GRADUATES OF COMMUNITY HEALTH NURSING AND NURSING ADMINISTRATION MASTER'S PROGRAMS have traditionally served as leaders in the development, implementation, and evaluation of health care programs and health policy for communities and organizations. In the past decade, however, enrollments in programs focused on population-level health and organizational administration have decreased significantly. Thus, throughout the country, there is a need for nurse leaders who will shape and strengthen systems of health care delivery for multiple and diverse populations. * Challenges confronting health care delivery systems providing integrated, interdisciplinary services have led to a heightened need for nurses with backgrounds in both Community Health Nursing and Nursing Administration, as well as the emerging specialty of Nursing Informatics. Some of these trends include an increased need to demonstrate accountability for cost, quality, and access to services to consumers and to the community, a heightened recognition of the interdependence of public and private health sectors, and a growing diversity among populations that require care across the continuum. - A faculty work group at the University of Nebraska designed an innovative master's curriculum, the Health Systems Nurse Specialist (HSNS) program, to respond to these needs. The program consists of three distinct specialties - Community Health Nursing, Nursing Administration, and Nursing Informatics. All build on a set of core courses that integrate the foundational knowledge and skills unique to the specialty that are needed by any nurse working at the systems level in health care. A systems perspective with a population-level focus and socialization as a leader, knowledge worker, and continuous learner are hallmarks of the program. * The creation and ongoing development of the HSNS program challenged nurse faculty from different specialties to practice the collaborative skills viewed as essential for leaders in emerging health care delivery systems. THIS ARTICLE DESCRIBES THE BACKGROUND AND VISION FOR THE HSNS PROGRAM, ITS INNOVATIVE CURRICULUM, AND THE STRATEGIES USED TO CREATE AN INTEGRATED PROGRAM ACROSS SPECIALTIES.
The Need for an Integrated Program It became clear during the 1990s that to provide leadership, nurses would need more than a solid grounding in nursing knowledge and practice. They would also need advanced skills in systems thinking and functioning, interdisciplinary collaboration, and information and communication technologies.
This was a decade of major transformation in the organization, delivery, and financing of health care in the United States (1,2). Driving forces for change included rapidly escalating costs, disparate health status indicators across populations, and consumer concerns about quality of care.
The 1990s saw a broad paradigm shift in health care delivery throughout the country - from a focus on illness to health and wellness; from the provision of health services to individuals to population-based services; from institutional care to communitybased care; and from professional, provider-centered decisionmaking to decision-making by patients and payers based on information about cost and quality. The interdependence of providers and organizations was recognized as essential for the advancement of health care. The integration of services, the management of costs and care, evidence-based accountability, and collaboration among multiple providers became major strategies within the emerging health care delivery system.
Another trend during this period was the proliferation of the nurse practitioner role in the delivery of care to individuals of all ages across the continuum of care. The nature of advanced practice nursing and educational preparation for this role were examined in depth (3,4). However, despite a call for creative and effective leadership by communities and health care organizations, the emphasis was primarily on advanced practice roles that addressed the health needs of individuals.
In Nebraska in the 1990s, health care needs varied widely. In a state known for its sparsely populated rural communities, eastern Nebraska contained dense urban areas. Two longstanding public health issues added complexity to the challenge of serving the citizenry - the lack of a formal organizational infrastructure or an established funding mechanism for public health (5). In fact, the state ranked SOth among all states in funding for public health.
As existing health care organizations were confronted by a growing shortage of nurses, several statewide trends emerged - an increase in new minority populations, reduced revenue streams from managed care, major fluctuations in census, and constantly merging and shifting alliances among systems. The volume and complexity of data and information required by payers, regulators, and consumers increased exponentially. Health care organizations were challenged to design and implement sophisticated systems for managing and reporting information and for using information technology to improve services to rural residents.
These statewide and national trends riveted attention on the need for advanced practice nurses with population and system-- focused competencies in three specialty areas:
* Community health nursing (CHN), to work with local partners to build the capacity of communities to identify priority health needs, develop and evaluate programs to meet those needs, and locate and manage the resources to support the programs.
* Nursing administration (NA), to participate in complex strategic and operational planning, manage organizational transitions, coordinate care across multiple sites, and develop healthy work environments that foster collaboration.
* Nursing informatics (NI), to analyze, design, and implement information systems to meet nursing practice and organization needs and participate in the redesign of care delivery systems. All these needs were foundational to the HSNS curriculum that evolved.
The Structure of the Curriculum The HSNS curriculum provides an efficient and effective foundation of knowledge and skill for providing leadership to communities and health care organizations and promotes rich interaction among students. Students develop a systems and specialty knowledge base, essential thinking and collaboration skills, and competence in advanced practice nursing.
The curriculum consists of three tiers of courses, one building on the other. (See Table 1.) Tier 1 courses are required of all graduate nursing students and provide a transition into graduate study. The key concepts and skills introduced in Tier 1 include health care systems and environments, advanced nursing practice, critical thinking and dialogue, research methods, nursing theory and knowledge development, personal and professional development, and interdisciplinary collaboration. These areas are refined and reinforced throughout the curriculum. In addition, each student begins a research project or thesis that is completed and presented before graduation.
Tier 2 consists of five health systems core courses that are required for all HSNS students. One of the following areas is emphasized in each course: health care delivery systems and health policy; health, health behavior, culture, and population-level nursing interventions; development of organizational and community capacity; nursing informatics and the selection and development of nursing information systems; and health care economic policy and financial management.
Because HSNS core courses are primarily didactic-based credits, students are required to develop advanced practice portfolio projects within the courses that serve as an adjunct to traditional clinical experiences. These are tailored learning experiences mutually designed by a student and faculty member to develop specific competencies and enhance practice skills. They may be clinically or health-system focused field experiences or special projects that will enhance the marketability of the graduate.
Students often develop their portfolio projects in several courses to build depth in a specific area. For example, for one course, a CHN student developed a policy analysis on smoking cessation based on a Healthy People 2000 objective. For a second course, the student researched and proposed an advanced practice nursing intervention for a population of smokers. For the third course, the student incorporated smoking as a risk factor in the design and utilization of scenarios to develop selection criteria for purchase of a clinical information system.
Tier 3 courses provide in-depth knowledge, skills, and socialization experiences in the selected specialty. Each HSNS specialty area has one cognate or elective course and two capstone practicum courses.
- CHN students take a graduate-level epidemiology course. Their first practicum provides content and hands-on experience with community assessment and health planning. The final course is an individualized practicum in managing or evaluating the health of a specific population.
NA students select one elective course to strengthen their abilities in areas such as negotiation, ethical decision-making, strategic planning, or human resource management. The first practicum provides an individualized experience in analyzing health care organizations, promoting transitions, and creating healthy, healing work environments. The focus of the final practicum is on strategic management, evaluation, and improvement of departments, programs, and systems.
To develop a knowledge base to work as a translator between clinical practitioners and information technologists, NI students select an elective from computer or information science courses. The first NI practicum provides a hands-on experience in the analysis and design of an information system using computeraided software engineering tools and object-oriented design and modeling techniques. The final practicum, an individualized experience, consists of implementing and evaluating a nursing information system in a health care agency.
Program Outcomes and Competencies Faculty from the three specialties worked together to guide the development of the curricula. To identify and refine program outcomes and associated competencies, they made extensive use of standards of practice, advanced practice curricula and certification requirements, and other documents from national nursing and specialty organizations.
By the end of the first three years, seven outcomes to guide course refinement were identified through a detailed curricular review and evaluation of the core courses (Tier 2) and the specialty clinical courses (Tier 3). The outcomes encompass 1) individual and systems-level skills in the use of data, 2) leadership to improve health care systems, 3) effective communication (written and oral) to achieve system and professional goals, 4) a sense of professional identity, 5) use of research findings and evaluation methods, 6) participation in strategic planning and management of resources, and 7) advanced practice within the graduate's chosen specialty (CHN, NA, NI) using a conceptual, theoretical, and experiential knowledge base. Outcomes and competency examples are routinely reviewed by an advisory panel and the national consultant to the HSNS project.
Creating the Curriculum The specialties spanned two existing departments in the College of Nursing and one new area that previously had not been approved or taught. The process of providing an integrated foundation and distinct specialization experiences for three advanced practice nursing specialties was formidable and involved several distinct steps as outlined below.
Generating a vision and clarifying values The CHN and NA faculty worked together for a year to articulate the vision for a new program and to clarify core values that would drive the curriculum and work group processes. Among the challenges faced by faculty was the need to explore values and assumptions about nursing, health care, advanced practice nursing roles, professional socialization, teaching and learning with graduate students, and curriculum development. Through this process, the participants developed a greater understanding of their colleagues' expertise. They also arrived at an appreciation of NI as an advanced practice specialty needed at the systems level.
Although time consuming, this process was essential for creating the shared vision that formed the basis for curriculum design and the eventual development of a grant proposal. A vision document was created that described the need for the innovation and how it was highly congruent with the mission, vision, and strategic initiatives of the campus and the College of Nursing. The final part of the document was a preliminary sketch of the proposed curriculum and a description of how an innovative, flexible program might be created to reach nurses in remote rural areas.
The initial vision document was used to enlist the support of administrators and faculty colleagues for the new master's curriculum and expanded distance delivery model. The document still functions as a compass, or common reference point, for ongoing work related to pedagogy, curriculum organization and delivery methods, and collaboration for faculty practice.
Identifying core knowledge and skills Over the course of several closely scheduled meetings, the faculty work group identified the core knowledge and skills that emerged for the three specialties. Prior to meeting, faculty reviewed literature related to the leadership roles needed in emerging health care delivery systems, certification requirements in their specific specialties, specialty curricula published for advanced practice nursing, and the work of health care "futurists" such as Leland Kaiser (6,7). Structured team processes, such as silent brainstorming and affinity diagrams (8), were used to generate and organize large amounts of information in a relatively short period of time while preventing any person or specialty group from dominating the process.
An initial grouping of knowledge and skills derived at the first meeting was used as the basis for further exploration and discussion. Several rounds to clarify topics and condense overlapping areas resulted in the identification of five major areas for specialty core course development. These eventually became Tier 2.
Content and learning experiences needed for specialty capstone courses were identified by specialty faculty. Program outcomes and competencies were refined in response to the outcomes of this process.
Developing specialty core courses With the exception of the financial management course, which was an established course in need of revision to better serve all specialties, the core courses were all new. It was decided that CHN and NA faculty would develop and teach jointly the two courses related to health care delivery and organizational and community assessment.
Each specialty area took responsibility for developing one of the other three courses with the proviso that each course would be applicable to all three specialty areas. The faculty group reviewed each course several times during the formative stages to identify and discuss gaps and overlaps and to clarify how the content and skills served students in each specialty. This process provided faculty with information needed for planning the specialty capstone courses.
Developing a shared identity Ideas for an appropriate name for the new program began to emerge as the curriculum development process progressed. Having a name led to a shared sense of identity as an integrated program, rather than three separate specialties sharing resources.
Seeking official support and resources Throughout the initial curriculum development phase, the participants were aware that the HSNS program would need the approval of the College of Nursing and campus-level graduate committees. These committees required that new programs be budget neutral and not overlap existing programs. This requirement mandated that careful attention be directed to phasing out old courses and using existing course numbers and resources to develop new courses. Thus, as knowledge and skills were reconfigured into an integrated curriculum, faculty had to consciously "let go" of existing courses and long-held areas of teaching expertise.
As the vision evolved in terms of what was both desirable and possible, the faculty work group decided to seek federal funding. The grant development process added a series of deadlines and another layer of complexity to the curriculum development and approval processes. Nevertheless, the faculty understood that external funding was needed to realize fully their vision, and this additional effort served as stimulus for working through the difficult impasses ahead.
Developing Partnering Relationships Among Diverse Faculty The development of partnering relationships among the work group members required constant attention and conscious intention. Competing demands on all faculty members to teach, practice, conduct research, and provide professional service within a competitive environment that recognizes and rewards individual contributions were major obstacles. Other challenges were manifest in the diverse philosophies of teaching and practice among HSNS faculty and the mix of clearly defined and emerging professional identities. The addition of a new specialty, the introduction of new faculty members to the group after the initial visioning process, and the pressures of meeting tight deadlines also contributed to the stress of the participants. With the realization that the chaotic academic environment mirrored the chaotic practice environment in health care, the faculty viewed the project as an opportunity to develop and practice the communication, collaboration, and integration skills needed by graduates of the integrated curriculum.
Specific strategies were used to facilitate the group process under extreme time pressure. The most significant was the presence of an excellent facilitator who was committed to the vision and had experience working with groups of highly individualistic faculty members. Ground rules were established early, visibly posted at meetings, and periodically reconfirmed.
Consensus, which was required for making decisions, was defined as taking place when group members could live with and support the decision outside the group. A commitment to support each decision was required, with the caveat that in an evolving curriculum process, decisions would be revisited when they were considered barriers or stumbling blocks to progress. Understanding consensus in this way helped the group keep moving and negotiate difficult terrain.
Another significant strategy was an emphasis on the use of dialogue. Careful listening was required, along with a willingness to suspend judgment and be influenced by others (9,10). The major principles of this type of dialogue were introduced at a daylong planning retreat where participants had an opportunity to practice specific listening and dialogue skills.
A Commitment to Relationships As the project advances, the work of relationship building and the challenges of developing a self-organizing work group continue to intensify. Partnering relationships require clarity, a focus on long- and short-term goals, and a fundamental respect for all group members, even in the face of serious interpersonal conflicts (11). Concentrating on the gifts each person brings to the group and on the behaviors the group wants to cultivate, rather than on an individual's deficits, serves to minimize polarizing interactions.
The commitment of each group member to the work of the project is essential as the actions and decisions of each person affect the workload of all. A periodic review and reconfirmation of ground rules, program values, strategic program goals, roles, and commitments to the project are useful for building good working relationships.
Partnership requires a commitment to continuous learning and the recognition that courses and programs can always be improved, and thus are never done. The collective acknowledgement and celebration of milestones and successes is necessary to help the group realize that progress is made even in the face of constant change. Carving out time to check in at the beginning of meetings, share meals occasionally, and celebrate personal and group achievements helps bring meaning and balance to the challenging work. Humor is essential and must be consciously introduced into the group process.
The continuous work of partnership constantly challenges faculty members to live what they teach. The rewards, however, are great. From a handful of students the first year, the HSNS program has several graduates from each specialty and over 60 matriculated students in a three-year period. Through this effort, new partnerships among faculty, students, community members, and health care organizations have been forged that are making a difference to nursing and to the health of organizations and communities in Nebraska.
Key Words Community Health Nursing - Core Curriculum Curriculum Development - Master's Degree in Nursing - Nursing Administration - Nursing Informatics
Health care delivery systems are challenged to provide and demonstrate accountability for cost-effective, high quality, and integrated interdisciplinary services to increasingly diverse populations across the care continuum. Nurses with advanced knowledge and skills in systems thinking, collaborative practices, and a population focus are needed to provide leadership to these emerging systems. The Health Systems Nurse Specialist (HSNS) program at the University of Nebraska is an innovative master's curriculum that prepares nurses in three distinct specialties: community health nursing, nursing administration, and nursing informatics. All build on a set of core courses that integrate foundational knowledge and skills from each specialty that are needed by any nurse working at the systems level in health care. HSNS students develop specific skills to work collaboratively to determine priority health and organizational needs; develop and implement interventions, programs, and supportive information infrastructures; and monitor and improve program and population outcomes.The background and vision for formation of the program and its curriculum are presented in this article.
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About the Authors Donna Westmoreland, PhD, RN, and Bevely J. Hays, PhD, RN, are both associate professors at the University of Nebraska Medical Center, College of Nursing, Omaha. This project was funded in part by Department of Health and Human Services Bureau of Health Professions Advanced Nurse Education Program Grant 6 D09 HP 00049-1. The authors are grateful to Bobbie Berkowitz, PhD, RN, FAAN, who served as consultant to the HSNS project, and to fellow HSNS faculty members Judith Heermann, PhD, RN, Karen Grigsby, PhD, RN, Carol Pullen, EdD, RN, Jan Atwood, PhD, RN, Judy Warren, PhD, RN, Katherine Kaiser, PhD, RN, and Kathleen Barr, PhD, RN.…