Strategies to Prepare Faculty to Integrate Genomics Into Nursing Education Programs

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1 GENETICS AND GENOMICS SERIES Strategies to Prepare Faculty to Integrate Genomics Into Nursing Education Programs Janet K. Williams, PhD, RN, FAAN 1, Cynthia A. Prows, MSN, CNS, FAAN 2, Yvette P. Conley, PhD 3, Julie Eggert, PhD, APRN-BC, GNP, AOCN R 4, Maggie Kirk, PhD, BSc(Hons), DipN, RGN 5, & Francine Nichols, PhD, RN 6 1 Gamma, Kelting Professor of Nursing, The University of Iowa, Iowa City, IA 2 Beta Iota, Clinical Nurse Specialist, Cincinnati Children s Hospital Medical Center, Cincinnati, OH 3 Associate Professor of Nursing and Human Genetics, University of Pittsburgh, Pittsburgh, PA 4 Gamma Mu, Associate Professor and Doctoral Program Coordinator, Mary Cox Professorship, Clemson University, Clemson, SC 5 Upsilon Xi at Large, Professor of Genetics Education, NHS National Genetics Education & Development Centre, University of Glamorgan, Wales, UK 6 Professor, Georgetown University, Washington, DC Key words Genetics, genomics, nursing education Correspondence Dr. Janet K. Williams, 50 Newton Road, Iowa City, IA Accepted March 5, 2011 doi: /j x Abstract Purpose: Faculty knowledge of genomics, learner competencies, and program requirements for nursing education are described to assist educators in introducing genomic information into nursing undergraduate, graduate, postgraduate, and continuing education programs regardless of geographic location. Selected programs in the United States and the United Kingdom are described to illustrate successful approaches used by nursing faculty to enhance their genomic knowledge in order to increase application of genetic and genomic content within nursing education curricula. Organizing Construct: Nursing education guidelines and nursing competencies provide benchmarks for educators in planning genetic and genomic curriculum content and expected learner outcomes. Methods: Elements within competencies from the United States and the United Kingdom are reviewed to provide the framework for faculty knowledge. Strategies to address development of faculty knowledge and expertise are suggested. Continuing education faculty development programs and strategies to develop doctorally prepared nurse scientists who will educate future students in the profession are described. Conclusions: Multiple faculty who are prepared to implement education on genetic and genomic topics are needed at all levels of nursing education. Faculty networking and application of genomic principles to nursing are key elements for sustaining nursing education to produce a nursing workforce that can apply essential genomic knowledge. Clinical Relevance: There is an urgent need to offer genomics in accessible and effective education for nursing practice to optimize health outcomes regardless of geographic location. Genomics, the study of all genes in the human genome, their interactions with the environment, and other psychosocial and cultural influences, is an essential component of nursing education. The ability to use knowledge of genomic aspects of health and disease is an expectation of the nursing profession in implementing each component of professional nursing roles (Consensus Panel on Genetic/Genomic Nursing Competencies, 2009; Kirk, McDonald, Anstey, & Longley 2003). The recognition of genomics as a component of the scientific foundation for nursing was supported in the United States (US) in the 1980s, when federally funded workshops Journal of Nursing Scholarship, 2011; 43:3, C 2011 Sigma Theta Tau International

2 Genomic Nursing Educators Williams et al. called for examining genomic content of curricula, identifying model programs to expand the genomic content, and developing a pool of nurse faculty with preparation in genomics (Forsman, 1988). A genomicsinformed nursing workforce is an international concern, as evidenced by activities in Israel, Canada, Korea, New Zealand, and Turkey to address the lack of genomic nursing educational content (Barnoy & Tabak, 2007, Bottorff et al., 2005; Kim & Han, 2010; Nicol, 2000; Vural, Tomatir, Kurban, & Taspinar, 2008). Efforts are furthest along in the US and the United Kingdom (UK). In the US, members of national nursing organizations, including the American Academy of Nursing, identified the need for genomic content across basic and continuing nursing education programs; opportunities for students to apply this knowledge in the clinical setting with people across the life span throughout the spectrum of health and illness; and resources to prepare faculty (Calzone et al., 2010). Gaps in inclusion of genomic concepts and applications in nursing curricula exist across countries where genomics is a component of health care. Preparation of educators to close this gap is an essential component of achieving a nursing workforce that can use genomic knowledge appropriately. One essential component of nursing education worldwide is agreement on expected genomic competencies. Competencies for the interdisciplinary healthcare workforce were issued by the National Coalition for Health Professional Education (NCHPEG) in 2001, revised in 2007, and served as a guide for creation of genomic competencies for nurses globally (National Coalition for Health Professional Education in Genetics, 2007). The UK developed a multifaceted strategy to assure that healthcare providers are prepared to use genomic information in health care throughout the National Health Service (NHS; Kirk, Tonkin, & Burke, 2008). The education framework developed to inform genomic nursing was recently revised from the original seven, to eight standard statements for U.K. nursing competencies in genetics-genomics (NHS National Genetics Education and Development Centre, 2010). In Japan, nurse leaders identified nursing practice competencies for general nurses and for genetic nurses (Arimori et al., 2007). Genetic and genomic competencies for entry level nurses in the US were developed (Consensus Panel on Genetic/Genomic Nursing Competencies, 2006) and updated in 2009 (Consensus Panel on Genetic/Genomic Nursing Competencies, 2009). Competencies in genomics for graduate nursing students in the US are in development (Seibert, Greco, & Tinley, 2010) and questions specifically addressing genomic concepts are included in some, but not all, advanced practice nursing certification examinations (Seibert, Edwards, & Maradiegue, 2007). Guidelines for Genomic Course Content In the UK, the Nursing and Midwifery Council is primarily responsible for ensuring that all preregistration nurse training programs, all to degree or diploma level, are fit for practice and meet the required standards. Other courses would be accredited either by the university hosting them through their own institutional validation process to nationally agreed benchmarks set by the Quality Assurance Academy for Higher Education, or by professional bodies such as the Royal College of Nursing. Accrediting bodies vary in their expectations for genomic content. The Essentials of Baccalaureate Education for Professional Nursing Practice are U.S. guidelines used by baccalaureate programs to prepare for accreditation by the American Association of Colleges of Nursing (AACN). The AACN Essentials were recently updated to emphasize the impact the Human Genome Project has had on education and clinical practice for nurses and the desire for all baccalaureate graduates to have a basic level of genomic knowledge upon entry into practice (AACN, 2008). Specific directions include genomics as part of a liberal arts education found in courses such as biology, microbiology, and physiology. To meet the AACN requirements and translate genomics to patient care, some U.S. baccalaureate programs now require an individual genomics course in the nursing curriculum (Clemson University, 2010). Others are integrating genomic content throughout the courses within the entire nursing curriculum. The National League for Nursing Accrediting Commission (NLNAC) is another U.S. agency responsible for the specialized accreditation of nursing education programs, including baccalaureate degree programs. NLNAC criteria for accreditation do not specifically address genomic competencies (National League for Nursing Accreditation Commission, Inc., 2008). In addition to regulatory guidelines, The Essentials of Genetic and Genomic Nursing: Competencies, Curricula Guidelines, and Outcome Indicators (2nd edition; Consensus Panel on Genetic/Genomic Nursing Competencies, 2009) and the revised U.K. competencebased framework, Fit for Practice in the Genetics/Genomics Era (http://tiny.cc/ffpggenursingprelimreport), provide useful direction when developing the objectives and syllabi for courses. Incorporating clinical genomics examples so that students can make links between basic concepts and the impact on patient health and patient care is crucial. Independent and Integrated Genomic Content Barriers Despite published competencies that provide the framework for genomics in nursing education across 232

3 Williams et al. Genomic Nursing Educators multiple countries, numerous barriers challenge nurse educators. These barriers reflect limited curricular time, access to education opportunities, and resources within the educational institution to sustain inclusion of genomic content into nursing curricula. A worsening global nursing faculty shortage with overstretched full-time faculty and the increasing use of part-time and clinical-only faculty (Rosenkoetter & Nardi, 2007) challenge any type of curriculum change. Some nursing faculty have limited foundational knowledge (Hetteberg, Prows, Deets, Monsen, & Kenner, 1999) from which to quickly respond to the enlarging research and clinical knowledge base regarding human responses to illness and promotion of health for conditions that have genomic components. In a 2005 national survey of nursing schools within the US, lack of nursing faculty knowledge of genomics was the second most frequently cited barrier to adding genomics to curricula (Prows, Calzone, Jenkins, & Johnson, 2006). Similarly, at a national conference of nurse practitioner faculty, limited genomic knowledge was reported as a critical barrier to teaching the content in nursing curricula (Edwards, Maradiegue, Seibert, Macri, & Sitzer, 2006). Nursing faculty who are prepared in genomics may be the sole genomics expert within the institution, and can quickly become overburdened with providing genomic content within their own courses as well as those of fellow faculty by way of guest lectures. These experts are also often charged with determining the genomics education needs of their fellow faculty. One approach is to use a genomic literacy tool (Daack-Hirsch, Driessnack, & Furukawa, 2010). Results from such assessments guide planning for genomics continuing education strategies such as brown bag series, workshops, online modules, and updates (Edwards et al., 2006; Hetteberg & Prows, 2004). Nursing faculty experts in genomics can assess the feasibility and potential effectiveness of requiring a separate genomics course within a nursing curriculum to assure that students are exposed to appropriate content and that established competencies in genomics are adequately addressed. However, all nursing faculty share responsibility for incorporating genomic content into their courses, and the presence of a separate course should not be viewed as a substitute. The use within the classroom of genetics professionals with medical, counseling, or epidemiological backgrounds is an alternative to bring a unique expertise and application to the student. Another option is to have interdisciplinary content experts from the greater campus community teach or co-teach the course for the nursing program or provide guest lecturers to supplement nursing faculty expertise. Regulatory guidelines and genomic resources can be used in working with faculty experts from other disciplines to identify how best to integrate nursing and genomic expertise into specific courses and clinical experiences. U.S. and U.K. Genomics Education Programs for Nursing Faculty Educators in the US and the UK independently applied elements of genomic nursing competencies in developing champion networks. Each group engaged leaders in the respective national nursing education organizations and engaged nurse educators in development, evaluation, and dissemination of genomic education resources for nurse educators. A champion network of educators across the U.K. universities and a new faculty champion initiative with individual educators in the US each created groups of faculty who are prepared to assist colleagues with curricular integration of genomics, serve as a resource, and determine opportunities to accelerate the change process (Kirk, Tonkin, & Burke, 2008; National Human Genome Research Institute [NHGRI], 2010). These approaches were designed to address the challenges of sustaining a genomics nurse educator workforce. Such challenges include engagement of faculty, including those in clinical settings; questioning the relevance; wondering how to add more content to an already packed curriculum; and the busy lifestyles of tenured and nontenured nursing faculty. U.S. Genomic Nurse Champion Network Federally funded by the NHGRI, Health Resources Services Administration, Bureau of Health Professions, Division of Nursing, and National Cancer Institute, the U.S. Faculty Champion Initiative was designed to assist educators within their own school. After attending an introductory program, invited participants returned to their own institutions and developed innovative approaches to meet the genomic education preparation and knowledge enhancement needs of their individual faculties. Specifically the champions established task forces, created faculty resource websites, developed and dispersed informative monthly newsletters, and identified key stakeholders in their institutions who could support the provision of time and financial resources to... build the genomic education infrastructure for their nursing programs (NHGRI, 2010). A list of these champions with contact information is available at U.K. Genomic Nurse Champion Network The UK takes a national approach to meet the challenges of preparing existing nursing faculty in 233

4 Genomic Nursing Educators Williams et al. genomics, through the work of the NHS National Genetics Education and Development Centre (http://www. geneticseducation.nhs.uk). The Centre was established in 2004 by the U.K. Department of Health to provide a focal point for genomics education and training for professionals throughout the NHS. The Centre aims to provide leadership in genomics education, raise awareness of genomics in healthcare, identify the genomic knowledge, skills, and attitudes that are useful for clinicians roles, develop a framework for competencies in genomics, facilitate the integration of genomics into curricula and courses, and identify and develop resources appropriate to the needs of health professionals and their trainer faculty. Key areas of the program work specifically to support nurses prior to and after their licensure, offer content to midwives and specialist community public health nurses, and include the development of free teaching and learning resources. As faculty integrates genomic content into the curriculum, they may develop independent courses as well as include genomic content across didactic and clinical courses in the nursing curriculum. As part of the U.K. program, the champions network of educators are either directly involved in the delivery of genomics education to nurses and midwives, or are interested in finding out more about the work of the Centre. There are currently 71 members from 53 out of a possible 88 universities involved in nursing-midwifery education. Network members act as a conduit between the Centre and their faculty to disseminate resources and information about new initiatives and training events and to share best practices. They may also become involved with specific initiatives led by Centre staff, such as participating in workshops to review the nursing and midwifery competence frameworks. In return, the staff may assist with delivering presentations to faculty, staff, or students, or meet with curriculum development teams to discuss how their curricula can move forward as genomics is integrated into nursing and midwifery education. The network champions may also contribute to education needs analyses and use that information to directly influence the direction of the program. In one analysis (Kirk & Tonkin, 2006), faculty champions highlighted the value of having access to genomics service professionals and the important role of the Centre in providing guidance and support for curriculum content and delivery. Nursing faculty can refresh their genomic clinical knowledge with a U.K. online resource, Telling Stories Understanding Real Life Genetics (NHS National Genetics Education and Development Centre, 2010). Additional U.S. online genomic resources can be accessed at the Genetics/Genomics Competency Center for Education (G2C2; 2008). The G2C2 portal (http://www.g-2-c- 2.org/) offers a repository of peer-reviewed curricular materials and resources for nurse, physician assistant, and genetic counselor educators. Featured resources are primarily from the US and the UK, although further international representation is possible as new resources can be submitted by any user for consideration. The repository links discipline-specific competencies to peerreviewed relevant genomic continuing education opportunities as well as instructional resources (G2C2, 2010). Doctoral Education Doctoral education in nursing leads to the advanced academic degree awarded by universities that prepares the graduate for a research career or for advanced nursing practice. The AACN (2010) report on the future of the research-focused doctorate emphasizes the need for advancing nursing science to keep pace with basic and applied sciences in health care, noting the importance of interdisciplinary mentorship. Doctor of Philosophy (PhD) and doctor of nursing science (DNS) programs prepare graduates for research. These graduates have the opportunity to use genomics when conducting basic, clinical, and translational research to improve human health. Professional practice doctoral programs, such as those awarding the doctor of nursing practice (DNP), prepare nurses in specialized advanced clinical practice (AACN, 2006). DNPs are increasingly being encouraged to use genomic knowledge in all aspects of advanced clinical practice. For the graduate student interested in a genomics specialty, each type of doctorate requires a strong scientific foundation and appropriate research or clinical training in genomics. In the US, at the University of Iowa both the PhD and the DNP are awarded. The University of Pittsburgh School of Nursing provides a PhD in nursing that is focused on genomics. Another U.S. model is an interdisciplinary program at Clemson University that is accessible to students online. It offers the terminal research degree to students from multiple health-related disciplines including nursing. Some institutions in the US offer either the traditional dissertation or a dissertation in which the student s research is reported in the format of publishable manuscripts. In addition to the traditional route to a PhD through coursework and a dissertation, in the UK, a PhD may also be earned through portfolio. This route is particularly useful for experienced genomics nurses to consolidate existing clinical and research experience to earn a doctorate. At the University of Glamorgan, the doctoral submission must comprise a critical overview to a portfolio of three projects based on the candidate s research and be sufficiently extensive as to provide convincing evidence that the research constitutes a substantial contribution to knowledge or scholarship. These educational 234

5 Williams et al. Genomic Nursing Educators Table 1. Genomic Nursing Postdoctoral Opportunities in US The University of Iowa Postdoctoral Training in Clinical Genetics Research (T32 NR007110) The University of Pittsburgh Targeted Research and Academic Training of Nurses in Genomics (T32 NR ) NINR Extramural Training and Career Opportunities opportunities can prepare doctoral scholars with expertise in focused areas of genomic research, practice, and leadership who can subsequently bring important genomic knowledge to an institution s nursing faculty and curriculum. Postdoctoral Education An important route for PhD-prepared nursing faculty to extend their scientific knowledge as educators of nursing science and to develop their potential for research is through the completion of postdoctoral fellowships (Table 1). In the US, nurses who are U.S. citizens or noncitizen nationals of the US, or who have been lawfully admitted for permanent residence, may qualify for National Institutes of Health (NIH)-funded institutional or individual postdoctoral fellowships for genomic-focused training programs. Generally 2 years in length, these programs provide focused research training including mentorship with senior scientists in nursing and related disciplines, course work, and informal learning opportunities. Postdoctoral fellowships enable nurse faculty to increase the depth of their expertise in specialty areas within which genomics is a key component. Postdoctoral fellowships often build on a genomics focus of research and study during undergraduate and graduate education. Similar opportunities exist in the UK through funding schemes offered by the government-funded research councils or through major charitable organizations. These opportunities would not normally be exclusive to nurses. Continuing Education In addition to formal training leading to a degree or completion of postdoctoral fellowships, continuing education is a key component of preparation for genomic nursing educators. Continuing education includes postdegree education activities that further the nurse s knowledge and skills. In some states in the US, documentation of continuing education is required for renewal of the license to practice professional nursing. The Cincinnati Children s Hospital Medical Center s Genetics Education Program for Nurses (GEPN) is an extension of the NIH and Health Resources and Services Administration funded Genetics Program for Nursing Faculty (GPNF) that began in 1997 (Prows, et al., 2003). This program is designed to help nurses meet NCHPEG and nursing competencies, and provides access to instructional resources to help faculty add genomic content to their curricula. The GPNF phased out an on-site genetics summer institute (GSI) and in its place provided an 18-week, teacher-facilitated, web-based genomics institute (WBGI) in 2002 to continue to provide foundational knowledge in genomics (Prows, Hetteberg, Hopkin, Latta, & Powers, 2004). The purpose of the GSI and the 18-week WBGI was to provide foundational knowledge in genomics. The WBGI continues to be offered twice a year and nursing faculty are the primary participants in each session. Since its inception, 155 nursing faculty and 54 nurse clinicians from the US, Puerto Rico, Mexico, Japan, South Korea, Nigeria, and New Zealand have completed the WBGI. During the sessions, nursing faculty and clinicians developed plans for increasing genomic content in their curricula or practice. Nursing faculty from over 100 different schools of nursing received a copy of a genomics curriculum checklist (Hetteberg & Prows, 2004) to help them evaluate baseline content in their curricula and evaluate changes after their curriculum plans were implemented. Participants from the 14 different WBGI offerings rated their ability to develop a plan, as a result of WBGI content and instructor and participant-peer feedback, as excellent or good. A 5-week Web-based offering, Applying Genomics in Nursing Practice (AGNP), was initiated by the GEPN in The focus of the AGNP is on preparing nurses to obtain family health history, construct pedigrees, identify risk factors, and make referrals (Cincinnati Children s Genetics Education Program for Nurses, 2010). Although the AGNP target audience is nurse clinicians, 73% of the 26 who have completed an AGNP were nursing faculty. In an open-ended question about what participants would tell others about the AGNP, participants overwhelmingly commented on how it enabled them to understand how to apply genomic knowledge in clinically relevant cases with applicability to any area of practice. In addition to supporting preregistration education in the UK, the National Genetics Education and Development Centre has a role in supporting continuing professional development. One approach has been its work with a number of regional genetic centers throughout the UK to develop new roles for practicing genetic counselors. The genetic counselors are released from their clinical roles on a part-time basis to act as genetics education facilitators (GEFs). The GEFs work with the Centre to provide support and training opportunities for nurse faculty, students, and practitioners in their local region, being linked to members of the champion education network where appropriate. The GEFs have been instrumental in 235

6 Genomic Nursing Educators Williams et al. strengthening ties with higher education and developing links between specialist healthcare professionals. National Institute of Nursing Research Summer Genetics Institute The Summer Genetics Institute (SGI) was developed as a competitive 2-month summer research training program by the National Institute of Nursing Research (NINR). It was originally held on the NIH campus in Bethesda, Maryland. The program was designed to provide a foundation in medical molecular genomics for clinical practice and the research laboratory. In 1999, the NINR convened a panel of experts in genomics from nursing and other disciplines to develop the curriculum for the SGI. The expert panel identified foundational and cutting-edge content for the curriculum that included lectures, seminars, and laboratory components. When the reports of the Consensus Panel on Genetic/Genomic Nursing Competencies (2006, 2009) became available, they were used as guidelines for annual curriculum reviews. During the decade of the 8-week SGI program, 182 graduate students, faculty, or clinicians who are citizens or permanent U.S. residents from 126 different universities successfully completed the program. Fifty percent (n = 91) were doctoral students, 42% (n = 75) were faculty in schools of nursing, and 8% (n = 15) were advanced practice nurses. The proportion of doctoral students in the SGI increased steadily each year of the course, from 35% to 68% (SGI enrollment statistics, ). The primary evaluation criteria are the number of federally funded research proposals and peerreviewed journal articles in the genomics area awarded to SGI graduates. As of mid-2010, SGI graduates have published over 150 articles related to genomics in peerreviewed journals. Thirty-five percent of SGI graduates received U.S. federally funded research awards for their proposals initially developed during the SGI. Faculty graduates of the SGI have used their intensive education to implement genomics into nursing curricula. These efforts range from undergraduate curriculum revisions to full doctoral-level courses or programs in genomics. The last SGI in its original 8-week format was held in This program has been revised, and in 2010 the program was condensed to 4 weeks and is currently administered by the Foundation for Advanced Education in the Sciences at the NIH (NINR, 2010). Lessons Learned Despite different models for preparing nursing educators to integrate genomics into their education programs, there are several common experiences. One is that students vary widely in the level or prior preparation on genomics topics. For example, at one university, it was first assumed that undergraduate and graduate students could take the same full semester introductory genomics course and that there would be separate expectations and means of evaluating students at different levels. However, the preparatory knowledge among the students showed significant differences, with the traditional undergraduate students coming into the course with a greater breadth of understanding and appreciation for genomics than registered nurse completion and graduate students. In this setting, faculty offered separate courses for undergraduate and graduate students. The second common experience is the educators need for a network of resources to provide ongoing genomic preparation in this area of ever-expanding knowledge. In the UK, although membership of the champions education network represents 60% of universities responsible for nurse training, 40% do not subscribe to the initiative, and some champions are themselves lone voices. Recognizing the importance of preparing multiple faculty with genomic knowledge, several schools of nursing funded participation for three or more faculty in continuing education programs. Faculty who lack the opportunity to share the responsibilities for including genomic content may find it difficult to sustain and update content across the entire nursing program, and may personally find it difficult to maintain their own expertise. Participation in organizations such as the International Society of Nurses in Genetics, which offers a buddy system in addition to yearly meetings, is an important opportunity for ongoing faculty support. The third common experience is the need for practica that allow students to apply genomic knowledge in clinical decision making. These clinical experiences can be augmented through genomics courses at the undergraduate and graduate level, which include clinical application with appeal to students outside of nursing. When students from other disciplines enroll in these courses, particularly at the graduate level, their diverse backgrounds add tremendously to in-class discussions. The use of case studies to analyze family pedigrees for risk of developing inherited cancers is one strategy for preparing for clinical decisions and implementation of genomic principles into practice, making application immediately apparent to the learner. Conclusions Regardless of the type of educational preparation in genomics, a team of people with genomics expertise and training in a nursing education program is essential to 236

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