- Email: [email protected]
Integrating Preventive Care and Nursing Standardized Terminologies in Nursing Education: A Case Study
INTEGRATING PREVENTIVE CARE AND NURSING STANDARDIZED TERMINOLOGIES IN NURSING EDUCATION: A CASE STUDY LISA BURKHART, PHD, RN,*
AND
SHERYL SOMMER, PHD, RNy
This study investigated the development of a community-focused curriculum integrating primary, secondary, and tertiary prevention and nursing standardized terminologies as an organizing infrastructure. This is a case study of the curriculum redesign of the Marcella Niehoff School of Nursing, Loyola University Chicago. Faculty developed a conceptual framework integrating core concepts into curriculum design, course content, and clinical applications. A coherent curriculum was designed using a community-focused approach; primary, secondary, and tertiary prevention strategies; and standardized terminologies as the organizing infrastructure to teach and apply nursing practice. The curriculum provides a meaningful correlation between the classroom and clinical experience. Students journey with their patients throughout the health care experience, applying nursing concepts using standardized terminologies. Clinical experiences provide students with the opportunity to transfer knowledge to the health experiences of patients in their care. Patient encounters, whether at the primary, secondary, or tertiary level of prevention, are used to assist students in developing critical thinking skills through the use of standardized nursing terminologies. (Index words: Preventive care; Nursing standardized terminologies; Nursing education) J Prof Nurs 23:208–13, 2007. A 2007 Elsevier Inc. All rights reserved.
R
ECENT CHANGES IN both nursing practice and the health care system have required nurse educators to reevaluate how nursing is taught. Historically, nursing has differentiated itself from medicine in that nursing is more concerned with the physical, psychosocial, and spiritual responses to illness, whereas medicine is more interested in treating disease (American Nurses Association [ANA], 2003). Nursing practice has grown beyond that distinction to integrate advocacy and preventive care for individuals, families, and communities (ANA, 2003). Nurse educators have been
*Assistant Professor, Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL. yAssociate Professor & Program Chair, Creighton University, School of Nursing, Omaha, NE. Address correspondence and reprint requests to Dr. Burkhart: Assistant Professor, Marcella Niehoff School of Nursing, Loyola University Chicago, 6525 North Sheridan Road, Chicago, IL 60626. E-mail: [email protected] 8755-7223/$ - see front matter 208 doi:10.1016/j.profnurs.2007.01.002
challenged to reflect this expanded community-focused role in nursing education. At the same time, as the health care industry moves toward computerizing health care records, nurses have been developing standardized terminologies to capture their domain of practice in a computer-friendly format. Historically, documentation systems fulfilled a legal requirement and were necessary to communicate information to other health care providers. With automation, the computerized health record has increased its utility by becoming a database for research to determine health care trends and best practices (Ozbolt, 2000). Nurses have an opportunity to incorporate nursing information into these databases through the use of standardized terminologies so that the impact of nursing practice on patient outcomes can be studied. Nurse educators are also challenged to teach students how to reflect the expanding nursing role in a computerized format using standardized terminologies. The Marcella Niehoff School of Nursing, Loyola University Chicago, has embraced these challenges by
Journal of Professional Nursing, Vol 23, No 4 (July–August), 2007: pp 208–213 A 2007 Elsevier Inc. All rights reserved.
COMMUNITY-FOCUSED NURSING CURRICULUM
redesigning the curriculum using a communityfocused approach while integrating primary, secondary, and tertiary prevention strategies. To prepare students to capture their practice in computer documentation systems, nursing theory courses have structured content using standardized nursing terminologies: nursing diagnoses (NaNDA) for issue identification, the Nursing Interventions Classification (NIC) for nursing interventions, and the Nursing Outcomes Classification (NOC) for assessment and goal measurement (Dochterman & Bulechek, 2004; Moorhead, Johnson, & Maas, 2004; NANDA International, 2005). By using standardized terminologies as the organizing infrastructure to teach nursing practice, students learn the terms used in documentation while they learn relevant concepts of nursing. This article will present how both a community-focused curriculum and standardized terminologies are integrated into the curriculum.
Changes in Nursing Practice: Focus on Health Care Experience The ANA (2004) has recognized the growth in nursing practice and has subsequently revised the definition of nursing to reflect a more complex and wholistic perspective of nursing, including primary, secondary, and tertiary prevention strategies for individuals, families, groups, and populations. The revision of the ANA definition better reflects the complexity of nursing and impacts how nurse educators prepare nurses in the future. The previous definition, bthe diagnosis and treatment of human response to actual and potential health problemsQ (ANA, 1980), has been revised to the following (ANA, 2004): The protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation
209
of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations.
This statement implies that nurses not only identify problems but, more accurately, bjourneyQ with patients throughout the health care experience across the life span. The Marcella Niehoff School of Nursing, Loyola University Chicago, has reflected the new definition of nursing in the bhealth experience model,Q as shown in Figure 1. The health care experience of patients is not limited to the walls of an institution because it also incorporates lifestyle choices, health care behaviors, and access to health care services. This shift toward preventive care is also supported by Healthy People 2010 (Department of Health and Human Services, 2000). Nurses have the opportunity to affect an individual’s health care experience throughout the patient’s lifetime and across the health care continuum. Figure 1 presents one way to conceptualize the nurses’ role in the health care experience and serves as a model for the structuring of nursing data to better reflect the flow of nursing practice, integrating preventive care across the continuum of care. As stated in the ANA definition, nurses promote, protect, and optimize health, and prevent illness and injury. Primary, secondary, and tertiary prevention strategies are inherent in this definition of nursing practice. As shown in the diagram, individuals live their lives incorporating chosen health care behaviors. People choose what they eat, whether and how they exercise, and to what degree they incorporate health-promoting or health-deterring behaviors (e.g., nutrition, smoking, and use of sunscreen). Nurses have an opportunity to affect these behaviors through primary prevention strategies (e.g., education, counseling, and advocacy).
Figure 1. The health care experience.
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This point in the journey is depicted as bhealth behaviorsQ on the far left portion of Figure 1. The nurse’s role at this point is reflected on the bar at the bottom of the figure as bprimary prevention.Q Secondary prevention occurs when the nurse both detects problems early and initiates treatment quickly (Leavell & Clark, 1965). As people live their lives, signs and symptoms of diseases emerge. These signs and symptoms may be silent, ignored, or acted upon. Nurses are involved at this point in the journey by identifying the early onset of signs and symptoms of disease through screening, history and physical examinations, and referrals to other health care professionals. These signs and symptoms eventually precipitate entre´e into the health care system. Once in the system, individuals—now patients—are tested, diagnosed, and treated medically, surgically, or both medically and surgically in a variety of settings, including ambulatory care facilities, diagnostic centers, and hospitals. For example, a chronic smoker makes repeated office visits for bronchitis and shortness of breath and may be hospitalized for the treatment of chronic obstructive pulmonary disease or lung cancer. The nurse’s role in terms of secondary prevention is to recognize abnormal signs and symptoms early to facilitate entre´e into the health care system (i.e., early detection). This is depicted in Figure 1, as the shortened time between bsigns and symptomsQ and bdiagnostic testing.Q This occurs between bdiagnostic testingQ and inpatient and outpatient medical, surgical, or both medical and surgical treatments. Tertiary prevention involves appropriate rehabilitation and follow-up care (Leavell & Clark, 1965). Although nurses begin planning care once the patient enters the health care system, the plan materializes once the acute illness episode is resolved. Nurses coordinate discharge planning, identifying the most appropriate resources to maximize recovery. Throughout the health care experience, nurses also assist patients in evaluating health care choices in relation to ethics and personal values, cultural practices, and faith beliefs, while addressing financial constraints and lifestyle choices. In the model, these elements are integrated within the professional nursing role and appear at the bottom of Figure 1. The dotted bar represents the interactive nature across all phases of preventive care.
Standardized Terminology as an Organizing Infrastructure Once individuals are diagnosed and formally enter the health care system, they become bpatients.Q Patients rotate through both ambulatory and inpatient settings, obtaining medical, surgical, or both medical and surgical services. The nurses’ role at this point in the patient’s journey is to continue to monitor for signs and symptoms of illness and complications and to intervene appropriately. The documentation of nursing care during this phase of the health care experience is
structured in terms of the nursing process, integrating standardized terminologies. Standardized terminologies are a set of terms representing concepts recognized by a given profession as relevant to the practice and fulfilling certain criteria (Chute, Cohn, & Campbell, 1998; Ozbolt, 2000). Professional organizations, standards organizations, and vendors have worked together to develop a standardized system of health care terms to become the foundation for computerized health records (American Society for Testing and Materials, 1989; Bakken, 2001; Bakken, Campbell, Cimino, Huff, & Hammond, 2000; Berner, Detmer, & Simborg, 2005; Fenton, 2000; Goosen et al., 2004; McCormick et al., 1994; Ozbolt, 2000). This standardized system includes nursing terminology and is the database infrastructure for terms that appear on nursing documentation screens (Bakken, 2001; Dochterman & Bulechek, 2004; Elfrink, Bakken, Coenen, McNeil, & Bickford, 2001; Hardiker, Hoy, & Casey, 2000; Moorhead et al., 2004; Ozbolt, 2000; Werley & Lang, 1988). The ANA has endorsed several nursing standardized terminologies (McCormick et al., 1994). Three of these systems are NANDA, NIC, and NOC, where NANDA is a list of patient problems, issues, and concerns; NIC is a list of nursing interventions; and NOC is a list of measurable outcomes (Dochterman & Bulechek, 2004; Moorhead et al., 2004; NANDA International, 2005). Because NOC includes a measurement system, each NOC label can be used during initial patient assessment and for measuring outcomes of care. Professionally recognized standardized terminologies—including NANDA, NIC, and NOC—have been merged into one database infrastructure, called the Systematic Nomenclature of Medicine, Clinical Terms (SNOMED CT). SNOMED CT is a comprehensive clinical health care terminology that enhances interoperability through the convergence of a variety of terminologies, including both medical and nursing terms (SNOMED International, 2004). SNOMED CT has been designated as the core terminology for the U.S. National Health Information Infrastructure by the National Committee on Vital and Health Statistics (National Library of Medicine, 2003; Stead, Kelly, & Kolodner, 2005). The development, endorsement, and adoption of nursing standardized terminologies in SNOMED CT provide an opportunity for nursing education to better integrate nursing education, research, and practice. By teaching nursing concepts using the corresponding terms in standardized terminologies, student nurses will passively learn how to document their future practice more accurately. The resulting data in the documentation systems will be the basis for researching trends in nursing practice, which subsequently will support nursing education. It is critical that nurses learn how to reflect their day-to-day nursing practice to support the reliability and validity of documentation databases. The challenge in nursing education is to
COMMUNITY-FOCUSED NURSING CURRICULUM
211
Figure 2.
Course template.
develop a model integrating both the expanded role of nursing across patients’ health care experience and the use of standardized terminologies.
Case Study: Loyola University Chicago In the late 1990s, the faculty at Loyola University Chicago voted to redesign the undergraduate curriculum. A driving force in curriculum development was the desire for a community-focused nursing program. The faculty endorsed the belief that nursing practice arises out of the mutual interaction of a person, community, environment, nursing, and health. The communityfocused curriculum provided a structure for a student’s educational journey toward becoming a professional nurse, providing a means for the student to explore the many dimensions of nursing and to gain knowledge of nursing practice from beginners to advanced practitioners of nursing. Faculty developed a new conceptual framework, which identified curricular themes that flowed throughout all courses and provided guidance in dividing content between courses. A philosophy of embracing a commitment to wellness, a desire to prevent illness, and a focus on restoring health were foundational to the curriculum. Through collaboration and accurate understanding and appreciation of cultural, ethnic, and individual differences, the nurse can help individuals make informed decisions
regarding health care. Effective communication of ideas and feelings allows the nurse to individualize care. The conceptual framework called for nursing content to be structured based on organizing concepts, rather than a medical systems theory model. Curriculum content was divided between courses based on growth and development phases and health care experiences, rather than physical systems. Obstetrics, pediatrics, and mental health were already based on growth and development and health care experiences. However, medical–surgical courses required redistribution. Content in these courses was categorized based on the care of young and middle-aged adults and the care of older adults. Courses were developed to specifically address the more global nursing issues recognized in the conceptual framework. Based on this work, individual courses on nursing research, ethics, and leadership emerged. Content within courses was structured based on health care experiences; general descriptions; epidemiology; primary, secondary, and tertiary prevention; nursing care in terms of standardized terminologies; and application to prototypical conditions. Specific prototypical conditions were chosen based on common conditions identified in Healthy People 2010 and morbidity and mortality statistics (Center for Disease Control and Prevention, 2002; Department of Health
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and Human Services, 2000) from the U.S. Department of Vital Statistics. Emphasis is placed on critical thinking so that students would be able to apply those principles to other similar situations.
Course Templates To assist faculty in restructuring courses, a course template was developed, as shown in Figure 2. Course faculty identified global patient health care experiences based on the nature of the nursing theory content and the common experiences of that population. For example, in the bcare of the young and middle-aged adultsQ medical–surgical course, common health care experiences include the surgical experience, the medical experience of upper and lower gastrointestinal conditions, the cancer experience, and chronic health behaviors that can lead to health promotion or disease. In each category of health experience, faculty identified common prototypical conditions that fall under that category. For example, when teaching the medical experience of lower gastrointestinal conditions, prototypical conditions include appendicitis, Crohn’s disease, and ulcerative colitis. This forms a two-tiered hierarchy of information: global health experiences and the more specific prototypical conditions. Information is presented at the most global level possible, given the content covered. For example, when teaching the medical experience of gastrointestinal disorders, more global information would include the etiology and description of gastrointestinal conditions and epidemiology. Primary prevention would include diet, exercise, and maintenance of appropriate weight. bSecondary prevention: early detectionQ would include signs and symptoms of gastrointestinal disorders that would require nursing or medical interventions and a discussion of diagnostic testing. bSecondary prevention: early treatmentQ includes responsive nursing care. This includes nursing assessment areas and common physical, psychological, social, and spiritual complications/ issues (using NANDA terminology). For each NANDA diagnosis, both nursing interventions (using NIC terminology) and care goals (using NOC terminology) are presented. The emphasis in lectures is on assessment areas, common issues, nursing interventions, and goals of care. In this way, the standardized terminology is not banother list to memorizeQ but rather helps students streamline and apply nursing concepts. The terminology is used in lectures to assist the students in understanding nursing concepts by structuring nursing information that is compatible with the flow of nursing practice. Specific course content is applied at the prototypical level. As shown in Figure 2, all content areas are covered with greater specificity at the prototypical level in terms of appendicitis, Crohn’s disease, and ulcerative colitis. This material can be taught in a lecture format, tackled in group discussions, or incorporated into case study assignments. By having students apply global concepts to more specific cases,
they learn critical thinking in prototypical situations, and they practice critical thinking in other bnonprototypicalQ situations through out-of-class case study assignments or clinical experiences. Clinical experiences provide students with the opportunity to transfer knowledge of prototypical conditions to the health experiences of patients in their care. Patient encounters, whether at the primary, secondary, or tertiary level of prevention, are used to assist students to develop critical thinking skills through the use of standardized nursing terminologies. After identifying the priority NANDA, NIC and NOC for a patient, that information is transferred into computerized health care records. Several of the clinical sites use computerized documentation. At these sites, students clearly apply critical thinking when documenting care using standardized terminologies for each of their patients. Rapid movement toward the use of standardized nursing terminologies and computerized health care records presents challenges. Nurse educators must incorporate standardized terminologies into the curriculum as they strive to structure the curriculum in a manner that provides a meaningful correlation between the classroom and clinical experience. As students are taught to journey with their patients throughout the health care experience, they must apply nursing concepts, using standardized terminologies, effectively as they work with patients and electronic medical records.
References American Nurses Association (ANA). (1980). Nursing: A social policy statement. Kansas City: Author. American Nurses Association (ANA). (2003). Nursing’s social policy statement (2nd ed.). Washington, DC: Author. American Nurses Association (ANA). (2004). Nursing scope and standards of practice. Washington, DC: Author. American Society for Testing and Materials. (1989). Terminology in ASTM standards. Form and style for ASTM standards (8th ed.). Philadelphia: Author. Bakken, S. (2001). An informatics infrastructure is essential for evidence-based practice. Journal of the American Medical Informatics Association, 8, 199 – 201. Bakken, S., Campbell, K. E., Cimino, J. J., Huff, S. M., & Hammond, W. E. (2000). Toward vocabulary domain specifications for Health Level 7—Coded data elements. Journal of the American Medical Informatics Association, 7, 333 – 342. Berner, E. S., Detmer, D. E., & Simborg, D. (2005). Will the wave finally break? A brief view of the adoption of electronic medical records in the United States. Journal of the American Medical Informatics Association, 12, 3 – 7. Center for Disease Control and Prevention. (2002). Morbidity and Mortality Weekly Report. Available: www.cdc.gov/mmwr/. Chute, C. G., Cohn, S. P., & Campbell, J. R. (1998). A framework for comprehensive health terminology systems in the United States: Development guidelines, criteria for selection, and public policy implications. Journal of the American Medical Informatics Association, 5, 503 – 510. Department of Health and Human Services. (2000). Healthy people 2010. Available: www.healthypeople.gov. Dochterman, J., & Bulechek, G. (2004). Iowa intervention project: Nursing Interventions Classification (NIC). St. Louis: Mosby.
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Elfrink, V., Bakken, S., Coenen, A., McNeil, B., & Bickford, C. (2001). Standardized nursing vocabularies: A foundation for quality care. Seminars in Oncology Nursing, 17, 18 – 23. Fenton, S. H. (2000). Clinical vocabularies and terminologies: Impact on the future of health information management. Topics in Health Information Management, 21, 74 – 80. Goosen, W. T. G., Ozbolt, J. G., Coenen, A., Park, H., Mead, C., Ehnfors, M., et al. (2004). Development of a provisional domain model for the nursing process for use within the Health Level 7 reference information model. Journal of the American Medical Informatics Association, 11, 186 – 194. Hardiker, N. R., Hoy, D., & Casey, A. (2000). Standards of nursing terminology. Journal of the American Medical Informatics Association, 7, 523 – 528. Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in his community, an epidemiologic approach. New York: McGraw-Hill. McCormick, K. A., Lang, N., Zielstorff, R., Milholland, D. K., Saba, V., & Jacox, A. (1994). Toward standard classification schemes for nursing language: Recommendations of the American Nurses Association steering committee on databases to support
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clinical nursing practice. Journal of the American Medical Informatics Association, 1, 421 – 427. Moorhead, S., Johnson, M., & Maas, M. (2004). Nursing Outcomes Classification. St. Louis: Mosby. NANDA International. (2005). Nursing diagnoses: Definitions and classification. Philadelphia: Author. National Library of Medicine. (1999). HHS launches new efforts to promote paperless health care system. Available: http:// www.nlm.nih.gov/news/press _ releases/paperlesspr03.html accessed November 3, 2003. Ozbolt, J. (2000). Terminology standards for nursing: Collaboration at the summit. Journal of the American Medical Informatics Association, 7, 517 – 522. SNOMED International. (2004). SNOMED clinical terms user guide. Northfield, IL: Author. Stead, W. W., Kelly, B. J., & Kolodner, R. M. (2005). Achievable steps toward building a national health information infrastructure in the United States. Journal of the American Medical Informatics Association, 12, 113 – 120. Werley, H. H., & Lang, N. M. (1988). Identification of the nursing minimum data set. New York: Springer.
AND
SHERYL SOMMER, PHD, RNy
This study investigated the development of a community-focused curriculum integrating primary, secondary, and tertiary prevention and nursing standardized terminologies as an organizing infrastructure. This is a case study of the curriculum redesign of the Marcella Niehoff School of Nursing, Loyola University Chicago. Faculty developed a conceptual framework integrating core concepts into curriculum design, course content, and clinical applications. A coherent curriculum was designed using a community-focused approach; primary, secondary, and tertiary prevention strategies; and standardized terminologies as the organizing infrastructure to teach and apply nursing practice. The curriculum provides a meaningful correlation between the classroom and clinical experience. Students journey with their patients throughout the health care experience, applying nursing concepts using standardized terminologies. Clinical experiences provide students with the opportunity to transfer knowledge to the health experiences of patients in their care. Patient encounters, whether at the primary, secondary, or tertiary level of prevention, are used to assist students in developing critical thinking skills through the use of standardized nursing terminologies. (Index words: Preventive care; Nursing standardized terminologies; Nursing education) J Prof Nurs 23:208–13, 2007. A 2007 Elsevier Inc. All rights reserved.
R
ECENT CHANGES IN both nursing practice and the health care system have required nurse educators to reevaluate how nursing is taught. Historically, nursing has differentiated itself from medicine in that nursing is more concerned with the physical, psychosocial, and spiritual responses to illness, whereas medicine is more interested in treating disease (American Nurses Association [ANA], 2003). Nursing practice has grown beyond that distinction to integrate advocacy and preventive care for individuals, families, and communities (ANA, 2003). Nurse educators have been
*Assistant Professor, Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL. yAssociate Professor & Program Chair, Creighton University, School of Nursing, Omaha, NE. Address correspondence and reprint requests to Dr. Burkhart: Assistant Professor, Marcella Niehoff School of Nursing, Loyola University Chicago, 6525 North Sheridan Road, Chicago, IL 60626. E-mail: [email protected] 8755-7223/$ - see front matter 208 doi:10.1016/j.profnurs.2007.01.002
challenged to reflect this expanded community-focused role in nursing education. At the same time, as the health care industry moves toward computerizing health care records, nurses have been developing standardized terminologies to capture their domain of practice in a computer-friendly format. Historically, documentation systems fulfilled a legal requirement and were necessary to communicate information to other health care providers. With automation, the computerized health record has increased its utility by becoming a database for research to determine health care trends and best practices (Ozbolt, 2000). Nurses have an opportunity to incorporate nursing information into these databases through the use of standardized terminologies so that the impact of nursing practice on patient outcomes can be studied. Nurse educators are also challenged to teach students how to reflect the expanding nursing role in a computerized format using standardized terminologies. The Marcella Niehoff School of Nursing, Loyola University Chicago, has embraced these challenges by
Journal of Professional Nursing, Vol 23, No 4 (July–August), 2007: pp 208–213 A 2007 Elsevier Inc. All rights reserved.
COMMUNITY-FOCUSED NURSING CURRICULUM
redesigning the curriculum using a communityfocused approach while integrating primary, secondary, and tertiary prevention strategies. To prepare students to capture their practice in computer documentation systems, nursing theory courses have structured content using standardized nursing terminologies: nursing diagnoses (NaNDA) for issue identification, the Nursing Interventions Classification (NIC) for nursing interventions, and the Nursing Outcomes Classification (NOC) for assessment and goal measurement (Dochterman & Bulechek, 2004; Moorhead, Johnson, & Maas, 2004; NANDA International, 2005). By using standardized terminologies as the organizing infrastructure to teach nursing practice, students learn the terms used in documentation while they learn relevant concepts of nursing. This article will present how both a community-focused curriculum and standardized terminologies are integrated into the curriculum.
Changes in Nursing Practice: Focus on Health Care Experience The ANA (2004) has recognized the growth in nursing practice and has subsequently revised the definition of nursing to reflect a more complex and wholistic perspective of nursing, including primary, secondary, and tertiary prevention strategies for individuals, families, groups, and populations. The revision of the ANA definition better reflects the complexity of nursing and impacts how nurse educators prepare nurses in the future. The previous definition, bthe diagnosis and treatment of human response to actual and potential health problemsQ (ANA, 1980), has been revised to the following (ANA, 2004): The protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation
209
of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations.
This statement implies that nurses not only identify problems but, more accurately, bjourneyQ with patients throughout the health care experience across the life span. The Marcella Niehoff School of Nursing, Loyola University Chicago, has reflected the new definition of nursing in the bhealth experience model,Q as shown in Figure 1. The health care experience of patients is not limited to the walls of an institution because it also incorporates lifestyle choices, health care behaviors, and access to health care services. This shift toward preventive care is also supported by Healthy People 2010 (Department of Health and Human Services, 2000). Nurses have the opportunity to affect an individual’s health care experience throughout the patient’s lifetime and across the health care continuum. Figure 1 presents one way to conceptualize the nurses’ role in the health care experience and serves as a model for the structuring of nursing data to better reflect the flow of nursing practice, integrating preventive care across the continuum of care. As stated in the ANA definition, nurses promote, protect, and optimize health, and prevent illness and injury. Primary, secondary, and tertiary prevention strategies are inherent in this definition of nursing practice. As shown in the diagram, individuals live their lives incorporating chosen health care behaviors. People choose what they eat, whether and how they exercise, and to what degree they incorporate health-promoting or health-deterring behaviors (e.g., nutrition, smoking, and use of sunscreen). Nurses have an opportunity to affect these behaviors through primary prevention strategies (e.g., education, counseling, and advocacy).
Figure 1. The health care experience.
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This point in the journey is depicted as bhealth behaviorsQ on the far left portion of Figure 1. The nurse’s role at this point is reflected on the bar at the bottom of the figure as bprimary prevention.Q Secondary prevention occurs when the nurse both detects problems early and initiates treatment quickly (Leavell & Clark, 1965). As people live their lives, signs and symptoms of diseases emerge. These signs and symptoms may be silent, ignored, or acted upon. Nurses are involved at this point in the journey by identifying the early onset of signs and symptoms of disease through screening, history and physical examinations, and referrals to other health care professionals. These signs and symptoms eventually precipitate entre´e into the health care system. Once in the system, individuals—now patients—are tested, diagnosed, and treated medically, surgically, or both medically and surgically in a variety of settings, including ambulatory care facilities, diagnostic centers, and hospitals. For example, a chronic smoker makes repeated office visits for bronchitis and shortness of breath and may be hospitalized for the treatment of chronic obstructive pulmonary disease or lung cancer. The nurse’s role in terms of secondary prevention is to recognize abnormal signs and symptoms early to facilitate entre´e into the health care system (i.e., early detection). This is depicted in Figure 1, as the shortened time between bsigns and symptomsQ and bdiagnostic testing.Q This occurs between bdiagnostic testingQ and inpatient and outpatient medical, surgical, or both medical and surgical treatments. Tertiary prevention involves appropriate rehabilitation and follow-up care (Leavell & Clark, 1965). Although nurses begin planning care once the patient enters the health care system, the plan materializes once the acute illness episode is resolved. Nurses coordinate discharge planning, identifying the most appropriate resources to maximize recovery. Throughout the health care experience, nurses also assist patients in evaluating health care choices in relation to ethics and personal values, cultural practices, and faith beliefs, while addressing financial constraints and lifestyle choices. In the model, these elements are integrated within the professional nursing role and appear at the bottom of Figure 1. The dotted bar represents the interactive nature across all phases of preventive care.
Standardized Terminology as an Organizing Infrastructure Once individuals are diagnosed and formally enter the health care system, they become bpatients.Q Patients rotate through both ambulatory and inpatient settings, obtaining medical, surgical, or both medical and surgical services. The nurses’ role at this point in the patient’s journey is to continue to monitor for signs and symptoms of illness and complications and to intervene appropriately. The documentation of nursing care during this phase of the health care experience is
structured in terms of the nursing process, integrating standardized terminologies. Standardized terminologies are a set of terms representing concepts recognized by a given profession as relevant to the practice and fulfilling certain criteria (Chute, Cohn, & Campbell, 1998; Ozbolt, 2000). Professional organizations, standards organizations, and vendors have worked together to develop a standardized system of health care terms to become the foundation for computerized health records (American Society for Testing and Materials, 1989; Bakken, 2001; Bakken, Campbell, Cimino, Huff, & Hammond, 2000; Berner, Detmer, & Simborg, 2005; Fenton, 2000; Goosen et al., 2004; McCormick et al., 1994; Ozbolt, 2000). This standardized system includes nursing terminology and is the database infrastructure for terms that appear on nursing documentation screens (Bakken, 2001; Dochterman & Bulechek, 2004; Elfrink, Bakken, Coenen, McNeil, & Bickford, 2001; Hardiker, Hoy, & Casey, 2000; Moorhead et al., 2004; Ozbolt, 2000; Werley & Lang, 1988). The ANA has endorsed several nursing standardized terminologies (McCormick et al., 1994). Three of these systems are NANDA, NIC, and NOC, where NANDA is a list of patient problems, issues, and concerns; NIC is a list of nursing interventions; and NOC is a list of measurable outcomes (Dochterman & Bulechek, 2004; Moorhead et al., 2004; NANDA International, 2005). Because NOC includes a measurement system, each NOC label can be used during initial patient assessment and for measuring outcomes of care. Professionally recognized standardized terminologies—including NANDA, NIC, and NOC—have been merged into one database infrastructure, called the Systematic Nomenclature of Medicine, Clinical Terms (SNOMED CT). SNOMED CT is a comprehensive clinical health care terminology that enhances interoperability through the convergence of a variety of terminologies, including both medical and nursing terms (SNOMED International, 2004). SNOMED CT has been designated as the core terminology for the U.S. National Health Information Infrastructure by the National Committee on Vital and Health Statistics (National Library of Medicine, 2003; Stead, Kelly, & Kolodner, 2005). The development, endorsement, and adoption of nursing standardized terminologies in SNOMED CT provide an opportunity for nursing education to better integrate nursing education, research, and practice. By teaching nursing concepts using the corresponding terms in standardized terminologies, student nurses will passively learn how to document their future practice more accurately. The resulting data in the documentation systems will be the basis for researching trends in nursing practice, which subsequently will support nursing education. It is critical that nurses learn how to reflect their day-to-day nursing practice to support the reliability and validity of documentation databases. The challenge in nursing education is to
COMMUNITY-FOCUSED NURSING CURRICULUM
211
Figure 2.
Course template.
develop a model integrating both the expanded role of nursing across patients’ health care experience and the use of standardized terminologies.
Case Study: Loyola University Chicago In the late 1990s, the faculty at Loyola University Chicago voted to redesign the undergraduate curriculum. A driving force in curriculum development was the desire for a community-focused nursing program. The faculty endorsed the belief that nursing practice arises out of the mutual interaction of a person, community, environment, nursing, and health. The communityfocused curriculum provided a structure for a student’s educational journey toward becoming a professional nurse, providing a means for the student to explore the many dimensions of nursing and to gain knowledge of nursing practice from beginners to advanced practitioners of nursing. Faculty developed a new conceptual framework, which identified curricular themes that flowed throughout all courses and provided guidance in dividing content between courses. A philosophy of embracing a commitment to wellness, a desire to prevent illness, and a focus on restoring health were foundational to the curriculum. Through collaboration and accurate understanding and appreciation of cultural, ethnic, and individual differences, the nurse can help individuals make informed decisions
regarding health care. Effective communication of ideas and feelings allows the nurse to individualize care. The conceptual framework called for nursing content to be structured based on organizing concepts, rather than a medical systems theory model. Curriculum content was divided between courses based on growth and development phases and health care experiences, rather than physical systems. Obstetrics, pediatrics, and mental health were already based on growth and development and health care experiences. However, medical–surgical courses required redistribution. Content in these courses was categorized based on the care of young and middle-aged adults and the care of older adults. Courses were developed to specifically address the more global nursing issues recognized in the conceptual framework. Based on this work, individual courses on nursing research, ethics, and leadership emerged. Content within courses was structured based on health care experiences; general descriptions; epidemiology; primary, secondary, and tertiary prevention; nursing care in terms of standardized terminologies; and application to prototypical conditions. Specific prototypical conditions were chosen based on common conditions identified in Healthy People 2010 and morbidity and mortality statistics (Center for Disease Control and Prevention, 2002; Department of Health
212
BURKHART AND SOMMER
and Human Services, 2000) from the U.S. Department of Vital Statistics. Emphasis is placed on critical thinking so that students would be able to apply those principles to other similar situations.
Course Templates To assist faculty in restructuring courses, a course template was developed, as shown in Figure 2. Course faculty identified global patient health care experiences based on the nature of the nursing theory content and the common experiences of that population. For example, in the bcare of the young and middle-aged adultsQ medical–surgical course, common health care experiences include the surgical experience, the medical experience of upper and lower gastrointestinal conditions, the cancer experience, and chronic health behaviors that can lead to health promotion or disease. In each category of health experience, faculty identified common prototypical conditions that fall under that category. For example, when teaching the medical experience of lower gastrointestinal conditions, prototypical conditions include appendicitis, Crohn’s disease, and ulcerative colitis. This forms a two-tiered hierarchy of information: global health experiences and the more specific prototypical conditions. Information is presented at the most global level possible, given the content covered. For example, when teaching the medical experience of gastrointestinal disorders, more global information would include the etiology and description of gastrointestinal conditions and epidemiology. Primary prevention would include diet, exercise, and maintenance of appropriate weight. bSecondary prevention: early detectionQ would include signs and symptoms of gastrointestinal disorders that would require nursing or medical interventions and a discussion of diagnostic testing. bSecondary prevention: early treatmentQ includes responsive nursing care. This includes nursing assessment areas and common physical, psychological, social, and spiritual complications/ issues (using NANDA terminology). For each NANDA diagnosis, both nursing interventions (using NIC terminology) and care goals (using NOC terminology) are presented. The emphasis in lectures is on assessment areas, common issues, nursing interventions, and goals of care. In this way, the standardized terminology is not banother list to memorizeQ but rather helps students streamline and apply nursing concepts. The terminology is used in lectures to assist the students in understanding nursing concepts by structuring nursing information that is compatible with the flow of nursing practice. Specific course content is applied at the prototypical level. As shown in Figure 2, all content areas are covered with greater specificity at the prototypical level in terms of appendicitis, Crohn’s disease, and ulcerative colitis. This material can be taught in a lecture format, tackled in group discussions, or incorporated into case study assignments. By having students apply global concepts to more specific cases,
they learn critical thinking in prototypical situations, and they practice critical thinking in other bnonprototypicalQ situations through out-of-class case study assignments or clinical experiences. Clinical experiences provide students with the opportunity to transfer knowledge of prototypical conditions to the health experiences of patients in their care. Patient encounters, whether at the primary, secondary, or tertiary level of prevention, are used to assist students to develop critical thinking skills through the use of standardized nursing terminologies. After identifying the priority NANDA, NIC and NOC for a patient, that information is transferred into computerized health care records. Several of the clinical sites use computerized documentation. At these sites, students clearly apply critical thinking when documenting care using standardized terminologies for each of their patients. Rapid movement toward the use of standardized nursing terminologies and computerized health care records presents challenges. Nurse educators must incorporate standardized terminologies into the curriculum as they strive to structure the curriculum in a manner that provides a meaningful correlation between the classroom and clinical experience. As students are taught to journey with their patients throughout the health care experience, they must apply nursing concepts, using standardized terminologies, effectively as they work with patients and electronic medical records.
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