Essential components of professional nursing include the nursing process, therapeutic use of self and a conceptual approach to nursing care, that is, one based upon the goal of meeting known human needs regardless of the specific medical diagnosis of the client. Baccalaureate nursing schools often organize their educational programs around these components. But this organization creates a number of difficulties. For example, which technical skills are essential to include? Which health problems do you include? How do you help the student function effectively in a system that is organized around a medical-model/bodysystems approach? Though these are not easy questions to answer, this article will discuss one approach to a solution.
In 1979, a new baccalaureate nursing curriculum was introduced at the University of North Carolina at Chapel Hill, which utilized the epidemiology and management strategies of common health problems as its organizing framework. The decision to organize the curriculum around only "common" health problems was chosen in order to narrow the ever-increasing volume of knowledge, and thus diagnoses in health care; to present content in parallel with the medical model organization of health care delivery; and to incorporate more elements of health maintenance and illness prevention into the curriculum. UaiagNational Center for Health Statistics Data and The Length of Stay in PAS Hospitals by Diagnosis, United States, Southern Region, 1975, the faculty identified "common" health problems, the conditions which place one at risk for developing these problems, and the illness-prone individuals and groups. Providing students with the knowledge and skills necessary to care for individuals and groups in these at-risk states or with these common health problems was a major objective of the new curriculum.
The integration of what is recognized as the essential components of professional nursing (nursing process, therapeutic use of self, and conceptual approaches ) into this new health-problem body-systems framework became a challenging task for the faculty. The development and organization of a theory course on "Nursing Care of Clients with Common Health Problems of the Cardiovascular System, the Pulmonary System or of Mental Illness is used here to illustrate the components of that professional nurse integration.
Each major content area, or module, in the course (Mental Health, Cardiovascular or Pulmonary) was further subdivided into the specific major health problems of that body system. The health problems listed for each module span both the life-cycle (from infancy through old age), and the healthillness continuum (from outpatient, generalized primary-care problems through inpatient, specialized tertiary-care problems.) For example, the specific health problems included in the cardiovascular module are balance and imbalance in the hematologic system: nutritional anemias and sickle cell anemia; balance and imbalance in hemostasis: hemophilia; hypertension; ischemic heart disease: angina, myocardial infarction, sequelae; valvular heart disease: streptococcal infections and rheumatic fever; congenital heart disease; cerebral vascular disease; and peripheral vascular diseases.
Students enter the course in either thespringoftheirjuiiioryearorthefiUl of their senior year. Since UNC-Chapel Hill has an upper-division nursing curriculum, the students have had one summer session of nursing-process theory combined with skills-practice in a laboratory setting; one academic semester of basic growth and development, nutrition, pharmacology and pathophysiology; one clinical course that focuses on mastering basic nursing care skills through the use of the nursing process; and a three- week physical assessment module. They begin the course in the nursing care of patients with common health problems inexperienced in the subtleties of assessing, planning, intervening and evaluating care of patients with specific health problems. Thus this course has the basic task of presenting each health problem in a manner such that the students have the data base to competently care for clients with that problem. It also has two additional tasks. The first is to develop the student's understanding of useful conceptual groupings, client groups who have similar needs though their specific health problems may differ (such as clients with chronic illness, clients in crisis situations, hospitalized children, and the aged! The second task is to point out general principles, such as the principles of surgical and medical nursing; diet therapy and pharmacology; patient education; the team approach to client care; and promotion of self-help and healthful behavior. Moreover, in the teaching of all of these specifics and principles the course must present the nursing process as the essence of the professional nurse's approach.
This course has now been taught four times and the following approach has been utilized. When a specific health problem is presented, all the data needed to give competent nursing care to clients at risk for, or having the health problem are presented. Additionally, the discussion of each health problem focuses on at least one conceptual grouping or general principle. For example, in the cardiovascular module, the session on congenital heart disease also includes a discussion of the hospitalized child; the sessions on hypertension include "contracting" with clients to enhance compliance, and screening as a secondary prevention technique; the sessions on myocardial infarction deal with crisis intervention in a life-threatening illness and with denial as a protective defense mechanism. Efforts are made to assist the student to recognize the transferability of these principles from client to client and from health problem to health problem. Additionally, in order to facilitate application of these principles to patient care, students are concurrently enrolled in a clinical course where faculty can assist them to apply the appropriate principles, regardless of their client's presenting health problems.
When the course was developed, health problems and principles were matched using a cross-reference sheet. All the common health problems were listed on a vertiefe axis, and all the essential nursing concepts and principles on a horizontal axis. All appropriate matches were checked, and the "best" health problem for teaching a specific principle was then selected. Thus an effort was made to assure that no concept, principle or approach would be completely overlooked while another was being repeatedly discussed.
In order to reinforce the importance of the nursing process in professional nursing; the four steps of the nursing process (assessment, planning, implementation, evaluation) are used as the structure for content presentation. When a health problem is discussed, the relevant client, group or community assessments are first presented - whether physical, psychological, social, environmental, or diagnostic. Appropriate nursing diagnoses are then shared, and the usual goals for care of clients with that health problem are discussed. The various treatment modalities, including diet therapy and pharmacology, are detailed as the intervention/implementation phase of the nursing process. Evaluation of treatment outcomes is covered by outlining realistic achievable objectives for the nursing care of clients with the health problems being presented. Thus the student proceeds through the four phases of the nursing process in learning the course content.
Sample nursing care plans, which are included in the pre-purchased syllabus, serve as written examples of the nursing process approach; for example, in the class materials for chronic obstructive pulmonary disease a patient profile is included. The appropriate, individualized nursing diagnoses are then discussed, e.g., "alteration in self-care activities related to a chronic disability compounded by hospitalization." An example of the goals and outcome criteria that are associated with this nursing assessment and diagnosis, and are included in the care plan, is
Patient will maintain the fullest possible functioning role as evidenced by establishing and carrying out own daily care routines while hospitalized; developing adaptive approaches to the performance of activities of daily living: and progressive increases in activity and exercise without tachypnea, dyspnea, tachycardia or hypotension.
Suggested nursing interventions include the following: position all hygiene supplies at the sink on a table such that the patient can sit, with elbows supported, when shaving, washing, brushing teeth, etc.; observe for and encourage diaphragmatic inspiration and pursed-lip expiration during activities of daily living; instruct the patient in, and assist in the performance of "general conditioning" tid., i.e., walk with the patient until the patient's pulse is 110, rest for five minutes; check the patient's pulse for return to his normal baseline; repeat twice . . . gradually increase the pace and distance of walking to achieve the 110 pulse. The evaluation phase would then be discussed as the phase where predesignated criteria are checked and the level of goalattainment is measured. Thus, use of the nursing process is clearly identified as the basis of all nursing care.
Though organizing a baccalaureate nursing curriculum around health problems makes it difficult to include the essential elements of professional nursing, faculty have found the task to be achievable. Students have found the course to be "challenging," "rewarding," and "extremely relevant to their clinical practice." In an evaluation done by students (N = 70) at the end of the first running of the course, 74% found that the course met its purpose of providing a basis for nursing care of patients with common health problems "very well." The remaining 26% thought the course met its objective "adequately." No one felt that the course met its objective "poorly" or "very poorly." One-hundred percent found lectures and class outlines helpful.
The only negative aspect of the course from the students' perspective was the quantity of material covered; 11% found the required readings to be too numerous, and a few (N = 5) commented that the pace in the course was too rapid. When the course was taught the first time some students were also concerned that an excessive amount of time was given to pathophysiology. That was corrected in the subsequent semester by offering a pathophysiology course prior to the health-problems course rather than concurrently. Subsequent student groups have not expressed this concern.
The overall positive responses to the courses success have continued, though the volume of material continues to be a problem for some students. Despite these few negatives, the approach has proven valuable to helping students to learn conceptually-based professional nursing and to feel more comfortable in the world of health care which is organized around the medical-model/body-systems framework.