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Clinical Prevention and Population Health Curriculum Framework: The Nursing Perspective
ORIGINAL ARTICLES Clinical Prevention and Population Health Curriculum Framework: The Nursing Perspective JANET D. ALLAN, PHD, RN, FAAN,* JOAN STANLEY, PHD, RN, CRNP, FAAN,y M. KATHERINE CRABTREE, DNSC, ANP, RNC, FAAN,z KATHRYN E. WERNER, MPA,§ AND MELINDA SWENSON, PHD, FNPO The Clinical Prevention and Population Health Curriculum Framework (Curriculum Framework) was developed by the Healthy People Curriculum Task Force comprised of representatives from allopathic and osteopathic medicine, dentistry, nursing and nurse practitioners, pharmacy and physicians assistants. This multidiscipline Task Force was covened to address the Healthy People 2010 objective of increasing the health promotion/prevention content in health professional education. A focus on clinical prevention and population health activities is central to the goal of improving the health status of the nation and offers the greatest potential to reduce many leading causes of death and improve quality of life across diverse populations. The Curriculum Framework provides a set of 4 components (evidence base for practice, clinical preventive services, health systems/health policy and community aspects of practice) and 19 domains for organizing and implementing the curriculum. The title "Clinical Prevention and Population Health" includes both individual and population
*Dean and Professor, University of Maryland School of Nursing, Baltimore, MD. yDirector of Education Policy, American Association of Colleges of Nursing, Washington, DC. zProfessor, School of Nursing, Oregon Health and Science University, Portland, OR. §Executive Director, National Organization of Nurse Practitioner Faculties, Washington, DC. OProfessor, School of Nursing, Indiana University, Bloomington, IN. Address correspondence and reprint requests to Dr. Allan: University of Maryland School of Nursing, 655 West Lombard Street, Room 505, Baltimore, MD 21201. E-mail: [email protected] 8755-7223/$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2005.07.006
focused health promotion and prevention efforts. The role of nursing in developing the Curriculum Framework, and the tailoring and implementation of the Curriculum Framework for undergraduate and graduate programs in nursing is discussed. (Index words: Health promotion/prevention curriculum; Healthy people 2010; Inter-professional prevention and population health curriculum) J Prof Nurs 21:259-267, 2005. A 2005 Elsevier Inc. All rights reserved.
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EALTH PROMOTION AND disease prevention provide a cornerstone for the discipline of nursing. Traditionally, health promotion and disease prevention content have been included in both undergraduate and graduate nursing curricula but to what degree and in what context? More importantly, to what extent is the health promotion and prevention content translated into practice? Have we assumed that this content presented rather than evaluated the performance of health promotion and disease prevention competencies of our graduates? Has the content on health promotion and disease prevention kept pace with the growing evidence base for this content? In a survey of entry-level baccalaureate nursing education programs (DHHS, 2000), the American Association of Colleges of Nursing (AACN) found that only 72% of responding schools (N = 334) indicated that the Healthy People 2000 objectives were used in the curriculum planning or review process. As pressure to expand content in the nursing curriculum continues to grow, we must ensure that health promotion and disease prevention remain fundamental components of the nursing curriculum.
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These areas are foundational to nursing practice and were instrumental beliefs upon which Florence Nightingale founded the profession. Not only is nursing rooted in the tradition of health promotion and disease prevention; we have contributed greatly to the health of the nation and the world by mounting immunization, nutrition, and numerous other programs that have benefited people throughout the country and throughout the world. What we put into practice is critical in achieving health for all. However, effective health promotion and disease prevention requires interdisciplinary cooperation. The Institute of Medicine (IOM, 2001) identified interdisciplinary practice as one of five critical competencies for all health professionals for the 21st century. The interprofessional Healthy People Curriculum Task Force, with nursing as a major participant, has created the Clinical Prevention and Population Health Curriculum Framework for Health Professions (Allan et al., 2004). The work of this task force is an important landmark of cooperation to achieve our goal of health for all Americans and the world. The Clinical Prevention and Population Health Curriculum Framework for Health Professions, along with recommendations for implementing the framework within undergraduate and graduate nursing curricula, is presented as a first step toward this common goal.
Background
Healthy People 2010 set two major goals for the United States: (1) to increase quality and quantity of years of healthy life and (2) to eliminate health disparities among segments of the population (U.S. Department of Health and Human Services, 2003). These goals challenge health systems, health professionals, and policy makers to address changes in education and practice that are needed to meet these goals. Such changes imply that health systems must create a stronger focus on primary care and prevention; educators need to place greater emphasis on prevention and population health in the education of future practitioners, and policy makers must develop polices to support the institutionalization of preventive services. A focus on health promotion, prevention and population health offers the greatest potential to reduce many of the leading causes of death and disability and improve the quality of life across diverse populations (Clancy, 2003; Whitlock,
Orleans, Pender, & Allan, 2002). Over half of premature deaths in the United States are caused by lifestyle-related behaviors, such as smoking, inactivity, alcohol misuse, risky sexual behaviors, and poor dietary habits (McGinnis & Foege, 1993). To emphasize the importance of addressing these lifestyle behaviors, Healthy People 2010 (U.S. Department of Health and Human Services, 2003) identified five lifestyle behaviors (inactivity, tobacco use, unhealthy eating patterns, substance misuse, and risky sexual practices) as health indicators by which to track progress in improving health. Policy makers have over the last decade expanded the coverage for preventive care under Medicare and Medicaid (Clancy, 2003) and other third-party payers. Despite these goals and policy changes, the focus on prevention and population health continues to lag behind the strong emphasis on a disease-based, acute care approach to health care. Furthermore, the competencies needed to assist people in adopting healthy lifestyles and making lifelong changes in health behavior require more than a grasp of the benefits. The health professional also must be skilled in communication, education, and evaluation of behavior. The education of future health professionals is critical to efforts to change health-care and health systems (Allan et al., 2004). Health promotion, disease prevention, and population health have long been viewed as core components of the nursing role (AACN, 1996, 1998; National Organization of Nurse Practitioner Faculties [NONPF], 1995, 2005). Concepts in support of this role are found in nursing curricula of baccalaureate and master’s degree programs. Despite the long-standing commitment to these concepts, nursing lacks a structured, comprehensive curriculum integrating concepts of health promotion, disease prevention, and population health across programs. The time may be right for a new and more structured approach. In addition to the Healthy People 2010 goals, the convincing links of lifestyle behaviors to leading causes of death, and policy changes in Medicare and Medicaid, several recent IOM reports (Greiner & Knebel, 2003; Hernandez, 2003) have supported a renewed attention to health promotion, disease prevention, and population health in the education of nurses. Specifically, these landmark reports have focused attention on the need to change the way we educate nurses. The IOM identified (1) evidencebased practice as a core competency of all future health professionals (Greiner & Knebel, 2003) and (2) advocated for a more population-focused and
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ecological approach to the conditions and diseases affecting the American public (Hernandez, 2003). The nursing profession is increasing its focus on developing curricula and practices that are evidencebased (Hinshaw, 2000; Melynk & Fineout-Overholt, 2005). Competencies include the ability to use the evidence base to improve the quality of health care. As the evidence base for health promotion and disease prevention expands and changes, future health professionals must be able to evaluate the evidence and design care that integrates this knowledge and skill. Competency in delivery of health promotion and disease prevention care cannot be left to chance but must be part of the on-going evaluation of nursing education and practice. Healthy People Curriculum Task Force
The Association of Teachers of Preventive Medicine (ATPM) had a goal of developing a curriculum framework in prevention content that could be used by various health professions. In the 1980s, the ATPM formed a working group to develop the Inventory of Knowledge and Skills Relating to Disease Prevention and Health Promotion. This beginning work did not offer the breadth of scope envisioned by the ATPM but provided a foundation for addressing the Healthy People 2010 Objective I-7, to bincrease the proportion of schools of medicine, schools of nursing and health professionals training schools whose basic curriculum for health care includes the core competencies in health promotion and disease preventionQ (U.S. Department of Health and Human Services, 2003). In 2000, the ATPM collaborated with the Association of Academic Health Centers (AAHC) to convene a multidisciplinary task force to develop a framework for prevention education. The ATPM and the AAHC invited seven clinical health education professional organizations to participate on the Healthy People Curriculum Task Force (Task Force). Each of the following organizations agreed to participate and to have a senior academic member and the executive director or designee serve on the Task Force: allopathic medicine: Association of American Medical Colleges; dentistry: American Dental Education Association; nursing: AACN and NONPF; osteopathic medicine: American Association of Colleges of Osteopathic Medicine;
pharmacy: American Association of Colleges of Pharmacy; physician assistants: Association of Physician Assistant Programs. ATPM and AAHC also expanded the Task Force to include representation from the Student Health Alliance, the Association of Schools of Public Health, and Community–Campus Partnership for Health. The interprofessional composition of the Task Force and the collaborative process facilitated by the ATPM and the AAHC provided a structure extremely conducive to addressing Healthy People 2010 Objective 1.7 (U.S. Department of Health and Human Services, 2003). The significant outcome of the Task Force work to date is The Clinical Prevention and Population Health Curriculum Framework for Health Professions, a consensus framework that has achieved endorsement from all seven represented health professions (Allan et al., 2004). The framework provides guidance to faculty, students, and practitioners in recognizing the priorities for clinical prevention and population health education and practice within their disciplines. Framework Development
The Task Force followed an ambitious time schedule to develop the generic framework. At its first organizing meeting in January 2003, the Task Force assessed the extent of health promotion and disease prevention content within educational programs of each health profession. This discussion identified common foci and variations, leading to the initial mapping of the framework and selection of terminology. Over the next 6 months, the Task Force met twice more and communicated electronically to develop the framework. To ensure that the framework remained generic to accommodate all disciplines, the Task Force decided to provide a layered structure to the framework, which included (1) broad components for structuring curriculum, (2) domains of content areas, and (3) specific examples of content and materials that might be included in a curriculum. By the end of summer 2003, the Task Force had completed a draft of the framework. The second phase of the framework development included seeking broad input and support from members of the health professions represented on the Task Force. During fall 2003, ATPM coordinated a web-based review process to solicit feedback on the relevance and comprehensiveness of the components
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and domains. The organizations represented on the Task Force, including the two nursing organizations, assisted the review process by engaging in and promoting the review process among members and generating organizational-level discussion about the framework. After incorporating relevant comments received from external reviewers, the Task Force reached unanimous agreement on the framework in spring 2004. Early in its development, the framework assumed a working title of Health Promotion–Disease Prevention, consistent with the wording in the Healthy People 2010 objective. After several discussions about the title, the Task Force concluded that the framework also should reflect consistency with terminology incorporated in the U.S. Preventive Services Task Force’s recommendations (2002), as well as the IOM reports related to public health (Cuff & Vanselow, 2004; Hernandez, 2003). Given the emphasis in these documents on bclinical preventionQ as well as bpopulation healthQ and the intent for health professionals to address both individual- and population-oriented preventive efforts, the Task Force agreed on the title Clinical Prevention and Population Health for the framework. The Role of Nursing in Developing the Framework
To inform the work of the Task Force, each discipline reviewed its respective curriculum guidelines and standards to assess their consistency with the preliminary framework for prevention and health promotion. The two groups representing nursing, the AACN and the NONPF, cross-referenced the framework with the standards for baccalaureate and graduate nursing education. The Essentials of Baccalaureate Education for Professional Nursing Practice (Essentials of Baccalaureate Education) (AACN, 1998) provides a framework for baccalaureate nursing education. Health promotion and disease prevention, one of the core knowledge areas, is a major component of baccalaureate nursing education. Additional core competencies related to clinical prevention and population health are integrated throughout the document. By cross-referencing the core competencies included in the Essentials of Baccalaureate Education with the content areas delineated in the bprevention and health promotionQ framework, consistencies, weaknesses, and gaps were identified. All major content areas were included in the Essentials of Baccalaureate
Education; however, emphasis and terminology did vary across documents. The focus on epidemiology and policy were two areas with less emphasis in the baccalaureate curriculum guidelines. A similar comparison was made between the competencies and content delineated in the Essentials of Master’s Education for Advanced Practice Nursing (Essentials of Master’s Education) (AACN, 1996) and the prevention and health promotion framework. Health promotion and disease prevention is also a major component of master’s education. Core competencies related to clinical prevention and population health were found in greater depth in the Essentials of Master’s Education as compared to the Essentials of Baccalaureate Education. Specifically, there was an increased emphasis on clinical prevention concepts, research, epidemiology, policy, organization, and financing of health care identified in the core content for master’s education. The comparison of baccalaureate and master’s degree curriculum guidelines confirmed that almost all areas of health prevention and disease prevention are included within nursing education. However, increased emphases and new contexts in which the content may be presented were identified, which would better prepare future nursing practitioners to address the health promotion and disease prevention needs of the population. A major responsibility of the nurse practitioner (NP) role historically has been health promotion. The NONPF Domains and Core Competencies of Nurse Practitioner Practice has provided the curriculum framework for NP education since the first release in 1995 (and subsequent editions in 2000 and 2002), and the health promotion/disease prevention emphasis of the NP role is reflected throughout the core competencies. In preparation for the initial Task Force meeting, NONPF (2002) reviewed the domains and core competencies and identified over 70 competencies that describe in general the prevention and health promotion emphasis of the role. The core competencies include a section on bHealth Promotion, Protection, and Disease PreventionQ in Domain 1: Management of Patient Health/Illness Status (NONPF, 2002). While working to develop the NP primary care specialty competencies in five areas, a national, multiorganizational panel renamed this domain for the specialty competencies to reflect more fully the health promotion and prevention aspect of the NP role: Health Promotion, Health Protection, Disease Prevention, and Treatment. The primary care specialty competencies (NONPF &
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AACN, 2002) elaborate on the core competencies and highlight significant common areas of focus for health promotion, protection, and disease or injury prevention that need emphasis in the primary care NP curriculum, including abuse, violence, substance use, and mental health issues. NONPF mapped the NP core competencies within the 4 components and 19 domains of the framework. NONPF found that despite some variances in terminology, many of the related competencies and domains were congruent with the components and domains of the framework. Two domains that did not have clearly corresponding NP core competencies are immunizations and chemoprevention under the clinical preventive services— health promotion component; however, some competencies within the specialty areas of NP preparation do fall under these domains. NONPF concluded that although the emphasis of some of the domains might differ between NPs and other disciplines, the framework in general could be applicable to NP education. One example of this variation in emphasis or focus is chemoprophylaxis, which is covered in the NP competencies under borders and administers medications.Q
include general information and principles of immunizations, whereas, the education of NPs working with children and their families in a communitybased practice will have greater depth and emphasis on immunizations than that found in programs preparing occupational health NPs. However, all nursing programs will include information and principles of immunizations relevant to their scope of practice and population served. I. Evidence Base for Practice 1. Epidemiology and Biostatistics
For example: ! Rates of disease (e.g., incidence, prevalence,
case-fatality) ! Types of data (e.g., nominal, continuous,
qualitative) ! Statistical concepts (e.g., estimation [relative
! !
Clinical Prevention and Population Health Curriculum Framework for Health Professions
The Clinical Prevention and Population Health Curriculum Framework for Health Professions presents a set of 4 components (evidence base for practice, clinical preventive services, health systems/ health policy, and community aspects of practice) and 19 domains for organizing and implementing curriculum for the health professions. The four broad components have numbered domains within each, and the examples cited reflect content for individual and population-oriented prevention and health promotion. Each health profession is expected to determine the depth and context of each content area of the curriculum for its educational programs. However, in addition to providing a consistent framework for health prevention and population-focused curricula across health professions, the framework will facilitate communications within and among disciplines. For nursing, the framework reflects the cumulative educational preparation as a nurse. The depth of content in each of the four components will vary from entry through advanced nursing education and according to the area of practice and specialization. For example, entry-level nursing education will
!
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! !
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risk/odds ratio and number-needed-to-treat], statistical significance/confidence intervals, adjustment for confounding variables, causation) 2. Methods for Evaluating Health Research Literature For example: Study designs (e.g., surveys, observational studies, randomized clinical trials) Quality measures (e.g., validity, accuracy, reproducibility, biases) Sampling and statistical power 3. Outcome Measurement, Including Quality and Costs For example: Measures of mortality, e.g., infant mortality rates, life expectancy Measures that include quality of life/utility (e.g., QALYs, DALE) Measures that include cost (e.g., cost-effectiveness, incremental cost-effectiveness) Measures of quality of health care (e.g., HEDIS) 4. Health Surveillance For example: Vital statistics/legal documents (e.g., birth certificates, death certificates) Disease surveillance (e.g., passive surveillance [reportable disease], active surveillance for epidemics and bioterrorism) Biological, social, economic, geographic, and behavioral risk factors 5. Determinants of Health For example: Burden of illness (e.g., distribution of morbidity and mortality by age, sex, race, socioeconomic status, and geography)
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! Contributors to morbidity and mortality
(e.g., genetic, behavioral, socioeconomic, environmental, health care [access and quality]) II. Clinical Preventive Services—Health Promotion 1. Screening For example: ! Approaches to testing and screening (e.g., range of normal, sensitivity, specificity, predictive value) ! Criteria for successful screening (e.g., effectiveness, safety, cost, patient acceptance) ! Evidence-based recommendations 2. Counseling For example: ! Approaches to culturally appropriate behavioral change (e.g., education, motivation, obligation) ! Clinician–patient communication (e.g., patient participation in decision making, informed consent, risk communication) ! Criteria for successful counseling (e.g., effectiveness, safety, cost, patient acceptance) ! Evidence-based recommendations 3. Immunization For example: ! Approaches to vaccination (e.g., live vs. dead vaccine, pre- vs. postexposure, boosters, target population, population-based immunity) ! Criteria for successful immunization (e.g., effectiveness, benefits and harm, cost, patient acceptance) ! Evidence-based recommendations 4. Chemoprevention For example: ! Approaches to chemoprevention (e.g., prevs. postexposure, time limited vs. long term) ! Criteria for successful chemoprevention (e.g., effectiveness, benefits and harm, cost, patient acceptance) ! Evidence-based recommendations III. Health Systems and Health Policy 1. Organization of Clinical and Public Health Systems For example: ! Clinical health services (e.g., continuum of care—hospital, ambulatory, home, long-term care) ! Public health responsibilities (e.g., public health functions [IOM]; 10 essential services of public health) ! Relationships between clinical practice and public health
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2. Health Services Financing
For example: ! Clinical services coverage and reimbursement
(e.g., Medicare, Medicaid, employment based, the uninsured) ! Methods of financing of health-care institution (e.g., hospitals, long-term care, community health centers) ! Financing of public health services ! Other models (e.g., international comparisons) 3. Health Workforce For example: ! Methods of regulation of professions and health care (e.g., certification, licensure, institutional accreditation) ! Discipline-specific history, philosophy, roles, and responsibilities ! Racial/ethnic workplace composition, including underrepresented minorities ! Relations of discipline to other health professionals ! Legal and ethical responsibilities of healthcare professionals (e.g., malpractice, healthcare information privacy, confidentiality) 4. Health Policy Process For example: ! Process of health policy making (e.g., local, state, federal governments) ! Methods for participation in the policy process (e.g., advocacy, advisory processes) ! Impact of policies on health care and health outcomes, including impacts on vulnerable populations IV. Community Aspects of Practice 1. Communicating and Sharing Health Information with the Public For example: ! Methods of assessing community needs/ strengths and options for intervention (e.g., community-oriented primary care) ! Media communications (e.g., strategies of using mass media, risk communication) ! Evaluation of health information (e.g., websites, mass media, patient information, including literacy level and cultural sensitivity) 2. Environmental Health For example: ! Sources, media, and routes of exposure to environmental contaminants (e.g., air, water, food) ! Environmental health risk assessment and risk management (e.g., genetic, prenatal) ! Environmental disease prevention focusing on susceptible populations
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3. Occupational Health ! ! !
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For example: Risks from employment-based exposures Methods for control of occupational exposures Exposure and prevention in health-care settings 4. Global Health Issues For example: Roles of international organizations Disease and population patterns in other countries (e.g., burden of disease, population growth, health, development) Effects of globalization on health (e.g., emerging and reemerging diseases/conditions) 5. Cultural Dimensions of Practice For example: Cultural influences on clinicians’ delivery of health services Cultural influences on individuals and communities (e.g., health status, health services, health beliefs) Culturally competent health care 6. Community Services For example: Methods of facilitating access to and partnerships for health care Evidence-based recommendations for community preventive services Public health preparedness Next Steps of the Task Force
The implementation and dissemination of the Clinical Prevention and Population Health Curriculum Framework will be the responsibility of the Healthy People Curriculum Task Force and each participating profession. Implementation plans of the Task Force include a number of activities, several of which have been accomplished: seeking endorsements from each participating profession, publishing an article accompanied by several commentaries on the framework and the work of the Task Force (Allan et al., 2004; Carey & Roper, 2004; Carmona, 2004; Riegelman, Evans, & Garr, 2004); posting the framework and reports of Task Force activities on the Task Force Web site, http://www.atpm.org/taskforce/ HPC_Taskforce.html, developing an evaluation plan for the adoption of the framework content in the curricula of each discipline; and the development of an on-line Clinical Prevention and Population Health Resource Center (Resource Center) (Riegelman et al., 2004). The Resource Center will serve as a clearinghouse for educational materials and resources relevant
to the teaching of clinical prevention and population health. The Task Force website will provide the medium for the initial phase of the Resource Center. Funding to further the development of the Center is being sought. Next Steps for Nursing
By summer 2004, the Board of Directors of AACN and NONPF endorsed the Clinical Prevention and Population Health Framework. Both organizations are currently developing ways to disseminate and implement the framework, including widespread distribution to their members the Task Force (2004) article and related commentaries. Copies of the article and framework have been broadly disseminated to baccalaureate and graduate nursing schools and NP faculties. In addition, the AACN and NONPF Task Force representatives agreed to seek publication of the framework in a discipline-specific journal that would reach the nursing community at large. Beyond dissemination, the next charge for AACN and NONPF is to work with their respective memberships on implementation. Ways to effectively integrate clinical prevention and population health content throughout nursing education curricula at all levels are needed. Increasing awareness and emphasis is one primary approach. Investigation of current curriculum guidelines is a second approach. Through a series of motions in spring 2004, the AACN Board of Directors reconfirmed its commitment to baccalaureate nursing education as the basic nursing education for professional nursing practice. As part of this commitment, AACN is pursuing ways of strengthening and supporting baccalaureate nursing education and the assessment of the baccalaureate competencies, including those related to health promotion delineated in the Essentials of Baccalaureate Education (AACN, 1998). In other initiatives that address the future of nursing education, AACN is committed to seeking ways to integrate the elements of the Clinical Prevention and Population Health Curriculum Framework. These new initiatives include the pilot project to implement the Clinical Nurse Leader role (AACN, 2004a) and the implementation of the Position Statement on Doctor of Nursing Practice (AACN, 2004b). The Clinical Nurse Leader draft Curriculum Framework (AACN, 2004c) incorporates the Clinical Prevention and Population Framework. The newly created AACN task force to develop the Essentials for the Doctor of Nursing Practice will be
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asked to review and consider the Clinical Prevention and Population Framework as appropriate for inclusion in the highest level of nursing practice. Within NP education, the challenge is how to translate the generic, prevention, and population health framework with the current framework of the seven domains and core competencies for NPs. The domains and competencies of NP practice were derived from research exploring the clinical practice of experienced nurses by Dr. Karen Brykczynski (1989), who built on the definitions developed by Dr. Patricia Benner (1984). NONPF has updated the competencies to reflect current practice and added a domain to capture cultural competence and spirituality. As described earlier, many of the NP competencies also can fall within the domains delineated for the generic prevention and population health framework. The framework may provide guidance to NP programs in curriculum design, and perhaps, over time, future iterations of the NP domains and core competencies may reflect more apparently its domains. An upcoming revision in 2005 of Advanced Nursing Practice: Curriculum Guidelines and Program Standards for Nurse Practitioner Education (1995) will include discussion and inclusion of the framework to reaffirm the emphasis of clinical prevention and population health in the NP role. Further discussion is needed about the depth and emphasis of content areas, such as population health, within the NP curriculum. Nursing education at both the baccalaureate and graduate levels must be examined and strengthened to ensure that future practitioners are prepared to address the health promotion and disease and injury prevention needs of the population. Aside from the work on dissemination at the AACN and NONPF organizational levels, the nursing profession at large can help to support the implementation efforts. To track the progress toward achievement of the Healthy People 2010 goals, the U.S. Department of Health and Human Services is collecting baseline, midcourse, and end data to measure the success of selected goals. For Objective 1.7, the focus of the
Task Force, the various health professions are contributing data relative to the implementation of the generic framework in curricula. Data obtained through the AACN Women’s Health curriculum survey conducted in 1999 have been shared with DHHS. It is hoped that reemphasis on the health promotion and disease prevention content and competencies nationally will increase the inclusion and refocus attention on the relevance of this content for all nurses. NONPF and AACN conducted a collaborative NP program curriculum survey in 2000 –2001 in which some relevant baseline data were collected. The joint data task force will review the survey instruments for possible expansion to collect data more specific to the framework. The next NP curriculum survey is projected for 2006.
Opportunities for the Future
Health promotion and disease prevention may offer the greatest potential for decreasing morbidity and mortality and improving quality of life in the United States (Whitlock et al., 2002). The Clinical Prevention and Population Health Curriculum Framework provides a structure for increasing the health promotion and disease prevention content in the educational programs of health professionals. The process used by the Task Force to develop the framework models successful interprofessional work The publication and wide distribution of the framework among all Task Force member disciplines provides an opportunity and challenge for these disciplines to work together to implement the framework in their curricula and create interprofessional courses based upon the components and domain in the framework. The curricula and courses developed through these processes will promote consistency in the education of future health professionals and guide evaluation of educational programs to ensure the necessary competencies.
References Allan, J., Barwick, T., Cashman, S., Cawley, J., Day, C., Douglass, C., et al. (2004). Clinical prevention and population health curriculum framework for health professions. American Journal of Preventive Medicine, 27, 471–476. American Association of Colleges of Nursing. (1996). Essentials of master’s education for advanced practice nursing. Washington, DC: Author.
American Association of Colleges of Nursing. (1998). Essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Association of Colleges of Nursing. (2004a). Working paper on the role of the clinical nurse leader. Retrieved August 30, 2005, from http://www.aacn. nche.edu/Publications/docs/CNL6-04.DOC.
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American Association of Colleges of Nursing. (2004b). Position statement on the practice doctorate in nursing. Retrieved August 30, 2005, from http://www.aacn. nche.edu/DNP/pdf/DNP.pdf. American Association of Colleges of Nursing. (2004c). Preparing graduates for practice as a clinical nurse leader draft curriculum framework. Retrieved August 30, 2005, from http://www.aacn.nche.edu/CNL/pdf/DraftCurriculumFramework12-04.pdf. Benner, P. E. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Brykczynski, K. A. (1989). An interpretive study describing the clinical judgement of nurse practitioners. Scholarly Inquiry for Nursing Practice: An Interpretive Journal, 3, 113 –120. Carey, T., & Roper, W. (2004). Healthy people curriculum task force: A commentary by the Surgeon General. American Journal of Preventive Medicine, 27, 484 – 485. Carmona, R. (2004). Healthy people curriculum task force: A commentary by the Surgeon General. American Journal of Preventive Medicine, 27, 482. Clancy, C. (2003). Clinical preventive services for older Americans: A report to Congress from the Agency for HealthCare Research and Quality. Rockville, MD: Agency for Healthcare Research and Quality. Cuff, P. A., & Vanselow, N. (2004). Improving medical education: Enhancing the behavioral and social science content of medical school curricula. Washington, DC: National Academy Press. Greiner, A. C., & Knebel, E. (2003). Health professional education: A bridge to quality. Washington, DC: National Academies Press. Hernandez, L. (2003). Who will keep the public health?: Educating public health professionals for the 21st century. Washington, DC: National Academies Press. Hinshaw, A. (2000). Nursing knowledge for the 21st century: Opportunities and challenges. Journal of Nursing Scholarship, 32, 117– 123. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
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McGinnis, M., & Foege, W. (1993). Actual causes of death in the United States. JAMA, 270, 2207 –2212. Melynk, B., & Fineout-Overholt, E. (2005). Evidencebased practice in nursing and health care: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins. National Organization of Nurse Practitioner Faculties. (1995). Advanced nursing practice: Curriculum guidelines and program standards for nurse practitioner education. Washington, DC: Author. National Organization of Nurse Practitioner Faculties. (2000, 2002). Domains and core competencies of nurse practitioner practice. Washington, DC: Author. National Organization of Nurse Practitioner Faculties, & American Association of Colleges of Nursing. (2002). Nurse practitioner primary care competencies in specialty areas: Gerontological Nurse Practitioner competencies. Rockville, MD: DHHS, Health Resources and Services Administration, BHPr. National Organization of Nurse Practitioner Faculties. (2005). Advanced Nursing Practice: Curriculum guidelines and program standards for nurse practitioner education. Washington, DC: Author. Riegelman, R., Evans, C., & Garr, D. (2004). Healthy people curriculum task force: A commentary by the Surgeon General. American Journal of Preventive Medicine, 27, 481. U.S. Department of Health and Human Services. (2000). Women’s Health in the Baccalaureate Nursing school Curriculum Report of a Survey and Recommendations. (BHPR-98-0584(P))Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2003). Healthy people 2010. Washington, DC: U.S. Government Printing Office. U.S. Preventive Services Task Force. (2002). Guide to clinical preventive services, 2 vols. Washington, DC: Agency for Healthcare Research and Quality. Whitlock, E., Orleans, T., Pender, N., & Allan, J. (2002). Evaluating primary care behavioral counseling interventions: An evidence-based approach. American Journal of Health Promotion, 22, 267– 284.
*Dean and Professor, University of Maryland School of Nursing, Baltimore, MD. yDirector of Education Policy, American Association of Colleges of Nursing, Washington, DC. zProfessor, School of Nursing, Oregon Health and Science University, Portland, OR. §Executive Director, National Organization of Nurse Practitioner Faculties, Washington, DC. OProfessor, School of Nursing, Indiana University, Bloomington, IN. Address correspondence and reprint requests to Dr. Allan: University of Maryland School of Nursing, 655 West Lombard Street, Room 505, Baltimore, MD 21201. E-mail: [email protected] 8755-7223/$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2005.07.006
focused health promotion and prevention efforts. The role of nursing in developing the Curriculum Framework, and the tailoring and implementation of the Curriculum Framework for undergraduate and graduate programs in nursing is discussed. (Index words: Health promotion/prevention curriculum; Healthy people 2010; Inter-professional prevention and population health curriculum) J Prof Nurs 21:259-267, 2005. A 2005 Elsevier Inc. All rights reserved.
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EALTH PROMOTION AND disease prevention provide a cornerstone for the discipline of nursing. Traditionally, health promotion and disease prevention content have been included in both undergraduate and graduate nursing curricula but to what degree and in what context? More importantly, to what extent is the health promotion and prevention content translated into practice? Have we assumed that this content presented rather than evaluated the performance of health promotion and disease prevention competencies of our graduates? Has the content on health promotion and disease prevention kept pace with the growing evidence base for this content? In a survey of entry-level baccalaureate nursing education programs (DHHS, 2000), the American Association of Colleges of Nursing (AACN) found that only 72% of responding schools (N = 334) indicated that the Healthy People 2000 objectives were used in the curriculum planning or review process. As pressure to expand content in the nursing curriculum continues to grow, we must ensure that health promotion and disease prevention remain fundamental components of the nursing curriculum.
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These areas are foundational to nursing practice and were instrumental beliefs upon which Florence Nightingale founded the profession. Not only is nursing rooted in the tradition of health promotion and disease prevention; we have contributed greatly to the health of the nation and the world by mounting immunization, nutrition, and numerous other programs that have benefited people throughout the country and throughout the world. What we put into practice is critical in achieving health for all. However, effective health promotion and disease prevention requires interdisciplinary cooperation. The Institute of Medicine (IOM, 2001) identified interdisciplinary practice as one of five critical competencies for all health professionals for the 21st century. The interprofessional Healthy People Curriculum Task Force, with nursing as a major participant, has created the Clinical Prevention and Population Health Curriculum Framework for Health Professions (Allan et al., 2004). The work of this task force is an important landmark of cooperation to achieve our goal of health for all Americans and the world. The Clinical Prevention and Population Health Curriculum Framework for Health Professions, along with recommendations for implementing the framework within undergraduate and graduate nursing curricula, is presented as a first step toward this common goal.
Background
Healthy People 2010 set two major goals for the United States: (1) to increase quality and quantity of years of healthy life and (2) to eliminate health disparities among segments of the population (U.S. Department of Health and Human Services, 2003). These goals challenge health systems, health professionals, and policy makers to address changes in education and practice that are needed to meet these goals. Such changes imply that health systems must create a stronger focus on primary care and prevention; educators need to place greater emphasis on prevention and population health in the education of future practitioners, and policy makers must develop polices to support the institutionalization of preventive services. A focus on health promotion, prevention and population health offers the greatest potential to reduce many of the leading causes of death and disability and improve the quality of life across diverse populations (Clancy, 2003; Whitlock,
Orleans, Pender, & Allan, 2002). Over half of premature deaths in the United States are caused by lifestyle-related behaviors, such as smoking, inactivity, alcohol misuse, risky sexual behaviors, and poor dietary habits (McGinnis & Foege, 1993). To emphasize the importance of addressing these lifestyle behaviors, Healthy People 2010 (U.S. Department of Health and Human Services, 2003) identified five lifestyle behaviors (inactivity, tobacco use, unhealthy eating patterns, substance misuse, and risky sexual practices) as health indicators by which to track progress in improving health. Policy makers have over the last decade expanded the coverage for preventive care under Medicare and Medicaid (Clancy, 2003) and other third-party payers. Despite these goals and policy changes, the focus on prevention and population health continues to lag behind the strong emphasis on a disease-based, acute care approach to health care. Furthermore, the competencies needed to assist people in adopting healthy lifestyles and making lifelong changes in health behavior require more than a grasp of the benefits. The health professional also must be skilled in communication, education, and evaluation of behavior. The education of future health professionals is critical to efforts to change health-care and health systems (Allan et al., 2004). Health promotion, disease prevention, and population health have long been viewed as core components of the nursing role (AACN, 1996, 1998; National Organization of Nurse Practitioner Faculties [NONPF], 1995, 2005). Concepts in support of this role are found in nursing curricula of baccalaureate and master’s degree programs. Despite the long-standing commitment to these concepts, nursing lacks a structured, comprehensive curriculum integrating concepts of health promotion, disease prevention, and population health across programs. The time may be right for a new and more structured approach. In addition to the Healthy People 2010 goals, the convincing links of lifestyle behaviors to leading causes of death, and policy changes in Medicare and Medicaid, several recent IOM reports (Greiner & Knebel, 2003; Hernandez, 2003) have supported a renewed attention to health promotion, disease prevention, and population health in the education of nurses. Specifically, these landmark reports have focused attention on the need to change the way we educate nurses. The IOM identified (1) evidencebased practice as a core competency of all future health professionals (Greiner & Knebel, 2003) and (2) advocated for a more population-focused and
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ecological approach to the conditions and diseases affecting the American public (Hernandez, 2003). The nursing profession is increasing its focus on developing curricula and practices that are evidencebased (Hinshaw, 2000; Melynk & Fineout-Overholt, 2005). Competencies include the ability to use the evidence base to improve the quality of health care. As the evidence base for health promotion and disease prevention expands and changes, future health professionals must be able to evaluate the evidence and design care that integrates this knowledge and skill. Competency in delivery of health promotion and disease prevention care cannot be left to chance but must be part of the on-going evaluation of nursing education and practice. Healthy People Curriculum Task Force
The Association of Teachers of Preventive Medicine (ATPM) had a goal of developing a curriculum framework in prevention content that could be used by various health professions. In the 1980s, the ATPM formed a working group to develop the Inventory of Knowledge and Skills Relating to Disease Prevention and Health Promotion. This beginning work did not offer the breadth of scope envisioned by the ATPM but provided a foundation for addressing the Healthy People 2010 Objective I-7, to bincrease the proportion of schools of medicine, schools of nursing and health professionals training schools whose basic curriculum for health care includes the core competencies in health promotion and disease preventionQ (U.S. Department of Health and Human Services, 2003). In 2000, the ATPM collaborated with the Association of Academic Health Centers (AAHC) to convene a multidisciplinary task force to develop a framework for prevention education. The ATPM and the AAHC invited seven clinical health education professional organizations to participate on the Healthy People Curriculum Task Force (Task Force). Each of the following organizations agreed to participate and to have a senior academic member and the executive director or designee serve on the Task Force: allopathic medicine: Association of American Medical Colleges; dentistry: American Dental Education Association; nursing: AACN and NONPF; osteopathic medicine: American Association of Colleges of Osteopathic Medicine;
pharmacy: American Association of Colleges of Pharmacy; physician assistants: Association of Physician Assistant Programs. ATPM and AAHC also expanded the Task Force to include representation from the Student Health Alliance, the Association of Schools of Public Health, and Community–Campus Partnership for Health. The interprofessional composition of the Task Force and the collaborative process facilitated by the ATPM and the AAHC provided a structure extremely conducive to addressing Healthy People 2010 Objective 1.7 (U.S. Department of Health and Human Services, 2003). The significant outcome of the Task Force work to date is The Clinical Prevention and Population Health Curriculum Framework for Health Professions, a consensus framework that has achieved endorsement from all seven represented health professions (Allan et al., 2004). The framework provides guidance to faculty, students, and practitioners in recognizing the priorities for clinical prevention and population health education and practice within their disciplines. Framework Development
The Task Force followed an ambitious time schedule to develop the generic framework. At its first organizing meeting in January 2003, the Task Force assessed the extent of health promotion and disease prevention content within educational programs of each health profession. This discussion identified common foci and variations, leading to the initial mapping of the framework and selection of terminology. Over the next 6 months, the Task Force met twice more and communicated electronically to develop the framework. To ensure that the framework remained generic to accommodate all disciplines, the Task Force decided to provide a layered structure to the framework, which included (1) broad components for structuring curriculum, (2) domains of content areas, and (3) specific examples of content and materials that might be included in a curriculum. By the end of summer 2003, the Task Force had completed a draft of the framework. The second phase of the framework development included seeking broad input and support from members of the health professions represented on the Task Force. During fall 2003, ATPM coordinated a web-based review process to solicit feedback on the relevance and comprehensiveness of the components
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and domains. The organizations represented on the Task Force, including the two nursing organizations, assisted the review process by engaging in and promoting the review process among members and generating organizational-level discussion about the framework. After incorporating relevant comments received from external reviewers, the Task Force reached unanimous agreement on the framework in spring 2004. Early in its development, the framework assumed a working title of Health Promotion–Disease Prevention, consistent with the wording in the Healthy People 2010 objective. After several discussions about the title, the Task Force concluded that the framework also should reflect consistency with terminology incorporated in the U.S. Preventive Services Task Force’s recommendations (2002), as well as the IOM reports related to public health (Cuff & Vanselow, 2004; Hernandez, 2003). Given the emphasis in these documents on bclinical preventionQ as well as bpopulation healthQ and the intent for health professionals to address both individual- and population-oriented preventive efforts, the Task Force agreed on the title Clinical Prevention and Population Health for the framework. The Role of Nursing in Developing the Framework
To inform the work of the Task Force, each discipline reviewed its respective curriculum guidelines and standards to assess their consistency with the preliminary framework for prevention and health promotion. The two groups representing nursing, the AACN and the NONPF, cross-referenced the framework with the standards for baccalaureate and graduate nursing education. The Essentials of Baccalaureate Education for Professional Nursing Practice (Essentials of Baccalaureate Education) (AACN, 1998) provides a framework for baccalaureate nursing education. Health promotion and disease prevention, one of the core knowledge areas, is a major component of baccalaureate nursing education. Additional core competencies related to clinical prevention and population health are integrated throughout the document. By cross-referencing the core competencies included in the Essentials of Baccalaureate Education with the content areas delineated in the bprevention and health promotionQ framework, consistencies, weaknesses, and gaps were identified. All major content areas were included in the Essentials of Baccalaureate
Education; however, emphasis and terminology did vary across documents. The focus on epidemiology and policy were two areas with less emphasis in the baccalaureate curriculum guidelines. A similar comparison was made between the competencies and content delineated in the Essentials of Master’s Education for Advanced Practice Nursing (Essentials of Master’s Education) (AACN, 1996) and the prevention and health promotion framework. Health promotion and disease prevention is also a major component of master’s education. Core competencies related to clinical prevention and population health were found in greater depth in the Essentials of Master’s Education as compared to the Essentials of Baccalaureate Education. Specifically, there was an increased emphasis on clinical prevention concepts, research, epidemiology, policy, organization, and financing of health care identified in the core content for master’s education. The comparison of baccalaureate and master’s degree curriculum guidelines confirmed that almost all areas of health prevention and disease prevention are included within nursing education. However, increased emphases and new contexts in which the content may be presented were identified, which would better prepare future nursing practitioners to address the health promotion and disease prevention needs of the population. A major responsibility of the nurse practitioner (NP) role historically has been health promotion. The NONPF Domains and Core Competencies of Nurse Practitioner Practice has provided the curriculum framework for NP education since the first release in 1995 (and subsequent editions in 2000 and 2002), and the health promotion/disease prevention emphasis of the NP role is reflected throughout the core competencies. In preparation for the initial Task Force meeting, NONPF (2002) reviewed the domains and core competencies and identified over 70 competencies that describe in general the prevention and health promotion emphasis of the role. The core competencies include a section on bHealth Promotion, Protection, and Disease PreventionQ in Domain 1: Management of Patient Health/Illness Status (NONPF, 2002). While working to develop the NP primary care specialty competencies in five areas, a national, multiorganizational panel renamed this domain for the specialty competencies to reflect more fully the health promotion and prevention aspect of the NP role: Health Promotion, Health Protection, Disease Prevention, and Treatment. The primary care specialty competencies (NONPF &
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AACN, 2002) elaborate on the core competencies and highlight significant common areas of focus for health promotion, protection, and disease or injury prevention that need emphasis in the primary care NP curriculum, including abuse, violence, substance use, and mental health issues. NONPF mapped the NP core competencies within the 4 components and 19 domains of the framework. NONPF found that despite some variances in terminology, many of the related competencies and domains were congruent with the components and domains of the framework. Two domains that did not have clearly corresponding NP core competencies are immunizations and chemoprevention under the clinical preventive services— health promotion component; however, some competencies within the specialty areas of NP preparation do fall under these domains. NONPF concluded that although the emphasis of some of the domains might differ between NPs and other disciplines, the framework in general could be applicable to NP education. One example of this variation in emphasis or focus is chemoprophylaxis, which is covered in the NP competencies under borders and administers medications.Q
include general information and principles of immunizations, whereas, the education of NPs working with children and their families in a communitybased practice will have greater depth and emphasis on immunizations than that found in programs preparing occupational health NPs. However, all nursing programs will include information and principles of immunizations relevant to their scope of practice and population served. I. Evidence Base for Practice 1. Epidemiology and Biostatistics
For example: ! Rates of disease (e.g., incidence, prevalence,
case-fatality) ! Types of data (e.g., nominal, continuous,
qualitative) ! Statistical concepts (e.g., estimation [relative
! !
Clinical Prevention and Population Health Curriculum Framework for Health Professions
The Clinical Prevention and Population Health Curriculum Framework for Health Professions presents a set of 4 components (evidence base for practice, clinical preventive services, health systems/ health policy, and community aspects of practice) and 19 domains for organizing and implementing curriculum for the health professions. The four broad components have numbered domains within each, and the examples cited reflect content for individual and population-oriented prevention and health promotion. Each health profession is expected to determine the depth and context of each content area of the curriculum for its educational programs. However, in addition to providing a consistent framework for health prevention and population-focused curricula across health professions, the framework will facilitate communications within and among disciplines. For nursing, the framework reflects the cumulative educational preparation as a nurse. The depth of content in each of the four components will vary from entry through advanced nursing education and according to the area of practice and specialization. For example, entry-level nursing education will
!
! ! ! !
! !
!
!
risk/odds ratio and number-needed-to-treat], statistical significance/confidence intervals, adjustment for confounding variables, causation) 2. Methods for Evaluating Health Research Literature For example: Study designs (e.g., surveys, observational studies, randomized clinical trials) Quality measures (e.g., validity, accuracy, reproducibility, biases) Sampling and statistical power 3. Outcome Measurement, Including Quality and Costs For example: Measures of mortality, e.g., infant mortality rates, life expectancy Measures that include quality of life/utility (e.g., QALYs, DALE) Measures that include cost (e.g., cost-effectiveness, incremental cost-effectiveness) Measures of quality of health care (e.g., HEDIS) 4. Health Surveillance For example: Vital statistics/legal documents (e.g., birth certificates, death certificates) Disease surveillance (e.g., passive surveillance [reportable disease], active surveillance for epidemics and bioterrorism) Biological, social, economic, geographic, and behavioral risk factors 5. Determinants of Health For example: Burden of illness (e.g., distribution of morbidity and mortality by age, sex, race, socioeconomic status, and geography)
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! Contributors to morbidity and mortality
(e.g., genetic, behavioral, socioeconomic, environmental, health care [access and quality]) II. Clinical Preventive Services—Health Promotion 1. Screening For example: ! Approaches to testing and screening (e.g., range of normal, sensitivity, specificity, predictive value) ! Criteria for successful screening (e.g., effectiveness, safety, cost, patient acceptance) ! Evidence-based recommendations 2. Counseling For example: ! Approaches to culturally appropriate behavioral change (e.g., education, motivation, obligation) ! Clinician–patient communication (e.g., patient participation in decision making, informed consent, risk communication) ! Criteria for successful counseling (e.g., effectiveness, safety, cost, patient acceptance) ! Evidence-based recommendations 3. Immunization For example: ! Approaches to vaccination (e.g., live vs. dead vaccine, pre- vs. postexposure, boosters, target population, population-based immunity) ! Criteria for successful immunization (e.g., effectiveness, benefits and harm, cost, patient acceptance) ! Evidence-based recommendations 4. Chemoprevention For example: ! Approaches to chemoprevention (e.g., prevs. postexposure, time limited vs. long term) ! Criteria for successful chemoprevention (e.g., effectiveness, benefits and harm, cost, patient acceptance) ! Evidence-based recommendations III. Health Systems and Health Policy 1. Organization of Clinical and Public Health Systems For example: ! Clinical health services (e.g., continuum of care—hospital, ambulatory, home, long-term care) ! Public health responsibilities (e.g., public health functions [IOM]; 10 essential services of public health) ! Relationships between clinical practice and public health
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2. Health Services Financing
For example: ! Clinical services coverage and reimbursement
(e.g., Medicare, Medicaid, employment based, the uninsured) ! Methods of financing of health-care institution (e.g., hospitals, long-term care, community health centers) ! Financing of public health services ! Other models (e.g., international comparisons) 3. Health Workforce For example: ! Methods of regulation of professions and health care (e.g., certification, licensure, institutional accreditation) ! Discipline-specific history, philosophy, roles, and responsibilities ! Racial/ethnic workplace composition, including underrepresented minorities ! Relations of discipline to other health professionals ! Legal and ethical responsibilities of healthcare professionals (e.g., malpractice, healthcare information privacy, confidentiality) 4. Health Policy Process For example: ! Process of health policy making (e.g., local, state, federal governments) ! Methods for participation in the policy process (e.g., advocacy, advisory processes) ! Impact of policies on health care and health outcomes, including impacts on vulnerable populations IV. Community Aspects of Practice 1. Communicating and Sharing Health Information with the Public For example: ! Methods of assessing community needs/ strengths and options for intervention (e.g., community-oriented primary care) ! Media communications (e.g., strategies of using mass media, risk communication) ! Evaluation of health information (e.g., websites, mass media, patient information, including literacy level and cultural sensitivity) 2. Environmental Health For example: ! Sources, media, and routes of exposure to environmental contaminants (e.g., air, water, food) ! Environmental health risk assessment and risk management (e.g., genetic, prenatal) ! Environmental disease prevention focusing on susceptible populations
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3. Occupational Health ! ! !
! !
!
! !
!
! ! !
For example: Risks from employment-based exposures Methods for control of occupational exposures Exposure and prevention in health-care settings 4. Global Health Issues For example: Roles of international organizations Disease and population patterns in other countries (e.g., burden of disease, population growth, health, development) Effects of globalization on health (e.g., emerging and reemerging diseases/conditions) 5. Cultural Dimensions of Practice For example: Cultural influences on clinicians’ delivery of health services Cultural influences on individuals and communities (e.g., health status, health services, health beliefs) Culturally competent health care 6. Community Services For example: Methods of facilitating access to and partnerships for health care Evidence-based recommendations for community preventive services Public health preparedness Next Steps of the Task Force
The implementation and dissemination of the Clinical Prevention and Population Health Curriculum Framework will be the responsibility of the Healthy People Curriculum Task Force and each participating profession. Implementation plans of the Task Force include a number of activities, several of which have been accomplished: seeking endorsements from each participating profession, publishing an article accompanied by several commentaries on the framework and the work of the Task Force (Allan et al., 2004; Carey & Roper, 2004; Carmona, 2004; Riegelman, Evans, & Garr, 2004); posting the framework and reports of Task Force activities on the Task Force Web site, http://www.atpm.org/taskforce/ HPC_Taskforce.html, developing an evaluation plan for the adoption of the framework content in the curricula of each discipline; and the development of an on-line Clinical Prevention and Population Health Resource Center (Resource Center) (Riegelman et al., 2004). The Resource Center will serve as a clearinghouse for educational materials and resources relevant
to the teaching of clinical prevention and population health. The Task Force website will provide the medium for the initial phase of the Resource Center. Funding to further the development of the Center is being sought. Next Steps for Nursing
By summer 2004, the Board of Directors of AACN and NONPF endorsed the Clinical Prevention and Population Health Framework. Both organizations are currently developing ways to disseminate and implement the framework, including widespread distribution to their members the Task Force (2004) article and related commentaries. Copies of the article and framework have been broadly disseminated to baccalaureate and graduate nursing schools and NP faculties. In addition, the AACN and NONPF Task Force representatives agreed to seek publication of the framework in a discipline-specific journal that would reach the nursing community at large. Beyond dissemination, the next charge for AACN and NONPF is to work with their respective memberships on implementation. Ways to effectively integrate clinical prevention and population health content throughout nursing education curricula at all levels are needed. Increasing awareness and emphasis is one primary approach. Investigation of current curriculum guidelines is a second approach. Through a series of motions in spring 2004, the AACN Board of Directors reconfirmed its commitment to baccalaureate nursing education as the basic nursing education for professional nursing practice. As part of this commitment, AACN is pursuing ways of strengthening and supporting baccalaureate nursing education and the assessment of the baccalaureate competencies, including those related to health promotion delineated in the Essentials of Baccalaureate Education (AACN, 1998). In other initiatives that address the future of nursing education, AACN is committed to seeking ways to integrate the elements of the Clinical Prevention and Population Health Curriculum Framework. These new initiatives include the pilot project to implement the Clinical Nurse Leader role (AACN, 2004a) and the implementation of the Position Statement on Doctor of Nursing Practice (AACN, 2004b). The Clinical Nurse Leader draft Curriculum Framework (AACN, 2004c) incorporates the Clinical Prevention and Population Framework. The newly created AACN task force to develop the Essentials for the Doctor of Nursing Practice will be
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asked to review and consider the Clinical Prevention and Population Framework as appropriate for inclusion in the highest level of nursing practice. Within NP education, the challenge is how to translate the generic, prevention, and population health framework with the current framework of the seven domains and core competencies for NPs. The domains and competencies of NP practice were derived from research exploring the clinical practice of experienced nurses by Dr. Karen Brykczynski (1989), who built on the definitions developed by Dr. Patricia Benner (1984). NONPF has updated the competencies to reflect current practice and added a domain to capture cultural competence and spirituality. As described earlier, many of the NP competencies also can fall within the domains delineated for the generic prevention and population health framework. The framework may provide guidance to NP programs in curriculum design, and perhaps, over time, future iterations of the NP domains and core competencies may reflect more apparently its domains. An upcoming revision in 2005 of Advanced Nursing Practice: Curriculum Guidelines and Program Standards for Nurse Practitioner Education (1995) will include discussion and inclusion of the framework to reaffirm the emphasis of clinical prevention and population health in the NP role. Further discussion is needed about the depth and emphasis of content areas, such as population health, within the NP curriculum. Nursing education at both the baccalaureate and graduate levels must be examined and strengthened to ensure that future practitioners are prepared to address the health promotion and disease and injury prevention needs of the population. Aside from the work on dissemination at the AACN and NONPF organizational levels, the nursing profession at large can help to support the implementation efforts. To track the progress toward achievement of the Healthy People 2010 goals, the U.S. Department of Health and Human Services is collecting baseline, midcourse, and end data to measure the success of selected goals. For Objective 1.7, the focus of the
Task Force, the various health professions are contributing data relative to the implementation of the generic framework in curricula. Data obtained through the AACN Women’s Health curriculum survey conducted in 1999 have been shared with DHHS. It is hoped that reemphasis on the health promotion and disease prevention content and competencies nationally will increase the inclusion and refocus attention on the relevance of this content for all nurses. NONPF and AACN conducted a collaborative NP program curriculum survey in 2000 –2001 in which some relevant baseline data were collected. The joint data task force will review the survey instruments for possible expansion to collect data more specific to the framework. The next NP curriculum survey is projected for 2006.
Opportunities for the Future
Health promotion and disease prevention may offer the greatest potential for decreasing morbidity and mortality and improving quality of life in the United States (Whitlock et al., 2002). The Clinical Prevention and Population Health Curriculum Framework provides a structure for increasing the health promotion and disease prevention content in the educational programs of health professionals. The process used by the Task Force to develop the framework models successful interprofessional work The publication and wide distribution of the framework among all Task Force member disciplines provides an opportunity and challenge for these disciplines to work together to implement the framework in their curricula and create interprofessional courses based upon the components and domain in the framework. The curricula and courses developed through these processes will promote consistency in the education of future health professionals and guide evaluation of educational programs to ensure the necessary competencies.
References Allan, J., Barwick, T., Cashman, S., Cawley, J., Day, C., Douglass, C., et al. (2004). Clinical prevention and population health curriculum framework for health professions. American Journal of Preventive Medicine, 27, 471–476. American Association of Colleges of Nursing. (1996). Essentials of master’s education for advanced practice nursing. Washington, DC: Author.
American Association of Colleges of Nursing. (1998). Essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Association of Colleges of Nursing. (2004a). Working paper on the role of the clinical nurse leader. Retrieved August 30, 2005, from http://www.aacn. nche.edu/Publications/docs/CNL6-04.DOC.
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American Association of Colleges of Nursing. (2004b). Position statement on the practice doctorate in nursing. Retrieved August 30, 2005, from http://www.aacn. nche.edu/DNP/pdf/DNP.pdf. American Association of Colleges of Nursing. (2004c). Preparing graduates for practice as a clinical nurse leader draft curriculum framework. Retrieved August 30, 2005, from http://www.aacn.nche.edu/CNL/pdf/DraftCurriculumFramework12-04.pdf. Benner, P. E. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Brykczynski, K. A. (1989). An interpretive study describing the clinical judgement of nurse practitioners. Scholarly Inquiry for Nursing Practice: An Interpretive Journal, 3, 113 –120. Carey, T., & Roper, W. (2004). Healthy people curriculum task force: A commentary by the Surgeon General. American Journal of Preventive Medicine, 27, 484 – 485. Carmona, R. (2004). Healthy people curriculum task force: A commentary by the Surgeon General. American Journal of Preventive Medicine, 27, 482. Clancy, C. (2003). Clinical preventive services for older Americans: A report to Congress from the Agency for HealthCare Research and Quality. Rockville, MD: Agency for Healthcare Research and Quality. Cuff, P. A., & Vanselow, N. (2004). Improving medical education: Enhancing the behavioral and social science content of medical school curricula. Washington, DC: National Academy Press. Greiner, A. C., & Knebel, E. (2003). Health professional education: A bridge to quality. Washington, DC: National Academies Press. Hernandez, L. (2003). Who will keep the public health?: Educating public health professionals for the 21st century. Washington, DC: National Academies Press. Hinshaw, A. (2000). Nursing knowledge for the 21st century: Opportunities and challenges. Journal of Nursing Scholarship, 32, 117– 123. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
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McGinnis, M., & Foege, W. (1993). Actual causes of death in the United States. JAMA, 270, 2207 –2212. Melynk, B., & Fineout-Overholt, E. (2005). Evidencebased practice in nursing and health care: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins. National Organization of Nurse Practitioner Faculties. (1995). Advanced nursing practice: Curriculum guidelines and program standards for nurse practitioner education. Washington, DC: Author. National Organization of Nurse Practitioner Faculties. (2000, 2002). Domains and core competencies of nurse practitioner practice. Washington, DC: Author. National Organization of Nurse Practitioner Faculties, & American Association of Colleges of Nursing. (2002). Nurse practitioner primary care competencies in specialty areas: Gerontological Nurse Practitioner competencies. Rockville, MD: DHHS, Health Resources and Services Administration, BHPr. National Organization of Nurse Practitioner Faculties. (2005). Advanced Nursing Practice: Curriculum guidelines and program standards for nurse practitioner education. Washington, DC: Author. Riegelman, R., Evans, C., & Garr, D. (2004). Healthy people curriculum task force: A commentary by the Surgeon General. American Journal of Preventive Medicine, 27, 481. U.S. Department of Health and Human Services. (2000). Women’s Health in the Baccalaureate Nursing school Curriculum Report of a Survey and Recommendations. (BHPR-98-0584(P))Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2003). Healthy people 2010. Washington, DC: U.S. Government Printing Office. U.S. Preventive Services Task Force. (2002). Guide to clinical preventive services, 2 vols. Washington, DC: Agency for Healthcare Research and Quality. Whitlock, E., Orleans, T., Pender, N., & Allan, J. (2002). Evaluating primary care behavioral counseling interventions: An evidence-based approach. American Journal of Health Promotion, 22, 267– 284.