Preregistration adult nursing programmes and promotion of a population health agenda: an investigation

Nurses have been identified as key to achieving the United Nations Sustainable Development Goals, as their role has the potential to reduce health inequalities across the life course (World Health Organization (WHO), 2020). However, the role of health professionals is considered to be underutilised in addressing the root causes of poor health in our society (Marmot et al, 2020). Nurses need to develop a clear understanding of population health during their educational experience, if they are to have the knowledge and skills required to fully assume their role in promoting health and preventing ill health (Allen et al, 2013). In 2012, the Willis Commission criticised nursing education in the UK for being overly focused on illness and acute hospital care and failing to prepare nurses for 21st century practice. The report was influential in the subsequent review of nursing education and revised standards of proficiency, which acknowledge the key role of nurses to promote health and prevent ill health (Nursing and Midwifery Council (NMC), 2018).

The aim of population health is the improvement of the physical and mental health outcomes and wellbeing of a defined population, while reducing health inequalities (Robertson, 2018). For pre-registration adult nursing, the knowledge and skills required to contribute to population health are detailed in Platform 2 of the standards of proficiency for nursing education, ‘Promoting health and preventing ill health’, with clear guidelines for curriculum development (NMC, 2018). At the point of registration, nurses in the UK must meet the 12 proficiencies relating to Platform 2, to prepare them to be ‘actively involved in the prevention of and protection against disease and ill health and engage in public health, community development and global health agendas, and in the reduction of health inequalities’ (NMC, 2018). A qualitative study of 24 nurse leaders in Scotland (academia, practice and regulatory sectors) identified the difficulty of making population health learning meaningful to nursing practice; it suggested that giving population health a pivotal place in the programme would encourage educators to ‘develop learning through a population health lens’ (Lasater et al, 2020). Key aspects of a curriculum design that effectively engages students in population health learning have been identified as embedding population health across the curriculum design, enriching student experience through non-clinical work-based learning and ensuring that theory is clearly linked to experiential learning (Whitehead, 2007; Allen et al, 2013; Valentine-Maher et al, 2014).

The Institute of Health Equity recommends specific population health modules to develop students' understanding of wider social determinants, problem-solving in small groups to develop their understanding of how to tackle health inequalities, and non-clinical community placements (Allen et al, 2013). Indeed as far back as 1987, the WHO had already advised that ‘it was necessary to bring those studying for health professions into direct contact with the community environment in order to train them appropriately to practise in the community after graduation’ (WHO, 1987). A number of international studies have shown that exposing students to healthy populations in real-life conversations allows them to develop the communication skills necessary to promote health (Samuels-Dennis et al, 2016; Salerno et al, 2018).

Research has identified that, when taught too early in the curriculum, students doubt the relevance of population health to their future nursing practice (Mooney et al, 2011). A staged approach that develops knowledge as students gain professional maturity and introduces practical application in the third year has been found to be effective in developing student understanding of their role in population health and health promotion (Liimatainen et al, 2001; Mooney et al, 2011).

Norman (2015), in a qualitative study of 40 English secondary schoolchildren, found little understanding of the role of nurses working outside a hospital environment. If young people are to consider a career in nursing, it is important that they have a clear vison of the breadth of 21st century nursing practice. At present, many students enter nursing education with an altruistic desire to care for the sick, with little understanding of the extent of the role nor the wider context in which care takes place (Ten Hoeve et al, 2014). If potential nursing candidates do not imagine a role for nurses beyond a hospital environment, it may be more difficult for students to engage in teaching that is not clinically focused. Marcinowicz et al (2019), in their comparative study of nursing students in four European countries, found that educational practices in nursing education and societal factors influence the vision students have of their future professional role. In their discussion of the literature on the public image of nursing, Ten Hoeve et al (2014) recommended that nurses communicate the scope of their professional role and their contribution to the health care system more widely.

Health promotion and illness prevention in university course descriptions: a review

This review was undertaken as a preliminary stage of doctoral research to identify schools of nursing in England accredited by the NMC with a clear population health agenda (for further research into educational practices). The university webpages for 60 undergraduate adult nursing programmes were explored to discern how adult nursing was portrayed and what place population health was accorded in the programme description for future candidates.

The programme description, video content (n=28) and module information on the webpages were explored to understand how universities portray the wider context in which nurses practice. If the module title did not state key terms in relation to population health explicitly (such as ‘public or population health’, ‘health inequalities’, ‘community’, ‘health promotion’), the module details were consulted to understand if these concepts were included. The findings are presented in Table 1.

Some webpages provide a video tour of the university's simulation suite, which include images of home environments. However, faculty simulation suites are often used by different programmes (for example, paramedical science or post-registration courses) and images or videos of community-based simulation cannot be considered evidence that they are used to teach undergraduate adult nursing students. Only when community simulation was specifically referred to in the text or shown (picture/video) on the adult nursing page was this recorded.

Discussion

Despite health promotion now being a key outcome in the Standards of proficiency for registered nurses (NMC, 2018), only 20% of universities offering an adult nursing programme specifically mentioned health promotion in the main description of the programme on their website. Only three universities expressed their clear commitment to public health teaching (the term ‘population health’ was not used), including research or initiatives such as local partnerships for health promotion project work (for example, mental health awareness programmes). If students are to engage with this aspect of the programme and their future role in health promotion, universities should be identifying the nurses' role in population health as a crucial aspect of professional education (WHO, 2020).

From the review, 20% of universities did not identify a module specifically dedicated to teaching population health or health promotion as part of the pre-registration curriculum on their website. It is possible that these universities integrate the population health agenda into the curriculum by using case studies to illustrate key concepts. However, there is a danger that this strategy might take a biomedical disease-focused approach to teaching population health, in which the emphasis tends to be on individual behaviour alteration rather than examining the impact of the wider determinants of health (Allen et al, 2013; Marmot et al, 2020).

Half of the universities identify a first- or second-year module relating to population health, but only 20% of universities with a first-year module developed student understanding by further learning in the second year of the programme. Mooney et al (2011) added to previous research that warned of the risk that first-year students lacked the maturity to associate population health learning with clinical health promotion practice. Cumulative knowledge-building would allow students the opportunity to move from everyday knowledge on the social determinants of health to an understanding of its professional applications to improve population health (Bernstein, 2000).

Health inequalities are a public health priority and a learning outcome of the NMC (2018) standards of proficiency, but only four universities mentioned health inequalities or poverty in their written presentation of the programme or in the published module details.

Community health and care in the community are major aspects of 21st century health and social care (NHS England, 2019). Only four universities referred to community; one university highlighted research focused on projects aimed at building healthy, sustainable communities; and three other universities included community in the course description. One of these universities specifically mentioned community engagement, with students producing a community scrapbook in the second year, but this was an optional module. If we are to bridge the gap between policy and workforce supply, we need to offer prospective students a clear vision of community nursing roles (NHS England, 2019).

Immersion in non-clinical placements is considered a key aspect of improving students' understanding of the wider determinants of health, allowing students to develop the skills they will need for health promotion practice with the population they will serve after graduation (Allen et al, 2013). A total of 23% of universities promote placement partnerships with the voluntary sector, with two universities using the phrases ‘non-traditional’ or ‘alternative placements’. One university referred specifically to its leadership programme that offers opportunities for community engagement. Another, which had no specific module in population health, offers a second-year elective with experience in civic engagement, and a further two universities mentioned community initiatives that students could be involved in.

Images are a powerful representation of the profession, and the majority of images were hospital-based scenes: basic life support, drips, drugs or stethoscopes. Less than 10% of universities show images of home care or community settings.

Dominiak (2004) discussed how a lack of clear branding might impact nursing as a profession, because branding creates expectation and professional identity. If the brand focus for adult nursing is on hospital nursing, potential candidates who are looking for greater variety in their professional role may choose other professional pathways (Ten Hoeve et al, 2014).

Kearns and Mahon (2021) suggest that marketing nursing as a contemporary career choice has the potential to widen participation by challenging historical stereotypes. Universities need to capitalise on the image of nurses that has been broadcast during the pandemic: a profession founded on competence and adaptability, with strong leadership and a political voice. This would be a shift from the classic image of caring to encompass the breadth of professional proficiencies required for modern nursing practice, which includes nurses playing a key role in promoting health, preventing ill health and reducing health inequalities.

Conclusion

University webpages for adult nursing programmes do not present programme content in sufficient detail to be certain of the current state of population health learning, and elements of the new programme (post-2018 changes) could be missing. There is a lack of quantitative research to understand educational practices in population health and health promotion learning for adult preregistration nursing education programmes in England.

Despite clear evidence and recommendations for nursing education to develop students' understanding of population health through focused learning and non-clinical placement opportunities, only 26% of universities provide a clear vision of this agenda in the course description. In the information provided to future adult nursing students, the emphasis is on clinical skills and partnerships with hospital trusts for placement provision.

The majority of university websites for adult nursing programmes do not address the wider context in which care takes place and the current public health agenda in the description of the course, or in relation to future nursing practice. It would be interesting to compare this with the websites of mental health and child nursing programmes to understand if there are any differences in the way the roles are presented to future candidates.

To fulfil their potential to make a major contribution to improvements in population health and a reduction in inequalities, not only does how we teach nursing need to change, but also how we market the profession to potential students. Those defining the agenda for nursing education have a a responsibility to promote a broader vision of what it means to be a nurse in the 21st century during the recruitment process, which includes changing the vision we are presenting of the profession on university websites. By universities marketing nursing proficiencies, rather than focusing on technical skills, we can promote a contemporary image of the profession that has the potential to attract a broader range of candidates.

Key points

• Nurses need to develop a clear understanding of population health during their educational experience, if they are to have the knowledge and skills required to fully assume their role in promoting health and preventing ill health
• Nursing education has a responsibility to promote a broader vision of what it means to be a nurse in the 21st century during the recruitment process.
• Only 26% of universities in England promote a clear population health agenda in the information provided to future adult nursing candidates
• Educational establishments need to play a greater role in setting expectation of the future role of nurses by clear branding
• A review of the population health agenda in undergraduate nursing in England is recommended to understand current educational practice.

CPD reflective questions

• What importance do you place on promoting health and preventing ill health in your clinical practice?
• If you are supervising students, are you encouraging them to analyse patient situations through a ‘population health lens’?
• How do you portray the role of a nurse to people who express an interest in the profession?