Primary health care is being adopted by Canadian politicians as the organizing framework for reform of the health care system (World Health Organization, 1978). The nursing profession advocates the development of health-promoting, community-based services (Canadian Nurses Association, 1988, 1989). To facilitate the development of innovative and responsive health services based on a nursing perspective, an increasing number of nurses need to become involved in health policy decision-making. At present, nurses are infrequently colleagues in either policy formation or implementation, perhaps because of a lack of the necessary educational preparation. Through the acquisition of knowledge and skills, nurses may be in a better position to influence policy decision-making in a time of dramatic change in health care.
To develop competence in health policy, nurse authors advocate the integration of the study of policy within nursing education (Buerhaus, 1992; Choudhry & Callahan, 1993; Raudonis & Griffith, 1991; Thomas & Shelton, 1994; Winter, 1991). However, in a study of health policy content in the curricula of American schools of nursing, Andreoli, Muaser, and Otto (1987) found that health policy did not receive optimal placement in nursing curriculum at either the undergraduate or graduate level.
Andreoli et al. (1987) contend, at the undergraduate and graduate levels, health policy should be integrated into coureework to "whet the appetite" (p. 242) of students for the subject. They recommend sepárate health policy courses be offered as required CCUTBEB in graduate programa. They believe the integration of the subject matter into courses does not allow faculty sufficient time to address health policy issues adequately.
As graduate programs in nursing develop in Canadian universities, a replication of the survey conducted by Andreoli et al. (1987) was undertaken to determine nurses' learning opportunities in health policy.
Nurse authors provide direction in conceptualizing health policy roles and educational requirements. Nursing education for policy-making, according to Walker and Choate (1984), should provide the knowledge and skills for nurses to become evaluators, statespersons, researchers, and theorists. More specifically on the issue, Martin, White, and Hansen (1989) believe education should foster an awareness of healthcare issues and the relation of the health care sector to the economy and wider society. Supporting the idea, LeFort (1993) suggests nurses need to learn about assumptions underlying policy decisione, implications of policies, alternate health policies, and policy-relevant research.
Raudonis and Griffith (1991) highlight potential roles for doctorally prepared nurses in making federal health policy. Knowledge of health care issues, research methods, and policy formation would qualify nurses as primary advisors. Raudonis and Griffith (1991) argue nurses could address vital topics such as access to care, quality and effectiveness of care, ethical issues, and cost containment. Stimpson and Hanley (1991) believe nurses should have an opportunity to become policy analysts. They contend that development of a health policy nursing role as a specialty IB a major step toward including health expertise in policy decision-making and providing assurance that implemented programs will meet the health needs of consumers. StimpBOn and Hanley (1991) outline roles in public office, legislative staff positions, lobbying for health-related organizations, government administration, and the judicial system. In time, through the leadership of educationally qualified nurses, the nursing profession will he in a. better position to shape directions in health care and nursing practice.
While nurses' participation in policy decisions is advocated, the few studies undertaken to determine existence of health policy-making in educational programs are inconclusive. Duna, Hodges, and Colline (1986) found in a study of 72 graduate nursing programs in the United States that
there ia an incongnience between graduate educators' philosophy about the importance of health policy content and their practice in integrating that content into the curriculum (p. 52).
Andreoli et al. (1987) undertook a study of 210 schools to determine the types of courses in nursing programs which addressed health policy. They found that, while health policy is integrated within nursing curricula, it did not have optimal placement in nursing baccalaureate or graduate levels.
Solomon and Roe (1986) concluded through a telephone survey of 21 nursing programs that health policy is integrated into the curricula. Their findings indicate a general awareness of health policy is expected at the undergraduate level, a more thorough understanding at the master's level, and expertise in policy analysis and research at the doctoral level. However, as Solomon and Roe (1986) point out, the study included a convenience sample of schools. The sample was baaed on geographic representation and the likelihood that health policy was a component in the curricula. Therefore, generalization of the findings ia limited.
Andreoh et al. (1987) surveyed 210 randomly selected schools of nursing and found 80% of schools with baccalaureate programs or with baccalaureate and master's programs reported some integrated coursework and all schools with doctoral programs incorporated health policy. Approximately 80% of the schools with some health policy coursework reported that two or more faculty members teach the material. Their principal qualifications included interest in the subject (80%) and active membership in professional nursing organizations (84%). Publication on health policy, lobbying, or experience as an elected official was less common. The teaching strategies used most frequently included debating, writing letters to legislators, and inviting politicians to be claaa speakers. Writing mock bills or mock testimony or serving as legislative staff were the least frequently used methods.
The purpose of this study was to determine the integration of health policy in graduate nursing curricula in Canadian schools of nursing with emphasis on type of coursework, faculty preparation, and teaching strategies.
Health policy is defined as action consciously chosen and negotiated through a political process by elected federal, state, and local government bodies, which is directed toward the health of the public (Andreoli et al-, 1987).
Sample. The original study included schools of nursing offering baccalaureate, master's, and doctoral levels of education. The present study focused on health policy within master's and doctoral programs. Graduate education in nursing is expanding in Canada, particularly with the establishment of doctoral programs. It seemed timely to determine students' learning opportunities at the graduate level in preparation for political leadership.
All schools of nursing with graduate programs (N - 19) responded to the questionnaire, which indicates an interest in the subject. In 1995, there were 17 master's in nursing programs in Canada and 5 doctoral programs in nursing. One additional school had offered doctoral studies in nursing to one student as a special case. Two schools of nursing offered a master's degree in interdisciplinary health sciences, and one of these also offered a doctoral degree in interdisciplinary health sciences. Their responses have beeti included as part of the 19. In 1994, there were 602 nursing faculty in Canadian universities in full-time tenure positions and 22 in part-time positions. In the same year, there were 906 graduate students enrolled on either a full-time or part-time basis (Canadian Association of University Schools of Nursing, 1994).
Five respondents (26.3%) indicated neither a separate course on health policy was offered nor sufficient material on the subject was integrated to answer the rest of the questionnaire. Two of the five respondents stated there were plans to integrate health policy content within courses, while one respondent stated material was not integrated because it was offered in another department. Therefore, fourteen (73.6%) participants answered all the questions.
Instrument. A survey instrument on health policy in nursing curricula, developed by Andreoli et al. (1987), was used in the study. Knowledge of myriad health, health care, professional, organizational, and political issues is requisite to influencing health policy as shown in the Andreoli et al. (1987) health policy definition. The need for broad and indepth knowledge as the basis of reasoned negotiation in health policy decisions led the researchers to pose questions that reveal the prominence of health policy in the curricula, the incorporation of policy matters, the use of teaching strategies for learning about health policy, and the primary qualifications of faculty who teach health policy.
Minor editorial revisione were made to the instrument to make it suitable for a Canadian population. For example, because all Canadian schools of nursing receive government funding, a question to determine whether the respondent is from a private or public school of nursing was deleted.
The instrument was reviewed by two colleagues for face validity. Andreoli et al. (1987) had determined the instrument's reliability by test-retest method among five nurse administrators to be r" = .83. The data were analyzed by calculating the response to each question and percentages.
Procedure. The instrument was mailed to the deans or directors of each school of nursing in Canada that had a master's program or master's and doctoral programs (N - 19) to determine how many included or had planned to include health policy in their curricula. The deans, directors, administrators or faculty désignées were requested to complete the questionnaire.
Findings and Discussion
Type of Coursework. Four of the schools (28.5%) offered health policy as either a separate or an elective course at the master's level, and one of these schools offered an interdisciplinary degree in health studies in which the course was available through another department.
Ten of the 14 participants (71.4%) indicated integrating health policy material within other subject matter. Andreoli et al. (1987) had. a similar finding, slightly more than 80% of the schools with baccalaureate programa and baccalaureate and master's programa reported integrating the material, compared to 100% of schools with doctoral programs. Dunn et al. (1986), in studying graduate programs in nursing, found 31% of respondents offered separate required courses in health policy.
Within the master's and doctoral programs, the subject was included most frequently within professional nursing issues (n = 9, 64.2%); leadership and management (tt - 7, 50%); and community nursing (n = 7, 50%). Health policy was integrated less frequently into nursing research (n = 4, 28.5%). These findings are consistent with Andreoli et al.'s (1987) findings that 63% of respondents integrated health policy content into professional nursing issues, 56.9% into leadership and management, and 51.1% into community nursing. Similarly, health policy was integrated in nursing research less frequently. Dünn et al. (1986) found health policy courses were integrated most frequently into nursing administration and community nursing majors.
In the present study, five respondents included additional courses in which health policy is incorporated:
* Health care delivery system, human responses, and adaptation to alterations in health (ra = 1, 7.1%).
* Context of health care (n = 1,7.1%).
* Economics of health care delivery, health care organization, health care policy, and planning organizational structure, regulation of health professionals (n = 1, 7.1%).
* Policy process Oi = 1, 7.1%).
* Policy, politics, and change (TI = 1, 7.1%).
The 14 issues addressed most frequently in either separate or integrated courses are health care financing (n = 12, 85.7%); organization of health care services (n. - 12, 85.7%); resource allocation (n = 11. 78%); health planning (n = 10, 71.4%); cost containment (n = 10, 71.4%); licensing and accreditation (n - 9, 64.2%); nurse practice act (n - 9, 64.2%); comparative health systems policy (n - 9, 64.2%); economic regulations, governance and consumer control, history of health policy, intergovernmental regulations, health manpower, and long-term health- issues identified by 8 (57.1%) respondents as less relevant.
The health policy issues included most frequently in nursing curricula according to the Andreoli et al. (1987) study in rank order were:
* Nurse practice act.
* Licensing and accreditation.
* Health care financing.
* Organization of health care services.
* Quality assurance.
* Cost containment.
* Health promotion and disease prevention.
* Health planning.
* Resource allocation.
* Institutional accountability.
The health policy issues included in nursing curricula are similar between the present study and the Andreoli et al. (1987) study, with greater emphasis in the latter study on the nurse practice act and licensing and accreditation. The Canadian study finding that health care financing, organization of health care services, resource allocation, health planning, and cost containment are priority issues rather than the nurse practice act and licensing and accreditation may reflect the changing economic environment in the 9 years following the Andreoli et al. (1987) study. With respect to categorical health issues, the Andreoli et al. (1987) study found health promotion was incorporated most frequently, while long-term care was integrated most frequently in Canadian graduate programa in nursing. This finding may reflect nurses' concern for the health care issues of the population as it ages.
Faculty Who Teach the Subject. Seven schools (50%) reported two or more faculty members teach health policy content, while five (35.7%) reported one faculty member teaches the subject. One respondent indicated the number of faculty members teaching the subject varies from year to year. In the Andreoli et al. (1987) study, approximately 80% of the schools with some type of health policy coursework reported two or more faculty members teaching the subject matter.
The primary qualifications for the faculty members teaching the subject were identified as interest in the subject (n ~ 13, 92%); prior teaching of the subject in - 11, 78.5%); member of local, provincial, and national government committees (n = 9, 64%); active member of professional organization (n = 8, 57.1%); and graduate coursework related to health policy (n = 7, 50%). Ranked low as qualifications for teaching health policy were publication in health policy, serving as lobbyists, or experience as an elected official. Andreoli et al. (1987) had similar findings. Dunn et al. (1986) also found faculty were prepared by education, professional involvement, and employment experiences. Solomon and Roe (1986) reported relatively few faculty were well prepared to teach health policy and, therefore, rely on guest speakers.
Teaching Strategies. The teaching strategies used most frequently in either separate or integrated courses were participating in class debates on health policy issues (B = 11, 78.5%); inviting politicians as class speakers (n = 7, 50%); and writing position papers (n = 7, 50%). Ranked low were lobbying for health policy issues (« = 3, 21.4%); attending legislative sessions (n- 2, 14.2%); writing a bill for potential legislative enactment (n = 1, 7.1%); and writing mock testimony for hearings on a specific bill (n = 1, 7.1%). Two respondents indicated additional strategies which involved practical, experiential learning opportunities. For example, attending and analyzing key committee meetings or hearings (n = 1, 7.1%) and learning a methodology with which to analyze a political environment and learning how to intervene politically on a policy issue (n = 1, 7.1%) were mentioned. Andreoli et al. (1987) also found the least used teaching strategies were writing mock sills and mock testimonies, and serving as a legislative member.
Andreoli et al. (1987) recommend theoretical courees on health policy be offered as separate and required courses within graduate programs in nursing. The knowledge of policy needed for political leadership is diverse and indepth. Comprehensive learning about the material could be enhanced if theory from different areas including nursing, policy formation, and health care organisation were integrated within discrete courses.
Andreoli et al. (1987) also indicate students, especially at the graduate level, should be encouraged to participate in legislative internships and in mentorship opportunities with politically active health professionals. They suggest students could, thereby, learn about the policy-making process as well as the networks of organizations and individuals involved in the formation and implementation of policy. Through such practical learning opportunities, nurses could prepare for specialty roles such as policy analysts, as proposed by Stimpson and Hanley (1991), in health care reform.
Andreoli et al. (1987) suggest nurse educators, as role models for students, should be informed and enthusiastic about health policy issues. They believe faculty should participate in development programs on health policy and political initiatives of their professional associations. In addition, they contend faculty members should be encouraged by their administrators to conduct research and publish on health policy that affects nursing and nursing education.
However, this Canadian study of health polity in graduate education found, as in the 1987 Andreoli et al. study, that health policy content was integrated most frequently into professional nursing courses rather than offered within discrete courses; studente' learning experiences were primarily classroom based; and faculty members' interest in health policy or prior experience teaching the subject were most frequently cited aa qualifications for teaching health policy content- serving as lobbyists or elected officials was less common.
Although health policy is incorporated into Canadian graduate programs in nursing, there is minimal movement toward the offering of separate courses in health policy, internships, or enhancement of faculty qualifications, as Andreoli et al. recommended in 1987. One may ask, "Is health policy integrated into nursing curricula because of educators' deliberate plan for change or by chance, based on individual faculty members' interests and opportunities?"
Nurses who are educated in the area of health policy may be in a better position to contribute to health policy decisions and to advocate for health care reform based on nursing perspectives. However, preparing nurses adequately requires a concerted effort by a proportion of nurse educators in the development of the study of policy. To promote the integration of health policy in graduate programs, there is a need to further understand nurse educators' views on the role of nurses in health policy decisions, on the integration of health policy content including the most effective means to incorporate theoretical and practical learning experiences, and on the factors that act as, impediments to faculty participation in health policy decision-making and political activity. The research findings may serve as a catalyst for change in nursing education with potential long-term benefits in health care.
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