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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
An Assessment of College Health Nursing Practice: A Wellness Perspective Deborah Bray Preston , Geoffrey Walker Green & Patricia A. Irwin Published online: 07 Jun 2010.
To cite this article: Deborah Bray Preston , Geoffrey Walker Green & Patricia A. Irwin (1990) An Assessment of College Health Nursing Practice: A Wellness Perspective, Journal of Community Health Nursing, 7:2, 97-104, DOI: 10.1207/s15327655jchn0702_6 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0702_6
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1990, 7(2), 97-104 Copyright O 1990, Lawrence Erlbaum Associates, Inc.
An Assessment of College Health Nursing Practice: A Wellness Perspective
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Deborah Bray Preston, PhD, RN, Geoffrey Walker Greene, PhD, RD, and Patricia A. Irwin, BSN, R N The Pennsylvania State University
Currently, in the United States, there are in excess of 12 million students enrolled in 3,253 institutions of higher learning (Zapka & Love, 1986). Although some of these students are older adults and foreign students, the majority are young adults preparing for a variety of careers (American Nurses' Association [ANA], 1986). Many are away from home and from parental guidance for the first time and are having to assume, among other things, primary responsibility for their own health. This population is active, curious, risk taking and oriented toward personal growth and social concerns. It is fundamentally a healthy group whose illnesses for the most part are predominately acute and minor (e.g., upper respiratory infections, gastrointestinal infections, minor trauma, etc.; Zapka & Love, 1986). College life is a period of transition from adolescence to adulthood. It is a time of adventure and reality testing. For these reasons, students experience much stress and anxiety as they struggle to become differentiated from their parents and progress towards adult identities. Lifestyle choices that are made to cope with stress can place these young people at risk for substance abuse, suicidal behavior, pregnancy, sexually transmitted diseases (STDs-including acquired immune deficiency syndrome [AIDS]), and eating disorders to name a few (Peplau, 1986). The college health nurse is in a strong position not only to assist students in health maintenance and the management of illnesses but also to help them prevent ill health by promoting healthy behaviors (Heffern, 1985). Indeed, Peplau (1986) advocated that the emphasis of college health nursing practice should be on the latter through health counseling and health education. Although few studies have been done which document the scope of practice of college health nursing, the Council of Community Health Nurses, under the direction of the ANA, has developed standards reflecting current knowledge in the field. These standards depict a level of nursing performance that applies to nursing practice in any college health setting and are based on a model of nursing directed toward wellness and self-care. In addition, they are written within the framework of the nursing process. Intervention -
-
Requests for reprints should be sent to Deborah Bray Preston, PhD, RN, College of Health and Human Development, 309A Health and Human Development, The Pennsylvania State University, University Park, PA 16802.
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strategies suggested in these standards include the employment of teaching and learning theory and health counseling (ANA, 1986). There are, however, difficulties with this approach. One is that some college administrators view college health nurses in the traditional sense-that is, as acute care givers only. In addition, they fail to see college health nurses as effective professionals and colleagues within the academic community (Heffern, 1985). Another problem is that many college health nurses, either by choice or because of administrative barriers, limit their work to dispensing medications and dressings and carrying out medical orders (Peplau, 1986). A final difficulty may be that the educational preparation of college health nurses may not have included study of the nursing process, health promotion and disease prevention, and/or principles of health education and counseling. It seems that there may very well be a discrepancy between the expected standards of practice of college health nurses designed to meet the wellness needs of college students and the ability of college health nurses to actually meet these needs. This may be due to administrative barriers, nurses' perceptions of their roles in this regard, and possible limitations in their educational background. This pilot study was undertaken in an effort to explore the extent to which a sample of college health nurses was prepared to meet the needs of college students for wellness education.
REVIEW OF THE LITERATURE Issues concerning the importance of wellness education in college health programs and the role of the college health nurse in wellness counseling and education have long been subjects of concern in the literature. Of additional concern have been the educational needs of nurses for this role. College health services began as early as 1825 with the introduction of physical education into college programs. Initially, concerns for student health were instigated in order to improve class attendance (Boynton, 1962). However, the need for health education soon became evident and has been a component of college health since 1859 (Zapka & Love, 1986). College health, as a practice area, was officially recognized in 1920 at the first meeting of the American Student Health Association which later became the American College Health Association (ACHA; Boynton, 1962). Only physicians were present at this meeting although nurses had been active in college health programs since the late 19th century. Nursing participation in this association is documented as early as 1936 but the profession was not fully recognized in this organization until 1959 when it was designated a separate section (Heffern, 1988). The first study which documents the role of the college health nurse and the importance of college health nursing practice was published in 1935. In this study, Moorhouse (1935) personally interviewed directors of college health services in 11 different settings. Her purpose was to find out the extent to which nurses were con-
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tributing to these programs and to determine what the educational qualifications for college health nurses should be. Her findings suggested that nurses were actively involved in all aspects of college health from acute care to wellness programming but that these involvements were dependent on physician involvement. For example, in institutions with full-time physicians, nursing practice was limited mostly to the acute care needs of students and to assisting the medical staff. However, in institutions where nurses were in charge of health services, they were actively involved in the health education of students. Moorhouse concluded that professional preparation for college health nurses should be a bachelors degree which included public health training. She stressed the importance of college health nurses being of the same status as other college educators in order to function as full participants in the academic setting. In a landmark study of the role of the nurse in disease prevention in a university health service, Hathaway (1962) advocated that prevention was best initiated through health counseling by nurses during health examinations of new students. He felt that nurses with public health preparation or experience in outpatient services were best suited for health counseling. Results of the study in which nurseconducted interviews during health exams were compared to physician-conducted interviews suggest that students interviewed by a nurse reported more opportunity to discuss their health problems, a clearer idea of available health services, and were more likely to feel that the nurse was interested in them as individuals (Davie, 1962; Fitzgerald, Croughwell, & Brown, 1962; Hathaway, Brown, & Meigs, 1960). Since these early studies, a number of writers and researchers have supported these findings. For example, Ford (1964) asserted that nurses, including college health nurses, who were well-prepared for their modern roles, needed to view themselves as health educators and counselors and as part of the scholarly community. In a later article, Fitzgerald (1967) described university student populations as having overwhelming mental health and adjustment needs and advocated continuing education for college health nurses in health education and counseling to meet these needs. Similarly, Kelander (1968) suggested that college health programs needed to produce health outcomes and educational outcomes and that each contact a student had with health services needed to be an educational experience. He stated that college health nurses needed to fill this teaching role which should include individual and group teaching and counseling. He advocated that the educational preparation for college health nurses should include courses in teaching methodology, curriculum construction, and counseling. In 1965, the University of Colorado School of Nursing received a grant from the U.S. Public Health Service to conduct the nation's first continuing education course in college health nursing. Titled "New Perspectives in College Health Nursing," the program was designed to upgrade the educational levels of nurses who function in college health settings (Editorial Comment, 1965). The purpose of the program was to increase understanding and skills in health teaching, counseling, and administration with a focus on wellness. This was accomplished through a variety of experi-
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ences which included group work, role playing, and teaching projects. Results indicated that nurse participants reported increased insights into their practice and increased willingness to change and continue learning (Ford, 1969; Ford & Popiel, 1968). An evaluation of the effectiveness of this program indicated that overall, participants improved their knowledge of the young adult and their skills in counseling and health education. Many had changed their ideas of their role and their ability to improve the health of college students. Findings also suggested, however, that barriers in some college health systems reduced nurses' ability to practice in this expanded role (Popiel, 1971). In a small study of college health nurses, Sedgwick and Dykstra (1976) reported that nurses rated counseling and teaching as their most important functions in the student health center but, due to lack of time, these functions were the least practiced. They also expressed a sense of powerlessness to facilitate changes in the university system which might help them perform these functions. In 1986, Peplau suggested that college students often conceal personal difficulties such as fear of failure, loneliness, and family problems in vague physical complaints to college health nurses in university clinics. She asserted that effective use of counseling by the nurse can facilitate early intervention in students' problems of living. According to Peplau, counseling and sometimes psychotherapy are appropriate functions of college health nurses. Additional writers have advocated that college health nurses need to be university prepared in order to gain strength and acceptance as part of a scholarly community. Certainly, students who graduate from baccalaureate programs are usually trained in health education and counseling techniques and, having been university students themselves, have hopefully gained insight into students' problems (Ford & Popiel, 1968). Further examination of the literature, however, suggests that the educational preparation for college health nurses varies. For example, in 1965, of participants in the "New Perspectives in College Health Nursing" program, only 7.14% had academic degrees (Ford & Popiel, 1%8). In a later study of directors of college health centers, Williamson (1974) found that most nurses were diploma prepared. Similarly, in a study of college health nurse practitioners, researchers found that 60% were diploma educated, 30% baccalaureate, and 10% masters prepared (Moore, Kimball, & Dawson, 1981). Recently, the ACHA in collaboration with the Secretary of Health and Human Services Commission on Nursing surveyed all colleges and universities in the U.S. to determine the effect of the nursing shortage on student health programs. In all, 3,200 surveys were sent out. A total of 3,594 registered nurses were reported to be practicing in the field of college health by the 1,400 responding institutions. Of these, 53% were diploma or Associate Degree prepared, 23% were bachelors prepared, 16% were nurse practitioners, and 8% were masters prepared (Silverton, 1989). In 1987-1988, the nursing section of ACHA surveyed their members. The purpose was to document support for certification of college health nurses. Of the 963 nurses who responded, 85% supported certification. Of the 920 respondents who
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reported their educational backgrounds, 61% were diploma or A.D. prepared, 3 1% had bachelors degrees, and 9% were masters prepared. Educational criteria for certification supported by the majority of these respondents was that the level of preparation be set at the diploma graduate level and above with an additional requirement of experience in college health (DeVoe, 1988). A statement in 1984 by the ACHA advocated that the baccalaureate degree from a National League for Nursing (NLN) accredited school should be the preferred basic preparation for college health nursing practice. This statement suggested that college academic preparation helps nurses gain insight into problems of students and fosters an identification with the academic community ("Health Personnel: Qualifications, Duties and Education, " 1984). Standards for the educational preparation of college health nurses as suggested in the ANA (1986) Standards of Practice stated that "these standards are intended for the nurse generalist practicing in the area of college health nursing" (ANA, 1986, p. 1). In this document, a nurse generalist is defined as: A licensed professional nurse who has a baccalaureate in nursing and is therefore able to provide the full range of nursing care. The generalist seems to improve the quality of life by helping people establish patterns of living based on knowledge, attitude, values, and practices that will enhance optimal health and delay the onset of disease. (ANA, 1986, p. 18)
It is clear from this overview that there is a documented need for wellness education in college health programs and that there is and has been (over 50 years) strong support for college health nursing's role in meeting these needs. Inconsistencies seem to be evident in the education necessary for this role, whether or not college health nurses view this as their role and whether the structure of college health programs facilitate the nurses' provision of wellness care. The purpose of this study was to determine whether or not college health nurses are educationally prepared as health educators and counselors, whether or not they view this as part of their practice, and what difficulties they may have in conducting wellness programs in their practice settings.
METHODS Subjects in this pilot study consisted of a purposive sample of 18 college health nurses representing 18 branch campuses of a major eastern university. A telephone interview with each volunteer subject was conducted to ascertain educational preparation, willingness to provide wellness programming on their campuses, what difficulties might be encountered in presenting a wellness program, and what additional education might be needed in order to conduct these kinds of programs. Based on suggestions derived from the literature and on the suggestions of Kelander (1968) and Peplau (1986), subjects were asked what their highest educational preparation for nursing had been and whether or not either in their nursing educa-
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tion or in their continuing education they had had training in principles of health education, counseling skills, and group facilitation skills. Based on the notion that the ANA Standards of Practice (1986) for college health nurses are written within the framework of the nursing process, subjects were asked whether or not they utilized nursing diagnosis in their practice. In addition, respondents were asked whether or not within the constraints of their jobs they would be willing to offer a wellness program to their students and if so would this be easy or difficult. They were also asked what, if any, additional education they felt they might need to offer a wellness program to students.
RESULTS Results indicated that the majority of respondents were graduates of diploma or associate degree programs (61%) while 11% were bachelors prepared and 28% were masters prepared. Of these, 33% had strong backgrounds in psychiatric nursing, 11% had educational or health education degrees, and 1 nurse was certified in communit y health. Tiventy-eight percent had studied nursing diagnosis and utilized the nursing process in their assessments of students, 61% had learned counseling skills as part of their basic education, in continuing education courses or on the job as part of their mental health practice. Forty-four percent had been trained as group facilitators or had learned group dynamics. Most had learned principles of health education in their initial nursing programs, but only 3 had had advanced courses in health education. Although 89% of the sample professed a willingness to conduct a health promotion program, only 56% stated that they could do so with reasonable ease. Those who expressed difficulty in doing so stated reasons such as lack of administrative support, only able to do illness care due to heavy workload, and difficulty in getting students interested. Most subjects stated they would like more education in counseling skills, group facilitation skills, and curriculum development in order to expand their roles in these directions.
DISCUSSION We consider this study a first step into the investigation of this newly defined specialty area of nursing and we commend those leaders in the field who have put forth the effort to set standards and gain recognition for their practice. It has been over 50 years since Moorhouse's study of college health nurses in which she advocated wellness programming by nurses in college health programs and baccalaureate education with public health training as professional preparation in the field (Moorhouse, 1935). Although there have been many attempts over the years to support the unique-
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ness of college health nursing and to strengthen the professional identity of this specialty area, our data show that there are still barriers. For example, 44% of our sample stated that they would find it difficult to provide wellness programming, while many reported lack of education in counseling, group facilitation, and the nursing process (surely a necessity for understanding and utilizing the ANA Standards of Practice). In addition, the majority were not university educated. This latter finding supports findings reported earlier in this article that, currently, most college health nurses are not university prepared.
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CONCLUSIONS AND RECOMMENDATIONS College campuses are growth spaces for young adults and the objectives of college health services of the future need to be on the potentiation of students (Kaiser, 1988). It is predicted that students' needs for psychological support and preventive services will increase (McGinnis, 1987). We believe that college health nurses must be instrumental in the provision of these services. College health nursing priorities need to be based on a nursing model which focuses holistically on students' needs rather than on bureaucratic or traditional priorities (Field & Winslow, 1985). College health nurses must control their practice. They must do this by upholding ANA Standards of Practice, and by serving as advocates for the health needs of college students. In addition, they must work to change the structure of college health programs in favor of holistic health care which is based on a nursing model as well as on a medical model. We recommend strong continuing education programs which reflect the standards of college health nursing practice and, above all, a certification process for credentialing in the field. REFERENCES American Nurses' Association. (1986). Standards of college health nursingpractice. Kansas City, MO: Author. Boynton, R. E. (1962). Historical development of college health services. Student Medicine, 10(3), 294-305.
Davie, J. S. (1962). How students viewed their health service. Nursing Outlook, 10(8), 534-535. DeVoe, J. (1988). College health nurse certification. Community Health Nurse (CHN) Communique, 5(2), 4.
Editorial comment. (1965). New perspectives in college health nursing. Journal of the American College Health Association, 13(3), 295-297. Field, I,., & Winslow, E. H. (1985). Moving to a nursing model. American Journal of Nursing, 85, 1100-1101.
Fitzgerald, H. (1967). Full use of nurse potential in a college health service. Journal of the American College Health Association, 16, 178- 181. Fitzgerald, H., Croughwell, P., & Brown, M. L. (1962). A new dimension to the nurses role. Nursing O ~ t l o o k10(8), , 535-537. Ford, L. C. (1964). The changing nature of nursing. Journal ofthe American College Health Association. 16, 178-181. Ford, L. C. (1969). Learning experiences-privilege, power, potential and predictions. Journal of the American College Health Association, 17, 360-362.
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Ford, L. C., & Popiel, E. (1968). New perspectives in college health nursing. Journal of the American College Health Association, 16, 372-377. Hathaway, J. S. (1962). The role of the nurse in a university health service. Nursing Outlook, 10(8),
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533-534.
Hathaway, J. S., Brown, M. L., & Meigs, J. W. (1%0). The role of the nurse in the preventive services of a student health clinic: A preliminary report. Student Medicine, 9(2), 137-141. Health personnel: Qualifications, duties, and education. (1984). Journal of the American College Health Association, 32(4), 166- 170. Heffern, M. K. (1985). College health nursing: State of the art. Journal of the American College Health Association, 34, 148-149. Heffern, M. K. (1988). College health nursing past, present and future. Paper presented at the annual meeting of the American College Health Association. Kaiser, L. R. (1988). Impact of the future on college health. Journal of the American College Health Association, 36, 264-271. Kelander, H. F. (1968). The college health nurse's role in health education. Journal of the American College Health Association, 17, 24-28. McGinnis, J. M. (1987). A healthy campus-forecasting from the 1990 health objectives for the nation. Journal of the American College Health, 35, 158-170. Moore, D. J., Kimball, N., & Dawson, L. J. (1981). Nurse practitioners in college health: Where are they now? Journal of the American College Health Association, 29, 227-229. Moorhouse, E. L. (1935). The role of the nurses in a college health program. Public Health Nursing, 27(4), 180-185.
Peplau, H. E. (1986). The nurse as counselor. Journal of the American College Health Association, 34, 11-14.
Popiel, E. S. (1971). Evaluation of the effectiveness of the continuing education course, "New Perspectives in College Health Nursing." Journal of the American College Health Association, 19, 169-173.
Sedgewick, R., & Dykstra, C. (1976). How nurses see their function and power. Journal of the American College Health Association, 24, 245-248. Silverton, D. (1989). Survey of the nursing shortage within college health. Unpublished report to the American College Health Association, Bethesda, MD. Williamson, J. A. (1974). Survey of attitudes of directors of campus health centers toward potential college nurse practitioners. Journal of the American College Health Association, 22, 197-199. Zapka, J. G., & Love, M. B. (1986). College health services. Setting for community, organizational, and individual change. Journal of the American College Health Association, 35, 81-91.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
An Assessment of College Health Nursing Practice: A Wellness Perspective Deborah Bray Preston , Geoffrey Walker Green & Patricia A. Irwin Published online: 07 Jun 2010.
To cite this article: Deborah Bray Preston , Geoffrey Walker Green & Patricia A. Irwin (1990) An Assessment of College Health Nursing Practice: A Wellness Perspective, Journal of Community Health Nursing, 7:2, 97-104, DOI: 10.1207/s15327655jchn0702_6 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0702_6
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1990, 7(2), 97-104 Copyright O 1990, Lawrence Erlbaum Associates, Inc.
An Assessment of College Health Nursing Practice: A Wellness Perspective
Downloaded by [UQ Library] at 03:48 13 March 2015
Deborah Bray Preston, PhD, RN, Geoffrey Walker Greene, PhD, RD, and Patricia A. Irwin, BSN, R N The Pennsylvania State University
Currently, in the United States, there are in excess of 12 million students enrolled in 3,253 institutions of higher learning (Zapka & Love, 1986). Although some of these students are older adults and foreign students, the majority are young adults preparing for a variety of careers (American Nurses' Association [ANA], 1986). Many are away from home and from parental guidance for the first time and are having to assume, among other things, primary responsibility for their own health. This population is active, curious, risk taking and oriented toward personal growth and social concerns. It is fundamentally a healthy group whose illnesses for the most part are predominately acute and minor (e.g., upper respiratory infections, gastrointestinal infections, minor trauma, etc.; Zapka & Love, 1986). College life is a period of transition from adolescence to adulthood. It is a time of adventure and reality testing. For these reasons, students experience much stress and anxiety as they struggle to become differentiated from their parents and progress towards adult identities. Lifestyle choices that are made to cope with stress can place these young people at risk for substance abuse, suicidal behavior, pregnancy, sexually transmitted diseases (STDs-including acquired immune deficiency syndrome [AIDS]), and eating disorders to name a few (Peplau, 1986). The college health nurse is in a strong position not only to assist students in health maintenance and the management of illnesses but also to help them prevent ill health by promoting healthy behaviors (Heffern, 1985). Indeed, Peplau (1986) advocated that the emphasis of college health nursing practice should be on the latter through health counseling and health education. Although few studies have been done which document the scope of practice of college health nursing, the Council of Community Health Nurses, under the direction of the ANA, has developed standards reflecting current knowledge in the field. These standards depict a level of nursing performance that applies to nursing practice in any college health setting and are based on a model of nursing directed toward wellness and self-care. In addition, they are written within the framework of the nursing process. Intervention -
-
Requests for reprints should be sent to Deborah Bray Preston, PhD, RN, College of Health and Human Development, 309A Health and Human Development, The Pennsylvania State University, University Park, PA 16802.
Downloaded by [UQ Library] at 03:48 13 March 2015
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strategies suggested in these standards include the employment of teaching and learning theory and health counseling (ANA, 1986). There are, however, difficulties with this approach. One is that some college administrators view college health nurses in the traditional sense-that is, as acute care givers only. In addition, they fail to see college health nurses as effective professionals and colleagues within the academic community (Heffern, 1985). Another problem is that many college health nurses, either by choice or because of administrative barriers, limit their work to dispensing medications and dressings and carrying out medical orders (Peplau, 1986). A final difficulty may be that the educational preparation of college health nurses may not have included study of the nursing process, health promotion and disease prevention, and/or principles of health education and counseling. It seems that there may very well be a discrepancy between the expected standards of practice of college health nurses designed to meet the wellness needs of college students and the ability of college health nurses to actually meet these needs. This may be due to administrative barriers, nurses' perceptions of their roles in this regard, and possible limitations in their educational background. This pilot study was undertaken in an effort to explore the extent to which a sample of college health nurses was prepared to meet the needs of college students for wellness education.
REVIEW OF THE LITERATURE Issues concerning the importance of wellness education in college health programs and the role of the college health nurse in wellness counseling and education have long been subjects of concern in the literature. Of additional concern have been the educational needs of nurses for this role. College health services began as early as 1825 with the introduction of physical education into college programs. Initially, concerns for student health were instigated in order to improve class attendance (Boynton, 1962). However, the need for health education soon became evident and has been a component of college health since 1859 (Zapka & Love, 1986). College health, as a practice area, was officially recognized in 1920 at the first meeting of the American Student Health Association which later became the American College Health Association (ACHA; Boynton, 1962). Only physicians were present at this meeting although nurses had been active in college health programs since the late 19th century. Nursing participation in this association is documented as early as 1936 but the profession was not fully recognized in this organization until 1959 when it was designated a separate section (Heffern, 1988). The first study which documents the role of the college health nurse and the importance of college health nursing practice was published in 1935. In this study, Moorhouse (1935) personally interviewed directors of college health services in 11 different settings. Her purpose was to find out the extent to which nurses were con-
Downloaded by [UQ Library] at 03:48 13 March 2015
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tributing to these programs and to determine what the educational qualifications for college health nurses should be. Her findings suggested that nurses were actively involved in all aspects of college health from acute care to wellness programming but that these involvements were dependent on physician involvement. For example, in institutions with full-time physicians, nursing practice was limited mostly to the acute care needs of students and to assisting the medical staff. However, in institutions where nurses were in charge of health services, they were actively involved in the health education of students. Moorhouse concluded that professional preparation for college health nurses should be a bachelors degree which included public health training. She stressed the importance of college health nurses being of the same status as other college educators in order to function as full participants in the academic setting. In a landmark study of the role of the nurse in disease prevention in a university health service, Hathaway (1962) advocated that prevention was best initiated through health counseling by nurses during health examinations of new students. He felt that nurses with public health preparation or experience in outpatient services were best suited for health counseling. Results of the study in which nurseconducted interviews during health exams were compared to physician-conducted interviews suggest that students interviewed by a nurse reported more opportunity to discuss their health problems, a clearer idea of available health services, and were more likely to feel that the nurse was interested in them as individuals (Davie, 1962; Fitzgerald, Croughwell, & Brown, 1962; Hathaway, Brown, & Meigs, 1960). Since these early studies, a number of writers and researchers have supported these findings. For example, Ford (1964) asserted that nurses, including college health nurses, who were well-prepared for their modern roles, needed to view themselves as health educators and counselors and as part of the scholarly community. In a later article, Fitzgerald (1967) described university student populations as having overwhelming mental health and adjustment needs and advocated continuing education for college health nurses in health education and counseling to meet these needs. Similarly, Kelander (1968) suggested that college health programs needed to produce health outcomes and educational outcomes and that each contact a student had with health services needed to be an educational experience. He stated that college health nurses needed to fill this teaching role which should include individual and group teaching and counseling. He advocated that the educational preparation for college health nurses should include courses in teaching methodology, curriculum construction, and counseling. In 1965, the University of Colorado School of Nursing received a grant from the U.S. Public Health Service to conduct the nation's first continuing education course in college health nursing. Titled "New Perspectives in College Health Nursing," the program was designed to upgrade the educational levels of nurses who function in college health settings (Editorial Comment, 1965). The purpose of the program was to increase understanding and skills in health teaching, counseling, and administration with a focus on wellness. This was accomplished through a variety of experi-
Downloaded by [UQ Library] at 03:48 13 March 2015
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ences which included group work, role playing, and teaching projects. Results indicated that nurse participants reported increased insights into their practice and increased willingness to change and continue learning (Ford, 1969; Ford & Popiel, 1968). An evaluation of the effectiveness of this program indicated that overall, participants improved their knowledge of the young adult and their skills in counseling and health education. Many had changed their ideas of their role and their ability to improve the health of college students. Findings also suggested, however, that barriers in some college health systems reduced nurses' ability to practice in this expanded role (Popiel, 1971). In a small study of college health nurses, Sedgwick and Dykstra (1976) reported that nurses rated counseling and teaching as their most important functions in the student health center but, due to lack of time, these functions were the least practiced. They also expressed a sense of powerlessness to facilitate changes in the university system which might help them perform these functions. In 1986, Peplau suggested that college students often conceal personal difficulties such as fear of failure, loneliness, and family problems in vague physical complaints to college health nurses in university clinics. She asserted that effective use of counseling by the nurse can facilitate early intervention in students' problems of living. According to Peplau, counseling and sometimes psychotherapy are appropriate functions of college health nurses. Additional writers have advocated that college health nurses need to be university prepared in order to gain strength and acceptance as part of a scholarly community. Certainly, students who graduate from baccalaureate programs are usually trained in health education and counseling techniques and, having been university students themselves, have hopefully gained insight into students' problems (Ford & Popiel, 1968). Further examination of the literature, however, suggests that the educational preparation for college health nurses varies. For example, in 1965, of participants in the "New Perspectives in College Health Nursing" program, only 7.14% had academic degrees (Ford & Popiel, 1%8). In a later study of directors of college health centers, Williamson (1974) found that most nurses were diploma prepared. Similarly, in a study of college health nurse practitioners, researchers found that 60% were diploma educated, 30% baccalaureate, and 10% masters prepared (Moore, Kimball, & Dawson, 1981). Recently, the ACHA in collaboration with the Secretary of Health and Human Services Commission on Nursing surveyed all colleges and universities in the U.S. to determine the effect of the nursing shortage on student health programs. In all, 3,200 surveys were sent out. A total of 3,594 registered nurses were reported to be practicing in the field of college health by the 1,400 responding institutions. Of these, 53% were diploma or Associate Degree prepared, 23% were bachelors prepared, 16% were nurse practitioners, and 8% were masters prepared (Silverton, 1989). In 1987-1988, the nursing section of ACHA surveyed their members. The purpose was to document support for certification of college health nurses. Of the 963 nurses who responded, 85% supported certification. Of the 920 respondents who
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reported their educational backgrounds, 61% were diploma or A.D. prepared, 3 1% had bachelors degrees, and 9% were masters prepared. Educational criteria for certification supported by the majority of these respondents was that the level of preparation be set at the diploma graduate level and above with an additional requirement of experience in college health (DeVoe, 1988). A statement in 1984 by the ACHA advocated that the baccalaureate degree from a National League for Nursing (NLN) accredited school should be the preferred basic preparation for college health nursing practice. This statement suggested that college academic preparation helps nurses gain insight into problems of students and fosters an identification with the academic community ("Health Personnel: Qualifications, Duties and Education, " 1984). Standards for the educational preparation of college health nurses as suggested in the ANA (1986) Standards of Practice stated that "these standards are intended for the nurse generalist practicing in the area of college health nursing" (ANA, 1986, p. 1). In this document, a nurse generalist is defined as: A licensed professional nurse who has a baccalaureate in nursing and is therefore able to provide the full range of nursing care. The generalist seems to improve the quality of life by helping people establish patterns of living based on knowledge, attitude, values, and practices that will enhance optimal health and delay the onset of disease. (ANA, 1986, p. 18)
It is clear from this overview that there is a documented need for wellness education in college health programs and that there is and has been (over 50 years) strong support for college health nursing's role in meeting these needs. Inconsistencies seem to be evident in the education necessary for this role, whether or not college health nurses view this as their role and whether the structure of college health programs facilitate the nurses' provision of wellness care. The purpose of this study was to determine whether or not college health nurses are educationally prepared as health educators and counselors, whether or not they view this as part of their practice, and what difficulties they may have in conducting wellness programs in their practice settings.
METHODS Subjects in this pilot study consisted of a purposive sample of 18 college health nurses representing 18 branch campuses of a major eastern university. A telephone interview with each volunteer subject was conducted to ascertain educational preparation, willingness to provide wellness programming on their campuses, what difficulties might be encountered in presenting a wellness program, and what additional education might be needed in order to conduct these kinds of programs. Based on suggestions derived from the literature and on the suggestions of Kelander (1968) and Peplau (1986), subjects were asked what their highest educational preparation for nursing had been and whether or not either in their nursing educa-
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tion or in their continuing education they had had training in principles of health education, counseling skills, and group facilitation skills. Based on the notion that the ANA Standards of Practice (1986) for college health nurses are written within the framework of the nursing process, subjects were asked whether or not they utilized nursing diagnosis in their practice. In addition, respondents were asked whether or not within the constraints of their jobs they would be willing to offer a wellness program to their students and if so would this be easy or difficult. They were also asked what, if any, additional education they felt they might need to offer a wellness program to students.
RESULTS Results indicated that the majority of respondents were graduates of diploma or associate degree programs (61%) while 11% were bachelors prepared and 28% were masters prepared. Of these, 33% had strong backgrounds in psychiatric nursing, 11% had educational or health education degrees, and 1 nurse was certified in communit y health. Tiventy-eight percent had studied nursing diagnosis and utilized the nursing process in their assessments of students, 61% had learned counseling skills as part of their basic education, in continuing education courses or on the job as part of their mental health practice. Forty-four percent had been trained as group facilitators or had learned group dynamics. Most had learned principles of health education in their initial nursing programs, but only 3 had had advanced courses in health education. Although 89% of the sample professed a willingness to conduct a health promotion program, only 56% stated that they could do so with reasonable ease. Those who expressed difficulty in doing so stated reasons such as lack of administrative support, only able to do illness care due to heavy workload, and difficulty in getting students interested. Most subjects stated they would like more education in counseling skills, group facilitation skills, and curriculum development in order to expand their roles in these directions.
DISCUSSION We consider this study a first step into the investigation of this newly defined specialty area of nursing and we commend those leaders in the field who have put forth the effort to set standards and gain recognition for their practice. It has been over 50 years since Moorhouse's study of college health nurses in which she advocated wellness programming by nurses in college health programs and baccalaureate education with public health training as professional preparation in the field (Moorhouse, 1935). Although there have been many attempts over the years to support the unique-
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ness of college health nursing and to strengthen the professional identity of this specialty area, our data show that there are still barriers. For example, 44% of our sample stated that they would find it difficult to provide wellness programming, while many reported lack of education in counseling, group facilitation, and the nursing process (surely a necessity for understanding and utilizing the ANA Standards of Practice). In addition, the majority were not university educated. This latter finding supports findings reported earlier in this article that, currently, most college health nurses are not university prepared.
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CONCLUSIONS AND RECOMMENDATIONS College campuses are growth spaces for young adults and the objectives of college health services of the future need to be on the potentiation of students (Kaiser, 1988). It is predicted that students' needs for psychological support and preventive services will increase (McGinnis, 1987). We believe that college health nurses must be instrumental in the provision of these services. College health nursing priorities need to be based on a nursing model which focuses holistically on students' needs rather than on bureaucratic or traditional priorities (Field & Winslow, 1985). College health nurses must control their practice. They must do this by upholding ANA Standards of Practice, and by serving as advocates for the health needs of college students. In addition, they must work to change the structure of college health programs in favor of holistic health care which is based on a nursing model as well as on a medical model. We recommend strong continuing education programs which reflect the standards of college health nursing practice and, above all, a certification process for credentialing in the field. REFERENCES American Nurses' Association. (1986). Standards of college health nursingpractice. Kansas City, MO: Author. Boynton, R. E. (1962). Historical development of college health services. Student Medicine, 10(3), 294-305.
Davie, J. S. (1962). How students viewed their health service. Nursing Outlook, 10(8), 534-535. DeVoe, J. (1988). College health nurse certification. Community Health Nurse (CHN) Communique, 5(2), 4.
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Fitzgerald, H. (1967). Full use of nurse potential in a college health service. Journal of the American College Health Association, 16, 178- 181. Fitzgerald, H., Croughwell, P., & Brown, M. L. (1962). A new dimension to the nurses role. Nursing O ~ t l o o k10(8), , 535-537. Ford, L. C. (1964). The changing nature of nursing. Journal ofthe American College Health Association. 16, 178-181. Ford, L. C. (1969). Learning experiences-privilege, power, potential and predictions. Journal of the American College Health Association, 17, 360-362.
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Ford, L. C., & Popiel, E. (1968). New perspectives in college health nursing. Journal of the American College Health Association, 16, 372-377. Hathaway, J. S. (1962). The role of the nurse in a university health service. Nursing Outlook, 10(8),
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Hathaway, J. S., Brown, M. L., & Meigs, J. W. (1%0). The role of the nurse in the preventive services of a student health clinic: A preliminary report. Student Medicine, 9(2), 137-141. Health personnel: Qualifications, duties, and education. (1984). Journal of the American College Health Association, 32(4), 166- 170. Heffern, M. K. (1985). College health nursing: State of the art. Journal of the American College Health Association, 34, 148-149. Heffern, M. K. (1988). College health nursing past, present and future. Paper presented at the annual meeting of the American College Health Association. Kaiser, L. R. (1988). Impact of the future on college health. Journal of the American College Health Association, 36, 264-271. Kelander, H. F. (1968). The college health nurse's role in health education. Journal of the American College Health Association, 17, 24-28. McGinnis, J. M. (1987). A healthy campus-forecasting from the 1990 health objectives for the nation. Journal of the American College Health, 35, 158-170. Moore, D. J., Kimball, N., & Dawson, L. J. (1981). Nurse practitioners in college health: Where are they now? Journal of the American College Health Association, 29, 227-229. Moorhouse, E. L. (1935). The role of the nurses in a college health program. Public Health Nursing, 27(4), 180-185.
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Sedgewick, R., & Dykstra, C. (1976). How nurses see their function and power. Journal of the American College Health Association, 24, 245-248. Silverton, D. (1989). Survey of the nursing shortage within college health. Unpublished report to the American College Health Association, Bethesda, MD. Williamson, J. A. (1974). Survey of attitudes of directors of campus health centers toward potential college nurse practitioners. Journal of the American College Health Association, 22, 197-199. Zapka, J. G., & Love, M. B. (1986). College health services. Setting for community, organizational, and individual change. Journal of the American College Health Association, 35, 81-91.
