Infertility has been defined as the inability to conceive or complete a pregnancy after 1 year of sexual intercourse without birth control (Blenner, 1990). One of every six couples (approximately 17%) experiences infertility, and this number is increasing steadily (Daniluk, 1988). In 1990, more than 1 million new clients were reported to have Bought treatment for infertility, which ia six times the number treated for cancer and 10 times the number of AIDS cases reported (Sandelowski, 1993). This increasing number of couples entering the health care system seeking assistance with infertility necessitates preparation of nurse generaliste with the skills and knowledge necessary to provide high-quality nursing care in this area.
One of the more frequent problems reported in the literature regarding infertile couples' perception of their experience is the lack of understanding and knowledge of health care professionals about what they were going through (Daniluk, 1988). Davis and Dearman (1991) noted in a report of coping strategies of infertile women that "none of the subjects stated that health care providers helped them to cope" (p. 227).
Support has been cited as a very important intervention in assisting infertile couples to cope with their situation and is one of the primary functions of nurses (Berg & Wilson, 1990; Bernstien, Mattel, & Kellner, 1988; Valentine, 1986). When infertile couples begin the "maze" to resolve their infertility, nurses are often the first and most frequent members of the health care team with whom the couple will have contact. It is difficult for nurses to provide this support without adequate knowledge regarding infertility, particularly the emotional costs.
There is much emphasis in nursing education currently on the need to prepare new graduates to be able to meet the needs of clients, with increased emphasis on preparing nurse graduates to function in community and ambulatory care settinge where much of health care ie provided. For infertile couples, these are primary settings in which they receive assistance. Thus, nurse graduates will encounter these couples more frequently than ever, and the need to prepare nurses with the skills to meet those needs is pressing.
If nurees are not acquiring these skills in school then how do they provide supportive and adequate interventions for infertile couples? The question is: Are schools of nursing incorporating infertility education in their curricula? If infertility information is provided, what is included and how?
A descriptive research design was used for this study. To explore answers to questione regarding infertility information in baccalaureate nursing curricula, a questionnaire was mailed to all 517 baccalaureate nursing schools from the National League for Nursing 1991 listing of stateapproved programs of nursing for BNs. Approval was received from the University's Institutional Review Board. Each school was assigned a code number for follow up. A letter was mailed with the questionnaire and a self- addressed, stamped envelope to the nursing school administrator (e.g., Dean, Director, or Chair). The letter included an explanation of the survey and a request for the administrator to complete the questionnaire or forward it for completion to the most appropriate person. Completion of the questionnaire indicated consent. The questionnaire included five questions and a request for any additional comments respondents wished to include. The questions were:
* Is infertility content included in the curriculum?
* In what course(s) is(are) the content provided?
* What content is included?
* How is the content presented?
* How are students evaluated?
After follow up with postcards, 258 questionnaires comprised the data sample. One school was closing and was dropped from the original count of 517 schools, which yielded a 50% return rate.
Questionnaires were grouped into categories based on respondents' statements of whether infertility information was included in their curriculum. The three categories were:
* None. No infertility information included.
* Minimal If respondents stated such or stated that less than 1 hour was spent on the topic.
* Yes. Infertility information was included.
Descriptive statistics were used to analyze data.
Category I. Of the 258 responses received, 21 (8.1%) did not include infertility in their curricula. However, respondents did indicate the topic was important. The primary reason for nonincluBion was lack of time.
Category H. Thirty-two (12.4%) respondents indicated infertility was included minimally in their curricula. For 24 (75%) of these respondents, the content was provided primarily in a maternity course. The remaining 8 (25%) respondents included this content in courses such as Women's Health, Adult Health, Nursing Process and the Family, and Impaired Health. Topics covered by 4 or more but lees than 16 (50%) respondents in this minimal category included:
* Factors leading to male and female infertility,
* Assessment methods.
* Reproductive health issues.
* Psychosocial factors for couples and families.
* Pharmacological interventions.
* Ethical issues.
Only 7 (21.9%) respondents included content on the emotional and psychosocial factors related to infertility. Additionally, only 3 (9.4%) of the 32 included any information regarding the economic cost of infertility treatment. This area becomes particularly significant when considering how costly this care is and the lack of insurance coverage for much of this care. Only one respondent indicated the nurses' role was included in the content. Lecture and discussion was the most frequently (n = 18, 56%) cited method or teaching strategy for presentation of the material. The majority (n = 20, 62.5%) of respondents evaluated students on the material by use of multiple choice examinations. In those programs where the topic was covered minimally, respondents were more likely than those in Category HI not to evaluate students on the information on a test in = 12, 37.5%).
Of the 30 respondents who made additional comments, 17 (57%) were in agreement that this was an important topic, but the majority (n = 16, 53%) indicated there was not sufficient time to cover it adequately. Two planned to expand this topic's inclusion in the cuniculua in the future, and 5 stated infertility needed to be expanded and explored in greater depth.
Category III. Two hundred ñ ve respondents (79.46%) did include infertility content in their curricula. Five content areas were covered by more than 50% of the schools. These were male causes (n = 128, 62.4%), female causes (n = 138, 67.3%), assessment or work up (n = 125, 60.9%), interventions (n = 137, 66.8%), and emotional and psychosocial issues (n = 126, 61.5%). There were two topics addressed by more than one fourth of respondents- the definition of infertility (n - 55, 26.8%) and nursing roles in = 68, 33.1%). Alternatives such as surrogates and adoption (n - 45, 21.9%), the incidence of infertility (n = 48, 23.4%), and ethics considerations (n = 28, 13.7%) were the other most frequently cited content areas covered. As with the minimal category, the course in which this content was most frequently covered was a maternity/gynecological-type course (n - 171, 83.4%). Other courses included Health Deviation, Secondary Prevention, and Health Care Ethics of the Childbearing Process.
Many respondents used a combination of strategies to address infertility content in their curricula such as the most frequent strategy, lecture and discussion (n = 95, 46.3%). The next most frequently cited strategies were lecture only (n - 75, 36.6%); readings (n = 39, 19%); films, videotapes, or overhead projections (n - 39, 19%); and handouts (n - 22, 10.7%). Other strategies included case studies, seminars, and presentations. Only 12 (5.8%) respondents had reports from or visits to specialists such as obstetricians or gynecologists. Very few (n = 2, .98%) respondents indicated students spent any time in specific clinical experiences or personal contacts with infertile couples.
Tests were the most frequent method of evaluation (n = 180, 87.8%). Evaluation of class discussione (n = 12, 5.8%) and class presentations (n = 4, 1.9%) were the next most frequently cited methods. Graded papers, modules, and essays was the next most frequently cited evaluation method (n = 7, 3.4%). Four respondents did not evaluate the content in any way.
Additional comments from respondents in this category included responses similar to those in the minimal category. The topic was considered important, but inadequate time was again the most frequent comment cited. Other comments included "the high technological advances make it difficult to keep up" and " interesting field, needs more regulation." Several respondents (n = 7, 3.4%) commented that infertility should be emphasized because of the increased incidence. One respondent noted:
with the ever-growing number of couples experiencing infertility, the student is certain to come in contact with such individuala in the health system, in their personal contacte. Education regarding infertility will sensitize them to the seriousness and emotional roller coaster these couples ride.
Social and scientific progress, medical and technological advances, and an increasingly consumer-oriented society with demande for better health services will require a different set of skills and knowledge for nurses (Gordon & Anello, 1T74). Subsequently, curricula designed to prepare nurses must be different and reflective of the needs of current society. As the nature of needs for those members of society who require assistance with infertility increases, nurse educators are challenged to design and deliver a course of study which effectively prepares nurse généraliste to meet those needs. Nurse educators are constantly faced with the dilemma of time and strategy allocation for course content. The solution is the same it has always been- provide content that ie relevant and timely.
The increase in infertility needs certainly makes infertility timely and relevant, and therefore, it should be included in every baccalaureate nursing curriculum. As Sandelowski (1993) reported one specialist declared:
If any other disease showed such an overwhelming surge, the National Institutes of Health would have proclaimed an epidemic and thrown medical centers around the nation into a frenzy of research in a desperate effort M stem the tide (p. 7).
It seems clear the topic is considered important. The question arises: Why is it not included or only included minimally in any school of nureing? Time ie certainly a factor, but one other comment waa striking to this researcher. One respondent noted infertility ia not a significant portion of the NCLEX-RN* examination. The question which then arises is: Are nurses educators leaching to prepare nurse generaliata or to prepare nurses to pass the NCLEX-RN? U would certainly be futile to not acknowledge the importance of adequate preparation to pana the NCLEX-RN for !icensure because without a license nursea cannot practice. However, the education of nurse generellste should be ß reflection of their ability te meet the health needs of current society. Infertility is an increasing part of those needs.
Although time ia a scarce commodity when providing course contant, there can be adequate or effective tame if traditional topics which have little or no relevance to the health care needs of current cliente are limited. It is acceptable to not have enough tune for everything as long as the things included are appropriate. Whatever the time limitation may be, this researcher believe» it is somewhat negligent to not addreae at any point the topic of infertility in Btune manner. If time is a problem, there are many strategies such as some of those noted by the respondents which might entail limited class time but which would give nursing students an introduction and beginning understanding of infertility. These stratégies include videotapes, modulée, and computer simulations.
Some respondents included infertility in discussion of major concepts such as grief and loss, health promotion, and health deviation. When time is limited, it is crucial that several content ateas be addressed to provide basic knowledge and understanding of infertility. These topics include the incidence, etiology, and current treatment modalities including pharmacological factors. The most important of all content is the emotional and psychoeocia) impact of infertility. Infertility is more of an emotional than physical disease because the emotional trauma can be far more damaging than any physical ones. Additionally, as the medical and technological advances increase and emphasis on what can be accomplished physically to enhance the chances of conception ia elevated, the emotional aspects of infertility will become more relevant. Finally, the economic cost of infertility treatment should be addressed. Johnson (1995) noted the consistent minimal or lack of coverage of economic and coet-containment content in nursing curricula. Knowledge of this content becomes particularly significant with infertility treatment because many coste are not covered by insurance and must be paid by clients.
Caution is urged for those nurse educators who present infertility information but do not test or evaluate it. Students may not take the subject matter to heart if they are not tested on it. They are likely to assume that if it is not tested, it is not important, and if it is not important enough to be tested on, why include it at all. Subsequently, incorporation of concepts into practice may be minimal. Covering the information minimally and then not testing on it sends a distinct message about ite significance.
Nurse educators are well aware of time constraints for meeting curriculum goals and objectivée and the subsequent limit on what content can be addressed. Some nurse educators may contend there are many favorite or personal topics of interest certain nurse educators believe should be included in the curriculum, but they all cannot be included. As one respondent noted, "we cannot do the specifics in curriculums." This may be true, but nurse educators must be sure what is included is specific to the health needs of the society in which the nurse generalists will practice. For example, Johnson (1995) noted current nurses need more preparation in critical thinking, management skills, and spirituality. If preparation of nurse generalists is through major concepts, then specific examples are needed to enhance students' understanding of those concepts. Those specific examples should be ones most representative of current health care needs. Infertility is an ideal example to use.
The fact that more than 75% of those surveyed in this sample are including infertility in their curricula is encouraging. However, when the magnitude of the problem is considered, this still is somewhat disconcerting. Although there was a satisfactory return rate (SWb)1 still only hah" of those Hurveyed responded. One cannot be sure what, if anything, those who did not respond are including in their curricula about infertility. Additionally, only baccalaureate schools of nursing were surveyed. The largest number of nursing programs are associate degree programs, which subsequently produce the largest number of graduates who become RNs. Thus, because the largest number of graduates are prepared at the associate degree level, it is these nurses infertile couples are more likely to encounter. Therefore, future research should include a survey of associate degree programs.
Comparable data from a survey of medical schools also would examine content for the general practitioner who may be the first physician a couple visits. As the first medical care provider, sensitivity and understanding are crucial.
Finally, if time is limited for presentation of infertility information, nurse educators should focus on the emotional and peychoeocial aspects because these are the greatest concerns and needs according to infertile couples. Also, technology is continually changing, but the emotional needs of those experiencing the trauma of infertility remain relatively constant.
- Berg, B.J., & Wilson. J.F. (1990). Psychiatrie morbidity in the infertile population: ? «conceptualization. Fertility and Sterility. 53(4), 654-661 .
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- Blenner, J.L. (1990). Passage through infertility treatment: A stage theory Image, 22(3), 153-158.
- Daniluk, J.C. (1988). Infertility: Intrapersonal and interpersonal impact. Fertility and Sterility, 49(6), 982-990.
- Devis, D.. & Dearman, C. (1991). Coping strategies of infertile women. Journal of Obstetric, Gynecologic, and Neonata/ Nursing, 2<N3), 221-228.
- Gordon, M., & Anello, M. (1974). A systemic approach to curriculum revision. Nursing Outlook. 22(15), 306-310.
- Johnson, J.Y. (1995). Curricular trends in accredited generic baccalaureate nursing programs across the United States. Journal of Nursing Education. 3(4). 53-60.
- National League for Nursing. (1991). Slate approved schools of nursing: RN. New York Author.
- Sandelowski, M. (19931- With child in mind: Studies of personal encounters with infertility. Philadelphia: University of Pennsylvania Prese.
- Valentine, O.P. (1986). Psychological impact of infertility·. Ineatifying issues and needa. Social Work in Health Care, 11(4), 61-68.