Transforming Graduate Nursing Core Curriculum: Development of a Primary Health Care, Public Health, Population-Based Course
Andréa Sonenberg*1, Marie Truglio-Londrigan1, Renee Mcleod-Sordjan1
1Pace University, The College of Health Professions, Lienhard School of Nursing, USA
Stakeholders globally and nationally, including the World Health Organization, the Institute of Medicine and the American Association of Colleges of Nursing, have recently stressed the importance of population-based care and public health as drivers for health system reform where all providers practice in an integrated and comprehensive way. Heeding these recommendations, graduate nurse educators recognized the need to review curricula and strengthen the content in the area of public health which is population-based. Framing practice through the lens of primary health care is one way to achieve the goal of a more collaborative approach to improving population health. The purpose of this paper is to share the journey of a school of nursing as it re-committed itself to the vision of primary health care and to strengthen content in public health and population-based care. This manuscript presents one aspect of this work as illustrated in the development of one graduate core course entitled Advanced Nursing in Primary Health Care.
Keywords: Primary Health Care; Population; Graduate Nursing; Curricula Development
In one university there was a readiness among the graduate faculty to recommit themselves to their stated vision of Primary Health Care (PHC) and to strengthen content in the area of public health and population-based care that had been echoed throughout a variety of stakeholder reports. The purpose of this paper is to share the journey of this school of nursing as it re-committed itself to the vision of PHC by accepting the challenge to strengthen curricular content to ensure the integration of public health and population-based care. The result of this work, the development of a graduate core courses entitled Advanced Nursing in Primary Health Care, is presented, along with curricular samples from the course and affirmations obtained from end-of-semester student reflections.
Context for Change: Stakeholder Reports
In recent years, there has been a proliferation of materials published within and outside the discipline of nursing that focus on the importance of public health and population-based care. Publications reflect a variety of perspectives including global, national, local, and discipline-based. The Millennium Development Goals (MDG)  is an example of a global effort to reduce poverty among the world’s poorest populations. To address the issues that plague the world’s poor, the eight PHC-related target goals were established: the eradication of extreme poverty and hunger; provision of universal primary education; promotion of gender equality and empowerment of woman; reduction of child mortality; improvement of maternal health; eradication of HIV/AIDS, Malaria and other diseases; achievement of environmental sustainability and commitment to develop a global partnerships for development. Nationally, Healthy People 2020 (United States Department of Health and Human Services [USDHHS], 2012a)  is a collaborative effort among federal agencies, non-governmental organizations (NGO), and other stakeholders, which guides the development and implementation of population-based health initiatives. This initiative stresses an ecological and determinant-of-health approach through specific topics and detailed objectives. In the latest Healthy People 2020 edition, a specific to ‘global health’ objective was added, which directly addresses the need to improve public health to “strengthen U.S. national security through global disease detection, response, prevention, and control strategies” .
As one mean to reach the goals of Healthy People 2020  the Affordable Care Act (ACA), enacted in March of 2010, strives to provide access to care and services for greater numbers of Americans. Health information technology and the meaningful use of technology are essential throughout the development, implementation, and evaluation of each of these endeavors, noted above, in order to improve the quality and delivery of care, to achieve health for all.
Reports published by the Institute of Medicine (IOM) highlight the importance of primary care, public health, and population-based care. The IOM Committee on the Future of Primary Care  defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (p.31). Public health is “the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts…” . A fundamental key concept of public health is that it is a societal organized, collaborative effort to achieve population-based health; “what we, as a society, do collectively to assure the conditions, in which people can be healthy” . Additionally, public health is broader than a primary care perspective, focusing on populations living in communities with social, economic, psychological, environmental, and cultural considerations, etc.
A third IOM Report, Primary Care and Public Health: Exploring Integration to Improve Public Health,  highlights how primary care and public health care have traditionally existed as two distinct practice methods—“primary care focuses on providing medical services to individual patients with immediate health needs. Public health focuses on offering a broader array of services across communities and populations….” (p. 1). The dilemma noted is that each of these disciplines has practiced in “silos”, with the primary care model generally overshadowing public health and population-based care . The two approaches, primary care and public health, need to be integrated; the providers of both disciplines need to practice collaboratively . Overall, there needs to be a rebalancing of public health, population-based, and primary care, so that individuals and populations are mutually considered within the context of one another . Primary care providers, including advanced practice registered nurses, must be aware of, and knowledgeable about, public and population-based care, and must approach practice from this broader worldview.
The Institute of Medicine (IOM)  report, The Future of Nursing: Leading Change, Advancing Health recommends the need to transform nursing education, practice, regulation, and leadership. Nursing education needs to include competencies of public health and population-based care . These competencies must include essential content related to community; health policy; teamwork and collaboration; quality, access, and safety; as well as research and evidence-based practice. . The achievement of competencies in public health and population-based care does not imply “becoming” a public health practitioner. Rather, an understanding and appreciation of public health and population-based care is critical to all practice environments.
The Essentials of Masters Education
As presented in The Essentials of Masters Education in Nursing  “transformative thinking” and “evolutionary change” in graduate education is necessary to meet the complex needs of contemporary society, locally, nationally, and globally. Masters Essential VIII, Clinical Prevention and Population Health for Improving Health, is “central to achieving the national goal of improving the health status of the population of the United States” (American Association of Colleges of Nursing ). In addition, the Masters Essentials reflect the concepts that underlie population-based care, including the need for graduates to be knowledgeable and skillful in: the science and humanities, organizational and system leadership; quality & safety; evidence based-practice; translational science; informatics and communication technology; policy & advocacy; and inter-professional collaboration, inclusive of patient and family participation .
As the discussion thus far illustrates, the differences and relationships among primary care, public health, and population-based care are sometimes subtle and not always well-understood. The challenge for nurse educators is to envision the necessary curricular revisions for graduate nursing education programs and to implement these changes so that students may be competent in applying these practice areas their diverse roles. Framing these revisions through the lens of primary health care (PHC), which reflects all of these concepts, is essential. PHC thus becomes the integrating curricular pillar. PHC is defined as: …essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-relianceand self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process .
For graduate nursing students to achieve the required competencies, goes beyond educating them; their world-view must be transformed. Primary health care (PHC) is a view of health and care that is broad, holistic, and recognizes the multiple determinants (economic, sociocultural, political, educational, nutritional, and environmental/sanitation conditions within which people live) that influence a population’s health. PHC is complex and multi-dimensional and on founded on the understanding that empowerment comes from the collective. It therefore seeks partnerships with the people served, with their co-participation in the development, implementation, and evaluation of health initiatives, including those that are population, community, family, and/or individually based with intra-professional, inter-professional, and inter-sectorial collaborations. According to the report Primary Health Care Now More Than Ever (World Health Organization ), achieving population health in the face of challenges requires a commitment of all partners to address universal coverage reforms to ensure health equity and social justice; service delivery reforms that re-organize health services that are responsive to the needs of the people; public policy reforms that ensures the integration of public health with primary care; and leadership reforms inclusive of participatory work and negotiation. PHC, as a worldview, recognizes health as more than the physical or physiological and the accessibility of health services To facilitate application in nursing practice, the Declaration of Alma Ata (1978) is more currently framed as five basic principles of PHC (Canadian Nurses Association (2003) : 1. Accessibility to health services; 2. Use of appropriate technology; 3. Individual and community participation; 4. Increased health promotion and disease prevention; and 5. Intersectoral co-operation and collaboration .
Shaping a Worldview for Nursing Education Curriculum
In practice, PHC is a worldview- a philosophy which frames how nurses approach the care that they are delivering to individuals, families, communities, and populations in diverse settings. To frame a graduate nursing program with PHC and strengthen the curriculum in the area of public health and population based care, curricular revisions must address these questions:
• What knowledge and skills are required by nurses to have a kaleidoscopic view and that will enhance their ability to see the patient as an individual sitting before them, while taking into consideration the needs of the population of which the person is a member?
• How do we as advanced practice registered nurses work with individuals, families, and populations within diverse communities in a way that reflects PHC?
Advanced Nursing in Primary Health Care
Overall perspective: Advanced nursing in primary health care. In response to these two questions the graduate faculty developed and implemented a new graduate core course entitled Advanced Nursing in Primary Health Care. The course was designed to meet Masters Essential VIII ; reinforce the faculty’s commitment to primary health care (PHC); and provide content that would enhance the students’ knowledge and skills about PHC in order to practice with an appreciation of primary care, within the context of population-based care and public health. The faculty recognized that the expectation was not that students were being educated to be public health practitioners, but being transformed to be practitioners competent to practice with a broadened view; from a sole individual sitting in front of them to a member of the greater population. Overall, the objective of the course is to provide a context whereby students are offered the opportunity to analyze the philosophical perspectives of PHC and be able relate theories that transform these philosophical perspectives into practice. Students are further encouraged to practice with a kaleidoscope lens through which they are expected to reflect upon how their work may be delivered to the individual, family, community, and population.
Focused perspective: Advanced nursing in primary health care. The course empowers students to gain knowledge about PHC as it relates to the delivery of care to individuals, families, communities, and populations in diverse settings within a global, national, and local context. Multiple determinants of health are analyzed emphasizing the social determinants of health (SDH) with an emphasis on vulnerable populations and communities and their noted disparities. Students are provided with knowledge and skills necessary to access and assess large data sets and analyze the data; identifying trends and best practice strategies to address these trends. The work of the advanced practice nurse is considered part of a collective endeavor, with a focus on intra-professional, inter-professional, as well as inter-sectorial collaboration, therefore team work is an integral aspect of the coursework, with each student assigned to a team having a defined focal topic (SDH). In addition, the use of technology, for the purpose of system assessment, planning and design, as well as the implementation of technology for information dissemination and evaluation are introduced. Another important aspect that is presented in the course is how to strategically network with political leaders for evidence-based health systems and policy reform.
To facilitate the adult learning process, Advanced Nursing in Primary Health Care is delivered via a hybrid format through the use of a course internet platform which includes the syllabus, the sessions’ content (objectives, instructions to complete course work, readings and videos, faculty thoughts, and discussion boards); and detailed assignments with grading rubrics. The hybrid format facilitates an asynchronous and synchronous learning environment consisting of a total 14 sessions. The synchronous learning environment takes place as students come to campus for 3 face-to-face debriefing sessions. The on-campus debriefing sessions are a way to connect, dialogue, question, and collectively reflect upon readings, discussions, and exercises that take place during the online sessions. The remaining 11 sessions take place asynchronously throughout the semester, each taking either one or two weeks for completion. Each team explores the session topics through the lens of its assigned focal issue (Poverty, Environment, Water/sanitation, or Safety). The following are the session topics:
• Primary health care;
• Determinants of health with a focus on SDH;
• Health promotion, illness prevention, and risk factor reduction for improving population health with a focus on vulnerable populations and disparities;
• Assessing large data base trends;
• Culturally congruent community health partnerships in diverse settings and population- based intervention strategies;
• Policy, politics, and advocacy;
• Technology and culturally congruent use of informatics;
• Emergency preparedness, and
• Final reflections.
An important component of the asynchronous learning is the accompanying discussion boards, in which there are exercises and/or critical questions to address. These questions guide the student to critically appraise their readings and develop their ideas on the presiding topic. For example, one of the sessions concerns coalition building. The overall objective for this session is for students to gain an understanding of the value of coalitions; the process of coalition building; and community advocacy, including reflection on how coalitions may facilitate the development of best practices for population-based care. Faculty Thoughts accompany the sessions, providing a foundation from which students may develop their own perspectives and ideas. Required and Suggested Readings and Multimedia Resources are provided. Additionally, students are encouraged to search for additional literature to support and expand their reflections. Finally, the Discussion Board Forum asks students to search for an example of a contemporary coalition addressing a PHC issue and to present their findings as a discussion board post, to which their colleagues comment creating a scholarly dialogue.
Reflection on primary health care: During the final session, the discussion board is designed as a self-reflection. The final discussion board forum questions include:
• How might your new understanding of PHC and the SDH shape your practice?
• What do you value most about yourself and your abilities to affect change in the populations that you care for and about?
This final reflection is an important tool for faculty. It provides valuable information about students’ understanding of PHC, primary care, public health, and population-based care, and more importantly their beliefs and perceptions related to how the course has affected their practice. Students share their new interpretations of PHC theories and frameworks that now guide their practice. The application of the PHC framework in their course work demonstrates the acquisition of intra-professional, inter-professional, and inter-sectorial teamwork. Faculty also learned that students needed additional guidance in mining epidemiologic data, critically analyzing the validity of research, and interpreting education as a social determinant of health. Students view of education transformed from a passive experience of transferring information to an individual patient to an active PHC strategy to empower communities towards self-determination and self-reliance. The reflections also aided the faculty in identifying the need for future course revision. For example, faculty identified the need to strengthen content in the area of global health.
Reports and recommendations from a variety of stakeholders globally, nationally, and organizationally recommend that health care education curriculum include competencies in public health and population-based health. It is in this context that graduate faculty in one School of Nursing reaffirmed their belief in PHC as a fundamental pillar of graduate nursing education and developed its signature core course Advanced Nursing in Primary Health Care. Through this course, students broaden their world view of health care from one that is individually focused based on a primary care model to one that integrates an understanding of public and population health framed by a primary health care view. Through this approach students learn to recognize the multiple determinants of health, including system influences, which impact delivery of care as well as outcomes. Additionally, they gain the knowledge and skills necessary to identify disparities through large database searches, and to then address them through coalition building, partnerships, and policy/advocacy efforts, all of which are benefitted through augmentation with the use of team work and technology. Students’ course reflections confirm that they appreciate the enlightened world view gained and through which they will enhance their practice empowering individuals, families, communities, and populations in a variety of practice settings.
Patients with HF depend on healthcare proffessions to seek new and innovative approaches to educational programs. The challenge lies in applying reaserch in order to offer the most effective interventions to expand knowledge, promote self-care, and improve outcomes of HF patients . Maybe, the new approach where the healthcare providers, including cardiac nurse,take into consideration frailty in this group of patients which will help to improve the management of educational programs for HF patients. The literature revealed that the key to HF manangement is possible through knowlegable and effectice patient self-care.
4.Molla S. Donaldson, Karl D. Yordy, Kathleen N. Lohr, and Neal A. Vanselow. Institute of Medicine/Committee on the Future of Primary Care. Primary care: America’s health in a new era. Washington, DC: National Academies Press. 1996.
Cite this article: Sonenberg, A., Truglio-Londrigan, M., Mcleod-Sordjan, R. Transforming Graduate Nursing Core Curriculum: Development of a Primary Health Care, Public Health, Population-Based Course. J J Nurs Care. 2014, 1(1): 002.