups also highlighted the need for knowledge and skills in public health such as epidemi-
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ology and environmental health, health system skills such as measuring organizational change, and people skills such as negotiation and collaboration as crucial (Gebbie & Hwang). Nurses practicing in the current environment, which demands high-quality services at a reasonable cost, will play a major role in developing and implementing change to improve the functioning of the health system (American Association of Colleges of Nursing, 1999). The American Association of Colleges of Nursing encourages nursing education to anticipate and prepare for these changes to educate students for the emerging health care environment, which includes preparation of advanced practice nurses. In 1996, the American Association of Colleges of Nursing published The Essentials of Master’s Education for Advanced Practice Nursing. This consensus-based document defined the essential curricular elements of master’s education in nursing for advanced practice as a clinical nurse specialist, nurse practitioner, nurse anesthetist, or nurse midwife. The master’s curriculum outlined for these graduate nursing practitioners recommended: (1) graduate core curriculum content essential for all master’s degree in nursing students, (2) advanced practice nursing clinical core content focused on the provision of direct patient/client services, and (3) specialty curricula. C/PHN and nursing administration specialty curricula were not included in the advance practice nurse clinical core because the document focuses on preparation for the provision of clinical care for individuals. However, in addition to the education of advanced practice nurse practitioners who deliver primary care services, the American Association of Colleges of Nursing recommended preparation of advanced practice nurses who can work with populations and health care systems to strengthen and support clinical services. Advanced practice nursing is characterized by: (1) specialization, or delimiting the practice focus to part of the whole field of nursing; (2) expansion, or acquisition of new knowledge and skills; and (3) advancement, or a research, theory, and experiential integration of knowledge within graduate study (American Nurses Association, 1995). Advanced practice C/PHN must additionally consider the practice and science of public health with a focus on populations (Josten, Clarke, Ostwald, Stoskopf, & Shannon, 1995; Keller, Strohschein, Lia-Hoagberg, & Schaffer, 1998). This population focus has as a central goal promotion of better population health status through strategies such as health management and community health program
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development. Similar to other nursing specialties, advanced practice C/PHN provides clinical services as necessary in the provision of population-focused care. However, they also contribute to population health status through improvement of the health system via quality monitoring and management, population data management, policy development, and promotion of evidence-based practice. The 1996 American Association of Colleges of Nursing’s The Essentials of Master’s Education for Advanced Practice Nursing document sparked significant discussion and debate within professional nursing. One of the primary discussion points centered on the recommendations regarding core preparation for advanced practice nurses preparing for primary care roles and those focused at a population or system level. Because advanced practice C/PHN programs focus on community and population-based theory and practice, the American Association of Colleges of Nursing position paper stimulated the C/PHN specialty to re-examine and solidify its advanced practice position papers to promote clarity and to reaffirm the direction of advanced practice C/PHN. The C/PHN specialty has responded to the American Association of Colleges of Nursing recommendations by revising specialty documents including the Scope and Standards of Public Health Nursing (American Nurses Association, 1999) and the Graduate Education for Advanced Practice in Community/Public Health Nursing (Association of Community Health Nursing Educators, 1999). These documents serve as useful tools for C/PHN educators to use when developing and enhancing advanced practice curricula to be responsive to the emerging and current health care environment. Developing and delivering educational programs that prepare nurses for advanced C/PHN practice requires both a clear sense of the current and emerging scope of the specialty and creative use of the educational resources available. Traditional educational models, such as (1) a nursing major within a master’s of public health program or (2) a clinical nurse specialist program in community health nursing, are not always readily available to many nurses who seek them. Such is the case for many of Nebraska nurses owing to distance and workforce influences. Therefore, innovative methods such as distance delivery are critical for training the public health nursing workforce (Gebbie & Hwang, 2000) and for preparing advanced practice C/PHN to provide leadership in local, state, regional, and national arenas to ensure that population health needs are being met with consideration of quality and cost.
SETTING A NEW COURSE FOR ADVANCED PRACTICE
The goal of public health nursing has been articulated as “promoting and protecting the health of the population” (American Nurses Association, 1999, p. 2). For this aim to be realized, graduates of advanced practice C/PHN programs must be ready to assume leadership in today’s health care environment with a relevant set of professional population-level competencies. With these ideas clearly in mind, the C/PHN faculty contributed to the HSNS expected student outcomes discussions a variety of information from C/PHN documents and literature, population data sources, and an understanding of the uniqueness of our state and region from population and community perspectives. The nursing faculty at the University of Nebraska Medical Center responded to the needs in our state and region, and the changing health care and educational environments, by developing the Health Systems Nurse Specialist curriculum with specialty options in C/PHN, nursing administration, and nursing informatics. A cornerstone of that process was the development of outcomes and competency indicators that are core to each of the HSNS specialty options, as well as unique to each specialty. Those relevant to advanced practice C/PHN are presented.
Specification of Expected Outcomes and Competency Indicators
For advanced practice C/PHN it was important for the outcomes to reflect two major elements: (1) the knowledge and skill from traditional C/PHN to prepare graduates to sit for advanced practice certification as clinical nurse specialists in C/PHN and (2) the system-level knowledge and skill necessary for advanced practice in a state with such significant health workforce and population health needs. After a careful review of the target outcomes of the C/PHN curriculum that were in place, the C/PHN faculty participated in nominal group process and dialogue sessions that were conducted with the entire HSNS faculty. From the beginning, the HSNS faculty adopted the attitude that development of the outcomes and competency indicators would be a work in progress, with formative review and refinement. In fact, we have found that the expected outcome statements and essential competency indicators have been refined through the process of course development, implementation, evaluation, and revision. Achieving precision in language and sorting the essential ideas
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from the nonessential ones has been a key feature in the ongoing work of HSNS faculty. A national consultant, whose contribution was made possible through the HSNS grant funding, provided a crucial external, expert perspective to identify areas in which we needed to either get more precise in our articulation or reduce the density within the outcomes and competency indicators initially developed. The HSNS faculty hold a strong value of promoting individual learning experiences, which often leads to tailoring the course projects and practicum experiences to meet the student’s interests and career goals. For these reasons, the decision was made to select competency indicators for each outcome rather than articulating a definitive list of competencies that every student would achieve. In other words, the expected outcomes were viewed as universal for graduates but the faculty recognized that a variety of competencies could indicate achievement of the outcome. Seven program outcomes have evolved with associated HSNS core and specialty-specific competency indicators. The language of competency indicators is important to help students recognize that not every student will achieve every competency, nor is the listing comprehensive. Yet the concrete examples provided by the competency indicators give students a sense of the possibilities open to them and provide them with language to speak to colleagues and potential employers about the relevance of the HSNS Advanced Practice C/PHN curriculum. Table 1 presents the current expected outcomes and competency indicators that guide our curriculum implementation, formative evaluation, and curriculum enhancement. The first expected outcome focuses on the ability of the graduate of this program to be able to articulate what HSNS C/PHN is and what constitutes a personal philosophy, or model of advanced C/PHN. This includes competency indicators related to values, ethics, and systems thinking. Graduate education for advanced practice in C/PHN emphasizes the values of health promotion, disease prevention, and community- and population-based practice. Also important to graduate C/PHNs are the values of diversity, social justice, community partnership, and interdisciplinary action (Association of Community Health Nursing Educators, 1999). These values are all consistent with the values of this HSNS C/PHN program. Research utilization and use of evaluation methods focused on policy development and client outcomes are concepts central to the second expected outcome. Competency indicators relevant to this outcome en-
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1. Outcomes and Competencies for C/PHN Health Systems Nurse Specialists Expected Outcomes
Outcome 1: articulates professional identity, values, and beliefs that guide her/his advanced practice
Outcome 2: uses research findings and evaluation methods to achieve desired system and population outcomes
Outcome 3: shows relationship-building and cultural competency behaviors to improve the health care system for the promotion of client health Outcome 4: communicates effectively to facilitate achievement of health system, population, organizational, and professional goals Outcome 5: accesses databases and/or gathers accurate and appropriate data to make informed decisions affecting health systems and/or populations Outcome 6: participates in strategic planning, allocation, and management of health system(s) resources
Outcome 7A: practices advanced practice Community/Public Health Nursing using a conceptual, theoretical, and experiential base
Competency Indicators
Applies ethical thinking to practice situations Uses professional standards, guidelines, and best practices Engages in systems thinking Articulates for self and others practice values and beliefs Understands quality management Evaluates health programs Identifies best clinical practices Fosters evidence-based practice Evaluates desired population and/or system outcomes Considers policy implications in outcome assessment Partners with individuals, organizations, populations, and communities Participates in developing coalitions Participates in capacity-building activities Participates in resolving conflict Uses culturally acceptable and relevant approaches Communicates effectively in oral discussions and presentations Communicates effectively in written forms Uses data appropriately (qualitative and/or quantitative) in making decisions Represents data accurately and in a useful format
Understands major factors in health care environment that influence health and health systems Shows knowledge of strategic planning processes Uses systematic financial thinking Shows knowledge of effective and parsimonious management of health system resources Integrates nursing and population sciences Appreciates the history and heritage of the specialty Uses a systematic approach to population and community assessment Participates in a community diagnosis based on data from multiple sources Develops health programs and population interventions based on assessed need Understands principles of community development and organization Uses community networking, referral systems, and principles of care coordination in practice Facilitates health behavior change for clients and target populations Advocates for underserved and vulnerable populations and communities Differentiates the organization of CHN services by mission statement at local, regional, and national levels
compass key knowledge and skill areas such as quality management, program evaluation, evidenced-based practice, and consideration of policy implications. Because research is a key content area for all the areas of specialization within the master’s program in our college, the HSNS curriculum uses the base of the research courses to help students to tailor these beginning research skills toward the public health and population-focused nursing practice skills that are so essential in advanced practice C/PHN. Outcome 3 relates to leadership and cultural competency behaviors needed to promote client health and improve the health care system. The development of community partnerships that link people to services in a culturally competent manner is viewed as core to the
education for C/PHN. Outcome 3 is consistent with recommendations regarding population-focused practice and health system improvement skills desired for the public health workforce in the 21st century. These recommendations include: cultural competency, health promotion skills, and leadership development (U.S. Department of Health and Human Services, 1997). The fourth outcome reflects the necessary written and oral communication skills of the advanced practice C/PHN. Not only are writing and oral presentation skills a signature of the well-educated person, they are critical in today’s health care environment that is characterized by the transmission and receipt of information (Mohr, 1999; Silva, Cary, & Thaiss, 1999).
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Information generation and manipulation is one essential element in the ability of the advanced practice community/public health nurse to access and analyze data effectively for the purpose of enhancing population health decision making (Outcome 5). The advanced practice community/public health nurse works with and in communities that often provide frontline opportunities to influence health decision making. This highlights the importance of data-based decisions in ensuring population health. Resource management and strategic planning (Outcome 6) are essential in the current health care environment, which is driven by economics, politics, and quality improvement forces. Tools such as financial thinking and strategic planning enhance the ability of the advanced practice community/public health nurse to show responsible stewardship of the community’s resources for allocation toward improvement of the health of the population as a whole. Such skills also promote leadership behaviors with multidisciplinary teams. The seventh and final outcome addresses the tradition, experience, and conceptual/theoretical base of C/PHN. Understanding the history and heritage of C/PHN is important in helping today’s professionals appreciate the challenges of the past to learn to work with the challenges of the present and future. Advanced practice C/PHN graduates need to be able to participate, collaborate, and lead interventions that encompass population and community health promotion and risk reduction. This includes incorporation of the skills of community networking and care coordination, community organization and development, active participation in health and social policy analysis and development, and provision of leadership in the enforcement of laws and regulations that protect health and ensure safety. The seventh expected outcome reflects specialty-specific content and learning experiences and differs markedly among the 3 HSNS specialties. This necessitates specialty-specific competency indicators consistent with the practice and theory of
each HSNS specialty. Only the C/PHN seventh outcome is presented in Table 1. Discussion
Community/public health nursing has had to evolve to be consistent with changing social forces and to be relevant to the communities and populations that are its dominant responsibility (Association of Community Health Nursing Educators, 2000). To meet the challenges that come with social change, professional educational institutions need to periodically examine their curricula to be sure they are meeting the needs of their students and the populations and communities their graduates serve. The development of the HSNS C/PHN curriculum evolved from the health and workforce needs within the state of Nebraska at a time of significant change within the health care environment. The C/PHN graduates have provided the UNMC C/PHN faculty with feedback that the skills and knowledge they have received in the program are marketable and relevant for the needs of their employers and communities. They appreciate the breadth of competencies they have acquired and have integrated the health system and clinical perspectives of C/PHN. Curriculum needs to prepare graduates with a relevant knowledge base and skills set. In Nebraska, and in varying degrees nationally, advanced practice community/public health nurses are needed who have a firm foundation in traditional public health content, hold the values of nursing and public health, and possess knowledge and skills that help them participate at a systems level in the health care changes occurring in their communities. Acknowledgments Appreciation is expressed to fellow HSNS faculty members Drs. Donna Westmoreland, Jan Atwood, Judith Heermann, Karen Grigsby, Carol Pullen, and Cheryl Thompson.
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(1999). Graduate education for advanced practice in community/public health nursing. Pensacola, FL: Author. Association of Community Health Nursing Educators (2000). Essentials of baccalaureate education for entry level community/public health nursing. Pensacola, FL: Author. Boyle, R.E. (1972). Articulation: From associate degree through master’s. Nursing Outlook, 20, 65-67. Boyle, R.E., (1977). Expectations of the educator for the new nurse graduate. In National League for Nursing Pub. No. 23-1691. Collaboration between service and education: Fact or fancy? (pp. 3-5). New York, NY: National League for Nursing Press. Eichelberger, L., & Hewlett, P. (1999). Competency model 101 the process of developing core competencies. Nursing and Health Care Perspectives, 20, 204-208. Gebbie, K.M., & Hwang, I. (2000). Preparing currently employed public health nurses for changes in the health care system. American Journal of Public Health, 90, 716-720. Josten, L., Clarke, P., Ostwald, S., Stoskopf, C., & Shannon, M. (1995). Public health nursing education: Back to the future for public health sciences. Family Community Health, 18, 36-48. Keller, L.O., Strohschein, S., Lia-Hoagberg, B., & Schaffer, M. (1998). Population-based public health nursing interventions: A model from practice. Public Health Nursing, 15, 207-215. Leichsenring, M. (1972). Teaching seminars for new faculty. Nursing Outlook, 29, 528-531. Lia-Hoagberg, B., Schaffer, M., & Strohschein, S. (1999). Public health nursing practice guidelines: An evaluation of dissemination and use. Public Health Nursing, 16, 397-404. Lutrell, M.F., Lenburg, C.B., Scherbul, J.C., Jacob, S.R., & Koch, R.W. (1999). Competency outcomes for learning and performance assessment. Nursing and Health Care Perspectives, 20, 134-141. Mohr, W. (1999). Reflections on writing. Nursing Outlook, 47, 198-199. Nebraska Health and Human Services System (1999). Nebraska’s plan to strengthen and transform public health in our state). Lincoln, NE: Author. Nebraska Preventive Health Advisory Committee. (1998, December 14). Minutes. Unpublished document. Peterson, K.W., & Kane, D.P. (1997). Beyond disease management: Population-based health management. In W.E. Todd, & D. Nash (Eds.), Disease management: A systems approach to improving patient outcomes (pp. 305-346). Chicago, IL: American Hospital Publishing, Inc. Public Health Nursing Section (2001). Public health nursing interventions—applications for public health nursing practice. St. Paul, MN: Department of Health.
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Shugars, D., O’Neil, E.H., & Bader, J.D (Eds.). (1991). Healthy America: Practitioners for 2005: An agenda for action for U.S. health professional schools: A report of the PEW Health Professions Commission. Durham, NC: PEW Health Professions Commission, Duke University Medical Center. Silva, M.C., Cary, A.H., & Thaiss, C. (1999). When students can’t write: Solutions through a writing-intensive nursing course. Nursing and Health Care Perspectives, 20, 142-145. The Center For The Health Professions. (2000). Summary of the ten recommendations [On-line]. Available: http:// futurehealth.ucsf.edu/summaries/reforming.html. Accessed: November 7, 2000. U.S. Census Bureau. (2000). Census 2000 Redistricting Data (P.L. 94-171) Summary File, Table PL1 and 1990 census. U.S. Census Bureau [On-line]. Available: http:// www.census.gov/dmd/www/2kresult.html. Accessed: July 25, 2001. United States Department of Health and Human Services Public Health Services (1991). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: Author. United States Department of Health and Human Services Public Health Service (2000). Healthy people 2010: National health promotion and disease prevention objectives. Washington, DC: Author. United States Department of Health and Human Services (1997). The Public Health Workforce: An Agenda for the 21st Century. Full Report of the Public Health Functions Project). : Washington, DC: Prevention and Health Promotion. United States Government. (2000). Healthy people 2010 [On-line]. Available: http://web.health.gov/healthypeople/ html. Accessed: November 7, 2000. Westmoreland, D., & Hays, B.J. (2002). The health systems nurse specialist: Collaborating across specialties to prepare nurse leaders. Nursing Education Perspectives, 23, 172177. Yeaworth, R.C. (1996). Consortia arrangements and educational telecommunication. Journal of Professional Nursing, 12, 147-153. Yeaworth, R.C., Pullen, C.H., Zimmerman, L., & Hays, B.J. (2001). Distributed learning strategies: Improving educational access in nursing. In N.L. Chaska (Ed.), The nursing profession: Tomorrow and beyond (pp. 165-175). Thousand Oaks, CA: Sage. Yeaworth, R.C., Schmidt, M.A., (1999). The nursing school advisor: What you need to know about distance learning in nursing education. Peterson’s Guide to Nursing Programs 1999-2000. American Association of Colleges of Nursing: Princeton, NJ.
In recent years the changes in the organization and delivery of health care have created an environment that places great demands on nursing education at all levels. Determining a sound, responsive course of study in advanced practice community/public health nursing (C/PHN) is dependent on clear educational outcomes and competencies. Outcomes and competencies for C/PHN practice need to continue to be derived from the rich knowledge, experience, and research tradition with populations living in the community. However, in today’s health care environment, these outcomes and competencies also must be integrated within the context of a very different health care system perspective. This article describes the outcomes and competency indicators developed to guide a curriculum designed to integrate traditional C/PHN and a health systems perspective for students seeking advanced practice education in C/PHN at the College of Nursing, University of Nebraska Medical Center. (Index words: Advanced practice community/ public health nursing; outcomes/competancy)
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N RECENT YEARS there has been an emphasis on articulating clear outcomes and associated competencies for nursing educational programs as one way to evaluate effectiveness of curricula (Eichelberger & Hewlett, 1999; Lutrell, Lenburg, Scherbel, Jacob, & Koch, 1999). This article describes the outcomes and competency indicators developed to guide the curric-
*Associate Professor, University of Nebraska Medical Center College of Nursing, Omaha, NE. †Emeritus Associate Professor, University of Nebraska Medical Center College of Nursing, Omaha, NE. Supported in part by a Department of Health and Human Services Bureau of Health Professions Advanced Nurse Education Program grant (1-D23-NU-01260-01) and a University of Nebraska Medical Center Educational Technology small grant (MGA/22-071-081). Address correspondence and reprint requests to Dr. Kaiser: University of Nebraska Medical Center College of Nursing, Room 4061, 985330 Nebraska Medical Center, Omaha, NE 681985330. E-mail: [email protected] © 2003 Elsevier Inc. All rights reserved. 8755-7223/03/1904-0000$30.00/0 doi:10.1016/S8755-7223(03)00088-7
ulum for students seeking advanced nursing practice education in community/public health nursing (C/PHN) at the College of Nursing, University of Nebraska Medical Center. Specification of the expected student outcomes, by the faculty, was influenced strongly by the characteristics and health needs of Nebraska along with the evolution and current tensions within the health care environment and professional nursing. This expected outcomes and competencies development work occurred in conjunction with a curriculum revision that resulted in a Health Systems Nurse Specialist (HSNS) program, with C/PHN as 1 of 3 advanced nursing practice options. The University of Nebraska is a land-grant university whose College of Nursing has a long history of innovative delivery of nursing education via multiple campuses and distance educational methods to prepare basic and advanced practice nurses (Boyle, 1972, 1977; Leichsenring, 1972; Yeaworth, 1996; Yeaworth, Pullen, Zimmerman, & Hays, 2001; Yeaworth & Schmidt, 1999). In a recent example of this commitment to meet the educational needs of Nebraskans, several graduate nursing faculty developed a creative curriculum to prepare advanced practice nurses with skills tailored to practice at a health systems level. The curriculum encompasses the specialty options of C/PHN, nursing administration, and nursing informatics (Westmoreland & Hays, 2002). The interactions among faculty from within these 3 specialties fostered identification of shared expected outcomes that (1) facilitate student development needed for each specialty’s practice, but also (2) promote the strong shared knowledge base that is necessary when a health systems perspective is emphasized. The health system perspective that provided a foundation for the curriculum work considered the dramatic health care system changes that were emerging at the time. Primarily these included the information explosion, health care organization and financing paradigm shifts, and the demand for a better match of health system outcomes to
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expenditures that were occurring when this faculty group began their work in 1996-1997. The expected outcomes presented are a synthesis that evolved from this faculty’s curriculum-building effort. Before describing the expected outcomes and competency indicators for C/PHN graduates of this curriculum, a discussion of the national and regional influences that stimulated this new curriculum are presented.
Characteristics and Health Needs of Nebraska
Nebraska is a mostly rural state with 87 of 93 counties designated as either rural or frontier. Forty-one rural counties are federally designated medically underserved areas and 53 counties are health professional shortage areas. Rural Nebraska counties have a poverty level of 12 percent, compared with 8 percent in metropolitan counties. Nebraska faces several challenges in the ongoing effort to improve the health status of its residents. Many of the state’s rural areas are medically underserved with needs in both public health and medical systems capacity. The 2000 census revealed an overall growth rate of 8 percent in Nebraska, but 53 Nebraska counties (57 percent) experienced a decrease in size, generally owing to an outward migration of the younger population (U.S. Census Bureau, 2000). Such decreases in the population base make it even more difficult to provide important public health and medical services in these areas because it is more difficult to recruit and retain health care professionals and to sustain institutional health services such as hospitals (Nebraska Health and Human Services System, 1999). Many of Nebraska’s rural health care organizations, including 75 rural hospitals, are struggling to remain viable. These delivery systems are being stressed by (1) the farm crisis that has increased the number of uninsured, (2) a shifting and increasing ethnic diversity, (3) a large elderly population with chronic health problems, (4) substantial shifts in patterns of rural health care funding, (5) inadequate funding and infrastructure for public health initiatives, and (6) increasing demands to use data to design programs and deliver the health care needed for Nebraskans. Additionally, the state has underdeveloped systems of nonacute care such as case management, community health supports, personnel training and development, data management, and quality monitoring. The changing composition of Nebraska’s citizenry
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requires adjustments in priority health services to avoid an exacerbation of health disparities. In recent years, the ethnic minority populations have grown throughout Nebraska so that there are now minorities in every county in the state, with minorities in 2000 comprising 10.4 percent of the state’s population (U.S. Census Bureau, 2000). In addition, Nebraska has 4 major Native American nations located primarily in rural areas across the northern areas of the state. Migrant or seasonal farm workers, largely located in rural western and central Nebraska, total about 20,000 and contribute to the high unintentional injury rate. At the same time, the state continues to face the challenges of providing for the health needs of the elderly who comprise a high percentage of Nebraska residents, with 13.6 percent of Nebraskans now 65 years or older. Nebraska ranks ninth among all states in populations over 65 and second with populations over 85. The population in rural Nebraska is disproportionately elderly, averaging 18 percent of county totals compared with 10 percent in Nebraska’s metropolitan counties. Chronic health problems with this population constitute an important health need within the state and providing community-level services to assist the elderly to maintain independence is crucial but highly variable among communities. Two major issues in public health in the state have been lack of an established funding mechanism for public health and a long-standing lack of formal organizational infrastructure for public health (Nebraska Preventive Health Advisory Committee, December, 1998). In fact, throughout the 1990s Nebraska ranked 50th among all states in funding for public health. In an encouraging development, the 2001 Nebraska legislature allocated $9 million dollars of Nebraska’s tobacco settlement monies to develop public health infrastructure and better address minority health needs across the state. Now and in the foreseeable future, advanced practice community/public health nurses will be needed to help communities who are medically underserved participate in the development of public health services throughout Nebraska. The present ability of the state of Nebraska to respond to the health needs of its rural medically underserved citizenry is compromised owing to workforce shortages of advanced practice nurses who can provide leadership in building public health infrastructure, culturally competent health care, skilled use of data (data analysis, integrated data systems), community partnering, and population capacity building. In addition, skills in community assessment and programming are
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needed throughout the state to help identify priority needs, recommend possible solutions, and participate in program development to ameliorate such challenging health needs. In summary, there is a crucial need in Nebraska for advanced practice community/public health nurses with traditional public health skills who also have a solid knowledge base and skill set with a focus on the systems level. This is particularly important in our state, which has an emerging, nontraditional public health infrastructure. Using community and population health skills, these advanced practice nurses can partner with communities and geographically unique health systems across the state to determine priority health needs, develop interventions and programs, and monitor population health outcomes. Tensions Within America’s Health Care Environment and Professional Nursing HEALTH CARE
One aspect of the Health Care Reform movement of the 1990s was a discussion of the need to move the health system eventually toward managing population health rather than just managing care (Peterson & Kane, 1997). At the same time, the U.S. Federal government’s preventive health initiatives, Healthy People 2000 and Healthy People 2010 (U.S. Department of Health and Human Services, 1991; 2000) brought increasing attention to the importance of populationbased health management practice. Nursing’s Agenda for Health Care Reform emphasized increased access and better health care for broad segments of the population through primary health care, which could be delivered through a variety of health care alternatives that would reduce costs and allow clients to have more choice (American Nurses Association, 1991). Health policy statements have called for setting a new course for health care in many specific areas, including health promotion, disease prevention, screening, immunizations, and preparation of health care providers. In addition, Healthy People 2010 sets a specific goal to increase the proportion of schools of medicine, schools of nursing, and other health professional training schools whose basic curriculum includes preventive health training as part of the core curriculum. Current policy statements and health system recommendations signal that the health care system is being purposively steered away from its 20th century course that focused primarily on the provision of medical services driven by technologic advances toward health
promotion and primary care. These health system directional changes require important shifts in emphasis within professional nursing. The C/PHN specialty has a rich tradition of valuing and striving to integrate population-focused services with all social systems, especially the health system. However, because of workforce and categoric funding issues the specialty has not had adequate tools or opportunities to consistently make health system integration a practice emphasis. The Minnesota Department of Health’s Public Health Nursing Practice for the 21st Century model emerged from the public health nursing experience of over 200 public health nurses practicing in Minnesota in 1994 (Keller, Strohschein, LiaHoagberg, & Schaffer, 1998). The work of public health nurses included interventions focused at the systems level. Population-based systems-focused practice is described as changing “organizations, policies, laws, and power structures” (Keller et al. p. 209). This intervention level relates to the systems’ impact on health and can be a more effective way of impacting population health than an individual focus. The model that emerged from the Minnesota work, known as the intervention wheel, provides system-focused examples of public health nursing for all 17 identified interventions (Lia-Hoagberg, Schaffer, & Strohschein, 1999; Public Health Nursing Section, 2001). NURSING EDUCATION
The rapidly changing health care environment has created a call to shift the academic vision that has guided the education of health professionals (Shugars, O’Neil, Badger, 1991; American Association of Colleges of Nursing, 1999; Center for the Health Professions, 2000). The call for such shifts has generated dispute and debate regarding what constitutes the best match of professional personnel in regard to training and skill acquisition, and the future needs of the health care system and the populations it serves. Two national focus groups of key informants convened to examine the training needs of the C/PHN workforce and enumerated a lengthy list of social, economic, technological, epidemiologic, and governmental forces that affect C/PHN practice and the context of that practice (Gebbie & Hwang, 2000). Many of the points listed from the focus group work indicate that a great deal of the change in the health care environment is related to needed health systems change. The results of the national focus groups also highlighted the need for knowledge and skills in public health such as epidemi-
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ology and environmental health, health system skills such as measuring organizational change, and people skills such as negotiation and collaboration as crucial (Gebbie & Hwang). Nurses practicing in the current environment, which demands high-quality services at a reasonable cost, will play a major role in developing and implementing change to improve the functioning of the health system (American Association of Colleges of Nursing, 1999). The American Association of Colleges of Nursing encourages nursing education to anticipate and prepare for these changes to educate students for the emerging health care environment, which includes preparation of advanced practice nurses. In 1996, the American Association of Colleges of Nursing published The Essentials of Master’s Education for Advanced Practice Nursing. This consensus-based document defined the essential curricular elements of master’s education in nursing for advanced practice as a clinical nurse specialist, nurse practitioner, nurse anesthetist, or nurse midwife. The master’s curriculum outlined for these graduate nursing practitioners recommended: (1) graduate core curriculum content essential for all master’s degree in nursing students, (2) advanced practice nursing clinical core content focused on the provision of direct patient/client services, and (3) specialty curricula. C/PHN and nursing administration specialty curricula were not included in the advance practice nurse clinical core because the document focuses on preparation for the provision of clinical care for individuals. However, in addition to the education of advanced practice nurse practitioners who deliver primary care services, the American Association of Colleges of Nursing recommended preparation of advanced practice nurses who can work with populations and health care systems to strengthen and support clinical services. Advanced practice nursing is characterized by: (1) specialization, or delimiting the practice focus to part of the whole field of nursing; (2) expansion, or acquisition of new knowledge and skills; and (3) advancement, or a research, theory, and experiential integration of knowledge within graduate study (American Nurses Association, 1995). Advanced practice C/PHN must additionally consider the practice and science of public health with a focus on populations (Josten, Clarke, Ostwald, Stoskopf, & Shannon, 1995; Keller, Strohschein, Lia-Hoagberg, & Schaffer, 1998). This population focus has as a central goal promotion of better population health status through strategies such as health management and community health program
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development. Similar to other nursing specialties, advanced practice C/PHN provides clinical services as necessary in the provision of population-focused care. However, they also contribute to population health status through improvement of the health system via quality monitoring and management, population data management, policy development, and promotion of evidence-based practice. The 1996 American Association of Colleges of Nursing’s The Essentials of Master’s Education for Advanced Practice Nursing document sparked significant discussion and debate within professional nursing. One of the primary discussion points centered on the recommendations regarding core preparation for advanced practice nurses preparing for primary care roles and those focused at a population or system level. Because advanced practice C/PHN programs focus on community and population-based theory and practice, the American Association of Colleges of Nursing position paper stimulated the C/PHN specialty to re-examine and solidify its advanced practice position papers to promote clarity and to reaffirm the direction of advanced practice C/PHN. The C/PHN specialty has responded to the American Association of Colleges of Nursing recommendations by revising specialty documents including the Scope and Standards of Public Health Nursing (American Nurses Association, 1999) and the Graduate Education for Advanced Practice in Community/Public Health Nursing (Association of Community Health Nursing Educators, 1999). These documents serve as useful tools for C/PHN educators to use when developing and enhancing advanced practice curricula to be responsive to the emerging and current health care environment. Developing and delivering educational programs that prepare nurses for advanced C/PHN practice requires both a clear sense of the current and emerging scope of the specialty and creative use of the educational resources available. Traditional educational models, such as (1) a nursing major within a master’s of public health program or (2) a clinical nurse specialist program in community health nursing, are not always readily available to many nurses who seek them. Such is the case for many of Nebraska nurses owing to distance and workforce influences. Therefore, innovative methods such as distance delivery are critical for training the public health nursing workforce (Gebbie & Hwang, 2000) and for preparing advanced practice C/PHN to provide leadership in local, state, regional, and national arenas to ensure that population health needs are being met with consideration of quality and cost.
SETTING A NEW COURSE FOR ADVANCED PRACTICE
The goal of public health nursing has been articulated as “promoting and protecting the health of the population” (American Nurses Association, 1999, p. 2). For this aim to be realized, graduates of advanced practice C/PHN programs must be ready to assume leadership in today’s health care environment with a relevant set of professional population-level competencies. With these ideas clearly in mind, the C/PHN faculty contributed to the HSNS expected student outcomes discussions a variety of information from C/PHN documents and literature, population data sources, and an understanding of the uniqueness of our state and region from population and community perspectives. The nursing faculty at the University of Nebraska Medical Center responded to the needs in our state and region, and the changing health care and educational environments, by developing the Health Systems Nurse Specialist curriculum with specialty options in C/PHN, nursing administration, and nursing informatics. A cornerstone of that process was the development of outcomes and competency indicators that are core to each of the HSNS specialty options, as well as unique to each specialty. Those relevant to advanced practice C/PHN are presented.
Specification of Expected Outcomes and Competency Indicators
For advanced practice C/PHN it was important for the outcomes to reflect two major elements: (1) the knowledge and skill from traditional C/PHN to prepare graduates to sit for advanced practice certification as clinical nurse specialists in C/PHN and (2) the system-level knowledge and skill necessary for advanced practice in a state with such significant health workforce and population health needs. After a careful review of the target outcomes of the C/PHN curriculum that were in place, the C/PHN faculty participated in nominal group process and dialogue sessions that were conducted with the entire HSNS faculty. From the beginning, the HSNS faculty adopted the attitude that development of the outcomes and competency indicators would be a work in progress, with formative review and refinement. In fact, we have found that the expected outcome statements and essential competency indicators have been refined through the process of course development, implementation, evaluation, and revision. Achieving precision in language and sorting the essential ideas
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from the nonessential ones has been a key feature in the ongoing work of HSNS faculty. A national consultant, whose contribution was made possible through the HSNS grant funding, provided a crucial external, expert perspective to identify areas in which we needed to either get more precise in our articulation or reduce the density within the outcomes and competency indicators initially developed. The HSNS faculty hold a strong value of promoting individual learning experiences, which often leads to tailoring the course projects and practicum experiences to meet the student’s interests and career goals. For these reasons, the decision was made to select competency indicators for each outcome rather than articulating a definitive list of competencies that every student would achieve. In other words, the expected outcomes were viewed as universal for graduates but the faculty recognized that a variety of competencies could indicate achievement of the outcome. Seven program outcomes have evolved with associated HSNS core and specialty-specific competency indicators. The language of competency indicators is important to help students recognize that not every student will achieve every competency, nor is the listing comprehensive. Yet the concrete examples provided by the competency indicators give students a sense of the possibilities open to them and provide them with language to speak to colleagues and potential employers about the relevance of the HSNS Advanced Practice C/PHN curriculum. Table 1 presents the current expected outcomes and competency indicators that guide our curriculum implementation, formative evaluation, and curriculum enhancement. The first expected outcome focuses on the ability of the graduate of this program to be able to articulate what HSNS C/PHN is and what constitutes a personal philosophy, or model of advanced C/PHN. This includes competency indicators related to values, ethics, and systems thinking. Graduate education for advanced practice in C/PHN emphasizes the values of health promotion, disease prevention, and community- and population-based practice. Also important to graduate C/PHNs are the values of diversity, social justice, community partnership, and interdisciplinary action (Association of Community Health Nursing Educators, 1999). These values are all consistent with the values of this HSNS C/PHN program. Research utilization and use of evaluation methods focused on policy development and client outcomes are concepts central to the second expected outcome. Competency indicators relevant to this outcome en-
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1. Outcomes and Competencies for C/PHN Health Systems Nurse Specialists Expected Outcomes
Outcome 1: articulates professional identity, values, and beliefs that guide her/his advanced practice
Outcome 2: uses research findings and evaluation methods to achieve desired system and population outcomes
Outcome 3: shows relationship-building and cultural competency behaviors to improve the health care system for the promotion of client health Outcome 4: communicates effectively to facilitate achievement of health system, population, organizational, and professional goals Outcome 5: accesses databases and/or gathers accurate and appropriate data to make informed decisions affecting health systems and/or populations Outcome 6: participates in strategic planning, allocation, and management of health system(s) resources
Outcome 7A: practices advanced practice Community/Public Health Nursing using a conceptual, theoretical, and experiential base
Competency Indicators
Applies ethical thinking to practice situations Uses professional standards, guidelines, and best practices Engages in systems thinking Articulates for self and others practice values and beliefs Understands quality management Evaluates health programs Identifies best clinical practices Fosters evidence-based practice Evaluates desired population and/or system outcomes Considers policy implications in outcome assessment Partners with individuals, organizations, populations, and communities Participates in developing coalitions Participates in capacity-building activities Participates in resolving conflict Uses culturally acceptable and relevant approaches Communicates effectively in oral discussions and presentations Communicates effectively in written forms Uses data appropriately (qualitative and/or quantitative) in making decisions Represents data accurately and in a useful format
Understands major factors in health care environment that influence health and health systems Shows knowledge of strategic planning processes Uses systematic financial thinking Shows knowledge of effective and parsimonious management of health system resources Integrates nursing and population sciences Appreciates the history and heritage of the specialty Uses a systematic approach to population and community assessment Participates in a community diagnosis based on data from multiple sources Develops health programs and population interventions based on assessed need Understands principles of community development and organization Uses community networking, referral systems, and principles of care coordination in practice Facilitates health behavior change for clients and target populations Advocates for underserved and vulnerable populations and communities Differentiates the organization of CHN services by mission statement at local, regional, and national levels
compass key knowledge and skill areas such as quality management, program evaluation, evidenced-based practice, and consideration of policy implications. Because research is a key content area for all the areas of specialization within the master’s program in our college, the HSNS curriculum uses the base of the research courses to help students to tailor these beginning research skills toward the public health and population-focused nursing practice skills that are so essential in advanced practice C/PHN. Outcome 3 relates to leadership and cultural competency behaviors needed to promote client health and improve the health care system. The development of community partnerships that link people to services in a culturally competent manner is viewed as core to the
education for C/PHN. Outcome 3 is consistent with recommendations regarding population-focused practice and health system improvement skills desired for the public health workforce in the 21st century. These recommendations include: cultural competency, health promotion skills, and leadership development (U.S. Department of Health and Human Services, 1997). The fourth outcome reflects the necessary written and oral communication skills of the advanced practice C/PHN. Not only are writing and oral presentation skills a signature of the well-educated person, they are critical in today’s health care environment that is characterized by the transmission and receipt of information (Mohr, 1999; Silva, Cary, & Thaiss, 1999).
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Information generation and manipulation is one essential element in the ability of the advanced practice community/public health nurse to access and analyze data effectively for the purpose of enhancing population health decision making (Outcome 5). The advanced practice community/public health nurse works with and in communities that often provide frontline opportunities to influence health decision making. This highlights the importance of data-based decisions in ensuring population health. Resource management and strategic planning (Outcome 6) are essential in the current health care environment, which is driven by economics, politics, and quality improvement forces. Tools such as financial thinking and strategic planning enhance the ability of the advanced practice community/public health nurse to show responsible stewardship of the community’s resources for allocation toward improvement of the health of the population as a whole. Such skills also promote leadership behaviors with multidisciplinary teams. The seventh and final outcome addresses the tradition, experience, and conceptual/theoretical base of C/PHN. Understanding the history and heritage of C/PHN is important in helping today’s professionals appreciate the challenges of the past to learn to work with the challenges of the present and future. Advanced practice C/PHN graduates need to be able to participate, collaborate, and lead interventions that encompass population and community health promotion and risk reduction. This includes incorporation of the skills of community networking and care coordination, community organization and development, active participation in health and social policy analysis and development, and provision of leadership in the enforcement of laws and regulations that protect health and ensure safety. The seventh expected outcome reflects specialty-specific content and learning experiences and differs markedly among the 3 HSNS specialties. This necessitates specialty-specific competency indicators consistent with the practice and theory of
each HSNS specialty. Only the C/PHN seventh outcome is presented in Table 1. Discussion
Community/public health nursing has had to evolve to be consistent with changing social forces and to be relevant to the communities and populations that are its dominant responsibility (Association of Community Health Nursing Educators, 2000). To meet the challenges that come with social change, professional educational institutions need to periodically examine their curricula to be sure they are meeting the needs of their students and the populations and communities their graduates serve. The development of the HSNS C/PHN curriculum evolved from the health and workforce needs within the state of Nebraska at a time of significant change within the health care environment. The C/PHN graduates have provided the UNMC C/PHN faculty with feedback that the skills and knowledge they have received in the program are marketable and relevant for the needs of their employers and communities. They appreciate the breadth of competencies they have acquired and have integrated the health system and clinical perspectives of C/PHN. Curriculum needs to prepare graduates with a relevant knowledge base and skills set. In Nebraska, and in varying degrees nationally, advanced practice community/public health nurses are needed who have a firm foundation in traditional public health content, hold the values of nursing and public health, and possess knowledge and skills that help them participate at a systems level in the health care changes occurring in their communities. Acknowledgments Appreciation is expressed to fellow HSNS faculty members Drs. Donna Westmoreland, Jan Atwood, Judith Heermann, Karen Grigsby, Carol Pullen, and Cheryl Thompson.
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