Precision health (PH), often associated within precision medicine (PM), is defined as the emerging approach for disease treatment and prevention that considers individual variability in genes, environment, and lifestyle for each person (National Institute of Health [NIH], 2020). The PM Initiative promises improvements in the health care system by learning exact disease causations, targeting preventable risk factors, and improving treatments through precise care from genomic sequencing and data analytics. These improvements aim to promote wellness, reduce health care costs, and improve quality. Tremendous support for innovations in PM, and the broader PH, is seen in various industries, including health care, technology, science, finance, and politics.
The PM Initiative, launched by President Obama during his State of the Union address in 2015, allocates $215 million to the efforts of individualizing health care based on the promise of genomics and big data (NIH, n.d.). Advances in science and technology are making this highly individualized type of care possible, notably using “omics.” On the scientific front, there is growing evidence that use of omics—a collective term that integrates features of disparate disciplines including genomics, proteomics, and metabolomics—assists clinicians to accurately identify molecular characteristics of health, diseases, treatments, and individual responses so that appropriate treatments and medications can be identified (Pierce & Henly, 2017). One advancement in PM is in pharmacogenetics through the development of medications based on individual gene makeup, which promises safer and more accurate dosing and increased efficacy (Hull, 2018). On the technological innovation side, one of the proposed strategies that will allow PM to become more accessible is to devise a way to classify data to create meaningful relationships and knowledge that can systematically represent patient-precise information to improve diagnosis and medical treatments. The article by Haendel et al. (2018) explained how electronic health records afford the availability of a wide range of objective and subjective data obtained from observations related to demographic findings, results, symptoms, medications, and nursing interventions. The Office of the National Coordinator was established to support the development of interoperability standards and requirements that address privacy and enable secure exchange of data across systems in a way that is central to the patient and/or consumer. This focus on interoperability (i.e., formation and exchange of health care data and information that are both comparable and shareable) forms a nerve center of activity and conversations central to improving the efficiency and effectiveness of care processes.
Leaders across many disciplines are encouraged to collaborate in creating innovations, explaining emergent ideas, and integrating concepts to praxis. Similarly, the discipline of nursing has received a call to incorporate PM and the broader PH in one's own practice. Several national nursing organizations have voiced support for the PM Initiative. For example, the American Association of Colleges of Nursing (AACN) continues to raise awareness about PM through its research program called All of Us (AACN, 2019), a joint venture with the NIH that provides money to member schools to promote the project and recruit subjects to achieve the goal of enrolling more than one million participants from diverse backgrounds. This research is aimed at discovering the influence of multidimensional influences upon our health and wellness emanating from data where we “live, work, and play.” The Department of Nursing at California State University, San Bernardino (CSUSB) was one of nine U.S. schools to receive the distinctive award during the first cycle of the AACN grant, which culminated in a campus and community-wide event called, So, This is Precision Medicine! (CSUSB, 2019). Similarly, in their conference on Transforming Health and Driving Policy, the American Academy of Nursing (2019) held a session to explore the complexities of PH and encourage future steps in education, research, and practice.
Nursing education should be involved in integrating PM and the broader PH throughout undergraduate and graduate education including in the PhD curricula (Pirschel, 2016). The AACN encourages nursing programs to create doctoral programs of study that sustain excellence and relevance to support the future of nursing by integrating advances in science and using big data analytics (Breslin et al., 2015). Breslin et al. (2015) also asked nurse educators to immerse students at all program levels to develop a culture of inquiry that promotes continuous innovations in patient care. Wyman & Henly (2015) and Barbato et al., (2019) identified that only a few PhD programs offer a plan of study in genomics and genetics. Henly et al. (2015) found that although most PhD programs offer courses in theory, research, statistics, and qualitative methods, it is rare to see programs focusing on emerging areas in science and technology, especially in genomics and big data. Today's nurse educators generally lack formal preparation in informatics and emerging phenomena, such as PM and PH, leaving nurses and novice nurse scientists ill-prepared to grasp the cross-disciplinary innovations necessary to support the goals of the Institute for Healthcare Improvement's Triple Aim initiative (2020), as suggested in the AACN's New Era report (AACN, 2016).
This is a critical time for nursing education to seize the opportunity provided by these new developments in omics technology and science and incorporate them into curricula. Accompanied by heightened consumer engagement in precise care. It is anticipated that PM will soon exist outside of the large institutions and academic medical centers where it is primarily found today (Dorrance et al., 2018). Although practicing nurses and nurse scientists are urged to learn the knowledge, skills, and attitudes in genetic sequencing and conduct omics research, respectively, nursing practice is shaped by those of us who prepare undergraduate students for entry into the profession (Taylor et al., 2017). This group of nurse educators must be responsive and include evidence-based research and advances in science and technology in their plan of study. One challenge brought to higher education in molding imminent practice is to incorporate innovations in medicine and health care information growth; this is evident in newer artificial intelligence and machine learning methods, necessary to manage the abundance of available data. As nursing students fully understand this incorporation of multiple data sources into a single digital health record and decision-support system, they can form actionable insights into care strategy in real time. Nurse educators are uniquely positioned to bridge this chasm—presuming they are involved in scholarly work themselves—that embraces these aspects of nontraditional science and omics technology.
To respond to the national call from the American Academy of Nursing, a small urban department of nursing in Southern California proposed to integrate PH into the undergraduate curriculum. The proposal included revising the mission, vision, and values of the department of nursing and the Bachelor of Science in Nursing conceptual framework to embrace and highlight PH. Essential curriculum threads relevant to precise care, genomics, and big data analytics were distributed across the baccalaureate plan of study, Both the program and course learning outcomes were updated to reflect PH principles and competencies, diffusing critical strands across six selected courses. These courses were selected as key courses that elaborate and apply the concepts of PH. Additionally, to ensure that faculty are supported in these efforts, the authors proposed examples of selected readings, guided activities, and meaningful assignments to address PH which may not be widely available in text print, but more commonly found online outside of traditional scholarly publishing (e.g., professional society meeting proceedings or position statements) (Table A; available in the online version of this article). The authors considered establishing faculty work groups to develop the six nursing courses selected and to facilitate the submission of intramural instructional grants to fund course development opportunities. A set of nine competencies were drafted to elucidate the knowledge, skills, and attitudes of PH capabilities that will help measure student outcomes (Table 1).
Proposed Changes to Integrate Precision Health (PH) in Six Courses
Precision Health (PH) Competencies for the Baccalaureate-Prepared Nurse Graduate
The six courses selected for PH integration were: Foundational Concepts in Nursing, Pathophysiology, Pediatrics, Maternal–Child Health, Nursing Research/Evidence-Based Practice, and Community/Public Health, with PH being applied most heavily in the last two courses. Pharmacology would be another logical course that can integrate innovations in pharmacogenomics, similar to courses above. However, in the BSN curriculum, pharmacogenomics is already included. Therefore, it was not considered in the selected courses.
First, in Foundational Concepts, PH is defined and introduced using digital storytelling that captures the essence of the phenomenon. In Pathophysiology, the profound influence of genetics and genomics are emphasized to associate the extraordinary effect of this content in diagnostic, treatment, and prevention encounters, particularly where effectiveness and avoidance of adversity are involved. In Pediatrics and Maternal–Child Health courses, the discussion of childhood diseases and the trajectory of the pregnancy experience is made more contemporary by adding discussion of the exponential growth in direct-to-consumer genetic testing. The case is made for nursing to play a central role in genetic family counseling given the hype and hope implicit in this growth of consumer-directed testing, especially because it can occur in a dearth of surveillance traditionally expected from the Food and Drug Administration or by government data protection regulation (Federal Trade Commission, 2018; Harbord, 2019).
In nursing research, students are introduced to traditional scientific inquiry, including quantitative, qualitative, and mixed-methods, as well as the development of evidence-based practice. The promise of PH is elaborated through discussion about the adoption of principles of data analytics, which, by definition, entrain the artificial intelligence and machine learning research methods necessitated within. This signals a clear change in direction within undergraduate education towards the population health and informatics competencies often discussed but less often seen.
In the Community Health course, the focus is on the role of the nurse in the community and public health. The nurse is at the center, brokering resources that can easily be deployed with the use of digital software. This level of technology is available through platforms such as ArcGIS®, used for geospatial reasoning to solve location-based clinical dilemmas. Other disciplines are using these strategies to enhance the care of community or population health. Nurse educators should be advocating, for the use of these technologies (i.e., Geographic Information System mapping) for such serious public health problems as temporal spikes in the opioid-crisis or rapidly changing contact-tracing data for pandemics.
The curriculum revision launched in fall 2020, becoming the first integration of conceptual strands on PH taught in the six selected courses (Table 1). One to two test questions were included in the theoretical component of the course to assess student learning outcomes. Clinical applications of PH concepts were measured through its inclusion in patient care maps. At the end of each course, a five-item survey is distributed to the students to assess the level of knowledge, skills, and attitudes competencies achieved by the students. After five semesters, a collection of data will be reviewed to determine whether a PH integration in the curriculum reflects achievement of student learning outcomes. Areas for improvement will be reviewed and a plan for changes will be delivered to the faculty organization.
We value PH as a logical tangent to a more visible emerging phenomenon (i.e., PM) and appreciate that each movement exists in an early evolutionary stage in the nursing, medical, scientific, and innovation literature. Although precision nursing has yet to be defined—given that the term and concept currently exist in rudimentary and pluripotential stages—we believe that nurse educators are well-positioned to begin teaching future nurses about PH and PM, discussing scientific advances in omics technologies and big data that result in actionable patient care insights and aspirations for improved nursing research abilities. The question remains: Are nurse educators going to transform nursing education or expose another “missed opportunity” instead—that of continued siloed scholarship and a failure to develop interprofessional partnerships that will secure nursing's place on the table in deciding the pathway for improved health care (AACN, 2016)? It is incumbent upon nurse educators and nurse scholars to move with the health care revolution and equip future nurses with the knowledge, skills, and attitudes needed to practice efficiently and effectively.
- American Academy of Nursing. (2019, October29–31). The future of personalized care: Exploring the complexities of precision health [Conference]. Transforming Health, Driving Policy Conference. , Washington, DC, United States. .
- American Association of Colleges of Nursing. (2016). Advancing health-care transformation: A new era for academic nursing. Manatt Health.
- American Association of Colleges of Nursing. (2019). All of us research mini grant. https://www.aacnnursing.org/Policy-Advocacy/View/ArticleId/23339/All-of-Us-Research-Mini-Grant-Program
- Barbato, E. S., Daly, B. J. & Darrah, R. J. (2019). Educating nursing scientists: Integrating genetics and genomics into PhD curricula. Journal of Professional Nursing, 35(2), 89–92 doi:10.1016/j.profnurs.2018.09.002 [CrossRef] PMID:30902411
- Breslin, E., Sebastian, J., Trautman, D. & Rosseter, R. (2015). Sustaining excellence and relevance in PhD nursing education. Nursing Outlook, 63(4), 428–431 doi:10.1016/j.outlook.2015.04.002 [CrossRef] PMID:26187081
- California State University San Bernardino. (2019). CSUSB Department of Nursing will host ‘So This is Precision Medicine!’ on Jan. 16. https://www.csusb.edu/inside/article/447126/csusb-department-nursing-will-host-so-precision-medicine-jan-16
- Dorrance, K. A., Robbins, D. A., Kimsey, L., LaRochelle, J. S. & Durning, S. (2018). Toward a national conversation on health: Disruptive intervention and the transformation from health care to health. Military Medicine, 183(Suppl. 3), 193–197 doi:10.1093/milmed/usy215 [CrossRef] PMID:30462345
- Federal Trade Commission. (2018). Direct-to-consumer genetic tests. https://www.consumer.ftc.gov/articles/0166-direct-consumer-genetic-tests
- Haendel, M. A., Chute, C. G. & Robinson, P. N. (2018). Classification, ontology, and precision medicine. The New England Journal of Medicine, 379(15), 1452–1462 doi:10.1056/NEJMra1615014 [CrossRef] PMID:30304648
- Harbord, K. (2019). Genetic data privacy solution in the GDPR. Texas A & M. Law Review, 269(1), 270–297.
- Henly, S. J., McCarthy, D. O., Wyman, J. F., Stone, P. W., Redeker, N. S., McCarthy, A. M., Alt-White, A. C., Dunbar-Jacob, J., Titler, M. G., Moore, S. M., Heitkemper, M. M. & Conley, Y. P. (2015). Integrating emerging areas of nursing science into PhD programs. Nursing Outlook, 63(4), 408–416 doi:10.1016/j.outlook.2015.04.010 [CrossRef] PMID:26187080
- Hull, S. C. (2018). Are we ready for precision health?Nursing management,49(7), 9–11.
- Institute for Healthcare Improvement. (2020). IHI Triple Aim Initiative: Better care for individuals, better health for populations, and lower per capita costs. doi:10.1097/01.numa.0000538923.68406.3c [CrossRef]
- National Institute of Health. (n.d.). The Precision Medicine Initiative® cohort program. NIH: National Institute on Minority Health and Health Disparities. https://www.nimhd.nih.gov/programs/collab/pmi/
- National Institute of Health. (2020). What is precision medicine?U.S. National Library of Medicine: Genetics Home Reference. https://ghr.nlm.nih.gov/primer/precisionmedicine/definition
- Pierce, J. D. & Henly, S. J. (2017). Omics in nursing science. Nursing Research, 66(2), 61–62 doi:10.1097/NNR.0000000000000205 [CrossRef] PMID:28252567
- Pirschel, C. (2016). How is nursing education embracing precision medicine?ONS Connect, 31(12), 17 PMID:30550673
- Taylor, J. Y., Wright, M. L., Hickey, K. T. & Housman, D. E. (2017). Genome sequencing technologies and nursing: What are the roles of nurses and nurse scientists?Nursing Research, 66(2), 198–205 doi:10.1097/NNR.0000000000000211 [CrossRef] PMID:28252579
- Wyman, J. F. & Henly, S. J. (2015). PhD programs in nursing in the United States: Visibility of American Association of Colleges of Nursing core curricular elements and emerging areas of science. Nursing Outlook, 63(4), 390–397 doi:10.1016/j.outlook.2014.11.003 [CrossRef].
Precision Health (PH) Competencies for the Baccalaureate-Prepared Nurse Graduate
|The Bachelor of Science in Nursing graduate will be able to:
Define basic concepts of PH and other concepts underpinned by PH. (NURS 2602, NURS 3080)
Describe the use of PH and its promise for highly personalized care (NURS 2602, NURS 3080)
Describe the role of global digitalization of health in achieving PH. (NURS 4417)
Describe the importance of genomics and genetics in PH. (NURS 3080)
Identify strengths and weaknesses of personally generated health data in overall health and wellness management of individuals and its importance in the consumer's electronic health record. (NURS 3633, NURS 3635, NURS 4417, NURS 4222)
Apply knowledge of technological innovations, issues and new developments to precise care and clinical social media data. (NURS 3633, NURS 3635, NURS 4222, NURS 4417)
Discuss the reuse of stored clinical/consumer/health systems data for diagnostic, treatment, nursing care, and research purposes. (NURS 4222)
Demonstrate appreciation of the ethical issues surrounding information technology related to security and confidentiality. (NURS 2602, NURS 3633, NURS 3635, NURS 4417, NURS 4222)
Participate in advocacy for the application and advancement of PH. (NURS 2602)
Proposed Changes to Integrate Precision Health (PH) in Six Courses
|Course (Course Abbreviation)||Course Learning Outcomes (CLO)a||Concept Strands||Assigned Readings and Activities|
|Concepts (NURS 2602)||CLO 2: Learners will analyze concepts necessary for PH and culturally competent nursing care.||PH
Digital health||What is Precision Health?https://ihpi.umich.edu/policy-priorities/precision-healthWhat is Precision Medicine?https://www.youtube.com/watch?v=zhS9WZiU46sThe Story of Digital Health https://www.youtube.com/watch?v=HSOhdmV8WsY|
|Pathophysiology (NURS 3080)||CLO 5: Describe genetic, genomics, and epigenetic influences on disease.||Genomics||Genomic Competency Website Genetics 101
|Pediatrics (NURS 3635)||CLO 1: Demonstrate precise, culturally sensitive, ethical, developmentally appropriate, evidence-based care of neonates, infants, children, and adolescents with acute and chronic conditions and their families/caregivers.||Precise care direct-to consumer testing
Genetic Information Nondiscrimination Act
Global Data Protection Regulation||Family Health History and Your Childhttps://www.cdc.gov/genomics/famhistory/famhist_child.htmWhat Parents Need to Know about Genetic Testing?https://jamanetwork.com/journals/jamapediatrics/fullarticle/2725883Family Health History Case Studies for Clinicians
|Maternal–Child Health (NURS 3633)||CLO 4: Discuss health promotion and disease and injury prevention while providing precise care for women, newborns, and family.||Carrier screening: Current recommendations||What Moms-To-Be Need to Know about Prenatal Genetic Testinghttps://healthblog.uofmhealth.org/womens-health/what-moms-to-be-should-know-about-prenatal-genetic-testingFamily Health History Case Studies for Clinicians
|Research/Evidence-Based Practice (NURS 4222)||CLO 1: Describe the relationship of nursing theory, research, evidence-based practice, quality improvement, and data analytics.
CLO 3: Describe the research process (traditional & data analytical approaches) from development of the research question through dissemination of findings.
CLO 7: Demonstrate information literacy skills for retrieval, organization, leveling, and evaluation of evidence.
CLO 9: Demonstrate beginning competence in the evidence-based practice process from clinical question formation through judging implications of a body of evidence for practice change.||Data analytics: Nontraditional approaches in conducting research
Gray literature||Genomic Competency Website: Information for Researchershttps://www.cdc.gov/genomics/famhistory/famhist_researchers.htmThe NINR Strategic Plan: Advancing Science, Improving Liveshttps://www.ninr.nih.gov/sites/files/docs/NINR_StratPlan2016_reduced.pdfCoronavirus Global Data Tracker https://www.tableau.com/covid-19-coronavirus-data-resources|
|Community/PH (NURS 4417)||CLO 5: Apply public health principles in the control of disease and the promotion of environmental and PH.
CLO 6: Discuss evidence-based practice in community and PH nursing practice, including the global digitalization of health care.
CLO 8: Use information literacy skills for acquisition of scholarly community and PH literature and access to and use of census data, population databases, and other resources for planning and delivery of community and PH nursing.||Global digitalization of health care
Census data||Genomic Competency Website: Family Health History, in Adults
https://blogs.cdc.gov/genomics/2020/04/06/using-digital/Genomics and Precision Public Health at a Glancehttps://www.cdc.gov/genomics/about/aag/index.htmFamily Health History Case Studies for Clinicians